Workflow GuideEpic EHR

Epic EHR APCM Patient Enrollment Workflow Guide

Streamline APCM enrollment in Epic EHR. Learn how to use registries, MyChart, and AI automation to identify and onboard eligible chronic care patients.

Implementing Advanced Primary Care Management (APCM) within Epic requires a precise orchestration of patient registries, MyChart notifications, and automated outreach. This guide details how to leverage Epic’s robust infrastructure alongside AI-powered call handling to streamline the enrollment process, ensuring compliant documentation and high patient participation rates.

The Challenge

Health systems struggle to identify APCM-eligible patients using manual Epic reports, often resulting in fragmented outreach and missed enrollment opportunities. Without integrated AI workflows, the burden of manual phone calls and care plan documentation in Epic becomes unsustainable.

Step-by-Step Workflow

1

Configure the APCM Patient Registry

Utilize Epic SlicerDicer or Reporting Workbench to build a dynamic registry that filters patients based on CMS-defined chronic conditions, risk scores, and recent encounter history.

Best Practices
  • Use specific ICD-10 code groups to automate eligibility updates
  • Set up a 'Pending APCM' status in the registry for tracking
Common Pitfalls
  • Relying on outdated static patient lists
  • Failing to exclude patients already enrolled in CCM
2

Deploy MyChart Enrollment Campaign

Send bulk MyChart messages to registry-identified patients explaining APCM benefits. Include a digital consent form or a 'Click-to-Call' button for immediate AI-assisted onboarding.

Best Practices
  • A/B test MyChart subject lines to increase open rates
  • Embed a brief video explaining the value of APCM
Common Pitfalls
  • Overwhelming patients with too many portal notifications
  • Not providing a clear opt-out mechanism in the message
3

Automated AI Phone Outreach

For patients who do not respond to MyChart, trigger an AI-powered call to explain the program, answer common questions, and capture verbal consent directly into the system.

Best Practices
  • Program the AI to recognize common Epic-specific terminology
  • Schedule calls during peak patient availability hours
Common Pitfalls
  • Using robotic scripts that lack empathy
  • Failing to sync call outcomes back to the Epic registry in real-time
4

Document Consent via Epic SmartForms

Use a dedicated APCM SmartForm within the patient's chart to record consent. This should automatically update the 'Informed Consent' flag required for G-code billing.

Best Practices
  • Create a SmartLink to pull consent dates into progress notes
  • Ensure the SmartForm is accessible to both clinical and admin staff
Common Pitfalls
  • Storing consent as a scanned PDF instead of discrete data
  • Forgetting to update the 'Effective Date' for the APCM benefit
5

Initialize the Epic Care Management Module

Link the enrolled patient to an Epic Care Management episode. Pre-populate the care plan using SmartText templates that meet CMS requirements for APCM documentation.

Best Practices
  • Map problem list items directly to the APCM care plan goals
  • Assign a lead care manager within the Epic provider team
Common Pitfalls
  • Leaving the care plan goals generic and non-patient specific
  • Failing to link the care plan to the active APCM encounter
6

Establish Billing Best Practice Advisories

Configure BPAs to alert the billing team when the required monthly APCM service minutes are met, ensuring no revenue is lost due to documentation gaps.

Best Practices
  • Set thresholds at 15 and 20 minutes to track progress
  • Automate the addition of the APCM G-code to the wrap-up screen
Common Pitfalls
  • Ignoring BPA alerts during the busy clinical day
  • Not auditing BPA triggers for accuracy after Epic upgrades

Expected Outcomes

1

90% reduction in manual patient identification time

2

Increased enrollment rates through multi-channel AI outreach

3

100% audit-ready documentation within Epic SmartForms

4

Seamless integration between MyChart and phone-based enrollment

5

Automated tracking of APCM billing requirements via BPAs

Frequently Asked Questions

Epic uses Care Management activity timers and specialized SmartLinks to aggregate time spent on non-face-to-face care coordination, which can then be pulled into billing reports.

Yes, using Epic's App Orchard or FHIR APIs, AI-powered call platforms can write consent status and call summaries directly into the patient's chart as discrete data or clinical notes.

The AI immediately updates the patient's registry status to 'Opted Out' in Epic, which triggers a BPA to prevent future outreach and ensures compliance with patient preferences.

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Epic EHR APCM Patient Enrollment Workflow Guide | Tile Health