The National Library of Medicine and Biomedical Communications, 1975
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THE NATIONAL LIBRARY OF MEDICINE AND BIOMEDICAL COMMUNICATIONS* [*PRESENTED BY MARTIN M. CUMMINGS, M.D., DIRECTOR, NATIONAL LIBRARY OF MEDICINE TO THE ACADEMY OF PHYSICAL, MATHEMATICAL AND NATURAL SCIENCES, CARACAS, VENEZUELA, JANUARY , 1975.] MR. PRESIDENT, MEMBERS OF THE ACADEMY, GUESTS: MAY I EXPRESS MY GREAT PLEASURE AND APPRECIATION FOR THE HONOR YOU SO GENEROUSLY BESTOW TODAY. I AM DOUBLY PLEASED BECAUSE YOU HAVE GIVEN THIS RECOGNITION TO A PHYSICIAN WHO HAS NOT BEEN ENGAGED IN RESEARCH IN THE HARD SCIENCES BUT RATHER HAS BEEN MORE CONCERNED WITH THE APPLICATION OF SCIENCE AND TECHNOLOGY IN BEHALF OF MANKIND'S HEALTH. I AM REMINDED, HOWEVER, THAT YOUR GREAT LIBERATOR, SIMON BOLIVAR, HAD EXTENSIVE CONNECTIONS WITH PHYSICIANS IN SEVERAL PARTS OF THE WORLD. IF HE HAD LIVED IN THIS CENTURY HE WOULD NOT HAVE DIED AT AGE 47 FROM TUBERCULOSIS, A DISEASE WHICH IS SUCCESSFULLY TREATED WITH MODERN DRUGS. WITH THE ADVENT OF VENEZUELAN INDEPENDENCE MANY PHYSICIANS BECAME ACTIVIS'TS IN BEHALF OF NATIONALTST CAUSES. IN FACT SOME WERE DIRECTLY INVOLVED I N PLANNING THE MOVEMENT FOR INDEPENDENCE. DR. JOSE LUIS CABRERA, FIRST PRESIDENT (1827) OF THE CARACAS MEDICAL SOCIETY, BECAME A PROMINENT POLITICIAN AS WELL AS BEING AN EXCELLENT CLINICIAN. DR. M. PALACIO GAVE UP A UNIVERSITY CHAIR FOR THE REVOLUTIONARY CAUSE, PARTICIPATED IN THE CONGRESSES OF 1811 AND 1819 AND LATER SERVED AS BOLIVAR'S SECRETARY OF STATE AND TREASURY. DR. C. ARVELO WAS APPOINTED SURGEON-IN-CHIEF OF THE ARMY BY BOLIVAR AND AFTER BEING SERIOUSLY WOUNDED IN BATTLE HE SERVED

Page  2 AS A SENATOR AND MEMBER OF THE SUPREME COUNCIL OF STATE. AMONG THE FIRST TO PLAN YOUR REVOLUTION WITH BOLIVAR WAS THE PERSON WHO INTRODUCED VACCINATION INTO VENEZUELA, VICENTE SALIAS, NOTED POET AND MARTYR. BOLIVAR RECOGNIZED THAT YELLOW FEVER AND TYPHOID DECIMATED ARMIES MORE INSIDIOUSLY THAN DID ENEMY TROOPS. HE LEARNED FROM THE WORK OF THE PERUVIAN, JOSE HIPOLITO UNANUE, AND FROM YOUR FIRST GREAT SURGEON, JOSE MARIA VARGAS, MUCH ABOUT THE IMPORTANCE OF CONTROLLING DYSENTERY AND OTHER INFECTIOUS FEVERS. A FRAMER OF YOUR CONSTITUTION, VARGAS WAS ELECTED PRESIDENT IN 1835. ONE PROBLEM THAT FACED THESE MEN, BOTH AS PHYSICIANS AND AS REVOLUTIONARIES OR POLITICIANS, WAS COMMUNICATION. SOUTH AMERICA'S RUGGED TERRAIN AND GREAT SIZE MEANT THAT COMMUNICATION WAS SLOW AND CUMBERSOME, EVEN FOR THAT PRE-20TH CENTURY ERA. UNRELIABLE POSTAL SERVICE AND DIFFICULT CONDITIONS FOR TRAVEL MADE RAPID COMMUNICATION, WHETHER FOR MILITARY INTELLIGENCE OR FOR CIVILIAN NEEDS, EXTREMELY DIFFICULT. TODAY, A CENTURY AND A HALF LATER, MEDICAL COMMUNICATION CONTINUES TO BE OF CRITICAL IMPORTANCE TO HEALTH PRACTITIONERS, RESEARCHERS, AND EDUCATORS. I WOULD LIKE TO RECOUNT FOR YOU SEVERAL IMPORTANT MILESTONES IN THE DEVELOPMENT OF THE MODERN COMMUNICATIONS TECHNOLOGIES WE ENJOY TODAY. I MUST CAUTION YOU AS I BEGIN, HOWEVER, THAT THE METHODS OF INFORMATION TRANSFER WE CONSIDER REVOLUTIONARY TODAY WILL BE LOOKED ON AS PRIMITIVE OR ANTIQUATED BY HISTORIANS A CENTURY FROM NOW.

Page  3 IT IS A TRUISM IN HUMAN AFFAIRS THAT THE IMPORTANCE OF AN EVENT IS FREQUENTLY NOT RECOGNIZED BY THOSE IMMEDIATELY INVOLVED WITH IT. HISTORY OFTEN RELEGATES TO A FOOTNOTE WHAT WE PROCLAIM IN HEADLINES. CONVERSELY, AN EVENT THAT PASSES ALMOST UNNOTICED TODAY MAY LATER BE VIEWED AS HAVING BEEN OF CRUCIAL IMPORTANCE. WITH THE ADVANTAGE OF HISTORICAL HINDSIGHT, I WOULD LIKE TO DESCRIBE TO YOU TWO UNRELATED EVENTS THAT OCCURRED IN THE UNITED STATES IN 1880, AND HOW, AFTER THE PASSAGE OF ALMOST A CENTURY, THEY COMBINED TO HAVE A MOST PROFOUND EFFECT ON MEDICINE. THE FIRST EVENT CAME ABOUT BECAUSE OF A YOUNG MAN'S LIKING FOR CHICKEN SALAD, SURELY ONE OF THE FEW FOOTNOTES OF HISTORY SO PRECIPITATED. THE YOUNG MAN'S NAME WAS HERMAN HOLLERITH AND HE WORKED IN THE U.S. CENSUS OFFICE. ONE EVENING, AT A BOAT CLUB ENTERTAINMENT ON THE POTOMAC RIVER, A YOUNG LADY NOTICED HOW HOLLERITH SEEMED TO BE ENJOYING THE CHICKEN SALAD. SHE INVITED HIM TO COME TO SUPPER SO THAT HE MIGHT TRY HER MOTHER'S VERSION OF THAT DELICACY.[1] HER FATHER WAS JOHN SHAW BILLINGS, AN ARMY OFFICER AND DIRECTOR OF THE LIBRARY OF THE SURGEON-GENERAL'S OFFICE, THE FORERUNNER OF THE U. S. NATIONAL LIBRARY OF MEDICINE. OVER THE CHICKEN SALAD, DR. BILLINGS, WHO WAS ALSO IN CHARGE OF VITAL STATISTICS IN THE 1880 CENSUS, TALKED ABOUT THE NEED FOR A MACHINE TO DO THE PURELY MECHANICAL WORK OF TABULATING THE CENSUS AND

Page  4 POPULATION STATISTICS. BILLINGS SUGGESTED THAT STATISTICAL DATA MIGHT BE RECORDED ON A CARD BY PUNCHING SMALL HOLES IN IT AND THAT THESE CARDS MIGHT THEN BE COUNTED AND SORTED BY A MACHINE.2 YOUNG HOLLERITH, WHO WAS AN ENGINEER BY TRAINING, TOOK THESE DISCUSSIONS TO HEART. AS HE LATER WROTE: "AFTER STUDYING THE PROBLEM I WENT BACK TO DR. BILLINGS AND SAID I THOUGHT I COULD WORK OUT A SOLUTION FOR THE PROBLEM AND ASKED HIM WOULD HE GO IN WITH ME. THE DR. SAID NO HE WAS NOT INTERESTED ANY FURTHER THAN TO SEE SOME SOLUTION TO THE PROBLEM WORKED OUT."3 HOLLERITH DID INDEED WORK OUT A SOLUTION TO THE PROBLEM, AND THE FIRST ELECTRIC TABULATOR HE DEVELOPED, BASED ON THE PRINCIPLES BILLINGS SUGGESTED, WAS EMPLOYED WITH GREAT SUCCESS IN THE 1890 CENSUS. WITH HIS EQUIPMENT, THE CLASSIFICATION AND COUNTING WAS DONE IN ONE-THIRD THE TIME OF THE 1880 CENSUS. HOLLERITH SUBSEQUENTLY IMPROVED AND REFINED HIS MACHINE AND EVENTUALLY SOLD HIS PATENTS TO WHAT IS NOW IBM--THE INTERNATIONAL BUSINESS MACHINES CORPORATION. THE SECOND EVENT I WISH TO DESCRIBE ALSO INVOLVES DR. JOHN SHAW BILLINGS. IT HAS ITS GENESIS IN BILLINGS' EXPERIENCE AS A MEDICAL STUDENT ATTEMPTING TO WRITE A DISSERTATION, WHEN HE REALIZED THAT THERE WAS NO LIBRARY IN THE UNITED STATES, PUBLIC OR PRIVATE, WHERE A MEDICAL PRACTITIONER OR RESEARCHER MIGHT FIND A LARGE BODY OF THE PUBLISHED LITERATURE RELATING

Page  5 TO ANY MEDICAL SUBJECT. THUS IT WAS, WHEN THE POSITION WAS OFFERED TO HIM LATER, HE EAGERLY ACCEPTED THE RESPONSIBILITY OF DIRECTING THE LIBRARY OF THE SURGEON-GENERAL'S OFFICE. IN THE THREE DECADES HE HEADED THE LIBRARY, BILLINGS WAS ASTONISHINGLY SUCCESSFUL IN BUILDING UP THE COLLECTION. HIS SUCCESS CAN BE MEASURED BY THE FACT THAT THE LIBRARY HAD ONLY 2,200 VOLUMES WHEN BILLINGS TOOK IT OVER AT THE END OF THE AMERICAN CIVIL WAR; WHEN HE RETIRED, IN 1895, IT CONSISTED OF 116,000 VOLUMES AND 191,000 ADDITIONAL PAMPHLETS. IN 1879 DR. BILLINGS DEVELOPED AN INDEX TO THE WORLD'S BIOMEDICAL JOURNAL LITERATURE WHICH HE PUBLISHED AS INDEX MEDICUS. BILLINGS' GREATEST ACHIEVEMENT, HOWEVER, WAS THE PUBLICATION, BEGINNING IN 1880, OF THE INDEX-CATALOGUE OF THE LIBRARY OF THE SURGEON-GENERAL'S OFFICE. THIS COVERED ALL OF THE WORLDS PUBLISHED LITERATURE IN THE LIBRARY'S COLLECTION ORGANIZED BY SUBJECT AND AUTHOR. IT WAS TO TAKE FIFTEEN YEARS FOR THE ENTIRE SIXTEEN-VOLUME CATALOG TO BE PUBLISHED, THROUGH THE LETTER "Z." NOW, FOR THE FIRST TIME, ANY MEDICAL STUDENT WRITING A DISSERTATION HERE OR ABROAD HAD UNDER FIRM CONTROL THE BULK OF THE LITERATURE WHICH HE NEEDED.[4] BILLINGS WAS UNDER NO ILLUSION AS TO THE VALUE OF ALL THESE PUBLICATIONS, HOWEVER, FOR HE COMMENTED THAT "THE PROPORTION OF WHAT IS BOTH NEW AND TRUE IS NOT MUCH GREATER IN MEDICINE THAN IT IS IN THEOLOGY,"5

Page  6 LOOKING BACK AT THIS PERIOD SOME 50 YEARS LATER, WILLIAM H. WELCH, ONE OF THE GREATEST FIGURES IN AMERICAN MEDICINE, DECLARED THAT THERE WERE FOUR MAJOR MEDICAL CONTRIBUTIONS OF THE UNITED STATES IN THE NINETEENTH CENTURY: THE DEVELOPMENT OF ANESTHETICS, THE DISCOVERY OF THE INSECT TRANSMISSION OF DISEASE, THE ESTABLISHMENT OF THE MODERN PUBLIC HEALTH LABORATORY, AND THE DEVELOPMENT BY JOHN SHAW BILLINGS OF THE ARMY MEDICAL LIBRARY AND THE INDEX-CATALOGUE. OF THESE, IT WAS WELCH'S OPINION THAT THE LAST WAS THE GREATEST.6 THESE TWO ACCOMPLISHMENTS, THE DEVELOPMENT OF A RUDIMENTARY COMPUTER AND A COMPREHENSIVE INDEX TO THE WORLD'S COLLECTION OF MEDICAL LITERATURE, EVOLVED INDEPENDENTLY DOWN THROUGH THE YEARS. THEN, IN THE 1960s, THEY WERE BROUGHT TOGETHER IN A WAY THAT EVEN DR. BILLINGS COULD NOT HAVE FORESEEN. MODERN COMPUTERS WERE USED IN OUR LIBRARY TO ORGANIZE AND PRODUCE THE BIBLIOGRAPHIC PRODUCTS OF THE NATIONAL LIBRARY OF MEDICINE. THE RESULT OF THIS UNION WAS MEDLARS, THE COMPUTERBASED MEDICAL LITERATURE ANALYSIS AND RETRIEVAL SYSTEM, WHICH BECAME OPERATIONAL IN 1964. MEDLARS IS BASED ON THE SKILLED INDEXING AND CATALOGING OF PUBLISHED MATERIALS RECEIVED BY THE NATIONAL LIBRARY OF MEDICINE. THIS ASPECT OF THE SYSTEM--EXTRACTING PERTINENT DATA FROM THE PRINTED PAGE-WOULD BE QUITE FAMILIAR TO BILLINGS AND, IN FACT, IS ESSENTIALLY SIMILAR TO THE ABSTRACTING AND INDEXING HE ACCOMPLISHED FOR THE INDEX-CATALOGUE AND THE ORIGINAL

Page  7 INDEX MEDICUS. NOW, HOWEVER, WITH MEDLARS, IT BECAME POSSIBLE TO JOIN THIS INTELLECTUAL PROCESS WITH A SOPHISTICATED ELECTRONIC COMPUTER FOR THE STORAGE AND RETRIEVAL OF MEDICAL INFORMATION. USING THE SYSTEM, THE LIBRARY CAN PRODUCE, IN A MATTER OF HOURS, TYPESET COPY FOR A THOUSAND-PAGE BIBLIOGRAPHY CONTAINING MORE THAN 20,000 ARTICLES INDEXED EACH MONTH. THE PROBLEM OF REDUNDANCY AND POOR QUALITY MEDICAL LITERATURE, WHICH PLAGUED BILLINGS 100 YEARS AGO, IS STILL WITH US TODAY. THE LIBRARY ENTRUSTS THE VERY IMPORTANT TASK OF SELECTING JOURNALS TO BE INDEXED TO AN ADVISORY GROUP OF CONSULTANTS THAT INCLUDES PHYSICIANS, EDITORS, AND LIBRARIANS. OF THE 6,000 MEDICAL PERIODICALS PUBLISHED IN THE WORLD TODAY, 2,300 ARE CHOSEN FOR INDEXING AND INPUT INTO MEDLARS. EVEN WITH THIS HIGH DEGREE OF SELECTIVITY, THE NUMBER OF JOURNAL ARTICLE CITATIONS ADDED EACH YEAR TO MEDLARS APPROACHES A QUARTER MILLION. WITH THE PASSAGE OF TIME THE SIZE OF THE MEDLARS STORE OF CITATIONS GREW TO NEARLY THREE MILLION AND THE DEMAND FOR COMPUTER SEARCHES OF THE LITERATURE ALSO INCREASED, REACHING A PEAK IN 1970 WITH A TOTAL OF SOME 24,000 SEARCHES. ALTHOUGH THE PRODUCTION OF PRINTED BIBLIOGRAPHIES AND INDEXES REMAINED CENTRALIZED AT THE NATIONAL LIBRARY OF MEDICINE, THE SEARCH SERVICE WAS DECENTRALIZED TO 9 COMPUTERS IN THE UNITED STATES AND 8 COMPUTERS IN OTHER COUNTRIES. MEDLARS CENTERS WERE ESTABLISHED IN AUSTRALIA, CANADA, FRANCE, WEST GERMANY,

Page  8 GREAT BRITAIN, JAPAN, SWEDEN, AND THE WORLD HEALTH ORGANIZATION IN GENEVA, SWITZERLAND. SPURRED BY INCREASING DEMANDS FOR SEARCH SERVICES AND A GROWING BACKLOG OF REQUESTS, THE LIBRARY UNDERTOOK, IN THE LATE 1960s, TO DEVELOP A MORE RAPID AND WIDELY ACCESSIBLE SYSTEM. THE RESULT, AFTER SEVERAL YEARS OF EXPERIMENTATION, WAS THE IMPLEMENTATION MEDLINE (MEDLARS ON-LINE), A NEW SERVICE BEGUN IN OCTOBER 1971. USING MEDLINE, IT IS POSSIBLE FOR HEALTH PROFESSIONALS THROUGHOUT THE UNITED STATES (AND IN SEVERAL FOREIGN COUNTRIES) TO HAVE IMMEDIATE ACCESS TO A DATA BASTED STATES (AND IN SEVERAL FOREIGN COUNTRIES) TO HAVE IMMEDIATE ACCESS TO A DATA BASE OF ABOUT HALF A MILLION CITATIONS TO THE MOST RECENT BIOMEDICAL JOURNAL ARTICLES. THIS IS DONE BY USING COMPUTER TERMINALS THAT ARE TED STATES (AND IN SEVERAL FOREIGN COUNTRIES) TO HAVE IMMEDIATE ACCESS TO A DATA BASE OF ABOUT HALF A MILLION CITATIONS TO THE MOST RECENT BIOMEDICAL JOURNAL ARTICLES. THIS IS DONE BY USING COMPUTER TERMINALS THAT ARE LINKED TO THE NATIONAL LIBRARY OF MEDICINE'S COMPUTER BY TELEPHONE AND OTHER COMMUNICATION LINES. MORE THAN 250 MEDICAL INSTITUTIONS IN THE UNITED STATES HAVE MIEDLINE TERMINALS AND MORE THAN 300,000 COMPUTER SEARCHES ARE PERFORMED EACH YEAR. AFTER IDENTIFYING THE MEDICAL LITERATURE NEEDED, THERE IS STILL THE TASK OF ACQUIRING THE JOURNAL ARTICLE. NOT ALL HEALTH SCIENCE LIBRARIES, OF COURSE, HAVE ALL THE JOURNALS PHYSICIANS AND SCIENTISTS REQUIRE. NOT ONLY DOES THE NATIONAL LIBRARY OF MEDICINE PROVIDE MEDLINE SEARCHES BUT IT IS THE HUB OF A NETWORK OF ALMOST 500 LIBRARIES THROUGHOUT THE UNITED STATES. EACH YEAR THE NATIONAL LIBRARY OF MEDICINE HAS FURNISHED OVER 200,000 PHOTOCOPIES OF SCIENTIFIC JOURNAL ARTICLES FREE OF CHARGE TO PROFESSIONALS IN THE HEALTH SCIENCES.

Page  9 THE MEDLINE SEARCH SERVICE HAS RECEIVED ENTHUSIASTIC ACCEPTANCE BY THE MEDICAL PROFESSION--BY PRACTITIONERS, RESEARCHERS, AND EDUCATORS THROUGHOUT THE WORLD. THIS ACCEPTANCE IS REFLECTED NOT ONLY IN THE GROWING NUMBER OF TERMINALS AND THEIR GEOGRAPHIC DISTRIBUTION, BUT ALSO IN ADDITIONAL INFORMATION SERVICES AND PRODUCTS WE ARE MAKING AVAILABLE. WORKING WITH THE PAN AMERICAN HEALTH ORGANIZATION WE HAVE ESTABLISHED A REGIONAL MEDICAL LIBRARY FOR SOUTH AMERICA WHICH IS LOCATED IN SAO PAULO, BRAZIL. THIS LIBRARY NOW PROVIDES 50,000 LOANS OF MATERIALS TO OTHER LIBRARIES IN LATIN AMERICA AND ALSO OPERATES A MEDLINE CENTER WHICH PROVIDES COMPUTERIZED REFERENCE SERVICES TO THE BIOMEDICAL COMMUNITY. WITH OUR ASSISTANCE AND WITH FINANCIAL SUPPORT FROM UNDP IT WILL SOON PROVIDE AUDIOVISUAL MATERIALS TO THE HEALTH EDUCATIONAL INSTITUTIONS THROUGHOUT SOUTH AMERICA. IN 1967 THE NATIONAL LIBRARY OF MEDICINE TOOK THE FIRST STEP AWAY FROM ITS TRADITIONAL ROLES OF ACQUIRING, INDEXING AND MAKING AVAILABLE THE BIOMEDICAL LITERATURE WITH THE ESTABLISHMENT OF A SPECIALIZED INFORMATION SERVICE, THE TOXICOLOGY INFORMATION PROGRAM. THE PROGRAM'S MISSION IS TO SET UP COMPUTER-BASED DATA BANKS OF TOXICOLOGY INFORMATION DERIVED FROM THE SCIENTIFIC LITERATURE AND FROM THE FILES OF COLLABORATING GOVERNMENTAL AND NON-GOVERNMENTAL ORGANIZATIONS, AND TO PROVIDE UPON DEMAND TOXICOLOGY INFORMATION AND DATA TO THE SCIENTIFIC COMMUNITY.

Page  10 THE TOXICOLOGY INFORMATION PROGRAM PROVIDES A COMPUTER BASED ON-LINE INFORMATION RETRIEVAL SERVICE, TOXLINE. LIKE MEDLINE, TOXLINE PROVIDES REMOTE, ON-LINE ACCESS TO A FILE OF 320,000 BIBLIOGRAPHIC RECORDS AND ABSTRACTS DEALING PRIMARILY WITH THE TOXICOLOGY AND PHARMACOLOGY OF DRUGS, PESTICIDES, ENVIRONMENTAL POLLUTANTS AND HAZARDOUS INDUSTRIAL AND HOUSEHOLD CHEMICALS. THE USER COMMUNITY FOR TOXLINE HAS GROWN TO 105 ORGANIZATIONS. ANOTHER ACTIVITY OF THE NATIONAL LIBRARY OF MEDICINE, THE LISTER HILL NATIONAL CENTER FOR BIOMEDICAL COMMUNICATIONS, IS EMPHASIZING THE MORE RAPID DISSEMINATION OF INFORMATION THROUGH THE USE OF MODERN TELECOMMUNICATIONS TECHNOLOGY. THE ESTABLISHMENT OF THE LISTER HILL CENTER CAN BE CONSIDERED THE CULMINATION OF A SERIES OF REPORTS CONCERNED WITH THE DEVELOPMENT OF NATIONAL INFORMATION NETWORKS. THE THEME OF ALL THESE STUDIES IS THAT NATIONAL NETWORKS OR INFORMATION SYSTEMS ARE INCREASINGLY NECESSARY SO THAT THE RESULTS OF SCIENTIFIC RESEARCH CAN BE APPLIED WITHOUT DELAY TO THE SOCIAL PROBLEMS OF TODAY. DR. RUTH M. DAVIS, A DISTINGUISHED COMPUTER SCIENTIST, WAS NAMED AS THE CENTER'S FIRST DIRECTOR. IN ANNOUNCING ITS ESTABLISHMENT, THE SECRETARY OF HEALTH, EDUCATION, AND WELFARE SAID: "THIS CENTER ... WILL SERVE AS THE DELEGATED AGENT FOR THE DEPARTMENT IN THE DEVELOPMENT AND COORDINATION OF NETWORKS AND INFORMATION SYSTEMS TO IMPROVE HEALTH EDUCATION, MEDICAL RESEARCH, AND THE DELIVERY OF HEALTH SERVICES." THIS VERY BROAD CHARTER GIVES THE LISTER HILL CENTER A WIDE RANGE OF RESPONSIBILITIES. THE BASIC MANAGEMENT DECISIONS,

Page  11 SINCE THE BEGINNING OF THE CENTER, HAVE BEEN THE CHOICE OF SELECTED AREAS IN WHICH TO USE OUR RELATIVELY LIMITED FUNDS FOR MAXIMUM IMPACT AND BENEFIT TO THE NATION'S HEALTH EDUCATION AND PRACTICE. THE CENTER'S SEVEN YEARS OF EXPERIENCE TO DATE MAY BE DIVIDED INTO TWO PERIODS: A PLANNING PHASE (1968-1971) AND AN OPERATING PHASE (1971-1974). AS A NEW ORGANIZATION, WITH A VERY BROAD POTENTIAL FIELD OF OPERATION, THE CENTER DEVOTED MUCH OF ITS FIRST THREE YEARS TO PLANNING. EXTENSIVE STAFF ACTIVITIES WERE SUPPLEMENTED BY CONTRACTS WITH INDEPENDENT RESEARCH ORGANIZATIONS. ONE CONTRACT LED TO THE DEVELOPMENT OF THE NEW HAMPSHIRE/VERMONT MEDICAL INTERACTIVE TELEVISION NETWORK; ANOTHER BUILT MEDLINE-THE FIRST LARGE ON-LINE MEDICAL INFORMATION SYSTEM. STILL OTHERS INVOLVED THE PLANNING OF AN ALASKA.SATELLITE COMMUNICATIONS NETWORK. THE EMPHASIS DURING THIS FIRST PERIOD, HOWEVER, WAS MORE ON CAREFUL LONG-RANGE PLANNING FOR FUTURE NETWORKS THAN ON BUILDING OPERATING SYSTEMS. I AM SURE YOU WILL BE MORE INTERESTED IN THE RESULTS OF THIS PLANNING THAN IN THE PLANNING ITSELF. THEREFORE, I WOULD LIKE TO DESCRIBE BRIEFLY SEVERAL OF THE COMMUNICATIONS NETWORKS THAT HAVE EMERGED AND ARE NOW OPERATING. THE FIRST OF THESE IS LOCATED IN ALASKA--A REMOTE AND RUGGED REGION OF WIDELY SCATTERED NATIVE VILLAGES ISOLATED FROM EACH OTHER AND FROM THE FEW POPULATION CENTERS. MEDICAL CARE FOR THE VILLAGERS HAS ALWAYS BEEN A SERIOUS PROBLEM. WORKING WITH THE INDIAN HEALTH SERVICE, WE HAVE SUPPLIED 26 VILLAGES WITH

Page  12 INEXPENSIVE RADIOS AND ANTENNAE WHICH USE THE NATIONAL AERONAUTIC AND SPACE ADMINISTRATIONS ATS-1 SATELLITE AS A COMMUNICATIONS LINK. THIS PERMITS REGULAR VOICE COMMUNICATION BETWEEN VILLAGE HEALTH AIDES AND DOCTORS AT A CENTRALLY LOCATED HOSPITAL. CONVENTIONAL HIGH-FREQUENCY RADIO, USED BEFORE THE SATELLITE BECAME AVAILABLE, IS VERY UNRELIABLE IN THESE NORTHERN CLIMES BECAUSE OF THE AURORA BOREALIS ATMOSPHERIC PHENOMENON. THIS INTERFERENCE FREQUENTLY RESULTED IN EXTENDED PERIODS OF "BLACKOUT" WHEN NO COMMUNICATION WAS POSSIBLE. EVERY DAY THE DOCTOR CALLS EACH HEALTH AIDE IN TURN ON THESINGLE "PARTY-LINE" SATELLITE RADIO CHANNEL. HEALTH AIDES MAY ASK THE PHYSICIAN FOR SPECIFIC INSTRUCTIONS AFTER DESCRIBING THE PATIENT'S SYMPTOMS, THE MEDICAL FACILITIES IN THE VILLAGES ARE STILL VERY LIMITED, SO THAT IT MAY BE NECESSARY FOR SERIOUS CASES TO BE EVACUATED. THE SATELLITE RADIO IS USED TO ARRANGE FOR AN AIRPLANE TO TRANSFER SUCH PATIENTS TO THE NEAREST MEDICAL FACILITY. THE COMMUNICATION NETWORK HAS BEEN CREDITED WITH SAVING LIVES IN MEDICAL EMERGENCIES, SUCH AS HUNTING ACCIDENTS, SEVERE BURNS FROM EXPLOSIONS OR FROM SERIOUS COMPLICATIONS DURING CHILDBIRTH. THE SATELLITE RADIO MADE POSSIBLE IMMEDIATE STEP-BY STEP FIRST-AID INSTRUCTION FOR THE HEALTH AIDE FOLLOWED BY PROMPT AIR EVACUATION OF THE PATIENT. ALTHOUGH RELIABLE VOICE CONSULTATION ENHANCES THE HEALTH AIDE'S ABILITIES, IN MANY SITUATIONS IT IS NOT POSSIBLE THROUGH WORDS ALONE TO PROVIDE ENOUGH INFORMATION TO THE PHYSICIAN ABOUT THE PATIENT'S CONDITION. DELAYS IN DIAGNOSIS AND UNNECESSARY

Page  13 EVACUATION COULD IN MANY CASES BE AVOIDED IF THE PHYSICIAN HAD MORE ADEQUATE VISUAL INFORMATION AS WELL. "TELEMEDICINE," NOW POSSIBLE IN ALASKA WITH A NEW SATELLITE, THE ATS-6, MAY PROVIDE THE ANSWER. ATS-6 IS THE WORLD'S LARGEST AND MOST POWERFUL COMMUNICATIONS SATELLITE, WEIGHING 3080 POUNDS. IT BEAMS MESSAGES AND PICTURES DOWN TO "GIANT FOOTPRINTS" ON EARTH COVERING AN AREA ABOUT 1600 BY 480 KILOMETERS. TWO HIGH-POWERED TRANSMITTERS BOUNCE SIGNALS OFF THE SATELLITE'S 30-FOOT DIAMETER ANTENNA, SENDING COLOR TELEVISION PROGRAMS ACCOMPANIED BY FOUR VOICE CHANNELS TO RECEIVERS ON THE GROUND. BECAUSE OF THE SATELLITE'S POWER, THE GROUND ANTENNA RECEIVERS ARE SMALL AND INEXPENSIVE. THIS SYSTEM WILL DETERMINE WHETHER HEALTH CARE IN REMOTE AREAS CAN BE FURTHER IMPROVED BY TWO-WAY VOICE AND PICTURE TRANSMISSION. THE EXPERIMENT IN TELEMEDICINE IS BEING CONDUCTED AT FIVE ALASKA SITES EQUIPPED TO TRANSMIT AND RECEIVE VIDEO, VOICE, PHYSIOLOGICAL INFORMATION, AND PATIENT RECORD DATA. MEDICS AND HEALTH AIDES AT THE SMALL VILLAGE CLINICS PRESENT PATIENTS TO PHYSICIANS AT THE INDIAN HEALTH SERVICE HOSPITAL AT TANANA FORDIAGNOSIS AND TREATMENT. CONSULTATION WITH SPECIALISTS IS AVAILABLE BY SATELLITE FROM MAJOR MEDICAL CENTERS IN FAIRBANKS, ANCHORAGE OR EVEN SEATTLE. A MEDICAL-EDUCATION EXPERIMENT INVOLVES THE FACULTY OF THE UNIVERSITY OF WASHINGTON IN SEATTLE AND STUDENTS LOCATED AT

Page  14 THE UNIVERSITY OF ALASKA IN FAIRBANKS. THERE ARE FULL TWO-WAY VOICE AND VIDEO INTERACTION FOR CLASSES IN BASIC SCIENCES AND FOR COMPUTER-AIDED INSTRUCTION. LECTURES, DEMONSTRATIONS, AND CLASSROOM EXPERIMENTS ORIGINATE FROM BOTH SITES AND PERMIT AN EVALUATION OF STUDENT PERFORMANCE. THE EXPERIMENTERS HOPE TO SHOW THAT LEARNING VIA SATELLITE IS FULLY AS EFFECTIVE AS LEARNING IN A "NORMAL" CLASSROOM ENVIRONMENT. IT WILL BE IMPORTANT TO DETERMINE IF THIS NEW TECHNOLOGY IS ACCEPTABLE TO THE REMOTELY LOCATED STUDENTS AND TO THE FACULTY AT BOTH SITES. A PART OF THE EXPERIMENT DEALING WITH THE TEACHING OF CLINICAL MEDICINE INVOLVES THIRD- AND FOURTH-YEAR MEDICAL STUDENTS WORKING IN A RURAL SETTING IN CENTRAL WASHINGTON. THE STUDENTS WILL PRESENT PATIENTS, BY VIDEO AND VOICE TRANSMISSIONS, TO THE MEDICAL FACULTY OF THE UNIVERSITY OF WASHINGTON IN SEATTLE. IT IS HOPED THAT THE TWO-WAY SATELLITE COMMUNICATION WILL ALLOW THE STUDENTS TO BE TRAINED IN PREPARING CASE STUDIES AND THAT IT WILL ALSO PERMIT A CAREFUL EVALUATION OF THE STUDENTS' KNOWLEDGE AND ABILITY IN THE ACTUAL CARE OF PATIENTS SEEN IN PRACTICE. OUR EXPERIMENTS WITH THE ATS-6 SATELLITE DO NOT REPRESENT THE LIBRARY'S FIRST INVOLVEMENT WITH TELEVISION. SINCE JULY 1970 WE HAVE BEEN WORKING WITH DARTMOUTH COLLEGE AND THE UNIVERSITY OF VERMONT IN PLANNING, BUILDING, AND HELPING TO SUPPORT THE OPERATION OF THE NEW HAMPSHIRE/VERMONT MEDICAL INTERACTIVE TELEVISION NETWORK LINKING TWO UNIVERSITY TEACHING HOSPITALS AND A NUMBER OF COMMUNITY HEALTH CENTERS.

Page  15 THE NEW HAMPSHIRE/VERMONT MEDICAL INTERACTIVE TELEVISION NETWORK CONSISTS OF SEVEN INSTITUTIONS IN THE TWO STATES LINKED THROUGH A MOUNTAINTOP MICROWAVE NETWORK. THE HUB OF THE NETWORK IS THE DARTMOUTH MEDICAL SCHOOL IN HANOVER, NEW HAMPSHIRE. THREE OF THE INSTITUTIONS ON THE NETWORK, ALL WITHIN A 2O-MILE LINE-OF-SIGHT RADIUS OF THE TOWER ON MT. ASCUTNEY, ARE SERVED BY A SPECIAL MOBILE UNIT THAT CARRIES MICROWAVE TRANSMITTING AND RECEIVING EQUIPMENT, AND TV CAMERAS AND MONITORS. ON ARRIVAL AT AN INSTITUTION, THE MOBILE VAN IS CONNECTED TO LOCAL POWER AND THE SITE BECOMES PART OF THE NETWORK. WITH LIVE TWO-WAY VOICE AND VIDEO COMMUNICATION, THE NETWORK HAS BECOME A REGULAR WORKING TOOL FOR THE MEDICAL AND ALLIED HEALTH PERSONNEL AT THE SEVEN LOCATIONS. EACH WEEK BROADCAST TIME IS ALLOTTED FOR TEACHING CONFERENCES, SPEECH THERAPY, PSYCHIATRIC CONSULTATIONS, AND SPECIAL COURSES FOR NURSES. AN EVALUATION MADE BY A MANAGEMENT CONSULTING FIRM SHOWS THAT INTERACTIVE TELEVISION IS AN EFFECTIVE MEDIUM FOR PROVIDING EDUCATIONAL AND OTHER SERVICES IN A RURAL MEDICAL SETTING--THAT INDEED, FOR FORMAL EDUCATIONAL PURPOSES THE TELEVISION CAN BE AS EFFECTIVE AS COMPARABLE CLASSROOM INSTRUCTION. ALSO, THE NETWORK MAY BE OF HIGH VALUE IN PROMOTING "BEST MEDICAL PRACTICE" BY AFFIRMING PRACTITIONER

Page  16 JUDGMENTS ON CASE MANAGEMENT AND BY ENCOURAGING THE MORE WIDESPREAD ADOPTION OF NEW PRACTICES ALREADY INTRODUCED 'TO THE RURAL MEDICAL COMMUNITY. THE MOST RECENT OF THE EXPERIMENTAL NETWORKS DEVELOPED BY THE LIBRARY ADDRESSES THE PROBLEM OF DEVISING METHODS FOR THE EFFICIENT SHARING OF EDUCATIONAL RESOURCES. THIS IS PARTICULARLY IMPORTANT IN A TIME OF RISING COSTS OF EDUCATION AND PRESSURE TO INCREASE MEDICAL STUDENT ENROLLMENT. THE NEW NETWORK HAS AS ITS GOAL THE SHARING OF COMPUTER ASSISTED INSTRUCTION (CAI) PROGRAMS AMONG MEDICAL SCHOOLS AND HOSPITALS. THIS PROJECT HAS BEEN SPURRED BY INTEREST IN RECENT YFARS IN DEVELOPING TUTORIAL PROGRAMS TO BE PLACED ON A COMPUTER WITH WHICH STUDENTS CAN INTERACT USING KEYBOARD TERMINALS. STUDENTS PROGRESS THROUGH SUCH A COURSE AT THEIR OWN PACE, GUIDED AT EVERY TURN BY THE PROGRAM. IN THE NEW NETWORK, OVER 80 INSTITUTIONS, MOSTLY MEDICAL SCHOOLS, HAVE ACCESS TO A WIDE RANGE OF CAI PROGRAMS. THERE ARE BASIC SCIENCE PROGRAMS FOR THE FIRST TWO YEARS OF MEDICAL EDUCATION, AS WELL AS PROGRAMS THAT SIMULATE DISEASE SYNDROMES AND CLINICAL ENCOUNTERS APPROPRIATE FOR THE SECOND TWO YEARS. MANY A COMPUTERIZED "PATIENT" HAS DIED AS A RESULT OF HIS ENCOUNTER WITH A YOUNG PHYSICIAN-TO-BE, SO THAT RIGHT CHOICES MIGHT BE MADE IN REAL PRACTICE. THERE ARE ALSO PROGRAMS OF INTEREST TO NURSING STUDENTS AND STAFF MEMBERS OF COMMUNITY HOSPITALS.

Page  17 THE INSTRUCTIONAL PROGRAMS AVAILABLE WERE DEVELOPED AT THE MASSACHUSETTS GENERAL HOSPITAL, THE OHIO STATE UNIVERSITY COLLEGE OF MEDICINE, AND THE UNIVERSITY OF ILLINOIS MEDICAL CENTER, CHICAGO. COMPUTERS AT THE FIRST TWO OF THESE INSTITUTIONS ARE TIED INTO A NATIONWIDE COMMUNICATIONS NETWORK SO THAT THE PROGRAMS CAN BE ACCESSED BY MANY INSTITUTIONS AROUND THE COUNTRY. ACCORDING TO EVALUATION REPORTS SENT IN BY THE USING INSTITUTIONS, ABOUT 70 PERCENT OF THE CAI'S CURRENT USE IS BY MEDICAL STUDENTS, THE REMAINDER BY PHYSICIANS, NURSES, AND ALLIED HEALTH PERSONNEL. TOTAL USAGE HAS RANGED AS HIGH AS 2.800 HOURS A MONTH (THERE ARE ON THE AVERAGE 2.5 TEACHING SESSIONS PER HOUR). SINCE THERE IS A TENDENCY FOR SEVERAL STUDENTS TO GROUP AROUND A TERMINAL AND TO INTERACT WITH EACH OTHER AS VIGOROUSLY AS WITH THE PROGRAM, IT IS PROBABLY CONSERVATIVE TO ESTIMATE THAT THE NETWORK IS PROVIDING OVER 15,000 INTERACTIVE TEACHING SESSIONS PER MONTH. THE EXPERIMENT IS DEMONSTRATING THAT ALTHOUGH UNIVERSITIES ARE INTERESTED IN SHARING CAI MATERIALS, AND STUDENTS ARE EAGER TO USE THEM, THE PRESENT CONFIGURATION OF THE NETWORK IS TOO COSTLY FOR THE LONG RUN. THEREFORE, NLM IS EXPLORING ALTERNATIVE DISTRIBUTION METHODS, SOME OF WHICH MAY INVOLVE THE USE OF MINI-COMPUTERS, WHICH WE BELIEVE WILL RESULT IN SUBSTANTIALLY REDUCED OPERATING COSTS. HERE, THEN, ARE BUT A FEW EXAMPLES OF HOW PEACEFUL APPLICATIONS OF MILITARY-INSPIRED TECHNOLOGIES CAN BE MADE TO

Page  18 SERVE SOCIETY. IT WILL NOT BE LONG BEFORE THESE AND OTHER NEW COMMUNICATIONS SYSTEMS WILL BE AVAILABLE TO ALL NATIONS. I ADMIT, HOWEVER, THAT THIS DOES NOT COMPLETELY SATISFY MANS URGE AND NEED TO RELATE MORE INTIMATELY WITH HIS FELLOW MAN. ALTHOUGH COMMUNICATIONS AND INFORMATION TRANSFER PROVIDE FOR IMPROVED EDUCATION AND HEALTH CARE DELIVERY IT STILL REQUIRES COMPASSION AND HUMANISM TO COMFORT THE SICK AND DISABLED. THIS TROUBLED WORLD NEEDS BOTH IMPROVED COMMUNICATIONS AND MORE HUMANISM IN OUR INTERPERSONAL RELATIONSHIPS.

Page  19 REFERENCES 1. HOLLERITH, VIRGINIA, "BIOGRAPHICAL SKETCH OF HERMAN HOLLERITH." ISIS. VOL. 62, SPRING 1971. PP. 69-78, 2. GARRISON, FIELDING H. JOHN SHAW BILLINGS; A MEMOIR, NEW YORK: G. P. PUTNAM SONS, 1915. 3. LETTER OF AUGUST 7, 1919; QUOTED BY J. FRASER MUIRHEAD IN HIS ARTICLE "DOCTORS AFIELD; JOHN SHAW BILLINGS," NEW ENGLAND JOURNAL OF MEDICINE 268: 778-9, 1963. 4. SCHULLIAN, DOROTHY M. AND ROGERS, FRANK B. "THE NATIONAL LIBRARY OF MEDICINE." THE LIBRARY QUARTERLY, VOL. XXVIII, No. 2, APRIL 1958. P. 95, 5. IBID. 6. HUME, EDGAR E. VICTORIES OF ARMY MEDICINE. PHILADELPHIA: LIPPINCOTT, 1943, PP. 45-6.