CONTACTS 

SUBJECTS
Pharmacist Orders Capecitabine (Xeloda) 13th Cycle Decadron Review S

5603 -
5603 -    ..
5604 - Summary/Objective
5605 -
560501 - Follow up ref SDS D4 TZ4I, ref SDS D0 TZ4I.
560502 -
560503 -
560504 -
560505 -
560506 -
560508 -  ..
5606 -
5607 -
5608 - Discussion
5609 -
560901 - Communication Oncology Coagulation Balance Treatments
560902 - Xeloda Coumadin Balance Treatments Collaboration Required
560903 - Pharmacist Orders Capecitabine Decadron; Coordinate with Coumadin
560904 - Pulmonary Emboli Pharmacist Not Aware Communication Medication Fails
560905 -
560906 - Talked to Gloria at Kaiser's Coagulation Treatment Clinic in Martinez.
560908 -  ..
560909 - Gloria explained that after the call last Friday, 061020, from Ross
560910 - with Kaiser's Oncology Clinic Pharmacy in Walunt Creek, ref SDS D4
560911 - VE57, Millie's list of medication prescriptions was updated to show
560912 - capecitabine (Xeloda) on the computer in the Coagulation Treatment
560913 - Clinic.
560915 -  ..
560916 - Gloria said that capecitabine (Xeloda) affects the way the blood
560917 - absorbs and processes Coumadin.  Treatment with this combination will
560918 - present more problems achieving stable INR requirements for a level
560919 - between 2 and 3.  This means Millie will need more blood tests, at
560920 - least once a week, rather than every 4 weeks or so without Xeloda.
560921 -
560922 -        [On 061214 treatment mistake pulmonary embolism warfarin
560923 -        (Coumadin) conflicts with prescription for Diflucan; blood test
560924 -        INR rises 6.4 danger zone for hemoraging; blood clot
560925 -        coagulation treatment paused for 3 days; INR update test
560926 -        advanced. ref SDS D9 HF4O
560928 -         ..
560929 -        [On 081229 computer problem recurring in CT Department staff
560930 -        not aware of doctor's referral to perform test using Power Port
560931 -        for injecting contrast medium, and not aware accessing Power
560932 -        Port scheduled in Infusion Clinic, and requires coordinating
560933 -        support from IS. ref SDS F4 5G3I
560935 -  ..
560936 - Gloria seemed to indicate that Kaiser has a lot of data in computers.
560937 - The part of the computer system that shows capecitabine (Xeloda) was
560938 - prescribed by the Oncology Department for Millie on 061002 is
560939 - different from the part where the Clinic manages coagulation
560940 - treatments with Coumadin.  She indicated that remembering how to use
560941 - other parts of Kaiser's computer system, in this case finding the list
560942 - that shows capecitabine (Xeloda) for Millie, takes extra time to for
560943 - training, learning, and then using a particular sequence of commands.
560944 - Sometimes the computer system is immediately responsive, and it is
560945 - down for repairs, and sometimes it is very slow due to high volume of
560946 - activity.  These conditions cause people with a hectic schedule not to
560947 - follow up and check the computer, even when they have the training and
560948 - skills, and intent to do so.  As a result, the Clinic appreciated
560949 - getting the call from Ross last Friday with notification that Millie's
560950 - treatments with Coumadin needs adjustment relative to her treatments
560951 - with capecitabine (Xeloda).
560953 -         ..
560954 -        [On 061110 doctor's list of current medications incorrect not
560955 -        listing Coumadin, and also does not list antibiotics for
560956 -        cellulitus, Lovenox, also, for PE, Procrit is not listed for
560957 -        anemia (low energy) to redress low blood counts for hemoglobin,
560958 -        Tums is not listed for GERD. ref SDS D6 SE86
560960 -         ..
560961 -        [On 061024 case study medical practice computer access limited
560962 -        even with everything on the computer, people can't find details
560963 -        stored in parts of the computer (software modules) that are not
560964 -        frequently used. ref SDS 0 JD9L
560966 -         ..
560967 -        [On 061112 Doctor Seier found patient history on 061027
560968 -        prepared by lead ER physician, and this assisted diagnosis and
560969 -        treatment for cellulitus relapse on 061112 ref SDS D7 XS5J;
560970 -        patient history of other doctors treating Millie for cellulitus
560971 -        beginning on 061027 under Kaiser's team care practice was not
560972 -        available. ref SDS D7 5L6H
560974 -  ..
560975 - This aligns with understandings from the primary care physician on
560976 - 061020 who was dissappointed that common access to patient medications
560977 - in Kaiser's computer system is not sufficient for coordination between
560978 - doctors in Oncology and staff in the Coagulation Treatment Clinic.
560979 - ref SDS D5 YQ8J  Similar problem occurs with omission of vitals and
560980 - other details in the medical chart that are harder to access on the
560981 - computer, cited the same day on 061020. ref SDS D5 ET5J
560983 -  ..
560984 - Frustrations with computer access problems is shown on 061012 by the
560985 - study on continuing failure of analysts to make correct comparisons
560986 - with prior medical tests for trend analysis to discover emerging
560987 - problems in time for effective treatment. ref SDS D3 2935
560989 -  ..
560990 - Frustrations from incorrect listing of patient medications is shown on
560991 - 061020 by primary care physician omitting treatment with Coumadin for
560992 - pulmonary embolism, prescribed 3 weeks earlier on 061002. ref SDS D5
560993 - SE86
560995 -  ..
560996 - This further aligns with the long delay of over 2 years discovering on
560997 - 060711 that the biopsy on 040419 was tested for status change,
560998 - ref SDS B6 SW7O, but this was not known to the primary care physician
560999 - nor to the surgeon in Kaiser's Oakland office, because the part of
561000 - Kaiser's computer system that shows status change required additional
561001 - training and experience to use.  A long list of similar incidents
561002 - working with Kaiser's computer system, as further reported on 060711,
561003 - ref SDS B6 5Y5J, explains why Kaiser's Team Care practice is essential
561004 - for effective control, collaboration, and coordination in this case
561005 - between Oncology and the Coagulation Treatment Clinic.
561006 -
561007 -
561008 -
561009 -
5611 -

SUBJECTS
Knowledge Management Case Study Computers Bigger Storage Faster Acce

6603 -
660401 -  ..
660402 - Case Study Knolwedge Management Paperless Office Better Storage Access
660403 - Computer Access Storage Knowledge Management Goals Paperless Office
660404 - Paperless Office Everything on Computer Fast Access Knowledge Management
660405 - Knowledge Management Case Study Everything on Computer Fast Access
660406 -
660407 - Research on 011102 describes Knowledge Management begun by Larry
660408 - Prusak with a seminar in 1993 sponsored by IBM and others.  Goals seem
660409 - a bit hazy, other than to sell tickets to seminars.
660410 -
660411 - Knowledge management presents many challenges to increase speed and
660412 - accuracy converting information into useful intelligence, as set out
660413 - on 000307. ref SDS 22 767G
660415 -  ..
660416 - Jack Park noted on 000221 that knowledge management is a pandora's box
660417 - of complexity. ref SDS 21 L58O
660419 -  ..
660420 - Shove All That Paer into Computer Access Remains Problem
660421 -
660422 - Researchers, inventors, engineers, and pundits describe a core goal
660423 - to store everything on the computer, sometimes called the "paperless
660424 - office," for fast and easy access....
660425 -
660426 -    1.  Paperless office efficiencies electronic
660427 -        records management shove all that paper
660428 -        into computer requires subject indexing
660429 -        for precision access using trails of
660430 -        association........................... 880628, ref SDS 1 GA6L
660432 -         ..
660433 -    2.  Intel reporting in Byte magazine
660434 -        featuring advances toward paperless
660435 -        office plans computer technology to
660436 -        integrate all information streams
660437 -        for getting things
660438 -        done.................................. 910418, ref SDS 2 2744
660440 -         ..
660441 -    3.  Artificial Intelligence solve complex
660442 -        problems research article project at
660443 -        Stanford mediators actors agents
660444 -        use fusion to connect disparate data
660445 -        into useful knowledge................. 940603, ref SDS 3 9861
660447 -         ..
660448 -    4.  Desk piled high with documents at US
660449 -        Army Corps of Engineers illustrates
660450 -        self-evident benefits of SDS to shove
660451 -        all that paper into the computer improve
660452 -        productivity with subject index for
660453 -        precision access using organic
660454 -        subject structures.................... 960208, ref SDS 4 8908
660456 -         ..
660457 -    5.  Vanevar Bush article "As we may think,"
660458 -        published by Atlantic Monthly in
660459 -        1945.................................. 960304 ref SDS 5 L47F
660460 -        described vision of paperless office
660461 -        shove all that paper into the
660462 -        computer.............................. 960304 ref SDS 5 H68K
660463 -        fast and easy access to everything on
660464 -        the computer with robust subject indexing
660465 -        and trails of associations linking
660466 -        cause and effect in human
660467 -        thought............................... 960304, ref SDS 5 GX59
660468 -        gives everybody command and control
660469 -        of microcosm finding information
660470 -        in complex history like using
660471 -        an encyclopedia of personal
660472 -        experience............................ 960304, ref SDS 5 BE6L
660474 -         ..
660475 -    6.  Intel demonstration paperless office
660476 -        proposed for Asilomar Conference typical
660477 -        desk piled high with paper sweep onto
660478 -        floor..... ........................... 960315, ref SDS 6 9956
660479 -        and show how all that paper can be
660480 -        shoved into the compter and handled
660481 -        more efficiently with electronic
660482 -        records management proposed by
660483 -        Bush in 1945.......................... 960315, ref SDS 6 9924
660484 -        Intel disclosed this cannot be done
660485 -        with technology used at Intel, so
660486 -        paperless office technology was
660487 -        demonstrated by
660488 -        SDS................................... 960326, ref SDS 7 G450
660490 -         ..
660491 -    7.  Turner Construction Company presented
660492 -        goals using computers for paperless office
660493 -        to store everything that provides
660494 -        efficiencies of electronic
660495 -        precision access...................... 960405, ref SDS 8 7466
660497 -         ..
660498 -    8.  Desk piled high with documents contract
660499 -        manager illustrates requirement for paperless
660500 -        office to shove all the paper into a
660501 -        computer self-evident benefits
660502 -        efficient electronic access
660503 -        discussed with Tom at
660504 -        USACE................................. 960418, ref SDS 9 8840
660506 -         ..
660507 -    9.  Desk piled high with documents contracting
660508 -        officer overwhelms ability to manage daily
660509 -        work solved SDS shove all that paper into
660510 -        the computer paperless office efficiencies
660511 -        electronic records management Tom
660512 -        Bonero USACE.......................... 960916, ref SDS 11 CX3F
660514 -         ..
660515 -   10.  Contract scope document lost in papers
660516 -        piled up on desks, nobody can find anything
660517 -        illustrates requirements for efficiencies
660518 -        electronic records management uisng SDS
660519 -        for paperless office at
660520 -        USACE................................. 960801, ref SDS 10 V176
660522 -         ..
660523 -   11.  Bill Gates (Microsoft) and Larry
660524 -        Ellision (Oracle) proposed "Killer
660525 -        Application" software to improve
660526 -        productivity beyond information
660527 -        technology............................ 970222, ref SDS 12 8529
660529 -         ..
660530 -   12.  Paperless office efficienceis electronic
660531 -        records management SDS enables shoving
660532 -        all the paper piled up on desks into a
660533 -        computer and finding everything with
660534 -        precision access in time to be effective
660535 -        USACE report on contract
660536 -        using SDS............................. 970418, ref SDS 13 4614
660538 -         ..
660539 -   13.  Paperless office using computer
660540 -        networks was presented in an
660541 -        article............................... 971021, ref SDS 14 7400
660543 -         ..
660544 -   14.  Paperless office, and virtual
660545 -        office summarize goals for computers
660546 -        to consolidate storage and
660547 -        increase speed accessing
660548 -        information........................... 980613, ref SDS 15 2070
660550 -         ..
660551 -   15.  Papers piled high on the desk overwhelm
660552 -        people managing daily work everywhere
660553 -        requires paperless office efficiencies
660554 -        of electronic records management reported
660555 -        by Jim Lovo at USACE HQ
660556 -        Washington DC......................... 981218, ref SDS 16 8280
660558 -         ..
660559 -   16.  Paperless office efficiencies of electronic
660560 -        records management slowly becoming reality
660561 -        but denial creates resistance without SDS
660562 -        support for granular subject indexing to
660563 -        provide precision access because nobody
660564 -        can find anything on the computer,
660565 -        Jim Lovo USACE HQ
660566 -        Washington DC......................... 990105, ref SDS 17 2O8G
660568 -         ..
660569 -   17.  SRI proposal prepared by Doug Engelbart
660570 -        in 1962 for implementing the Bush
660571 -        vision 15 years earlier to store
660572 -        everything on the computer for fast
660573 -        electronic access that would organize
660574 -        and link information to augment
660575 -        human intelligence.................... 991222, ref SDS 19 XS9N
660577 -         ..
660578 -   18.  Colloquium at Stanford Doug Engelbart
660579 -        extended team describes Knowledge
660580 -        Management goals for computers to
660581 -        solve world problems with better
660582 -        storage and faster access to
660583 -        everything............................ 000120, ref SDS 20 1215
660585 -         ..
660586 -   19.  Collaboration on Engelbart Colloquium
660587 -        yields goals for computer storage
660588 -        with fast access to solve problems
660589 -        applying open hyperdocument system
660590 -        (OHS) and a dynamic knowledge
660591 -        repository (DKR)...................... 000120, ref SDS 20 2688
660593 -         ..
660594 -   20.  Doug Engelbart 1972 paper defines
660595 -        knowledge workshop to store all
660596 -        information streams to improve
660597 -        traditional documentation with
660598 -        fast and easy electronic access
660599 -        for a paperless office model that
660600 -        augments intelligence................. 000327, ref SDS 23 3971
660602 -         ..
660603 -   21.  Shove all the paper piled up on the
660604 -        desk into the computer paperless office
660605 -        efficiencies electronic records management
660606 -        eliminate clutter information overload
660607 -        objectives Knowledge Management
660608 -        Jack Park SRI
660609 -        project............................... 000623, ref SDS 24 0023
660611 -         ..
660612 -   22.  Engine to organize and find information
660613 -        on the computer was described in a
660614 -        letter from Jack Park................. 000623, ref SDS 24 2915
660616 -         ..
660617 -   23.  Shove all that paper piled high on the
660618 -        desk into the computer paperless office
660619 -        efficiencies electronic records management
660620 -        discussed SDS support for Knowledge
660621 -        Management with Pat Lincoln
660622 -        at SRI................................ 000725, ref SDS 25 I3R5
660624 -         ..
660625 -   24.  Shove all the information in the head,
660626 -        papers on the desk, in filing cabinets
660627 -        into computer for paperless office using
660628 -        networks for Enterprise Management
660629 -        efficient access, discussed with
660630 -        Pat Lincoln SRI....................... 000725, ref SDS 25 A55A
660632 -         ..
660633 -   25.  Paperless office efficiencies of electronic
660634 -        records management demonstrated SDS records
660635 -        shoved all the paper into the computer for
660636 -        precision access required for Knowledge
660637 -        Management of OHS/DKR project at
660638 -        SRI................................... 001017, ref SDS 26 3995
660640 -         ..
660641 -   26.  Paperless office efficiencies electronic
660642 -        records management supported by SDS have
660643 -        not been realized at leading technology
660644 -        firms where nobody can find anything
660645 -        at aerospace firm reported by
660646 -        Gary Johnson.......................... 011222, ref SDS 28 E77G
660648 -         ..
660649 -   27.  Manager of Oncology Department at Kaiser
660650 -        desk piled high with papers did not have
660651 -        enough time for communication with
660652 -        patients.............................. 020402, ref SDS 29 557L
660654 -         ..
660655 -   28.  Bill Gates announces Microsoft new
660656 -        software project to solve problem of
660657 -        information piling up on computers
660658 -        that nobody uses because people
660659 -        cannot find details; Microsoft will
660660 -        build tools with powerful
660661 -        integrated commands................... 021108, ref SDS 34 EFBE
660662 -        that make finding critical details
660663 -        fast and easy......................... 021108, ref SDS 34 EF5I
660665 -         ..
660666 -   29.  Boeing robust, world class knowledge
660667 -        management program credits Kaiser
660668 -        for advanced accomplishments in the
660669 -        field................................. 041013, ref SDS 70 W14V
660671 -         ..
660672 -   30.  Kaiser began computer systems for team
660673 -        care collaboration on diagnosis, treatment
660674 -        prescriptions, capturing a legible record
660675 -        in the medical chart, referrals, and
660676 -        doctor/patient communications, which
660677 -        together implement Knowledge Management
660678 -        for efficient, comprehensive
660679 -        health care........................... 060106, ref SDS B1 FE4I
660680 -        however, initial system limitations
660681 -        paralyze productivity with inaccurate,
660682 -        cursory, and incomplete communication
660683 -        that increases mistakes with
660684 -        the illusion of
660685 -        efficiency............................ 060106, ref SDS B1 1O8F
660687 -  ..
660688 - This record shows a lot of time and money have been invested, and
660689 - yielded considerable progress since 1945 on increasing storage of
660690 - information on computers.
660692 -  ..
660693 - Review on 011003 indicates more progress is needed to improve
660694 - productivity by increasing access to information on computers.
660695 - ref SDS 27 EC5N
660696 -
660697 -
660698 -
660699 -
660700 -
660701 -
6608 -

SUBJECTS
Case Study Computer Access Fails Infrequent Use Paperless Office Eve

7603 -
760401 -  ..
760402 - Case Study Computer Access Prevented by Infrequent Use
760403 - Computer Access Case Study Details Not Readily Available
760404 - Paperless Office Everything on the Computer Reduces Access
760405 -
760406 - Computer systems today have a lot of information which people cannot
760407 - access because infrequent requirements prevent getting training,
760408 - experience, and confidence with skills using technology to find
760409 - critical details in time for performing daily work.
760411 -  ..
760412 - Kaiser illustrates this point.  There is software for a great many
760413 - fields of practice and for managing the organization.  Doctors in
760414 - oncology are highly skilled using the oncology program.  Pharmacists
760415 - are skilled creating and accessing prescriptions for medicine.
760416 - Imaging technicians and medical anlaysts are skilled with records
760417 - management and manipulation of scan files.  Orthopedics, Internal
760418 - medicine, surgery, laboratory doctors and staff are excellent using
760419 - Kaiser's lab management software.  Finance, Engineering, Buildings and
760420 - Grounds, Cafeteria, and other support departments have software tools
760421 - and data for performing their work.  Everything is stored on the
760422 - computer, as planned by Bush, Engelbart, et al. ref SDS 0 UN6L
760424 -  ..
760425 - People learn to quickly access 80% - 90% of what they need.  The other
760426 - 10% - 20% is needed so infrequently and occurs across a broad range
760427 - that skills to access this part cannot be maintained.  Practitioners
760428 - face a dilemma of ignoring a small part of the record as unnecessary
760429 - overkill, or asking someone for help on rare occassions when needed.
760430 - Since problems from ignorance about knowledge of causation are usually
760431 - deferred and often transferred to others, people get comfortable
760432 - saving time, expediting, and avoiding embarrassment by not investing
760433 - time to get the 10% - 20% of information that is not as fast and easy
760434 - to get as the information they normally use.  This comfort level rises
760435 - over time, because there seems to be no harm nor penalty for relying
760436 - on ignorance.
760438 -  ..
760439 - As more information piles up on computers people feel frustrated by
760440 - lack of access, shown in the study on 011003. ref SDS 27 O76L
760441 -
760442 -    1.  People cannot find anything on computer
760443 -        productivity paralyzed overwhelmed
760444 -        by information
760445 -        density............................... 011003, ref SDS 27 EC5N
760447 -         ..
760448 -    2.  Putting everything on the computer
760449 -        creates Pandora's Box of complexity;
760450 -        productivity falls because information
760451 -        density overwhelms limited span of
760452 -        attention preventing people from
760453 -        finding anything on the computer
760454 -        without effective support for
760455 -        context management.................... 011003, ref SDS 27 O76L
760457 -         ..
760458 -    3.  People giving up on using computer to
760459 -        link information into trails of
760460 -        associations called out by Vannevar
760461 -        Bush in 1945 for understanding cause
760462 -        and effect in time to save lives,
760463 -        time, and money....................... 011003, ref SDS 27 SP6G
760465 -         ..
760466 -    4.  Doing everything on the computer requires
760467 -        remembering a lot of commands to do a
760468 -        wide range of tasks; people remember
760469 -        familiar tasks performed frequently,
760470 -        but cannot remember computer commands
760471 -        for tasks that are not needed
760472 -        frequently............................ 021214, ref SDS 35 X24K
760473 -        Infrequency problem denies access
760474 -        to critical information in Kaiser's
760475 -        Coagulation Control
760476 -        unit.................................. 061024, ref SDS 0 TE6M
760478 -  ..
760479 - Work with Kaiser shows...
760480 -
760481 -    5.  Doctor cannot find in the medical chart
760482 -        the schedule for radiation treatments
760483 -        ordered weeks earlier; asks patient
760484 -        for assistance finding health
760485 -        records............................... 020726, ref SDS 33 4Y5I
760487 -         ..
760488 -    6.  Doctor cannot find in medical chart a single
760489 -        record on extensive consultations for 2nd
760490 -        opinions required for case management
760491 -        of Millie's complex patient
760492 -        history............................... 020726, ref SDS 33 MO37
760494 -         ..
760495 -    7.  Doctor cannot find in medical chart results of
760496 -        Tumor Board hearing ordered by the doctor to
760497 -        analyse Millie's complex patient
760498 -        profile............................... 020726, ref SDS 33 WF42
760500 -         ..
760501 -    8.  Doctor could not find in medical chart the
760502 -        date when radiation treatments ended, and
760503 -        in order to analyse cancer
760504 -        relapse............................... 030109, ref SDS 36 GK51
760506 -         ..
760507 -    9.  Doctor cannot find test reports in
760508 -        patient's medical chart on Kaiser's
760509 -        computer system for trend analysis
760510 -        to assess progression of
760511 -        cancer................................ 040318, ref SDS 38 8T8K
760513 -         ..
760514 -   10.  Doctor failed perform follow up examinations
760515 -        for surgery; limited time and computer
760516 -        glitches for automated scheduling prevent
760517 -        doctors from implementing team care
760518 -        requirements.......................... 040419, ref SDS 43 XU75
760520 -         ..
760521 -   11.  Doctor lucky to find in medical chart results
760522 -        of 2nd Tumor Board hearing to analyse rising
760523 -        complexity of patient profile and prescribe
760524 -        treatment in time to be
760525 -        effective............................. 040517, ref SDS 49 4Q65
760527 -         ..
760528 -   12.  Doctor cannot find test reports in
760529 -        patient's medical chart on Kaiser's
760530 -        computer system for, trend analysis
760531 -        to assess progression of
760532 -        cancer................................ 040812, ref SDS 62 LQ5L
760534 -         ..
760535 -   13.  Errors and omissions patient
760536 -        medical chart in Kaiser's
760537 -        computer.............................. 041014, ref SDS 71 T49J
760539 -         ..
760540 -   14.  Doctor cannot find patient history
760541 -        for prescribing treatment that
760542 -        avoids heart damage................... 041230, ref SDS 77 XQ84
760544 -         ..
760545 -   15.  Doctor cannot access patient
760546 -        history for emergency room
760547 -        treatment............................. 050212, ref SDS 81 2Y75
760549 -         ..
760550 -   16.  Doctor asks when pulmonary emboli was
760551 -        diagnosed that requires treatment with
760552 -        anticoagulants (Coumadin) for life in
760553 -        the case of cancer
760554 -        patients.............................. 051007, ref SDS A8 EQ7K
760556 -         ..
760557 -   17.  Nurse cannot find on the computer
760558 -        scope and justification required
760559 -        to process patient for
760560 -        surgery............................... 051021, ref SDS B0 QV4H
760562 -         ..
760563 -   18.  PET scan test 060120 omits
760564 -        comparison prior test because
760565 -        Kaiser cannot find report for
760566 -        test on 051005........................ 060126, ref SDS B2 XF3K
760568 -         ..
760569 -   19.  PET scan test on 060414 fails to
760570 -        make comparison with prior test on
760571 -        on 060120 that reported findings
760572 -        of likely esophagitis; did prior
760573 -        findings simply disappear, get
760574 -        worse, was it a mistake, what
760575 -        happened?............................. 060428, ref SDS B3 OX62
760577 -         ..
760578 -   20.  CT test on 060505 ordered for
760579 -        contrast study with PET scan test
760580 -        on 060414 failed to perform the
760581 -        comparison, and instead compared
760582 -        with a test a year
760583 -        earlier............................... 060523, ref SDS B4 006P
760585 -         ..
760586 -   21.  MRI test on brain omitted comparison
760587 -        with prior test on 020617 because
760588 -        analyst could not find the prior
760589 -        report in Kaiser's computer
760590 -        system................................ 060711, ref SDS B6 QPRT
760592 -         ..
760593 -   22.  Computer access to part of pathology
760594 -        report not familiar to doctor;
760595 -        delayed finding status change analysis
760596 -        for a biopsy performed on 040419
760597 -        for over 2 years...................... 060711, ref SDS B6 5Y5J
760599 -         ..
760600 -   23.  CT test on 060930 ordered comparison
760601 -        with prior test on 041103 that
760602 -        previously discovered pulmonary
760603 -        embolism; analyst ignored request
760604 -        compared only with most recent
760605 -        CT test on 060505 which did not
760606 -        report PE............................. 061012, ref SDS D3 2935
760608 -         ..
760609 -   24.  Despite common access to patient
760610 -        medications with Kaiser's computer
760611 -        system, Oncology pharmacist unaware
760612 -        Oncology doctor prescribed Coumadin
760613 -        3 weeks earlier to treat pulmonary
760614 -        embolism recurrence; asks patient to
760615 -        notify Coagulation Treatment Clinic
760616 -        about balancing dosage with prescription
760617 -        for capecitabine (Xeloda) to maintain
760618 -        effectiveness treating cancer; does
760619 -        not trust computer system
760620 -        to make automatic
760621 -        notification.......................... 061020, ref SDS D4 T650
760623 -         ..
760624 -   25.  Computer common access to patient
760625 -        medications did not notify Coagulation
760626 -        Treatment Clinic patient taking Coumadin
760627 -        for pulmonary embolism also treated
760628 -        with capecitabine (Xeloda) for cancer
760629 -        which interacts with Coumadin and so
760630 -        Coumadin dose must be
760631 -        adjusted.............................. 061020, ref SDS D4 VE57
760633 -         ..
760634 -   26.  Nurses have difficulty accessing
760635 -        data on computers that provide fast
760636 -        easy access because of multiple
760637 -        programs with different commands
760638 -        with overlapping data and
760639 -        functions............................. 061020, ref SDS D4 P18K
760641 -         ..
760642 -   27.  Oncology doctor demonstrates common
760643 -        access to patient medications fast
760644 -        and easy on Kaiser's computer system,
760645 -        frustrated doctors have to personally
760646 -        notify pharmacy and Coagulation
760647 -        Treatment Clinic rather than rely
760648 -        on computer system.................... 061020, ref SDS D5 XA3J
760650 -         ..
760651 -   28.  Fast easy access by some users to
760652 -        one part of computer system may not
760653 -        be fast and easy for others who only
760654 -        need particular data infrequently
760655 -        and so skills with commands
760656 -        dissipates............................ 061020, ref SDS D5 M76I
760658 -         ..
760659 -   29.  Pulmonary embolism infrequent highly
760660 -        lethal disease; symptoms misdiagnosed
760661 -        as side effects of chemotherapy
760662 -        present "wicked problem" because memory
760663 -        and skills using computer system to
760664 -        order CT scan tests dissipate without
760665 -        frequent use; doctors don't remember
760666 -        special steps are needed in the computer
760667 -        to order CT scans that search for
760668 -        pulmonary embolism; after many regular
760669 -        CT scans do not find pulmonary embolism,
760670 -        symptoms are diagnosed as side effects
760671 -        (low blood counts) from chemotherapy;
760672 -        as a result diagnosis of pulmonary
760673 -        embolism mostly occurs by autopsy
760674 -        after death........................... 061020, ref SDS D5 S56G
760676 -         ..
760677 -   30.  Heart disorder from enlarged right
760678 -        ventricle that presents complication
760679 -        for pulmonary embolism overlooked
760680 -        because access in the computer to
760681 -        Findings is not as fast and easy to
760682 -        reviw as "Impressions," and not all
760683 -        findngs are summarized by first
760684 -        impressions........................... 061020, ref SDS D5 VJ4J
760686 -         ..
760687 -   31.  Doctor's report to patient omits
760688 -        details because accessing data on
760689 -        the computer takes training, and
760690 -        experience to gain skills with
760691 -        infrequently used commands that make
760692 -        finding and extracting the omitted
760693 -        data as fast and easy as getting
760694 -        data which the doctor already knows
760695 -        how to find........................... 061020, ref SDS D5 ET5J
760697 -         ..
760698 -   32.  Coagulation Treatment Clinic uses
760699 -        software that requires accessing another
760700 -        part of Kaiser's computer system to
760701 -        coordinate patient treatments; such
760702 -        access requires training, and time for
760703 -        performance; therefore direct notice
760704 -        from the doctor and support staff in
760705 -        Oncology Pharmacy, as occurred on
760706 -        061020, 3 weeks after treatments
760707 -        began, ref SDS D4 VE57, and also by
760708 -        the patient, as encouraged by the
760709 -        pharmacist, ref SDS D4 S69H, assists
760710 -        the Coagulation Treatment Clinic in
760711 -        making an accurate and effective
760712 -        balance of treatments for pulmonary
760713 -        embolism with chemotherapy treatments
760714 -        for cancer using capecitabine
760715 -        (Xeloda) in this
760716 -        case.................................. 061024, ref SDS 0 TZ4I
760717 -
760718 -            [...infrequency using computer commands prevents access to
760719 -            critcial information. ref SDS 0 QJ4G
760721 -         ..
760722 -   33.  Doctor's computer system list of
760723 -        current medications incorrect;
760724 -        progress notes for patient's medical
760725 -        chart missing 3 out of 5 currently
760726 -        prescribed treatments................. 061110, ref SDS D6 SE86
760728 -         ..
760729 -   34.  Doctor Seier found patient history
760730 -        on 061027 prepared by lead ER physician,
760731 -        and this assisted diagnosis and
760732 -        treatment for cellulitus relapse on
760733 -        061112, ref SDS D7 XS5J; patient history
760734 -        of other doctors treating Millie for
760735 -        cellulitus beginning on 061027 under
760736 -        Kaiser's team care practice was not
760737 -        available............................. 061112, ref SDS D7 5L6H
760739 -         ..
760740 -   35.  Kaiser computer system improves
760741 -        prescribing treatments that avoid
760742 -        conflicts which harm patients;
760743 -        doctor prescribes Diflucan to treat
760744 -        rash on left and right
760745 -        breast................................ 061208, ref SDS D8 KW45
760747 -         ..
760748 -   36.  Pulmonary embolism treatment warfarin
760749 -        (Coumadin) conflicts with Diflucan to
760750 -        treat new rash left, right breast;
760751 -        blood test INR rises 6.4 danger zone
760752 -        for hemoraging; blood clot coagulation
760753 -        treatment paused for 3 days;
760754 -        INR update test
760755 -        advanced.............................. 061214, ref SDS D9 HF4O
760757 -         ..
760758 -   37.  Doctor reports CA 15-3 56 "stable"
760759 -        referral coordination fails; doctor
760760 -        patient partnership collaboration fails;
760761 -        mistake occurred because patient history
760762 -        weeks earlier reporting CA 15-3 36 and
760763 -        then only a few days earlier reporting
760764 -        decline to 29, both well below 56, and
760765 -        submitted to the doctor through Kaiser's
760766 -        email system, were not entered into
760767 -        the Kaiser's computer program Medical
760768 -        Chart for patient case
760769 -        management............................ 070516, ref SDS E0 RH9H
760771 -         ..
760772 -   38.  Kaiser needs email with link to find
760773 -        details that make sense of complex
760774 -        patient history in order to solve
760775 -        difficult medical
760776 -        problems.............................. 071006, ref SDS E1 EX8K
760778 -         ..
760779 -   39.  Kaiser case manager invested a few minutes
760780 -        learning to use SDS precision access by
760781 -        clicking links to find context and
760782 -        verify accuracy
760783 -        instantly............................. 071006, ref SDS E1 R57H
760785 -         ..
760786 -   40.  Kaiser cannot find accurate record in
760787 -        the computer system of Kaiser's failure
760788 -        to perform requirements for payment of
760789 -        Millie's treatment in a clinical
760790 -        trial on referral to
760791 -        UCSF.................................. 071030, ref SDS E2 FM6N
760793 -         ..
760794 -   41.  Kaiser plans to request from UCSF computer
760795 -        records on billings supported by Doctor's
760796 -        and Nurses Notes verifying work performed
760797 -        so that the amount claimed by UCSF can
760798 -        be accurately determined and Kaiser can
760799 -        assess the amount owed for payment
760800 -        of Millie's care...................... 071030, ref SDS E2 FM95
760802 -         ..
760803 -   42.  Kaiser requests assistance getting records
760804 -        from UCSF computers required to approve
760805 -        payment to UCSF for medical services
760806 -        performed treating Millie on referral
760807 -        by Kaiser to a clinical study
760808 -        at UCSF............................... 071031, ref SDS E3 TH8L
760810 -         ..
760811 -   43.  Patient offers assistance to Kaiser getting
760812 -        the record of case history missing from
760813 -        documentation to in computers at Kaiser
760814 -        and UCSF needed to resolve dispute between
760815 -        Kaiser and UCSF for payment of Millie's
760816 -        treatment in clinical study at
760817 -        UCSF on referral from
760818 -        Kaiser................................ 071101, ref SDS E4 2U3J
760820 -         ..
760821 -   44.  Kaiser reports UCSF has not submitted
760822 -        records promised on patient history that
760823 -        shows accuracy of UCSF billings for
760824 -        medical services treating Millie
760825 -        on clincial trial..................... 071105, ref SDS E5 K36X
760827 -         ..
760828 -   45.  Kaiser reports patient history on Millie's
760829 -        treatment is long and complex finding
760830 -        everything on computer difficult; makes
760831 -        resolution of payment dispute with
760832 -        UCSF difficult to
760833 -        understand............................ 071105, ref SDS E5 K43W
760835 -         ..
760836 -   46.  Patient offers Kaiser assistance applying
760837 -        Kaiser doctor/patient partnership to find,
760838 -        assemble, and understand complex case
760839 -        history which Kaiser cannot get from
760840 -        Kaiser and UCSF
760841 -        computers............................. 071105, ref SDS E5 K44S
760843 -         ..
760844 -   47.  Kaiser reports continuing problems finding
760845 -        only partial and conflicting data in Kaiser's
760846 -        computers and received from UCSF prevents
760847 -        determining amount to pay UCSF for medical
760848 -        services performed on referral
760849 -        from Kaiser........................... 071114, ref SDS E6 NE5P
760851 -         ..
760852 -   48.  Kaiser requests assistance from patient's
760853 -        computer to find case history in Kaiser's
760854 -        computer and requested, but not yet
760855 -        received, from UCSF showing entitlement
760856 -        to payment for medical services
760857 -        treating Millie in clinical trial
760858 -        on referral from
760859 -        UCSF.................................. 071126, ref SDS E8 TH8L
760861 -         ..
760862 -   49.  Kaiser requests from patient data which
760863 -        Kaiser received weeks earlier from CMS
760864 -        on Kaiser's dispute with UCSF on paying
760865 -        for medical services provided by
760866 -        UCSF for Millie on referral
760867 -        from Kaiser........................... 071126, ref SDS E8 H68Y
760869 -         ..
760870 -   50.  Emergency care physician does not have
760871 -        time to find patient history on Kaiser's
760872 -        computer to evaluate scope of current
760873 -        problem; talking seems fast and
760874 -        easy to rely on assumptions from
760875 -        foggy memory of enfeebled
760876 -        patients.............................. 080409, ref SDS E9 PXPW
760878 -         ..
760879 -   51.  Blood tests incorrectly reported stable;
760880 -        collaboration failure referral coordination
760881 -        blood test at UCSF on 080306 sent to Kaiser
760882 -        on 080307 was not evaluated for emergency
760883 -        care at Kaiser on 080409; Kaiser compared
760884 -        blood test on 080409 with data on 071017
760885 -        because nobody entered 6 months of test
760886 -        data in Kaiser computer; if data is
760887 -        not in the computer it does "not
760888 -        exist"................................ 080409, ref SDS E9 439L
760890 -         ..
760891 -   52.  Discharge instructions waived releasing
760892 -        patient from Emergency care because
760893 -        Admissions doctor trained to use computer
760894 -        for admitting patient to hospital does
760895 -        not have skills using computer to discharge
760896 -        patients; nobody available to help
760897 -        the doctor use the
760898 -        computer.............................. 080409, ref SDS E9 F194
760900 -         ..
760901 -   53.  Black Box of confusion ordering
760902 -        medication prescription for Neupogen
760903 -        using Kaiser's computer
760904 -        system................................ 080502, ref SDS F0 NM4J
760906 -         ..
760907 -   54.  Confusion using Kaiser computer causes
760908 -        mistake ordering Neupogen treatments
760909 -        at Kaiser Outpatient
760910 -        Pharmacy.............................. 080609, ref SDS F1 837J
760912 -         ..
760913 -   55.  Confusion using Kaiser computer causes
760914 -        mistake correcting error ordering
760915 -        Neupogen at Kaiser Outpatient
760916 -        Pharmacy.............................. 080609, ref SDS F1 IS47
760918 -         ..
760919 -   56.  Computer in Surgery Department did not
760920 -        notify Coagulation Control Clinic to
760921 -        pause patient's Coumadin treatments
760922 -        for 5 days prior to operation,
760923 -        essential for safe
760924 -        surgery............................... 080707, ref SDS F2 JP7W
760926 -         ..
760927 -   57.  Erroneous schedule core biopsy to evaluate
760928 -        for expanding cancer treatment options.
760929 -        because medical staff did not know how
760930 -        to press Page Down to see work already
760931 -        scheduled............................. 081106, ref SDS F3 PQ9Y
760933 -         ..
760934 -   58.  CT Department staff not aware of doctor's
760935 -        referral to perform test using Power Port
760936 -        for injecting contrast medium, and not
760937 -        aware accessing Power Port scheduled in
760938 -        Infusion Clinic, and requires coordinating
760939 -        support from IS. because of infrequency
760940 -        accessing referral
760941 -        comments.............................. 081229, ref SDS F4 5G3I
760943 -         ..
760944 -   59.  Dentist cannot find in medical chart results
760945 -        implementing 2nd opinion on scope of
760946 -        critical procedcure................... 100325, ref SDS F5 AO5F
760947 -
760948 -
760949 -
760950 -
760951 -
7610 -