Resource GuideeClinicalWorks

2026 eClinicalWorks APCM Care Plan Documentation Guide

Master APCM documentation in eClinicalWorks. Learn setup, billing, and care plan best practices for eCW practices in 2026.

Optimizing care plan documentation within eClinicalWorks (eCW) is essential for succeeding with the Advanced Primary Care Management (APCM) model in 2026. This guide outlines the technical configurations and workflow optimizations required to leverage eCW's internal modules and AI-driven call handling to ensure compliance, maximize reimbursement, and improve patient outcomes.

Difficulty:
Impact:

eCW Module Configuration for APCM

8 items

Care Plan Template Customization

Build structured templates in eCW to capture required APCM elements like goals and barriers efficiently.

IntermediateHigh Impact

HEDIS Dashboard Setup

Configure the eCW HEDIS analytics tool to track gaps in care for chronic patients in real-time.

AdvancedHigh Impact

Population Health Registry

Utilize the Registry to segment patients by diagnosis codes and APCM eligibility automatically.

IntermediateHigh Impact

Registry Filter Optimization

Create custom UI filters to identify patients with two or more chronic conditions for enrollment.

Intermediate

Order Set Mapping

Link specific APCM care plan goals to eCW Order Sets for faster clinical decision support and ordering.

Beginner

Billing Code Activation

Update the eCW Charge Capture screen to include G0511 and G0512 for APCM reporting and tracking.

BeginnerHigh Impact

Care Plan Alerts (CDSS)

Set up Clinical Decision Support System alerts to notify staff when a care plan update is due.

Intermediate

Document Management Setup

Map scanned external records to the Care Plan folder in the eCW Document Management system for continuity.

Beginner

Workflow Integration and AI Automation

8 items

AI Call Routing for APCM

Use Tile Health AI to route APCM inquiries to care managers instead of overloading the front desk.

BeginnerHigh Impact

Automated Appointment Reminders

Set up eCW Messenger to send text reminders for monthly care plan review calls to improve engagement.

Beginner

Patient Portal Engagement

Push care plan updates to the healow portal to ensure patient access and compliance with CMS rules.

IntermediateHigh Impact

Virtual Scribe Integration

Use eCW Scribe or AI tools to document care plan discussions during patient encounters in real-time.

Intermediate

Telehealth Visit Documentation

Utilize the eCW Televisit module to conduct and document virtual care plan check-ins seamlessly.

BeginnerHigh Impact

Real-time Eligibility Verification

Verify insurance eligibility for APCM services directly through the eCW clearinghouse interface.

Beginner

Integrated Secure Messaging

Use internal eCW jellybeans for communication between the care manager and the primary provider.

Beginner

Voice-to-Text Documentation

Leverage eCW Mobile or Scribe to dictate care plan changes during patient rounds or calls.

Beginner

Documentation and Compliance Standards

8 items

Chronic Condition Status Mapping

Ensure all ICD-10 codes are correctly mapped to the Problem List to trigger APCM workflows correctly.

BeginnerHigh Impact

Longitudinal Care Plan Review

Use the Care Plan tab in eCW to maintain a continuous record of patient progress over time.

IntermediateHigh Impact

Medication Reconciliation Logs

Document drug interactions and adherence within the eCW Rx screen as part of the longitudinal plan.

Beginner

Transition of Care Documentation

Document hospital discharges and follow-up plans using the P2P or CCDA exchange in eCW.

AdvancedHigh Impact

Patient Goal Tracking

Set specific, measurable goals within the eCW Notes section that are visible to the entire clinical team.

Beginner

Care Manager Time Tracking

Log non-face-to-face time in the Care Management module to support billing audits and compliance.

IntermediateHigh Impact

SDOH Screening Integration

Implement the PRAPARE template within eCW to document social determinants of health systematically.

Intermediate

AWV Alignment

Synchronize the Annual Wellness Visit documentation with the ongoing APCM care plan for consistency.

Intermediate

Pro Tips

1

Use eCW Smart Forms to standardize data collection for APCM quality metrics and reduce charting time.

2

Leverage the eCW Messenger for automated care plan check-ins to meet the monthly interaction requirement.

3

Enable the 'Care Plan' tab in the Progress Note to ensure all providers have visibility into the longitudinal plan.

4

Configure eCW Registry filters to identify high-risk patients who qualify for APCM but aren't currently enrolled.

5

Integrate Tile Health AI call handling to capture patient updates outside of clinic hours directly into eCW notes.

Frequently Asked Questions

Go to the Fee Schedule, search for the specific G-codes (G0511/G0512), and ensure they are mapped to the correct CPT categories for your practice type.

Yes, by utilizing the Care Management module's built-in timer or creating a custom 'Time Tracking' category in the 'Actions' section of the progress note.

Yes, care plans can be published to the healow portal automatically upon signing the note, allowing patients to access their goals and instructions 24/7.

Use the 'Social History' section or dedicated SDOH Smart Forms to capture standardized data that informs the patient's care plan and risk score.

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2026 eClinicalWorks APCM Care Plan Documentation Guide | Tile Health