Workflow GuideEpic EHR

Epic EHR APCM Monthly Check-In Workflow Guide

Optimize APCM workflows in Epic EHR. Learn how to automate monthly check-ins, integrate MyChart, and streamline care plan documentation for chronic care.

Mastering the monthly APCM check-in within the Epic EHR ecosystem requires a blend of automated outreach and precise documentation. This guide outlines how to leverage Epic's care management tools alongside AI-powered call handling to ensure high-quality patient interactions and full regulatory compliance without increasing staff burden.

The Challenge

Most health systems struggle with the manual effort required to initiate monthly calls, update Epic care plans, and ensure that MyChart messages align with phone-based outreach, leading to fragmented care, documentation gaps, and missed revenue opportunities.

Step-by-Step Workflow

1

Identify Eligible Patients via Epic Registry

Utilize the Healthy Planet registry to pull a list of patients with two or more chronic conditions who have not had their monthly APCM contact. This ensures your outreach list is always accurate and up-to-date based on the latest clinical data stored in Epic.

Best Practices
  • Filter by last contact date to prioritize patients at risk of missing the monthly window
Common Pitfalls
  • Ignoring inactive patients who still meet the clinical criteria for APCM
2

Trigger AI-Powered Outreach

Sync the Epic registry with your AI call center platform to initiate automated check-ins. The AI handles initial screening, routine health questions, and medication reconciliation updates, freeing up staff for complex cases.

Best Practices
  • Set specific call windows to match when patients are most likely to answer
Common Pitfalls
  • Not updating the sync frequency between Epic and the AI platform
3

Sync MyChart Notifications

Ensure a MyChart message is sent automatically 24 hours prior to the call to increase pickup rates. Coordinated messaging ensures patients recognize the incoming call as a legitimate part of their care plan within the Epic system.

Best Practices
  • Use standard Epic templates for MyChart notifications to ensure professional branding
Common Pitfalls
  • Sending duplicate messages manually when automation is already active
4

Documenting in Epic Care Management

As the AI call concludes, the system pushes a summary into the Epic Care Management module, updating the contact date. This documentation must include specific APCM elements like goal progress and barriers to care.

Best Practices
  • Use SmartPhrases for consistency in documentation across the care team
Common Pitfalls
  • Forgetting to link the clinical note to the specific APCM encounter type
5

Review and Update Care Plans

Care managers review AI-flagged insights to update the patient’s longitudinal care plan and problem list within Epic. This ensures that the clinical record reflects the most current status of the patient's chronic conditions.

Best Practices
  • Focus on the 'Goals' and 'Interventions' sections for APCM compliance
Common Pitfalls
  • Leaving outdated or completed goals in the active care plan
6

Automate Time Tracking for Billing

Leverage Epic’s internal timers or API-integrated logs to ensure every minute of the AI interaction and clinical review counts toward the APCM threshold. Accurate time tracking is essential for audit-proof billing.

Best Practices
  • Validate time logs weekly to ensure all billable minutes are captured
Common Pitfalls
  • Under-reporting time spent on non-face-to-face care coordination
7

Audit via Reporting Workbench

Run weekly Reporting Workbench reports to identify gaps in documentation or patients who were missed during the monthly cycle. Dashboards provide a high-level view of program performance and clinician productivity.

Best Practices
  • Save the report as a favorite for quick access by the management team
Common Pitfalls
  • Relying solely on manual spreadsheets instead of Epic's native reporting tools

Expected Outcomes

1

Increased APCM enrollment through automated registry screening

2

Reduced administrative burden on care managers via AI-driven phone outreach

3

Improved documentation accuracy within the Epic Care Management module

4

Enhanced patient engagement through coordinated MyChart and phone communication

5

Higher reimbursement rates with automated time-tracking and billing verification

Frequently Asked Questions

We utilize Epic's App Orchard APIs to push call transcripts and summaries directly into the patient's chart as discrete data or clinical notes, ensuring they are linked to the correct encounter.

Yes, by configuring Epic’s billing triggers to automatically capture time spent on AI-managed outreach and subsequent manual care coordination tasks performed by the staff.

AI agents can check MyChart for recent patient messages before initiating a call, ensuring the conversation is relevant and informed by the patient's recent digital updates.

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Epic EHR APCM Monthly Check-In Workflow Guide | Tile Health