Workflow GuideeClinicalWorks

eCW Chronic Care Risk Stratification Workflow Guide

Optimize chronic care risk stratification in eClinicalWorks for APCM. Learn to use eCW registries and AI automation for patient identification.

Efficient risk stratification within eClinicalWorks (eCW) is the foundation of a successful Advanced Primary Care Model (APCM). By leveraging eCW’s Registry and Population Health tools alongside Tile Health’s AI-driven outreach, practices can proactively identify high-risk patients, ensuring they receive the intensive management required for CMS compliance and improved clinical outcomes.

The Challenge

Most eCW practices underutilize the Registry module, relying on manual chart reviews that miss high-risk patients. This leads to inaccurate HCC coding, lost APCM revenue, and reactive rather than proactive chronic care management.

Step-by-Step Workflow

1

Configure eCW Registry Criteria

Define specific ICD-10, lab value, and medication parameters within the eCW Registry to segment patients by chronic condition severity. This allows the system to automatically pull lists of patients meeting APCM eligibility requirements.

Best Practices
  • Use the 'Registry' shortcut in the e-menu for quick access
  • Filter by 'Last Visit Date' to target active patients first
Common Pitfalls
  • Setting criteria too broadly, resulting in unmanageable patient lists
2

Activate Population Health Dashboards

Enable the eCW Population Health module to visualize gaps in care and identify patients with rising risk scores. Use the HEDIS dashboards to monitor compliance across your chronic care population in real-time.

Best Practices
  • Sync data nightly to ensure dashboards reflect recent encounters
  • Focus on patients with multiple co-morbidities for APCM prioritization
Common Pitfalls
  • Ignoring the 'Gap in Care' alerts during the patient check-in process
3

Deploy AI Call Handling for Screening

Integrate Tile Health AI agents to automatically call patients identified in your eCW Registry. The AI performs initial APCM screenings and updates the patient's status, reducing the burden on your nursing staff.

Best Practices
  • Configure the AI to ask specific social determinant of health (SDOH) questions
  • Schedule AI calls during off-peak hours to improve reach rates
Common Pitfalls
  • Failing to update the eCW 'Phone' field with the most current patient number
4

Standardize SmartForm Documentation

Implement custom eCW SmartForms for APCM encounters to ensure providers capture Hierarchical Condition Category (HCC) data accurately. This structured data is essential for maintaining accurate risk-adjustment scores.

Best Practices
  • Link SmartForm fields to the 'Problem List' for auto-population
  • Train providers on the 'MEAT' (Monitor, Evaluate, Assess, Treat) documentation standard
Common Pitfalls
  • Using free-text notes that cannot be parsed by eCW reporting tools
5

Automate Appointment Scheduling via AI

When the AI identifies a high-risk patient needing an APCM visit, it uses the eCW API to check provider availability and book the appointment directly into the eCW schedule, closing the care loop immediately.

Best Practices
  • Set specific 'APCM Visit' slots in the eCW schedule to prevent overbooking
  • Ensure the AI provides a confirmation number to the patient
Common Pitfalls
  • Not setting up proper 'Visit Type' codes in eCW for AI-booked appointments
6

Audit APCM Billing via Financial Module

Regularly review the eCW Financial Management reports to ensure that stratified high-risk patients are being billed with the correct APCM G-codes. Cross-reference registry lists with claims data to find missed revenue.

Best Practices
  • Use the 'Claim Analysis' report to identify rejected APCM codes
  • Verify that the 'Time Spent' in care management is documented in the eCW hub
Common Pitfalls
  • Assuming the billing team knows which patients were risk-stratified manually

Expected Outcomes

1

100% identification of APCM-eligible patients through eCW Registry automation

2

Significant reduction in staff time spent on manual outreach via AI call handling

3

Improved HCC coding accuracy leading to optimized risk-adjusted reimbursement

4

Increased patient engagement rates for chronic care follow-up appointments

Frequently Asked Questions

Tile Health connects to eCW via secure API or SFTP exports. It identifies patients from your registry and uses natural language AI to conduct outreach, updating the eCW contact logs automatically.

eCW can calculate HCC scores and display them in the patient hub, but it requires structured data input via SmartForms and accurate ICD-10 coding to be effective.

The 'Care Management' module in eCW is designed for this. You should use the 'Timer' feature within the module to ensure all non-face-to-time is captured for billing.

Ready to transform your eclinicalworks practice?

See how Tile Healthcare's AI call center can handle scheduling, triage, and patient communication for your practice.

Schedule a Demo
eCW Chronic Care Risk Stratification Workflow Guide | Tile Health