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The recent sacking of Peter Gøtzsche from the Cochrane Collaboration Board raised strong responses and highlights the neglected issue about priorities-maintaining the reputation of the organization or vigorously debating the merits of scientific approaches to find answers to complex problems? The Cochrane approach hales the randomized trial (RCT) as the gold standard research approach and affirms that meta-analysis provides the ultimate proof (or platinum standard) to settle contentious issues confronting the clinician. However, most published medical research is wrong, and critics coined the acronym GIGO (garbage in, garbage out) as a meme to highlight the risks of blind faith in the hyped-up procedures of the EBM movement. This paper firstly explores the differences between the prevailing scientific method arising from the linear cause-and-effect assumption and the complex adaptive systems science methods arising from observations that most phenomena emerge from nonlinearity in networked systems. Most medical conditions are characterized by necessary features that by themselves are not sufficient to explain their nature and behaviour. Such nonlinear phenomena require modelling approaches rather than linear statistical and/or meta-analysis approaches to be understood. These considerations also highlight that research is largely stuck at the data and information levels of understanding which fails clinicians who depend on knowledge-the synthesis of information-to apply in an adaptive way in the clinical encounter. Clinicians are constantly confronted with the linked challenges of doing things right and doing the right thing for their patients. EBM and Cochrane with their restrictive approaches are the antithesis to a practice of medicine that is responsive to constantly changing patient needs. As such, the EBM/Cochrane crisis opens a window of opportunity to re-examine the nature of health, illness and disease, and the nature of health care and its systems for the benefits of its professionals and their patients. We are at the cusp of a paradigmatic shift towards an understanding a praxis of health care that takes account of its complexities.

There is a significant need for reforming healthcare systems in most contexts worldwide, and radical proposals based on complexity science and systems thinking are necessary. Health systems around the world are failing on three fronts – they fail to meet the needs of people/patients, they are disease-focused rather than health centered, and they are economically unsustainable. Failed/failing systems cannot be reformed by incremental cost-management or policy changes; they need to be redesigned based on peoples/patients’ needs – these are far broader than disease-specific management and include social, community, work, and environmental domains. Embracing these insights is a major challenge for policy makers, not only do they have to convey the direction, they also have to facilitate the necessary adaptive work required by a large and diverse workforce within the health system and its institutions. Health system redesign, while not easy, is possible. The organizational change management literature provides the foundations to lead the process, and the complex adaptive systems literature provides the conceptual understanding of the dynamic interdependencies within and across the organizational scales of the health system. And finally, there are a number of examples that can guide the redesign process toward effective, efficient, and sustainable health systems.

Introduction: Multiple dynamics of internal and external network interactions result in the emergent observable state of a person’s health and care. A tsunami of Big Data predictions are developing to identify specific interventions to improve health. Anticipatory care on the other hand, can be understood, using Rosen's model – to recognize our innate nature to anticipate health journeys with multiple ways of knowing including biopsychosocial domains. Theory/Methods: Monash Health is the largest public hospital and community care system in Victoria. Over 12,000 patients have a Big Data prediction of 3+ admission per year, with >30% potentially avoidable. The challenge for Monash Health remains how to improve their readmission. rates. Monash Health implemented the Patient Journey Record System (PaJR), a biopsychosocial telehealth tool to understand and manage potentially avoidable hospitalizations in a pilot service of 300 patients. Telecare guides regularly converse with “at risk” individuals to track their concerns and self-perceived health. The main journey characteristics of 3 randomly selected cases from PaJR, were descriptively analysed to examine the interface between prediction and anticipation. Results: Three cases, monitored for >25 calls over 6/12, were 1 male with gastrointestinal, alcohol, mild frailty and family problems, 1 male with moderate frailty, COPD and social isolation and 1 female with COPD, social isolation and moderated frailty. All had lower socioeconomic status. ANOVA (analysis of variance) demonstrated statistically significant differences among trajectories of ’Self Rated Health (SRH)’, ’Health/Care Change’, ’Medication/Drug/Alcohol Change’ and ’Support Structure Change’ within each and among all cases. Only ’Health/Care Change’ was consistently high and not statistically significantly different across all journeys (p>0.5). Only 2 patients had an admission. On examination of each trajectory, no admission was definitely predicted with both false negatives and positives. Admission rates reduced over time. Care responses fluctuations were continual. Discussion: Prediction would seem to be an imprecise activity in a patient with multiple unstable trajectories. It was not clear how, when and what root causes triggered each admission where they occurred, from the PaJR data, although Big Data analytics predicted the occurrence of >1 admission in the time period. Each person’s health and biopsychosocial circumstances were unique. Admission rates reduced over time and high levels of healthcare change suggested anticipatory care was enacted in response to the monitoring data. Conclusion: Three case studies of patients, with predicted high readmission risk, demonstrated journeys with fluctuating — ’SRH’, ’Medication/Drug/Alcohol Change’ and ’Support Structure Change’ and admission rates. All reported fluctuating ’Health/Care Change’. Anticipatory care may be informed, but not replaced by Big Data and journey analytics. Lessons learned: Close monitoring of highly variable journeys identified by Big Data predictions should enable anticipatory care. each trajectory in each setting Limitations: Case studies are not externally generalisable. Disease management was not a focus of the monitoring activity. Suggestions for future research: Research into the improvement in the nexus of Big Data predictive analytics and anticipatory care in the quest to intervene in the emergent observable state of a person’s health to improve health and better utilize health care resources.

We argue that 'multimorbidity' is the manifestation of interconnected physiological network processes within an individual in his or her socio-cultural environment. Networks include genomic, metabolomic, proteomic, neuroendocrine, immune and mitochondrial bioenergetic elements, as well as social, environmental and health care networks. Stress systems and other physiological mechanisms create feedback loops that integrate and regulate internal networks within the individual. Minor (e.g. daily hassles) and major (e.g. trauma) stressful life experiences perturb internal and social networks resulting in physiological instability with changes ranging from improved resilience to unhealthy adaptation and 'clinical disease'. Understanding 'multimorbidity' as a complex adaptive systems response to biobehavioural and socio-environmental networks is essential. Thus, designing integrative care delivery approaches that more adequately address the underlying disease processes as the manifestation of a state of physiological dysregulation is essential. This framework can shape care delivery approaches to meet the individual's care needs in the context of his or her underlying illness experience. It recognizes 'multimorbidity' and its symptoms as the end product of complex physiological processes, namely, stress activation and mitochondrial energetics, and suggests new opportunities for treatment and prevention. The future of 'multimorbidity' management might become much more discerning by combining the balancing of physiological dysregulation with targeted personalized biotechnology interventions such as small molecule therapeutics targeting specific cellular components of the stress response, with community-embedded interventions that involve addressing psycho-socio-cultural impediments that would aim to strengthen personal/social resilience and enhance social capital.

BACKGROUND AND METHODS: Health systems are complex and constantly adapt to changing demands. These complex-adaptive characteristics are rarely considered in the current bureaucratic top-down approaches to health system reforms aimed to constrain demand and expenditure growth. The economic focus fails to address the needs of patients providers and communities and ultimately results in declining effectiveness and efficiency of the health care system as well as the health of the wider community. A needs-focused complex-adaptive health system can be represented by the healthcare vortex model; how to build a needs-focused complex-adaptive health system is illustrated by Eastern Deanery AIDS Relief Program approaches in the poor neighbourhoods of Nairobi Kenya. FINDINGS AND CONCLUSIONS: A small group of nurses and community health workers focused on the care of terminally ill HIV/AIDS patients. This work identified additional problems: tuberculosis (TB) was underdiagnosed and undertreated a local TB-technician was trained to run a local lab a courier services helped to reach all at need collaboration with the Ministry of Health established local TB and HIV treatment programmes and philanthropists helped to supplement treatment with nutrition support. Maternal-to-child HIV-prevention and adolescent counselling services addressed additional needs. The theory of the healthcare vortex indeed matches the empery of the real world experiences. Locally developed and delivered adaptive people-centred health systems a bottom-up community and provider initiated approach deliver highly effective and sustainable health care despite significant resource constraints. (c) 2016 John Wiley & Sons Ltd.

Health and disease are largely seen as structural phenomena - visible changes in tissues and organs, rather than the result of complex adaptive physiological dynamics within the person, constrained by his internal structures and external environments. Health and disease are ecological phenomena; internal structures and external environments provide the landscapes in which the functions - physiological network interactions at the micro and behavioural interactions at the macro level - occur. These interactions are the functional responses in the quest for health and life.Embracing the person as a whole, that is, being person-centered, is thus an expression of a paradigm shift, a shift from the reductionist focus on disease to the complex-adaptive understandings of the person experiencing health, illness and disease.

Big data provide the hope of major health innovation and improvement. However, there is a risk of precision medicine based on predictive biometrics and service metrics overwhelming anticipatory human centered sense-making, in the fuzzy emergence of personalized (big data) medicine. This is a pressing issue, given the paucity of individual sense-making data approaches. A human-centric model is described to address the gap in personal particulars and experiences in individual health journeys. The Patient Journey Record System (PaJR) was developed to improve human-centric healthcare by harnessing the power of person-centred data analytics using complexity theory, iterative health services and information systems applications over a 10 year period. PaJR is a web-based service supporting usually bi-weekly telephone calls by care guides to individuals at risk of readmissions.

Max Planck observed that ‘If you change the way you look at things, things you look at change’. It is high time for healthcare professionals to embrace the challenge—the linear reductionist view of health and disease is failing our patients, our profession and our societies. These insights are not really new, Osler has coined many aphorisms to emphasise the need to understand the person with an illness over and above the diseases that might be responsible for his predicament.

Background Resilience in the face of adversity is a human experience that leads to better health, both mentally and physically. We briefly review its historical origins rooted in ecological biology and its adoption into health care. Resilience is the common response to adversity or potential traumatic events. Individual differences in emotion regulation and coping skills as well as social capital and one's physical environment influence a person's ability to achieve resilience. Proposed mechanism One potential biopsychosocial measure of resilience includes stress habituation to repeated stress as demonstrated in the laboratory, possibly providing a tool to observe mastery of resilience training in the clinic. Evidence-based interventions at the individual and small group level (eg, family, classroom) have successfully shown development of resilient behaviours and improved mental and physical health outcomes. However, the role of social context and public policy clearly influence an individual's ability to be resilient. Conclusions Despite the current limited evidence of the effectiveness of resilience building interventions, clinicians, researchers, and other health care professions have an obligation to become advocates for laws and policies that support the most vulnerable, and least resilient, in our society to attain resilience for their health. This salutary effect will enable them to become socially as well as economically productive members of the community at large. It is not possible to remove stress or adversity from life, but we can influence the development of regulatory flexibility and decrease the sociocultural factors linked to the nonresilient experience, thus mitigating adversity's long-term effects on health.

Background: The Australian Ecology of Medical Care indicates that 255/1,000 Australians consult a GP 1.8 times/month (466 consultations/month) resulting in 42 specialist, 1.4 ED and 1.9 hospital referrals, 478 prescriptions, 220 pathology and 48 radiology tests, costing the Government $ 72,009 (2012–13). Government believes this to be unsustainable and controllable by setting price signals. Objectives: To investigate the impact of ‘small changes’ to health service utilisation and/or resource use. Method: Modelling the impact of increases and decreases to healthcare utilisation/resource use over a 5-year period. Results: Strategies targeting only one variable had a small and linear impact on healthcare expenditure (± 0.6–7.2%); combining changes had an exponential effect, achieving an up to 15% reduction or an over 20% rise in expenditure. Discussion: Change invariably results in trade-offs; modelling is a tool that can provide a basis to engage in shared discussions about the ‘ yes, but/yes, and’ considerations of reform propositions

Obesity decreases people’s well-being and contributes to the early development of diseases like diabetes, heart disease, and arthritis. Obesity is rising rapidly as much in the developed world as in low and middle income countries. Government and non-government funders of health care fear that this epidemic of obesity will threaten the viability of health systems.

Rationale The new area of health system research requires a revision of the taxonomy of scientific knowledge that may facilitate a better understanding and representation of complex health phenomena in research discovery, corroboration and implementation. Method A position paper by an expert group following and iterative approach. Results ‘Scientific evidence’ should be differentiated from ‘elicited knowledge’ of experts and users, and this latter typology should be described beyond the traditional qualitative framework. Within this context ‘framing of scientific knowledge’ (FSK) is defined as a group of studies of prior expert knowledge specifically aimed at generating formal scientific frames. To be distinguished from other unstructured frames, FSK must be explicit, standardized, based on the available evidence, agreed by a group of experts and subdued to the principles of commensurability, transparency for corroboration and transferability that characterize scientific research. A preliminary typology of scientific framing studies is presented. This typology includes, among others, health declarations, position papers, expert-based clinical guides, conceptual maps, classifications, expert-driven health atlases and expert-driven studies of costs and burden of illness. Conclusions This grouping of expert-based studies constitutes a different kind of scientific knowledge and should be clearly differentiated from ‘evidence’ gathered from experimental and observational studies in health system research.

Purpose The purpose of this study was to evaluate the veracity of a theoretically derived model of health that describes a non-linear trajectory of health from birth to death with available population data sets. Methods The distribution of mortality by age is directly related to health at that age, thus health approximates 1/mortality. The inverse of available all-cause mortality data from various time periods and populations was used as proxy data to compare with the theoretically derived non-linear health model predictions, using both qualitative approaches and quantitative one-sample Kolmogorov–Smirnov analysis with Monte Carlo simulation. Results The mortality data's inverse resembles a log–normal distribution as predicted by the proposed health model. The curves have identical slopes from birth and follow a logarithmic decline from peak health in young adulthood. A majority of the sampled populations had a good to excellent quantitative fit to a log–normal distribution, supporting the underlying model assumptions. Post hoc manipulation showed the model predictions to be stable. Conclusions This is a first theory of health to be validated by proxy data, namely the inverse of all-cause mortality. This non-linear model, derived from the notion of the interaction of physical, environmental, mental, emotional, social and sense-making domains of health, gives physicians a more rigorous basis to direct health care services and resources away from disease-focused elder care towards broad-based biopsychosocial interventions earlier in life.

PURPOSE Over the past 7 decades, theories in the systems and complexity sciences have had a major influence on academic thinking and research. We assessed the impact of complexity science on general practice/family medicine. METHODS We performed a historical integrative review using the following systematic search strategy: medical subject heading (humans) combined in turn with the terms complex adaptive systems, nonlinear dynamics, systems biology, and systems theory, limited to general practice/family medicine and published before December 2010. A total of 16,242 articles were retrieved, of which 49 were pub- lished in general practice/family medicine journals. Hand searches and snowball- ing retrieved another 35. After a full-text review, we included 56 articles dealing specifically with systems sciences and general/family practice. RESULTS General practice/family medicine engaged with the emerging systems and complexity theories in 4 stages. Before 1995, articles tended to explore common phenomenologic general practice/family medicine experiences. Between 1995 and 2000, articles described the complex adaptive nature of this discipline. Those published between 2000 and 2005 focused on describing the system dynamics of medical practice. After 2005, articles increasingly applied the breadth of complex science theories to health care, health care reform, and the future of medicine. CONCLUSIONS This historical review describes the development of general prac- tice/family medicine in relation to complex adaptive systems theories, and shows how systems sciences more accurately reflect the discipline's philosophy and identity. Analysis suggests that general practice/family medicine first embraced systems theories through conscious reorganization of its boundaries and scope, before applying empirical tools. Future research should concentrate on applying nonlinear dynamics and empirical modeling to patient care, and to organizing and developing local practices, engaging in community development, and influ - encing health care reform.

It is stated everywhere that chronic care poses one of the biggest challenges for the future of medicine. Critical analysis however suggests that these statements are oversimplistic and based on limited, and at times, spurious assumptions. This paper highlights some basic realities: epidemiology shows that at any time, 80% of people experience 'good enough health', and that only 0.8% require tertiary medical care; most people with chronic conditions experience a stable illness trajectory; 'true' multi-morbidity is a pattern of advanced age; ageing and the physiological decline of our organ systems is a slow and steady process starting at the age of 30; and, as our health declines in a variety of patterns with disease and ageing, our psycho-socio-semiotic care needs increase dramatically. I argue that managing the complexities associated with chronic disease care successfully requires an equally complex management approach, 'muddling through', defined by Lindblom as making decisions based on successive limited comparisons. Our patients - rightly - expect that we make these decisions in their best interest. Individual health care professionals and health care policy makers firmly need to put the patient at the centre of the health care system.

Background Governments around the world are looking at means to improve health care services and health outcomes for their communities within a sustainable expenditure framework. There is a general agreement that strengthening primary health care is the way for the future. Primary health care organizations (PHCOs) are seen as a means to achieving more effective and efficient health care. Results and conclusions This paper proposes a complex adaptive framework for PHCOs, taking account of health and illness being subjective experiences, health care being ‘whole person’-focused, and PHCOs focusing on all of a community's health determinants and community-based health care needs. Such approach would foster building healthy local communities as much as seamless integration of health services for all. However, despite the expressed intensions towards patient-centred health care reform the bureaucratic mindset of Australian health policy makers risks true reform by imposing highly structured – rather than ‘simple’– policy and operational rules.

Changing how we think about healthcare improvement, as Braithwaite suggests,1 does not tackle the key questions facing healthcare systems as “socially designed complex adaptive systems.”2 How many people require healthcare—from whom and where? Most of us are healthy enough to not require health professional services. Kerr White’s groundbreaking study in 1961 showed that health and …

Contemporary views hold that health and disease can be defined as objective states and thus should determine the design and delivery of health services. Yet health concepts are elusive and contestable. Health is neither an individual con- struction, a reflection of societal expectations, nor only the absence of pathologies. Based on philosophical and sociological theory,empirical evidence,and clinical expe- rience, we argue that health has simultaneously objective and subjective features that converge into a dynamic complex-adaptive health model. Health (or its dysfunction, illness) is a dynamic state representing complex patterns of adaptation to body, mind, social, and environmental challenges, resulting in bodily homeostasis and personal internal coherence.The "balance of health" model—emergent, self-organizing, dy- namic, and adaptive—underpins the very essence of medicine.This model should be the foundation for health systems design and also should inform therapeutic approaches, policy decision-making, and the development of emerging health service models.A complex adaptive health system focused on achieving the best possible"per- sonal" health outcomes must provide the broad policy frameworks and resources re- quired to implement people-centered health care. People-centered health systems are emergent in nature, resulting in locally different but mutually compatible solutions across the whole health system.

Context India has rudimentary and fragmented primary health care (PHC) and family medicine systems, yet it also has the policy expectation that PHC should meet the needs of extremely large populations with slums and difficult to reach groups, rapid social and epidemiological transition from developing to developed nation profiles. Historically, the system has lacked impetus to achieve PHC. Objective To provide an overview of PHC approaches and the current state of PHC and family medicine in India in order to assess the opportunities for their revitalization. Methods A narrative review of the published and grey literature on PHC, family medicine, Web2.0 and health informatics key papers and policy documents, pertinent to India. Outcomes A conceptual framework and recommendations for policy makers and practitioner audiences. Findings PHC is constructed through systems of local providers who address individual, family and local community basic health needs with strong community participation. Successful PHC is a pre-eminent strategy for India to address the determinants of health and the almost chaotic of massive social transition in its institutions and health care sector. There is a lack of an articulated comprehensive framework for the publicly stated goals of improving health and implementing PHC. Also, there exists a very limited education and organization of a medical and PHC workforce who are trained and resourced to address individual, family and local community health and who have become increasingly specialized. However, emerging technology, Health2.0 and user generated health care informatics, which are largely conducted through mobile phones, are co-evolving patient-driven health systems, and potentially enhance PHC and family medicine workforce development. Conclusions In order to improve health outcomes in an equitable manner in India, there is a pressing need for a framework for implementing PHC. The co-emergence of information technologies accessible to the mass population and user-driven health care provide a potential catalyst or innovation for this transition.

Health systems have all the hallmarks of complex adaptive systems, they organise around a common focus (core value), out of which arise simple rules (operating principles) whose constant application results in the dynamics of the system. Today’s health systems focus on the management of specific diseases and/or budgetary demands. These approaches fail to appreciate that people are complex adaptive systems living in complex adaptive environments. They constantly re-evaluate their health experiences (health, disease and somatisation) which arise from nature’s simple rules of the interconnected dynamics between inflammatory mediators, the adreno-cortical and the hypothalamic-pituitary-adrenal axis. These biological units of health are constantly perturbated by the effects of the social and physical environment including those of health professional ones. Reformed healthcare systems will have different simple rules which allow the emergence of a highly networked health system that provides seamless, fully integrated and coordinated care between all levels of care and across all levels of healthcare organisation.

The healthcare system no longer is a unified system, it has disintegrated into ever smaller insular entities controlled by vested interests in specific disease entities and/or treatment approaches. Disease has become the centre of interest, divorced from the person experiencing disease and having to cope with its consequences. It has become an imperative to re-embrace holism as the basis for understanding health, providing health care and organising an effective and efficient healthcare system. This chapter outlines important concepts that are prerequisite to achieving this goal: •Mental models determine how we understand and approach problems •Natural phenomena follow a Pareto (power law) distribution •Natural and social entities show the structure and dynamic function of complex adaptive systems (CAS) •The whole is more and different than the sum of the parts •Health is a dynamic entity defined as a personal adaptive state •The person and his health experience have to be the central focus for all engaged in the health system

The key feature of the Greater Murray Clinical School model is the attachment of students to patients. Students follow their patients through the health care system, in contrast to the standard approach where students are attached to doctors or speciality based clinical units. The patient/student coupling occurs at the primary care level, which mostly but not exclusively will occur in the GP's office. Students anchor their knowledge by seeing the natural progression of common illnesses, the impact of behavioural aspects on health and disease, and by experiencing continuity of care. Along their path they develop good problem solving skills and learn to understand the health care system they will become part of. The main obstacle in teaching a medical undergraduate curriculum in a rural setting is that large geographical distances separate students, teachers and resources. Consequently, information technology will play an important role in terms of delivery of the GMCS curriculum. Moreover, there is potential for flow-on benefits to the community following integration of new information technology into the local health infrastructure.

Rationale, aims, objectives and Methods Framing allows us to highlight some aspects of an issue, thereby bringing them to the forefront of our thinking, talking and acting. As a consequence, framing also distracts our attention away from other issues. Over time, health care has used various frames to explain its activities. This paper traces the emergence of various health care frames since the 1850s to better understand how we reached current ways of thinking and practicing. Results and Conclusions The succession of the most prominent frames can be summarized as: medicine as a social science; the germ theory of disease; health care as a battleground (or the war metaphor); managing health care resources (or the market metaphor); Health for All (the social justice model); evidence-based medicine; and Obama Care. The focus of these frames is causal, instrumental, political/economic or social in nature. All remain relevant; however, recycling individual past frames in response to current problems will not achieve the outcomes we seek. Placing the individual and his/her needs at the centre (the attractor for the health system) of our thinking, as emphasized by the World Health Organization's International Classification of Function framework and the European Society of Person Centered Health Care, may provide the frame to refocus health and health care as interdependent experiences across individual, community and societal domains. Shifting beyond the entrenched instrumental and economic thinking will be challenging but necessary for the sake of patients, health professionals, society and the economy.

Clinical practice guidelines (CPGs) have not been widely adopted by general practitioners despite their obvious benefits of improving health care. Personal characteristics have been identified as one factor influencing doctors' attitudes towards guidelines. This study examined the impact of personal characteristics of Australian general practitioners on their attitudes towards guidelines. Favouring a fee-for-service remuneration system is highly associated with a negative view towards guidelines. This finding needs to be taken into account when developing strategies for the implementation of guidelines in the Australian context.

Contains fulltext : 118470.pdf (Publisher’s version ) (Open Access) BACKGROUND: A growing proportion of people are living with long term conditions. The majority have more than one. Dealing with multi-morbidity is a complex problem for health systems: for those designing and implementing healthcare as well as for those providing the evidence informing practice. Yet the concept of multi-morbidity (the presence of >2 diseases) is a product of the design of health care systems which define health care need on the basis of disease status. So does the solution lie in an alternative model of healthcare? DISCUSSION: Strengthening generalist practice has been proposed as part of the solution to tackling multi-morbidity. Generalism is a professional philosophy of practice, deeply known to many practitioners, and described as expertise in whole person medicine. But generalism lacks the evidence base needed by policy makers and planners to support service redesign. The challenge is to fill this practice-research gap in order to critically explore if and when generalist care offers a robust alternative to management of this complex problem.We need practice-based evidence to fill this gap. By recognising generalist practice as a 'complex intervention' (intervening in a complex system), we outline an approach to evaluate impact using action-research principles. We highlight the implications for those who both commission and undertake research in order to tackle this problem. SUMMARY: Answers to the complex problem of multi-morbidity won't come from doing more of the same. We need to change systems of care, and so the systems for generating evidence to support that care. This paper contributes to that work through outlining a process for generating practice-based evidence of generalist solutions to the complex problem of person-centred care for people with multi-morbidity.

The notion of health care, and in particular primary health care, being a public good was strongly expressed in the Declaration of Alma-Ata in 1978 [ 1 ] .

Common to complex systems are two fundamental themes—the universal interconnectedness and interdependence of all phenomena, and the intrinsically dynamic nature of reality [2]. “At each level of complexity we encounter systems that are integrated, self-organizing wholes consisting of smaller parts and, at the same time, acting as parts of larger wholes” (Capra [3]).

This chapter discusses the role of open health information management in the the development of a novel, adaptable mixed-platform for supporting health care informational needs. This platform enables clients (patient users) requiring healthcare to enter an unstructured but detailed account of their dayto- day health information requirements that may be structured into a lifetime electronic health record. It illustrates the discussion with an operational model and a pilot project in order to begin to explore the potential of a collaborative network of patient and health professional users to support the provision of health care services, and helping to effectively engage patient users with their own healthcare. Such a solution has the potential to allow both patient and health professional users to produce useful materials, to contribute to improved social health outcomes in terms of health education and primary disease prevention, and to address both pre-treatment and post-treatment phases of illness that are often neglected in the context of overburdened support services.

This chapter discusses the role of e-health in creating persistent clinical encounters to extend the scope of health care beyond its conventional boundaries utilizing social networking technology to create what the authors’ term ‘user driven health care’. It points out the necessity to direct the development of health information systems such that they serve as important vehicles between patient and health professional users in communicating and sharing information other than their role in automated alerts and responses. A project is described that plans to create a system of online sharing of health information in a user driven manner that necessarily becomes persistent due to being stored in electronic health records.

Background The Chronic Care Model (CCM) is widely taken up as the universal operational framework for redesigning health systems to address the increasing chronic disease burden of an ageing population. Chronic care encompasses health promotion, prevention, self management, disease control, treatment and palliation to address ‘chronicity’ of long journeys through disease, illness and care in the varying contexts of complex health systems. Yet at an operational level, CCM activities are predominantly based on an evidence-base of discreet chronic disease interventions in specific settings; and their demonstrable impact is limited to processes of select disease management such as diabetes in specific disease management programs. Aims This paper proposes a framework that makes sense of the nature of chronicity and its multiple dimensions beyond disease and argues for a set of building blocks and leverage points that should constitute the starting points for ‘redesign’? Findings Complex Adaptive Chronic Care is proposed as an idea for an explanatory and implementation framework for addressing chronicity in existing and future chronic care models. Chronicity is overtly conceptualized to encompass the phenomena of an individual journey, with simple and complicated, complex and chaotic phases, through long term asymptomatic disease to bodily dysfunction and illness, located in family and communities. Chronicity encompasses trajectories of self-care and health care, as health, illness and disease co-exist and co-evolve in the setting of primary care, local care networks and at times institutions. A systems approach to individuals in their multi-layered networks making sense of and optimizing experiences of their chronic illness would build on core values and agency around a local vision of health, empowerment of individuals and adaptive leadership, and it responds in line with the local values inherent in the community's disease-based knowledge and the local service's history and dynamics. Complex Adaptive Chronic Care exceeds the current notions of disease management as an endpoint. Primary care team members are system adaptors in partnership with individuals constructing their care and system leadership in response to chronic illness, and enable healthy resilience as well as personal healing and support. Outcomes of complex adaptive chronic care are the emergence of health in individuals and communities through adaptability, self-organization and empowerment. Discussion Chronic care reform from within a complex adaptive system framework is bottom up and emergent and stands in stark contrast to (but has to co-exist with) the prevailing protocol based disease care rewarding selective surrogate indicators of disease control. Frameworks such as the Chronic Care Model provide guidance, but do not replace individual experience, local adaptive leadership and responsiveness. The awareness of complexity means opening up problems to a different reality demanding different set of questions and approaches to answer them.

Current approaches to health care reform are largely based on the metaphor of imminent flood waves threatening to inundate the health care system. This metaphor reflects the system's preoccupation with disease and disease management in a hospital-centric environment. We suggest that the debate needs to be reframed around health, or more precisely the patient's health experience. Most patients are healthy most of the time, and even those with identifiable morbidities generally regard themselves as being in good health. The majority of people receive most of their care in the community from primary care professionals. An integrated, effective and efficient primary health care system supports continuity of care through a primary care provider and fosters clinical leadership that is supported by other primary health care professionals and medical specialists. Each primary care setting will have its own model that best provides flexible and responsive services to meet its patients' needs and expectations.

The chapter starts from the premise that illness and healthcare are predominantly social phenomena that shape the perspectives of key stakeholders of healthcare. It introduces readers to the concepts associated around the term ontology with particular reference to philosophical, social and computer ontology and teases out the relations between them. It proposes a synthesis of these concepts with the term ‘social cognitive ontological constructs’ (SCOCs). The chapter proceeds to explore the role of SCOCs in the generation of human emotions that are postulated to have to do more with cognition (knowledge) than affect (feelings). The authors propose a way forward to address emotional needs of patients and healthcare givers through informational feedback that is based on a conceptual framework incorporating SCOCs of key stakeholders. This would come about through recognizing the clinical encounter for what it is: a shared learning experience. The chapter proceeds to identify problems with the traditional development of top down medical knowledge and the need to break out of the well meaning but restrictive sub specialty approach. It uses the term de specialization to describe the process of breaking out of the traditional top down mold which may be achieved by collaborative learning not only across various medical specialties but also directly from the patient and her “other” caregivers. Finally it discusses current efforts in the medical landscape at bringing about this silent revolution in the form of a Web-based user driven healthcare. It also supplies a few details of the attempts made by the authors in a recent project trying to create electronic health records in a user driven manner beginning with the patient’s version of their perceived illness with data added on as the patient traverses his/her way through various levels of care beginning from the community to the tertiary care hospital. The data contained within these records may then be effectively and anonymously shared between different patients and health professionals who key in their own experiential information and find matching individual experiential information through text tagging in a Web 2.0 platform.

As previously described health is an experiential state resulting from the dynamic interactions between the somatic, psychological, social and semiotic or cognitive domains that characterize a person’s integrity. Contrast that with the prevailing discrete disease and economic rationalist approaches to managing the healthcare, or should one better say disease management, system. The epidemiology of health in the community indicates that 96% of the community does require something other than those highly specific and successful discrete disease interventions offered in the secondary and tertiary care environment. A healthcare system build around the experience of health of the community will organise care in a much broader though highly sophisticated way. It will in particular include a focus on health promoting/destroying local community circumstances. Such a systemic approach is illustrated by the healthcare vortex model.

Primary health care (PHC) reforms focus on improving access to and effectiveness of general practice services, with greater emphasis on health promotion, prevention and chronic disease management, and integration with population health approaches. Currently, reforms are often based on scant evidence from the most accessible and easily known PHC domains and activities, yet most PHC is complex and poorly understood. Complexity theory is based on understanding patterns that are not predictable by traditional evidence and social knowledge, within a complex adaptive system. Complexity knowledge provides a way of understanding the general practitioner's role in PHC in self-organising local networks, with a capacity to generate new solutions integrated through historical and social connections. Complex systems provide a framework for an expanded knowledge base, debate and discussion of reforms and development of PHC goals and strategies.

Miles and Mezzich have proposed person-centered medicine as the way forward to overcome the rapidly escalating crisis of dehuminisation of medical care and the healthcare system at large. The crisis in medical care is caused by a Zeitgeist characterised by 2 themes – conquering disease and profit maximising activities . Overcoming this crisis requires a change of the prevailing worldview and its reductionist thinking about discrete diseases to a worldview that recognises the complexities arising from the interconnections and interdependencies between all facets of a person’s life – his health and illness and disease trajectories. As Kant said: each man has his particular way of being in good health . This paper presents 5 themes that argue for a complexity based framework to achieve a person/patient-centered understanding of health and healthcare: (1) health, illness and disease are complex adaptive states that impact personhood; (2) healthcare must grow health ; (3) healing results from personal sense-making and must be fostered; (4) complex adaptive systems thinking allows an exploration and understanding of personal and community health issues and (5) person/patient-centeredness results in an effective and efficient healthcare system. A person/patient-centered focus, the person/patient at the centre of concern, will result in a seamlessly integrated healthcare system. Such a system will show great diversity between communities, each having emerged as a result of best adaptation to local circumstances. Such a system will have substantial benefits – for the person (in terms of staying healthy) / patient (in terms of regaining his health), the community and the economy.

The Greater Murray Clinical School provides a community based medical education pro gramme for the clinical years at the University of New South Wales. Being a new clinical school in rural Australia allowed the development of a patient-centred longitudinal curriculum. Students follow patients through the health care system, with each exposure stimulating the learning about d(fferent aspects of a patient problem. The paper outlines the con- ceptual approach towards the development and implementation of this novel approach to community based medical education.

Aims This paper aims to describe the contextual factors that gave rise to evidence-based medicine (EBM), as well as its controversies and limitations in the current health context. Our analysis utilizes two frameworks: (1) a complex adaptive view of health that sees both health and healthcare as non-linear phenomena emerging from their different components; and (2) the unified approach to the philosophy of science that provides a new background for understanding the differences between the phases of discovery, corroboration, and implementation in science. Results The need for standardization, the development of clinical epidemiology, concerns about the economic sustainability of health systems and increasing numbers of clinical trials, together with the increase in the computer’s ability to handle large amounts of data, have paved the way for the development of the EBM movement. It was quickly adopted on the basis of authoritative knowledge rather than evidence of its own capacity to improve the efficiency and equity of health systems. The main problem with the EBM approach is the restricted and simplistic approach to scientific knowledge, which prioritizes internal validity as the major quality of the studies to be included in clinical guidelines. As a corollary, the preferred method for generating evidence is the explanatory randomized controlled trial. This method can be useful in the phase of discovery but is inadequate in the field of implementation, which needs to incorporate additional information including expert knowledge, patients’ values and the context. Conclusion EBM needs to move forward and perceive health and healthcare as a complex interaction, i.e. an interconnected, non-linear phenomenon that may be better analysed using a variety of complexity science techniques.