CONTACTS 
0201 - Kaiser Permante                                                                                                                                                    O-00000652 0202
020101 - Dr. Craig Boulris, M.D.; Orthopedic Surgon
020102 - Orthopedic Department                                                                                                                                            O-00000652 0202

SUBJECTS
Medical, Kaiser
Knee Examination Shows Problem on 990625
Knee Examination by Orthopedist on 990910
Policy Procedures on Communication
Medical History, Xrays Not Submitted for Meeting
Email Does Not Improve Productivity, Degrades It
Email Degrades Writing, Understanding
Document Management Systems
Email Applications
Inexperience Causes Fear, Denial
Web Mail Objectionable, Takes Time Access Web
Email Needs Organization
Xrays on Knees, 990813
Xrays on Knees, 990910

2316 -
2316 -    ..
2317 - Summary/Objective
2318 -
231801 - Follow up ref SDS 59 0000, ref SDS 58 0000.
231802 -
231803 - Craig recommended a particular oral medication, ref SDS 0 9633, to
231804 - supplement exercise that builds strength, as treatment of knee
231805 - problems.  Knee replacement may be needed in 10 years on left leg.
231806 - ref SDS 0 9733  He will submit a report confirming the name of the
231807 - medication and other findings.  The examination was delayed and
231808 - incomplete because medical history and xrays were not submitted in
231809 - time for Craig to prepare for the meeting.  Craig said Kaiser's
231810 - policies prevent giving his email address to expedite communication
231811 - with web mail.  He is worried that getting medical history via web
231812 - mail will not be effective because he does not have a good way to use
231813 - this information to guide a medical examination.  I will work with
231814 - Patient Assistance to solve this problem. ref SDS 0 2040  Since the
231815 - medical records were not provided, Craig ordered another set of xrays,
231816 - and this resulted in another mistake when the Kaiser ID was switched
231817 - with another patient. ref SDS 0 6305  After this was resolved, got
231818 - good advice on treatment options, and developed ideas for follow up.
231819 - ref SDS 0 7388
231820 -
231821 -      [On 990913 submitted record to Craig. ref SDS 62 7728]
231823 -       ..
231824 -      [On 990916 record forwarded to Craig. ref SDS 64 0001]
231826 -       ..
231827 -      [On 990925 received Craig's report, developed issues. ref SDS 66
231828 -      0001]
231830 -       ..
231831 -      [On 990927 submitted issues from report. ref SDS 67 0001]
231833 -       ..
231834 -      [On 990928 Craig received issues from report. ref SDS 68 0001]
231836 -       ..
231837 -      [On 991011 Craig submitted clarifications. ref SDS 72 0001]
231839 -       ..
231840 -      [On 000124 follow up examination. ref SDS 77 0001
231841 -
231842 -
231844 -  ..
2319 -
2320 -
2321 - Progress
2322 -
232201 - Xrays on Knees and Medical History Not Submitted to Boulris
232202 -
232203 - Follow up ref SDS 59 9890, ref SDS 58 0584.
232204 -
232205 - Craig advised that Kaiser Park Shadelands did not submit xrays taken
232206 - on 990813, ref SDS 56 1457, and did not submit medical history for him
232207 - to prepare for meeting today.
232209 -  ..
232210 - This conflicts with the record on
232211 -
232212 -     1.  On 990625 Kaiser's Team Care policy calls for doctors to
232213 -         review medical history. ref SDS 40 6970
232214 -
232215 -     2.  On 990907, ref SDS 60 1080, requesting Patient Assistance to
232216 -         ensure that xrays and medical history were submitted to Craig
232217 -         for the meeting today. ref DIP 9 0001
232219 -          ..
232220 -         [On 990913 received letter from Mark Mangrai that he was sick
232221 -         last week and as a result was unable to take action on the
232222 -         request sent on 990907. ref SDS 62 8058]
232224 -          ..
232225 -         [On 990912 article on front page of Sunday papers cites high
232226 -         cost of medical mistakes. ref SDS 61 0001]
232228 -          ..
232229 -         [On 991006 Team Care policy to provide medical history and
232230 -         xrays to team members was not followed because a doctor does
232231 -         like web mail. ref SDS 70 0002]
232233 -          ..
232234 -         [On 991008 requested meeting with medical management to review
232235 -         procedures. ref SDS 71 9055]
232237 -          ..
232238 -         [On 000121 Kaiser emphasizes careful handling of patient
232239 -         records, and plans to roll out electronic system in late 2001
232240 -         to improve present system. ref SDS 76 7654]
232242 -          ..
232243 -         [On 000211 Dale Ames was misdiagnosed, and wrong xrays used.
232244 -         ref SDS 78 3600]
232246 -          ..
232247 -     3.  990829 submitted ref DIP 8 4270 to remind Kaiser's staff about
232248 -         submitting xrays and medical history to Craig. ref SDS 59 7387
232250 -          ..
232251 -     4.  990813 submitted ref DIP 7 5810 requesting medical history be
232252 -         submitted to support meeting with orthopedic doctor.
232253 -         ref SDS 56 1457
232255 -  ..
232256 - As a result, a second set of xrays were taken.
232258 -  ..
232259 - Craig said this will only take 15 minutes, and then we can proceed
232260 - with the planned meeting; however, it took 45 minutes due to problem
232261 - reported below. ref SDS 0 6305
232262 -
232263 -     Consideration is needed to review Kaiser procedures that encumber
232264 -     the patient for half of a work day, considering travel and
232265 -     traffic, to take xrays weeks in advance of a meeting, which can be
232266 -     accomplished on-site within 20 minutes on the day of the meeting.
232267 -
232269 -  ..
232270 - Email Hampers Management, Need Communication Metrics for Web Mail
232271 - Doctor Does Not Have Time to Review Medical History on the Web
232272 -
232273 - I offered to submit the medical history via web mail for Craig to
232274 - review, and we can reschedule the meeting so he has time to be
232275 - prepared, per Kaiser policy reported on 990625. ref SDS 40 6970
232276 -
232277 - Craig does not want to do this, similar to Syed on 990802, ref SDS 53
232278 - 9108, and Sylvia on 990625. ref SDS 40 1846
232280 -  ..
232281 - Craig advised he does not need to review medical history, because
232282 - xrays, examination and discussion with the patient are sufficient to
232283 - treat the patient.  Reliance on immediate impressions from sight and
232284 - sound is a common desire in medical practice, ref SDS 23 0866, and
232285 - among executives in business, reported on 990625. ref SDS 41 4914
232287 -  ..
232288 - On 940728 Doctor Kory Zipperstein, who reviewed an actual SDS record,
232289 - reported that medical history saves time and money. ref SDS 14 0001
232291 -  ..
232292 - Craig said he does not have time to examine medical history, as
232293 - reported previously by Doctor Sylvia Connolly on 990625. ref SDS 40
232294 - 2652  He noted that medical charts have history, but these are not
232295 - always available, as occurred today.  He wants me to send a letter
232296 - that pulls together all of the relevant history he needs to review.
232297 -
232298 -     [On 990912 article on front page of Sunday papers cites high cost
232299 -     of medical mistakes. ref SDS 61 0001]
232301 -      ..
232302 -     [On 000121 Jeanne Bradley reported doctors are frustrated when
232303 -     medical history is not submitted in time for meeting with a
232304 -     patient. ref SDS 76 0783]
232306 -  ..
232307 - I explained that critical history going back 10 - 20 years takes a lot
232308 - of time and effort to assemble, but that web mail links to relevant
232309 - portions of the medical history, which expedites his time and my time.
232310 -
232311 -     [On 991011 Craig reports having reviewed medical history, and that
232312 -     it is not relevant to diagnosis. ref SDS 72 2303]
232313 - ..
232314 - Craig said Kaiser's policies prevent him from giving patients
232315 - his email address.
232317 -  ..
232318 - Craig also worried that he would have to spend a lot of time searching
232319 - for relevant history if he gets web mail.  He wants to save time.
232321 -  ..
232322 - I explained, again, that web mail saves time by providing direct links
232323 - to relevant portions of medical history, and, also, provides the full
232324 - record, so that he can judge what needs further review, rather than
232325 - place the burden on the patient to guess about what is important for
232326 - effective medical practice.
232328 -  ..
232329 - Craig clarified his concern about not using email for communicating
232330 - medical history.
232332 -  ..
232333 - He said he is overwhelmed by email, which is pretty common everywhere,
232334 - as reported on 980807. ref SDS 29 2426
232336 -  ..
232337 - If he gets an email today or tomorrow, then by the time we meet in a
232338 - few weeks, that email will be buried, lost or deleted and he won't be
232339 - able to remember what is relevant to our meeting, and he wont' be able
232340 - to find the email to review it during the meeting.  He said that if he
232341 - can rely on talking to the patient, or getting a printed letter from
232342 - the patient, then his responsibility is limited to what the patient
232343 - discloses.  He can review the record during the meeting with the
232344 - patient, rather than prepare in advance of the meeting.
232346 -  ..
232347 - These issues were reviewed on 990625 concerning Kaiser's Healthwise
232348 - Handbook Guidelines for doctor patient partnership. ref SDS 40 9577
232350 -  ..
232351 - I thanked Craig for considering this initiative, and apologized for
232352 - requesting consideration of methods outside conventional practice.
232354 -  ..
232355 - I explained that Welch web mail works better than conventional email,
232356 - and it is much better than Kaiser's practice of using printed
232357 - documents, as seen, for example, from the record on 990802.
232358 - ref SDS 53 0406  Craig does not have experience with this method to
232359 - judge the correctness of my representations today, so I stood down on
232360 - the issue.
232362 -  ..
232363 - I will review with Patient Assistance how to help Kaiser accomplish
232364 - effective doctor/patient communcation without burdening his time, as
232365 - was done on 990907. ref SDS 60 1080
232366 -
232367 -    [On 990913 requested help from Patient Assistance. ref SDS 62 1269]
232368 -
232369 -    [On 990924 Patient Assistance noted objections; reviewed advantages
232370 -    of web mail again. ref SDS 65 9964]
232372 -     ..
232373 -    [On 990925 requested Pataient Assistance support again. ref SDS 67
232374 -    3966]
232376 -     ..
232377 -    [On 990928 report that Craig is using web mail. ref SDS 68 0001]
232378 -
232379 -
232381 -  ..
232382 - Patient Account Card Switched
232383 -
232384 - The medical assistant prepared a work order for new xrays.
232385 -
232386 - I took it to the xray department, and placed the work order in a
232387 - processing cabinet.
232389 -  ..
232390 - The xray technician retrieved the work order about 15 mintues later,
232391 - and returned to his office to prepare for taking my xrays.  He
232392 - returned in five minutes, and asked for someone else to come into the
232393 - xray room.
232395 -  ..
232396 - I explained my understanding that I was next in line for xrays.
232398 -  ..
232399 - The technician asked if I am so and so, and I gave my name.  Since I
232400 - was only person in the waiting area, the technician exclaimed another
232401 - mistake has occurred, asked me to wait a minute.  He went back to his
232402 - office and handed me the xray work order and asked if I was the person
232403 - on the work order.
232405 -  ..
232406 - Since I was not, he concluded the work order was prepared incorrectly.
232408 -  ..
232409 - He went to the medical administration area.  A few minutes later, he
232410 - returned with the Medical Technician who prepared the work order. The
232411 - Medical Technician asked to see my Kaiser Card.  I opened my wallet
232412 - and pulled out the card, and showed it to the technician.  She asked
232413 - if I am so and so, and I gave my name.
232415 -  ..
232416 - The Medical Technician said she filled out the xray work order
232417 - incorrectly, and that she gave me another patient's Kaiser Card.  I
232418 - checked and saw I had my Kaiser card still in my wallet, even though
232419 - I had just handed a card to the Medical Technician.
232421 -  ..
232422 - What seems to have happened is that there was another patient's Kaiser
232423 - card on the Medical Technician's desk for processing something else,
232424 - at the time the work order for my xrays was prepared.  She used the
232425 - other patient's Kaiser account card to prepare the xray work order,
232426 - instead of asking for my Kaiser card, and then and gave the other
232427 - patient's Kaiser card to me, which I put in my wallet, assuming it was
232428 - mine, because she handed it to me.
232430 -  ..
232431 - It was just a series of small mistake that the mind makes when rushed,
232432 - due to limited span of attention.
232433 -
232434 -     [On 991001 space ship crashes on Mars due to small mistake.
232435 -     ref SDS 69 0001]
232436 -
232437 -     [On 050907 Kaiser attendant in Business Office submitted medical
232438 -     records for 2nd opinion on the wrong patient. ref SDS 79 FB41
232439 -
232441 -  ..
232442 - The NWO... paper explains the compounding effect of small mistakes
232443 - over time. ref OF 4 JV3G  In this case, we caught the problem early,
232444 - so harm was contained.
232446 -  ..
232447 - Presumably, if I was on a bed, medicated and unable to speak, the same
232448 - mistakes could have been compounded by switching paperwork on an elbow
232449 - surgery for a heart transplant.
232450 -
232451 -     [On 990912 article in Sunday Times about high cost of medical
232452 -     mistakes. ref SDS 61 0001]
232454 -      ..
232455 -     [On 991008 requested meeting with medical management to review
232456 -     procedures. ref SDS 71 6256]
232457 -
232458 -
232459 -
232460 -
2325 -

SUBJECTS
Medical, Kaiser
Knee Examination Shows Problem on 990625
Knee Examination by Orthopedist on 990910
Synvisc Injection Therapy
Strength Relieves Stress on Knee Joints

2807 -
280801 -  ..
280802 - Knee Therapies Limited for General Arthritis
280803 -
280804 - Follow up ref SDS 58 0879, ref SDS 56 1716.
280805 -
280806 - When the xrays were ready, Craig examined my knees, and discussed
280807 - potential treatments in a general way.
280809 -  ..
280810 - We reviewed symptoms set out in the record on 990625, ref SDS 40 4420,
280811 - and, also, medical history, in a general way based on the same record.
280812 - ref SDS 40 5152
280813 -
280814 -     [On 990915 Jeanne submitted medical history to Craig. ref SDS 63
280815 -     2255]
280817 -  ..
280818 - Craig pointed out in the xray an arthritic condition of the left knee
280819 - which shows a markedly narrower gap between the upper and lower leg
280820 - bones, than is shown for the right knee.
280821 -
280822 -     I did not mention this to Craig during the meeting, today, but I
280823 -     was struck that the xray of the left knee looked very much the
280824 -     same as I recall the xray taken on 881010, where one side has a
280825 -     nearly normal gap, and other side is angled down to where the
280826 -     upper and lower bones are nearly touching. ref SDS 1 6295
280828 -  ..
280829 - I asked what accounts for the significant pain the right knee, that
280830 - seems similar to pain in the left knee, as reported in the record on
280831 - 990625, ref SDS 40 4420, if the right knee seems to be in better shape
280832 - than the left knee in the xrays?
280834 -  ..
280835 - Craig speculated there may be pockets of cartilage that are missing in
280836 - the right knee that don't show up on the xray.  These pockects
280837 - evidently cause pain during exercise.  He drew a plan view diagram of
280838 - the cartilage surface to illustrate how isolated cartilage could be
280839 - missing from interior areas, but are not shown in a standard xray
280840 - because the angle of the camera is limited by the configuration of the
280841 - knee. (See also below. ref SDS 0 7872)
280842 -
280843 -     [On 991011 Craig advises that the cause of comparable pain in the
280844 -     right knee is not known. ref SDS 72 3088]
280846 -      ..
280847 -     [On 991018 article says MRI may be able to show cause of pain,
280848 -     ref SDS 73 4620, submitted letter requesting comment. ref SDS 73
280849 -     0001]
280851 -      ..
280852 -     [On 000124 Vincint suggests causes of pain in right knee and says
280853 -     MRI will not show pockets of cartilage missing. ref SDS 77 2860]
280854 -
280856 -  ..
280857 - He examined the knees by bending them in various directions, similar
280858 - to the method used by Sylvia on 990625, ref SDS 40 0882, and he asked
280859 - if there is pain when sitting for extended periods, per meeting with
280860 - Christy on 990816. ref SDS 58 8769
280862 -  ..
280863 - Craig advised that his father was an active athlete, and had a knee
280864 - replacement.  Not sure if he said the work had to be re-done, or will
280865 - require re-work soon, because the cement fails over time.  The main
280866 - point is that knee replacement does not restore a condition that
280867 - supports athletic stress on the knee.  His dad has changed to activity
280868 - that is less stressful to knees, like swimming and biking.
280870 -  ..
280871 - I mentioned having started biking.
280873 -  ..
280874 - Craig indicated mountain biking provides a comparable workout to
280875 - running.  He does mountain biking, and looks to be in pretty good
280876 - shape.
280877 -
280878 -     [On 990927 reported good results from biking. ref SDS 67 0001]
280879 -
280880 -
280882 -  ..
280883 - Pain Relief Does Not Prevent Continued Failure of Knee
280884 -
280885 - Craig advised that cortisone shots can relieve pain, which was
280886 - cited in the letter from Sylvia received on 990706. ref SDS 44 0045
280887 -
280888 - I asked if this fixes the underlying problem that causes the pain?
280890 -  ..
280891 - Craig advised cortisone does not solve the problem I have,
280892 - particularly in the left knee of degenerative arthritis, which worsens
280893 - with use.
280894 -
280895 -
280897 -  ..
280898 - Knee Replacement May be Needed in 10 Years
280899 -
280900 - Craig seemed to say that in 10 years I may or will likely need a knee
280901 - replacement.
280902 -
280903 - Since knee replacement does not support an active life, this is not a
280904 - good solution at this time.
280905 -
280906 -     [On 990925 Craig's report makes this point. ref SDS 66 2951]
280907 -
280909 -  ..
280910 - Cartilage Replacement Still Experimental; No Effective Cure
280911 - Injection Therapies Treat Isolated Pockets Not General Arthritis
280912 -
280913 - Craig explained that cartilage and its integration with bone and other
280914 - components is highly complex, and therefore impossible to replicate
280915 - with present technology.
280916 -
280917 - Craig drew a series of sketches to explain his impression from
280918 - extensive research and experience, that some injection therapies help
280919 - by providing lubrication, but none have been effective in restoring
280920 - pervasive loss of cartilage that has been removed by surgery, or worn
280921 - away, as shown in the xray of my left knee.
280922 - ..
280923 - Since we did not have the list of new therapies, ref OF 2 0001,
280924 - reported on 990625, ref SDS 40 5400, we could not address them
280925 - individually; except, Craig specifically does not recommend Synvisc,
280926 - which was cited in my letter to Syed, ref DIP 6 5841, on 990731.
280927 - ref SDS 52 0001
280928 -
280929 -      [On 990924 Doctor Boulris recommends Synvisc. ref SDS 66 3955
280930 -      and ref SDS 66 0770]
280932 -       ..
280933 -      [On 991011 Craig says success for Synvisc treatment has not been
280934 -      as high as he would like to see. ref SDS 72 3942]
280936 -       ..
280937 -      [On 000124 Vincint was familiar with article on 8 new therapies
280938 -      from work with another patient. ref SDS 77 2772]
280939 - ..
280940 - Craig seems to have a good knowledge of effective treatments, as
280941 - well as current fads being promoted in journals and the Internet.  I
280942 - got the impression he is comfortable using the Internet.
280943 -
280944 -      [On 990915 all of Kaiser's providers do not have access to the
280945 -      Internet on their office computers. ref SDS 63 4524]
280947 -  ..
280948 - Since the medical history was not submitted, ref SDS 40 5152, Craig
280949 - was unable to review all of the treatments submitted in the record on
280950 - 990625, when Sylvia made the initial examination. ref SDS 40 5400
280951 - This conflicts with the objective cited by Sylvia in the call on
280952 - 990701. ref SDS 43 0855
280954 -  ..
280955 - He mentioned in the discussion "hyaluronic acid" treatments, which are
280956 - cited in the list of 8 new therapies, ref OF 2 7921, and seemed to
280957 - indicate these are not effective for my case.  Hopefully, he can
280958 - clarify this in his report.
280959 -
280960 -      [On 990925 the report makes general reference to "injectible"
280961 -      therapies, but does not review the 8 new therapies, except for
280962 -      Synvisc. ref SDS 66 0770]
280964 -       ..
280965 -      [On 000124 Doctor Vincint Yamamoto advised the article on 8 new
280966 -      therapies was helpful, based on prior work with another patient.
280967 -      ref SDS 77 2065]
280968 -
280969 -
280971 -  ..
280972 - Muscle Strength, Some Pill Therapies are Helpful to Knee Joints
280973 -
280974 - Craig confirmed Christy's recommendation on 990819 that exercise can
280975 - be a significant factor in relieving stress on the knee joint that
280976 - causes ware during exercise. ref SDS 58 5612
280977 -
280978 -     [On 991011 received letter from Craig confirming advantages of
280979 -     exercise to build strength, reduce weight. ref SDS 72 9588]
280981 -      ..
280982 -     [On 000124 Doctor Yamamoto suggested special shoes to reduce
280983 -     stress on knees during exercise. ref SDS 77 4160]
280985 -  ..
280986 - He explained advantages of taking certain medications, like Motrin.
280987 - Craig seemed to advise that medications should be taken before
280988 - exercise, rather than afterwards, because medication retards swelling
280989 - from inflamation.
280991 -  ..
280992 - I asked why preventing swelling is useful, despite not treating the
280993 - cause of swelling.
280995 -  ..
280996 - Craig explained it, but I did not follow the explanation. Hopefully
280997 - this will be covered in his report. ref SDS 0 3555
280998 -
280999 -      [On 990924 the report does not cover this point. ref SDS 66 4524]
281001 -  ..
281002 - Craig said a particular pill, or other form of ingested medication,
281003 - has been found to be effective for contributing to knee joint support,
281004 - either as a lubricant or other form of aid, rather than a mere pain
281005 - and swelling treatment.  He said it has been succesful on dogs and
281006 - horses in Europe.  Evidently it has been used on humans with success.
281008 -  ..
281009 - Craig recommendsd it be purchased from Costco at a cost of $30.
281010 -
281011 -       [On 990925 Glucosamine is the medication. ref SDS 66 3120]
281012 -
281013 -       [On 991011 purchased Glucosamine Chondroitin. ref SDS 72 2478]
281014 -
281015 -       [On 991026 Don Harms recommends Glucosamine and Chondroitin.
281016 -       ref SDS 74 3392]
281018 -        ..
281019 -       [On 991125 Steve considering this treatment. ref SDS 75 7654]
281021 -      ..
281022 -     Millie asked later, why this is not available from Kaiser, as a
281023 -     prescribed treatment?
281025 -  ..
281026 - We should probably try to get some liturature on this.
281027 -
281028 -     This clarifies Sylvia's comments on 990701. ref SDS 43 2015]
281029 -
281030 -     [On 990915 Jeanne Bradley printed this record for Doctor Connolly.
281031 -     ref SDS 63 0001]
281033 -  ..
281034 - I asked Craig to submit a report explaining the various therapy
281035 - options he discussed today, setting out which seem most appropriate
281036 - and promising to achieve the objective of remaining active.
281038 -  ..
281039 - Craig will include the name of the medication he recommends, in his
281040 - report.
281041 -
281042 -     [On 990916 Jeanne submitted this record to Craig for reference in
281043 -     preparing his report. ref SDS 64 0001]
281044 -
281045 -     [On 990925 received Craig's report. ref SDS 66 0001]
281046 -
281047 -
281048 -
281049 -
281050 -
2811 -