Clozapine RX 4 Ecstasy: 2018

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[SELFIE IN BLACK SHIRT]

2018 Selfie - Keith Torkelson

Primary Source Document(s)

11_CBC_FY_2017_18_18082101_Summary Report

Blog

Clozapine RX 4 Ecstasy

Blogger Title

Complete Blood Count (CBC) Component of Clozapine Management – By Keith Torkelson MS (Pathology)

Google Plus Information

Monthly CBC Routinely Showing Marked Improvement – 2012-2018 – Clozapine Cost Containment – Errors by Chester D Mojica MD – Central City Community Health Center (CCCHC)

A CBC Driven Progress Report

Abstract – Executive Summary

The subject of this report is Keith E Torkelson, MS. The topic of this report is the monthly Complete Blood Count (CBC) lab work required for prescribing Clozapine in the United States of America (USA). Keith E Torkelson, MS is the principal about Mentalation Solutions Group (MSG). This paper is the product of us here at MSG. Yearly we publish our findings in a report we call our Christmas Report Card (CRC). This report about CBCs is just one of this year’s topics selected for our 2018 overall report. The data window for the CBCs described in this report is from August 8, 2017 till September 18, 2018. We closed our CBC data collection with the completion of Keith’s yearly physical (September 27, 2018). This paper details the clinical and clerical processes associated with a routine CBC. For the purpose of sampling (capturing) the CBC experience MSG created an assessment tool. We call our assessment tool our Vitals Plus Instrument. It was built upon the online MD Rating Service Vitals’ standard instrument. We extended Vitals 7 Items to 25 Items.

Of Complete Blood Counts (CBCs)

Our CBC blood collection services are performed at Central City Community Health Center (CCCHC) in Garden Grove California. The first CBC in this year’s series was on August 8, 2017. For that encounter we awarded our CBC Team 85.7%. 100.0% would be a perfect encounter. The last or final CBC in this series was on September 18, 2018. For that encounter we awarded our CBC team 76.2%. The data points in-between are non-linear. As we retrieve and re-evaluate a year’s worth of CBC related records we discover some calculation errors. In hindsight our Calculation Error Rate (CEE) is approximately 1/16 (+/- 2). We briefly address incidences of being called in over ½ late. We were called in late on over half of the occasions. For the lab results data we now use Quest Diagnostics directly via their Patient Portal MyQuest. We assume all data we get directly from Quest is always true and correct. Notice we SKIP some months in collecting detailed information. We do this because our Confidence in the CBC Team has grown justifiably. Near the end we include our Dynamic Cast of Characters (DCC). In one year there has been substantial turnover in our CBC Team. One element that would greatly assist our CBC Team @ Central City Community Health Center (CCCHC) is the re-implementation of routine Satisfaction Surveys. CCCHC abandoned Satisfaction Surveys somewhere back in 2014 or even earlier. On this we dovetail an emerging problem.

Emerging Problem – PCP Error Rate

Today September 27, 2018 at 1030AM we had our routine yearly physical with our CCCHC PCP, Chester D Mojica (CDM). We were prepared and confident that the only issue we have is COPD. He discussed some problems. We will address two only. CDM stated that our last A1c was 6.1. The lab running the CBC test, Quest Diagnostics, reported our last A1c is 5.3. 5.3 (% of Total Hemoglobin) is well within the normal range. Doctor Mojica indicated our A1c is a problem warranting some lifestyle restrictions. He says we are pre-diabetic! Just to cover two Ostrich Eggs with one stone, we will share our A1c as reported by Quest in whom we trust. Doctor Mojica also indicated that we were overweight. The day of the exam the nurse weighed us at 142 Pounds. We are 5’ 7-1/2” tall.

Partners

List of Tables – Matrices – Figures

Matrix – CCCHC Mediated CBC Ledger – Part 1 of 3 – 201708-201712

Matrix – CCCHC Mediated CBC Ledger - Part 2 of 3 – 201801-201802

Matrix – CCCHC Mediated CBC Ledger - Part 3 of 3 – 201803-201809

Figures – Physical Exam – A1c Results [LAST MINUTE]

Charting for the Record – 2018 - Database (MSG) – Metadata

Charting for the Record – 2017 - Database (MSG) – Metadata

Matrix - CBC Savings – CALC – Last Reviewed: 20180928-F:

Table CBC Tracking Information – Results

Figures – CBC Results

Matrix – Rubric for MSG Binary Scoring

Table - Cast of Characters – Centered About CBC (2017-2018)

Table - Vitals-Plus Method – Combined Scores

Table - Vitals-Plus Method – Vitals Standard Elements

Table - Vitals-Plus Method – Vitals-Plus Elements – Part 1 f 2

Table - Vitals-Plus Method – Vitals-Plus Elements – Part 2 f 2

Table - Vitals-Plus Method – Vitals-Plus Elements – Combined Parts 1 and 2

Matrix – CCCHC Mediated CBC Ledger – Part 1 of 3 – 201708-201712

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Appt Date	Vitals	Vitals Plus	Vitals + Plus	Note(s) & Scheduling
-
20170808-TU-CBC	4.5/5 90%	13.5/16 84.4%	18.0/21 85.7%	Baseline for 2017/18 Cycle Weight = 150 lbs
20170905-TU-CBC	4.5/5 90%	13.5/16 84.4%	18.0/21 85.7%	Jocelyn
20171003-TU-CBC			SKIP
20171010-TU Yearly Physical				2017 Physical Exam CDM Weight = 147 lbs
20171031-TU-CBC	5.0/5 100%	14.0/15 93.3%	19.0/20 95.0%
20171128-TU-CBC				Rescheduled
20171129-W-CBC	5.0/5 100%	14.0/15 93.3%	19.0/20 95.0%

20171227-W-CBC	5.0/5 100%	14.0/15 93.3%	19.0/20 95.0%	Weight = 144 lbs
2017-END

Matrix – CCCHC Mediated CBC Ledger - Part 1 of 3 – 201708-201712

Last Reviewed: 20180928-F:

Sources of Intel

At-A-Glance Planners (2017 & 2018)

Wall Calendar

Vitals Plus Data Sheets

Appointment “Cards”

MSG Database

Other PRN

Matrix – CCCHC Mediated CBC Ledger - Part 2 of 3 – 201801-201802


Appt Date	Vitals	Vitals Plus	Vitals + Plus	Note(s) & Scheduling
-

20180124-W-CBC	5.0/5 100%	14.0/15 93.3%	19.0/20 95.0%	Gabby Weight = 145
20180209-F-IFL	4.0/5 80%	6.0/15 40.0%	10.0/20 50%
20180221-W-CBC	5.0/5 100%	14.0/15 93.3%	19.0/20 95.0%	Gabby Weight = 142

Matrix – CCCHC Mediated CBC Ledger - Part 2 of 3 – 201801-201802

Last Reviewed: 20180928-F:

Matrix – CCCHC Mediated CBC Ledger - Part 3 of 3 – 201803-201809

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Appt Date	Vitals	Vitals Plus	Vitals + Plus	Note(s) & Scheduling
-
20180307-W-CBC			SKIP	Jocelyn

20180404-W-CBC	5.5/6 91.7%	13/14 92.9%	18.5/20 92.5%	Gabby No BP or TEMP Self Weight = 142
-
20180502-W-CBC			SKIP	Jocelyn
20180529-TU-CBC	3.0/5 60.0%	9.5/15 63.3%	12.5/20 62.5%	Beatrice (*) What’s up with this? Self Weight = 145
20180626-TU-CBC			SKIP	Team Martha
20180724-TU-CBC			SKIP	Rebecca
20180810-Full Lab				Source of A1c Result 5.3 % of Total Hbg
20180821-TU-CBC			SKIP	No Note
20180918-TU-CBC	4/5 80.0%	14.0/16 87.5%	18.0/21 85.7%	Team Martha QC – ERRORS FOUND with US
20180918-TU-ERR Correction	4/5 80.0%	12.0/16 75.0%	16.0/21 76.2%	ReCALC
-
20180927-TH-PHYS			Separate Report Pending	Yearly cycle ends Our PCP made some remarkable errors Weight = 142
-

Matrix – CCCHC Mediated CBC Ledger - Part 3 of 3 – 201803-201809

Last Reviewed: 20180928-F:

Gabby V Beatrice (Beatriz)

In the table(s) above we reference both Gabby and Beatrice. Early in 2018 we tried to figure out the Clerical Counter Dynamic (CCD). We came to believe that Gabby was user friendly and Beatrice too serious. For our last six CBC appointments or so Gabby has not been about Central City anywhere. (*) For our May 29, 2018 CBC we noticed that Beatrice has become user friendly. Beatrice has sustained this change.

½ Late: What would you do?

We ask ourselves what is the appropriate behavior when your practitioner's team has not called you in and are running behind over a half hour. Some members in the waiting room just get up and leave. For us we do not have just leaving as an option. At about the ½ late point we begin to stress or feel a bit anxious. Anxiety is what we are being treated for. So you go to the doctor and the tardy timetable aggravates one’s conditions. One of the issues is: They do not appropriately perceive we consumers have things to do. We cannot always allocate a ½ day just to getting our monthly CBC run.

Improvement Bonus & Decreased Vigilance

When the CBC Team demonstrated substantial improvement we used to award them 1.0 point for an improvement bonus. We also gave the team member most deserving a, thumbs up, reward. In the data above notice we SKIPPED assessing every monthly transaction. We were able to skip because our confidence has grown across the CBC delivery team.

Physical Snag

We picked our Yearly Physical as the date to close this year’s CBC Report. We had our Physical yesterday September 27, 2018. It was supposed to be our best Physical yet for the term 2012-2018. Our doctor Chester D Mojica made some errors. We will include just two of his errors below: A1c error and weight error. This paragraph is part of our preparation to address Dr. Mojica’s errors at our next routing CBC in October (2018).

[INSERT PHYSICAL NOTICE]

Signage About Central City

Table – CaseNotes – Needing Correction – Physical with Chester D Mojica MD

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Declarations	CDM	Actual
-
Weight	Says We’ve gained weight	20180927-TH 142 lbs
A1c	Says A1c is 6.1 and problematic	20180809 Quest says A1c = 5.3
-

Table – CaseNotes – Needing Correction – Encounter Physical – 20180927-TH – Last Reviewed: 20180928-F:

Link To Celery Diet

Celery Diet (Includes Data on Weight)

Double XX – Nutrition – Celery Diet – Digital Appointment – By Keith Torkelson (2018)

Blood Glucose Level & Celery Diet 2018/09/

Date Chartered = 9/6/18

[INSERT ACTUAL SCALE MEASUREMENT]

Sample Actual Weight Measurement for Keith Torkelson (2018)

Keith is Five Foot Seven with a 30" Waist

Figures – Physical Exam – A1c Results

Source Document

Assess_Vitals_18092704_CDM_Physical

[INSERT A1C RESULTS]

Results From 8/9/2018

Our Latest A1c

Results From 8/9/2018

Our Latest A1c

Charting for the Record - 2018

Database (MSG) – Metadata

Charting for the Record - 2017

Database (MSG) – Metadata

Potential For Savings - CBC Cost Containment

About two years ago (2016) we were discussing cost containment about Behavioral Health Services (BHSs) with our Behavioral Health Doctor (BHD). His name was Bum Soo Lee MD. We both agreed that BHSs were quite pricey. One of the components that we thought might save the systems such as CMS was the monthly Complete Blood Count (CBC) work associated with prescribing Clozapine. We agreed that it might be wise for public health to intervene and dictate that only once every other month is now indicated. We here at MSG envisioned the savings at around one-hundred million per year. Below we finally got around to approximating potential saving about Clozapine related CBC testing. We are quite surprised.

Matrix - CBC Savings – CALC – Last Reviewed: 20180928-F:

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	# With Schizophrenia (Americans)	Fraction Prescribed Clozapine	# On Clozapine
	3,200,000	0.04	128,000
-
	# On Clozapine -	Cost/CBC	CBC expenses
	128,000	$100 Per CBC	12,800,000 Per Month
-
	Cost per Month	CBC/Year	CBC Cost per Year
	12,800,000	12	153,800,000

	Cost per Month	CBC/Year	Potential Savings per Year
	12,800,000	6	76,800,000
-

Matrix - CBC Savings – CALC – Last Reviewed: 20180928-F:

Approximations

We used the following information for our CBC savings approximations. Unfortunately the Diagnostic Labs will be hit with less CBC related income.

Source

http://www.treatmentadvocacycenter.org/fixing-the-system/features-and-news/3613-research-weekly-clozapine-by-the-numbers

FYI - Number of People with Schizophrenia in the US?

“Worldwide about 1 percent of the population is diagnosed with schizophrenia, and approximately 1.2% of Americans (3.2 million) have the disorder. About 1.5 million people will be diagnosed with schizophrenia this year around the world.”

Source Report – Reprint

MSG_Psychiatry_Referral_Bera_18032002_Part-IIIB

Vignette - Here Is The News! – Clozapine Risk & Contingency

As we write this paragraph it is June 26, 2018. We will carry this paragraph through multiple publications because we find it important. There is an issue with our primary medication, Clozapine, for which we have no tangible fix. Today while at the clinic for our routine Complete Blood Count (CBC) work we overheard another consumer, Sam I Am, sharing in the waiting room. Sam reports that after being rather stable on Brand-name Clozaril (Generic Clozapine) for over twenty (20) years his CBC lab values converted. In other words he is now suffering low numbers of White Blood Cells (WBCs). Most likely it is his Neutrophils of the WBC family that are low. This is termed Neutropenia. Bad news! Neutropenia indicates that you cannot be prescribed Clozaril (Clozapine) anymore. We will leave the “doctor” anonymous. In response “doctor” stops Sam I Am’s Clozaril cold turkey while he waits for a second lab to confirm the problem. Sam reports he has not been sleeping because Clozaril is essential for a full restful night of sleep. When we left him about 11am we wished him luck because the lab and his Clozaril disposition are pending. Sam is quite bright when it comes to how much he has learned as a Behavioral Health Consumer (BHC). He said that a relative said why not reduce the Clozaril rather than take it away cold turkey. Further his relative advices that on a reduced dose he might get the benefit of sleep and get his WBC number(s) up again. For us, also on Clozapine, we have worried quite a bit about a life without Clozapine. Actually in 2012 we suffered catastrophic losses and Clozapine was in the scenario. As Sam puts it Clozaril was a real game changer for him. We agree, for us Clozapine has been a game changer. In the next paper we will address what we call our Clozapine Contingencies. This puzzle should be printed and shared with Medical students in their Pharmacology Course because good “fixes” are pending.

Table CBC Tracking Information - Results

-
Field	Detail	Note
-
Client	Keith Torkelson
Collection Lab	Central City
Referrer	Rimal B Bera MD
Testing Lab	Quest Diagnostics
Date(s) of Interest	20180208 - 20180917	9 CBCs
-

Table CBC Tracking Information – Results

Results for Keith Torkelson

From 8/9/18

Time Series Results for Keith Torkelson

White Blood Cell Count

From 8/9/18

How is it a fuss?

We will not address why CBCs are a fuss for us in much detail. Basically we have been on Clozapine since 2006. Since that time we have only suffered one gap about our monthly Clozapine prescription. Clozapine has been associated with damaging the consumers’ blood cell system. CBCs measure the blood cell system. If there is drop in ones polynuclear cells (PMNs) AKA Neutrophils the consumer’s health may deteriorate. CBC exams are required to support the risk mitigation efforts while the consumer is dependent on daily Clozapine. Our elevated PMNs might be translated as slightly protective. Without monthly and favorable values as reported by CBC our or any pharmacy will not fill our prescription. Historically (one incidence) without Clozapine we will end up in the hospital within 72 hours.

[INSERT VITAL PLUS ASSESSMENT]

Associated Document > Assess_Vitals_18091802_CBC QC Cleaned

Scoring

Assessment_Scoring_17121201_Rules V2018

20171212 - Assessment Scoring

We routinely apply a few types of scoring methods. We describe them as: Binary, Stars, and Percentiles.

Matrix – Rubric for MSG Binary Scoring

-
Nature	Range	Best	QUAL
-
Binary	0.00 \| 0.50 \| 1.00	1.00	No \| SoSo \| Yes Options 0.25 – 0.75 PRN
Stars	0.0 – 5.0	5.0	Example Compare with CMS Stars Scores
Percentile	000.0 – 100.0	100.0	Inter-assessment comparisons and migrations (Portability) Fidelity with Education Standards
-

Matrix – Rubric for MSG Binary Scoring – Last Updated: 20180810-F:

Binary Scoring Method (BSM)

P-Pass (1.0) | So-So (0.5) | F-Fail (0.0)

Note: Example of Share - Clozapine & BND 1.5

Legacy Publication

Keith Torkelson – Awarded Provider High Scores (201711)

Post Title

MSG Vitals-Plus Assessment Instrument – Applied to Central City Community Health Center – By KE Torkelson (MS-Pathology) (MSG, 2017) - Satisfaction Survey for Health and Human Services – Context of Annual Christmas Report Card (MSG, 2017).

Central City Vitals Plus Scores 2017/11

CBC Centered Encounter Notes

Site = Central City Community Health Center - Garden Grove

Table - Cast of Characters – Centered About CBC (2017-2018)

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Character	Clerical & E_Clerical	Clinical	Note
-
Anon MD		X	Should have business cards
Anon PA		X	Should have business cards
Beatrice/Beatriz	X		Vast improvement (2018)
Bethany	X		Possibly maternity leave
Bum Soo Lee MD	X	X	Behavioral Health Doctor – 2012-2017
Chester D Mojica MD	X	X	New issues at Physical
Cynthia	X
Gabby	X		Looks like she has moved on
Jeff Gibbs			Unproductive partner Investigating how to kill the association
Jocelyn	X
Martha	X	X	Most reliable
Others PRN		X
Rimal B Bera	X	X	New 2018
-

Table - Cast of Characters – Centered About CBC (2017-2018)

Last Reviewed: 20180928-F:

Measures of Quality & Satisfaction

Table - Vitals-Plus Method – Combined Scores

Measures of Quality and Satisfaction – Process Clozapine Related CBC

Date of Encounter: 20180918-TU:

-
		Clinical	Clerical & Scheduling
	Patient Ratings Service Experience Element	20180918 (TU) CBC Team	Appt Made 20180821-TU By Team Martha For: 20180918-TU	Sample CALC
-
	Items = 7	4/5 80.0%	4/5 80%	Sum/# Scored 4.5/5 %
-
	Items = 18	12.0/16 75.0%	13.0/16 81.3%	Sum/ # Scored 13.5/15 %
-
	Items = 25 (CALC)	16.0/21 76.2%	17.0/21 82.0%	Sum/# Scored 18.0/20 %
-
	Star Equivalents (5.0 Stars is the Best)	3.8	4.0	4.50
	With Bonus IF – THEN Impression Add 1 to Numerator	Stayed	Stayed	(18+1)/20 * 100 = 95.0%
-

Indications of Satisfaction: Actual Data from 20180918-TU: Encounters (CBC and Scheduling) – Last Reviewed: 20180928-F:

Table - Vitals-Plus Method – Vitals Standard Elements

Measures of Quality and Satisfaction – Process Clozapine Related CBC

Date of Encounter: 20180918-TU:

-
		Clinical	Clerical & Scheduling
Item #	Patient Ratings Service Element	20180918 (TU) CBC Team	Appt Made 20180821-TU By Team Martha For: 20180918-TU	Sample CALC
-
01	Ease of Appointment	1.0	1.0	1.0
02	Promptness	0.0	0.0	1.0
03	Courteous Staff	1.0	1.0	1.0
04	Accurate Diagnosis	NA	NA	X
05	Bedside Manner	1.0	1.0	1.0
06	Spends Time w Me	1.0	1.0	0.5
07	Follows Up After Visit	NA	NA	X
-
	Items = 7 (MAX)	4/5 80.0%	4/5 80%	Sum/#Scored 5.0/5*100
	Star Equivalents =	4	4
-

Indications of Satisfaction: Actual Data from 20180918-TU: Encounters (CBC and Scheduling) – Last Reviewed: 20180928-F:

Table - Vitals-Plus Method – Vitals-Plus Elements – Part 1 f 2

Measures of Quality and Satisfaction – Process Clozapine Related CBC

Date of Encounter: 20180918-TU:

-
		Clinical	Clerical & Scheduling
Item #	Patient Ratings Service Element	20180918 (TU) CBC Team	Appt Made 20180821-TU By Team Martha For: 20180918-TU	Sample CALC
-
01	Accountability	1.0	1.0	1.0
02	Clozapine Awareness	1.0	0.5	1.0
03	Doctor’s Orders	1.0	1.0	0.5
04	Error Free	1.0	1.0	1.0
05	Guidance	1.0	1.0	X
06	Paper Trail (E-Paper Trail)	0.0	1.0	1.0
07	Pharmacy	NA	NA	X
08	Phone Support	NA	NA	X
09	Promotes Recovery	1.0	1.0	1.0
10	Satisfaction Survey Offered	0.0	0.0	0.0
-
		6.0/8	6.5/8
		Carry	Carry	Stayed
-

Indications of Satisfaction: Actual Data from 20180918-TU: Encounters (CBC and Scheduling) – Last Reviewed: 20180928-F:

Table - Vitals-Plus Method – Vitals-Plus Elements – Part 2 f 2

Measures of Quality and Satisfaction – Process Clozapine Related CBC

Date of Encounter: 20180918-TU:

-
		Clinical	Clerical & Scheduling
Item #	Patient Ratings Service Element	20180918 (TU) CBC Team	Appt Made 20180821-TU By Team Martha For: 20180918-TU	Sample CALC
-
11	Scheduling	1.0	0.5	1.0
12	Situational Awareness	1.0	0.0	1.0
13	Timeliness	1.0	1.0	1.0
14	TimeSpent	1.0	0.0	1.0
15	Values Consumer (Member-Account)	1.0	1.0	1.0
16	Values Consumers Time	1.0	0.5	1.0
17	Healthful Environment	1.0	1.0	1.0
18	Agent of Remedy	1.0	1.0	1.0
-
		8.0/8	5.0/8
		Carry	Carry
-

Indications of Satisfaction: Actual Data from 20180918-TU: Encounters (CBC and Scheduling) – Last Reviewed: 20180928-F:

Table - Vitals-Plus Method – Vitals-Plus Elements – Combined Parts 1 and 2

Measures of Quality and Satisfaction – Process Clozapine Related CBC

Calculations

Date of Encounter: 20180918-TU:

[ERRORS FOUND 20180926 Recalculations]

-
		Clinical	Clerical & Scheduling
Item #	Patient Ratings Service Element	20180918 (TU) CBC Team	Appt Made 20180821-TU By Team Martha For: 20180918-TU	Sample CALC
-
	Plus Part 1	6.0/8	6.5/8	Carried Forward
	Plus Part 2	6.0/8	6.5/8	Carried Forward
-
	Plus Parts 1 & 2 Items = 18 (MAX)	12.0/16 75.0%	13.0/16 81.3%	Sum/# Scored 13.5/15*100
	Star Equivalents =	3.8	4.1
	Impressions - Sustained or Improvement Bonus			1.0
-

Vitals-Plus – Last Revision: 20170926-TU: (Theta Version) Indications of Satisfaction: Actual Data from 20180918-TU: Encounters (CBC and Scheduling) – Last Reviewed: 20180928-F:

This is the End

Images At the End