Horizon EMR Data Extraction; Paragon EMR Data Extraction

In light of Allscripts recent acquisition of McKesson’s EIS business, which we analyzed in a prior blog article, we thought it would be beneficial to share our lessons learned in harvesting data from McKesson Horizon, Paragon, and Star.

First, let’s examine the platforms Allscripts acquired.

1. Paragon: ~200 client hospitals left; down from a peak of near 275
   1. Financials: Solid access & rev cycle; ERP – rare integrated suite (which Cerner, Epic & AS lack)
   2. Clinicals: 180 ONC-attested EMRs; Ancillaries – Lab, Rx & RIS
   3. Practices – integrated RCM; no EMR

2. HealthQuest: About 120 hospital clients still on this aging RCM system, which has IBM mainframe roots. Mostly large clients that integrate it to a different vendor EMR.
3. Star: About 100 client hospitals on aging system originally developed by HBOC. Solid financials; rudimentary clinicals (no certified EMR).
4. Horizon: About 70 large clients left on this robust clinical system with an ONC-certified EMR (200 MU attestations). Includes a wide array of interfaced ancillaries acquired over the years by HBOC, but lacks native integration. Some clients tried to convert to Paragon when McK announced it as their “go-forward” system, but the installs failed and they switched to Epic or Cerner.
5. Series: Based on dynamic control & JS data from the 70s & 80s. Only a dozen or more clients still run it for financials.

Next, let’s consider some high-level stats for the Paragon clinical database (v13):

• 3900 tables
• 600 views
• 105,000 columns
• 4,000 stored procedures

There are two types of data in Paragon. The first is the common reference masters (what is often referred to as “dictionaries” in other EMRs). It defines configuration of the system, from charge master, item master and caregivers. The other type of data is often referred to as the patient index, consisting of visit files and other clinical data. A prerequisite to build in Paragon is having the common reference masters defined in the system.

Key tables that contain core patient demographic & visit information include:

• TPM_300_PAT_VISIT
• TSM040_PERSON_HDR
• TSM950_LOCATION_REF

Most of the “master” tables are prefixed with “TSM180_MST_COD_DTL” and key tables include:

• TSM180_MST_COD_DTL_caregiver
• TSM180_MST_COD_DTL_gender
• TSM180_MST_COD_DTL_pat_type
• TSM180_MST_COD_DTL_visit_status

Other key insights and resources regarding Paragon:

• McKesson designed it without fixed length fields, interface requirements or other set design features, letting the EHR be customized to fit a hospital or health system’s needs.
• The McKesson EIS community is supported by the Insight user group as well as the Yahoo Paragon HIS user forum.

Industry Perspectives:

We would tell you that we believe with certainty that the total cost of ownership for Paragon as a hospital HIS will be less than Horizon and will be less than Cerner and will be less than Epic. There’s nothing that’s changed internally in terms of corporate structure or movement of products between or amongst divisions that would create any kind of bundling. The customer still has the ability to choose solutions that are right for either gaps in their current portfolio, or if they want more capability from one vendor, we would portray that we have the broadest selection. You can get connectivity, population management, risk management, care coordination, analytics, and your HIS from one place, which is McKesson Technology Solutions.

– David A. Souerwine, former president of McKesson Provider Technologies

We realized that McKesson was focusing on a different segment of the healthcare market with the Paragon system. Therefore, we had begun surveying the landscape to be proactive about the move at the same time that McKesson sent us the announcement. We have enjoyed a long history with Epic as one of their first revenue cycle clients, dating back to 1995. We had made a decision to upgrade our revenue cycle and billing system to a more recent Epic version for inpatient and outpatient billing. We also have Cerner’s lab system. Our decision, therefore, was to migrate our revenue cycle/clinical/lab environment to Epic/Epic/Cerner or Epic/Cerner/Cerner. Paragon is a system constructed with a different size and complexity health system in mind. Both Cerner and Epic were good choices for us, and after a thorough evaluation, we chose Epic for our clinical system.

– Kevin Johnson, MD, MS, Chief Informatics Officer, VUMC

The move from Horizon to Paragon has actually been pretty painful for McKesson and for their customers. That’s not a secret. It’s a little bit of a perfect storm that Paragon got caught up in. They took a product that had really struggled. They reset expectations and have actually done a really good job of developing on that. But now you’ve got all these external pressures that they haven’t been able to meet. Meaningful Use made EHRs become a physician tool, and so that part has been the biggest gap and they are having a hard time getting to the point where physicians are happy with it. That’s not unique to Paragon, but that is definitely one of Paragon’s struggles and one of the reasons why you’ve seen their scores drop in the small market.”

-Coray Tate, Vice President of Clinical Research, KLAS

As McKesson rushed to be first to market with a comprehensive, integrated solution, they used an acquisition strategy, which led to not achieving that goal of having an integrated product. While they were first to market, they came to the conclusion with their Better Health 2020 announcement that the acquisition strategy created technical, geographic, and personnel challenges. Making an integrated product through an acquisition strategy was not a feasible way to go about it. That was unfortunate because it was a product that early on had great promise.

I’ve had the fortune of being a product manager and leading the implementation of the Paragon solution, It was a KLAS market leader for smaller community hospitals. They had good satisfaction. For a lot of customers, it was their first EMR.

The idea of trying to get folks that were Horizon customers with higher expectations to move to the Paragon product was premature. It was something that most of the customers did not see as a feasible solution or alternative. That’s what you’ve seen. The vast majority of Horizon customers have gone elsewhere.

The other thing working against Paragon is that the healthcare market, due to other forces, needs economy of scale. You’ve seen a huge consolidation in healthcare. That consolidation has favored EMRs that can handle a large scale, which in our market means Cerner and Epic. When a larger organization consolidates smaller hospitals and organizations, they certainly aren’t going to uptake that smaller community EMR. They’re going to continue to deploy Cerner and Epic. That has contributed to their market dominance.

Paragon right now doesn’t have an ambulatory solution, so people that are making the jump to Paragon right now are putting faith into that product developing into a comprehensive solution. Their ED product is brand new and their ambulatory product does not exist yet. That’s a major limitation for Paragon right there.

-Mike Jefferies, VP/IS, Longmont United Hospital

Finally, what are current McKesson EIS client options if they choose to migrate? Below are tables listing vendor alternatives, and EMR market share courtesy of HIMSS Analytics LOGIC:

In conclusion, see the below clinical data migration (data conversions) and archival resources:

• HSCIO Webinar: Exploring Healthcare Data Archival Strategies
• HSCIO Webinar EHR Transitions: Legacy Support and Staff Augmentation
• EMR Data Archival Strategy Whitepaper
• EMR Replacement, Migration & Archival Resources
• Tackling Transition Blog Series
• Expert Panel: Seamless EHR Transition Through Data Migration