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Health System Builds Population Health Platform, Reduces Readmissions by 19%

About the Client

The client is a multi-hospital health system managing 2.1 million patient lives across a network of hospitals and clinics. Patient data was fragmented across multiple EHRs and care settings, limiting coordinated care delivery. Lack of unified visibility impacted outcomes and quality metrics. To address this, the system partnered with Zymr.

Key Outcomes

Readmissions Reduced by 19%
4-Star CMS Rating Achieved in First Submission

Business Challenges

The health system operated across 47 EHR systems and 18 clinics, resulting in highly fragmented patient data. Care teams lacked a unified longitudinal view of patients, making it difficult to coordinate care and track outcomes effectively.Population health initiatives were limited by inconsistent data integration and lack of real-time insights. Identifying high-risk patients and closing care gaps required manual effort and siloed workflows.Social determinants of health (SDOH) data was not integrated into clinical decision-making, further limiting proactive care interventions. Quality reporting and performance tracking across HEDIS measures were also inconsistent.The organization needed a unified population health platform capable of integrating diverse data sources, enabling risk stratification, and supporting care gap closure at scale.

Business Impacts / Key Results Achieved

Zymr helped the health system transform its population health strategy into a data-driven, proactive care model. By unifying patient data and enabling advanced analytics, the organization improved outcomes and strengthened quality performance.

  • Readmissions Reduced by 19%
  • Improvement Across 8 HEDIS Measures
  • 4-Star CMS Rating Achieved in First Submission
  • Enhanced Risk Stratification Accuracy
  • Improved Care Gap Closure Rates

Strategy and Solutions

Zymr implemented a scalable population health platform combining interoperable data integration, analytics, and care coordination workflows.

  • FHIR-Based Data Lakehouse
    Built a unified data platform integrating data from 47 EHR systems and multiple care settings using FHIR standards.
  • Patient 360 Longitudinal View
    Enabled a comprehensive patient profile by combining clinical, operational, and behavioral health data.
  • Risk Stratification Models
    Developed advanced analytics models to identify high-risk patients and prioritize timely care interventions.
  • Care Gap Closure Workflows
    Implemented intelligent workflows to track, manage, and close preventive care and chronic condition gaps.
  • SDOH Data Integration
    Integrated social determinants of health (SDOH) data to enhance care planning and improve intervention strategies.
  • Quality Reporting and Dashboards
    Delivered real-time dashboards providing insights into HEDIS performance, patient outcomes, and population health metrics.
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