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Population Health Lakehouse: 19% Readmission Reduction

About the Client

The client is a multi-hospital health system managing a diverse patient population across acute, ambulatory, and post-acute care settings. Fragmented data across claims, clinical systems, pharmacy records, and social determinants limited their ability to run effective population health programs. To address these challenges and enable advanced analytics, the organization partnered with Zymr.

Key Outcomes

19% Reduction in 30-Day Readmissions Within 12 Months
Unified Data Platform Supporting 5+ Active ML Programs

Business Challenges

The health system operated with siloed data sources, including claims, EHRs, pharmacy systems, and external datasets. This fragmentation made it difficult to gain a unified view of patient populations and limited the effectiveness of care gap identification and risk stratification initiatives.

Without a centralized data platform, analytics teams struggled to generate reliable insights for readmission prediction and population health management. Data inconsistencies and latency further impacted decision-making and delayed interventions for high-risk patients.

The absence of a scalable data architecture also made it challenging to support value-based care reporting requirements. Quality metrics, care outcomes, and contract reporting required significant manual effort, increasing operational overhead and reducing efficiency.

The organization needed a modern lakehouse platform capable of integrating diverse data sources, enabling real-time analytics, and supporting machine learning use cases for population health.

Business Impacts / Key Results Achieved

Zymr designed and implemented a population health lakehouse that unified enterprise data and enabled advanced analytics and ML-driven insights. This transformation improved care outcomes, operational efficiency, and reporting capabilities.

  • 19% Reduction in 30-Day Readmissions Within 12 Months
  • Enabled 5+ Active Machine Learning Programs
  • Improved Accuracy of Risk Stratification Models
  • Accelerated Care Gap Identification and Interventions
  • Streamlined Value-Based Care Reporting

Strategy and Solutions

Zymr built a scalable lakehouse architecture designed to support population health analytics, machine learning, and regulatory reporting.

  • Unified Data Lakehouse Architecture
    Integrated claims, clinical, pharmacy, and SDOH data into a centralized platform with Bronze, Silver, and Gold layers optimized for analytics.
  • Population Health Gold Layer
    Designed a curated data layer specifically for population health use cases, enabling efficient querying and feature generation for ML models.
  • Readmission Prediction Models
    Developed and deployed machine learning models trained on lakehouse data to identify high-risk patients and enable proactive interventions.
  • FHIR-Based Data Integration
    Leveraged FHIR standards to ensure interoperability and seamless integration across diverse healthcare systems.
  • Care Gap and Risk Stratification Analytics
    Enabled advanced analytics capabilities to identify care gaps, stratify patient risk, and prioritize interventions.
  • Value-Based Care Reporting Enablement
    Automated data pipelines and reporting workflows to support compliance and contract reporting requirements.
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