River Garden Senior Services, in Jacksonville, Florida, USA, is a long-time user of Harmony and has more recently implemented the clinical modules. River Garden’s clinical staff, including doctors, nurses, social workers, dieticians and therapists, now have access to vital information at the point-of-care through touchscreen tablets and laptops. Nursing supervisors can monitor in real-time whether residents get their medication on time. Integration with third parties, such as pharmacies, laboratories and specialist Web services, is completely automated.
- The Challenge
- The Project
- River Garden Senior Services
- Harmony on the floor
- River Garden’s praise for AHC
- Company and System Information
When Marcia DeRosia, President of American Health Care Software (AHC), purchased the company and its Harmony solution in 1990, she recognized the potential but also knew she took on a huge challenge. Having been a user of Harmony herself as the CEO of a nursing home chain, she realized that not being able to meet the looming deadline of the federally required MDS (Minimum Data Set) would be disastrous to any software company operating in the USA. The MDS, a clinical assessment process of nursing home residents, was about to become federally mandated for Medicare and Medicaid certification and funding.
In the first three months after purchase, AHC’s technical team developed the MDS module and rolled it out to all Harmony customers. Ever since AHC has been quick to update its Synon and RPG developed Harmony software to add new functionality and comply with constantly changing federal and state regulations.
By 2005 several state-specific MDS applications and MDS 2.0 were applied and Harmony had become a leader in its field. But although it was functionally rich and its database well designed, its 5250 (character-based) screens became too restrictive, especially for use by clinical staff on the nursing care units. Another concern was that Harmony wouldn’t be able to meet the growing demands for integration with third parties, such as with pharmacies and laboratories.
DeRosia and her team started looking for a gradual modernization and redevelopment technology. “Harmony consists of millions of lines of code and hundreds of long term care facilities are using the solution. Redeveloping from scratch would be a massive effort and result in a risky and disruptive migration path for our customers. Moreover, we simply could not afford to put innovation on hold for our existing customers, while working on a brand new solution. Therefore we were looking for a development environment that would allow us to gradually modernize and redevelop Harmony,” explains DeRosia.
After researching available options, AHC opted for LANSA. "Visual LANSA gave us the capability to modernize, extend and progressively redevelop our IBM i-based application, and also allowed us to add Windows-based functionality and touch-screen tablets,” says DeRosia. “In addition, although we love the IBM i operating system, it’s good to know that LANSA doesn’t lock us in.”
With Visual LANSA we could modernize, extend and progressively redevelop, and add Windows-based functionality and touch-screen tablets.
The decision to use Visual LANSA is now several years ago. AHC decided to use the Framework development approach, which is available as an option within Visual LANSA.
The Framework provides a pre-built application in which you can plug-in newly developed Windows and IBM i components, as well as call existing RPG programs. “It allowed us to continue to utilize parts of our legacy application, for as long as we still needed to, in combination with new functionality. Another reason for using the Framework was that it saved us a massive amount of development time, as it comes with standard navigation and MS office integration functionality,” says Warren Rice, senior developer at AHC.
Melissa Carter, Technical Manager at AHC, explains “Redevelopment is now almost finished. Besides redeveloping our existing Harmony system in LANSA and moving from MDS 2.0 to MDS 3.0, we have spent the bulk of our effort on building a new clinical package, which we didn’t have before. We now have a comprehensive E.H.R. (Electronic Health Record) solution with eMAR (electronic Medication Administration Record) and Point-of-Care modules.”
The clinical modules were developed by working closely with nurses and health care providers. The eMAR and Point-of-Care modules have a touchscreen interface, so they can be used on tablets by nursing and medical staff. The clinical modules contain graphs, for example to show differences in weight, vital signs and glucose levels over time.
All Harmony modules - clinical, but also waiting list management, admission, census tracking, billing, accounts receivable, financial and others - are integrated with MS Office. “Whenever users have a grid/list on their screen, they can push a button to export to MS Excel,” explains Rice. “Free format text fields, extensively used by doctors and nurses for progress notes and other comments, are all based on LANSA memo fields and utilize MS Word’s dictionary and spell checking.”
Integration with third parties is done with LANSA Composer, for example:
- Exchange of physician orders with pharmacies (NCPDP and HL7)
- Receiving and processing of test results from laboratories into the E.H.R. module (HL7).
- Receiving details from therapists regarding the amount of time spent on a resident (XML), recording this as part of the resident’s treatment plan and exporting it for billing.
- Checking the interactions of multiple medications against each other (Web service with TruvenHealth), showing a bright red warning in eMAR in case of a contradiction.
- Exporting information in XML format for uploading in the government’s portal.
“For any software vendor ease of deployment is crucial,” says Carter. Harmony has a rich client interface, which requires that client computers of individual users need to be updated with each new release. For this AHC uses Visual LANSA’s just-in- time deployment feature. Client computers automatically check for release updates on the customer’s server when they login and get updated automatically. “It greatly speeds up the release update process for our customers and reduces errors and support calls,” continues Carter.
Visual LANSA Framework saved us a massive amount of development time, as it comes with standard navigation and MS office integration functionality.
River Garden Senior Services
One of the Harmony customers who has made the modernization journey with AHC, is River Garden Senior Services (River Garden,) a not-for-profit, mission-driven organization established in 1946 and sponsored by the Jewish community in Jacksonville, Florida. Located on a 40-acre campus, River Garden offers a variety of services including a 180 bed skilled nursing and rehabilitation facility, 80 apartment homes for Independent Living, Home Health Care and Adult Day Care.
River Garden is a multi-time recipient of the prestigious Florida Governor’s Gold Seal Award for Excellence in Long-Term Care, along with 5-Star ratings by state and federal regulatory authorities. Needless to say that River Garden understands quality of care.
Martin Goetz, CEO at River Garden, explains “We have been using Harmony since 1988. Initially we used it mostly for administrative purposes, such as waiting list management and finances. But when the government started mandating electronic records, beginning with the MDS we decided it was time to put technology in the hands of clinical staff. Having seen Harmony’s existing modules move from green screens to graphical with LANSA, we were enthused and keen to get involved in the design of the clinical modules.”
Over a period of three years with weekly phone calls, River Garden’s clinical staff was extensively consulted for their feedback as a beta customer. “AHC was very responsive to our needs. They really understand our business and know which features are for the greater benefit of all Harmony users, and which requirements are unique. We have always been completely happy with the standard version of Harmony, and wanted to stay with that,” says Goetz.
We decided it was time to put technology in the hands of clinical staff.
Harmony on the floor
River Garden’s skilled nursing facility has five distinct units: two traditional, two memory care and one short stay program. Implementation of the clinical modules was unit by unit and is now available throughout the facility. eMAR is accessible through touchscreen thin terminal services tablets mounted on medication carts, of which there are seven. On each of the 20 nursing wings, clinical staff has access to kiosks and the full set of clinical modules through rich client Windows PCs, also with touchscreens.
Nursing staff add their comments to the system, for example relating to appetite, food and fluid intake, independence in tasks such as getting dressed, and general wellbeing. Doctors, dieticians, and therapists also add their comments, as well as medicine orders and treatment plans, making it immediately available to others. This combined and timely data provides very meaningful information.
Carol Thomas, RN Chief Nursing Officer at River Garden, explains, “All data entered in Harmony is automatically time stamped. It allows us to monitor risk factors in real-time and take preventative steps before they result in actual problems. For example, in eMAR we can see how nurses are progressing with administering medicine and treatment to residents. eMAR screens show photos of each resident to ensure medication is given to the correct person, with a red border around the photos of those residents who are at risk of receiving their medication late.”
“The biggest impact of capturing and displaying information at the point-of-care, is that it is now actually being consistently used,” continues Carol. “Previously information was spread over numerous pages of paper sitting in a folder that was updated on a weekly basis by a charge nurse, but otherwise it was hardly used. Now staff literally have the resident’s information at their fingertips with easy to interpret charts and with alerts and warnings when appropriate.”
Other benefits include that physician medication orders are transmitted instantly to the pharmacy and that the pharmacy’s responses are automatically processed (using LANSA Composer). “Direct communication with the pharmacy gives a much timelier turnaround for medication orders than in the manual system,” adds Carol.
Although the Harmony system itself is easy to use, there was an extensive learning curve according to Carol, mostly related to nursing staff having to master the MDS standard terminology. It requires training for nursing staff to agree on and consistently apply terms such as ‘extensive assistance needed’, ‘Independent’ and all the gradations in between.
Previously charge nurses (ward/unit supervisors) would enter detailed information based on paper-based information they received from the nursing assistants, commonly referred known as “certified nursing assistants” in the USA, mostly consisting of checkmarks. This was a huge administrative task for the charge nurses, taking away from their time to be actively involved in care.
According to Thomas and Goetz, most nursing homes in the USA employ “MDS Coordinators,” individuals whose sole job is to capture information from clinical users and to then encode and transmit data sets to federal authorities. It isn’t uncommon to find 2-3 such individuals in a skilled nursing facility the size of River Garden. River Garden though has never used an MDS coordinator. Instead, clinical staff have been trained in the terminology of the MDS and competency validated by its staff educator. And so having clinical staff capable of assessing, encoding the MDS and planning resident care makes for a seamless system of care. It also saves money by not having to hire individuals whose sole purpose is “feeding the MDS”.
Jeremy Green, Director of IT at River Garden, manages the computing environment with just two staff. It consists of an IBM i server, over 150 PCs for administrative, business and other office staff, 20 touchscreen rich client PCs at nursing kiosks and 10 terminal services laptops mounted on medicine carts. “Applying release updates is easy and we hardly get any support calls,” says Green.
The biggest impact of capturing and displaying data at the point-of-care, is that it is now actually used.
River Garden’s praise for AHC
River Garden is proud of its Governor’s Gold Seal Award and 5-Star ratings. Nursing homes are audited by government regulators every year on their care and documentation and assessed on how clinical care is being rendered to residents. River Garden has not been cited for any clinical care deficiencies in over four years, and it has never received a deficiency in its preparation of the MDS. “That’s a huge accomplishment which would not have been possible without our excellent nursing and clinical staff and the robust Harmony solution,” says Goetz.
According to Thomas and Goetz, “LANSA has made it possible for American Health Care to bring exceptional software into the 21st Century. Moving from a traditional green screen environment to a graphical Windows world has been nothing short of revolutionary. We now have well over 150 staff using the AHC software. Our staff love it and it’s made a huge difference in our ability to document and manage care.”
“The new Harmony solution has made it possible for agencies such as ours to utilize electronic records in an environment that supports and nourishes our work. It has allowed us to keep the integrity of the work we have always been doing, but do it better,” concludes Goetz.
“AHC is an excellent partner with a passionate commitment to their clients and the residents we serve. You can feel they are not in the business just for the money. Without the software transition to a graphical Windows environment, we would not have been able to advance our relationship with AHC. For River Garden, our relationship with AHC is that of a valued partner that embraces our mission, vision and values around resident care. Colleagues of their caliber simply do not come along all that often.”
Thanks to our excellent staff and the robust Harmony solution, we are a seven-time recipient of the Governor’s Gold Seal Award and have 5-Star rating.
Carter concludes, “AHC has enjoyed the technical productivity gain with the LANSA tool. When the decision was made to move forward with LANSA, we employed four developers, who we hired right out of technical college. They have all been outstanding and learned how to use LANSA very quickly. Now they are all experienced and even our newest employee has been with us for over five years.”
“At the moment all our customers run Harmony on IBM i, either on-premise or hosted. It’s important to us to keep Harmony in a single set of source code. There are still some programs and routines that are RPG-based, but once we have everything converted to LANSA we can be platform independent and offer Harmony on Windows, as well as on Linux and IBM i.“
We employ four developers, who we hired right out of technical college. They have all been outstanding and learned how to use LANSA very quickly.
Company and System Information
- American Health Care Software is a national software solution provider to the healthcare industry and a LANSA and IBM business partner located in South Burlington, Vermont. Through its Harmony solution, AHC customers encompass nursing homes, long-term care, home care, elder care, retirement homes, assisted living, apartments, outpatient clinics, and others. For more information visit: www.ahconline.com
- River Garden Senior Services is a not-for-profit, mission-driven agency located in Jacksonville, Florida. River Garden serves residents from diverse religious and ethnic backgrounds while maintaining an environment supportive of Jewish identity and informed by Jewish values. For more information visit: www.rivergarden.org
- River Garden deploys Harmony on an IBM Power 720 server. The PCs used at the nursing stations have planar touch screens and are from Lenovo.