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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.

When natural time sequences were replaced by clocks, time became a measurable commodity and the ‘speedy use of time’ a virtue. In medical practice shorter consultations allow more patients to be seen, whereas longer consultations result in a better understanding of the patient and her problems. Crossing the line of time-efficiency and time-effectiveness compromises the balance between short-term turnover and long-term outcomes. The consultation has all the hallmarks of a complex adaptive system whose characteristics are not determined by the characteristics of the components, but by the patterns of interaction among the components. Systems are dynamic and change over time; the dynamic nature is not incidental, but necessary as complex systems operate at conditions far from equilibrium. The central notion when we talk of time and complexity is that of ‘memory’. Memory is carrying something from the past over into the future. Memory is filtered/interpreted, separating noise from information. Memory therefore is not an instantaneous thing, it takes time to develop; it is slow. The dynamics between the participating agents in the consultation will create shared memories that live on to shape future interactions. Shared memories are stronger and contain more relevant knowledge if they are based on frequent interactions and ongoing doctor–patient relationships, leading to a better understanding of the whole person – a process that takes time. Sufficient time, that is, ‘a certain slowness’, is an essential element of the healing relationship in the consultation. It creates a sufficiently stable, but adaptive, environment that can withstand changing demands. Hence a more complete understanding of the consultation and its time demands will not only lead to more effective treatment, it will also humanize a situation which has become to a large extent purely instrumental. This process of humanization is important not only for the patient, but also for the doctor.

‘If it is complex it means we don’t really understand it,and the way forward is to break the problem down into its partsto make sense of it’. This thought reflects the way we havebeen taught, and the way we largely practise in clinical care everyday.But are we really functioning on this basis? Or is it the only waywe know how to live? We all experience situations every daywhere the evidence does not really fit our understanding of aproblem – the familiar reductionist approach limits our ability tofully explore new problems and to gain new insight. An increas-ingly persistent question has emerged in relation to what consti-tutes the knowledge we need for effective and efficient clinicalcare, an issue taken up by this new

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.

Medical news often receives intense, but distorted, media coverage, which can lead to high levels of insecurity in both patients and doctors.To elicit general practitioners' self reported behaviour regarding hormone therapy (HT) advice and prescribing, before, immediately after, and 2 years following the release of the first results of the combined oestrogen and progesterone arm of the Women's Health Initiative (WHI) study; to elicit GPs' understanding of statistical risk terminology; and to explore their personal preferences relative to the trade offs between quality and length of life in medical treatment.In October 2004, a questionnaire was sent to all 169 GPs working on the central coast of New South Wales.The response rate was 67.5%. Before the release of the WHI study, 43.8% of GPs recommended HT; 5.9% did so immediately after, and 1.8% 2 years later. When expressed as number needed to treat (NNT), 20.8% of GPs stated that they were unable to interpret the absolute risk of HT use. Half of the 84 GPs who stated that they understood the concept of NNT were not going to reconsider the advice to give HT. General practitioners with a personal preference toward length of life over quality of life proved to be significantly more likely to advise against HT use (p=0.008 in a group comparison).The sensationalising of the disease specific mortality differences in HT users had a dramatic and lasting effect on GPs' attitudes to, and prescribing of, HT. General practitioners acknowledged their poor understanding of basic statistical risk terminology. Providing absolute risk terms did not alter clinical decision making in 50% of GPs, clinical decision making may well be more powerfully influenced by a doctor's personal preferences relative to the trade off between quality and quantity of life.

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.

Systems organise themselves upward toward larger wholes, and downward toward ever smaller parts. The upward view describes holism or emergence (complexity science view), the downward view reductionism or analysis (Newtonian science view). Both views provide valid and valuable information, one being contextual, the other specific. A systems and complexity view allows a simultaneous understanding of a phenomenon from different perspectives, providing the opportunity to identify potentially different outcomes from a single action. The findings from studies on prescribing antibiotics and continuity of care will demonstrate and draw attention to the potential of this approach for primary care research.

Many problems encountered in general practice cannot be sufficiently explained within the Newtonian reductionist paradigm. Systems and complexity thinking - already widely adopted in most nonmedical disciplines - describes and explores the contextual nature of questions posed in medicine, and in general practice in particular. This article briefly describes the framework underpinning systems and complexity sciences. A case study illustrates how systems and complexity thinking can help to better understand the contextual nature of patient presentations, and how different approaches will lead to different outcomes.

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.

The Greater Murray Clinical School (GMCS) was founded with two main aims in mind one, to provide a community-based learning environment offering diversified clinical educational experiences, and two, by doing so, to help address the doctor shortage for Australians living in rural and remote areas. The GMCS is a community-orientated and community-based clinical school, which has replaced the typical discipline-based curriculum with a longitudinal, patient-centred one. Students are attached to patients--called "the longitudinal patient"--whom they follow through all stages of their care. They share with patients their experience of illness and disease, their varying care needs, and how these are addressed by different service providers. The philosophy of the course, its implementation and our initial experiences are described.

Increasingly, reforms to health care systems appear to interfere with the traditional (healer) role of the general practitioner, and are perceived to disrupt patient care and the therapeutic relationship.To outline measures for the survival and future development of the discipline of general practice in Australia.In order to preserve longitudinal relationship centred care and high level primary care clinical expertise, health bureaucracies and general practice itself, must re-focus care on the individual and community, integrating new developments rather than allowing 'new ideas and system pressures' to continually distort functional general practice.

Background Governments are increasing pressure on GPs to provide better services to their patients without giving consideration or due recognition to the impact of those initiatives on their already heavy workload. Objective This pilot study aimed to measure accurately the impact of case mix on general practice workload. Method The general practice-specific care category (GP-SCC) model was developed and applied to a random sample of patients who attended a four-doctor suburban practice four or more times between July 1995 and June 1997. Results The random sample comprised 245 patients (126 males, 119 females) out of a total practice population of approximately 4000. The mean patient age was 42.7 years (CI 39.6-45.8; range: 0-95). The mean patient consulted 10.70 times (CI 9.62-11.77) and discussed 13.19 health problems (CI 11.74-14.63), which equated to 1.20 problems per consultation (CI 1.17-1.23). The ambulatory case mix concept allowed the development of the GP-SCC model--defined as GP-SCC 1, acute/self-limiting problems and preventive care; GP-SCC 2, primarily chronic health problems; GP-SCC 3, psychological problems in conjunction with up to two other problem categories; and GP-SCC 4, a combination of four or more problem categories. GP-SCC 1 comprised 31.1% of patients (CI 29.1-35.1), accounting for 25.6% of visits (CI 24.0-27.3) and 21.9% of all problems encountered (CI 20.5-23.3); GP-SCC 2 comprised 16.7% of patients (CI 10.6-19.6), accounting for 10.6% of visits (CI 9.5-11.9) and 9.9% of all problems encountered (CI 8.9-11.0); GP-SCC 3 comprised 7.1% of patients (CI 4.4-11.2), accounting for 7.8% of visits (CI 6.8-8.9) and 7.7% of all problems encountered (CI 6.8-8.7); and GP-SCC 4 comprised 42.0% of all patients (CI 35.8-48.2), accounting for 56.0% of all visits (CI 54.2-57.8) and 60.5% of all problems encountered (CI 58.8-62.2). Conclusions The GP-SCC model, built on the ambulatory case mix concept, is a useful tool to analyse the morbidity of practice populations, and has a good predictive value in terms of a practice' workload.

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.

BACKGROUND The traditional concept of continuity of care, i.e. care from the cradle to the grave, is no longer sustainable in modern society. OBJECTIVE The aim of this study was to propose a definition of 'continuity of care' based on the experiences of a group of practising Australian GPs. METHOD Five focus group discussions were conducted to explore the understanding and practice of continuity of care, the individual's measurement of having achieved continuity of care in his/her practice and the advantages/disadvantages of providing continuity of care. Results and conclusions. The experiences of this group of GPs points towards three essential aspects to help with a definition of continuity of care. Firstly it requires a stable care environment, secondly good communication to build a responsible doctor-patient relationship and thirdly the goal of achieving an improvement of the patient's overall health.

Background Chronic disease is a major global challenge. However, chronic illness and its care, when intruding into everyday life, has received less attention in Asia Pacific countries, including Australia, who are in the process of transitioning to chronic disease orientated health systems. Aim The study aims to examine experiences of chronic illness before and after the introduction of Australian Medicare incentives for longer consultations and structured health assessments in general practice. Methods Self-help groups around the conditions of diabetes, epilepsy, asthma and cancer identified key informants to participate in 4 disease specific focus groups. Audio taped transcripts of the focus groups were coded using grounded theory methodology. Key themes and lesser themes identified using a process of saturation until the study questions on needs and experiences of care were addressed. Thematic comparisons were made across the 2002/3 and 1992/3 focus groups. Findings At times of chronic illness, there was need to find and then ensure access to 'the right GP'. The 'right GP or specialist' committed to an in-depth relationship of trust, personal rapport and understanding together with clinical and therapeutic competence. The 'right GP', the main specialist, the community nurse and the pharmacist were key providers, whose success depended on interprofessional communication. The need to trust and rely on care providers was balanced by the need for self-efficacy 'to be in control of disease and treatment' and 'to be your own case manager'. Changes in Medicare appeared to have little penetration into everyday perceptions of chronic illness burden or time and quality of GP care. Inequity of health system support for different disease groupings emerged. Diabetes, asthma and certain cancers, like breast cancer, had greater support, despite common experiences of disease burden, and a need for research and support programs. Conclusion Core themes around chronic illness experience and care needs remained consistent over the 10 year period. Reforms did not appear to alleviate the burden of chronic illness across disease groups, yet some were more privileged than others. Thus in the future, chronic care reforms should build from greater understanding of the needs of people with chronic illness.

3. Weule G. IT uptake lower than expected. Medical Observer 2003 Aug 22: 24. 4. Askew DA, Glasziou PP, Del Mar CB. Research output of Australian general practice: a comparison with medicine, surgery and public health. Med J Aust 2001; 175: 77-80. 5. Australian Department of Health and Ageing. Review of the role of Divisions of General Practice. July 2003. Available at: www.health.gov.au/hsdd/gp/divisions/divfuture.htm (accessed Aug 2003).

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.