Development of an interactive, web-based shared care plan to facilitate the follow-up care of colorectal cancer patients
Abstract Introduction A shared model of care between cancer services and primary health care is safe and acceptable and can address the increasing demands on cancer services for long term follow-up. This paper describes the challenges developing an interactive shared care plan for colorectal cancer follow-up care that supports collaboration between the care team and patient. Methods A systematic literature review was undertaken to identify web-based care plans for follow-up cancer care that would inform the implementation of a system to share an individualised care plan. We conducted individual consultations with 25 key informants/stakeholders to understand the requirements and challenges of establishing the web-based care plan and to identify the technical options to share the care plan. This was followed by a structured group consultation with 13 key stakeholders to obtain agreement on the model of care and the technical solution to share the care plan. Results We identified five web-based shared care plans for cancer follow-up care. These systems supported the creation and/or access to view or share the care plan via internet log-in, email or hard copy. None of the SCP had interactive functionalities to support collaboration and none of the included papers reported formalised models of shared care between cancer services and primary care. The challenges identified included the security, privacy and sharing of patient information between public health services and primary health care and poor integration of clinical information systems. A primary care practitioners’ care planning system was selected for the pilot as it addressed the challenge of sharing clinical information between the public health system and external clinicians, partially addressed integration (integrated with the primary care clinical information systems but did not integrate with the cancer centre systems), supported collaboration between the care team and patient and was relatively inexpensive. Conclusion Primary care shared care planning systems seem a suitable option for sharing clinical information between a cancer service and primary care practitioners. We plan to evaluate the feasibility and acceptability of this interactive shared care plan to support shared cancer follow-up care.