ELLiE is Orlando Health’s customized version of the Epic comprehensive health record (CHR). ELLiE includes all of the traditional features of the Epic medical record, ranging from clinical documentation to appointment scheduling, and medical billing to patient portals. However, Orlando Health was able to work with its partners at Epic as they were launching ELLiE to incorporate several features meant to drive greater value to providers and patients, including the adoption of the major population health management applications known as Healthy Planet and Compass Rose.

Orlando Health Network’s administrative and clinical leadership are fortunate to partner with a dedicated group of Orlando Health information technology professionals, who also happen to be value-based care subject matter experts. Collectively, this team works on all aspects of clinical integration to optimize reporting tools, streamline workflows for providers, expand patient monitoring capabilities and, ultimately, better patient outcomes. Much of the team’s work in the past year has centered around enabling more timely and comprehensive identification of at-risk populations. By doing so, the system can prompt work queues for care coordination team interventions. For patients who engage in these programs, reporting has also been developed to track and trend their clinical outcomes over time, thereby enabling the network to discern which programs have the greatest effectiveness and which could be further refined.

A new care management dashboard was launched this year with the added functionality to track patients in near-real-time across all sites of care. Clinical outcomes are populated in this report to highlight changes in various clinical and utilization indicators, such as hemoglobin A1c, blood pressure, body mass index and glomerular filtration rate. Utilization data is also monitored in this report, such as avoidable emergency room usage and hospital readmissions. Lastly, patient engagement in care episodes is monitored to help determine adequate care manager caseloads and understand differences in outcomes for patients who participate in such programs, versus their non-engaged counterparts.


In 2022, Orlando Health Network released its leading point-of-care solution designed to support physician practices and drive better outcomes for patients aligned under value-based care arrangements. This solution, known as Orlando Health InNote, was launched in collaboration with one of the health system’s data partners.

Primary care providers can integrate the solution into their existing practice regardless of which electronic health record (EHR) they choose to utilize. Orlando Heath InNote streamlines workflows by delivering relevant and concise information about patients to the physicians and their care teams without requiring them to leave their native EHR workflows. This information includes addressable care gaps, ongoing care plans, cost and utilization patterns for their panels and so much more. Additionally, the solution syncs in real-time with the connected claims and clinical systems to ensure the most up to date data is presented to the providers.

Orlando Health InNote removes the need for practices to navigate multiple platforms to ascertain myriad sets of information, including multiple existing provider and payer portals. Moreover, the tool provides in-network physicians with access to performance scorecards where they can track quality-based outcomes and health plan expenditures with a few simple clicks. Lastly, Orlando Health InNote provides a simple and easy to use interface which offices can install and be trained on in a matter of just a few minutes. This allows providers to focus more on care delivery and less on hunting for data, which drives better performance in value-based care arrangements as well as better care for patients.

Patient Campaigns and InConnect

Orlando Health Network (OHN) has used Orlando Health’s patient engagement platform, InConnect, an interactive patient outreach module, to promote preventive care and patient engagement. This platform has served to reduce patient engagement barriers by offering an omnichannel connection to patients through text message, email, phone call and patient portal pathways. Expanding communication channels has opened opportunities for improved patient adherence with clinical protocols and increased the clinically integrated network’s ability to close care gaps. By leveraging advanced data analytics, patient-specific cohorts are established which ensure patients are receiving messages tailored to their unique needs, allowing for greater ease of use in interacting with the services they need, such as scheduling wellness exams or cancer screenings. The network’s goal in using InConnect is to equip patients with information and the necessary resources to take charge of their health. The service also supports providers by offering a proactive approach to patient outreach, automating several functions of the patient engagement process that would otherwise be performed by the practice staff. In 2022, several thousand aligned BHN patients were successfully contacted through InConnect and, subsequently, engaged in their recommended care plans.


Orlando Health Network (OHN) entered a partnership this year with PointClickCare (PCC), a cloud-based healthcare software service that allows health systems to better utilize post-acute care data for patients. The partnership permits OHN to use PCC’s Post-Acute Care (P-AC) Management platform, which is a skilled nursing facility (SNF) management tool for population health programs, including bundled payment and accountable care organization (ACO) arrangements. OHN can leverage real-time data to improve care transitions and outcomes.

The OHN care coordination team uses the platform to track patients using claims and encounter data, in addition to clinical sources, which enables timely care interventions, improves length-of-stay and readmissions management and optimizes transitions of care to home. With the ability to pull clinical intelligence from Epic, Orlando Health’s CHR, the State of Florida’s Health Information Exchange, and SNF progress notes via PCC integration, subscribers to P-AC Management have access to chart-level clinical data for managed patients and can perform all necessary care interventions.

Performance metrics and trends are also accessible through the platform, including reporting for readmissions, length-of-stay and quality outcomes across all aligned P-AC provider sites. This partnership will transform the way OHN can proactively monitor and engage patients post-hospitalization, while driving success in bundled payment programs and value-based care contracts.