The U.S. National Library of Medicine, 1981
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580-106-5 the us national library of medicine it is a pleasure for me to be here this morning to share with you some observations about the current state of medical information services and what the future holds i appreciate the warm hospitality shown me by dr hart your chief of medicine your library director miss brown and their many colleagues your kindness encourages me to believe that you value the long history of cooperation between the national library of medicine and canadian medical institutions this cooperation has its roots in the last century back to the friendship between your celebrated countryman sir william usler and dr john shaw billings the first director of the national library of medicine usler frequently wrote to billings to ask for the loan of a book or pamphlet from the library then known as the library of the surgeon generals office it would appear that some library problems are timeless because at least on one occasion billings complained in a letter about usler losing a book to which usler replied presented by martin m cummings md director of the national library of medicine to the staff of the uttawa civic hospital ottawa canada october 14 1981

Page  2 2 dear dr billings bring a club with you on your next visit and pummel me well what an aggravating devil i am yes do order the book and make me pay double for it if possible before describing the services of the national library of medicine i would like to say a few words about the most important link in the communications chain and that is you the user in the hospital setting much of my own medical career has been spent in the teaching hospital environment so it should be no surprise to learn that i believe that hospitals should serve as centers for health communication as well as for patient care and medical education from my observations and discussions with mabel brown i would say that your institution serves this function well dr osler summarized more eloquently than i ever could the value of the hospital when he said about the hospital centers all that is best and highest in the profession of medicine in it not in the medical school proper not in laboratories not in museums we doctors live and move and have our being 2

Page  3 3 we at the national library of medicine view the hospital medical library as the most important link between the individual health professional and the biomedical literature the entire regional medical library network in the united states rests on the base of the 4000 or so hospital medical libraries although there are important roles in this network for the national library of medicine the 11 regional medical libraries and the 125 major resource libraries it is to the hospital library that the physician or other health professional should most logically turn for access to the literature if the library isnt open when he or she needs it if the nurse or student isnt allowed access to the doctors library if the staff of the library is part-time or poorly trained and unable to take advantage of the many resources available then this most important link between user and literature cannot be forged the problems faced by hospital libraries are exacerbated by both the unabated growth in the volume of health-science literature being published and the increasing costs of acquiring and processing it indeed these are facts of life for all health-science libraries american and canadian including the national library of medicine when combined with the frequent phenomenon of level or declining budgets

Page  4 4 the unfortunate effect of these two trends is to reduce the proportion of the important scientific literature in many libraries this is confirmed by studies showing that libraries are cutting back on journal subscriptions and to an even greater degree reducing their book purchases john shaw billings once commented that the proportion of what is both new and true is not much greater in medicine than it is in theology unfortunately dr billings left us no clue as to how we are to distinguish what is both new and true from that which is old or false and as a result many medical libraries are confronted with tffe need to purchase a greater volume of more expensive literature with fewer dollars this is a problem that would confound the combined sagacity of usler and billings the national library of medicine is attempting to ameliorate this situation in several ways first we are maintaining the integrity and comprehensiveness of our own collection under our present collection policy we acquire and catalog some 15000 monographs each year and the library regularly receives about 20000 periodical publications of which 2600 are indexed for index medicus the nlm collection now comprises over 2-5 million items a second method to alleviate the burden on medical libraries is to develop networks for rapidly accessing the literature and for sharing resources among libraries

Page  5 5 a network with which some of you are already familiar is our online bibliographic retrieval system known as meuline although medline is 10 years old this month nlms involvement with computers goes back to the early nineteen sixties when we mechanized the production of the monthly index medicus with a system called medlaks dr billings began the index medicus over 100 years ago in 1879 but its rapid production would be impossible today without the aid of the high-speed medlars computers medline is available internationally under formal agreements between nlm and 14 major foreign institutions around the world canada in fact was one of our earlier partners in return for access to medline we receive support from the canada institute for scientific and technical information to index literature for our database the online database medline contains approximately 6uu,u0u references to biomedical journal articles published in the current and two preceding years an english abstract if published with the article is frequently included the articles are from 3000 journals published in the us and 70 foreign countries including all index medicus references coverage of earlier periods back to 1966 is provided by ancillary files that total over three million references

Page  6 6 in addition to medline which is our largest and most well-known database there are some 15 other online files these cover such areas as the literature of toxicology and pharmacology cancer research information and of special interest in a teaching environment a database of references to some 10000 audiovisual materials used in health-science education all these databases are available in the united states through a network of some 1500 online centers at universities medical schools hospitals government agencies and commercial organizations almost two million computer searches of nlms databases are done by these centers each year canadian institutions constitute an important part of our network in fact hospitals in your country constitute one of the fastest-growing sectors of the network conducting thousands of searches each year the ottawa clvic hospital is a member of the online network

Page  7 7 just last june two canadian medical librarians published in the canadian medical association journal an excellent article titled how community doctors have easy access to the medical literature 5 according to the article there are now more than 100 canadian medical and hospital libraries with access to medline to be able to search rapidly through millions of references to articles books and even audiovisual materials is an advantage enjoyed in the same degree by no other profession the authors illustrate the potential of the system by citing a hypothetical example of a medline search it would be possible they say to identify specifically only those papers written in english that deal with the use of oxytetracycline in treating non-gonococcal urethritis in middle-aged women in borneo i asked one of our specialists at nlm to attempt this search to see if there really were such references she reported that the computer was happy to accommodate oxytetracycline treatment non-gonococcal urethritis female middle-aged and english but that it balked at combining all these elements with borneo i assuaged her feelings of defeat by saying that borneo no doubt was literary license on the the part of the authors

Page  8 8 i can give you a true example however of an occasion when a medline terminal in a hospital library much like yours made an important contribution to the management of a patient it happened at the overlook hospital in summit new jersey where attending physicians were perplexed about the diagnosis and prognosis of their hospitalized patient the hematologist said the young mans weakness was caused by thalassemia the neurologist said the patients partial paralysis was caused by advanced spinal cord compression were the two conditions related was surgery a necessary therapeutic option the hospital librarian was asked to do a search of the literature using medline and one reference was retrieved the article noted that the combination of the two conditions was indeed rare and that radiotherapy had been successfully used to treat it based on this information the hospital's radiologists prescribed a course of treatment and the patient recovered

Page  9 9 as important as the computerized search of the literature is the ability to locate rapidly the actual documents referenced in the search in the example i just described the hospital library fortunately held the journal in many cases the full text articles identified through an online search will not all be available in that library the answer to this problem although it is not a fully satisfactory answer is the long established practice of lending materials among libraries to help make interlibrary lending an orderly and efficient process the national library of medicine has established 11 regional medical libraries each responsible for a different geographic area in the us these regional libraries in turn support 125 resource libraries usually located in medical schools at the local level are the 4000 hospital libraries these are the primary entry points into the network for the majority of the nations health workers only when the materials needed are not available locally are the requests passed up the network last year the national library of medicine provided 250000 interlibrary loans of material not available elsewhere

Page  10 10 total interlibrary loan transactions throughout the entire network approaches two million per year the term loan is a misnomer because in practice most loans are photocopied journal articles which the requester may keep in addition to books and journal articles videocassettes are also available on interlibrary loan from nlm health professionals in canada also have regional and national networks for supplying documents on request in ontario for example the academy of medicine in toronto and the ontario medical association provide excellent btomedical information services at the national level the health sciences resource center of the canada institute for scientific and technical information provides both interlibrary loan service and coordinates medline availability throughout the country i mentioned earlier that interlibrary lending was not a fully satisfactory answer to the problem of providing access to the immense literature of biomedicine that is because our current systems are dependent on or perhaps i should say at the mercy of the mails canadians particularly know the meaning of this allusion about 90 percent of all loan requests are filled within four days of arriving at nlm but mail service back and forth at least doubles the time required for the entire process

Page  11 11 we hope that medlars iii now under development will ultimately ease the problem of document delivery medlars iii will apply computerized techniques to controlling the internal library processes of indexing cataloging acquisitions serial processing inventory control and document delivery and the integration of all these processes through a single authoritative master bibliographic record there are four basic network services that would be of great value to the health-science community and that will be incorporated as major components in medlars iii these are standardized bibliographic control and support for centralized record creation and maintenance bibliographic retrieval centralized national locator information with automated linkages to a national document delivery system and the document delivery system itself only two of these network services exist at present bibliographic retrieval which is already highly automated through medline and document delivery essentially a manual interlibrary loan operation dependent on the postal service

Page  12 12 the problem of improving the document delivery system is the subject of several developmental efforts now going on at the nlm the first of these employs a digital facsimile network called international electronic post intelpost to send black-and-white text material via satellite between the british lending library and nlm although the initial demonstration was successful there are still unanswered questions regarding costs and standards of quality for transmitting photographs for example x rays complex drawings and fine print the second research effort is to develop a system that will store large quantities of information from printed documents on optical discs and allow rapid retrieval and transmission of the information the contents of up to 108000 pages can be stored on both sides of one optical disc and nlm is now exploring the possibility of a system capable of storing 1000 such discs with online access time of a few seconds such a system if implemented would occupy less than 100 square feet of floor space and contain a collection equivalent to several million journal issues the ability to store tens of millions of pages of text and graphics combined with a system that would provide access to and display this information at terminals in medical libraries around the country would be a true revolution in handling medical information

Page  13 13 both these research projects are being conducted by nlm's research and development component known as the lister hill national center for biomedical communications the lister hill center is unique in that it blends the talents of health professionals and experts in computers and communications technology one of its first projects in the late sixties was to develop the prototype for medline since then the center has experimented with communication satellites two-way cable and microwave television computer-assisted-instruction networks and mini and microcomputers all with the purpose of improving the efficiency and effectiveness of biomedical communication i would like to describe briefly one of the lister hill centers current research projects that may have special interest for you it is intended to assist practitioners engaged in health-care delivery as you know it is an almost impossible task for conscientious practitioners to keep abreast of the new procedures drugs and methods of treatment constantly being reported from biomedical research to help with this problem nlm is developing a method to bring to health-care professionals the current and reliable information they need when they need it and in a form that can be readily understood and used

Page  14 14 in a departure from our traditional involvement in bibliographic work nlm is building a series of computerized knowledge bases knowledge bases may be described as computer-based condensed representations of current published information organized in several levels of detail including citations to the original articles upon which the synthesis is based the information is entered into a minicomputer and accessible by keyboard terminals a prototype has been developed and is being tested on a first such knowledge base on hepatitis 6 the content of the knowledge base has been selected and is continually updated by a group of experts and it is being field-tested at their institutions by physicians medical students librarians and other health professionals the computerized hepatitis knowledge base contains 2 million characters corresponding to approximately 400 printed pages and is organized hierarchically by topic for each topic heading there is an accompanying synthesis statement that represents the state of current knowledge each heading and synthesis is followed by supporting elements derived from published source documents updating of the hepatitis knowledge base is facilitated by use of a computer conferencing network that serves as the principal medium of communication linking the geographically dispersed experts with the nlm

Page  15 15 two additional knowledge bases on peptic ulcer and human genetics are in early states of development also under investigation is the important question of how to make these knowledge bases conveniently accessible to health practitioners in addition to carrying out such research and development within the library we are able to fund a variety of activities throughout the biomedical community under a grant program grants are available for developing library resources research projects in health communications publications and training in this last category we are supporting the training of about 60 health professionals in how to use computer technologies to organize and transmit knowledge these training programs are being conducted in ten us academic institutions and its graduates are eagerly snapped up by academia and industry to serve on faculties and as researchers i dont wish to sound like a polyanna but i believe it is fair to sum up the present state of medical library services by saying that our present systems work well and that future applications of technology such as satellites

Page  16 16 optical discs and knowledge bases promise significant improvements the one demurrer i would add to this optimistic assessment is that many health professionals do not take advantage of the systems available to them i may say that underuse does not seem to be a problem at your medical library and if you are ever accused of being misinformed about the national library of medicine you may at least plead that your misinformation came from an authoritative source-its director i quoted billings and osler earlier in this presentation and i would like to close with two historical quotes that predate them john mayow in 1668 wrote disease as it stalks through the land cannot keep pace with the incurable vice of scribbling about it 7 on the other hand the story is told that when boerhaave the most accomplished and celebrated physician of the 18th century died he left behind him an elegant volume the title page of this book declared that it contained all the secrets of medicine on opening the volume every page except one was blank on that page was written keep the head cool the feet warm and the bowels open

Page  17 17 somewhere between these extremes lies the difficult path of todays medical information systems thank you

Page  18 references 1 keys te sir william osier and the medical library bull med libr assoc 1961 49 35 2 osier w on the influence of a hospital upon the medical profession of a community in wm osier the continuing education john p mcgovern md and chattes g roland md springfield charles c thomas 1969 p 134 3 fry bm white hs publishers and libraries a study f scholarly and research journals lexington mass dc heath and company 1976 4 schullian dm rogers fb the national library of medicine library quarterly 1958 apr 28 2 95 5 groen f kerr a how community doctors have easy access to-the medical literature can med assoc 1981 jun 15 124 1628-35 6 bernstein lm siegel er goldstein cm the hepatitis knowledge base a prototype information transfer system ann intern med 1980 93 169-81 7 mayow j on rickets 1668 8 century of american medicine 1776-1876 philadelphia henry c lea 1876