Key Roles and Responsibilities of a Collaborative Model for a Cloud-Based Shared Care Plan

Key RolesCharacteristics of Individuals and/or System to Fulfill RoleResponsibilities
Team leaderA single individual or teamReview all sections of the care plan and clarify conflicting, redundant, or confusing content with section “owner” on a routine basis
Medical expertise caring for CMC (knowledgeable about the range of child’s medical conditions)Find contributors to fill gaps in the care plan
Has a 10 000-ft view of the child (understands how 1 change may impact child as a whole)Maintain an active problem list
Sees the child most often
ContributorsHas the most current information about a particular section of the care plan (eg, tracheostomy settings, care coordination, family history)Review and update sections of the care plan that pertain to their area of expertise after all encounters with child
Includes caregivers and other family membersCaregivers should review the care plan to ensure it is feasible to implement and reflects actual care
Caregivers should update child’s family, social, or developmental history on a routine basis
HIT systemCloud-based platform to enable multiuser updates in real timeAutopopulate relevant content from the EHR to various sections of the care plan
Robust HIPAA-compliant data infrastructureAuto–sign off when changes are made with person, date and time stamp
Copy and paste functionality to transfer editable content from provider notesTrigger users to update the care plan at specified intervals
Capability to set permissions at the user level (eg, edit content, view only, share, download)Grant access to sections of the care plan depending on user’s permission level