Population Health

eClinicalWorks^® offers a suite of affordable, integrated solutions for Population Health, helping practices understand disease patterns, more accurately assess risk, improve patients’ engagement and satisfaction, and promote better medical outcomes.

HEDIS: Measures for Effective Care Delivery

Measuring the effectiveness of care delivery is essential to ensuring your practice is taking the right approach to patients’ needs. The Healthcare Effectiveness Data and Information Set (HEDIS®) is an essential tool for Population Health planning.

HEDIS Analytics from eClinicalWorks^® offers a set of industry-standard performance measures to evaluate care access and delivery, measure compliance, and evaluate provider performance.

HEDIS® is a registered trademark of the National Committee for Quality Assurance.

Hierarchical Condition Category: Bring Transparency to Risk Adjustment

Our Hierarchical Condition Category (HCC) module uses demographic data and diagnoses to calculate Risk Adjustment Factor (RAF) scores used by Medicare and other programs.

Identify coding gaps based on historical coding data
Calculate real-time, patient-level RAF scores
Risk stratify patients and filter by RAF, provider, or insurance
Use an HCC dashboard to analyze trends and compare RAF scores

Transition Care Management: Protect Patients

Our Transition Care Management (TCM) module helps providers maintain the continuity and quality of care during the critical times when patients are moving among care settings.

Manage patients as they move among care setting
Track appointments to ensure timely follow-up care after hospitalizations
Reconcile medications to help ensure patient safety
Better understand which patients are being hospitalized and why

Chronic Care Management: Easing the Burdens of Chronic Illness

Our Chronic Care Management (CCM) module helps practices with Medicare’s CCM program, which offers reimbursement for non-face-to-face care provided to patients with multiple chronic conditions.

Manage patient enrollment and program activities
Utilize content for evidence-based care covering 27 chronic conditions
Track time spent on non-face-to-face care with a built-in time tracker
Simplify claim submission with automated batch billing

Population Care planning: Gain a Full View of Each Patient’s Health

Population Care Planning gives providers a clearer view of patients’ overall health and wellness, from lifestyle and activities of daily living to home and community supports. Collaborative care planning with all care team members, the patient, and their family or caregivers is the cornerstone of patient-centric care.

Member Management – Member enrollment, care team assignment, program management
Identify and Manage Risk – Health assessment, risk stratification, gaps in care
Care Plans – Customizable care plans to monitor progress and patient action plans
Productivity Tools –Dashboards for tasks, reminders, referrals, messaging, and reports

Integrating Behavioral Health with Your Healthcare Practice

Goal Tracking – Assign, track, and monitor progress toward goals for your patients
Care Plan Reviews – Set up automated reviews for the patient and care team to receive reminders when the Care Plans are due for review.
Patient and Care Team Sign-offs – Capture signatures from patients and care team members
Schedule Management and Group Visits – Easily schedule and document group visit encounters for multiple patients.