No, Dricky were somewhere else. Escape! We have a man who is to die at the hands of... as Hugh Cave tells it in his silent horror. That watch, eh? Well, why I keep it hanging up there? Do you own the bar? They're strangers, I mean. Of course, none of that. Radio station 2. Here you are. Take a look. Twenty-one jewels. A sealed case. Belong to Tom Dawson, the painter. He was a little washed-out guy, or we'd look kind of lost. Nobody knew much about him, except he painted good pictures. I didn't know much about Elizabeth either. That girl he brought up from Sydney. That was pretty easy to guess about her. She gave him the watch. Yeah. Still runs if you want it, see? Got quite a tick if you hold it close up to your ear. And a little light jungle drum, way off in the distance. I suppose that's how it sounded to Tom Dawson there at the last. Then that watch meant life or death, and they were waiting for him out there in the darkness. Oh, that's quite a story. Only it's kind of hard to know what it starts, see? With Elizabeth, perhaps. Anyhow, Tom was telling it himself in his own words. I think he'd start with Elizabeth. They didn't understand Elizabeth. How it was between us, what she meant to me. None of them did. They gossiped a lot the way they always do in traffic ports. But they didn't really know anything about Elizabeth. They didn't know how sweet and how convincing she could be. How she could wrap a man around her finger. Like the time she gave me the watch. Go on, Tom, open it. I want to see if you like. Like what, Elizabeth? Open it and see. You come home with a package and... It's a watch. It's a good one, too. It's made for the tropics. All sealed and everything. It'll run forever. Yeah, honey, but where'd you find a watch like this in Port Moresby? Well, I didn't exactly. I got it from Captain Ducar. Ducar? He has a trading schooner. I used to know him in Sydney. Yes, I... I think I've heard him mention recently around the bar at the hotel. Probably. He's been in Port for a couple of weeks. Do you really like it, Tom? The watch, I mean. Sure, baby. Who wouldn't? Now, you can always tell just how long you've been away from me. In that case, I won't need it all. It sounds like a heartbeat when you're holding it close. I guess that's what it is in a way. A heartbeat of time. Measure not your life. My life. Second by second. Oh, Tom, that's a morbid idea. Do you love me? Crazy about you. You don't have to bring me presents to keep you that way. I want it too, Tom. Yeah, I know, but this thing's too expensive, Elizabeth. I can't keep it. But you must. I gave it to you. It's worth a couple of hundred dollars. Have you thought of how you're gonna pay for it? Well, I had some savings. I didn't tell you, Bob. I thought you were flat broke when I ran into you in Sydney. Well, I wasn't though. I... Look, Tom, why don't you forget it? Let me worry about it. And anyway, I've already paid for the watch. Why prolong this story? Everybody else knew, and I didn't. That's all right. Pure self-delusion. Because I had plenty of opportunity to know. Insinuations around the hotel bar, talk along the harbor front, remarks about Pierre Ducard. But like I say, I was crazy about Elizabeth. And I ignored it all, went on painting, and didn't know. Maybe I didn't want to know. I'd been out on a two-day painting trip and made it fishing boats. We got back to port a day earlier than I'd expected. It was about midnight when I climbed onto the wharf with my canvases and headed around the harbor front. I walked about 50 yards when I heard it. Came from a schooner moored at the wharf just ahead of me. I walked closer. There was no mistaking that life. Elizabeth. You're like all the others. Pull the words you don't mean. And the schooner was Pierre Ducard. Yeah, but they are pretty words, my carry. And you like to hear them, no? Of course, I like to hear them. And maybe that only shows I'm a fool, too. No, I think it is not you and I are fools. But that does seem to be yours. Well, he's all right. But he's so boring at the time. Elizabeth. How did you like to watch, I sent him? Well, only he wondered how I was going to pay for it. Some men would have killed one or both of them. Other men would have killed themselves. I didn't either. Standing here in the darkness, I realized suddenly that my whole life up to that moment had been completely useless. Nothing.  And the real woman, too, was useless. Harlow, nothing. I threw my paintings into the waters of the harbor, turned away into the night, and ran. Nearly three weeks later, my crazy flight from the past had carried me deep into the black heart of New Guinea. Beyond the dank rainforests are the coast up through the foothills in the mid-slope jungles of Bamboo and Lyanna. Until I stood one morning in a narrow pass that led through steep-walled rocks to a hidden valley. And I knew that civilization lay far behind. That the Papuan natives who moved towards me were headhunters, cannibals. The chief of the tribe, a giant of a man towering a foot or more above me, raised his arms. Why you come here, why double? I'm Tom Dorset. Why you come here? I've come to live with you, if I may. May I? Where you come from? A place called Port Moresby, many days from here.  No, no, and I don't have any wish to be headman here. You could not be headman you aren't. I, Ramabu, headman here. With hands alone, Ramabu can kill any man in tribe. I don't doubt it.  I don't doubt that either. I show you. I hold you over my head like this. Feel good? How you like? I think you're not be headman here. I think you're not good for much anything. No, I... I guess I'm not. I guess that's why I ran away. Why I came here. You still want to live here? Yes. All right, you stay.  Understand? Yes, I understand. But you... The weeks went by and gave me little time for thinking or remembering. I built a house at the far end of the valley, planted a garden, roamed the woods to search for berries and nuts, and lived the life the natives lived. Timing each day by the watch which I still wore on my wrist. I was fairly content. Pass seemed far away. Then Jerry came into my life. I had gone exploring in the north end of the valley and when I came back at dusk, she was waiting in the door of my house. Young, brown skin, beautiful. Hello? My name is Jerry. I've been watching you. Why? Just because. You did not notice me though. Why should I notice you? Well, are you not like other men? What are you doing here? I come to live with you. I don't want anybody living with me. It is not good to be alone. Who will sweep your floors and cook for you? I do those things myself. But it is better to have a woman. Not for me. You will not let me stay? No. All right. I come again tomorrow. Maybe you change your mind. Not a chance. We see. Good night. That was the beginning and in a way the beginning of the end. Jerry came back the next day and the next and the next. I argued, pled, cursed. But nothing I could do would change that round-eyed persistence of hers in the least. And then I made the first big mistake. It started the whole mess. It involved the watch. You're late tonight. A little while longer. All the things I cooked for you would be spoiled. What of it? I didn't ask you to come here. I can cook for myself. Bah! Look what I have cooked. A strawberry cake, jam, chestnut. Jerry, I've told you over and over again you've got to stop coming here. Why? Because I said so. Perhaps it's because you think I am ugly? You know better than me. You're lovely. That's a trouble. I do not understand you. I mean you have no business hanging around here. Look, Jerry, I already have a woman, a wife, back in Port Moresby. You love her? Yes. She is coming here again? No, no, she won't be coming. Then it does not matter. What good is she? That's not the point. Look, she gave me this. See, it says from Elizabeth. That's her name. To Tom. That's me. What is this thing? It's a watch. What does it do? Well, it counts the hours. Tells what time the sun will come up and tells when it will go down. How does it do these things? Is it magic? Well, yes, in a way you could call it magic. And that is why you will not let me stay? Because the woman has given you this thing? That's right. But she has not come in here? No, she isn't. You know what I think? No.  Jerry talked, of course, told the villagers about the magic watch. By 2003s they came to look at it, stare at it solemnly, exchange a word or so of gossip and depart. I welcomed them at first, realized how lonely I'd been, except for Jerry's daily visits. Now I'd suddenly become a popular celebrity. But there was one thing I hadn't counted on, and that one thing was Ramaboo. Much talk in village of magic thing you keep here. Ramaboo, come see this thing. I'm glad you did. Welcome to my house. House? Fine house. You build with magic? No, I just happen to know a few things about construction. Better house than Ramaboo. Thanks. Not good for one how better house than headman. Here, do you want to see the watch? So this magic thing Ramaboo hear about. Oh, it isn't really magic, it's just a watch. You and I know that. Jerry say magic, tell sun and moon. Well, you know how women talk. Yeah, magic thing. Fine house. You know what I say when you come here? Yes. What I say? You said if I caused any trouble you'd kill me. It's right.  But I didn't think I'd caused any trouble. Just one way go out of valley. And guard watch all time. I'm not planning to escape if that's what you mean. You remember now. Ramaboo headman here.  I watched him stride off sneering a little swaggering. I knew of course that he had the mind and attitudes of a ten-year-old child and that he was dangerous. But I didn't realize how deadly. Not then. So I went right ahead and made my one big final mistake. We will return to escape and tonight's story the silent horror in just a moment. Lots of folks will be driving on our highways during the Labor Day weekend. It's a weekend for pleasure so let's keep it pleasant for everyone. Stay the traffic laws. Don't speed. Stay on the right side of the road and don't drink when you drive. Be careful. The life you save may be your own. And now back to escape. That's all right. It's the same watch you've figured in all of Tom Dawson's troubles. Right up to the end. Or especially at the end you might say. Of course I didn't get it from Tom himself. Now a back country trader named Will Jones has been hanging there behind the bar ever since. And once in a while I wind it up when some stranger asked me what it's there for like you did. Ticks away as good as new. It was a fellow I got the story from too but sometimes listening to that watch ticking away I can almost imagine that Tom's telling the story himself in his own words. The week after Rambo came to see the watch I started on a new project. Weeks before I'd found a spring in a waterfall halfway up the cliffs behind my house and I thought of a way to use hollow bamboo tubes to pipe the water to my kitchen. I spent nearly a month cutting the bamboo carrying it up to the cliff and fitting the lengths together. And then one day everything was ready and I turned the water into my new aqueduct. The villagers heard of course the marvel taste of water and look at me ascance. Jerry was around during all those weeks there seemed to be nothing I could do to get rid of it but perhaps I was growing less inclined to get rid of it. I suppose I should have expected trouble but I didn't when trouble finally did come it came right to my door. What is this? What's it all about? Rambo what's this all about? I come find out if man who live in better house than Rambo man who make river come to house can also fight. Fight? You want spear, club or hand. I don't want any of them. What reason have I got to fight with you? Maybe you want be a head man. Of course not. I told you that before.   Say we fight, see who is head man. I see. I don't have a choice is that it? You want spear, bear hand. What's the difference? I'm not good at any of them. It was pleasant here. I thought maybe. Well Rambo let's get on with it.  Lift your high like this. Throw you on ground.  Stop, stop.  He told me so. It's lie not true. There will never be a sun again. Only night and darkness.  Jocopi, Jocopi, Pango. Man, Javo. There's no use Rambo. They will not let you kill him. Rambo, put him down. Put him down. You tell them lie. You live for a while. But I think this magic thing like bamboo sway and wind. I think one day it stop. When it stop I think sun still come up.  Come on, come on.  Such as it is. Whatever you want of me. Love the woman, love me. Jiri, if I dared love any woman it would be you.   Rambo came the next morning to look at the watch. He saw that it was running and left without a word. And he came the next day and the next and the next. First it was amusing but gradually the terror began to creep in. As long as it ran I'd live and whenever it stopped for whatever reason I'd die. I took the wine that a half a dozen times a day and hold it to my ear and listen to it. The drums in the village seemed to be constant. The drums of watch in my own heartbeat became mixed into one crazy quilt of sound. Craziest still when I came down with malaria. When Rambo came and saw the fever in my face he smiled and left and I cursed him as I wound the watch for the third time since dawn. Two nights later Jiri slipped into my room.  I have heard you are sick. It's a fever. Where have you been all week? They would not let me come. Tonight they ran away for a while. What do you mean? I mean if my father accepts the marriage gift I am to be the wife of Rambo. He is head man. I had no choice. Do you care? What if I did? I ask you. Do you? If you were married to me you could only look forward to being a widow. There is a way. If you care enough. Wait. Just stop. What is wrong? Here. Let me have it. I got to get it started. I must have forgotten to wind it. What are you doing? What are you saying? It won't run. It won't run. Rambo will find out. What is this running? Hold it to your ear. Where is the drums? I thought it was a watch. I thought it was a watch. Listen. There is a way out of the valley. I know about it. So do I, Jiri. There are twenty guards watching. No. I mean another one. It is behind the waterfall where you made the magic thing of Rambo. What?  It is steep. Could I have climbed it? We can go together if you care. But I'm sick. Maybe in a day or two. If the magic thing stops a day or two, maybe too late. If I'd known about it a week ago before I caught the fever. In a few days I may be married to Rambo. All right. Marry him. Don't say that. I'm sick, Jiri. I can't do it. Go ahead and marry him if you want. Leave me alone. I tossed away the hours at night and day. Lying on my cot baton sweat. And time itself seemed to gel into one great mass of fever with no form nor dimensions. And the fever sang in my ears when I strained to hear the watch. Sometimes I mistook the drums of my own heart. I fought to stay awake, to keep my senses to live. Fought against odds it grew greater by the hour. Sometimes in my delirium I thought that Jiri had slipped into the room like a ghost had wound the watch and talked to me and left. But I could never remember anything that she'd said. And then finally one night, just before dawn, I woke and knew suddenly the name of the terror. Jiri, Jiri are you here? It's like it stopped. The watch is broken and stopped. Sometimes in a fever there comes a moment of clarity and strength and I knew suddenly what I must do. Without trying to find the watch, I leave from my cot and headed for the waterfall. By daylight I was halfway up the rock wall, drenched by the falling spray and dog tie. But the slope from here on was gentler and I kept moving on up the cliff. Now and then I stopped to look back. And that's when I saw. Jiri! But I saw something else too. Jiri was a hundred feet below me and beyond her at the base of the cliff was Ramabou in half the tribe. There was nothing I could do now, but... Mommy! I saw Ramabou raise his bow, draw back the arrow and let it go. I saw her fall and lie there on the rocks. I saw Ramabou pick her up, carry her back toward the village. I knew the greatest thing I'd ever owned was gone.  They turned and plunged into the jungle. Three months later when Tom Dawson showed up in Port Moresby again, Elizabeth had sold all his paintings and left on Ducard's schooner long before so. Tom moved into his old house and he stayed pretty clear of everybody, except for a night here in the bar now and then. He didn't tell any of us what he'd done or where he'd been. I suppose we never would have known if that hadn't been for a coincidence I was tending bar just as I am now and suddenly some fellow walks up and slaps a carder. On your feet, Joe! We'll join us this back in time! Well, what's that? I'm six months dry and rare to go. Where have you been to WB? Oh, so far back countries never even heard of beads. How can you cheat them? Oh, say, I stumbled under something. Oh, you remember that painter Tom Dawson? Yes. Well, you remember that watch, what's her name? I'll give them a... Well, there it is. Well, where'd you get that?  Believe me, Joe, if I... Where'd you get that watch? Where'd you get that watch? Well, I guess from the person you left it with. I didn't leave it with anybody. That's not what she said. What do you mean? Tell me, who? Was it Jerry? Yeah, yeah, that's her name. She's living in that house you built. Alone, if you're interested. What about him? Oh, the head man. Yes. Yeah, well, it seems he lost face when he let you get away. They figured you for their good luck or something. Anyway, they put him out a long time ago. And Jerry, she's all right. She's living in my house. Yeah, yeah, alone. She made that plenty clear in case... Thanks for everything. Yeah, I'm glad... Hey, hey, where you going? Well, what about this watch? It's yours. Well, I'll be up. Hey, Joe. Yes? This watch for a bottle. How about it? It was five or six years ago. Nobody around here has ever seen Tom Dawson since. It was all of us. They got a pretty good idea where he went though. Yeah. And I'll lay out some one thing, stranger. I'll bet you he's after it. The direction of Norman MacDonald Escape has brought you the silent horror by Hugh Cave, specially adapted for radio by Les Crutchfield, starring Harry Bartell with Georgia Ellis. Reached in the cast were Jack Krushen, Ben Wright, Ann Diamond, Stan Waxman, and Luke Rougman. The special music for Escape is composed and conducted by Leith Stevens. The light, heavyweight boxing title goes up on the chopping block later tonight when champ Joey Maxim squares off against challenger Bob Murphy. With this exciting championship go, your Wends Denight fight exclusives on CBS Radio begin another action-packed season. Don't miss it, blow-by-blow for most of these same stations later tonight. Next week, Hearthstone of the Death Squad returns to the air. Be sure to listen next week at the same time for the first of this new series. Clarence Cassell speaking. This is the CBS Radio Network.


I'm Greg Lee. Thanks for joining us for another edition of Made in Riverside. But tonight, they're here rehearsing for the Festival of Life, such as the West Nile virus. And so recently, City Mosquito Control was undertaken by the City of Columbia. I fell in love with Greg's personality. He was always hosting events. He was always involved in the community. He just talks to everybody and knows everybody. I'm in the business of talking to people. They said I could do it with these. They said he came natural. I think it's a gift. He really brings people together. Greg and I became engaged in 2014 in Oahu, Hawaii. We were so much in love. In September of 2015, Greg started to develop flu-like symptoms. And I ended up taking him to the emergency room. Greg presented with nonspecific symptoms. He had some nausea, some vomiting. He then developed a condition known as hydrocephalus and that swelling of the brain. And that can quickly cause damage to the brain and permanent injury. They ended up inducing him into a coma. When Greg arrived, he had been diagnosed with West Nile virus. And we confirmed that diagnosis. Our team quickly realized that he was going to need the expertise of many different areas. He was soon seen by our intensive care physicians, our infectious disease specialist, our cardiologist, our neurologist. He's the most severe West Nile encephalitis patient that we've seen. He then developed cardiac arrest and respiratory failure. I remember the care team at Kaiser Permanente being very aggressive with their care. Being very open to letting us know what was going on. Knowing that really takes a burden off of you. Our entire team came together to surround Greg with all of the specialty knowledge that was needed to get him through this hospitalization. All of those specialists communicating with one another seamlessly depended on our integrated system of care. Dr. Dall started to build a sense of clarity. He knew that there was potential to move forward. I woke up like, where am I? Why am I like this? My face couldn't move. It couldn't move. The only thing that was moving was his eye. And I can see that little spark in his eye that something there is something that we're fighting for. He's just one of a kind. There's no one like Greg. Greg basically had to start from scratch. He had to relearn how to eat, how to talk, and now walk. He started regaining his upper body strength. He needs his bicep and tricep. I have a great care team around me. Dr. Dall has always been there for me. Kaiser Permanente has always been there for me. They brought me back to life. Dr. Dall is one of our guardian angels throughout this whole process. He just genuinely cares about Greg and his recovery. Hard work, patience, and faith. Faith that this will end. To see him continue with that attitude of determination is something that I can't describe. It just, it makes me very proud. Greg's taken the initiative to start planning our wedding again. Walking Gina down the aisle. Look forward to what that means. This whole experience has brought me to our family. But that keep going. That's the only way keep going. There's two steps.


Hello. My name is Ruth Beyn. I'm a psychiatrist by background and currently in the role of Deputy Chief Medical Officer with the Commonwealth and I'm absolutely thrilled to be giving this opening address to the Mental Health Professionals Network conference. Of course I'd like to start by acknowledging the traditional custodians of the lands on which we meet. For me it's the Wurundjeri people of the Kulin Nation and I pay my respects to their elders past, present and emerging and of course that extend that respect to any person of Aboriginal and Torres Strait Islander background who may be listening to this talk today. So I might bring up the slides now if we can. And the title of this conference was All Together Better, Collaborative Mental Health Care in a Changing World. So I'm going to talk a little bit about some of the changes that have been happening in my world and how they relate to collaborative care. Next slide, thank you. So look I'll talk very briefly about Australia's mental health system which we all live and breathe. I'll touch of course on most of the audience for this I'm assuming are people who work within health and who have a particular interest in mental health if not part of the mental health workforce. I'll then talk a bit about one of the things that's been occupying a lot of my time in recent months or even the last year or two which was the evaluation of better access which is a very significant chunk of Australia's mental health investment. Then touch on the agreement and then go to where to next. So next slide thanks. When we think about mental health in Australia it's hard not to remember the last two or three years and COVID and the impact that that may have had but even if we go pre-COVID we know that there were a lot of concerns about Australia's mental health system and about the mental health of Australians. Our system is made more complex because of our federation with different responsibilities being shared between the states and territories but before COVID and during COVID we had a number of really important bits of work and plans and reports that pointed out some of the issues in our system and also some of the levels of distress and anxiety and other mental health concerns that people in the community were experiencing and I have to say we as in the Commonwealth where I worked kept a very close eye during COVID on the number of calls going through to lifeline or kids helpline or reach out and they were all pretty worrying in their risers although of course they'd also recognise that people were reaching out for help. Next slide thank you very much. One of the very important pieces of work that was done amazingly was done during 2020-21 was the second national study of mental health and well-being and this is a really important study because it's carried out by trained interviewers using a standardised interview schedule that's capable of a reasonable assumption at diagnosis and really what it showed was that in many ways things hadn't changed since the last survey which was back in 2007 in that one in five Australians had experienced mental health disorder in the mental disorder in the previous 12 months. That was about the same but the thing that was particularly concerning was that 40 percent of young people had experienced that sort of problem in the previous 12 months. There were some particular groups that were at very high risk or more likely to so particularly women rather than men as I said young people rather than older and particularly 54 percent of people who identified as LGBTIQIA plus reported having experienced a mental disorder. So this survey provided a deeper understanding of the some of the challenges that have been faced by Australia. It also gave us some information on who was using which services, their social and economic circumstances and perhaps one of the positives if there is a positive out of this is that around about half of those who had experienced a mental disorder in the previous 12 months had sought support. Now half doesn't sound like a really great number but in fact that was significantly better than the 2007 results. So it's sort of it's hard to extrapolate cause and effect but but I think what we could say out of this is that people were we did have to have high levels of of mental distress most often mood anxiety people are by and large reaching out for help but there are significant parts of the population that seem to be experiencing higher levels of distress and may or may not be able to access that help. So next slide thank you very much. Just want to touch on the mental health workforce because when people reach out for help they most often will reach out to either support services or clinical services in both the private public state or Commonwealth funded sections and we hear a lot about workforce don't we are not just mental health workforce not even just the health workforce we hear a lot about challenges of getting the right people in the right place and certainly within mental health there are I'll come to it shortly but there are significant gaps in absolute numbers of of various professions as well as a maldistribution. So the whole sort of importance of supporting people and trying to improve workplace culture and improve the sort of recognition the person centered care and people feeling like they're doing a good job is pretty important perhaps just as an example of some of this we have a thing called the national mental health services planning framework which is a really useful tool to try and plot the type of workforce you might need for a given population and in 2019 according to that planning framework there was a 32% shortfall in mental health workers compared to the target and it was expected that that shortfall would increase if we didn't do something about it and the largest relative gaps were for consumer and carer workers now that that's it's a larger relative gap although it's a much smaller workforce and it's a growing workforce but also there was a shortage of psychologists as well as nurses and others next slide thank you very much so this just gives you a bit of a graphical sort of display of of where we've where we've got shortages I'm not sure if you can read that if it's too small for you but basically the top one shows is the general practitioners then psychiatrists then going down to registered nurses which is the biggest workforce but a very significant gap through psychology OT indigenous health workers and then the second big one is the vocationally qualified mental health worker again a really important part of our workforce providing support particularly in the community and probably particularly in relation to NDIS services so there's shortages but we also know during COVID that our workforce experienced quite significant distress and particularly psychological distress there was a quite there was an important survey that canvassed health care workers and from that I think about 62 percent reported experiencing anxiety during COVID 58 reported being burnt out feeling like they weren't bringing value to their work or they were you know just couldn't get the same enjoyment and satisfaction from their work and in particular I think that affected doctors and nurses who had increased rates of depression and suicidal ideation so there were also sorts of disruptions to workforce and all of those roster changes not only those people who had COVID but of course the impact of having to work in COVID affected environments one of the things that the department funded for workforce during that time was the essential network or 10 run by the Black Dog Institute and just to highlight that during from sort of May 2020 through to January 2023 there were almost 90,000 people who accessed 10 so that was health professionals looking at the resources and programs by the digital hubs as well as a very large number reaching out for assessment or even one-on-one support so people did did and maybe still are have a tough time working in health and not and mental health's included in that during the last two or three years so we've got we've got a difficult system we've got people who are experiencing high levels of distress and a workforce under pressure next slide thank you. So now I'm just going to move to it as I said one of the things that's been occupying a lot of my time better access people might might remember better access came in around about 2006 it might have been called better outcomes back then but but basically it was a it was a recognition by the Commonwealth Government that there was limited access to evidence-based treatment particularly again for anxiety and depression and that one of the ways of doing that would be to create an MBS funded system for a limited number of sessions for people to be able to access focused psychological strategies or other psychological therapies on referral from their general practice and over the years better access has changed a bit we of course had additional sessions in relation to some disasters like bushfires additional sessions were also created during COVID the the original six went up to 10 and then that went up to an additional tender in COVID they came to an end at the end of December along with the other COVID measures but but better access was certainly taken up and and in 2021 an evaluation was carried out looking at better access from a number of viewpoints I won't go into the detail of that evaluation it's it's available publicly but what that evaluation found was that in 2021 one in every 10 Australians received some better access service now that could be the mental health treatment plan provided by a general practitioner and around one in 20 received at least one session of psychological treatment which could have been delivered by a psychologist clinical psychologist OT social worker or of course a general practitioner but but while that says a lot some of the recent inquiries particularly the productivity commission which reported in 2020 said well how do we know that this is being targeted to the right groups how do we know whether it's having a good outcome or not clearly lots of people are using it but is it is it working and so that's was the other reason for really looking at getting this independent evaluation and as it says there that evaluation was published in release publicly in December 2022 it yeah just the next slide thank you sorry about that I'm so one of the the things that the better access evaluation did was that firstly it combined a number of databases so one of their studies enabled us to look across the population at linking people who'd used a better access MBS item with other things socioeconomic variables like place of address income use of other health health items and so forth we also were able to do some questionnaires of individual users of better access as well as surveys and questionnaires of those who provided better access it was a fairly large sort of consultative forum that happened with a whole range of providers consumers carers and others that that generated a number of ideas and as I said there was also sort of plotting out who was getting better access how much and with what apparent outcome and basically what the evaluation found was that those who did receive better access by and large said it was helpful and they had positive outcomes and in fact the more unwell a person was at the beginning of the the episode of care the greater the improvement and and that was found again and again but it also found that some parts of the population and some segments within the population were more likely to access better access and more likely to access more of better access than than others so people in regional rural remote areas those from lower socioeconomic areas by by postcode or modified non-ash area tended to be missing out either getting just a treatment plan and no psychological services or a fewer number of sessions and and the the evaluation also found that well better access was initially targeted towards those with if you like relatively uncomplicated presentations that over time that that had changed and people with quite severe quite complex needs were were accessing treatment through better access if they could get it but there were also of course a number of barriers for for getting access and particularly those were geography which I've already touched about but also affordability and again over time and this was really even more noticeable in the in the last 12 months so during 2021-22 the gap fee had actually increased in size and in the number of services where gap fee was charged and again that sort of says that this which is a it's a publicly funded psychological access to psychological services was in a sense being distorted to those areas where more practitioners were available but also where people were more likely to be able to afford and pay a gap fee and so that the the the work for shortages that I've just talked about were again getting a bit distorted by by where people were moving to provide services and and I think the the evaluation absolutely it sort of emphasised that better access is good but it's not equitable and and it's not equally available to across the population and one of the very interesting findings which is I'll just mention because it was fascinating to me is if you look at level of need as measured by something like the K-10 then overall within the population there are higher levels of need amongst those who if you like have lower socioeconomic profiles or who live in areas where there's greatest socioeconomic disadvantage those those people tended to have higher rates of prescribing of antidepressants and lower rates of access to psychological treatments now now there might be all sorts of reasons for that there's reasons of choice and availability and all that sort of stuff but it did feel like the more intensive and if you like time time investment that goes with psychological treatments was again being more available to people in in particular areas and not to others and I think this is demonstrated on this slide next slide thanks so look at this is a really neat graph as I've mentioned the greatest barrier to accessing better access probably was that affordability and and you can see there the price going up or the cost rather going up during 2022 and probably if we looked at why people in those lower socioeconomic areas were having fewer sessions it's not to do with severity it's probably to do with availability and affordability clearly the availability of telehealth changed some of this but but we all know that particularly for psychological treatments telehealth is of value but it's not the whole answer and it's not going to resolve the equity issues and and I think the number of newt the one of the other areas of concern was that with the extra 10 sessions those extra 10 sessions didn't seem to be going to people with more complex presentation at the beginning it seemed more likely that the extra sessions that you know up to 20 sessions were more likely to be going going to those who could afford rather than need and there also may have been a compounding factor there because the number of new people accessing better access treatment reduced from 56% in 2018 down to 50% in 2021 when those additional sessions were in place so you know I guess the conclusion from better access is people are using it it's great it's expanded I'm sure those who provide better access services are providing excellent care and and interventions but it certainly needs a bit of attention and a bit of reform if we're going to say that it is also about improving access across across the community and and targeting perhaps those with particular needs thanks very much next slide now along the along the other time the the better access evaluation was happening and COVID was happening and all of that we were also in the process of developing the national mental health and suicide prevention agreement this was again a really important piece of work and and again in response to a number of reports but most particularly the productivity commission inquiry and really again highlighting that there is great fragmentation that different jurisdictions do things differently that there's been confusion in roles and responsibility and and that if we're going to try and bring the system together more and make it both more accessible but also more easily navigated as well as address gaps then it can't be done by one level of government alone and and clearly this agreement which was a bit of a miracle I think that we managed to get get done and get all states and territories agreed but clearly it will take time and particularly again if we come back to workforce there's a pipeline things take a long time to get in place next slide thanks very much so just a few of the outcomes that we expect from the national agreement and clearly the government has changed it was the previous government that commenced and signed off that national agreement but my experience is that the momentum is continuing and that people continue to recognize the importance of this so I won't go through all of this but clearly some of the outcomes of the agreement were around better data better information sharing some about better and more standardized approaches to entry to the system through more consistent initial assessment a better articulation of the roles and responsibility and and trialing some new models of care and I might just go to that now so we'll go to the next slide thanks um when one of the recommendations from the better access evaluation was acknowledgement that a fee-for-service model doesn't it is it is you know it's great it's good in many circumstances but a fee-for-service model doesn't always allow the sort of supports and interventions that people who particularly who might present with more complex problems might need so one of the big emphasis in the agreement is some of the new models of care that are affordable that have a more multi-disciplinary workforce and and that are more easily accessible so some of these are just beginning some are some are sort of well established but i'm just going to talk through them a bit and there are three main streams if you like which I'll touch on the head to health kids which is probably a long overdue recognition of just how important it is for young young children and their families to be able to access mental health assessment and care the headspace which headspace has been around a long time but during COVID it became obvious that there were quite long wait lists in some places and real struggles in in attracting the right workforce and then head to health adults and as you can see in that slide the the common factors of these are that it's targeting towards not the ultra ultra acute or severe that are so you know that by and large receive treatment and care in the state funded systems but but do involve multi-disciplinary teams have a more holistic approach and not defined by narrow eligibility criteria thanks very much next slide so head to health and these these things are just at the beginning but we did have the opportunity to have a bit of an experiment with head to health because during COVID people might recall that Victoria had pop-up head to help clinics and they also were opened in ACT and New South Wales but we're and and for those of you who are in Victoria Victoria has a sort of different profile because Victoria as a result of the Royal Commission has announced and is developing a whole stack of local mental health and well-being centres that are very similar I think to the head to health model anyway we've already got we've already got nine of them and I'm actually went to the opening of one in Canberra at about mid-feb and I think just at the end of Feb I'm going to the opening of one down in Geelong so you know they're happening and the 21-22 budget announced funding for establishment and ongoing operation of a whole stack of of others dotted around the country and the the idea of these is that they're located in places that are easily accessible by their community that they can be accessed through ringing the central number 1-800-595-212 or by walking in and that they do provide a mixture of sort of if you like support and coordination nearly all of them will have a significant number of peer workers to provide that sort of welcome and support but also access to clinical treatment not not not intensive or forever because these things have to have throughput but much more flexibly driven and with a variable workforce and the funding model sort of allows for a degree of regional variation to address local needs and although you know I think these this model is still evolving to have a flexible workforce that will meet the needs so for example the one in Canberra that I went to recently had a couple of clinical psychologists part-time psychiatrist as well as I think I think an OT and I can't remember if there was a social worker and several peer workers as well and so so we're really you know able to respond to different needs but then and they also have I hope we'll all have very strong relationships with their state and territory funded service the one in Darwin is co-located with the top end acute mental health service run by the NT government the one in Canberra likewise has a really strong relationship with with with the local health service. Next slide thank you the the next model here just to touch on is the Head Health Kids Hub this is much much earlier days I think there's not one fully established fully open yet but but there are there are some that are on the way and there will be at least one in each jurisdiction I think the kids have each jurisdiction by 22-23 and ACT and in Northern Territory a little bit further behind I think they'll get theirs by 23-24 but again the idea is that these will complement that they'll integrate well with the state-funded maternal and child health services as well as child mental health services they'll they'll be able to offer assessments and as I said not predetermined by diagnosis these will need to be carefully watched because there's a lot of need out there and we know that there's not much point to have something that is not accessible or that you've got a six or 12 month waiting list for so these are again a very exciting model one that I'm really looking forward to keeping really close eye on next slide thank you and by the way if anyone can hear my dog streaking in the background they're not in pain if you can't hear them I'm very glad the the next one just to touch on is Headspace. Headspace has been around for a long time there's a lot of them I think there's 153 out there at the moment of which a significant number are located in rural and regional Australia and that it's very much a primary care model so Headspace was not intended to care for those with more complex presentations and for many in many places that that was a real gap that there was a threshold if you like for accessing adolescent mental health services funded through the state was quite high and Headspace struggled to to respond to that level of need so there is a at the moment a rollout of of an increase in the funding base for Headspace and the expectation of that is that it will now enable a stronger workforce that will help deal with some of those weight less problems and perhaps also be able to respond to people with with more complex needs although I'd sort of be very you know very important to emphasise Headspace is a primary health model there are of course a limited number of early youth psychosis services that are more intensive for particular subgroups of young people but but those then there are not so many of those so again this this intention is to enhance the more coordinated multi-disciplinary care for cohorts of young people and hopefully all of these services also provide a platform for students for graduates for people in early on in their career to be able to have exposure and work in order to grow the workforce as well as grow their experience so those are some of the things that's happening under the national agreement next slide things I also just wanted to sort of point out that we do look for what what other models are happening and what what sort of innovations or models of care are being developed because Australia is not not alone we may be an island but but we share many of the mental health pressures with with others so just to mention a couple there in the UK they're improving access to psychological therapies or IAT started quite a while ago now it's it's pretty extensive I'm sure there's criticisms of it but one of the things that IAT has done is really put in place a very robust measure for outcome reporting and and that enables people to compare and contrast outcomes over time and also across areas and and I think you know one of the things we don't have is is a sort of embedded outcome measurement in New Zealand it's relatively new the access and choice program and the model there is to actually place mental health practitioners clinicians and support workers within existing general practices and and again a really strong part of their model is that you'll get a same-day appointment and they they do a lot of sort of single session goal focused interventions but if you need more you can you can get more so they're really trying to have a strong focus on availability immediacy so opportunistic availability as well as a focus on being culturally and socially appropriate and then one of the things that's happening in Australia developed by Beyond Blue is a thing called new access which is it's effectively a sort of a mixture of face-to-face and online coaching to individuals who present with mostly sort of mild mild problems or particular life stresses or workplace stresses so I think it's important to recognise that there are other other things happening and I think the final slide thank you so to sort of round it up I I try very hard to remain an optimist in my career I have to say things go up and down a bit I mean they're quite sure if you're heading in the right direction but I do think hand on heart that we've we've got some really important bits of work that have been done that we can build on so better access being evaluated and now looking at what what either major changes or minor changes might need to be made to that to improve it I think of course that sits alongside some of the work in the strengthening Medicare area but through the agreement looking across state and territory and Commonwealth funded services and also how how funding models like how salaried services like the head to health platforms might fit alongside FIFA service MBS services is happening really I think acknowledging that sometimes multi-disciplinary care is important now that's not new I mean community mental health centres have always been multi-disciplinary but of course the over time their availability has narrowed and thresholds have become quite challenging so so trying to sort of loosen that up and I think you know as I said to use think about workforce all the way and think about balancing placements expanding people's interest in mental health and and really it's sort of thinking what is the right workforce and are we using people to the best of their skills and ability so I know reform will take time I'm sure we'll talk about many aspects of that during the mental health professionals network conference thank you again very much for inviting me to be part of it and I wish you a happy conference thank you goodbye


The 2020 Nebraska Book Awards will honor authors and publishers of books with a Nebraska connection published in 2019. The 2020 Nebraska Book Award winner for poetry was described by poet Stacy Waite as, while many of the poems in the collection reach back in time and mythology, the book could not be more essential and more poignant than it is right at this moment. The book is a retelling of the story of Persephone, Demeter, and Hades' engorgeously crafted poems. This Bright Darkness by Sarah McKinstry-Brown, published by Black Lawrence Press. Hello, first I want to say thank you so much to the Nebraska Center for the book for their continuous advocacy for literary arts. I so appreciate the work that you have done and continue to do to help support Nebraska writers and Nebraska presses. I also want to say thank you to the Kimmel-Harding Nelson Center for the Arts in Nebraska City. It was at a residency at the Kimmel-Harding Nelson Center for the Arts where I first began writing the poems for this Bright Darkness, the collection which has won this year's Nebraska Book Award. Having protected time and space and recognition of my work through that residency was huge for me and so I am so grateful to them and for what they do to make Nebraska look good in terms of the arts that's a world-class organization that brings in artists from all over the country and the world and so thank you Kimmel-Harding Nelson Center for the Arts. I want to acknowledge that while it is strange that we can't all be together in the same room, it feels really appropriate given the nature of the work that we do as writers. So much of the work that we do as writers is in isolation. It is invisible the work that we do from the first idea, the first drafts as we continue to work and revise and rewind and re-imagine. So much of that is invisible and done in solitude and what keeps us going I believe as writers is the knowledge of the other writers in the world and in our community, the fact of their presence through their books, their ideas, the lives that they've lived. That is what sustains us as we pursue our art. So I am not with you in person but I know that we are all always together in spirit and in work. I also want to acknowledge that writing this book was very difficult for many reasons and what enabled me to continue to press on and finish this collection is the support and love of course from my family, my dear, silly, wonderful, strong, supportive husband, my girls and the wonderful friends I have in the writing community here in Nebraska that has embraced me since I first set foot in Omaha in 2002. I was doing a spoken word poetry tour in 2002, took the Greyhound bus here and have been embraced by the writing community ever since then. Finally I am thinking of course of my parents who are both far away. I know right now all of us are thinking of our loved ones who we can't be with and so I want to thank them and acknowledge them. Their love for each other brought me into the world and when I think about what birthed my love for poetry and my pursuit of poetry, I know that it was my parents' empathy, imagination, their creativity, their love of music and you know my dad is a salesman and my mom was a nurse and their lives were poetry. They lived poetry and how they engaged with other people in the world and so thank you to them. Thanks again to the Nebraska Center for the book for acknowledging this bright darkness for the Nebraska Book Award and I hope you all you know stay safe and keep writing, pressing on. Describing the winner for poetry honor book, poet Marjorie Seizer says, here is an unblinking eye we can trust, a voice we can believe when Mark Sanders says, loveliness endures, even in grief, loss felt is never really loss but keeping. Our work like his may well include close observation of life and its ghosts. The book is In a Good Time by Mark Sanders, published by WSC Press. Hi everyone, this is Mark Sanders from Nacodotius, Texas currently, however just to make it clear for those of you who don't know me, I'm a Nebraska boy, was born and raised there, lived in the San Jills part of the country for a long, long while, was educated at Carnish State College and at the University of Nebraska and I will always be a Nebraska and so it's with the great pleasure that I'm taking part of this event today. I wish I could be on Lincoln, I wish I could be there but obviously we're going to be doing things a little bit differently this year. I want to say thank you to the Nebraska Center for the book for picking In a Good Time, my latest collection of poetry for the Poetry Honor Award. This book was published by Wayne State College Press and up there I have to thank Chad Christensen and J.D. Grommels for the work on the book and for their passionate diligence in getting the collection done back in 2019. The book was a result of about three or four years worth of writing poems and it was a considerable labor trying to come up with what we wanted to have for the final collection and you know it's something that I was very proud of and it was written in a good time and so the title of the collection comes from the fact that it was such a positive event for me. I want to thank Rod Wagner of the Nebraska Center for the book, he's been very supportive of me over the years and the Nebraska Book Award is a very significant thing for me. I truly appreciate it. I've had a few other awards along the way and the Nebraska Book Awards is an important thing for the writers of the state and I hope that it continues. I'd like to also thank my wife Kimberly who has done with me the long haul on all my poetry writing and she's done a bear, I'm not a work in supporting writers herself and you know she knows just how important this thing is to a poet like me and so you know thank you in behalf of a prayer too. To close off I'd like to read one poem from the book, this is called Still Life. The poem was originally published in the Midwest portal and that was later on reprinted in the New York Times and I think this is a poem that speaks well for all of us in the current age that we're living in, all the fears and concerns and anxieties that people have and so if this brings peace to anybody then I'm very happy that it has done so, the Still Life. Now just at that silent place between sadness and gratitude, when worn balances we all weather, the cardinal leaps from a bare-trimmed limb, its red bloom lingering, the sun down and deepening, darkness where night clouds consume it, evanescence of orange and purple, how moment passes, how memory holds, the heart must break if it has ever felt joy, the heart must break because diminished things matter and having mattered hold still, you were here for us, then break heart, your fingers lie upon the pulse of our days. Again, thank you so very much to Nebraska Center for the book and for the Nebraska Book Award. I truly appreciate it.


Hello, my name is Sophia Shahu, and I'm a Principal Investigator at Mass Eye Near and Harvard Medical School. Along with David Miller, a medical oncologist and dermatologist at Massachusetts General Hospital, we're excited today to present Storyboarder, an R-Package and Shiny application designed to visualize real-world data from clinical patient registries. We hope to present this package that we created and discuss its applications. So here's an overview of our talk today. I'll begin with describing the unmet need that inspired us to create Storyboarder. Next, I'll provide a general schema overview of the app, and then I'll hand off the presentation to Dr. Miller. We'll discuss how to install Storyboarder from GitHub. Next, we'll discuss the background on the data capture instruments in Storyboarder and show how to install them into Redcap. This will be followed by a demonstration of the application using a built-in data set. Then he will discuss data science principles behind Storyboarder and conclude with limitations and potential solutions. Okay, let's get started with the unmet need. Tumor registries are a rich source of real-world data which can be used to test important hypotheses that inform clinical care. Exploratory data analysis at the level of the individual patient when coupled with interactive data visualizations has the potential to provide novel insights and allow us to generate new hypotheses. Unfortunately, software that can be integrated into an oncological data collection effort and generate interactive data visualizations of a subject's cancer journey are very limited, and that's what inspired us to create Storyboarder. So let's move on to the general Storyboarder schema. Storyboarder takes as input clinical data that's structured and captured in the electronic data capture system, Redcap. Storyboarder is designed to wrangle, transform, and ultimately provide a visualization of the patient cancer's journey using the data that's stored in Redcap. The generated visualization is a timeline that displays the key elements of the cancer patient's journey. It does this using the data stored in a structured fashion in Redcap. In reality, it's a little bit more complicated because not only does it function as a standalone package, but it's also built as a shiny application. Again, the input of the shiny application are clinical registry data captured in a structured electronic data capture system and users interface with Storyboarder in a web browser. That's where they're able to control which patient's record they would like to create the interactive data visualization timeline for. And it's the server side of the shiny application that executes the code of the R package, which then wrangles, transforms, and visualizes this clinical data. So this data visualization output is a plotly interactive graph that displays a timeline of the patient's key elements along their journey. So now I'll hand it off to Dr. Miller to start with how to install Storyboarder from GitHub. Thank you, Dr. Shalhout. Now we're going to provide background on the data capture instruments incorporated in Storyboarder and show how to install them into Redcap. I'm aware that most of you are familiar with Redcap. For those of you that are not, it is a secure web application for building and managing online surveys and databases. It's been implemented by over 5,000 institutions across the world. Storyboarder incorporates the following 11 data collection instruments that capture information across the patient journey. And they include subject status, patient characteristics, presentation and initial staging, lesion information, pathology, surgery, radiotherapy, systemic antineoplastic therapy, adverse events, lab results, and genomics. These data capture instruments are utilized by the Mass. General Brigham, Merkel-Selcarcinoma patient registry. And they incorporate data elements for M code, the minimum common oncology data elements, and fast healthcare interoperability resources or FHIR. They also include disease specific unique variables. In an effort to aid in the implementation of these data collection instruments, we've created a series of posts and placed them on the Miller Lab website. These posts provide insight into these individual lesion information instruments. We also talk about some of the limitations and solutions. We recognize that various investigators use different ontologies and nomenclatures when they create their data collection instruments. And in an effort to help aid in implementation, we've created lookup tables and other tools to help map to other nomenclatures. We've also made this data dictionary freely available to all of you. We spent over four years working on this data dictionary. It has over 4,000 data elements that you can collect on. And we've provided this for you in order to help you use Storyboarder. We place this on our GitHub, the Miller Lab Storyboarder. It is found in the data raw folder. You can click on this CSV file and upload it into your RedCap project. In order to aid in the implementation, we've created a fake data set of five simulated patients that's found within Storyboarder when you load it into your R session. It must be said any information that is similar to any real patient is completely coincidental. All the data in these simulated patients are completely fabricated. We've incorporated these data collection instruments into our clinical informatics ecosystem that includes the electronic health record or electronic data warehouse, electronic data capture system, and an integrated development environment. And our overall clinical informatics pipeline is probably pretty similar to many of you that are using Epic RedCap and RStudio. We've also created several R packages in order to both help augment data abstraction and in years past. At R Medicine, we've talked about ELab in genetics and we've built now packages to help augment data analysis and body mapper in Storyboard. Now we're going to provide a demonstration of Storyboarder with the built-in data set. So once you've installed this from GitHub and loaded the Storyboarder into your library, when that happens it'll load dependent packages such as those found in the tidyverse, plotly, shiny and shiny dashboard. We're going to use that embedded data set Storyboard underscore data set and we're going to store it as an R object DT. Let me take a look at that R object. This simulated data set has 115 observations of those five patients. Next, to launch Storyboarder, you use the function launch Storyboarder. This function takes two argument, a data argument, and then has a date shift argument which defaults to false. If you want to shift all of the dates in a systematic way in order to protect certain protected health information, you can change this to true. But we're going to leave it as false and we're going to load the DT object. This will, once launched, cause the application to launch in an embedded browser and we're going to go ahead and click that so we have our Storyboarder shiny application embedded in Safari. What you'll see in the sidebar are two options. The first option which defaults is the subject dashboard. This allows the investigator to select the patient for which you want a Storyboard generated. The first display is a tabular form of relevant patient characteristics. For example, demographics, initial staging, subject status of the patient, their burden of disease. We also display genomic information. Perhaps the patient had next generation sequencing, kind of a standard of care in 2023. Perhaps that information was collected using the genetics package that we created. That is displayed in this dashboard here. Furthermore, the dashboard contains any therapeutic intervention that a patient may have had and has been captured by investigators. And this is very useful as a lot of information right at the fingertips. But we think that the main attraction of Storyboarder is this interactive data visualization. So when you click on Storyboard in the sidebar, what happens is that information from RedCap gets displayed on this horizontal timeline. When you see this timeline right out of the gate, there's a lot of information stored in the data visualization, which you can see here. You can see elements of the patient's disease journey, the type of staging that they had, various treatments, and their overall subject status. But better yet, we have a lot of information stored within the hover text. So let's take a look at simulated patient one. This simulated patient's journey began with a left ankle skin primary tumor. And for this simulated patient set, these patients all have myrchal cell carcinoma. So that myrchal cell cancer and the simulated patient presented on their left ankle. And that was histologically confirmed in this hypothetical date of May 9th, 2019. This patient underwent next generation sequencing using the MGH Snapshot Next Generation Sequencing Panel. Here in the hover text, it has displayed the alterations that were detected via that snapshot analysis. Due to standard of care procedures, this simulated patient went on to have surgery and embedded in the hover text is details of that surgery. So you can see what type of surgery. Do the patient have an excision? Let's note the section. You can see the margins the surgeon used and the outcome. This patient had an R0 over section, which means that the tumor, thankfully, was completely removed. As a result of that tumor being completely removed, the subject status, which is an M-code data element, a minimum common oncology data element, we see that that patient's subject status is NED or no evidence of disease, which is what we want every patient to be throughout their patient journey. However, unfortunately, this patient, like many with mercosile cancer, had a recurrence of their disease with left cath, shin, and transit metastasis. Therefore, the patient underwent definitive radiotherapy and completed definitive radiotherapy. And we see the details right here in our storyboard. The patient had 30 fractions and received a total dose of 6,000 senigrate. This patient was then rendered NED until, unfortunately, recurred once again with a left groin lymph node metastasis. Due to that, simulated patient one received one of the FDA approved options for mercosile cancer and anti-PDL1 monoclonal antibody of valiumab. What storyboarder does is displays each and every dose that a patient receives if that information was collected in red cap. Now this patient, fortunately, went on to have a complete response so their subject status was no evidence of disease on March 12, 2019. This simulated patient then went on to receive maintenance dosing. What storyboarder does is it allows you to create that dashboard and storyboard for every single patient in your registry. Here are three storyboards that are created. Now we use this storyboard, a storyboarder, data visualizations to help us generate new hypotheses by looking at patient level data.  It also has other potential applications. We've heard people talk about using this, for example, at a tumor board where a case is being presented to other clinicians that might not know the patient's overall journey. This is a way to get a quick data visualization, a sense of that patient journey. We hope that all of you who are interested in this type of research can use storyboarder and customize it to meet your research needs. Therefore, I want to discuss a few of the data science and software engineering principles of storyboarder to allow you to customize it for your needs. These are the functions that storyboarder incorporates and we're going to talk about these. We think about them in three different levels of functional programming. What we've done is created a series of base level functions. These are functions that are specific to each data collection instrument. So you see here we have functions for subject status, for staging, for lesions, for surgery, anti-neoplastic, so on and so forth. And what all of these base level functions do is they parse the data and wrangle it to create the same data frame, a data frame with five vectors, record ID, description, value, date, and hover. Now let's look under the hood a little bit more. Now let's use our storyboarder data set to do that. First we're going to call the lesion function. And what the lesion function does is it takes information from this lesion instrument that has a lot of information about, for example, here that left ankle skin primary that simulated patient one presented with. This instrument's capturing information on, for example, the date that this lesion was detected, the location, the size, its response to treatment, various other data elements of interest. What the function does, first thing it does, it replaces the values in the registry with the appropriate strings from the data dictionary. So instead of just displaying numbers on the storyboard data visualization, it's going to display relevant text. The next thing it does is it selects variables from those instruments that you want displayed on the data visualization. Some of these instruments have hundreds of variables. It's not useful to have all of those displayed on the data visualization, so we've selected the relevant data instruments. You are able to select whatever variable you want again to enhance that customizability. And finally, what story this lesion instrument function does is it returns a data frame of five variables. Record ID, description, value, date, and hover. And let's take a look at those. So here we see our embedded dataset after we call lesion. Record ID, it's pretty self-explanatory. Description is the instrument from which the data comes from. Value is the information, the strings that are actually on the timeline. And then we have the dates and the hover text that we saw, for example, right, but our primary that lesion tag is then also concatenated with the date for which that lesion was detected. Another example, when we call the surgery function, it's going to select the relevant variables from the surgery data collection instrument. It's going to replace the numbers with the appropriate strings, create hover text, and then return those five variables. Record ID, description, value, date, and hover. And this is what the data frame looks like when you call surgery with the embedded dataset. So that's our base level functions. Our next function, mid-level function, is Combine Story Border. And what that does is it takes and calls each individual base level function and stores it as an R object, and then concatenates those into a single data frame with those five variables. Record ID, description, value, date, and hover. Now it's taking all of the different base level functions and concatenating them with all of the information from each patient in the registry. This data frame then becomes the argument for the final top level function, which is Storyboard Plot. And that creates the data visualization that we walked through earlier. Now every package has limitations and so does Story Border. Story Border is to be used in conjunction with the data collection instrument of a clinical registry, such as the Mercosel Carcinoma Patient Registry. Therefore it functions optimally when those forms are installed in a RedCap project. As a solution, we have made the data dictionary freely available so that others may adopt a similar platform. So to summarize, tumor registries are an important form of real-world data and the data they contain can be used for both hypothesis generation as well as hypothesis testing. Story Border is an R package with a shiny application front end that produces an interactive data visualization of patient level data. When built around a core data capture system, such as a cancer registry, R-based packages like genetics, elab, bodymapper, Story Border can combine to form a powerful data informatics ecosystem to both augment data abstraction as well as facilitate data analysis with the goal of accelerating time to action for patients with rare tumors. With that, I'd like to thank all of you for your attention and for the organizers for inviting us to give this presentation. Thank you. That was really fantastic. I can see how that would be very useful for visualizing patient histories. And we have a couple of questions in the Q&A that maybe you wouldn't mind just answering live for everyone to hear. The first says, I see a lot of info is encoded in the hover text. Have you guys looked into accessibility software, for example, for blind users? I think hover text can cause issues for those types of users. Are you able to unmute and answer that, David? Does he have access? All right. I think I've been freed. Sorry about that. No, it's a great point. I, you know, honest him.  And I think we should absolutely look into it. That's a great point. And so part of the point about a blind spot on my part to think about the visually impaired users. So thank you, community, for bringing that to my attention. Awesome. And there's one other question about whether you can produce storyboards for multiple patients at a time. For example, if you wanted to see patterns of treatment patterns. And on the same, in the same data visualization, I haven't optimized that yet, but we can we can definitely work on that. I think that would be that would be a nice way to, you know, to add some more texture to the to a registry, for example. It's another great suggestion. Okay, great. Well, thanks again, and we'll move on to the next talk. Thanks, everyone.


Was going everybody forced here. We're ripping it 22 23 spectra basketball That's right spectra basketball case number one pick your team style Justice Tech here for some reason Shopify has been acting a little funky today You refresh this There they are All right, PYT case number one Aaron S. Spurs Anthony M. Chicago Bos with the Clippers Brandon R. Heechang with the Hawks Shunwei Thunder Cody has the Cavs David S. Pelicans Edward P. Nix Hank with the magic Joel T. Celtics Jonathan G. Pistons Rockets Pacers Lakers and Hornets Kai with the Bucks Lee G. Kings Mark M. Jazz Marvin and Nuggets Mitchell H. Raptors Nathaniel S. Wizards Patrick C. Sons Patrick R with Mavericks Robert P. Blazers Sean M. Warriors Tim V. Nets Tony W. T. Wolves and Sixers and Wen Shun with the Grizzlies Let's go ahead and get started Wade's solar eclipse. I'm down with that. Let's see a color blast first case here So we're looking for so we're looking for Knife there's the knife This is a knife some psychedelics some marble some nebulas Hopefully some palo Ivy maybe Steph Curry Paul George has autos in this. That's kind of a big deal Paul George signed for this Last time he had Bonacart autos has the dullest knife of all time right there Fix that today It's last time Paul George had all his own products like 16 17 All right, here we go All right, so we are looking for base Scott Westbrook clips to 149 a Redemption first up Luca Donchich that's color graphs meta Yeah That's how we start the day Dallas Mavericks Patrick are Color graphs meta Now we do it It's how we do it color graphs color graphs color graphs meta is gonna be number to 25 To 25 on the meta that was the first pack y'all Not not stopping not stopping here. We're just gonna keep going Got a big old shack to 99 for the Lakers It's 99 want to scondor Anderson jazz auto It's gone to Anderson jazz auto Thanks, leave any chance. I'll start seeing some of this stuff Only three teams go in the next one now Robert Williams and Gordon Dirt and events. Yeah, that's a cool-looking one to 49 for Dallas Dallas got them cards right now and Max Christie on the rookie Jersey autograph to 75 for the Lakers Mabs Warriors Lakers left in case number two y'all That is 92 of 99 on the Max Christie Watson rookie there and a paint Watson nugs rookie. That's out of 149 and a heat deep space autograph of Caleb Martin Caleb Martin was big for them in the playoffs 25 out of 25 Let's see. Let's see. Let's see a live big hit now More Nebula Come on Nebula Other redemption we big name the bronze arms men not and a Kade Piston 12 of 99 and a redemption For Christian Brown rookie Jersey autograph for the Nuggets Very nice hit for Denver there is Palo band caro rookie for Orlando 62 of 149 Nice card that right there awesome Palo base of Ubrea and Jaden McDaniels and I thought this was the basketball prize. You got a Matt Ryan auto 49 for the T-wolves. There you go Matt Ryan T-wolves auto Christian would yeah, I was a that was a good signing by them Lakers are gonna be good this year Drew Holiday Orlando Robinson Towns to 149 Minnesota Herbert Jones on the catalysts autograph Pelicans Number to 49 Yeah, so who's gonna win the World Cup is USA still gonna win you got Tobias Harris Sixers on the What is this called against the short print? What does it call? What is it called? Menagerie, it's not psychedelic So I guess it is menagerie. That's the only one that's not numbered that other than psychedelic, so Let's stick with that for now and a Jalen Williams out of 75. I believe There are no 199 Ricky Jersey auto for okc In those awesome Ricky Jersey autos Ricky patch autos are on card. I made two boxes down You guys Matt Sliva fanatics with with baseball right now Richard we live tomorrow on fanatics at 420 Eastern Derek Jeter and Michael Rubin high-end baseball fanatics live HQ That's an event right there Riches get rich rich is going to the Big Apple Pull the bring us back some pizza Got melt into 99 for the Sixers Nice one here, rookie Jersey auto Jalen Durin pistons There we go to 199 pistons Jalen Durin Sure, Sam's excited to say his name tonight. All right Christian Wood Jimmy Butler the Montess a bonus to 25 for the Kings. Oh, that's pretty cool Steven Jackson sky high signatures Steven Jackson Pacers 32 of 49 Sky highs are cool. Oh redemption redemption have been the biggest card so far other than the Durin Yeah, I read ish for the Blazers one of 99 and the redemption is a Jaren Jackson junior deep space signatures astral Going to Memphis. What is the astral number two on deep space? astral to 49 Defensive player of the year Grizzly's got a Jordan Goodwin Deontay Murray and Adil and Brooks now Grizzly's the 149 and 725 jazz rookie aspiring pink auto Oce Agbaji That is say though, let's go with their yellow to the yellow and pink Pink auto Oce Agbaji. Very nice.  All right, let's keep it rolling here got coups Wendell Moore and a Kyrie Kyrie is the 49 and a KG deep space signatures Kevin Garnett anything is possible 59 to 75 like the deep space. That one's different though And the other one, right? Rolling rolling on Soon-moo rookie Ryan Rollins for the dubs. This is gonna be to 149 and Kelly Ubre sky-high signatures for Charlotte camera does not want to does not want to focus on that crazy Cracked high second parallel 44 of 49 Sky-high Ubre. Oh, that's nice. We're gonna go right to it rookie neon marble for the jazz Oce Agbaji Congrats Utah doing really well now Neon marble Agbajita 5 I like that one. That's sweet. That's sweet Utah All right, Bam and Lofton and a holy cow Nick van Exel sky-high signatures Nick van Exel Man, that is uh, that's a name right there 71 of 99 Lakers Nick van Exel All right, Jalen Brown at Trey Murphy and a John Collins that have 99 for Atlanta And it's got a pippin junior to 99 on the autograph for the Lakers What's up chris? Mitchell Mitchell. What's up? What's up? All right, let's keep it going here. That was the first half the case had some bangers. I'm digging it so far It's spectra. If you like spectra, you like what we're ripping Never seen spectra. Hope you like a lot of colors Bobby portis bucks five of 25 And checked out one out retrospect auto pal gasol Pal gasol this says It's that's a 99. It looks like it's going to be a dual team card. Look at the back Back has Memphis and LA Checklist I think has both as well. So that will be a random Yeah, retrospect pow Yeah, that is a lakers and grizzlies card. You guys I'll give you the checklist link But that is a random between both of those at the end Has grizzlies here and then has lakers here. It's got both on the back checklist hasn't both as well Feel free to check it out. There's actually a lot of these two team cards They do it every year with spectra as well. I think basketball and and uh football But there's the checklist that'll be a random at the end. You look on that one grizzlies and lakers awesome Pow got LeBron James the knot and a sexton number to 149 for utah Some save by the bell. Yeah, it really is Gary Trent jr. Catalyst autograph for the Raptors Gary Trent 72 of 99 Cade Cunningham the uh davante gram And a bag lead for the pistons to 99 and lakers again michael cooper five of 10 illustrious legends gold auto The lakers gold auto that is awesome and it's on card cooper That is a gorgeous lakers hit Five of 10 to cooper Coop still three Unbelievable still three to go Every team is on sale. Okay. Okay Need a nebula now. Yeah, that's we need a nebula Got fronds out of 99 for Orlando Rudy go bear teawolves deep space auto teawolves having a solid break for sure 35 of 99 Yeah, there was a lot of 90 stuff like that though That looked like saved by the bell Saved by the bell, which is the most popular thing So everybody copied through all right kaminga The gowens. Hey, there's another neon marble deontay mary three of five for atlanta Nice mary for the hawks. Oh my god Is that what I think palo ben carol chat home grin gold rookie dual patch autograph Six of 10 Wow, excuse me Excuse me. Excuse me On an obi to 149 Derek harper to 49 on the mavericks icons auto There you go. Derek harper That wasn't even that loud It's she sam jammy sohan. You've got a wade a menagerie for the heat And mcgowens to 99 on the rookie jersey autograph for the hornets Now is a xion to 49 for the pelicans And a david roddy to 25 rookie patch auto grizzlies Grizzlies I don't think I'm gonna random that it's a huge garden. What the owners decide All right, Peyton watson. You've got levine for the bowls number two 99 And seven of 50 rookie aspiring autograph palo ban caro Green autograph Big time palo magic are killing it A keldon johnson out of 25 for the spurs And garuba to 99 on the radiant autograph rockets Usman garuba We got luka. We got dual chat palo gold. We got uh Uh, what else is there? Agbaji to five Chandler there Julius randall out of 49 for the nicks And to 99 a raptor's rookie auto christian colloco to 149 magic for the lakers And isaea mobley to 99 rookie aspiring autograph cavaliers spots Let's pull another banger right here Oh man Yeah, we're gonna try to random winner gets the nebula. Whoever's gonna get against the that's ideal honestly We're just pulling another gold and it's a 149 is a brand and clerk for the grizzlies We just pulled another one of those and not have to random at all and then just kind of random off whichever one I don't know Uh, Clyde the glides sky high signatures blazers Sky high at his gold to 10 nice hit for portlands Yeah, I mean it's always a judgment call with stuff like that Like it like it really depends on the card The how many spots it is like if it's a mole if it's like a $15 car, but it's like six spots then you know A lot of it's not worth like the headache because if we If we do sell that It has to go through the ebay auction process and obviously The fees or whatever, but then we also have to it has to be paid for how many ebay auctions and if people don't pay so like It can be a pain, but it's got to be an option for something that big And a psychedelic clay Thompson psychedelic clay short prints And jabari walker to 199 blazers box here rookie jersey auto Maybe not the rookie you're looking for but still a good box for your portlands We're the 199. Uh, I don't even I don't know mark I don't remember last year. I don't remember yesterday barely I couldn't tell you my my whole fantasy lineup right now. We drafted it yesterday. I don't know Fontechio harden sga to 149 okc And redemption and mark williams ricky jersey autograph celestial for the hornets We're gonna set a good break for their spot price for sure Williams good player too. Yeah good player under the radar But everybody is in charlotte last box It's gonna give us a drew a holiday to 99 And cool hit here for the seas deep space autograph is robert perish chief to 99 Okay, we do have a random to do For the pal gasol Then we're gonna recap. Do you mind writing down like order number and names for Both of those teams just so I can have it on the sticky note on the card All right before I do that though Uh, just two to go on the next one mabs and warriors abs and warriors. All right, let's get the randomizer going Magic thunder not magic thunder. Sorry lakers. That one's on my mind lakers and We'll just call pow out of 99 again retrospect pal gasol Make sure you check the checklist on this one on the back It has both teams very clearly the front just has like grizzlies kind of here lakers here Or checklist has it both pretty much evenly. So good luck on that random lakers and grizzlies. It's a cool pal One of the better players in the past 15 20 years, I guess you could say Uh, we'll go four times again. This is for the pal gasol. Let's just move that so we're not confused here four times on the gasol Uh, whoever's up top gets it one two three and four The lakers the lakers good break for the lakers. All right Let's do a recap First three picks eclair was the first one. I didn't even make the pick I was grocery shopping at the time grocery store draft for me And then I think I took mixon and then olave I think that was the order or olave mixon. I honestly don't remember. I think those are those are the first three for sure though All right, recap time hornets redemption mark williams grizzlies redemption jaren jackson jr A nuggets redemption christian brown rickie jersey auto. Yeah, jabari walker jalen durin nice one there for the pistons jalen williams max christie Juan toscano anderson nick van exel scottie pippin jr christian caloco usman garuba isaam moblie brice mcgowan's gary trend jr rudy gobert kevin garnett derrick harper Never pulled the derrick harper auto until now honestly matt ryan the t wall was matt ryan herbert jones That's kelly ubray steven jackson for the pacers Caleb martin david roddy pink agbaji is a really cool one for utah. You tell how to good break gold michael cooper for the lakers and a gold Clive the glide for the blazers Had the gasol went to the lakers and the random as well as robert paris celtics get a Neon marble rookie number to five for the jazzo chag bhaji You're getting jazz good break mabs first pack hit color graphs meta. I think it says at 25 I think it's what it said on the checklist luka donchich That'll be a banger Got a spiring green rookie auto magic palo ben caro That's out of 49 or 50. Excuse me 750 And then we'll be in contact with the magic and the thunder Again, congrats on this gold six of ten rookie dual patch autographs Palo Ben caro and shetholmgren Chunwei with the thunder hank with the magic congrats to you both As of right now We'll get in contact you with uh with the options on how to go about the car whether you decide a random it or Sell whatever whatever it may be Really good first case moving on a case two