THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net


S U M M A R Y


DIARY: June 25, 2009 03:39 PM Thursday; Rod Welch

Doctor Mates called about problems at Kaiser doing Millie's CT tests.

1...Summary/Objective
....Evidence Based Medicine Requires Comprehensivle Radiology Reports
....Bridge Between Technology and Using Radiology for Patient Care


..............
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SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 16 0000, ref SDS 14 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040508 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Doctor Mates called today, and explained his call follows discussions
040902 - he had with somone at Kaiser to call about Millie's care.
040904 -  ..
040905 - Doctor Mates asked "What's the problem?"
040906 -
040907 -    Research...
040908 -
040909 -    Background on Doctor Mates work as a radiologist at Kaiser Walnut
040910 -    Creek, beginning in 2005, is reported on the Internet at....
040911 -
040912 -              http://www.permanente.net/homepage/kaiser/doctor/jonathanmates/
040913 -
040915 -     ..
040916 -    Evidence Based Medicine Requires Comprehensivle Radiology Reports
040917 -    Bridge Between Technology and Using Radiology for Patient Care
040918 -
040919 -    Doctor Mates describes his work in radiology...
040920 -
040921 -        I am very interested in imaging informatics, which focuses on
040922 -        using systems (primarily technology) to improve access to and
040923 -        better utilize imaging information for the solving of medical
040924 -        problems. This is a natural outgrowth of my undergraduate
040925 -        training in anthropology and my experience in the
040926 -        computer-heavy field of radiology. I see myself as a bridge
040927 -        between the technical side of medicine and the people who
040928 -        actually have to use the technology.
040930 -         ..
040931 -        I chose the Kaiser Permanente system because I knew of its
040932 -        work on using technology to improve patient care and its
040933 -        emphasis on evidence-based medicine. It is the perfect place
040934 -        for me to work in my two chosen areas of interest.
040936 -     ..
040937 -    Professional paper.....
040938 -
040939 -        Diagnostic Imaging.com
040940 -        CMP Medica - United Business Media
040941 -
040942 -        January 30, 2007
040943 -        New system addresses `wet reads' in age of PACS
040944 -        Douglas Page
040945 -
040946 -              http://www.diagnosticimaging.com/display/article/113619/1183592
040948 -         ..
040949 -        Effective, efficient communication regarding urgent or
040950 -        emergent studies has been a problem in a wired radiology
040951 -        setting. A new way has been found to facilitate this
040952 -        communication.
040954 -         ..
040955 -        Researchers at the University of Pittsburgh Medical Center
040956 -        (UPMC) have developed the Collaborative Notification System
040957 -        (CNS). The technique is used to inform referring clinicians of
040958 -        urgent findings, or wet reads.
040960 -         ..
040961 -        CNS uses a system of Web pages integrated into PACS [picture
040962 -        archiving communication system] for sending and receiving
040963 -        succinct messages to provide clinical information at the point
040964 -        of need.
040965 -
040966 -               Wikipedia - Define "PACS"
040968 -                ..
040969 -               In medical imaging, picture archiving and communication
040970 -               systems (PACS) are computers or networks dedicated to
040971 -               the storage, retrieval, distribution and presentation
040972 -               of images. The medical images are stored in an
040973 -               independent format. The most common format for image
040974 -               storage is DICOM (Digital Imaging and Communications in
040975 -               Medicine).
040977 -                ..
040978 -               Typically a PACS network consists of a central server
040979 -               that stores a database containing the images connected
040980 -               to one or more clients via a LAN or a WAN which provide
040981 -               or utilize the images.
040983 -                ..
040984 -               More and more PACS include web-based interfaces to
040985 -               utilize the Internet as their means of communication,
040986 -               usually via VPN (Virtual Private Network) or SSL
040987 -               (Secure Sockets Layer). The client side software is
040988 -               often using ActiveX, JavaScript and/or Java.
040990 -                ..
040991 -               Definitions vary, but most claim that for a system to
040992 -               be truly web based, each individual image should have
040993 -               its own URL.[citation needed]
040995 -                ..
040996 -               Client workstations can use local peripherals for
040997 -               scanning image films into the system, printing image
040998 -               films from the system and interactive display of
040999 -               digital images. PACS workstations offer means of
041000 -               manipulating the images (crop, rotate, zoom, window,
041001 -               level and others).
041003 -         ..
041004 -        PACS has made communications among clinicians, technologists,
041005 -        and radiologists more complex. Radiologists are often removed
041006 -        from the physical location of the patient and the site of
041007 -        imaging.
041009 -     ..
041010 -    Paper.cites Doctor Mates extensively...
041011 -
041012 -        "Efficient communication of study interpretations has become a
041013 -        priority for radiologists as they struggle to maintain
041014 -        relevance and provide added value to patient care when PACS
041015 -        has already given clinicians access to images," said former
041016 -        UPMC resident Dr. Jonathan Mates, now a Kaiser Permanente
041017 -        radiologist in Walnut Creek, CA.
041019 -         ..
041020 -        CNS is an asynchronous communications tool designed to support
041021 -        reporting of urgent findings in a geographically distributed
041022 -        environment.  It consists of a PACS-integrated Web-based
041023 -        application that opens automatically for appropriate studies,
041024 -        allowing clinicians and radiologists to input interpretations
041025 -        into a text box.  The technique was documented in a recent
041026 -        paper (J Digit Imaging 2006 Dec. 27 [Epub ahead of print]).
041028 -         ..
041029 -        Mates admits that some of the advantages of CNS are lost on
041030 -        institutions that rely on full-time dedicated emergency
041031 -        department radiologists, who have less need for discordance
041032 -        adjudication or offsite coverage.
041033 -
041034 -        "Nevertheless, improved communication and efficiency that are
041035 -        available from an asynchronous communication model can provide
041036 -        benefit in any radiology department," Mates said.
041038 -         ..
041039 -        In an academic environment, for example, CNS can reveal
041040 -        patterns of discordance, illuminating potential gaps in
041041 -        resident education.
041042 -
041043 -        "Links to cases in PACS provide a means for creating a digital
041044 -        teaching file of missed cases, which can be presented during
041045 -        resident conferences," he said.
041047 -         ..
041048 -        Also, data on frequency, types, and nature of discordances or
041049 -        lack thereof can be mined for information on individual
041050 -        readers and clinicians to support various research endeavors,
041051 -        Mates said.
041053 -         ..
041054 -        One potential flaw is that the radiologist rendering the final
041055 -        interpretation must provide adjudication of the preliminary
041056 -        report, according to Mates.
041057 -
041058 -        "This represents an additional workflow step, compared with
041059 -        the traditional approach of doing nothing when the preliminary
041060 -        and final interpretations are in agreement," he said.
041062 -         ..
041063 -        UPMC found, however, that attending radiologists recognize the
041064 -        benefits of completing the communications loop. They also
041065 -        appreciate the reduction in interrupting phone calls when the
041066 -        preliminary report is formally confirmed.
041067 -
041069 -  ..
041070 - Thanked Doctor Mates for calling, and said there are several issues
041071 - pending on radiology that affect Millie's care.
041072 -
041073 -    1.  CT test oral contrast medium change to Gastrogafin...
041074 -
041075 -        Reviewed background on Millie having difficulty using Barium
041076 -        Sulfate Suspension, reported for the CT test on 090613.
041077 -        ref SDS 20 PPWX  On 090325, her doctor tried to order
041078 -        Gastrogafin, which is easier for Millie to tolerate, but could
041079 -        not find this option in Kaiser's Knowledge Management system.
041080 -        ref SDS 17 G58N
041082 -  ..
041083 - Doctor Mates asked why the patient assistant is complaining to the
041084 - Radiology Department?  He feels Kaiser case management best practices
041085 - requires the primary care physician to be a "single-point-of-contact"
041086 - for the patient dealing with subsidiary business units at Kaiser,
041087 - like in this case the Radiology Department.
041089 -  ..
041090 - Doctor Mate's analysis aligns with Section 2 of Kaiser's EOC reviewed
041091 - on 070927, which indicates the primary care physician performs case
041092 - management arranging and coordinating services for the patient dealing
041093 - with all elements at Kaiser. ref SDS 1 WS6M
041095 -  ..
041096 - Doctor Mate's asked why he should respond to the patient, since the
041097 - EOC says the primary care physician should coordinate the work?
041099 -  ..
041100 - Noted that Doctor Mates called this afternoon and asked about quality
041101 - care problems working with radiology that affect Millie's care, per
041102 - above. ref SDS 0 Y75I
041104 -  ..
041105 - Doctor Mates apologized.  He noted that Doctor Johnson should be able
041106 - to specify in Kaiser's computer Gastrogafin oral contrast medium for
041107 - Millie.  She should not suffer simply because the computer doesn't
041108 - list Gastrogafin.  Doctor Mates seemed to suggest that Doctor Johnson
041109 - can call the Pharmacy to order the correct care for Millie.  He also
041110 - suggested the doctor contact Kaiser's technical support to ask why
041111 - Gastrogafin is not listed as a choice in the computer ordering system,
041112 - and further request adding a "space" in the online Knowledge
041113 - Management program for the doctor to specify an alternate prescription
041114 - for oral contrast medium.
041116 -  ..
041117 - The record on 080609 shows that "calling the Pharmacy" is a not a
041118 - "simple" task. ref SDS 4 837J  Earlier on 080403, Doctor Rugo at UCSF
041119 - asked Millie to coordinate work with Doctor Johnson at Kaiser on
041120 - prescribing Neupogen for Millie, because calling the doctor at Kaiser
041121 - is very difficult. ref SDS 2 IM87  Similarly, on 080502 Doctor Johnson
041122 - explained that calling the Pharmacy to order a prescription takes a
041123 - lot of time, which is generally not available in his hectic schedule.
041124 - ref SDS 3 6J5J   Ordering drugs on the computer is fast and easy, but
041125 - can be frustrating, like a "black box," also noted by Doctor Johnson
041126 - on 080502. ref SDS 3 NM4J
041128 -  ..
041129 - We reviewed the record showing Millie's doctor has a heavy patient
041130 - practice, and has other responsibilities off-site starting up the new
041131 - Kaiser hospital in Antiock, and, also, launching the Palliation
041132 - project at Kaiser Walnut Creek.  This hectic schedule limits Doctor
041133 - Johnson's time to perform steps proposed by Doctor Mates today for
041134 - expanding oral contrast media that aligns with Millie's patient
041135 - profile.  Limited time is not uncommon at Kaiser, and so places a
041136 - premium on correcting the computer ordering system to optimize
041137 - everyone's time.
041139 -  ..
041140 - For example, on 090109, Dennis in the CT Department called and left a
041141 - message for Doctor Mates to call back about Millie's radiology issues.
041142 - ref SDS 16 XE9M  More recently, on 090617 Al Hutchins indicated Doctor
041143 - Mates would call to follow up the same issue pending since January.
041144 - It seems axiomatic that, if Doctor Mates takes 5 months from January
041145 - until today to return a call, relying on Millie's doctor to call the
041146 - pharmacy, as Doctor Mates suggests today, does not provide a realistic
041147 - solution to expedite case management of complex problems.
041149 -  ..
041150 - This record suggests that the Radiology Department is best positioned
041151 - to initiate changes that add Gastrogafin to the computer Knowledge
041152 - Management system, and which will optimize time for all doctors
041153 - ordering CT tests.
041155 -  ..
041156 - Doctor Mates then seemed to indicate that he would investigate to see
041157 - what is required to provide an efficient procedure using Kaiser's
041158 - Knowledge Management system for Doctor Johnson to order an alternate
041159 - oral contrast medium, so that quality care is provided for Millie.
041161 -  ..
041162 - Doctor Mates asked for the next problem...
041163 -
041164 -    2.  Consolidate findings in CT test reports to prevent mistakes...
041165 -
041166 -        Kaiser issued findings for the CT test on 081107, which were
041167 -        received in the record on 081112, ref SDS 5 DA6Q; a second set
041168 -        of findings on the same test were received the next day on
041169 -        081113. ref SDS 6 TP8L  Case study at that time on 081113 shows
041170 -        Kaiser had never previously issued multiple reports for a
041171 -        single CT test. in Millie's long 8-year patient history,
041172 -        ref SDS 6 HV4H
041174 -         ..
041175 -        This problem occurred again on 081230, reported on 090107,
041176 -        ref SDS 13 YO7M, and caused delay and confusion at UCSF the
041177 -        next day on 090108, reported on 090109, ref SDS 15 UE6X, and
041178 -        this occurred despite the primary care physician having ordered
041179 -        a consolidated report in the referral for the CT test on
041180 -        081210. ref SDS 7 PU3L  Someone changed the doctor's order,
041181 -        and it was changed back on 081219 to specify consolidated
041182 -        findings. ref SDS 8 587G
041184 -         ..
041185 -        This issue was explained to Dennis in the CT Department on
041186 -        090109, ref SDS 16 SV8O,
041188 -         ..
041189 -        On 090409 2018 Doctor Davidson, Director fo Radiology of Kaiser
041190 -        Mt Diablo Service Area, advised that Kaiser CT Department
041191 -        Walnut Creek made a mistake issuing multiple reports for the CT
041192 -        test on 090413, ref SDS 18 WB6G, and advised that findings for
041193 -        future CT tests will consolidate findings into a single report
041194 -        for each test. ref SDS 18 XZ6U
041196 -  ..
041197 - Today, Doctor Mates demonstrated during the call strong verbal skills,
041198 - and became frustrated that problems issuing multiple reports for each
041199 - CT test cannot be resolved through conversation on the telephone by
041200 - getting agreement from the customer that this new practice does not
041201 - reduce quaity care.
041203 -  ..
041204 - In a lengthy discussion of 30 to 40 minutes, Doctor Mates advised that
041205 - issuing multiple reports for Millie's CT test on 081107, again on
041206 - 081230, and most recently for the test on 090612 applies industry
041207 - standards based on highly technical medical advantages to patients,
041208 - which Kaiser is required to implement by regulatory requirements that
041209 - are too complicated for patients to understand.  As a result, Doctor
041210 - Mates refused to explain any benefits to patient care that may offset
041211 - severe problems this new practice causes.
041213 -  ..
041214 - Doctor Mates said he cannot conceive why getting multiple reports for
041215 - a CT test should harm patient care.  He asked several times for an
041216 - explanation.  This part of the discussion today was not constructive.
041217 - Tension and frustration reflected strong emotional investment in
041218 - issuing multiple reports, regardless of harm to the patient.  Before
041219 - getting 3-words of an explanation, the doctor interrupted to dispute
041220 - the factual record, and without reference to any documented source.
041222 -  ..
041223 - Tried to explain confusion during the meeting at UCSF on 081113 that
041224 - presented a false, and misleading picture of patient status with
041225 - respect to progression of cancer.  The meeting was called to evaluate
041226 - Millie changing treatment, after nearly 2 years on the cetuximab
041227 - protocol.  The CT test on 081107 at Kaiser was a principle evidence in
041228 - this decision.
041230 -  ..
041231 - Doctor Mates said he was told Millie wanted the Kaiser Radiology
041232 - Department to review or otherwise do somthing with a CT scan that was
041233 - done in Arizona.
041235 -  ..
041236 - Upon further discusison, Doctor Mates feels there was a mixup in
041237 - understanding communication with Al Hutchins.  He recalled Al Hutchins
041238 - said to to call Rod about Millie Buck, and there was also discussion
041239 - about a patient who needs a scan performed by a hospital in Arizona
041240 - read at the Kaiser Walnut Creek facility.  Either Al presented the
041241 - issues incorreclty, or by the time Doctor Mates was able to follow up,
041242 - understandings got reversed.
041244 -  ..
041245 - Doctor Mates seemed certain today that problems concerning oral
041246 - contrast medium and consolidating reporting for radiology tests were
041247 - entirely new issues, which he did not expect to discuss in calling
041248 - about Millie's care today.  He feels there was a communication mistake
041249 - somewhere in the many discussions that led up to his call today.
041250 -
041252 -  ..
041253 - We agreed that Millie does not require a special protocol that
041254 - formats reports on her tests differently from reports for other
041255 - patients.
041257 -  ..
041258 - Doctor Mates feels multiple reports may be more of a problem for
041259 - patients getting treatment on referral, because off-site and
041260 - out-of-system referrals do not have access to computer records that
041261 - directly link reports for each CT test.
041263 -  ..
041264 - This helps demonstrate requirements for referral coordination
041265 - planning.
041267 -  ..
041268 - Doctor Mates seemed to indicate in the call today that CT test on
041269 - 090612 shows Millie is in "good shape," and shows "nothing much," or
041270 - words to that effect.  He indicated that ground glass opacities can
041271 - eventually lead to lung cancer, but Kaiser practice is for the
041272 - radiologist to report "lung cancer," if evidence from radiology tests
041273 - justifies this finding.  He further seemed to say that nodules in my
041274 - lungs could be causing difficulty breathing, and since I recently had
041275 - a lot of radiation, there was likely a correlation.  This aligned with
041276 - Doctor Rugo's comments during the meeting at UCSF on 090514.
041277 -
041278 -            [On 090627 0221 Millie notified medical team that Doctor
041279 -            Mates findings from CT test on 090612 do not indicate
041280 -            cancer, and that Millie could recover from ground glass
041281 -            opacities caused by radiation. ref SDS 21 2X7R
041283 -  ..
041284 - Doctor Mates further indicated that my current lung problem of nodules
041285 - and/or "ground glass opacities" can "heal" and so I can recover former
041286 - lung capacity through continued exercise, and without direct
041287 - treatment.
041288 -
041289 -            [On 091112 0930 Kaiser's medical chart for Millie shows CT
041290 -            test on 090919 found ground glass opacity nodues resolved
041291 -            in some areas of the lungs, and new ones appear in other
041292 -            areas, ref SDS 22 WY8J, reflecting Doctor Hsu's report that
041293 -            radiation effects last for months after ending treatment,
041294 -            per above. ref SDS 19 YN5N
041296 -  ..
041297 - Need to clarify this analysis during the meeting with Doctor Johnson
041298 - tomorrow.  Specifically, the CT test on 090612 describes "ground glass
041299 - nodules" and "streaky atelectasis and bronchiectasis" what does this
041300 - mean?
041301 -
041302 -
041303 -
041304 -
041305 -
041306 -
041307 -
041308 -
041309 -
0414 -