1 The Challenge For more than 30 years, Adult Medicine of Lake County has served a mostly rural area north of Orlando, Florida, providing care to a population that includes many Medicare patients. Adult Medicine needed to improve the visibility of each patient’s case, better coordinate programs, and meet the demands of value-based care. The Solution While Adult Medicine has successfully used the eClinicalWorks EHR for more than 10 years, they began applying several Population Health tools in the last 18 months, including those for Chronic Care Management (CCM), Transition Care Management (TCM), as well as HEDIS® measures for better estimating their patients’ risks for developing health problems. The Results In just one year, Adult Medicine enrolled more than 800 patients

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