Strategy 15 min read

Configuring Your EHR for Value-Based Care: From Fee-for-Service to Outcomes (2026)

Value-based care is no longer optional. With 90 million patients projected in VBC models by 2027 and CMS mandatory bundled payments now live, your EHR configuration determines whether you earn shared savings or absorb losses. This guide covers the exact features, workflows, and dashboard configurations you need.

By Steve Gold, JD, MPH

Key Takeaways

  • 88% of hospitals now use EHRs to support value-based care. Over 60% of health organizations expect higher VBC revenue in 2026, with capitated models doubling since 2021.
  • MSSP ACOs generated $4.1 billion in shared savings in 2024, with 75% of ACOs earning payments. Your EHR configuration directly determines your share.
  • CMS's mandatory TEAM bundled payment model launched January 2026, affecting hospitals in 25% of U.S. markets. If you have not configured episode-of-care tracking, you are already behind.
  • Risk stratification, care gap closure, and SDOH capture are the three EHR capabilities that most directly impact quality scores and shared savings performance.
  • A VBC-optimized EHR configuration investment of $150K-$500K typically pays back within 12-18 months through quality bonuses and reduced avoidable utilization.

90M

Patients in VBC models by 2027

$4.1B

MSSP shared savings (2024)

75%

ACOs earning shared savings

28.5%

Healthcare payments in APMs with downside risk

Value-Based Care Landscape at a Glance

Metric 2022 Baseline 2025 Current 2027 Projected Growth Trend
Patients in VBC models 43 million ~65 million 90 million +109%
APM payments with downside risk 24.5% 28.5% ~35% Rising
MSSP participating ACOs ~480 476 500+ Stable
MSSP beneficiaries served ~10 million 11.2 million 12+ million +12%
ACO REACH participants N/A (launched 2023) 103 ACOs Transitioning to LEAD Evolving
Provider orgs increasing VBC ~50% 66% 77% Accelerating
Hospitals using EHR for VBC ~80% 88% 95%+ Near-universal
Capitated VBC contracts Baseline 2x since 2021 Continued growth Doubling

The trajectory is clear: two-thirds of provider organizations increased VBC participation in 2025, and 77% of health system C-suites plan further increases by 2027. The question is no longer whether to participate, but how to configure your infrastructure to perform.

Your EHR is the operational backbone. Without proper configuration for population health, risk scoring, and quality reporting, you are running a value-based contract with fee-for-service tools.

Fee-for-Service vs. Value-Based Care: EHR Requirements

Dimension FFS Workflow VBC Workflow EHR Feature Needed
Patient focus Individual encounter Entire attributed panel Patient registry + panel management
Revenue driver Volume of visits Quality scores + cost reduction Quality measure tracking + analytics
Documentation goal Justify the billing code Capture full clinical complexity HCC coding prompts + risk adjustment
Care coordination Referral and forget Closed-loop tracking Referral management + care team alerts
Preventive care Only if patient shows up Proactive outreach for overdue services Care gap detection + automated outreach
Risk assessment Not routinely performed Continuous risk stratification Risk scoring engine + population dashboards
Social factors Rarely captured Screened and integrated into care plans SDOH screening + Z-code mapping
Utilization tracking Claims-based, retrospective Real-time ADT alerts ADT notifications + ED/readmission alerts
Analytics Monthly billing reports Real-time quality + cost dashboards Population health analytics platform
Performance measurement RVUs and collections Total cost of care + outcomes TCOC benchmarking + outcomes reporting

Most EHRs were built for fee-for-service. The shift to value-based care requires enabling features that may already exist in your system but are not turned on, configured, or integrated into clinical workflows.

Common mistake: Organizations purchase a population health module but never configure care gap rules, risk stratification tiers, or attribution logic. The module sits unused while staff continue to operate in FFS mode. Configuration is the work -- not the purchase.

CMS Value-Based Payment Models: What Your EHR Must Support

Model Description Participants Risk Level EHR Requirements
MSSP Shared savings for ACOs managing Medicare beneficiaries; largest CMS APM 476 ACOs, 11.2M beneficiaries Low to Moderate eCQM reporting, APP Plus measures, attribution tracking, care coordination
ACO REACH Professional and global risk tracks through Dec 2026; emphasis on health equity 103 ACOs, 2.5M beneficiaries Moderate to High Risk adjustment (HCC), TCOC tracking, equity reporting, SDOH capture
LEAD Model Successor to ACO REACH; capitated population-based payments, broad eligibility New entrants + existing ACOs High (global risk) Capitation management, downstream VBC contracting, full population health suite
ACO PC Flex Enhanced primary care delivery within MSSP; prospective payments (2025-2029) MSSP ACOs with primary care focus Low to Moderate Panel management, chronic care management, care team workflows
TEAM (Bundled) Mandatory 30-day surgical episode bundles; inpatient and outpatient procedures + post-acute Hospitals in ~25% of U.S. markets Mandatory risk Episode-of-care tracking, post-acute care alerts, discharge planning, PAC utilization
Hospital VBP CMS withholds 2% of Medicare reimbursement; hospitals earn back based on quality performance All IPPS hospitals Moderate Clinical quality measures, patient experience tracking, safety event reporting

If you are new to value-based care, start with MSSP. It offers upside-only BASIC tracks for new ACOs, though CMS has reduced the time in one-sided risk to five performance years before requiring two-sided risk. For hospitals in TEAM-designated markets, episode tracking configuration is no longer optional.

2026 update: CMS updated the APP Plus quality measure set for MSSP, removing Quality ID 487 (Screening for Social Drivers of Health) while maintaining focus on clinical outcomes. ACO REACH lowers the shared savings/losses threshold from 25% to 10% of benchmark in PY2026 -- making EHR analytics accuracy even more critical. For full regulatory context, see our MIPS Promoting Interoperability guide.

EHR Vendor VBC Feature Comparison

Vendor Population Health Risk Stratification Care Gaps SDOH Analytics
Epic (Healthy Planet) Native Patient registries, Cosmos data (200M+ patients) Advanced HCC, predictive models, ML-based Automated HEDIS + custom rules, BPA alerts Integrated Screening + Z-code + referrals Comprehensive Real-time dashboards, Cosmos benchmarks
Oracle Health (Data Intelligence) Native Vendor-agnostic, community-wide aggregation Advanced HCC + proprietary algorithms Available Rule-based, requires configuration Available Screening tools, Z-code support Strong Cloud-based, cross-system data
athenahealth Native Multi-EHR support, network insights Moderate Rule-based + partner integrations Automated Quality measure dashboard, alerts Available Screening + documentation Good VBC-specific analytics, benchmarking
MEDITECH Expanse Available Population health module + FHIR Moderate Basic risk scoring, partner tools Available Configurable rules Basic Screening support, Z-codes Good BCA analytics, eCQM reporting
eClinicalWorks Available PHM module, HEDIS tracking Basic Rule-based, limited ML Available Quality measure alerts Basic Screening questionnaires Limited Standard reports, limited dashboards
Persivia CareSpace Native AI-driven, EHR-agnostic overlay Advanced AI + NLP-based, real-time Automated AI-detected, point-of-care Available Integrated screening Comprehensive Real-time VBC dashboards

Epic Healthy Planet remains the most deeply integrated VBC platform for organizations already on Epic. Oracle Health Data Intelligence stands out for community-wide, multi-vendor data aggregation. For organizations on smaller EHRs, Persivia CareSpace and similar EHR-agnostic overlays can add VBC capabilities without a platform migration.

For a broader vendor comparison, see our Top EHR Vendors Ranked guide.

Care Gap Identification and Closure Workflow

Care gaps are the single most actionable lever for improving quality scores. Each closed gap directly impacts your HEDIS measures, CMS star ratings, and shared savings eligibility.

Gap Type How EHR Detects Alert Mechanism Closure Action Quality Impact
Cancer screening (breast, cervical, colorectal) Age/sex criteria + no screening order/result in measurement year Pre-visit planning list, patient portal message Order placed at visit or outreach scheduled HEDIS BCS, CCS, COL
Diabetes management (A1C, eye exam, nephropathy) Dx code + missing lab result or referral in past 12 months In-chart BPA alert, care gap worklist Lab order, ophthalmology referral, medication review HEDIS CDC, MSSP
Blood pressure control Last BP reading >140/90 or no BP in past 12 months Vitals flowsheet flag, population dashboard Medication adjustment, follow-up visit, RPM enrollment HEDIS CBP, APP Plus
Medication adherence PDC < 80% from pharmacy claims or Rx fill data Pharmacist worklist, patient outreach trigger Medication reconciliation, barrier assessment, 90-day supply Star ratings, PDC
Annual wellness visit (AWV) Attributed Medicare patient, no AWV claim in current year Scheduling worklist, automated patient outreach Schedule AWV, complete risk assessment at visit RAF capture, MSSP
Depression screening (PHQ-9) No PHQ-9 documented in past 12 months for eligible patients Intake form trigger, MA workflow prompt Administer PHQ-9, document score, follow-up plan if positive CMS-159, APP Plus
Immunizations (flu, pneumococcal, COVID) Age criteria + no immunization record in registry Chart banner, patient portal reminder Administer vaccine, update immunization registry HEDIS FVO, PNU
Post-discharge follow-up ADT notification received, no follow-up visit within 7/14 days Care coordinator worklist, urgent outreach flag Schedule follow-up, medication reconciliation, TCM billing Readmission reduction, TCM

Configuration priority: Start with the five care gaps that most impact your specific VBC contract. For MSSP ACOs, diabetes management, blood pressure control, depression screening, and cancer screenings drive the majority of quality scores. Configure your EHR to surface these gaps at the point of care -- not on a report that staff review after the patient has left.

Risk Stratification Configuration Guide

Risk stratification is how you allocate scarce care management resources to the patients who will benefit most. A well-configured risk engine prevents both overinvestment in healthy patients and missed interventions for rising-risk populations.

Risk Tier Criteria EHR Data Sources Intervention Level Monitoring Frequency
Healthy / Low Risk 0-1 chronic conditions, no ED visits, HCC score < 0.5 Problem list, claims, demographics Preventive care outreach, AWV scheduling, portal engagement Annually
Rising Risk 2-3 chronic conditions, 1-2 ED visits/year, HCC 0.5-1.5, uncontrolled A1C or BP Problem list, labs, utilization, pharmacy claims Proactive care coordination, chronic care management (CCM), medication review Quarterly
High Risk 4+ chronic conditions, 3+ ED visits, 1+ hospitalizations, HCC 1.5-3.0, polypharmacy (10+ meds) Claims, labs, ADT feeds, medication list, SDOH flags Dedicated care manager, weekly check-ins, transitional care management Monthly
Complex / Critical 5+ chronic conditions, frequent readmissions, behavioral health comorbidity, SDOH barriers, HCC > 3.0 All sources + behavioral health, SDOH screening, ADT alerts, pharmacy Interdisciplinary care team, daily/weekly touchpoints, community health worker, social services Weekly

Configuration checklist for risk stratification:

1. Enable HCC risk score calculation -- Map diagnosis codes from your problem list and claims to the CMS-HCC model. Update annually with CMS coefficient changes.

2. Connect ADT feeds -- Subscribe to regional HIE ADT notifications so your EHR knows when attributed patients visit EDs or are admitted elsewhere.

3. Configure utilization rules -- Set thresholds for ED visits, hospitalizations, and specialist referrals that auto-escalate risk tier.

4. Integrate pharmacy data -- Pull medication fill data to identify polypharmacy, non-adherence, and high-risk medication combinations.

5. Build care manager worklists -- Auto-populate worklists by risk tier so care managers start each day with their highest-acuity patients.

SDOH Data Capture Checklist

CMS required SDOH screening for hospital inpatients starting in 2024, with outpatient mandates expected by 2026. Regardless of mandates, SDOH data improves risk stratification accuracy and identifies barriers that undermine care plan adherence.

SDOH Domain Screening Tool EHR Field Mapping ICD-10 Z-Code Reporting Use
Food insecurity Hunger Vital Sign (2 questions), PRAPARE Structured questionnaire response, social history Z59.41-Z59.48 Risk adjustment, community referral, equity reporting
Housing instability PRAPARE, AHC-HRSN Social history, problem list Z59.0-Z59.1 Risk stratification, housing resource referral
Transportation barriers AHC-HRSN, PRAPARE Social history, appointment no-show correlation Z59.82 No-show prediction, ride service referral
Financial strain PRAPARE (income, insurance, employment) Financial counselor fields, demographics Z59.5-Z59.7 Medication assistance programs, sliding scale
Education / literacy PRAPARE (education level, language) Demographics, language preference Z55.0-Z55.9 Health literacy-adjusted education, interpreter services
Social isolation AHC-HRSN (social connections), PRAPARE Social history, PHQ-9 correlation Z60.2-Z60.4 Behavioral health referral, community programs
Interpersonal violence AHC-HRSN (safety), HITS questionnaire Sensitive data fields (restricted access) Z63.0, Z65.4 Safety planning, advocacy referral
Employment status PRAPARE (employment, veteran status) Demographics, social history Z56.0-Z56.9 Vocational rehab referral, disability assessment

Critical EHR configuration step: SDOH responses must flow into structured fields, not free-text notes. If your SDOH data lives only in clinical notes, it cannot be used for risk stratification, population reporting, or community referral matching. Map each screening question to a discrete data element and configure auto-generation of Z-codes from positive responses.

PRAPARE (Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences) is the most widely adopted screening tool with EHR integration support across Epic, Oracle Health, and athenahealth. The AHC-HRSN (Accountable Health Communities Health-Related Social Needs) screening tool is the CMS-endorsed option.

VBC Dashboard KPIs: What to Track and When to Act

Your VBC dashboard should answer one question per metric: "Are we on track to earn shared savings?" Every KPI needs a target, a data source, and a clear action trigger when performance drifts.

KPI Metric Target Data Source Update Frequency Action Trigger
Total cost of care (TCOC) per beneficiary Below benchmark (varies by ACO) Claims data + EHR utilization Monthly If trending >5% above benchmark, review high-cost patients
Quality composite score >90th percentile (max shared savings) eCQM/HEDIS engine, EHR quality reports Weekly during measurement year If any measure <50th percentile, targeted intervention
Care gap closure rate >85% by end of measurement year Population health module Weekly If <70% at Q3, launch outreach campaigns
ED utilization rate <400 per 1,000 beneficiaries/year ADT feeds + claims Real-time (ADT alerts) Each avoidable ED visit triggers care manager review
30-day readmission rate <15% (CMS national avg ~15.5%) ADT feeds, discharge data Real-time Each readmission triggers root cause review
Attribution stability >90% retention quarter-over-quarter Claims alignment files, EHR scheduling Quarterly If attribution drops >10%, launch re-engagement
Risk adjustment factor (RAF) accuracy RAF recapture rate >95% Problem list, claims, coding audits Monthly If recapture <90%, launch HCC coding review
AWV completion rate >75% of attributed Medicare patients Scheduling + claims Monthly If <50% by Q2, automated outreach campaigns
Patient experience (CAHPS) >75th percentile CAHPS survey results, patient feedback Quarterly If <50th percentile, process improvement team
SDOH screening rate >80% of attributed patients screened annually SDOH questionnaire completion, Z-code capture Monthly If <60%, embed screening into intake workflow

Dashboard design principle: Build three views -- executive (monthly, 5 KPIs), operational (weekly, all metrics), and care manager (daily, patient-level worklists). Most EHR population health modules support role-based dashboards. If yours does not, consider an analytics overlay like Persivia, Arcadia, or Health Catalyst.

VBC Readiness Assessment: Where Do You Stand?

Use this assessment to identify the gaps between your current EHR configuration and what value-based care contracts require. Score each capability honestly before investing.

Capability Current State Evaluation Common Gap Priority Investment Needed
Population health module Licensed but not configured? Fully active? Not purchased? Module purchased but registries, rules, and workflows not built Critical $50K-$200K (config + training)
Risk stratification Manual? Rule-based? ML-driven? No automated scoring; care managers use spreadsheets Critical $25K-$100K (algorithm + data feeds)
Care gap detection Manual chart review? Automated rules? Real-time alerts? Gaps identified retrospectively, not at point of care Critical $15K-$75K (rule config + BPAs)
eCQM / quality reporting MIPS only? ACO measures configured? Real-time tracking? Reports run quarterly, not actionable in real-time High $10K-$50K (measure config + dashboards)
ADT notification integration Receiving ADT feeds? Routed to care teams? Acting on them? ADT feeds available from HIE but not consumed or acted on High $10K-$40K (integration + workflows)
SDOH screening Standardized tool? Structured data? Z-codes generated? Screening done on paper or free-text, not coded High $10K-$30K (forms + mapping)
Attribution / panel management Patients assigned to PCPs? Attribution file ingested? Panel size tracked? No empanelment process; attribution unknown until CMS report High $5K-$25K (workflow + data import)
HCC / risk adjustment coding Coding prompts at point of care? Annual recapture workflows? Chronic conditions not recaptured annually; RAF scores inaccurate High $15K-$50K (CDS rules + training)
Care coordination tools Referral tracking? TCM workflows? Shared care plans? Referrals sent but not tracked; no closed-loop follow-up Medium $10K-$40K (workflow design)
Analytics and dashboards Standard reports only? Custom dashboards? Real-time? Leadership reviews monthly reports but no operational dashboards Medium $20K-$100K (platform + development)

The typical organization entering its first VBC contract has the population health module licensed but requires 3-6 months of configuration work to activate risk scoring, care gap rules, and reporting dashboards. Budget for this configuration sprint separately from the software license.

ROI of a VBC-Optimized EHR Configuration

Investment Area Typical Cost Shared Savings Potential Quality Bonus Impact Est. Annual ROI
Population health module configuration $50K-$200K (one-time) Enables identification of high-cost patients; 10-20% utilization reduction Foundation for all quality tracking 3-5x
Risk stratification + care management $25K-$100K (setup) + $150K-$300K/yr (care managers) $500-$3,000 per high-risk patient through avoided admissions Reduces readmissions, improves TCOC 2-4x
Care gap closure automation $15K-$75K (rule config + outreach tools) Indirect: higher quality scores increase savings share Each 1% improvement can add $50K-$200K in quality bonuses (mid-size ACO) 5-10x
HCC risk adjustment coding $15K-$50K (CDS + training) Accurate RAF scores raise benchmark, increasing shared savings potential Supports accurate patient complexity reporting 5-15x
ADT integration + transitional care $10K-$40K (integration) + TCM billing revenue $3,000-$8,000 per avoided readmission Readmission reduction improves VBP score 4-8x
SDOH screening + community referrals $10K-$30K (forms + Z-code mapping) Addresses barriers to adherence; reduces no-shows and avoidable utilization 2026 CMS health equity adjustment bonus for safety-net providers 2-5x
Total VBC EHR configuration $150K-$500K MSSP ACOs averaged $8.6M in total savings per ACO in 2024 12-18 mo payback

$2.5B

Medicare savings from MSSP in 2024

$4.1B

Total shared savings distributed

75%

ACOs that earned savings payments

The math is straightforward: MSSP ACOs that perform well earn 40-75% of the savings they generate below benchmark, depending on their track. A mid-size ACO managing 20,000 beneficiaries with a properly configured EHR can realistically generate $1M-$5M in annual shared savings. The $150K-$500K EHR configuration investment pays for itself within the first performance year.

The cost of inaction: ACO REACH is lowering the shared savings/losses threshold from 25% to 10% in PY2026. For organizations in two-sided risk, poor EHR configuration does not just mean missed savings -- it means writing checks. CMS's mandatory TEAM model applies the same logic to surgical episodes. The financial risk of an under-configured EHR is now measurable and growing.

Frequently Asked Questions

What EHR features are required for value-based care?

At minimum, a VBC-ready EHR needs population health management with patient registries, risk stratification algorithms that score patients by acuity and utilization, automated care gap detection tied to HEDIS and CMS quality measures, SDOH screening with Z-code capture, attribution and panel management tools, and analytics dashboards for tracking total cost of care, quality scores, and shared savings performance. Most major EHRs offer these capabilities natively or through integrated modules -- Epic Healthy Planet, Oracle Health Data Intelligence, and athenahealth population health are the leading platforms.

How do I configure risk stratification in my EHR?

Risk stratification configuration involves defining risk tiers (typically 4 levels from healthy to complex), mapping data sources such as claims, diagnoses, utilization history, labs, and SDOH factors to a scoring algorithm, and setting intervention protocols for each tier. Most EHRs support HCC risk scores and proprietary algorithms. Configure your system to pull from problem lists, medication counts, ED visits, hospitalizations in the past 12 months, and social determinants. Assign care management workflows to each tier so that low-risk patients get preventive outreach, rising-risk patients get proactive care coordination, and high-risk patients get dedicated care managers with weekly touchpoints.

What CMS value-based payment models should my organization consider?

The Medicare Shared Savings Program (MSSP) is the largest and most accessible, with over 476 ACOs serving 11.2 million beneficiaries. Start with MSSP if you are new to value-based care, as it offers upside-only BASIC tracks before requiring two-sided risk. ACO REACH runs through December 2026 with 103 ACOs and 2.5 million beneficiaries, and is transitioning to the LEAD model with capitated payments. For hospitals, the TEAM mandatory bundled payment model launched January 2026 covering surgical episodes in 25% of U.S. markets. See our MIPS guide for detailed quality reporting requirements.

How do I capture social determinants of health (SDOH) data in my EHR?

Configure your EHR to embed standardized SDOH screening tools -- such as PRAPARE, AHC-HRSN, or the Hunger Vital Sign -- into intake and annual wellness workflows. Map screening responses to ICD-10 Z-codes (Z55-Z65) covering education, employment, housing, food insecurity, transportation, and social isolation. Ensure the data flows into structured fields rather than free-text notes so it can be used for risk stratification, quality reporting, and community resource referrals. CMS began requiring SDOH screening for hospital inpatients in 2024, with outpatient mandates expected by 2026.

What is the ROI of configuring an EHR for value-based care?

MSSP ACOs generated $4.1 billion in shared savings in 2024, with 75% of ACOs earning payments. A well-configured EHR directly impacts these results by improving care gap closure rates (each percentage point can add $50,000-$200,000 in quality bonuses), reducing avoidable ED visits and readmissions through risk stratification, and enabling accurate risk adjustment coding. The typical EHR VBC configuration investment of $150,000-$500,000 pays back within 12-18 months through shared savings and quality incentive payments for a mid-size ACO managing 15,000-25,000 beneficiaries.

The Bottom Line

Value-based care is a configuration problem, not a software problem. Most organizations already own the EHR capabilities they need -- population health modules, risk scoring, care gap rules, SDOH screening tools. The gap is in activation: turning on the features, building the workflows, training the staff, and connecting the data sources.

Start with your highest-impact VBC contract. Identify the 5 quality measures that most affect your shared savings. Configure your EHR to surface those care gaps at the point of care. Build risk stratification tiers and assign care management resources by tier. Connect ADT feeds. Embed SDOH screening. Then build the dashboards that tell you weekly whether you are on track.

The organizations earning shared savings in 2026 are not the ones with the most expensive EHR. They are the ones that configured it properly.

Next Steps