Carmel Martin
I am an Adjunct Associate Professor Department of Medicine, Monash University. I am active in clinical general practice in Holland Park, Brisbane with a particular interest in chronic disease and illness and patient centred care and complex systems.I am an Australian medical graduate from the University of Queensland. I completed my Masters in Community Medicine at the London School of Hygiene, University of London and my PhD at the Australian National University. My research in Australia, Canada and Ireland has focussed on reforms related to primary health care and chronic care, the nature of health in body, mind, society and the environment and meaning and sense making about personal health. I am co-editor, with Joachim Sturmberg, of the Forum on Systems and Complexity in Medicine and Healthcare in the Journal of Evaluation in Clinical Practice. I have achieved > $15,000,000 in research funding as PI, Co-PI and Co-I. I have over 100 peer reviewed journal article publications and many other publications. From Feb 2009- 2012, I was at the National Digital Research Centre (NDRC), Dublin, Ireland and completed in 2011 a project called the Patient Journey Record in complex chronic care at the NDRC- consortium of members comprising Dublin City University (DCU), Trinity College Dublin (TCD), University College Dublin (UCD), Dun Laoghaire Institute of Art, Design and Technology (IADT) and the National College of Art and Design (NCAD). Cara Health, a spin out company was located in Digital Accelerator 1871 www.1871.com in Chicago. Illinois until 2013. Since 2016 April, I have a part time position with Monash Health Hospital Without Walls program, implementing the Patient Journey Record System in the MonashWatch component of preventing avoidable hospitalisations in high risk groups. My main scholarly interests centre on Complex Adaptive Systems in human health, healthcare and assistive technology systems. I am influenced by Morin, Rosen and many other giants and continually working to improve my understanding of and improvement of anticipatory systems in health.
Address: Monash Health
Department of Medicine, Nursing and Allied Health
Clayton
Address: Monash Health
Department of Medicine, Nursing and Allied Health
Clayton
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Videos by Carmel Martin
This video reports a pragmatic summative evaluation of the MW service. We compared bed days for an intention-to-treat group versus a usual care control group for 30 months from the MW service commencement. The intention-to-treat group included an MW active telehealth group consisting of those who used the telehealth service and those who declined.
We demonstrated reduced bed days of 1.14 per person per year in the MW Intention to treat group (within the capitated budget) and consistently reduced bed days/person/month.
Papers by Carmel Martin
This video reports a pragmatic summative evaluation of the MW service. We compared bed days for an intention-to-treat group versus a usual care control group for 30 months from the MW service commencement. The intention-to-treat group included an MW active telehealth group consisting of those who used the telehealth service and those who declined.
We demonstrated reduced bed days of 1.14 per person per year in the MW Intention to treat group (within the capitated budget) and consistently reduced bed days/person/month.
This book plans to make a beginning toward that end utilizing a meta-narrative that examines the life of an academically failed physician and his relatively academically successful daughter. The short individual narrative beads that are threaded into this larger narrative represent a multi genre science and fantasy of medicine. On one hand it balances a postmodern stance with its incredulity toward absolute evidence based truth on the other a tolerant pluralism that simply recognizes all approaches as credible as long as the resultant is geared toward positive outcomes (and not driven by fear of negative outcomes).
The book portrays a non-linear narrative ontology interspersed in linear discourses on its relevance to human cognition and ontology. It creates a fictional conceptual model of a human that is visualized in physical form analogous to a notebook computer that hides an infinite backend process of cognition analogous to the human mind.
This particular backend entity is labeled con (shortened from a consciousness that is universal to all humans and other sentient life also sometimes represented simply as being) and is fictionally endowed with powers that enable it to run on multiple notebook computers (analogous or metaphorically morphologically indistinguishable from humans). This helps the meta-narrative to explore human cognition and its physical manifestations in an Earthly plain.
The story line begins with Con taking the plunge with his notebook June into an Earthy material life. A plunge that makes him fall through life and is bound to end in death. Death smashes his notebook’s hard disc into tiny bits and pieces. The nonlinear narrative as a result tries to pick up these broken fragments of memory and brings out Con’s journey through the human body (in its tree like statistical self-similarity with the Earth and the universe, which may be represented in an atom). It portrays microcosmic interactions inside the human body at a macrocosmic level of day to day living on an Earthy scale.
Con becomes well versed with the anatomy and circuitry of the various intricate components of his machine but also realizes that it has developed in an evolving assembly line whose creators are long dead and nobody till date understands perfectly how the damn thing works. However there are theories, stories of atoms and molecules and their subatomic families regularly utilized to explain how semi conductor chips work inside our bodies. Throughout the ages, stories take on multicolored hues, theories on the nature of Con, Earth and self-evolving machines…the science is ever changing.
National Strategies
National Evaluation Strategy
The National Evaluation Strategy (NES) was established to address the need expressed by First Ministers at their 2000, 2003 and 2004 meetings on health system renewal for better information throughout the health system.
The objective of the NES was to generate evidence on primary health care. More specifically, it would:
* Facilitate a process to generate evidence on the various approaches to primary health care, including the Primary Health Care Transition Fund and its impact on primary health care renewal; and
* Increase national capacity to evaluate primary health care, now and in the future.
The Strategy consisted of three initiatives:
* Evaluating Primary Health Care in Canada: The Right Questions to Ask;
* The Pan-Canadian Primary Health Care Indicator Development Project; and
* Toolkit of Primary Health Care Evaluation Instruments.
Evaluating Primary Health Care in Canada: The Right Questions to Ask
National Envelope
Lead and Partner Organization(s)
Primary and Continuing Health Care Division, Health Policy Branch, Health Canada
Background and Goals
To better understand and improve primary health care (PHC) renewal, Health Canada established the Primary Health Care Transition Fund National Evaluation Strategy (NES). The NES had two objectives: to facilitate a process to generate evidence on various approaches to PHC and the impact of PHC renewal; and to increase national capacity to evaluate PHC. The NES comprises three initiatives (evaluation questions, indicator development and a toolkit of evaluation instruments), of which Evaluating Primary Health Care in Canada: The Right Questions to Ask is the first. The objective of this initiative was to develop a set of evaluation questions pertinent to the PHC sector; these questions would then serve as the basis for developing a set of indicators and evaluation tools. The five common objectives of the PHCTF were used as the initial organizing framework for classifying these questions.
Activities
In Octob er 2004, Health Canada began a process to identify a set of evaluation questions. A variety of strategies were used to generate these questions, including:
* A scan of national and international policy documents: The international scan was limited to the United Kingdom, Australia and New Zealand. More than 800 explicit and implicit evaluation questions were abstracted and mapped, according to the PHCTF objectives.
* Further synthesis: With the input of a small group of PHC experts in Canada, the United Kingdom and Australia, the initial set of questions was further synthesized to 100 questions that addressed all the major inputs, activities, outputs and outcomes of the PHC Results-Based Logic Model developed by Watson et al. in 2004. Wherever possible, questions were formulated in a way that would suggest indicators.
* A two-day workshop: The synthesized questions and the insights that emerged from the scan of policy documents were presented to a group of pan-Canadian PHC researchers, evaluators and policy-makers. Participants clarified which PHC objectives should be evaluated, and identified key evaluation questions. At the workshop, small groups were asked to integrate the broader system objectives of equity, cost-effectiveness and sustainability of public funding into the questions.
* A final review of questions: Thirty-nine questions were agreed upon by key experts in the field. Nineteen were identified as being important to the PHC objectives and 20 were identified as being necessary supports for the successful delivery of PHC. Modification of the five PHCTF objectives took place, resulting in seven PHC objectives.
Resources
* A list of 39 evaluation questions for PHC
* A revised list of seven PHCTF objectives
Key Learnings
The list of evaluation questions developed through this initiative provides an overview of the performance of the PHC system as a whole, not just that of the PHCTF initiatives. This set of questions has helped the two subsequent initiatives of the NES to frame related endeavours. It was noted that the broader system goals of an efficient, effective and equitable system were implicit in the PHCTF objectiv es. As well, evaluators who took part in the initiative and policy documents consistently raised the issues of productivity, quality of health care, and responsiveness of providers to patients. These attributes of care represent an intermediate stage of achieving system efficiency, effectiveness and equity. Although they are largely under the direct control of PHC providers, it was felt that they should be included in the PHCTF objectives. In view of these and other insights, experts at the national workshop said that the language in the PHCTF objectives was ambiguous and did not address all the policy concerns of interest in PHC performance evaluation. As a result, the original five PHC objectives were expanded to seven.
Primary Health Care Transition Fund
Phone: 613-954-5163
E-mail: phctf-fassp@hc-sc.gc.ca
The full report is available in the language of the author on the PHCTF website, www.healthcanada.gc.ca/phctf.
"Do you think me a learned, well-read man?"
"Certainly," replied Zi-gong, "Aren’t you?"
"Not at all," said Confucius.
"I have simply grasped one thread which links up the rest."
(Recounted in Sima Qian (145-ca. 89 BC), "Confucius," in Hu Shi, The Development of Logical Methods in Ancient China, Shanghai: Oriental Book Company, 1922; quoted in Qian 1985:125, in Castells, M. (1996). The Rise of the Network Society, Oxford: Blackwell.)
Learning schools are redirecting the focus from what has been labeled “traditional computer-based learning environments” towards user-driven learning networks supported by social internet based applications. The assumption that computer-mediated learning will occur in the classroom, managed by a teacher, is now being challenged, not by schools and educational software developers, but by the consumer growth of personal technologies.i
'User driven learning' is a form of conversational experiential learning between networked users in web space. ‘User-driven healthcare’ is, “improved healthcare achieved with concerted collaborative experiential learning between multiple users and stakeholders, primarily patients, health professionals, and other actors in the care giving collaborative network across a Web interface.” The keyword here is learning.ii
The goal of ‘narrative medicine’ is to make doctors more empathetic by getting them to articulate and deal with what they feel and to develop sophisticated listening skills, ears for the revelations hidden in imagery and subtext. The field—alternatively called literature and medicine, or medical humanities, depending on the approach–began by most accounts about 30 years ago and is now widely reflected in medical school curricula around the U.S.iii
Often in day-to-day practice, both individual patients and health professionals are in situations where the information available is limited and difficult to apply to a given patient.
A gap between the paucity of what is proved to be effective for selected groups of patients and the infinitely complex clinical decisions required for individual patients has been recently recognized and termed ‘the inferential gap.’iv
Evidence based on average patient data, which occupies most of our present day information databases, does not fulfill the needs of individual patient-centered healthcare. In spite of the unprecedented expansion in medical information, we still do not have the types of information required to allow us to tailor optimal care for a given individual patient. As our current information is chiefly provided in disconnected silos, we need an information system that can seamlessly integrate different types of information to meet diverse user group needs.
Certain groups of individual medical learners, namely patients’ family and intimates, medical students, and involved professionals, share the patient’s need to increasingly interact with and seek knowledge and solutions offered by others (individual medical learners, often the physicians, nurses, and the wider healthcare team) who have the experiences of health and medical care provision that they would benefit to access and learn from.
Web-based user driven, collaborative and conversational narrative based experiential learning is an evolving stepping-stone to address the present problem of information oversupply in medicine that mostly remains underutilized, as it does not meet the needs of the individual patient, their support network, and health professional users including those in training.i
iSharples, M. (2002) Disruptive Devices: Mobile Technology for Conversational Learning. International Journal of Continuing Engineering Education and Lifelong Learning 12 (5/6), 504-520.
iiBiswas, R., Martin, C., Sturmberg, J., Shankar, R., Umakanth, S., Shanker, & Kasthuri AS. User driven health care - Answering multidimensional information needs in individual patients utilizing post EBM approaches: A conceptual model. Journal of Evaluation in Clinical Practice, 2008, 14, 742-749.
iiiHolloway M, When Medicine Meets Literature, Scientific American, May 2005, Web document downloaded June 7 from http://www.scientificamerican.com/article.cfm?id=when-medicine-meets-liter
ivStewart WF, Shah NR, Selna MJ, Bridging The Inferential Gap: The Electronic Health Record and Clinical Evidence, Health Affairs, March/April 2007; 26(2): w181-w191.
Implementing the Patient Journey Record System (PaJR) in Ireland and Australia
Context and aims
The Patient Journey Record System (PaJR) implements a complex adaptive (CAS) person- centered approach to potentially avoidable hospitalizations (PAH). Telecare guides (TCG) regularly converse with at risk individuals to track concerns and health. PaJR initially piloted in a rural Irish cohort with 1 PAH in past year is being trialed in MonashWatch (MW) - an Australian deprived inner-city cohort with 3 PAH/year predicted using hospital analytics. Aims
To compare profiles of MW (high risk hospital recruited) and Irish (lower risk primary care) cohorts.
Method
Telecare guides record conversation details in PaJR database which generates alerts for risk of deterioration, using algorithms validated in Ireland. Calls from the MW (n=616) and Irish (n=616) pilots were analysed. Variables include concerns, self-rated health, worrying disease symptoms transformed into alerts >24hour response, and high risk patterns requiring medical attention in 1-24 hours (red alerts).
Findings
Self-rated health (SRH) was similar in both cohorts (excellent to very poor categories). Concerns were raised in 238 (38%) MW calls and Irish calls 308 (50%); while 73% vs 83% calls reported no disease symptoms. Red alerts were generated in 28% of MW and 25% Irish calls. Pain, psychosocial distress and environmental problems clustered in MW (mean2.7 per call; median1) versus Irish (mean 0.45 per call, median 0). Irish alerts related more to breathlessness as the most frequent symptom.
Innovative contribution
SRH and alerts that require medical care demonstrated similar rates in MW and Irish cohorts. Pain, mental health, social and environmental concerns were clustered in the MW group, while the Irish had more physical disease and isolation. The MW group had a broader range of social and environmental problems of a non-urgent nature than the Irish group. The PaJR system using CAS is adaptable for use in 2 different cohorts and countries by addressing needs through person-centered conversations.