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Doc's Progress Notes

Week of April 10, 2000

Last Updated: 4/16/2000 at 10:48 PM PDT

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Monday April 10, 2000

Busy day and now night so far. Two meetings today and an appointment schedule that was full kept me busy all day. I finished dictating about 6:30 tonight then, since I am on call, I had to go admit two patients to the hospital. I finally got home somewhere around 9 PM and got paged four times on the way home from the hospital which takes about ten minutes. I have been answering calls almost nonstop since, with a little break to eat some dinner.

I did come home to find that one of our cats has disappeared. The man who first cleaned up the water damage at our house was back today to do some more work. He evidently left a door open and our social cat got out. The man last saw him outside but did not know that he was strictly an indoor cat who has been declawed and does not know that some animals will hurt him. Stacey and her mother spent several hours going around the neighborhood late this afternoon and tonight but the cat has not been found. My guess is that since he has been gone more than eight hours now and without being able to protect himself he will not return. This was the cat Stacey claimed as her own and it had to happen on the day before her birthday. We will keep praying for his safe return.

God does answer prayer, the wayward cat just came home. Literally, as I was writing the above, I heard a yowl behind me. I turned to look and it was our other cat meowing at the door to the outside. The door is a sliding glass door and on the other side was the lost cat. He seems to be no worse for his adventure. Needless to say, Stacey is a VERY happy girl now and our family is complete once again.

I want to close tonight with a letter about the Community Health Record and my reply. The letter is from Dan Seto and my reply to him is following the letter. Hopefully, I can get some sleep tonight and be ready for Stacey's birthday tomorrow.

-----Original Message-----
From: Dan Seto []
Sent: Monday, April 10, 2000 11:55 AM
Subject: Community Health Records

"My company's vision is that one day the medical record will be a community health record, open to all who need the information to care for the patient as well as the patient themselves. "

Please excuse my ignorance in the subject. But I assume the obverse is also taken care of? By that I mean, "and those who don't have any business seeing a person's health records can not do so?" Maybe I'm paranoid, but I get a little nervous when people start talking about putting health records into a database accessible via the web. All kinds of Bad Things can happen.

On the other hand, having health records available, to a physician in an emergency room, treating a patient they have never seen before can save lives! So I guess I'm just concerened that the benefits must equal or exceed the costs.

Aloha - Dan

Good observations. I don't know all the details since I am not on the team actually developing the CHR (I started in this practice too late to be chosen for it) but the servers that actually store the records are behind firewalls and are accessible from someone outside the company's network computers only by remote access, not a web address. Everything is password protected with access limited by your password and user ID. All users are tracked while in the CHR.

The actual records are only available to health care professionals such as physicians, not nurses or what are referred to as ancillary personnel such as lab techs. Nurses will have access to part of the record but not as much access as they now have to paper charts. It is interesting that people are more worried about the security of their records if they are stored on a computer than they are about their paper chart which I think is much less secure since almost any employee in the office could look at it. They sign an agreement not to but there is no other security.

The ability to share the electronic medical record with medical professionals who have a legitimate reason to examine it is the main benefit of the Community Health Record. As you mentioned, the example of the emergency department physician being able to access all the medical records of a patient, including the medication they are on, may very well be life saving. If not life saving, it should improve the quality of their medical care.

Beyond that, by using other technologies built into this electronic chart, errors can be cut down on. For example, medication errors due to wrong doses, interactions with other drugs, and illegible handwriting should be eliminated by the automatic checking of doses and drug interactions by the software. We should be able to do outcome studies more readily which should lead to better knowledge about how well specific interventions help or hinder people from recovering from acute illnesses or chronic diseases. It will also lend itself to using clinical guidelines of best care during the patient encounter rather than retroactively.

I believe the benefits will far outweigh any risk to patient confidentiality. As I said above, I actually think the medical record will be more secure than it is now. As you would say, YMMV.


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Tuesday April 11, 2000

Stacey did turn twelve today and her cat is still here. No running off today since no door was left open. He has been getting the pick him up and hug him treatment from Stacey for 24 hours now. He will get tired of it and hide so she goes looking for him. Her main party is Saturday, today she got sewing "stuff" along with a sewing machine. Her mother has promised her that when she turned twelve she would get a sewing machine. Now she has one and she is very excited about it.

The beeper went off all night and the calls from outside the hospital were mostly questions about infants. Our group is obviously not doing a good job educating new parents about illness in the first few years of life. I was getting calls after midnight last night asking rudimentary questions about mild coughs and colds. We need to look hard and see if we can find some handbook about infant illnesses that would save us from some of those calls at night. None of us mind true emergency calls at that time of the night but we resent being awakened over and over for questions that should have been asked during the day or could have waited until today.

The patients I did admit last night are all doing well. One went home today and one will go home tomorrow. The other one was an alcoholic who, in a impulsive gesture because his girlfriend would not wake up and talk to him, swallowed a bottle of her pills. He will be OK but will be very drowsy for a day or so. He will now have to have a psychiatric evaluation also before he can go home.

Stephen got his drivers handbook for Washington State today. He can study it and once he passes the written test can get a learner's permit and drive with one of us in the car with him. I am so looking forward to our auto insurance going up. Typical for Stephen, he thinks he can pass the test the first day he gets the book. We'll put off him taking the test for a little while.

Finally, I want to close with a question. Some of the discussion at the meeting this weekend was about using e-mail to communicate with patients. Since there are some inherent security questions about e-mail, I wonder what my readers think about communicating with their physicians using e-mail. From the physician side, I know I enjoy doing it since it allows me to answer questions at any time that is convenient for me and to document that exchange by simply printing it out. I encourage you to e-mail me here with your opinions. As always, if you do not want them published, please mark the e-mail as private. See you tomorrow...

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Wednesday April 12, 2000

Where did the day go? This was my day off and I am just now getting to update this site. Let me try and reconstruct the day.

First, I went to the hospital and office this morning around 9 AM. This was after talking to the workers pulling up the floor in our bathroom to replace it and shampooing the upstairs carpet. On the way I went by the post office and dropped Delanae's computer off at the computer repair shop who had replaced a hard drive before. Okay, I admit it, I can't repair my own computers like the rest of those Daynoters can. I have to depend on other professionals who have had time to learn what I have not had time to study. After delivering the computer, I ended up at the hospital and office doing some paperwork and signing some medical records, I went and bought fertilizer for the garden spot. Then, I got my hair cut and following that I came home and ate lunch. After lunch, I spread fertilizer on the garden spot and tilled it again to get it ready to plant Saturday morning.

I then took some time to read various daily journals on the Web; you know the group, those Daynoters while waiting for them to finish with the carpets and for Stacey to get home on the bus. When she was not home 45 minutes after her usual time I called her mother who proceeded to tell me that she was not going to be home on the bus this afternoon as she had auditions for a talent show and Delanae had forgotten to tell me that. So, I then went and ran and got home in time to have a conversation about my day with Delanae, take a shower, and eat. Then, it was off to a community wide worship service. I am now home for the rest of the night and telling you why I did not get this journal updated until now. I still have my lunch to make for tomorrow and clothes to find to wear tomorrow. I used to wait and pick out the clothes for that day that morning but I have no imagination early in the morning and I would end up trying to wear the same clothes every day of the week.

So, again, why have I not been able to update this journal page until now. The simple answer is that I didn't take the time to do it earlier today. Actually, I just didn't have the motivation, rather I wanted to be outside since it was a beautiful partly sunny day her today. Now, you know the truth, I picked being outside over writing this update earlier.

In other news, Aloha Dan has a review of an interesting article about healthcare in the future on his website here. It talked about some technology that was demonstrated at the conference this past Saturday. Specifically, video conferencing from the patient's home to the physician's office was demonstrated. Yes, the technology is available now but prohibitively expensive for everyone involved not to mention there is a lack of broad bandwidth access for the majority of patients and physicians. Hopefully, that will change in the very near future but remains a problem at the present and is one reason why such technology has not delivered on its promise yet and is not being widely used. Our company uses real-time video conferencing to conduct cancer conferences between here and Ketchikan, Alaska. Ketchikan does not have an oncologist so one of our oncologists does some consultations by video conferencing from our hospital here.

The article also mentioned a Smart Card that patients could carry with all their medical records encoded on it so they could be shared with a physician anywhere. This is an interesting concept but it will take a lot of work to come up with a universal format for those records and to get the technology needed to read those records in every healthcare facility in this country. Believe it or not, not every physician can use a computer and some still don't have one in their office. Plus, if someone stole your card, how would you replace those records? If they are kept in any database on a computer for backup, then that would invite hackers to break in which is the very thing that carrying around your records is supposed to prevent. Also, how do you limit access to your records by a clerical person if you just hand them your card? Many questions still to be answered and I am too tired now to think about them anymore.

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Thursday April 13, 2000

Another short night, and day for that matter. Today was very busy and then I went to a meeting sponsored by my malpractice insurance company. In this state, physicians are required to complete a certain number of hours of continuing medical education in risk management every year. Our malpractice insurance company provides those programs and tonight's was here in Longview. They discussed the most common types of malpractice cases and how to prevent them by documenting well and fully discussing plans with patients. These are common sense things but they also talked about tracking systems to be sure labs or important consults don't get lost in the everyday hubbub of a medical office. Again, things that are rudimentary but need to be re-emphasized every so often.

After that meeting was over, I went to pick up Stephen at one of the local high schools. There, for a senior project, a student had put together a band with some of the community musicians such as a bass player from our church and a drummer from another church. They were playing Eric Clapton songs and the ones I heard were very good. It was a benefit for a Children's Hospital in Portland and the auditorium was packed. The kids were really enjoying songs that I had listened to when I was growing up. We then talked about some of the songs on the way home and it struck me that I was Stephen's age when I first heard some of those songs. What a long, strange trip this life is.

Sorry the update is so short tonight. I have an early day again tomorrow and must get my lunch made tonight. See you tomorrow.....

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Friday April 14, 2000

No update yet.

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Saturday April 15, 2000

What! This is Saturday. Where did yesterday go?! Let's see now, what did I do on Friday. First, I had my usual Friday morning meeting to review charts to see if referrals are appropriate. The morning office was fairly routine but steady. Then, Delanae came by to visit and I took her to lunch at the hospital cafeteria (ok now, it has some ambiance). Now it is coming back to me. After lunch is when everything went south.

First, my physical scheduled for 1:30 wasn't there so we actually got started at 2 PM. But, the patient at 1:30 WAS actually in the waiting room, it was just that his chart got misplaced so at 2:30 the receptionist comes back to say that my 1:30 physical was here on time and what was she supposed to do. Well, now I had told two people to come in and I would see them as double appointments during the afternoon. Now, I had a physical to also shoehorn in somewhere. Shoehorn him in we did and we made it through the afternoon apologizing to everyone for any wait they had. The man who was supposed to be seen at 1:30 was very understanding about the mixup and left happy because I apologized to him for the mixup and was truthful with him about what happened. He also seemed to appreciate that the receptionist also went to explain to him what she had done.

We finally finish with patients around 5:30 but phone calls, refills, and dictating charts (I did not have time to dictate between patients, otherwise we would have been farther behind) took until about 6:45. I got home around 7 to find that Delanae was ill and Stacey with her two friends who were spending the night and Stephen are expecting me to take them bowling at 7. I manage to change my shirt then turn around and head back out the door to take them bowling. We met a group from our church at the bowling alley and me and five kids bowl on one lane for a couple of hours. I manage to beat all the kids although I had to make a major move in the last three frames of the last game to beat my son who managed to choke when he had a big lead (Delanae doesn't know about this yet so don't tell her). Stacey and her friends had fun and Stacey managed to bowl a couple of strikes.

After that, we came home and I finally got to eat some dinner. Delanae, Stephen, and I then played couch potatoes and watched a movie that did not end until a little after midnight so that is where Friday went and why I did not post anything yesterday. Stacey and her two friends are still sleeping this morning and probably will until noon unless the lure of her new Nintendo 64 wakes them up earlier. This afternoon is her birthday party and then her birthday will officially be over and we can return to our normal life of getting this house back together and the garden spot planted. It has rained hard now for two days and is supposed to rain today so I don't know if the garden will get planted today, it may wait until tomorrow. Original plans were to take Delanae to see the tulip fields near Woodburne, Oregon tomorrow but with the rain expected we may wait until next Saturday. The final call will be up to Delanae, her birthday is this coming Friday.

There, now I have something up today. I may have another update later today, will just see how the day unfolds. It is raining at the present time and what is left of the grass in the back yard is very high and needs mowing if it will stop raining long enough. Typical Washington State springtime weather, at least on the west side of the Cascades.

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Sunday April 16, 2000

No second update yesterday. The birthday party went well with all eight of the girls making necklaces or bracelets out of hemp and beads. The party was held at a local crafts "superstore" where they provide the tables, napkins, plates, and cups as well as a person to teach the kids how to make something during a two hour period. We had to furnish the cake and drinks but did not have to entertain the kids. They all went home with something they had made themselves. Two of the children were not picked up on time, as a matter of fact, we had to wait about 45 minutes after the party ended for them to be picked up. The mother said she got to talking on the telephone and lost track of time.

The garden spot is pretty well planted now. I have planted four rows of corn, two rows each of Oregon pod peas and green beans, one row of lettuce, one row of tomato seeds (both cherry and regular), 1/2 row of broccoli, 1/2 row of carrots, cucumbers, squash, and asparagus. I may put out a few tomato plants later this week and also may put out some cauliflower. Stacey wants to plant some celery somewhere also since it is the only green vegetable she will really eat. This is our first year to try a garden so we will see how much really comes up.

Stephen and I got most of the lawn mowed today (after some complaining from Stephen who thought that just because his friend was here this afternoon that he would not have to do any work). Tonight, I put together Delanae's birthday present which is a swing. She picked it out so she got what she wanted for her birthday. Also, we are going to see the tulips next Saturday which will be another birthday present for her (her birthday is Friday the 21st). We are going to try and go to the Skagit Valley rather than Woodburne, Oregon just to go somewhere different this year.

That's about it for tonight. I still have to do my weekly full system backup then it is time for bed. See you tomorrow.....

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