Six members grew to over 2,000 and 50 delegates at the inaugural COACH Conference jumped to over 1,500 at the 2015 e-Health Conference. COACH has come a long way in the past 40 years, bringing the adoption and use of computers and technology in health along with it. The founding Board of Directors, comprised of six talented, future thinkers, spearheaded the launch of a connection point that would progress the delivery of healthcare in Canada.
As founding President Steven Huesing stated in his Message from the President in the first COACH I/O (Input/Output) newsletter:
“Learning, they say, is a matter of two-way communication… That is what COACH is all about – to facilitate the process of learning for ourselves and through ourselves for others.”
This year, we acknowledge the advancements COACH has made in the field of health informatics (HI), with special thanks to all the members, volunteers and individuals who work to truly take HI mainstream. This article examines how the adoption of HI has evolved over time and the key changes and contributions manifested by COACH, based largely on back issues of this journal, Healthcare Information Management & Communications Canada. (Note: This is an overview of the highlights and is not intended to be totally comprehensive.)
Decade 1 (1975 – 1985)
Computers Advancing into Healthcare
The Canadian Organization for Advancement of Computers in Health (COACH) surged into existence on August 18, 1975 in Regina, Sask. After all the t’s were crossed, i’s dotted and strategic plan in place, 1976 was the year to take COACH public.
Opening with a newsletter, entitled COACH I/O (Input/Output), the first publication increased membership by an additional 17 people, for a total of 23 members!
Conference, Incorporation & More
Next on the to-do list was the inaugural COACH Conference, held in the nation’s capital in May 1976, just eight months after the association’s inception. Following this flood of popularity, it was time to get back to business, including: gaining federal incorporation, nominations for Board elections, establishing a Security & Confidentiality Committee and much more. Quickly and efficiently, federal incorporation was achieved in June 1976. Come 1978, COACH had put together a Security and Confidentiality Committee that would go on to produce the first copy of the Privacy and Security Guidelines in 1985.
Throughout this time, the Board continued with a bi-annual election process. The first female COACH President, Judy Moran, was elected in 1982. This was a great step for women leaders in HI.
Early Days of Mainframes
The Technicon Data System (TDS), out of the United States, was the leading system demonstrating where the future of health information was going.1 As the first medical application system developed in 1971, it proved as a great resource for healthcare applications in: result
reports, medicine tracking and scheduling, vital signs and more. This system influenced later information processing systems because of its processing speed and flexibility, which allowed many users in the system at once.2 Bill Childs was a leading proponent and information source for those US systems and a definite and long-term friend of COACH. The HI world in Canada was slowly budding with largely mainframe computers being used, though almost exclusively in hospitals. Even then, these systems were used for administrative and financial work, not so much on healthcare delivery until later.
UAH Leads in Canada
In Canada, at the University of Alberta Hospital, with Dr. Don Fenna and Al Haskall (COACH President, 1986 – 1988) leading the way, the first General Ledger, Payroll and Accounts Payable systems, underpinned by massive COBOL programs, were launched and quickly adopted, under a shared service arrangement, by Red Deer Regional Hospital and Alberta Children’s Hospital. In the late 1970s, Alberta also set up its own data centre with the Alberta Hospitals Association (AHA). Through this, Calgary General forged the way with the Burroughs BHIS system, one of the first comprehensive patient care systems used in North America. Similarly, the Manitoba Health Organizations, previously the Manitoba Hospitals Association (MHA), expanded its program service to other provinces. And York Central (now Mackenzie Health) in Richmond Hill, Ont., was also a leading and founding source of initial hospital systems that many looked to across the country. While mainly used for financial services, computers were in hospitals and taking the next step was in no way out of reach. Throughout this decade, the evolution of information systems moved from administration to patient management and ultimately through to a patient-care focus: the ultimate goal.
Decade 2 (1985 – 1995)
Hospital Information Systems Everywhere
During this decade, there was an apparent shift from information systems restricted to Admitting and other specific hospital departments to computer-supported information systems dealing with the hospital as a whole. That is, this decade was characterized by the growth of the Hospital Information Systems (HIS). This growth in HIS offered the opportunity to work within a patient centered care framework, a change that the HI community was trying to achieve.
State of the Union on Computer Use
The Canadian National Healthcare Computer Survey of 1988 – 89 was provided by the Kennedy Group with full support and assistance from COACH, Steven Huesing, the Health Information Science School at the University of Victoria and 17 members of the National Survey Advisory Committee. This state of the nation of computer use in Canada is the best source of where we were at the beginning of hospital systems expansion. Key results included:
• Over 90% of healthcare institutions had financial system automation.
• 6% of hospitals were in a shared system or multi-hospital system environment.
• Larger hospitals were spending in the area of 2% of operating budget for information systems.
• 69% of survey respondents had onsite computer processors, excluding microcomputers.
• 17% of hospitals reported use of nursing station order entry and results reporting.
• 66% of hospitals reported using commercial vendor systems, while the numbers using service bureau dropped to 9%. Self developed systems were still strongly in use.
• 42% of CIOs reported to CEOs and 52% reported to Vice Presidents or Chief Operating Officers (COOs).
• After financial systems, material management (73%), admitting (70%) and health records (64%) were the highest automated departments in hospitals in 1988. Pharmacy department automation was in about half of hospitals
• 13 hardware vendors held market share (Bull, Data General, IBM, Tandem, Wang, Cado, Digital Equipment, MAI, Texas Instruments, Contel, Hewlett Packard, NCR, Unisys) and 42 vendors shared the market for software.
Master Patient Index
This period was also characterized by the introduction of the master patient index (MPI), a database of patient information used across departments within a hospital or other healthcare facility.
Toward an EHR
Many individuals in HI predicted that in the 1990s, the focus of healthcare facilities would expand beyond the functions of HIS to determining quantifiable measures of performance as HI facilitated the – predicted – corporatization of healthcare. Targeted studies such as the 1993 “Leaving the Paper Behind, Toward an Electronic Health Record” by the Alberta Health Information Professionals and its HER task force outlined the feasibility of EHRs and were part of the driving force leading to the next decades success with EHRs.
CIHI is Born
1994 also marked the inception of the Canadian Institute of Health Information (CIHI), the not-for-profit organization that has become an essential member of the HI community. With the creation of CIHI, the National Health Information Council (NHIC) was disbanded and its Person-Oriented Information (POI) report referred to CIHI for action.
Decade 3 (1995 – 2005)
Launching HI and the Health Information HI-way
This 10-year period was defined by many big moments for COACH; transforming the COACH world, while still being true to its learning, education and networking roots. In 1995, a new set of Protection of Health Information guidelines was created. Throughout this decade, these guidelines were created, revised in 2001 and published online for the first time in 2004. Perhaps one of the most impactful changes was in the name. In 2001, COACH moved away from advancing the use of computers in health to the practice and adoption of HI as the driving force of the organization. From this broadened perspective emerged COACH: Canada’s Health Informatics Association with a new vision – Taking Health Informatics Mainstream.
National Health Information Highway
The foundation for the transforming changes in health information and technology was also launched in the late 90s. Canarie Inc led a vision, opportunities and future steps study titled “Towards a Canadian Health IWAY” published in 1996. HI then gained enormous support in 1997 when the federal government committed to developing a national Health Information Highway (HIH) after affirmation that setting up a HIH would significantly improve health services across Canada.6 This vote of confidence came forward from the government-mandated Information Highway Advisory Council (IHAC), established in 1994.
Following this commitment to support HI in Canada, the Advisory Council of Health Infostructure (ACHI) was established to provide advice and recommendations on the development of a widespread Canadian health infostructure. Its directive was to “consider how information technologies and systems could best support and promote informed decision making by health professionals, administrators, planners, policy makers and individual Canadians.”
Canada Health Infoway
In October 2000 the Government of Canada announced its intention to establish Canada Health Infoway (Infoway) as an independent not for-profit corporation with an initial investment of $500 million. In January 2001, Infoway was incorporated with a provisional Board of Directors and in March received the $500 million. Eric Maldoff was the first Chair and by fall of 2001 Infoway had its first CEO, Linda Lizotte MacPherson, in place. The purpose of this new federally funded initiative was to develop a pan-Canadian EHR infostructure to accelerate the use of EHRs in Canada.7 Shortly after the new Canadian Health Technology Strategy was developed in 2004 to guarantee ongoing access to appropriate healthcare technology and accelerate the use of EHRs and electronic health information systems (eHIS). After a few changes in Infoway leadership, Richard Alvarez took the helm in March 2004 and directed that national agency to stellar achievements in enabling EHRs and electronic medical records (EMRs) for all of Canada through the following decade.
SARS & Maclean’s
The need for key information sharing across the country during the Severe Acute Respiratory Syndrome (SARS) crisis put HI at the forefront. A number of articles were published stressing the need for timely access to the right information for frontline professionals, decision makers and governments. In addition, the Maclean’s magazine “Maclean’s Health Report” brought health data to the forefront and provided insight about how health data can be used to highlight and support planning for healthcare.
Decade 4 (2005 – 2015)
Taking “e” Records and HI Mainstream
This last decade can be characterized by the mainstreaming of the EHR infrastructure in Canada. EHRs were favoured because they would allow “providers to make better decisions and provide better care” while “reducing the incidence of medical error by improving the accuracy and clarity of medical records.”
The investments of $2.1 billion through Infoway since 2001 and the matching of at least equal investments by the provincial and territorial jurisdictions has resulted in the tipping point being reached for the foundations of “e” record infrastructure, EHRs and EMRs in Canada. Building on the near famous Holy Grail challenge by the Infoway CEO in 2004, Canada has seen success with the present 100% availability of client and provider registries, diagnostic imaging systems and clinical reports or immunizations, close to 100% on laboratory systems and better than two-thirds of jurisdiction medication systems in place. And 77% of family physicians recently reported use of electronic medical records, a great change from the starting point of 16% in 2004.
More on HIS
HIS received less attention until the latter part of this decade, with only a few hospitals now reporting top-level implementations, but many in various stages of major HIS replacement, revision or addition.
The Next Decade: Growing to 50 years of Service and Contribution
With a Merlin’s magic wand or fortune teller’s crystal ball, what can we see for the next decade? Well, much comes to mind, but we will all be greatly surprised by where HI and COACH are at in 2025. Today we can see the near-term potential of personalized, precision, participatory medicine, self-service/monitoring and care backed by electronically connected care teams, continued exponential growth in health data and information, printable organs and body parts, smarter and smarter (and smaller, more wearable) devices. Also on the radar are robot interactions and digital assistants for healthcare, genomic data for many of us, the Internet of things, health 2.0…3.0 and on and the integration of e-Health, mobile, virtual and telehealth.
Those are likely only some of the changes in HI over the next decade. And what of COACH? Well, much will change again. Memberships in the many of thousands or tens of thousands, services available on all devices and personalized to member needs, combined personal, virtual and continuous conferences, a very broad array of leading practices and guidelines, specialized support and advisory services for HI members and organizations, the most desired HI information service of the country and many more great changes, value and service to our HI community are on the horizon.
And in all this and in 10 years, much will be the same. People, connecting, networking, volunteering, writing, staffing, sharing, learning, celebrating and associating together in their much loved association…COACH.
COACH played and continues to play a large role in facilitating the development and successful integration of “e” records into Canada’s healthcare system through supporting and serving the almost 40,000 HI and health information management professionals in their practices, professionalism and adoption work.
• 2010: A major event was the merger of the Canadian Society of Telehealth (CST) with COACH in 2010. The value, contribution and benefit of telehealth technology and services to the access and delivery of healthcare is a major transforming agent for our health system and the work of every telehealth professional is vital to that transformation and also to the work of COACH as the voice of HI in Canada.
• Professionalism: This decade also saw huge advances in professionalism in COACH, including the introduction of the CPHIMS-CA credential and HIP® career matrix and Role Profiles, all underpinned by the 50 HI competencies. Concurrently, COACH’s practice guidelines program has grown to five major guidelines offerings covering privacy, security, confidentiality and e-Health safety.
• International Presence: Outside of Canada, COACH contributions included providing eSafety expertise to the ISO/TR 17791 standard, identifying a standards-based framework around safety in health software. COACH supported the Expert Task Force, under the auspices of the Infoway Standards Collaborative of Canada (ISC), which provided Canadian input to this important work.
Over the past decade, it is clear that COACH has become a respected, essential and mainstream organization for Canadian healthcare. COACH is the Voice of HI in Canada.
Initially created as a “reference point” where people with similar interests and backgrounds – specifically with the applications of computers in healthcare – could share their thoughts and ideas, COACH has become much more. COACH has shaped, as CEO Don Newsham, stated in a blog post, a HI community with generations of professionals who continue to learn and grow from and with one another. HI is an accepted, valued and essential part of healthcare and as our community grows, we will continue to strive in increasing the adoption and use of technology in delivering healthcare in Canada and in advancing the practice and professionalism of HI.
Cheers to 40 years and here’s to another decade (and more) of HI in Canada!