Population Health

Population Health

population health management software

Industry-Leading Solutions for Every Practice

Population Health solutions from eClinicalWorks help medical practices of every kind deliver care more effectively and efficiently. We have the solutions, experience, and insight to help your practice meet emerging challenges in 21st-century healthcare.


Measures for Effective Care Delivery
Provider Clinical Quality Measures Report Screenshot

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
provider hierarchical condition category module screenshot

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 at Their Most Vulnerable
Screenshot of provider transition care management module

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
provider chronic care management module screenshot

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
  • Pre-built templates for 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

Patient-Centered Medical Home

Put Your Primary Focus on the Patient

Patient-Centered Medical Home (PCMH) is an operational excellence program that recognizes providers who deliver advanced primary care and prepares practices for success through ongoing self-improvement.

  • Experienced consultants help transform your practice for value-based care
  • Develop a team-based approach for holistic patient care
  • Use 35 standard reports to reduce time spent gathering and arranging data
  • Pre-validated for up to 19 NCQA® auto-credits

Accountable Care Organizations

Turn Big Data Into Meaningful Data

eClinicalWorks can help Accountable Care Organizations manage chronic health conditions, improve risk management, and improve their estimates for cost and utilization of healthcare resources.

  • Use payer data to gain insight into costs, KPIs, readmissions, and avoidable ER visits
  • Estimate patients’ future costs and overall risk for hospitalization
  • Improve accurate of risk assessment with the John Hopkins (ACG®) model
  • Use an analytics platform to consume claims data from payers