Workflow GuideEpic EHR

Epic APCM Risk Stratification & Chronic Care Workflow Guide

Optimize Epic EHR chronic care management with AI-driven risk stratification, Healthy Planet registries, and automated patient outreach workflows.

Managing Advanced Primary Care Management (APCM) within Epic EHR requires a technical synergy between Healthy Planet registries and proactive patient engagement. This guide outlines how to leverage Epic’s native risk stratification tools while utilizing AI-powered call handling to bridge the gap between data identification and clinical enrollment, ensuring no high-risk patient is overlooked.

The Challenge

Health systems often find Epic's chronic care modules complex to configure, leading to manual, inefficient patient identification. The disconnect between Epic registries and phone-based outreach results in low enrollment rates and fragmented documentation that fails to meet CMS requirements.

Step-by-Step Workflow

1

Configure Healthy Planet Registry Criteria

Define specific inclusion and exclusion logic within Epic's Healthy Planet module. Use ICD-10 codes, HCC scores, and encounter history to build a dynamic registry of APCM-eligible patients.

Best Practices
  • Include patients with two or more chronic conditions expected to last 12 months.
  • Exclude patients currently enrolled in hospice or SNF care.
Common Pitfalls
  • Using static lists instead of dynamic registries that update as patient data changes.
2

Build Reporting Workbench Prioritization

Create a Reporting Workbench report that filters your registry by risk score and last contact date. This allows staff to prioritize the most vulnerable patients for APCM outreach.

Best Practices
  • Add a column for MyChart status to determine the best communication channel.
  • Filter by 'PCP of Record' to ensure continuity of care.
Common Pitfalls
  • Overwhelming staff with too many low-risk patients in the initial workqueue.
3

Deploy AI-Powered Outreach Integration

Connect AI call handling via Epic Interconnect to automate initial eligibility screenings. The AI identifies patient interest and availability, updating the Epic record in real-time.

Best Practices
  • Schedule AI calls during windows of high patient availability.
  • Ensure the AI references specific PCP names from the Epic record for trust.
Common Pitfalls
  • Relying solely on MyChart messages, which have lower response rates for elderly populations.
4

Standardize Care Plan Documentation

Develop SmartForms or SmartText templates in the Epic Care Management module. These must capture the required APCM elements, including goals, barriers, and intervention plans.

Best Practices
  • Map SmartForm fields to discrete data elements for easier reporting.
  • Include a 'Time Spent' timer to track billable minutes automatically.
Common Pitfalls
  • Using free-text notes that cannot be easily audited for CMS compliance.
5

Coordinate MyChart & Phone Workflows

Use Epic’s patient portal to send pre-call notifications and follow-up care plan summaries. This multi-channel approach ensures the patient remains engaged between formal calls.

Best Practices
  • Set up automatic MyChart alerts when a new care plan is published.
  • Use MyChart for non-urgent health data collection to save call time.
Common Pitfalls
  • Failing to document MyChart interactions as part of the total APCM care time.
6

Automate Billing Workflow Triggers

Configure Epic’s Charge Router to trigger APCM billing codes once documentation requirements and time thresholds are met within the system.

Best Practices
  • Enable hard stops for missing documentation elements before billing can be filed.
  • Audit the 'Time Tracking' logs weekly to ensure revenue capture.
Common Pitfalls
  • Manual billing entry which leads to missed revenue and increased claim denials.
7

Monitor Registry Health & Upgrades

Establish a maintenance schedule to review registry logic after every Epic upgrade cycle. Ensure that new Epic features are integrated into the existing APCM workflow.

Best Practices
  • Review the Epic 'Nova' release notes for care management enhancements.
  • Perform quarterly data validation on the risk stratification logic.
Common Pitfalls
  • Assuming registry logic remains static after a major Epic version upgrade.

Expected Outcomes

1

Increased identification accuracy for high-risk chronic care patients.

2

Higher APCM enrollment through automated, AI-driven patient outreach.

3

Reduction in administrative burden for Epic care managers and clinicians.

4

Improved HCC coding accuracy and overall risk adjustment scores.

5

Seamless documentation that meets all CMS and HIPAA requirements.

Frequently Asked Questions

The AI integration uses Epic Interconnect and FHIR APIs to write discrete data or progress notes directly into the patient's chart, ensuring the care team has immediate visibility.

Yes, by utilizing standard Epic modules like Healthy Planet and Reporting Workbench, the workflow is built on core Epic infrastructure designed to persist through upgrades.

While designed for APCM in primary care, the risk stratification logic can be adapted for specialty-specific chronic care management within Epic's various clinical modules.

The AI system operates within a HIPAA-compliant environment, using encrypted data transmission and verifying patient identity before discussing any clinical details, all logged in the Epic audit trail.

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Epic APCM Risk Stratification & Chronic Care Workflow Guide | Tile Health