CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 34 0000. ref SDS 33 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040507 -
040509 -  ..
0406 -
0407 -
0408 - Background
0409 -
040901 - On 091103 Paula reported the VA has scheduled a meeting today with
040902 - Doctor Stewart for planning Heller Myotomy surgery to correct
040903 - achalasia problem. ref SDS 20 PS60  On 091104 0718 Medical Chart
040904 - discharge guidance lists meeting with Doctor Stewart 091117 1300,
040905 - which conflicts with patient history today. ref SDS 21 Q03J  On 091119
040906 - 1000 Erick confirmed visit with Doctor Stewart on 091208, and is
040907 - reviewing date of surgery scheduled for 091217. ref SDS 23 935H
040909 -  ..
040910 - On 091208 Doctor Stewart advanced the schedule for surgery one day to
040911 - 091216. ref SDS 25 6E41
040913 -  ..
040914 - On 091216 0600 meeting Doctor Stewart for Heller Myotomy surgery to
040915 - correct achalasia; check in at ASU. ref SDS 29 PP8W
040917 -  ..
040918 - On 091217 0600 meeting with Joe and Jon on recovring from Heller
040919 - Myotomy surgery; report of complication during surgery on 091216,
040920 - which was repaired, with plan for test to evaluate recovery. reported
040921 - on 091217 0600, ref SDS 30 0042  Doctor Stewart visited and expects
040922 - can start eating after favorable test. ref SDS 30 027A
040924 -  ..
040925 - On 091218 0600 xray with gastrogafin to evaluate repair for
040926 - complicaiton during Heller Myotomoy surgery Wednesday, ref SDS 31 PP8W,
040928 -  ..
040929 - On 091219 0600 doctor plans discharge tomorrow after evaluating
040930 - progress eating solid food today. ref SDS 32 PP5V  Since now eating
040931 - solid food, switched to oral pill medication to replace IV injections;
040932 - this relieved pain that has been increasing using IV catheters set on
040933 - Wednesday, ref SDS 32 PQPX, and also eliminated need to replace IV
040934 - catheters per TCU protocol. ref SDS 32 7Q55  Doctors prescribed hiking
040935 - to recover from Heller Myotomy surgery resolving achalasia.
040936 - ref SDS 32 7Q6P   Doctor Ratcliff and Neil visit and discussing doing a
040937 - small business trial to apply SDS technology for upgrading VA and UCSF
040938 - case management. ref SDS 32 0M6S  Nurse advises that patient approved
040939 - for moving to a ward for non-critical care, as a predicate to
040940 - discharge, but since there are no rooms available, patient will remain
040941 - in TCU untill a room is available. ref SDS 32 0M8S
040943 -  ..
040944 - On 091220 0527 discharge approved from hospital today. ref SDS 33 PP8W
040945 - Left the hospital about 1220. ref SDS 33 HB5O
040947 -  ..
040948 - On 091221 1532 Isagani called to schedule meeting with Doctor Stewart
040949 - at VA in San Francisco on 100105. ref SDS 34 PP8W
040951 -  ..
040952 - On 091222 1109 letter from Isagani says meeting with Doctor Stewart is
040953 - on 100112 1400, not Jan 5th; possibly there are 2 meetings scheduled.
040954 - ref SDS 35 J57K
040956 -  ..
040957 - On 091223 1452 VA letter says meeting with Doctor Stewart scheduled on
040958 - 100105 1400, ref SDS 36 PP8W
040960 -  ..
040961 - On 091228 1049 letter to VA asks Isagani to clarify date for meeting
040962 - with Doctor Stewart, and whether there are two (2) meetings?
040963 - ref SDS 37 PP8W
040965 -  ..
040966 - On 091228 1418 letter from Isagani says meeting with Doctor Stewart is
040967 - on 100105, and there is only 1 meeting scheduled, not 2. ref SDS 38
040968 - PP8W
040970 -  ..
040971 - On 100104 0930 met with Doctor Sandhu to begin care for heart surgery
040972 - and follow up on Heller Myotomy surgery to recover from achalasia.
040973 - ref SDS 39 PP8W
040975 -  ..
040976 - On 100105 1300 meeting with Jan and Doctor Stewart; examination finds
040977 - good progress recovering from Heller Myotomy surgery on 091216, and
040978 - procedure effective resolving achalasia problem, swallowing improved.
040979 - ref SDS 0 PP8W
040980 -
040981 -
040983 -  ..
0410 -
0411 -
0412 - Progess
0413 -
041301 - Prior to meeting with Doctor Stewart, visited office for Release of
041302 - Patient Records, and ordered records from 091105 to present, to
041303 - supplement prior order on 091208 1300. ref SDS 25 EL31
041305 -  ..
041306 - After leaving the Office for Release of Patient Records, went to the
041307 - cafeteria for a sandwich to test swallowing prior to meeting with
041308 - Doctor Stewart to evaluate effectiveness of surgery to resolve
041309 - achalasia.  Discovered didn't have a billfold.  Went back to Office
041310 - for Release of Patient Records.  The attendant had found the billfold
041311 - on the counter, and so was able to return it.
041313 -  ..
041314 - Went back to cafeteria and ordered a sandwich and coke.  Took to the
041315 - Clinic.
041317 -  ..
041318 - Checked in at 1230 for meeting in Module #2 Clinic.
041320 -  ..
041321 - Worked at the counter across the way in Module #1, and ate the ham and
041322 - cheese sandwich.   Swallowing seemed to work well.
041324 -  ..
041325 - Was called at 1300 for meeting scheduled at 1400.  Very pleased to be
041326 - ahead of schedule.
041328 -  ..
041329 - Vitals were good, including weight 176, and oxygen 97.
041331 -  ..
041332 - Doctor Jen Chang did initial patient review.  Isagani did not submit
041333 - the report of progress, submitted in the letter to the medical team on
041334 - 091228 1049. ref SDS 37 JN8U
041336 -  ..
041337 - Previously, met with Jen several times while recovering from surgery
041338 - on 091216.  Jen advised today that he assisted Doctor Stewart
041339 - performing Heller Myotomy surgery to resolve achalasia on 091216.
041340 - ref SDS 29 KE9U
041342 -  ..
041343 - Reported meeting with Doctor Sandhu, primary care physician at VA in
041344 - Martinez, yesterday on 100104 0930. ref SDS 39 PP8W
041346 -  ..
041347 - Examination found swallowing significantly improved.  Vomitting still
041348 - occurs with eating meat like steak.  Hamburger is easier to swallow.
041349 - Recent experience eating lasauna was swallowed well, without
041350 - vomitting.
041352 -  ..
041353 - Doctor Stewart advised that the flap constructed to prevent reflex
041354 - from the stomach, may have some residual swelling from surgery.  She
041355 - expects this to improve, which will allow swallowing to get better.
041357 -  ..
041358 - The doctor recommended avoiding tough cuts of meat, eating slowly, and
041359 - cutting meat like steak in small bites.
041361 -  ..
041362 - There was also discussion that some vomitting continues from habit
041363 - formed the past 5 years dealing with achalasia.  Some food typically
041364 - stays in the esophagus, and eventually passes through the lower
041365 - esophageal sphincter.  People typically allow this to occur, but with
041366 - achalasia the habit of clearing the throat with vomitting continues.
041368 -  ..
041369 - Doctor Stewart examined the 5 punctures for laproscopic surgery on
041370 - 091216.  She feels these locations are healing well.
041372 -  ..
041373 - Follow up examination was not discussed.
041374 -
041375 - Reviewed considerations with Doctor Ratcliffe for clinical trial to
041376 - improve patient outcomes with better case management, reported on
041377 - 091219 0600. ref SDS 32 Z990
041379 -  ..
041380 - Doctor Stewart noted that developing and testing better case
041381 - management will require several levels of approval, and will resist
041382 - using email for timely, accurate communications, based on fears of
041383 - criticism for breach of patient confidentiality and privacy.  Doctor
041384 - Ratcliffe also raised this concern on 091219 0600. ref SDS 32 M75F
041386 -  ..
041387 - Doctor Stewart further noted that VA case management is significantly
041388 - stronger than other health care providers.  She described accessing
041389 - patient records throughout the VA.  This was demonstrated by Doctor
041390 - Brezinski on 091022, finding Doctor Lee's report on achalasia that
041391 - required adjustments for anesthesia to support heart surgery.
041392 - ref SDS 15 LN6F  A week later, Doctor Stewart, also, used VA records
041393 - to review findings of achalasia from barium sulfate swallow test, 5
041394 - years earlier, reported on 091030 0810. ref SDS 17 KE3B
041396 -  ..
041397 - The doctor feels this record demonstrates VA has strong capability for
041398 - "connectivity" that improves patient outcomes.
041400 -  ..
041401 - There was discussion that VA has developed a powerful culture of
041402 - knowledge from writing comprehensive chronology on daily patient care
041403 - that improves outcomes beyond capabilities of other providers.  VA
041404 - patient records are written ad hoc with very little context
041405 - management.  There is no "connectivity" between records, showing
041406 - causation with respect to diagnosis, treatment, recovery, and
041407 - adjustments.
041409 -  ..
041410 - As a result, VA patient records still create frustrations, cited by
041411 - Doctor Brezinski on 091022 0700. ref SDS 15 3W6L  More recently Doctor
041412 - Stewart and Doctor Tabrizi were unable to find patient history on the
041413 - manometry test, reported on 091208 1300. ref SDS 25 BJ3H  Doctor
041414 - Ratcliffe and the CT team were frustrated on 091031, because they
041415 - could not find VA records on endoscopy and manometry testing as well.
041416 - ref SDS 17 TZ4N
041418 -  ..
041419 - Frustrations, delays, and extra cost mounted when the CT surgery team
041420 - relied on a few "dots" from near term labs to evaluate albumin,
041421 - because nobody could "connect the dots" of patient history showing
041422 - nutrition was adequate without a feeding tube for recovering from
041423 - heart surgery. ref SDS 17 T84K
041425 -  ..
041426 - Synergy between the doctor/patient partnership adds the "power of
041427 - knowledge" from context and connection that significantly leverages
041428 - the VA's current practice of tracking patient history solely by
041429 - chronology.  NWO explains a theory of knowledge from "intelligence
041430 - support" that "connects the dots" of daily work. ref OF 12 I38N
041432 -  ..
041433 - Benefits improving patient outcomes from integrating chronology,
041434 - context, and connection were cited by Doctor Johnson at Kaiser on
041435 - 090213, and attributed to stronger case management through the
041436 - doctor/patient partnership, ref SDS 11 FZ4H, that has enabled Millie
041437 - to survive continuous treatment for stage IV cancer 4 times longer
041438 - than disease trajectory, reported on 090325. ref SDS 12 P39M  Extended
041439 - longevity for stage IV cancer leads to protocols for treating stage V
041440 - cancer as a chronic disease, shown in case study on 090325.
041441 - ref SDS 12 L15M  Doctor Johnson at Kaiser attributes improved patient
041442 - outcome to "yoeman's work" performing "evidenced-based practice" for
041443 - case management, reported on, ref SDS 13 T58R
041445 -  ..
041446 - Doctor Stewart feels the CT Surgery Department may be more conducive
041447 - to a pilot test for this type of clinical trial.
041448 -
041449 -
041450 -
041451 -
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041453 -
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041455 -
041456 -
0415 -