Caremap: A Digital Personal Health Record for Complex Care Coordination

Inclusion criteria for parents/caregivers of children/youth with special health care needs (CYSHCN): * Adult parent/legal guardian (age 18 or older) of a CYSHCN * Established care for their child/youth at Duke Pediatrics Primary Care or Duke Children's Cystic Fibrosis clinic (established = one or more completed visits in the past 12 months at the clinic) * High level of complex medical needs that could benefit from additional care coordination support (determined by clinical provider at the pilot site) * Primary provider enrolled in the study as a provider participant/clinical provider site champion * Active Duke MyChart (online EHR patient portal) account * Full proxy access activated/enabled for parent to the child/youth's medical record in Epic * Apple iOS device compatible with Caremap app requirements at time of consent Inclusion criteria for adult patients with multiple chronic conditions (MCC): * Adult patient (age 18 or older) with MCC * Established care for the patient at Duke Geriatrics clinic or Duke Pulmonary Transplant clinic (established = one or more completed visits in the past 12 months at the clinic) * High level of complex medical needs that could benefit from additional care coordination support (determined by clinical provider at the participating clinic site) * Primary provider enrolled in the study as a provider participant/clinical provider site champion * Active Duke MyChart (online EHR patient portal) account * Apple iOS device compatible with Car…