Workflow GuideEpic EHR

Epic EHR APCM Documentation & Workflow Guide

Optimize your Epic EHR for APCM documentation. Learn how to integrate AI call handling with MyChart and Epic registries for better care management.

Implementing Advanced Primary Care Management (APCM) within Epic EHR requires a strategic approach to documentation and registry management. While Epic offers robust modules, the complexity of configuring care plans and identifying eligible patients often leads to low adoption. This guide details how to leverage Epic's native tools alongside AI-powered automation to streamline APCM workflows.

The Challenge

Health systems struggle with Epic's complex APCM configuration, leading to documentation gaps and missed billing opportunities. Manually identifying eligible patients and coordinating MyChart outreach with phone-based care remains a significant operational bottleneck.

Step-by-Step Workflow

1

Configure the APCM Patient Registry

Use Epic's Reporting Workbench or SlicerDicer to build a dynamic registry of patients meeting APCM criteria, including chronic condition counts and risk scores. This ensures your care team focuses on the most eligible populations.

Best Practices
  • Filter by CMS-approved HCC codes
  • Automate registry refreshes weekly
Common Pitfalls
  • Relying on static Excel exports outside Epic
2

Build Custom SmartForms for Documentation

Build custom SmartForms within the Epic Care Management module to capture required APCM elements like care plan reviews and medication reconciliation. This standardizes data entry across the enterprise.

Best Practices
  • Use SmartPhrases for repetitive elements
  • Link SmartForms to the problem list
Common Pitfalls
  • Using free-text notes that are not reportable for CMS audits
3

Integrate AI Call Handling with MyChart

Deploy AI-powered call solutions that sync with MyChart. When an AI agent completes a care call, it should trigger a MyChart message or update the Epic communication log via Interconnect APIs.

Best Practices
  • Enable Epic API for real-time updates
  • Route AI-flagged issues to the nurse pool
Common Pitfalls
  • Operating phone outreach in a silo from MyChart communications
4

Establish Automated InBasket Triggers

Set up Epic InBasket notifications or Best Practice Advisories (BPAs) to alert providers when an APCM-eligible patient is due for a care plan update or has missed a scheduled follow-up call.

Best Practices
  • Limit BPAs to avoid alert fatigue
  • Target care managers specifically
Common Pitfalls
  • Overwhelming physicians with non-clinical administrative alerts
5

Streamline Billing via Charge Router

Map APCM documentation minutes directly to Epic's billing module to ensure codes like G0511 are captured automatically based on time spent in the patient record and phone interactions.

Best Practices
  • Audit documentation time logs monthly
  • Use Epic's Charge Router for automated APCM coding
Common Pitfalls
  • Manual entry of APCM codes at the end of the month

Expected Outcomes

1

Increased APCM enrollment rates

2

Reduced documentation time per patient

3

Improved MyChart engagement scores

4

Higher billing accuracy for chronic care

5

Streamlined clinical staff workflows

Frequently Asked Questions

While Epic provides the foundation, automation through AI call handling and API integrations is often necessary to scale outreach and documentation efficiently.

AI solutions can be configured via Epic APIs to drop call summaries or task alerts directly into the appropriate InBasket folder for clinical review.

Most systems use the existing Healthy Planet or Care Management modules, though specific SmartForms and registries must be custom-configured for APCM.

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Epic EHR APCM Documentation & Workflow Guide | Tile Health