1976 U.S. House of Representatives Appropriations Committee Budget Testimony, 94th Congress 1st Session, 1975
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DEPARTMENTS OF LABOR AND HEALTH, EDUCATION, AND WELFARE APPROPRIATIONS FOR 1976 HEARINGS BEFORE A SUBCOMMITTEE OF THE COMMITTEE ON APPROPRIATIONS HOUSE OF REPRESENTATIVES NINETY-FOURTH CONGRESS FIRST SESSION SUBCOMMITTEE ON THE DEPARTMENTS OF LABOR AND HEALTH, EDUCATION, AND WELFARE DANIEL J. FLOOD, Pennsylvania, Chairman WILLIAM H. NATCHER, Kentucky ROBERT H. MICHEL, Illinois NEAL SMITH, Iowa GARNER E. SHRIVER, Kansas BOB CASEY, Texas SILVIO O. CONTE, Massachusetts EDWARD J. PATTEN, New Jersey DAVID R. OBEY, Wisconsin EDWARD R. ROYBAL, California LOUIS STOKES, Ohio Henby A. Neil, Jr., Frederick F. Pfltjger, Robert L. Knisely, Nicholas G. Cavarocchi, and Gemma M. Weiblinoer, Subcommittee Staff PART 3 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE National Institutes of Health Printed for the use of the Committee on Appropriations 62-089 O U.S. GOVERNMENT PRINTING OFFICE WASHINGTON : 19758407002_00002.txt

Page  2 NATIONAL LIBRARY OF MEDICINE WITNESSES DR. MARTIN M. CUMMINGS, DIRECTOR DR. RONALD W. LAMONT-HAVERS, ACTING DIRECTOR, NATIONAL INSTITUTES OF HEALTH DR. DeWITT STETTEN, JR., DEPUTY DIRECTOR FOR SCIENCE, NA- TIONAL INSTITUTES OF HEALTH MELVIN S. DAY, DEPUTY DIRECTOR, NATIONAL LIBRARY OF MEDICINE KENT A. SMITH, ASSISTANT DIRECTOR FOR ADMINISTRATION, NA- TIONAL LIBRARY OF MEDICINE FRANK B. POH, FINANCIAL MANAGEMENT OFFICER, NATIONAL LIBRARY OF MEDICINE B. F. GARDNER, JR., CHIEF, BUDGET PRESENTATION AND COORDI- NATION BRANCH, DIVISION OF FINANCIAL MANAGEMENT, NA- TIONAL INSTITUTES OF HEALTH WILFORD FORBUSH, DEPUTY ASSISTANT SECRETARY, BUDGET Mr. Flood. Now we have the National Library of Medicine. The presentation will be made by Dr. Martin M. Cummings, the Director. We will include your biographical sketch in the record, Doctor, and is there anybody we don't know that you have with you here this morning ? [The biographical sketches follow:] Name, Martin Marc Cummings; position, Director, National Library of Medi- cine; birthplace and date, Camden, N.J., September 7, 1920; education, B.S., Bucknell University, 1941, M.D., Duke University, 1944. Experience : Present, Director, National Library of Medicine. 1963-64, Associate Director for Research Grants, National Institutes of Health. 1961-63, Chief, Office of International Research, National Institutes of Health. 1959-61, professor of microbiology and chairman, department of microbiology, University of Oklahoma School of Medicine. 1953-59, Director, Research Services, Veterans Administration Central Office. 1953-59, special lecturer in microbiology, George Washington University School of Medicine. 1953, associate professor of bacteriology, Emory University. 1949-53, Chief, Tuberculosis Research Laboratory, Veterans Administration Hospital of Atlanta. 1948-53, instructor through associate professor of medicine, Emory University. 1947-49, Director, Tuberculosis Evaluation Laboratory, Communicable Disease Center, U.S. Public Health Service. 1945-49, assistant resident, Boston Marine Hospital. 1944-45, intern, Boston Hospital. 1942-1944, U.S. Army, private first class. Association memberships: American Academy of Microbiology, Inc.; American Board of Microbiology; American Federation for Clinical Research (Emeritus) ; American Society for Clinical Investigation (Emeritus) ; Association for Amer- ican Medical Colleges ; Medical Library Association ; Society of Sigma XI; Amer- ican Clinical and Climatological Association ; American Society for the History of Medicine; Board of Directors, Gorgas Memorial Foundation; American Docu- mentation Institute; Association of Research Libraries; Society of Medical Ad- ministrators. (1255)8407002_00003.txt

Page  3 1256 Special awards, citations, or publications : Veterans Administration Exception- al Service Medal; DHEW Superior Service Award ; DHEW Distinguished Service Award; Honorary Doctor of Science, Bucknell University, 1969; Distinguished Alumnus Award, Duke University ; Honorary Doctor of Science, University of Nebraska, 1971; Honorary Doctor of Science, Emory University, 1971; Honorary Doctor of Humane Letters, Georgetown University, 1971; Honorary Members, Alpha Omega Alpha; Honorary Doctor of Medicine, Karolinska Institute, Stock- holm, Sweden, 1972; Honorary Fellowship, College of Physicians, Philadelphia, 1973; Rockefeller Public Service Award, 1973. Name, Melvin Sherman Day; position, Deputy Director, National Library of Medicine; birthplace and date, Lewiston, Maine, January 22, 1923; education, B.S., Bates College, Lewiston, Maine, 1943. Experience: Present, Deputy Director, National Library of Medicine. 1971-72, Head, Office of Science Information Service, National Science Foun- dation. 1966-71, Deputy Assistant Administrator for Technology Utilization, NASA headquarters. 1962-66, Director, Scientific and Technical Information Division, NASA Head- quarters. 1960-62, Deputy Director, Office of Technical Information and Education, NASA Headquarters. 1958-60, Director, Division of Technical Information, AEC. 1956-58, Chief, Technical Information Extension, AEC. 1955-56, Assistant Chief, Technical Information Extension, AEC. 1952-55, Operations Officer, Technical Information Services, AEC. 1948-52, Physical Science Information Editor, Technical Information Service, AEC. 1946-48, Chemist, Technical Information Division, AEC. 1944-46, U.S. Army Corps of Engineers and served as laboratory foreman (chemist), U.S. Army, Eastman Kodak Corp. 1943-44, Chemist, Metal Hydrides, Inc. Association memberships: American Association for the Advancement of Sci- ence ; New York Academy of Sciences; American Chemical Society; American Society of Information Science; Special Libraries Association; Medical Libary Association. Special awards, citations or publications: NASA Exceptional Service Medal Sustained Superior Performance Award, AEC. Name, Kent Ashton Smith; position, Assistant Director for Administration, National Library of Medicine; birthplace and date, Boston, Mass., September 3, 1938; education, B.A., Hobart College, I960, M.P.A., Cornell University 1962. Experience: Present, Assistant Director for Administration, National Library of Medicine. 1968-71, Executive Officer, Division of Research Resources. 1968, Acting Executive Officer, Division of Research Facilities and Resources. 1967-68, Assistant Executive Officer, Division of Research Facilities and Resources. 1965-67, Administrative Officer, Division of Research Facilities and Resources. 1962-65, Management Analyst, Office of the Secretary, Office of Management Policy. Association memberships: Sigma Phi Society, Society for Advancement of Management; American Society for Public Administration. Name, Frank Benedict Poh; position, Financial Management Officer, National Library of Medicine; birthplace and date, Washington, D.C.', April 5, 1931; edu- cation, B.B.A., Southeastern University, 1960, M.B.A., Southeastern University, 1965. Experience: Present, Financial Management Officer, National Library of Medicine. 1969-73, Budget Officer. National Library of Medicine. 1967-68, Grants Management Officer, Division of Research Facilities and Resources. 1966-67, Systems Accounting Officer, Department of the Army. 1962-66, business manager, Eastern area, Chrysler Corp. 1960-62, controller, P. J. Nee Co. 1958-60, director of finance, Heppner Engineering Co. 1955-58, office manager, Wissinger Chevrolet Co. 1949-55, U.S. Marine Corps., sergeant.8407002_00004.txt

Page  4 1257 Association memberships: Sigma Alpha Sigma; American Society of Public Accountants; Federal Government Accountants Association; American Society for Public Administration. Special awards, citations, or publications: DHEW Quality Performance Award, 1972. Dr. Cummings. I believe the committee previously has met Mr. Smith and Mr. Day, senior members of my staff. Mr. Flood. You have a statement. How do you want to handle that? Dr. Cummings. With your permission, I would like to read it and handle any questions you have. Mr. Flood. Please do. OPENING STATEMENT Dr. Cummings. Mr. Chairman and members of the committee, as our Nation prepares for its bicentennial observance the National Library of Medicine enters its 140th year. NLM traces its origin back to 1836 when a small collection of medical books and journals were acquired and located in the office of the Army Surgeon General. Today the National Library of Medicine with its 1,500,000-volume collection serves as the world's largest research library in a single scientific and professional field. Mr. Flood. This history and service, I am sure, is not generally known. It is simply not known; is it ? Dr. Cummings. Unfortunately, it isn't generally known to the public. I believe the medical community, however, has insight into this. Mr. Flood. Yes, I meant to the general public. Dr. Cummings. It continues to perform its legislative mandate to acquire, organize, and disseminate printed and audiovisual infor- mational materials in the biomedical sciences. Index Medicus, which had its genesis in 1879, still serves as an invaluable tool to the Nation's physicians and scientists and is sold to more than 6,000 institutions throughout the world. Mr. Flood. What is Index Medicus ? Dr. Cummings. Index Medicus is the listing of all the world's medi- cal literature as it appears monthly. It announces the articles pub- lished, the author's name and citations that may be used to reach this literature. In order to effectively and efficiently provide timely information services to the entire health community, a national biomedical com- munications network utilizing the latest in technological advances has been developed and is continually being enhanced. BIBLIOGRAPHIC SERVICES One of the prime tools of today's technology is the computer, and NLM has pioneered in its use for bibliographic information storage and retrieval. In 1964 NLM introduced the computer-based Medlars I system, which permitted both computerized production of Index Medicus and automated searches of the entire bibliographic data base by health professionals. I am pleased to inform this committee that in January of this year NLM implemented its new information system, Medlars II. This milestone culminates an intensive Sy2 year effort to develop a more sophisticated bibliographic processing system which employs 52-089 O - 75 -- 808407002_00005.txt

Page  5 1258 the most modern third generation computer technology. Medlars IT is installed on NLM's newly expanded computer configuration which allows the extension of our services to the entire health community. In addition to the increased speed and capacity to serve online users, Medlars II makes it possible to generate and photocompose new bibliographic publications, and to provide more flexible search formu- lations and information retrieval. Health professionals at over 300 institutions in this country and abroad can now directly interact with the computer through terminals which access the Medlars data base containing citations and abstracts of relevant medical literature. Approximately 300,000 searches were performed last year. In order to moderate the growth of Medline and to cover all of its communications costs, we are increasing our user charges moderately. Under a new agreement with the Commerce Department's National Technical Information Service, that agency will collect fees to offset the costs of making online data bases accessi- ble equally to all parts of the country. Any excess collections will be returned to the U.S. Treasury. Obtaining citations to the relevant literature is only the first step for the health professional seeking information. He must then obtain the literature for study. Few health science libraries subscribe to all of the 3,000 journals which NLM indexes for Medline, but they can locate and receive copies of literature needed by their patrons via an NLM-supported interlibrary loan network. Although NLM resource grants help many smaller medical libraries purchase the basic litera- ture most frequently consulted by practitioners, a local hospital library still may not have the particular article or book needed. In that case, the institution may request an interlibrary loan from a larger medical library in its region. NLM supports 10 such Regional Medical Libraries throughout the country, each responsible for providing interlibrary loans and Medline services in a defined geographic area. NLM itself, with the most comprehensive collection of health science literature in the world, backs up the entire network and attempts to supply materials unavailable from these primary sources. It also serves as the Regional Medical Library for the Mid-Atlantic Region. CANCERLINE Increasingly, other health agencies are benefiting from the com- munications expertise which NLM has developed over the years. Using NLM's computer and international telecommunications network, for example, the National Cancer Institute is providing cancer-related citations and abstracts for an online data base that is now available at each of the numerous Medline centers. Tn 1975 over 18,000 carcino- genesis abstracts will be added to this data base (called Cancerline). and the number of abstracts is expected to increase by about 10,000 each year. NLM's considerable experience with online systems allows it to make a significant contribution to worldwide cancer research and treatment. MEDICAL LIBRARY ASSISTANCE I have already referred to NLM's regional medical library and resource grants programs. These are part of the activities originally authorized by the Medical Library Assistance Act of 1965. Together with grants for training, special scientific projects, research, and bio-8407002_00006.txt

Page  6 1259 medical publications, these programs continue to support a coordi- nated approach to the problem of assuring equal and efficient access to biomedical information in all parts of the country. COPYRIGHT SUIT Before turning to other programs of the NLM, I would like to inform the committee of the status of the copyright suit against the National Library of Medicine and the NIH Library. As you know, a publisher of some biomedical journals alleged that the NLM and the NIH Library had infringed their copyright by providing photo- copies of journal articles to library patrons. The U.S. Court of Claims found in favor of the Government and in February 1974, the U.S. Supreme Court sustained their decision. This outcome has been enthu- siastically welcomed by the Nation's library and educational com- munity. With this ruling all interest in copyright is again focused on the congressional efforts to produce a new copyright law. AUDIOVISUAL SERVICES In 1967 the National Medical Audiovisual Center (NMAC) in Atlanta, Ga., which is responsible for developing a large and diverse collection of health science audiovisuals, was transferred to the Na- tional Library of Medicine. NMAC is much more than a repository; it is actively developing programs for applying audiovisual tech- nology to the problem of training sufficient health manpower to meet present and future needs. With the assistance of special panels of educators and biomedical specialists NMAC identifies, produces, col- lects, and evaluates mediated instructional materials appropriate for the basic and continuing education of health professionals. Instruc- tional materials judged to be sound in content and of high technical quality will become part of a new computerized online retrieval sys- tem analogous to Medline and available across the country through the NLM communications network. Called Avline, it enables a user to identify audiovisuals by subject matter. It also provides information on where audiovisuals may be obtained and on their content, quality, and intended audience. As with journal articles, however, identifying the needed material is only the first step. NMAC also makes loans of motion pictures and videotapes to schools of the health professions and consults with them on ways to utilize audiovisuals more effectively. In fiscal year 1975 NMAC will loan approximately 65,000 films and videotapes to the health communitv- They will be viewed by more than a million students and practitioners in the health sciences. NMAC works closely with the Bureau of Health Resources Devel- opment of the Health Resources Administration (HRA) in the pro- duction of nonprint teaching materials for the health community. One joint effort has produced instructional materials in operative dentistry and they are now in use in most dental schools. TOXICOLOGY INFORMATION NLM's toxicology information program is responsible for devel- oping and operating a computer-based toxicology information storage and retrieval system. It also provides publications, other information8407002_00007.txt

Page  7 1260 packages, and literature services to satisfy the rapidly growing needs of other Federal agencies, universities, and industrial firms for toxi- cology information. One of the ways in which the program meets these needs is through the development of Toxline—a computer-based information retrieval system which contains information about phar- macology, toxicology, environmetnal pollution, and occupational health and safety. Like Medline it is accessible via terminals which connect users to the NLM computer. The computerized data base, which currently includes over 350,000 searchable citations, index terms, and abstracts of the published literature, brings together infor- mation from diverse sources which otherwise would be much less accessible. In fiscal year 1976 the file will be enriched with additional references in areas of special significance, such as chemicals causing birth defects and cancer. LISTER HILL NATIONAL CENTER FOR BIOMEDICAL COMMUNICATIONS The Lister Hill National Center for Biomedical Communications is the research and development arm of the Library. It coordinates closely with other Federal agencies as well as the medical community. Its orientation is to seek to expand the horizons of problem solving in the areas of health care delivery, education and research through the use of communications technology. One example of such an approach is to increase the effectiveness of health care delivery in isolated communities by establishing communi- cations with sophisticated backup health facilities. Initially, this was done through voice communications where, for example, in Alaska it was shown that interference-free voice communication via the ATS 1 satellite was of great help in decisionmaking both with regard to sup- port for onsite treatment by health aides, and for determining the necessity of evacuating patients to more comprehensive health facilities. Experiments have been undertaken to determine to what extent these benefits may be increased through the introduction of 2-way video transmission as well as physiological monitoring through the use of the ATS 6 satellite. In this experiment it is possible both to see the patient, and examine his physiological data (e.g. electrocardio- gram) as well as monitor his vital signs. Additionally, experiments have been undertaken to determine the effectiveness of long range consultation particularly in the areas of psychiatry and dermatology via two-way communications systems. Thus, both in the Pacific Northwest via the ATS 6 satellite, and in the Northeast via a terrestrial interactive TV network, it is possible for a consultant to "examine" and treat a patient many miles away. In a similar fashion, the role of communications technology in both undergraduate and postgraduate medical education is being studied. The WAMI program in the Pacific Northwest represents an experi- ment in decentralization in undergraduate medical education. Mr. Flood. You had better translate WAMI. Dr. Cummings. That is an acronym for Washington, Alaska, Mon- tana, and Idaho. It is a consortium of four States in education and health programs. It is a very exciting educational program, Mr. Chairman. We believe that experiments of this nature may help solve the problem of training physicians in States whose population densi- ties cannot support medical schools, such as Wyoming and Idaho.8407002_00008.txt

Page  8 1261 Interactive communications systems make it possible to extend and integrate faculties in geographically distant areas into a cohesive and complementary whole. Using satellite communications, students re- ceive basic science instruction at the University of Alaska, and clinical training in rural parts of the State of Washington. They are instructed by the faculty of the University of Washington School of Medicine, in Seattle. In these experiments the Lister Hill Center has been work- ing closely with the Health Resources Administration. The Lister Hill Center is also participating with the Health Serv- ices Administration in creating a continuing medical education pro- gram for physicians in the newly established National Health Service Corps. One objective of the program is to reduce the degree of pro- fessional isolation experienced by these physicians, and hopefully to encourage them to remain in place and continue participation in these medically underserved areas. Together with the Health Resources Administration, efforts are being made to provide information to such practitioners in a timely and effective manner. An additional concern is to determine what in- formation is most valuable both from the point of view of alleviating their sense of isolation and in contributing to improvement of the quality of care. The Lister Hill Center acts as a forum, a coordinator, and an agent for initial funding of exploratory and demonstration projects. In these demonstrations it is consistently cognizant of the necessity to plan for the ultimate operational support should they prove successful. The Lister Hill Center works toward the evolution of local self-sufficiency if possible, and other agency support where nec- essary. The Lister Hill Center itself does not support proved operat- ing systems. To carry out these services, Mr. Chairman, the budget request for the National Library of Medicine for 1976 is $28,815,000. I shall be pleased to try to answer any questions and supply additional information which you may desire for the record. LISTER HILL CENTER FACILITY Mr. Flood. Doctor, last year you told us that the architectural and the engineering drawings for the Lister Hill building would be com- pleted by the end of calendar year 1974. Do you have a finalized set of drawings ? You know that this committee from the beginning has been very much concerned right along about the Lister Hill building, for Lister was an old friend of ours. How about that ? Dr. Cummings. I regret that my estimates last year were off by some 3 or 4 months, but I have been assured, Mr. Chairman, that the architects have completed design of this facility and that they will be delivered to NIH next month. Mr. Flood. I hope so. We want to see that thing underway. What will it cost to construct that building ? Dr. Cummings. The present estimates of cost for the Lister Hill facility without parking arrangements is about $20 million. Mr. Flood. What is the estimated cost per square foot ? Dr. Cummings. I believe the estimated cost per square foot is be- tween $95 and $100. Mr. Flood. Is there any money requested in the NIH budget for the construction of the Lister Hill building?8407002_00009.txt

Page  9 1262 Dr. Cummings. There is no money in the President's budget for this facility. , Mr.'Flood. If we delay the cost of this building another year, what is your best estimate of the cost ? Dr. Cummings. I am advised that the cost of construction goes up at a rate of about 10 to 12 percent a year. That would then raise the cost of the Lister Hill facility to a level of about $23 million or $24 million. Mr. Flood. In view of the fact that the fiscal year 1976 budget does not contain funds for this facilitv, the Congress can only appropriate a portion of the total cost of the project, could this project be sub- divided or phased in any way ? It is about time we get down to busi- ness on this thing. Dr. Cummings. Mr. Chairman, this question was raised last year by the Senate Subcommittee on Appropriations, and we have recently reexamined this issue. I am advised that the most desirable method of proceeding is to authorize the construction for this facility with a 3- year phasing of this appropriation. Such a plan would provide about 30 percent of the total cost within the first year or $5.7 million. An additional 50 percent of the cost during the second year would be needed or about $9V? million, with the re- maining 20 percent for the complex in the third year. Mr. Flood. If we funded only the first part of this construction what would be your estimate of cost ? Dr. Cummings. On a 3-year base situation it would require about $5.7 million. If the bnilclinp- were phased on a 2-year basis, it would be about $10 million for the first and $10 million for the second phase. Mr. Flood. It is about time this thing is off the ground. Dr. Cummings. It is 7 or 8 years since the ioint resolution of the Senate and House called for the creation of this facility. EXPERIMENTAL COMMUNICATION NETWORKS Mr. Flood. Last year we talked a lot, we had a very exciting talk about the satellite experiments which provide the live television con- sultation between the physicians in the Indian Health Service Hospi- tal and health aides at several of these remote clinics in Alaska. Have these experiments proved to be effective ? Dr. Cummtngs. Yes. sir. In mv view those experiments have not only proven to be interesting, but have in fact proved to have practical utility. I have been advised, for example, that on the basis of the success of these demonstrations that the State of Alaska is consider- ing developing a statewide communication system based on satellites. The efficiencv is quite impressive. Mr. Flood. Do you have plans to expand these experiments to in- clude other geographical areas of the country? Dr. Cummings. Yes, sir. With the present experiment using the more sophisticated satellite known as ATS-6, we are now aVe to cover the Rocky Mountain areas and a small part of the Southwestern States as well as some of the U.S. trust territories in the Pacific. In the future we look forward to work- ing with the Canadian telecommunications apparatus that would give us the opportunity to blanket larger portions of our Nation, in-8407002_00010.txt

Page  10 1263 eluding Appalachia ana other medically underserved components of our country. Mr. Flood. For what period of time do you support these experi- mental communication ret works? Dr. Cummings. Our experience so far suggests that it takes between 5 and 6 years to mount a program, to test it, and to evaluate its effi- ciency. That is the experience we have had to date. We then withdraw from the basic support and try to turn it over to the local community. Mr. Flood. Who will pick up the support of these communication networks if you withdraw your financial support ? Dr. Cummings. Hopefully the medical community itself, States and local governments which may be interested, will provide the support as we gradually withdraw. We do not cut off precipitously, I should point out. We try to phase this out and we try to maintain a relation- ship with the local institutions so that they are actually prepared for this. Mr. Flood. You mention in your opening statement that the role of the communication technology in both undergraduate and postgrad- uate medical education is being studied. You also mentioned WAMI, an experiment up in the Pacific Northwest. Can you tell us more about your experiment and your other work in this area ? Dr. Cummings. I can tell you that the students and the faculty at the University of Washington in Seattle both report that the teaching of basic science can take place through interactive communications, that the students who are physically located in Fairbanks, as members of the class of the University of Washington are doing as well as those students who are taking the courses on campus. I believe the strategy here is to have these students stay in place after they graduate so that students who come from remote places in Alaska and taste Seattle don't decide to live in Seattle but recognize they can maintain medical contact even when they return to their point of origin. Mr. Flood. There is a lot of talk and interest all through the country from small town colleges about tying into the larger metropolitan area medical universities and medical colleges in these combined courses. There are 6-year courses; 2 years at the local small college, and 2 years at the big medical college downtown and back to the small town for 2 more years getting an MD in these combined courses, tying in the hospitals, et cetera. Is that part of your program ? Do you help in these things ? Dr. Cummings. No, sir. That is not part of our program. I believe the Bureau of Health Resources Development of HRA would be more involved with those combined activities. Where such a program requires communication experitise for success, HRA has called upon us in developing this kind of linkage. Mr. Flood. I can see where telecommunications would be important for taking back the lectures of the university or the college operations perhaps even on patients, taking the whole thing back to the colleges, to the classrooms and the hospitals of the surrounding community. In many ways that would be beneficial for the interns and para- medics. Dr. Cummings. I believe there are many activities along the lines of your description that are now underway.8407002_00011.txt

Page  11 1264 DISSEMINATION OF RESEARCH RESULTS Mr. Flood. All the Institute directors who have testified here so far have placed a great amount of importance on the transmitting of new knowledge discovered in the laboratory to the practicing physician. How does the Lister Hill Center achieve that kind of objective? Dr. Cummings. I think the problem of dissemination of research re- sults into clinical application is a prime example of the programmatic interest of the Lister Hill Center. We have each year since the Center was developed maintained a structure through which we work with professional societies, learning of their needs in continuing education. We try to provide new communication modalities for the physician to get access to research information. Now this is done, of course, in many different ways. A physician can go to meetings if he can close up his office. As you know, many solo practitioners cannot do that. We are now trying to bring the informa- tion to his office, to his clinic and to his home. Mr. Flood. What kind of practitioner ? Dr. Cummings. The general practitioner. Mr. Flood. You used another term. Dr. Cummings. I said solo. He practices alone. Often he cannot afford to close his office to go to medical meetings to get this knowledge. We are trying to bring it to him through printed word and audio- visual forms and now through direct contact between him and an exoert at a great medical center. Mr. Flood. How do the Institutes at NIH use this center to dis- seminate new technology to the practicing physician? Dr. Cummings. As an example, through our bibliographic resources we tell the practitioner what has just come off the press in research results. We do this through a special publication called Abridged Index Medicus. It lists only the practical clinical findings. It does not have the exotic foreign language literature. Each month this reaches the practitioner and he can scan it and find the latest publications in diabetes, hypertension, carcinoma of the breast, et cetera. This is one way we try to serve him. Also, we put library resources in his com- munity hospital where he spends a good bit of his time. We consider the community hospital, Mr. Chairman, as the underdeveloped base of continuing education for health professionals. That is why the small resource grants, $3,000, $1,000, or $5,000, are critically important to giving him information in his hometown so he does not have to go great distances to seek it out. Mr. Flood. This sounds great. We have also heard a lot of testimony in the past weeks about educating the general public. That is a good idea, educating them about maintaining good health. What role does the Lister Hill Center play in that kind of program ? Dr. Cummings. The Lister Hill Center and indeed the library I must confess, has not developed an active program in providing con- sumer education or public education. We anticipate that the Center in Atlanta, the Center for Disease Control, which I believe has this mission added to its responsibilities, will assume that important task. However, the audiovisual materials8407002_00012.txt

Page  12 1265 that we provide are shared with them so that they can be used by patients and the public in learning how to take care of their general health problems. But we do not have that as a primary responsibility. user charges Mr. Flood. In your opening statement, you made quite a thing about this. You are increasing your user charges moderately, you say. For what services do you apply the user charge ? Dr. Cummings. We charge a user fee for every specialized service we provide. We are doing this, we believe, at the request of this com- mittee and the Office of Management and Budget. We think it is a use- ful concept, that the user pay at least the cost of reaching the central data base at NLM. We do not charge him for the cost of development of the information for which you appropriate funds or for the orga- nization of this material. But anything that connects him to the library requires a communication cost which he pays. Mr. F lood. How much do you collect annually on a user charge ? Dr. Cummings. The unit rate is $8 an hour. The physician or scien- tist can make four or five searches in an hour. Mr. Smith will answer. Mr. Smith. It will run approximately $400,000 this year. It will be about $800,000 next year with the charges going up. Mr. Flood. Does that all go back to the general Treasury ? Dr. Cummings. It is used to pay the communication cost for the net- work. Mr. Smith. Any excess goes back to the Treasury. Dr. Cummings. We are going to raise that fee to $15 an hour during prime time, because like the telephone system we are getting over- burdened during peak hours. Our intention, Mr. Chairman, is to take whatever excess collection there may be and return that to the Treas- ury. But so far we have had no money in this category. Mr. Flood. Do you plan in the future to apply a user charge to a much greater number of the services that you now provide to the medi- cal and industrial community, too ? Dr. Cummings. We intend to provide a user charge for any special- ized technical service but none for traditional library service like lend- ing and borrowing, but anything that requires specialized computer service we will charge for. Mr. Flood. To the medical community and the industrial community. Dr. Cummings. Yes, there will be an equal charge to any member of the health community. Mr. Flood. What effect will the increase in the user charge have on the utilization of your services by the institutions we are talking about and by the individuals ? Dr. Cummings. That, of course, is a most important question. I suffer with that question, because here---- Mr. Flood. You don't want to overplay your hand here. Dr. Cummings. You have to balance out the absolute requirement for information and not have charges that constrain people who have a right and a need to know.8407002_00013.txt

Page  13 1266 On the other hand, we need some lever to reduce trivial or frivolous use. Mr. Flood. You are obviously aware of this. Dr. Cummings. Painfully so. PERSONNEL REDUCTIONS Mr. Flood. Now you have a budget request increase of $367,000. It shows a decrease of seven jobs. Why is that ? Dr. Cummings. The budget increases shown in the table before you are almost exclusively to bear the cost of mandatory pay raises. The only real increase in that budget is for the cost of literature. Mr. Flood. There is a decrease of seven positions. Dr. Cummings. The decrease of seven positions is part of the overall NIH and I believe departmentwide need to cut back on positions. This was deemed to be our fair share. LITERATURE ACQUISITION Mr. Flood. You are asking for a total of $1,040,000 for equipment in 1976. Why do you need $1,040,000 for equipment in 1976 in view of the fact that you will be spending $940,000 for equipment in 1975? What is the gimmick there ? Dr. Cummings. That term "equipment" is an unfortunate one for libraries. Under the category of equipment comes things like books and journals. Nearly all the money under equipment is for the acquisi- tion of literature, books and journals. It is about $800,000. Mr. Flood. I don't doubt that. What does that have to do with my question? $1,040,000 in 1976 and you are spending $940,000 in 1975. Dr. Cummings. The cost of acquiring books and journals goes up at a rate of about 12 percent per year. Mr. Flood. You include them under equipment. Dr. Cummings. Yes, sir. That is the strange nomenclature of the budget under which we must fit the acquisition of books and journals. Mr. Flood. Mr. Michel. Mr. Michel. On that question, why can't you make that visible in your budget, as books and journals for the library ? Dr. Cummings. We do in our submissions to OMB. I think the lan- guage clearly shows that this is the purpose for which the money will be spent. In the budget books and journals do not appear as a line item. We would be happy to do so because you can appreciate it is a large part of our expenditure. REGIONAL MEDICAL LIBRARIES Mr. Michel. Where are these 10 regional medical libraries that you support and to what extent do you support them ? Dr. Cummings. They are located in Boston, New York, Phila- delphia, Chicago, Detroit, Omaha, Seattle, Dallas, Los Angeles, and in Bethesda. We provide in the aggregate support at a level of about $2.5 million for these 10 institutions to give their services regionally. Each then gets roughly about $250,000. Mr. Michel. There seems to be a void in the Southeastern area geographically.8407002_00014.txt

Page  14 1267 Dr. Cummings. You are very perceptive. I neglected to mention Atlanta. There is a regional library in Atlanta. Mr. Michel. Having named those cities, would those be in com- bination with medical complexes of those cities? Dr. Cummings. All of them are located in a medical institution of one nature or another. Seven of the 10 are in medical schools. Three of them are located in large, free-standing libraries. GROWTH OF COMMUNICATIONS NETWORK Mr. Michel. On this question of user charges, has the growth of the system come along faster than actual development of the system ? Dr. Cummings. It is a foot race. Mr. Flood. Will the gentleman yield ? Mr. Michel. Surely. Mr. Flood. Along that line, what about the hardware ? I happen to be a member of the Defense Appropriations Committee as well. I know something about telecommunication. You need a lot of hard- ware before you get into telecommunications. If you go from point A to point B, that is 200 miles, say. Where do the towers come from? Do you rent them from A.T. & T., or do you borrow them or does somebody give them to you, or what? Where do you get the equip- ment ? That is quite a project. Dr. Cummings. This committee has been generous and has provided us with computer resources that we have in place. Mr. Flood. That is just one thing. Dr. Cummings. We do not run our own lines or build our own towers. We use commercial telecommunication networks that exist domestically. We have a lease arrangement through which the more use we make the cheaper the unit cost. Mr. Flood. When you talk about telecommunication from Alaska to Ohio, that is great, but knowing what I know about telecommuni- cations since we started this business, and computers---- Dr. Cummings. To complete my answer, I should point out as I did last year that NASA has been very generous to us and has allowed us to have access to the satellites that they have in place. Mr. Flood. Without cost ? Dr. Cummings. Without any cost to us. We do pay for the ground terminals. Mr. Flood. You are not in the satellite business yet ? Dr. Cummings. No. I don't think Ave are going to be building or launching satellites. Mr. Flood. I don't mean building. They are up there. Dr. Cummings. We are using available time on those already in space. Mr. Michel. What would you estimate would be your maximum output with the Medlars II system ? Dr. Cummings. We expect to be able to deliver more than 600,000 searches in the next fiscal year. This will probably put us close to the point where there may be a deterioration in the time response. Our estimate is that we can go with our present configuration for about 2V2 years before success is going to do us in.8407002_00015.txt

Page  15 1268 SEARCHES Mr. Michel. I notice a change in your original testimony from over 400,000 searches to 300,000. Why is that ? Dr. Cummings. The number of Medline searches is 300,000 but the 400,000 figure includes Toxline and other searches. My staff persuaded me this morning to deal only with Medline. We are giving more than 400,000 computer searches on all our data bases. Mr. Michel. Do you have any figures on the average cost and time required for a search ? Dr. Cummings. Yes. The average thorough search of the literature can take place in less than 10 minutes. The average cost of searching is about $12 per hour. One search costs about $2.40. Five would run about $12 per hour. Mr. Michel. Are there any other computer systems of this nature established in any other countries that you know of ? Dr. Cummings. I believe data bases such as ours are being worked in other countries. I don't know of any as extensive as ours that has been generated de novo in other countries although Germany, Japan, and Sweden are very actively trying to get into this field. Mr. Michel. We do not currently have any of those foreign coun- tries abroad tying in, in any way, to our system, do we? Dr. Cummings. Yes; we do, sir. We receive from Sweden, West Germany, France, the United Kingdom, Canada, Australia, and Japan input into the system. It is in the form of indexing or abstract- ing which equates to $50,000 of effort from each of them for the privilege of their accessing our data base. Putting that in an aggregate, we are getting in return about $400,000 in services and input into the service internationally to allow them to access the system. foreign language publications Mr. Michel. How is the information translated from one language to another ? Dr. Cummings. Well, because half of the world's literature is in a foreign language, it does require members of my staff or our foreign partners to translate all of this literature into the English language. That does not mean that they translate it word for word, or line for line. They summarize it in the English language. Our system is an English language system which, I am pleased to say, all foreign part- ners are prepared to work with. Mr. Michel. You feel it is your responsibility to get it translated into English; right ? Dr. Cummings. We are not doing it for them. We are doing it for the American physicians who obviously cannot handle all the other languages. Mr. Flood. To what extent is technical terminology used in all lan- guages? Take a medical term, a word or even a phrase, especially if the derivation may be Latin. Whether it is or not, is that used inter- changeably in your telecommunications? Dr. Cummings. We have developed standards in part working with the World Health Organization. But I would say largely over the course of the last century, we have developed a vocabulary and nomen-8407002_00016.txt

Page  16 1269 clature of the medical literature that has become a standard so that a medical term like Parkinson's Disease means the same thing all over the world. Mr. Flood. Do they say "Parkinson's Disease," or what ? Dr. Cummings. By and large the vocabulary we have adopted for our use is now an international vocabulary. The problem is that physicians and scientists invent new terms as science progresses. We have to keep abreast of this and keep changing the dictionary and elaborate it. Mr. Flood. I know that, but I am talking about what exists now primarily. Dr. Cummings. We try to have an international vocabulary and the World Health Organization also works in establishing these norms. Mr. Flood. I would think so. Thank you. TOXLINE AND AVLINE Mr. Michel. What has been the growth rate of the other systems such as Toxline and Avline ? Dr. Cummings. I cannot give you precise data from memory. I can tell you the number of institutions that has signed up for these serv- ices has more than doubled in the past year. I can provide you with precise data for the record if you would like it. Mr. Michel. You might put in something. Dr. Cummings. It has grown exponentially. [The information follows:] The library performed aproximately 12,000 Toxline searches in fiscal year 1974. We estimate that the number will increase from 15,000 in fiscal year 1975 to aproximately 20,000 in 1976. The Avline system is currently in the test file stage and should be operational in fiscal year 1976. communication network requirements Mr. Michel. Do you anticipate that your present equipment will be able to keep up with demand ? Dr. Cummings. Our estimates suggest that we will be able to keep up with demand for the next 2y2 years, particularly by tuning the pricing structure. That is very important. Mr. Michel. You use time frame and Medlars II. What does that suggest 2^2 years from now ? Dr. Cummings. It suggests, hopefully, that new technologies in the computer field will allow us to improve our configuration by having, say, discs that compress information more than it does now or that the processing will be speeded up. We are hoping that tech- nology will make advances so our changes in configuration can keep up with the workload. It also suggests, Mr. Michel, that we may have to decentralize our system more than we have. It may well be that Bethesda can no longer be the base from which we give these services. We may have to package it and put it in some other libraries. Air. Michel. Would it follow, then, that you would utilize those 10 or 12 regional centers we alluded to earlier? Is that the most natural ?8407002_00017.txt

Page  17 1270 Dr. Cummings. Yes. They now, of course, serve as regional search centers for the States in their community of interest, but they do not all have computer apparatus to actually run the tapes. It is possible, I think, that in time they will. We may just have to package our material and have it operate in 8, 9, or 10 of the Centers. We do have one backup operation in New York now. The State University of New York system maintains a backup operation to the NLM. Mr. Michel. But to be practical, you could not very well have certain information at one regional Center and a concentration or a specialty in another, or is that practical ? Dr. Cummings. I think if the integrity of the information is kept in big pieces, it is more practical and economical. If you fracture this information to little tiny units, it becomes cost-ineffective. That would be my estimate. Mr. Michel. I was just thinking in terms of cost of leasing and lines, et cetera. If it were specialized and one specialty were on the east coast, then obviously all the information going to the west coast builds up a cost as distinguised from another discipline closer. It would average out, but your professional judgment would be one, offhand at least, that it would tend to hurt the system rather than enhance it. Dr. Cummings. I would be very glad to have some studies made of this important question and perhaps come prepared at a later date to give you the tradeoffs that we learned from this examination. Mr. Mickel. Since the chairman has made reference with respect to computers and how they originally came to us and in what size and description and then the first generation and second, et cetera, I am curious to know. I think in your own shop you had a MEDLARS-I, and MEDLAR S-II. That was a growing technological improvement. I am trying to look into the crystal ball for how many more dollars you will be asking us for 2y2 years from now if both of us are still here. Thank you, Mr. Chairman. Mr. Flood. Is there any kind of understanding in the medical re- search scientific world that when you give birth to a new term that it should be based, the derivatives, on Latin and Greek, preferably? Dr. Cummings. Not anymore, I'm afraid. Mr. Flood. That is too bad. I was afraid of that. Dr. Cummings. At the turn of the century there was that kind of standard lexicography and taxonomy. Now, you know, names are attached to people and geographic places. Eponyms are a terrible thing to contend with. Mr. Flood. Mr. Patten. Mr. Patten. The Doctor makes much of the audiovisual project up at Fairbanks. I wish some of you people would bring in some audio- visual. You have been talking here for an hour. I will bet you could put a couple of things on exihibit to prove your point a lot quicker. I dropped up to Dartmouth Medical College, which you did not men- tion this year in your presentation.8407002_00018.txt

Page  18 1271 Dr. Cummings. Yes, it is. That is one program which we are slowly withdrawing from to be picked up by the local community. With regard to your comment on the use of audiovisuals, I know the committee would do better with those than with my New Jersey English. Mr. Patten. No, I'm only kidding. I have heard some of these peo- ple say, "We learn 93 percent through the eye." I can understand your statement that the student up at Fairbanks, Alaska, is getting a great deal. That is very valid. We have a library at our medical school at Rutgers. I only hear good words about it from our doctors. You do not help that school any ? Dr. Cummings. Oh, yes, we have. Let me remind you first that the librarian who started that Rutgers medical library was recruited from our institution, a very fine gentleman. Rutgers has received resource grant support along with many other new medical schools. We have a very close relationship with that medi- cal school along with all others. They have benefited by the programs you support here. Mr. Patten. It would be a pleasure to talk about this and 10 other things, but I will not, because we want to get to Dr. Schwartz. But if I had my way, I would put right in the middle of the medical school a building for family physicians. What are you doing for the fellow who is good enough to come out at 11 o'clock at night or 2 o'clock in the morning that I have in my neighborhood who is no specialist? Does he use your service ? Dr. Cummings. Twenty-six percent of all the services we give now go to the family physician or the general practitioner. I can tell you, Mr. Patten, that that was not true 10 years ago. When I first came to the National Library of Medicine I was appalled to see how few physicians knew of its existence and knew of its resources available to them. That has climbed steadily. I am optimistic that the gentle- man who is taking care of you at midnight is now learning that he can get rapid access to medical information to give you the latest treatment. Mr. Flood. If you will yield, I am glad you mentioned that. I have been amazed—I have not admitted it—by the number of GPs that I meet in my own area who know about you and your operation in the last few years. I never heard it before but in the last 5, 7 or 8 years I have heard a lot about it. Mr. Patten. As lawyers, our library is right at our side. My pride in the law office is my books. Dr. Cummings. Doctors should do the same. Mr. Patten. The greatest doctor I ever knew was a general practi- tioner. What amazed me, he never stopped reading. He subscribed to the best journals. Every time I saw him he was reading or discuss- ing, running into NYU or Columbia. Still you called him a general practitioner. You mentioned about continuing to learn m the field. It looks to me like you have the same kind of budget you had 10 years ago. You are talking here about the growth and new cases. Back in 1974's budget vou received $27,738,000. It seems to me, your budget stays about the same without taking into consideration inflation, sal-8407002_00019.txt

Page  19 1272 ary increases and everything else. Of course, I will just tell you that this is my 41st budget*. I started as mayor in 1934. At the local level they said, cut the budget 10 percent. We cut out recreation and the libraries. Nothing further, Mr. Chairman. Mr. Flood. Mr. Smith. MEDICAL LIBRARY ASSISTANCE Mr. Smith. Dr. Cummings, I note a reduction in funds available for library assistance grants from the level of 2 years ago. Will the reduced amount permit you to develop your biomedical communication plan in a manner adequate to meet the needs of our practicing physi- cians and other health workers? What effect will this cut in grant funds have on your regional medical library program and companion efforts to improve biomedical library resources ? Dr. Cummings. The library assistance grant has been effective in increasing the capability of the medical libraries at the local level to respond to the needs of the practicing physician and allied health workers. The rate at which local medical library capabilities will be strengthened is dependent upon the funds available through the library assistance grant. A lowered funding level reduces local effectiveness and results in increased demands upon the regional medical libraries (RML) by the local libraries. This increased burden on the RML seriously under- mines its ability to be responsive to the burgeoning demand for medi- cal information by the health community and adversely affects the total biomedical library network with more and more requests being referred across the country to the already overloaded National Li- brary of Medicine. Mr. Smith. How do you assure yourself that the type of work being done with grant assistance is of a superior quality ? Dr. Cummings. Our grants program benefits from the same peer review system that has proved so effective for other components of the NIH. Each application is assigned for scientific review to a study sec- tion composed of nonfederal consultants with subject expertise. The biomedical library review committee is comparable in function to the other studv sections of NIH. For this committee, however, the sub- ject expertise of its members spans a wide variety of disciplines in- cluding computer science, information science, librarianship and medi- cal education. Grant applications for audiovisual programs are also routinely sent to the National Medical Audiovisual Center for tech- nical review. Resource project grant applications are similarly sent to the appropriate regional medical library for comments as to their regional impact and implications. Peer review, as practiced at NIH, has an excellent track record; and I am assured therefore that work of superior quality is being identified and supported. IMPROVEMENT OF HEALTH SCIENCE EDUCATION Mr. Smith. Dr. Cummings, how much attention are you giving to the need for improved educational activities in the fields of interest of the National Library of Medicine ? For example, isn't there a need for close coordination of the educational portion of the responsibilities of8407002_00020.txt

Page  20 1273 the NMAC, the Lister Hill Center, and the various activities supported by grants or contracts such as the regional medical libraries ? Dr. Cummings. The support of improvement of health science edu- cation is one of the main objectives of the National Library of Medi- cine's Biomedical Communications Network. Its implementation is contributed to by all components of the Library. For example, the National Medical Audiovisual Center working with the Lister Hill Center and the Health Resources Administration has developed a pro- gram for the review, testing, abstracting, indexing and cataloging of multimedia educational materials of demonstrated value. The Lister Hill Center is actively pursuing various options for the development of economic effective distribution systems for this material as well as utilizing communication technology to facilitate learning. The Lister Hill Center is particularly interested in the use of com- munications technology to minimize the effect of isolation of health scientists working in rural areas. Working with the National Medical Audiovisual Center and our regional medical libraries, programs are being developed with the Health Service Corps personnel to provide selected information in multiple formats. These needs for continual education of health practitioners constantly bring together not only all elements of the National Library of Medicine but also other Health agencies particularly HRA, HSA, and other NIH components. All of these activities are coordinated in the Office of the Director, NLM. MEDLINE Mr. Flood. Mr. Conte. Mr. Conte. Dr. Cummings, you said that you were increasing your user charges in order to moderate the growth of the Medline system. How much are you increasing your user charges ? How many searches do you expect to perform in 1976 with your increased user charges ? Dr. Cummings. Effective February 1, 1975, Medline user charges were raised to $8 per connect hour to reflect a more recent analysis of communications costs, usage patterns, and to recover a greater portion of communications or accessing costs. Effective July 1, 1975, variable rates of $15 per connect hour during prime time hours (10 a.m. to 5 p.m. ET) and $8 per connect hour during nonprime time hours will be implemented. The National Library of Medicine will perform ap- proximately 400,000 searches in fiscal year 1976. medlars Mr. Smith. Dr. Cummings, you said that more than 300 institutions are a part of your Medlars system. Do you expect this number to in- crease over the next year or several years? How does an institution join Medlars—is there a membership fee in addition to the user charge ? How much does it cost to become part of the system ? Dr. Cummings. Now that the NLM possesses greater computer ca- pability, Medline services are being offered to a wide segment of the health community. On the average, 75 institutions join the Medlars system each year since its inception in 1972. The annual increase antici- pated will be approximately the same next year. An institution joins the Medlars system by application through one of the eleven regional medical libraries.8407002_00021.txt

Page  21 1274 The applicant institution must acquire through purchase or lease, a terminal compatible with the network, and pay for installation costs. These are the principal costs associated with entry to the system. Once a center has become operational, monthly service charges are the only additional costs incurred. REGIONAL MEDICAL LIBRARIES Mr. Conte. Dr. Cummings, where are your 10 regional medical libraries? How long, on the average, does it take from the placing of an order to the receipt of the book or journal needed through the inter- 1 ibrary loan network ? Dr. Cummings. The National Library of Medicine also functions as a regional medical library, therefore, a total of eleven "RML's" form the backbone of the biomedical library network. I will furnish a list for the record. [The information follows:] New England Region I, Francis A. Countway Library of Medicine, 10 Shattuck Street, Boston, Mass. 02115. New York and Northern New Jersey Region II, New York Academy of Medicine Library, 2 East 103 Street, New York, N.Y. 10029. Mid-Eastern Region III, Library of the College of Physicians, 19 South 22d Street, Philadelphia, Pa. 19103. Mid-Atlantic Region IV, National Library of Medicine, 8600 Rockville Pike, Bethesda, Md. 20014. East Central Region V, Wayne State University Medical Library, 4325 Brush Street, Detroit, Mich. 48201. Southeastern Region VI, A. W. Calhoun Medical Library, Emory University, Atlanta, Ga. 30322. Midwest Region VII, John Crerar Library, 35 West 33d Street, Chicago, 111. 60616. Midcontinental Region VIII, University of Nebraska, College of Medicine, 42d Street and Dewey Avenue, Omaha, Xebr. 68105. South Central Region IX, University of Texas, Southwestern Medical School at Dallas, 5323 Harry Hines Boulevard, Dallas, Tex. 75235. Pacific Northwest Region X, University of Washington, Health Sciences Library, Seattle, Wash. 98195. Pacific Southwest Region XI, Center for the Health Sciences, University of California at Los Angeles, Los Angeles, Calif. 90024. All regional medical libraries report interlibrary loan activities on a quarterly basis. Throughout time measured is the length of time from receipt or request to the time the request is being sent out. About 85 percent of all requests are filled within the first 4 days of receipt. USER CHARGES AND REIMBURSABLE INCOME Mr. Conte. Dr. Cummings, what is the total income of the National Library of Medicine, including user charges and reimbursable income from all sources? Dr. Cummings. The NLM will recover and expend, in addition to its annual appropriation, approximately $1.5 million for services it performs for other Government agencies in fiscal year 1975. In addi- tion to its reimbursable activity, NLM operates under a user charge policy for its computerized search services. This policy permits NLM to apply its appropriated resources to building the data bases and to maintain the communications network while having the users pay the cost of accessing the system. It is anticipated that NLM users will be billed approximately $400,000 for these services in fiscal year 1975.8407002_00022.txt

Page  22 1275 COPYRIGHT SUIT Mr. Conte. Dr. Cummings, I'm sure that we are all pleased that the Government has won its copyright suit. Has the Library submitted its own proposal for revisions in the copyright law to deal with its own problems in this area ? Dr. Cummings. The NLM has not been asked to submit a legisla- tive proposal to amend the copyright law. We have developed a posi- tion, however, concerningH.R. 2223, the proposed General Revision of the Copyright Law. Our interlibrary loan practices, and those of the other libraries which constitute the regional medical library network, could possibly be regarded by some as an infringement of the revised copyright law as proposed in section 108(g)(2) of H.R. 2223. This section would prohibit the systematic reproduction and distribution of single copies of journal articles and of small parts of other copyrighted works. We would propose that subsection 108(g) (2) be either deleted or amended to permit a single copy of an article or brief excerpt from a book be made as "fair use." This modification, if incorporated in the final bill, would result in a copyright law which would make it possible for NLM and the other medical libraries in this country to continue to effectively serve the health science community by sharing their resources. LISTER HILL CENTER BUILDING Mr. Conte. As you may recall last year you had a little discussion with the chairman about plans for the construction of the Lister Hill Center. Could you give me a progress report on the Center's construc- tion and plans ? Dr. Cummings. We have made considerable progress since the time of our hearings last year. The final architectural and engineering drawings are now complete. As soon as funding becomes available we can begin the construction of this facility. This Center, when com- pleted, will enhance the NLM's ability to fulfill its congressional man- date to develop a comprehensive, integrated biomedical communica- tions network and at the same time will relieve a serious space prob- lem that exists in our present facility. COLLABORATION WITH THE BUREAU OF HEALTH RESOURCES DEVELOPMENT Mr. Conte. Dr. Cummings, could you give me some more examples of your cooperative work with the Bureau of Health Resources Devel- opment in producing teaching materials for the health community? Dr. Cummings. The collaborative program between the Bureau of Health Resources Development and the National Library of Medi- cine's National Medical Audiovisual Center has produced teaching materials now in use in medicine, dentistry, nursing, and allied health professions. Instructional materials are produced by BHRD/NLM as part of research and development efforts to discover effective ways for the health professional community to utilize instructional tech- nology in teaching. The results of these project activities are used in training and advisory service programs, and are used to encourage support and production of instructional media by health professional8407002_00023.txt

Page  23 1276 schools and other professional groups. The NLM currently has 71 ongoing cooperative projects with BHRD. Noteworthy examples are efforts in opthalmology on opthtalmoscopy, congenital heart disease, and hypoglycemia of the newborn. COLLABORATION WITH THE NATIONAL HEALTH SERVICE CORPS Mr. Conte. I am very interested in the work of the National Health Service Corps, for which we are considering the authorization later this week, and I wonder if you could tell me some more about your program with the Health Services Administration for Health Service Corps medical education ? Dr. Cummings. The National Library of Medicine and the Lister Hill National Center for Biomedical Communications are working with the Health Services Administration in developing improved in- formation and communication networks for the doctors and dentists in the National Health Service Corps. We want to decrease the sense of professional isolation experienced by members of the Corps. Our imme- diate purposes are to increase the opportunities for continuing post- graduate education and to facilitate the consultative services which are required for high quality patient care. The approach is to develop better communication networks with major patient referral centers and with regional medical libraries. In addition, various kinds of audio- visual and computer instructional packages are being identified and made available for use by the health professionals in their office. A longer range objective for the Lister Hill Center is to define its proper role in supporting educational efforts designed for practicing health professionals. We continually ask ourselves, what is needed and how should the information be supplied? The collaboration with the National Health Service Corps gives us the opportunity to work with a vigorous group of relatively young practitioners who can test the effectiveness of various approaches proposed. TOXLINE Mr. Conte. Dr. Cummings, how much does it cost to get hooked up to your Toxline system ? Is this the kind of thing that would be useful for local toxicology and poison control centers to subscribe to, or is this basically a research resource ? Dr. Cummings. All charges associated with entry into the Toxline system are built into the current user rate of $15 per connect hour. Toxline covers such a broad area of information that it is considered a valuable data resource to local toxicology and poison control centers serving the health communities throughout the country. BIOMEDICAL COMMUNICATION RESEARCH AND DEMONSTRATION PROJECTS Could you provide a summary of some of the demonstration projects which were funded through the Lister Hill Center during the past year ? Dr. Cummings. I would be glad to submit a summary for the record. [The information follows:] During the past year the Lister Hill National Center for Biomedical Com- munications has supported the following demonstration projects :8407002_00024.txt

Page  24 1277 Experimental computer-assisted instruction.—This project is designed to foster the interinstitutional sharing of computer-based instructional resources among medical schools, hospitals, and other health-related organizations. More than 60 institutions have participated. Application technology satellite-6 (ATS-6).—This project represents an effort to implement a coordinated telemedicine and health information system in Alaska and an experiment supporting decentralized medical education with the Uni- versity of Washington and the States of Washington, Alaska, Montana, and Idaho. New Hampshire/Vermont Medical Interactive TV Network.—This project pro- vides a two-way interactive television system to be used in rural communities for delivering postgraduate educational programs for health practitioners. In addition, the feasibility of medical consultations being conducted over long dis- tances has been explored. Cable television for consumer health education.—This project is designed to explore the application of closed-circuit television to the dissemination of health information to an innereity geriatric population. Mr. Conte. How do you make sure that your projects will become self-supporting if they are successful ? Suppose they aren't successful— what happens to them ? Have you had any failures you could tell us about during the past year? Dr. Cummings. The Lister Hill Center program has been deeply concerned about the problems of converting successful demonstration projects into operational systems. We are particularly cognizant of the fact that coordinative and effective planning is necessary early in the experimental project in order to insure a smooth transition into an operational mode. The Center strives to obtain local self-sufficiency whenever possible and turns to other agency support as an alternative when necessary. The Lister Hill program itself does not have the fund- ing or the mandate to support actual operating systems. If an experimental project were judged unsuccessful for any reason we would, of course, terminate our support. We are pleased to report that our experiments over the years have been most useful in fostering better health care and health education. Success, as measured in terms of actually implementing systems after their demonstration period has ended, remains an unanswered question. A number of our projects are currently in this transition stage. The New England Interactive Television Network is a case in point. The purpose of this experiment was to evaluate the effectiveness of interactive television in bringing continuing education and improved health care to rural settings. Its effectiveness has had demonstrated and we are now engaged in efforts to place the network on a self-sustaining basis. A management consult- ing firm has been retained to examine the management practices and operational funding required for the project to become self-supporting. COMMUNICATION TECHNOLOGY SATELLITE PROJECT Mr. Conte. Could you tell me some of the uses for the satellite you plan to launch in December ? What are some of the things being plan- ned by the various health agencies? Could a satellite system of this sort be used for international biomedical communication? Are any plans underway for such an endeavor ? Dr. Cummings. The communications technology satellite, CTS, which is scheduled to be launched in December 1975, will include the coordination of program and evaluation planning and the pro- vision of technical engineering support in six areas of application,8407002_00025.txt

Page  25 1278 namely, postgraduate education for practicing health professionals, dissemination of medical researqh results, specialized educational programs for targeted health problems, teleconferencing, decentral- ized medical education, and health delivery experiments. We are involved in planning activities with various organizations within the health agencies. Within the National Institutes of Health, the Heart and Lung Institute plans to sponsor educational programs in the control of hypertension. The Cancer Institute plans to involve their comprehensive centers in Denver and Seattle in a series of "Grand Round Conferences" which are designed to provide current in- formation on cancer diagnosis, treatment, and control to practicing physicians. Within the Health Resources Administration, the Divi- sion of Dentistry is planning experiments designed to provide dentists and dental auxiliaries access to computerized private practice simu- lation models. The models will be developed with the goal of improving health delivery practices. The Bureau of Health Resources Development is examining pro- grams responsive to the needs of the practicing primary care phy- sican. The Food and Drug Administration has indicated interest in exploring the potential of CTS communications for improving the dissemination of information on medical devices and new drugs. With respect to the use of satellite systems for international bio- medical communications, the Lister Hill Center at present is not planning such effort, although this clearly is technically feasible. NEW ENGLAND INTERACTIVE TELEVISION NETWORK Mr. Conte. What have you learned from your funding of the New England Interactive Television Network that can be applied to future such systems? Do you think that the New England system can be- come self-sustaining? How? Dr. Cummings. A management consultant firm was engaged by the Lister Hill Center to study the management and financial needs incident to the New Hampshire/Vermont Medical Interactive TV Network becoming a self-supporting operation. From the evidence at hand, we believe that future networks w^ill need to be justified on their potential operational value. If the tangible cost benefits of a proposed TV network cannot be predicted at the start, then the benefits will probably never be realized. Interactive television projects have high initial costs, require the early formulation of the long-run obiectives, and must have specific operational goals. We think that the New England network can become self-sustaining if properly managed. There is no question that it provides beneficial services. The problem is to adjust the cost of the services to users' ability to pay. Mr. Conte. I have no further questions. Mr. Flood. Thank you, Doctor. Dr. Cummings. Thank you, sir.8407002_00026.txt

Page  26 1279 Justification of the Budget Estimates Appropriation Estimate NATIONAL LIBRARY OF MEDICINE To carry out, to the extent not otherwise provided for, Section 301 with respect to health information communications and Parts I and J of Title III of the Public Health Service Act, [$28,450,000] $28,815,000. For the National Library of Medicine for the period July 1, 1976, through September 30, 1976, $6,572,000.8407002_00027.txt

Page  27 1280 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE NATIONAL INSTITUTES OF HEALTH National Library of Medicine Amounts Available for Obligation 1/ 1975 Estimate 2/ 1976 Appropriation....................... $28,450,000 $28,815,000 Comparative transfer to: "Office of the Director" (Trans- fer of Institutional Relations Branch from the Division of Research Grants, NIH Management Fund)............................ -2,000 --- Total Obligations............ $28,448,000 $28,815,000 1/ Excludes the following amounts for reimbursable activities carried out by this account: 1975 - $1,500,000; 1976 - $2,000,000 2/ Excludes 1973 restoration in the amount of $182,0008407002_00028.txt

Page  28 1281 Summary of Changes 1975 Estimated obligations. 1976 Estimated obligations. Net Change....... 28,448,000 28,815,000 +367,000 1975 Base Change from Base Pos. Amount Increases: A. Built-in: 1. Annualization of 1975 Pay Cost Increases............. 2. Withln-Grade Pay Increases... 3. FTS Rate Increase............ 4. Literature Acquisition....... 5. Increased Cost of Services and Supplies............... Subtotal Increases. B. Program: 1. MLAA - New Grants............ Total, increases...... -$4,743,000 +125,000 +165,000 + 21,000 +100,000 + 15,000 +426,000 +334,000 Decreases: Built-in: 1. Payment to National Institutes of Health Management Fund............ --- --- Program: 1. MLAA - Non-Competing Continuation Grants............................ --- 4,743,000 2. Lister Hill Nat'l Center for Biomedical Communications......... 26 --- 3. Nat'l Medical Audiovisual Ctr...... 102 --- 4. Library Operations................. 252_____--- Total, decreases............ ---_____ --- Total net change....... -59,000 -334,000 -393,000 +367,0008407002_00029.txt

Page  29 1282 Explanation of Changes A. Built-in: 1. These increases will provide $125,000 for annuallzation of 1975 pay cost increases ($6,000 for the Lister Hill National Center for Biomedical Communications, $22,000 for the National Medical Audiovisual Center, $5,000 for the Office of Computer and Com- munications Systems, $30,000 for Library Operations, $6,000 for the Toxicology Information Program, and $56,000 for Research Management and Program Services); 2. $165,000 for within-grade pay increases ($10,000 for LHNCBC, $35,000 for NMAC, $85,000 for LO, $10,000 for TIP, and $25,000 for RM&PS); 3. $21,000 (RM&PS) for increased cost in 1976 for using the Federal Telecommunications System; 4. $100,000 (L0) for literature acquisition; 5. $15,000 (RM&PS) for increased costs of services and supplies; B. Program: 1. $334,000 (MLAA) for eleven new grants for training specialists to integrate computer technology into all phases of clinical medicine. A. Built-in: A decrease of $59,000 in the assessment to the NIH Management Fund for centrally furnished services. Program: 1. A decrease of $334,000 for eight grants in the area of Medical Library Resources.8407002_00030.txt

Page  30 1283 Obligations by Activity 1975 197? Estimate Estimate ___________________________Pos.____Amount Pos.____Amount Medical Library Assistance Total.............. — 6,333,000 — 6,333,000 Direct Operations: Lister Hill Nat'l Ctr. for Biomedical Com- munications : (a) Project contracts. --- 2,025,000 --- 2,025,000 (b) Other direct...... 26 669,000 23 685,000 Nat'l Medical A/V Ctr: (a) Project contracts. --- 325,000 —- 325,000 (b) Other direct...... 102 2,599,000 100 2,656,000 Library Operations: (a) Project contracts. --- 1,920,000 -— 1,920,000 (b) Other direct......252 8,094,000 250 8,314,000 Toxicology Information: (a) Project contracts. --- 940,000 --- 940,000 (b) Other direct...... 16 890,000 16 906,000 Research Management & Program Services: (a) Project contracts.--- —- --- --- (b) Other direct...... 79 4,653,000 79 4,711,000 Subtotal....... 475 22,115,000 468 22,482,000 Page Ref. Increase or Decrease 307 309 312 317 -3 + 16,000 + 57,000 -2 +220,000 + 16,000 + 58,000 +367,000 Total Obligations... 475 28,448,000 468 28,815,000 -7 +367,0008407002_00031.txt

Page  31 1284 Obligations by Object Increase 1975 1976 or Estimate Estimate Decrease Total number of permanent positions........ 475 468 Full-time equivalent of all other positions................................ 40 40 Average number of all employees............ 534 527 Personnel compensation: Permanent positions...................... 8,246,000 8,506,000 Positions other than permanent........... 529,000 529,000 Other personnel compensation............. 117,000______117.,000 Subtotal, personnel compensation...... 8,892,000 9,152,000 Personnel benefits......................... 814,000 844,000 Travel and transportation of persons....... 160,000 160,000 Transportation of things................... 24,000 24,000 Rent, communications and utilities......... 2,307,000 2,307,000 Printing and reproduction.................. 369,000 369,000 Other services: Project contracts........................ 5,210,000 5,210,000 Payment to NIH Management Fund........... 1,755,000 1,696,000 Other.................................... 1,346,000 1,382,000 Supplies and Materials..................... 298,000 298,000 Equipment.................................. 940,000 1,040,000 Grants, subsidies and contributions........ 6,333,000 6,333,000 Total obligations by object........ 28,448,000 28,815,000 +260,000 +260,000 + 30,000 - 59,000 + 36,000 +100,000 +367,0008407002_00032.txt

Page  32 1285 Authorizing Legislation Legislation W Public Health Service Act Section 381 - Purpose and Establishment of Library.............................. Indefinite $22,482,000 2/ Health Services Research, Health Statistics, and Medical Libraries Act of 1974 Section 394 through 398................... $20,000,000 6,333,000 2/ Total.................... $28,815,000 2/ Funding estimate only __________1976______________ Appropriation Authorized Requested8407002_00033.txt

Page  33 1286 National Library of Medj cine Comparable Year Budget Estimate to Congress House Allowance Senate Allowance Appropriation 1966 9,185,000 9,184,000 9,684,000 9,684,000 1967 19,231,000 20,154,000 20,254,000 20,254,000 1968 21,162,000 18,662,000 21,162,000 19,912,000 1969 19,172,000 16,997,000 19,020,000 18,008,500 1970 22,882,000 19,682,000 19,682,000 19,682,000 1971 19,769,000 19,843,000 22,307,000 20,843,000 1972 21,981,000 22,781,000 25,086,000 24,086,000 1973 24,994,000 28,488,000 28,988,000 28,488,000* 1974 24,994,000 25,796,000 25,796,000 25,426,000** 1975 27,738,000 28,048,000 29,348,000 28,448,000 1976 28,815,000 *Note: This appropriation authority was the continuing resolution. The appropriations amount was the House Allowance, which was the lower of the House or Senate amounts in the first vetoed bill. **Appropriation after reduction.8407002_00034.txt

Page  34 1287 National Library of Medicine Actual Budget Estimate House Senate Year to Congress Allowance Allowance Appropriation 1966 9,185,000 9,185,000 9,685,000 9,685,000 1967 19,231,000 20,092,000 20,192,000 20,192,000 1968 21,162,000 18,662,000 21,162,000 19,912,000 1969 19,172,000 17,149,000 19,172,000 18,160,500 1970 22,882,000 19,682,000 19,682,000 19,682,000 1971 19,769,000 19,769,000 , 22,233,000 21,440,000 1972 21,981,000 22,781,000 25,086,000 24,127,000 1973 28,568,000 28,568,000 29,068,000 28,568,000 1/ 1974 24,994,000 25,871,000 25,871,000 25,871,000 2/ 1975 27,738,000 21,768,000 3/ 29,350,000 28,450,000 1976 28,815,000 1/ This appropriation authority was the continuing resolution. The appropriations amount was the House Allowance, which was the lower of the House or Senate amounts in the first vetoed bill. 2/ Appropriation after reduction. 3/ Excludes Medical Library Assistance Grants not considered by House due to lack of legislative authorization.8407002_00035.txt

Page  35 1288 Justification National Library of Medicine 1975 Estimate 1976 Estimate Increase or Decrease Pos. Amount Pos. Amount Pos Amount Personnel compensa tion 475 9,706,000 — 18,742,000 468 9,996,000 --- 18,819,000 -7 +290,000 + 77,000 475 28,448,000 468 28,815,000 -7 +367,000 General Statement The National Library of Medicine operates as the nation's principal national medical information resource by acquiring, organizing and distributing health related information in all forms. In order to adequately share this valuable health science information, NLM has developed a National Biomedical Communications Network to link major health care facilities, medical education centers and research institutions. It also has the specific responsibility to strengthen the nation's medical libraries and information services through resource, research, training and publication support. The NLM collects materials exhaustively in 40 broad biomedical areas and, to a lesser degree, in related subjects such as general chemistry, zoology, botany, and psychology. The Library continues to expand its on-line biblio- graphic retrieval system MEDLINE (MEDLARS on-line) to more fully serve the health community. This national and international telecommunication-based science information network now serves about 250 institutions throughout the United States and at points abroad. Additionally, CANCERLINE, an on-line data base of cancer related citations and abstracts provided by the National Cancer Institute, has been added to facilitate worldwide cancer research. The first half of FY 1975 saw the completion and acceptance of NLM's second generation computerized information system, MEDLARS II. This system is a greatly improved successor to the pioneering MEDLARS I, which had been In operation since 1963. With a much enhanced vocabulary capability, MEDLARS II will provide mors efficient, specific, and rapid bibliographic information retrieval. It also will permit the entry of author abstracts of journal literature into the MEDLINE data base. Plans have been developed to increase the user charges from $8 to $15 per connect hour. This is being done to moderate growth of the system. Any excess proceeds will be returned to the U. S. Treasury. NLM's Lister Hill National Center for Biomedical Communications was established in 1968 with a mandate to develop networks and information systems to improve health education, medical research, and the delivery of health services. An additional role assigned was to serve as the focal point within DHEW for the development and coordination of biomedical communications networks. In attempting to perform these functions, the Center has been confronted with the question of how to produce the most benefit from its limited resources. This has not been an easy question to answer. The need for improved biomedical communications is great, and the Center is acutely8407002_00036.txt

Page  36 1289 aware that many aspects of biomedicine could benefit from the application of advanced communications technology and programming. Constrained by limited levels of funding and manpower, however, the Center has been forced to choose projects carefully. Broadly speaking it will concentrate its major efforts in the area of communications for health professional education, with an emphasis on improving clinical proficiency and therefore the quality of health care. Also because of limited resources, the Center will continue to stress exploration and demonstration rather than sustained operational support. An educational mission lends itself far more naturally to such an emphasis than does any direct intervention in health care delivery or basic biomedical research. An added benefit of concentration in this area is that a small investment can have a proportionately greater impact. By "education" we do not mean merely the relatively brief span of time which a health practitioner spends obtaining his or her professional credential. The maintenance of proficiency in the health professions requires a lifetime of learning, and the Center will devote particular attention to the communications support for continuing education of practicing health professionals. In February 1975, the Lister Hill Center took a further step towards ful- filling its role as coordinator of a national biomedical communications network. In anticipation of a satellite to be launched jointly by the American and Canadian governments in December 1975, the Center hosted a meeting of representatives from all of DHEW's health agencies. The purpose was to inform them of the impressive capabilities of the new satellite and to stimulate planning in the health agencies for suitable programming. The satellite will provide nationwide, coverage and require relatively small ground terminals, thus offering a high degree of flexibility for two-way audiovisual programs between broadcasts. The National Medical Audiovisual Center (NMAC), located in Atlanta, Georgia, administers programs to improve the quality and facilitate the use of bio- medical audiovisuals in support of health care and education. In its efforts to enhance educational efficiency and innovation in schools of the health pro- fessions, NMAC seeks the advice of major national health professional organi- zations to ensure that its programs focus on the areas of greatest relevance to the biomedical community. Through its programs of medical library assistance, NLM provides grants for training, research, special scientific projects, publications, and medical library resources, and contracts for a national network of Regional Medical Libraries. Emphasis in the training program is on producing specialists who can integrate computer technology into all phases of clinical medicine--teaching, practice, and research. Research grants are intended to help medical libraries find more efficient means of meeting the biomedical information needs of the clinical, research, and academic communities which they serve. Resource grants support the establishment, expansion, and improvement of the basic collections and services of medical libraries. With this assistance, for example, libraries can acquire a core collection of monographs and journals most frequently needed by local health practitioners. This permits the small local library to meet the bulk of its users' information needs without the delays involved in borrowing from a more distant facility. In those few instances where the local library does not have the material requested, it can call on the nearest Regional Medical Library (RML). By helping to support a network of such RML's covering the entire nation, NLM guarantees smaller community medical libraries access to health science literature on the same basis as the larger libraries. Services provided by the RML's include document delivery and reference assistance. All of NLM's programs are based on the premise that effective communication and exchange of information among the world's scientists and health care8407002_00037.txt

Page  37 1290 practitioners will lead to better research and patient care with minimal dupli- cation of effort. More importantly, improved information transfer will narrow the gap between the generation of new knowledge in the laboratory and the application of that knowledge to the treatment and prevention of illness. The FY 1976 budget request will permit the National Library of Medicine to continue at approximately the same level of program activity as in the previous year. The areas in which there would be a shifting of emphasis and, in some cases, a modest expansion of on-going activity, are detailed below. Medical Library Assistance Programs Authorizing Legislation: Health Services Research, Health Statistics, and Medical Libraries Act of 1974 1975 1976 Increase or Estimate Estimate Decrease_____ No. of No. of No. of Awards Amount Awards Amount Awards Amount Non-competing Continuation Grants.. 63 4,743,000 55 4,409,000 - 8 -334,000 New Grants............. 59 1,590,000 70 1,924,000 +11 +334,000 Total............. 122 6,333,000 125 6,333,000 +3 NLM's programs of Medical Library Assistance are designed to meet the national need for more effective health information services. They provide grants to train professional personnel, improve resources and services of libraries, produce medical reviews and conduct research for improved application of infor- mation and communication technology. In addition, contracts assist in the development of a network of Regional Medical Libraries with the necessary resources and services to provide backup support locally for other medical libraries throughout the United States. Training grants have supported the education of medical librarians, bio- medical communications specialists, and other professional personnel essential to the health sciences information system. Over the past eight years the grants have supported the training of approximately 650 such individuals, most of whom now occupy positions of leadership throughout the country. By 1974 the critical shortage of medical librarians had been eliminated and program emphasis was shifted to the training of specialists who can effectively integrate computer technology into all phases of clinical medicine--teaching, practice, and research. Of the 11 grants funded in FY 1975, which supported the training of 55 individuals, all but two were in this area of interface between computers and medicine. In FY 1976 the emphasis will continue to be on training to involve health scientists in the medical applications of computers. Research grants support projects in medical library science, information science, biomedical communications, and educational technology. In FY 1975, for example, a team of physicians and information specialists was supported in the investigation of computer-aided decision making. Another research team studied the information needs of practicing physicians, particularly as related to their continuing education requirements. Approximately 30 more Research grants will be funded in FY 1976. Potential projects include studies8407002_00038.txt

Page  38 1291 of the impact of new information systems on health practitioners; the development of new information handling systems; and an analysis of educational technology and curriculum design as applied to the health sciences. Special Scientific Project grants support distinguished health scientists in the full-time analysis of major findings in their respective fields. Their results are published in monographs that facilitate the accessibility of their findings. Four awards were made in 1974 and three will be made in 1975. One review will cover the biologic and therapeutic aspects of one of the very few types of cancer for which chemotherapy has proven successful. The work suggests new theoretical insights which may be applicable to other types of malignancies. Another will provide a comprehensive, critical review of all literature con- cerned with hepatitis, a major cause of disability and death. Medical Library Resource grants are designed to assist in the improvement of the nation's health science libraries. These awards are not given to provide operating subsidies to libraries or to supplant existing support but are in fact intended to encourage increased financial support for the libraries by the institutions that they serve and the communities in which they are located. One-year, non-renewable improvement grants for up to $3,000 are made to health institutions—usually hospitals--which can demonstrate a need to establish basic collections and services. The FY 1976 budget estimate will support the award of 15 such grants. In addition to the one-year improvement grants, NLM awards a second type of Medical Library Resource grant. These project grants are funded for up to three years with a ceiling of $200,000 for any budget period. They are intended to make the growing scientific literature more readily accessible to health professionals throughout the nation and to introduce or demonstrate new information science technology. In FY 1976 NLM will fund an estimated 45 grants of this type. In FY 1975 Medical Library Resource grants have supported cooperative programs in which a strong library undertakes to provide training, consultation, and loan services for small community hospitals and clinics; studies on speeding the delivery of information through modern communications devices and automation techniques; and projects which, after an assessment of the actual information needs of health professionals, strengthen the information resources of an institution accordingly. In FY 1976 the grants will continue to complement NLM's Regional Medical Library program by upgrading the resources of local libraries within each region. In particular, NLM will support formal agreements among local hospitals to promote greater cooperation. The Library's Publication Grant Program provides support for non-profit studies in the biomedical sciences. One recent publication was the first of a series of collaborative reviews of allied health education and research, prepared by outstanding authorities in health care disciplines. Modern developments in medicine have created a need for new allied health specialists trained in increasingly complex technologies. This new series of collaborative reviews constitutes a timely appraisal of the situation and evaluates innovative programs for meeting the serious need for specialized health personnel. NLM contracts provide support for a national network of ten Regional Medical Libraries (RML's). The RML's, selected because of the depth and scope of their resources, provide an array of services which have clearly demonstrated that cooperative networking among health institutions of all types and sizes is not only feasible but economically imperative. The foundation of the developing network is the successful interlibrary loan program. Over 92 percent of the interlibrary loans made by the RML network are provided within four days of the receipt of the request. Reference, bibliographic, educational, and con- sultative services are also important activities of the RML's. The National8407002_00039.txt

Page  39 1292 Library of Medicine provides back-up service for the RML's and also serves as the RML for the Mid-Atlantic Region. By making available to the RML network its advanced on-line systems such as MEDLINE, SERLINE, and CATLINE, NLM considerably broadens the availability of bibliographic information in all parts of the country. The number of interlibrary loans supported by the RML's in FY 1975 remained at approximately the FY 1974 level of 500,000. The leveling off is indicative of strengthened resources at smaller, local libraries and increased sharing among them, which are important objectives of NLM's Medical Library Assistance programs. Utilization of and participation in the network by the health community is expected to increase substantially in FY 1976 for four major reasons: (1) health professionals have become increasingly aware of the utility and availability of interlibrary loans; (2) the continued development of MEDLINE will afford direct and greatly improved access by RML clients to a data base which is most relevant to a health professional's requirements; (3) many of the proposed national health care and health education systems, such as Health Maintenance Organizations, Area Health Education Centers, and Professional Standards Review Organizations, will place additional information requirements on health pro- fessionals; (4) the prohibitively high cost of purchasing biomedical literature will force smaller libraries to form local consortia which will satisfy a significant portion of the health information demands placed on them. While it is not anticipated that the federally subsidized interlibrary loans will increase in FY 1976, the main thrust of the program will be directed at refining the network at the local levels so that information needs can be met without sacrificing quality of service. Lister Hill National Center for Biomedical Communications 1975 1976 Increase or Estimate Estimate Decrease Pos.____Amount_____Pos.____Amount_____Pos.____Amount Personnel compensation and benefits.. . ,......... 26 541,000 23 557,000 -3 +16,000 Other expenses............. 2,153,000 -- 2,153,000 _______--- Total................. 26 2,694,000 23 2,710,000 -3 +16,000 The Lister Hill Center encourages the application of advanced computer and communication technologies to the solution of biomedical information problems. Microwave, cable television, data communications, computer-assisted instruction and satellite relay networks are among the experimental and operational technologies applied by the Center. 1. Satellite Communications: For the last several years the Center has supported an experimental satellite communications network in Alaska, where sparse settlement, rugged terrain, and severe climate make conventional com- munications difficult or impossible. The network, which utilizes a NASA Applications Technology Satellite (ATS-1), links remote native villages with Indian Health Service hospitals and medical centers in Alaska. A careful evaluation has shown a fourfold increase in the number of patients being treated with a doctor's advice since the network began. On the basis of that success, the Center has provided the Indian Health Service with projections for other telecommunications projects aimed at improving health care delivery and medical education.8407002_00040.txt

Page  40 1293 In FY 1975 the Center expanded the ATS-1 remote medical consultation network to support a series of experiments made possible by the recently launched ATS-6 satellite, which has greater capabilities than its predecessor. The ATS-1 com- munications link was broadened to connect native village clinics, medical centers, and the Tanana, Alaska Hospital with the Indian Health Service information service in Arizona. Through this link-up the village clinics are able to obtain up-to-date medical records on all listed village residents, thereby greatly assisting the health professional in patient care. In addition, five of the ATS-1 voice terminals have been made into operational audio links for the ATS-6 experiments, which already have proven to be a major improvement to the Alaskan biomedical communications network. With the advent of the ATS-6 satellite, the communications network has acquired the capability for two-way live television transmission. Under the Center's direction, seven satellite telecommunications terminals have been installed and operated in the states of Alaska and Washington to support the ATS-6. Some of the studies are evaluating the effectiveness of live television consultation between physicians at Indian Health Service hospitals and small, remote clinics manned by health aides and other "physician-extender" personnel. Others are studying the use of interactive television communications in support of medical education. For example, interactive video, audio and physiological data transmissions have been used to link basic science students at the University of Alaska with students and faculty at the University of Washington Medical School. A similar linkup has connected the school with medical students receiving clinical training under physicians some distance away at Omak, Washington. The transmissions have included lectures and demonstrations, administrative and educational conferences, computer-assisted evaluation, medical consultation, grand rounds, and other continuing medical education programming. In FY 1976 the Center will continue its experimental use of satellite com- munications to promote more effective dissemination of medical information among students, practitioners, and research scientists. The ATS-6 medical education program will be extended to other institutions to support the decentralized medical school project and provide continuing education for physicians, residents, and allied health care personnel at remote sites. 2. New England Interactive Television Network: From June 1970 to October 1973, the Center supported a medical interactive TV network in New Hampshire and Vermont. The purpose was to evaluate the effectiveness of interactive TV for bringing formal classroom instruction, continuing education, and improved health care to rural settings. Now that its effectiveness has been demonstrated, the Center has been working to place the network on a self-sustaining basis. A management consulting firm has been retained to determine whether the individual and institutional users of the network value its services sufficiently to support them financially. In FY 1975 the network has continued to provide 40 hours of interactive programming per week to between 1,000 and 2,000 viewers at seven institutions. Emphasis during this period has been on beginning the transition to a fully self-sustaining operation, which has involved negotiations with the Federal Communications Commission, seven user institutions, and the primary contractor, Dartmouth Medical College. Although FY 1976 will be the last year of NLM funding for the network, information produced by the project will be invaluable in planning broadband biomedical communication networks in the future. 3. Computer-Assisted Instruction (CAI): In FY 1972 the Lister Hill Center initiated an experimental computer-assisted instruction (CAI) network. The network has connected computer data bases at Ohio State University, Massachusetts General Hospital and the University of Illinois Medical Center, with 80 other8407002_00041.txt

Page  41 1294 institutions, primarily medical schools. Programs offered over the network have been used for undergraduate, graduate, and continuing medical education for a variety of purposes: as an introduction to CAI, a complement to local CAI activities, a resource for experimentation in education, and a tool for remedial instruction. Users of the network have always had to provide their own computer terminals, communications costs to the nearest access point in the network, and salaries of participating faculty members. In February 1974, users began sharing com- munications costs more broadly, paying $5.00 per connect hour. The implementation of user charges has produced only transitory decreases in both the number of institutions and the hours of usage. The experiment in network distribution of particular computer-assisted instructional materials is scheduled to terminate in May 1975. Forty-five of the user institutions have formed the Health Education Network Users Group. This organization is working with the Lister Hill Center and the network contractors to make a transition to a network managed and financed by the users. At the same time, the Center is planning a broader involvement with the many problems inherent in using computer-assisted instruction in medical education. This will include translation and standardization of CAI formats, and evaluation both of the content of computer-assisted programs and of their educational effectiveness. 4. Continuing Education of Health Professionals: Continuing education is now recognized as an important means of conserving health manpower, upgrading the quality of medical care, and promoting the flow of new information to the health care community. There is general awareness that continuing education and the benefits derived from it occur most readily in the university setting. The problem is that the majority of health care professionals and the populations they serve are not located near academic health centers. There are however, latent educational resources available in .local community hospitals. The Lister Hill Center has postulated that continuing education can be improved by structuring programs among groups of hospitals to mobilize this latent resource. The Lister Center is encouraging the development of such hospital educational consortia, and is interested in developing appropriate communications systems for their most efficient operation. As a first step the Center has completed a study of several of the more effective consortia in current operation. It now plans to test selected communications systems and computer-assisted instruction programs in the community hospital environment. Goals will include: determining the critical mass of a functioning system and optimal mix of local, regional or national networks; selecting and testing appropriate communications modalities; and studying the administrative structure necessary for effective operation. The Center also will be participating with the Health Services Administration (HSA) in the creation of a Continuing Medical Education Program for the medical officers of the National Health Service Corps. The Center will support the development of an interactive communication system to make possible (1) the acquisition of new information and technical skills in family medicine, internal medicine, pediatrics, obstetrics and the treatment of trauma; (2) the periodic reassessment of cognitive knowledge; (3) consultative services for specific problems in the day to day practice of medicine; and (4) the development of a process for auditing the quality of patient care appropriate to both the ambulatory and the hospital setting. Another objective is to reduce the degree of professional isolation experienced by these physicians by developing rewarding patterns of self-learning, consultation, and evaluation. A third objective is to experiment with new methods of assessing the quality of professional services.8407002_00042.txt

Page  42 1295 National Medical Audiovisual Center 1975 1976 Increase or Estimate Estimate Decrease Pos. Amount_____Pos. Amount_____Pos. Amount Personnel compensation and benefits............. 102 1,956,000 100 2,013,000 -2 +57,000 Other expenses............. ---______968,000 ______968,000 ______—- Total................. 102 2,924,000 100 2,981,000 -2 +57,000 The National Medical Audiovisual Center (NMAC), located in Atlanta, Georgia, applies audiovisual technology to the special needs of biomedical scientists, practitioners, and educators. The Center's primary focus is to stimulate the development and use of effective audiovisual media in schools of the health professions and in the continuing education of health professionals. In FY 1975 NMAC worked closely with schools of the health professions and national professional organizations, such as the Association of American Medical Colleges (AAMC), to identify and develop applicable models of instructional media. By seeking the advice of informed professionals at the earliest stages of development, NMAC hopes to assure that the resulting products will be appropriate and actually utilized by the health professional community. Significant projects already have been carried out in anatomy, dentistry, and other disciplines. During FY 1975 NMAC responded to 3,000 inquiries for instructional media information and provided 65,000 film loans and 2,000 videotape duplicates of instructional programs. Technical assistance in the development or use of audio- visual media, equipment, and communications systems included 3,000 technical reports and instructional monographs; 280 site consultations and in-house working sessions; and 15 audiovisual technology workshops. The Center continued to develop its on-line bibliographic information retrieval system, AVLINE (Audio- visuals on-line), for operation on NLM's computer to be made available on NLM's nationwide on-line retrieval network. AVLINE will contain records of audiovisuals which have been evaluated as highly effective for instructional purposes. It will permit the health science educator to make a rapid, comprehensive search to locate the particular materials most appropriate to his needs. In FY 1976 the Center will study the latest developments in medical, dental, and allied health professional education as they relate to needs for more effective instructional systems. Close cooperation will continue with other Federal agencies, health professional school faculties, and professional organizations such as the AAMC and the Association of American Dental Schools. The Center also plans to initiate the development of an integrated series of medical course outlines. These will cover testing, teaching and learning of psychomotor skills, diagnosis of educational problems, and design of appropriate media and facilities. Courses to be offered using these curriculum guidelines will extend the potential reach of workshop programs to all health sciences professional schools. In an ongoing effort to develop, improve, and evaluate the products of audiovisual educational technology, the Center works closely with the Bureau8407002_00043.txt

Page  43 1296 of Health Resources Development, HRA. Specific program collaborations have in- cluded the production of instructional media for dentistry. Under the auspices of dental professional organizations, dental schools, and government agencies, this project has developed exceptionally effective instructional materials in operative dentistry which are now in use at most dental schools. Library Operations 1975 1976 Increase or Estimate Estimate Decrease Pos.____Amount_____Pos.____Amount_____Pos.____Amount Personnel compensation and benefits............ 252 4,743,000 250 4,863,000 -2 +120,000 Other expenses............ 5,271,000 --- 5,371,000 --- +100,000 Total................ 252 10,014,000 250 10,234,000 -2 +220,000 Library Operations is responsible for selecting, acquiring, indexing, cataloging, preserving and disseminating the world's output of biomedical literature. It provides access to the material through manual and machine produced bibliographies; furnished reference and loan services; prepares and publishes indexes, catalogs, and other publications for use by the biomedical community; and manages a national on-line information retrieval network. It also serves as the Regional Medical Library for the five-state Mid-Atlantic Region, and provides back-up service for the national Regional Medical Library Network as a whole. The FY 1976 budget request will allow Library Operations to provide basic services at approximately the same level as in FY 1975: acquiring 110,000 serial pieces and 20,000 monographs; indexing 225,000 biomedical articles for inclusion in the computerized MEDLARS data base; publishing 30 recurring bibliographies; binding 32,000 volumes; and providing 176,000 interlibrary loans, 97,000 reader services, 300,000 MEDLINE searches, and 175,000 off-line prints of MEDLINE searches. In support of the National Cancer Institute, the National Library of Medicine has agreed to add CANCERLINE, an on-line data base of cancer-related citations and abstracts to existing NLM on-line data bases. CANCERLINE data provided by NCI is now accessible via NLM's telecommunications network, thus facilitating worldwide exchange of information on cancer research. The Library's second generation computerized information system, MEDLARS II, was completed and accepted during the first half of FY 1975. MEDLARS II is a greatly improved and more sophisticated successor to the MEDLARS I system which had been in operation since 1963. Under MEDLARS II a greatly expanded vocabulary capability will make possible improved specificity for retrieving bibliographic information. The system also will provide more rapid access, improved programs for maintaining files, and greatly enhanced on-line retrieval. It stores profiles of users' information needs and provides monthly printouts directly from the computer of the latest literature on these subjects.8407002_00044.txt

Page  44 1297 In November of 1974 NLM's computer resources were expanded, making possible the extension of its on-line services to a broader segment of the health care community. Beginning in February 1975, direct access to the MEDLINE data base is being made available to over 70 of the largest pharmaceutical and health related chemical organizations. Approximately half of these companies have already been accessing NLM's TOXLINE data base. In addition, the increased resources make possible the further extension of on-line services to local and community hospitals as well as to most of the major Veterans Administration and Armed Forces hospitals. A use connect charge ($8.00 non-prime time and $15.00 prime time) has been assessed in order to cover the added costs to the Library of providing on-line services. A new billing agreement has been established with the Commerce Department's National Technical Information Service (NTIS) to act as the billing and collecting agent for these services. The fees collected will be used by NTIS to offset the added costs incurred in making equal access and use of the on-line data bases available to any part of the United States. Any excess collections will be returned to the U. S. Treasury. During FY 1975 the Library renewed its agreements with eight international MEDLARS centers. Such centers have been established in the United Kingdom, Sweden, Germany, France, Canada, Australia, Japan and at the World Health Organization. These agreements have been updated to reflect the expanding capabilities available under the MEDLARS II system. In the past the Library has been receiving quid pro quo in the form of indexing of the foreign literature, which had been an important component of its computerized on-line MEDLARS system. In the new agreements the value of this quid pro quo has been increased from $30,000 to approximately $50,000 per year to reflect the increased capabilities which the MEDLARS II system provides. In addition to the indexing of scientific publications, the foreign centers are providing the necessary keyboarding of indexed material for input into NLM's computerized system. The foreign centers also provide subscriptions to the scientific publications which they are indexing. In addition, they will be providing author abstracts, which are being included for the first time in the MEDLARS data base and which will provide more definitive information to the user. The total value of this cooperative input which the foreign centers are providing is in excess of $400,000. In a number of instances the centers have opted to access the NLM computer directly through the biomedical communications network which now extends to several locations in Western Europe. Because of the time zone difference, such access from Western Europe occurs at different time intervals (3 a.m. to 9 a.m., E.S.T.) than the use requirements for domestic users, and thus does not impair NLM's ability to provide such services in the United States. NLM has expanded its cooperative cataloging program. Presently, five partners in the United States are contributing to NLM's cataloging data base, and NLM expects to include additional major medical libraries in the future. This will allow the Library to increase the amount of bibliographic and cataloging information announced to the biomedical community through its publi- cation, Current Catalog. The following are highlights of other major developments in FY 1975-1976: 1) In FY 1975 Library Operations has fully implemented its new INPROC file, which provides management information on acquisition and catalog production. During FY 1976 NLM hopes to make the data base available to the Regional Medical Library network and to book dealers throughout the nation. 2) In FY 1976 the Library will begin to index selected monographic literature for input into the MEDLINE data base. This will provide bibliographic access to individual chapters in addition to the customary entry provided by standard cataloging practices. 3) NLM plans to enhance its bibliographic data base further by entering approximately 100,000 English language abstracts into MEDLINE. This will greatly8407002_00045.txt

Page  45 1298 augment the utility of a system which already hat, gained wide and rapid acceptance in the health sciences community. 4) An on-line data base (AVLINE) on selected biomedical audiovisual materials is under development in cooperation with NLM's National Medical Audiovisual Center. Audiovisual material will be cataloged according to NLM cataloging standards and MEDLARS indexing rules. An abstract describing the material will be provided and a printed catalog of audiovisual citations will appear as a section in Current Catalog. Toxicology Information 1975 1976 Increase or Estimate Estimate___ Decrease Pos. Amount Pos. Amount Personnel compensation and benefits............. 16 491,000 16 507,000 --- +16,000 Other expenses............. --- 1,339,000 --- 1,339,000 ---______--- Total................. 16 1,830,000 16 1,846,000 -— +16,000 The Toxicology Information Program (TIP) is responsible for collecting and organizing toxicology data from diverse sources and making the relevant infor- mation more readily accessible. TIP obtains information from the published scientific literature and the files of governmental, industrial, and academic organizations; organizes and enters the information into computerized storage and retrieval system; and where appropriate, provides products such as literature searches in specific areas of toxicology. On-Line Systems In FY 1975, TIP operated and maintained TOXLINE, its on-line bibliographic retrieval service. The system, which employs the NLM computer and MEDLARS software, achieved a file size of over 350,000 searchable citations, index terms, and abstracts derived from the published literature. The information included data on pesticides, pharmaceuticals, environmental toxins, and hazardous house- hold and industrial chemicals. A use fee of $15 per hour was charged for TOXLINE service, which in FY 1975 produced over 20,000 on-line searches and 145,000 pages of off-line print. This fulfills our commitment to pass on to the user those charges which result from transmission of information from the NLM to the user. TIP also operated CHEMLINE in FY 1975. This on-line file aids TOXLINE users by providing Chemical Abstracts Service Registry numbers and chemical nomenclature information for substances mentioned in the TOXLINE file. In addition, signifi- cant progress was made in building a third on-line retrieval file, the Toxicology Data Bank, covering hazardous chemicals to which it is known that people are being exposed. TIP completed the basic design for this system, began extracting evaluated data from the literature, and entered records on 1,000 chemical com- pounds into a computer file.8407002_00046.txt

Page  46 1299 In FY 1976, TIP will enrich the TOXLINE file with additional references in areas of special significance, such as chemicals causing birth defects and cancer. Emphasis will be to service and assist more users from the health services community. Since existing NLM computer resources will limit the size of the TOXLINE file, TIP will reduce the number of years of literature searchable on-line to five and will provide the remainder for off-line batch searches. TIP will continue to operate CHEMLINE and to enhance it with additional on-line retrieval capabilities. The Toxicology Data Bank will be offered as a new on-line service with an initial file covering a broad spectrum of information on 1,000 chemical substances. This new service will allow scientists to coordinate widely differing attributes (e.g., chemical, biological, usage, and manufacturing) of hazardous compounds during on-line search. Through data exchange agreements worked out under the aegis of the Organi- zation of Economic Cooperation and Development (OECD), several European countries will contribute data in a common format to TIP's data bank, in an experiment on the cost-effectiveness of international collaboration in data base construction. TIP will conduct negotiations with institutions in several foreign countries in order to provide them with access to TOXLINE and CHEMLINE on a quid pro quo basis. In exchange for this service, the NLM will also receive specific toxicology data collected in these foreign countries for use in the Toxicology Data Bank. Specialized Services and Products In FY 1975 TIP provided input for the monthly abstract journal and companion tape service, Abstracts on Health Effects of Environmental Pollutants published by Biological Abstracts. TIP assigned Chemical Abstracts Service Registry Numbers to chemicals contained in its own files and those of several other Federal agencies, for the purpose of facilitating the use of such files for toxicology information retrieval. In collaboration with other agencies, TIP is maintaining a table linking the names (and CAS Registry Numbers) of over 1,200 hazardous compounds to the names of the agencies (e.g., NCI, DOT, and EPA) that are interested in specific compounds. The table is being made available to agencies in order to foster interagency coordination in scientific and regulatory activities. The computerized Name-Match system which TIP used in this effort was developed by it in cooperation with the Chemical Abstracts Service and the Computer Sciences Division of the Oak Ridge National Laboratory. Plans for FY 1976 call for the continued input of selected references from the NLM's MEDLARS data base for the abstract journal. TIP also will provide Name-Match services to other Federal agencies as needed. Toxicology Information Response Center In FY 1975, TIP supported the operation of the Toxicology Information Response Center (TIRC) at the Atomic Energy Commission's Oak Ridge National Laboratory. The Center, which partially recovers its operational costs by charging $50 per search, performed over 400 bibliographic literature searches in all areas of toxicology for the scientific community. The Center also sponsored several state-of-the-art reviews on topics of particular current interest in toxicology. The reviews were prepared by selected experts and published in Environmental Health Perspectives or other journals. In FY 1976 TIP will support the publication of reviews and annotated bibliographies. The emphasis will be on compounds of particular current importance in toxicology such as asbestos, arsenic, vinyl chloride, etc. Through the facilities of TIRC, TIP is establishing an extensive collection of published and unpublished documents on the biological effects of vinyl chloride and related compounds such as chloroprene, vinylidene chloride and epichlorohydrin.8407002_00047.txt

Page  47 1300 Collaborative Activities with Other Organizations Under the Toxicology Information Subcommittee of the DHEW Committee to Coordinate Toxicology and Related Programs, TIP carried out its responsibility for coordinating and developing special toxicology information activities in the Department. The initial project to be sponsored under the collaborative effort was a feasibility study to develop a data bank on base line responses in laboratory control animals. This collaborative effort has also involved the establishment of several interagency agreements whereby TIP provides various information services to other agencies. Plans for 1976 include the continuation of TIP's role in directing the activities of the Toxicology Information Subcommittee and in implementing the system and services identified as needs by this Subcommittee. Information services will be provided to other agencies under cost recovery agreements. These include: (1) a DHEW Toxicology Project Information System, which will help the Department and the agencies in identifying research activities in toxicology carried out under grants, contracts or in intramural projects; and (2) a Toxicology Data and Document Depository which will include (for distri- bution) toxicology data files and documents that now do not become part of the normal scientific publications system because of format, size or complexity. All systems and services sponsored by TIS and implemented by TIP will be funded through interagency sources via transfer of fund mechanisms. Research Management and Program Services 1975 1976 Increase or Estimate Estimate Decrease Amount Pos. Amount Pos. Amount Personnel compensation and benefits........... 79 1,975,000 79 2,056,000 -- +81,000 Other expenses...,....... 2,678,000 -- 2,655,000 -- -23,000 Total............... 79 4,653,000 79 4,711,000 -- +58,000 This activity provides program management and centralized administrative support necessary for the coordinated operation of all NLM activities. It also manages NLM's international activities funded by the Scientific Activities Overseas Appropriation. Primary functions include the preparation and processing of grant applications for review committees and NLM's Board of Regents; public information and and publications management; financial and personnel management; program analysis and contracts management; administrative services; and coordi- nation of NLM's equal employment opportunity activities. This activity also includes funds for NLM's payment to the National Institutes of Health Management Fund. NLM has developed an on-line computerized information system which contains data on all grants awarded by NLM. In FY 1975 this data was used for general reporting of program activity and for detailed analysis and evaluation. NLM categorized each grant by program objectives to facilitate measurement of past and future performance. In addition, it undertook formal evaluation of three Medical Library Assistance programs—Regional Medical Libraries, Training Grants, and Medical Library Resource Improvement Grants.8407002_00048.txt

Page  48 1301 Also in 1975, Research Management and Program Services conducted a workflow study for the entire NLM; performed a major analysis of NLM computer operations; and reorganized the operational arrangements of NLM's biomedical communications network. In FY 1976 the analysis of data contained in the computerized information system, combined with recommendations from public advisors, will be used to refine statements of grant program objectives. In particular the evaluation of Medical Library Resource Improvement Grants will continue in order to determine the advisability of modifying the program. Over 400 grant applications will be processed.8407002_00049.txt

Page  49 1302 NATIONAL INSTITUTES OF HEALTH National Library of Medicine Program Purpose and Accomplishments Activity: Medical Library Assistance (Health Services Research, Health Statistics, and Medical Libraries Act of 1974) __________________1976_______________ ________1975_______ Budget Estimate Pos, Amount Authorization Pos. Amount 6,333,000 20,000,000 --- 6,333,000 Purpose: NLM's programs of Medical Library Assistance provide grants to train professional personnel, strengthen library resources, produce medical reviews, and conduct research in ways of improving information transfer. In addition, contracts provide a network of Regional Medical Libraries with the necessary resources and services to provide backup support locally for medical libraries throughout the United States. Explanation: Awards are made to individuals directly or to public or non- profit institutions. Accomplishments in FY 1975; Of the eleven training grants funded in FY 1975, which supported the training of 55 individuals, all but two were in the area of computer applications to medicine. Biomedical Scientific Publication grants continued to support the preparation and publication of non-profit studies aimed at increasing the availability of information needed by health researchers, educators, and practitioners. Research grants provided assistance for investigative projects in medical library science, information science, biomedical communications, educational technology, and the history of medicine. Medical Library Resource grants are designed to assist in the establishment, expansion, and improvement of the nation's health science libraries and to encourage increased financial support for such libraries by the communities in which they are located. In FY 1975 Resource grants emphasized support for cooperative programs in which a strong library undertakes to provide training, consultation, and loan services for small community hospitals and clinics. Regional Medical Library (RML) contracts support a national network of ten Regional Medical Libraries which serve as a backup resource for smaller medical libraries. The number of interlibrary loans made through the RML's in FY 1975 remained at approximately 500,000. Objectives for FY 1976: In FY 1976, training grants will emphasize the uses of computers in the health sciences. Also in FY 1976 NLM will award approximately 20 Publication grants of which 10 will be new or competing renewals. Approximately 30 more Research grants will be funded. Potential areas of study include the cost-benefit analysis of computer based information systems; the impact of new information systems on health practitioners; and the development of new information handling systems. The FY 1976 budget estimate will support the award of 25 Medical Library Resource Improvement grants for core journals and other basic informational materials8407002_00050.txt

Page  50 1303 needed in community health care institutions. In addition, an estimated 45 Medical Library Resource Project grants will be funded. The grants will continue to complement the NLM's Regional Medical Library program by upgrading the resources of local libraries within each region. In particular, NLM will support formal agreements among local hospitals to promote greater cooperation. Utilization of the Regional Medical Libraries by the health community is expected to increase substantially in FY 1976 and beyond because health professionals have become increasingly aware of the availability of interlibrary loans; the continued improvement of MEDLINE will afford direct access by RML clients to a data base which is most relevant to health care; and the prohibitively high cost of purchasing literature will force smaller libraries to rely more on inter- library loans from the RML network. The main thrust of the RML program will be in attempting to cope with the expected demand for services while maintaining a high level of quality.8407002_00051.txt

Page  51 1304 NATIONAL INSTITUTES OF HliALTH National Library of Medicine Program Purpose and Accomplishments Activity: Lister Hill National Center for Biomedical Communications (Public Health Service Act, Title III, Part I, Sec. 381) ______________1976__________________ _____1975______ Budget Estimate Pos. Amount Authorization Pos. Amount 26 2,694,000 Indefinite 23 2,710,000 Purpose: The Lister Hill Center encourages the application of advanced computer and communications technologies to the solution of biomedical information problems. Explanation: The Center matches high priority needs with technological capa- bilities to develop experimental services and evaluate their effectiveness and feasibility. Accomplishments in FY 1975: The Center continued to support an experimental satellite communications network in Alaska utilizing a NASA Applications Technology Satellite (ATS-1). The network, which links remote native villages with Indian Health Service hospitals, has produced a fourfold increase in the number of patients being treated with a doctor's advice. In FY 1975 the Center expanded the ATS-1 remote medical consultation network to support a series of experiments made possible by the recently launched ATS-6 satellite, which has greater capabilities than its predecessor. Five of the ATS-1 voice terminals have been made into operational audio links for the ATS-6 experiments, which already have proven to be a major improvement to the Alaskan biomedical commu- nications network^ With the advent of the ATS-6 satellite, the communications network had acquired the capability for two-way live television transmission. Under the Center's direction, satellite telecommunications terminals have been installed and operated in the states of Alaska and Washington to support the ATS-6. Current programs are evaluating the effectiveness of live television consultation between physicians at Indian Health Service hospitals and remote clinics manned by health aides as well as the use of interactive television in support of medical education. The Center's New England Interactive Television network continued to provide 40 hours of interactive programming per week to between 1,000 and 2,000 viewers at seven institutions. Emphasis in FY 1975 has been on beginning the transition to a fully self-sustaining operation. Users of the Center's Computer-Assisted Instruction (CAI) network have always had to provide their own computer terminals, communications costs to the nearest access point in the network, and salaries of participating faculty members. In February 1974, users began sharing communications costs more broadly, paying $5.00 per connect hour. Objectives for FY 1976: The Center will continue its experiments with satellite communications to disseminate medical information among students, practitioners, and research scientists. The ATS-6 Medical education program will be extended to other institutions to provide continuing education for physicians, residents, and allied health practitioners at remote sites.8407002_00052.txt

Page  52 1305 Although FY 1976 will be the last year of NLM funding for the New England Interactive Network, information produced by the project will be invaluable in planning broadband biomedical communication networks in the future. The Center plans to test selected Computer-Assisted Instruction programs in the community hospital environment. The experiment in network distribution of particular Computer-Assisted Instruction materials is scheduled to terminate in May 1975. Some 45 of the user institutions have formed the Health Education Network Users Group. This organization will continue to work with NLM and the network contractors to make the transition to a network managed and financed by the users. The center will be participating with HSA in the creation of a Continuing Medical Education Program for the medical officers of the National Health Service Corps. The Center will support the development of an interactive communication system which, among many other goals, will make possible the acquisition of new infor- mation and technical skills in family medicine, internal medicine, pediatrics, obstetrics, and the treatment of trauma. A major objective will be to reduce the degree of professional isolation experienced by these physicians. 52-089 O - 75 -- 838407002_00053.txt

Page  53 1306 NATIONAL INSTITUTES OF HEALTH National Library of Medicine Program Purpose and Accomplishments Activity: National Medical Audiovisual Center (Public Health Service Act, Title III, Part I, Sec. 381) 1975_______ Budget Estimate Pos. Amount Authorization Pos. Amount 102 2,924,000 Indefinite 100 2,981,000 Purpose: The National Medical Audiovisual Center (NMAC), located in Atlanta, Georgia, applies audiovisual technology to the special needs of biomedical researchers, practitioners, and educators. Its primary mission is to stimulate the development and use of audiovisuals in schools of the health professions and in the continuing education of health professionals. Explanation: NMAC functions as a clearinghouse for assembling, cataloging, and disseminating information on available instructional media; evaluates, acquires, and distributes materials appropriate for biomedical education; provides con- sultation and training in the use of instructional audiovisual technology, conducts applied research in instructional technology and systems; and develops prototype instructional media programs. Accomplishments in FY 1975: NMAC continued to work closely with schools of the health professions and with national professional organizations to identify and develop appropriate instructional media. The Center already has completed significant projects in anatomy, dentistry, and other health science disciplines. NMAC responded to 3,000 inquires for instructional media information and provided 65,000 film loans and 2,000 videotape duplicates of instructional programs. Technical assistance included 3,000 reports and instructional monographs; 280 site consultations and in-house working sessions; and 15 audiovisual tech- nology workshops. The Center also continued to develop and implement its on-line bibliographic information retrieval system, AVLINE (Audiovisuals on-line). Objectives for FY 1976: NMAC will study recent developments in medical, dental, and allied health professional education as they relate to needs for more effective instructional systems. Close cooperation will continue with other Federal agencies, health professional school faculties, and professional organi- zations. NMAC will continue to identify, catalog, and index instructional media for inclusion in AVLINE, which will be made available through NLM's computer and its on-line retrieval network. The Center also plans to initiate the development of an integrated series of medical course outlines. Courses to be offered using these curriculum guidelines will extend the potential reach of workshop programs to all health sciences professional schools.8407002_00054.txt

Page  54 1307 NATIONAL INSTITUTES OF HEALTH National Library of Medicine Program Purpose and Accomplishments Activity: Library Operations (Public Health Service Act, Title III, Part I, Sec. 381) _______________1976_________________ Budget Estimate Authorization Pos. Amount Indefinite 250 10,234,000 Purpose: Library Operations is the NLM activity responsible for selecting, acquiring, indexing, cataloging, and preserving the world's output of bio- medical literature. It also serves as the Regional Medical Library for the five-state Mid-Atlantic Region and provides back-up service for the national Regional Medical Library Network as a whole. Explanation: Library Operations provides access to the material through manual and machine-produced bibliographies; furnishes reference and loan services; prepares and publishes indexes, catalogs, and other publications for use by the biomedical community; and manages a national on-line information retrieval network. Accomplishments in FY 1975: The Library acquired 110,000 serial pieces and 20,000 monographs; indexed 225,000 biomedical articles for inclusion in the computerized MEDLARS data base; published 30 recurring bibliographies; bound 32,000 volumes; and provided 176,000 interlibrary loans, 97,000 reader services, 300,000 MEDLINE searches, and 175,000 off-line prints of MEDLINE searches. Under an agreement with the National Cancer Institute, NLM added CANCERLINE, an on-line data base of cancer-related abstracts and citations provided by NCI, to existing data bases available through NLM's on-line network. This develop- ment should greatly facilitate worldwide exchange of information of cancer research. NLM's second-generation computerized information system, MEDLARS II, was completed and accepted in FY 1975. A sophisticated successor to the older MEDLARS system in operation since 1963, the new system will make possible much more specific and rapid bibliographic information retrieval. A use connect charge was assessed to cover the added costs to the Library of providing on-line services. Under a new agreement with NTIS, that agency will act as the billing and collecting agent for these services, with any excess collections being returned to the U. S. Treasury. NLM renewed agreements with 8 international MEDLARS centers which have been providing NLM with quid pro quo indexing of the foreign literature. In the new agreements the value of this quid pro quo has been increased from $30,000 to approximately $50,000 per year to reflect the increased capabilities which the MEDLARS II system provides. The foreign centers will provide subscriptions to the scientific publications which they are indexing, as well as author abstracts, which are haing Included for the first time in the MEDLARS data base. The total value of th*» cooperafciv-e input is in excess of $400,000. 1975_______ Pos. Amount 252 10,014,0008407002_00055.txt

Page  55 1308 Objectives for FY 1976: In FY 1976 TIP will enr'ch the TOXLINE file with additional references in areas of special significance, such as chemicals causing birth defects and cancer. Since existing NLM computer resources will limit the size of the TOXLINE file, however, TIP will reduce the number of years of literature searchable on-line. The Toxicology Data Bank will be offered as a new on-line service with an initial file covering 1,000 chemical substances. Plans for FY 1976 also call for the continued Input of selected references from the NLM's MEDLARS data base for the abstract Journal, Health Effects of Environmental Pollutants. TIP will continue support for the Toxicology Infor- mation Response Center for the publication of reviews and annotated bibli- ographies. The emphasis will be on particularly important areas of toxicology such as asbestos and vinyl chloride. The program also will continue to direct the activities of the Toxicology Information Subcommittee and to provide infor- mation services to other agencies under cost-recovery agreements.8407002_00056.txt

Page  56 1309 Objectives for FY 1976: Basic library services will continue at approximately the same level as in FY 1975. Work will proceed to augment CANCERLINE with Information on cancer research still In progress and to increase the number of citations and abstracts in the data base. NLM plans to Include additional major medical libraries in its ongoing cooperative cataloging program, thus allowing the Library to increase the amount of information made available to the biomedical community through its publication, Current Catalog. Utilizing the enhanced capabilities of MEDLARS II, NLM will enter approximately 100,000 ' English language abstracts of biomedical journal literature into the MEDLINE data base. This additional information will greatly augment the utility of a system which already has gained wide and rapid acceptance in the health sciences community. Library Operations will cooperate with NLM's National Medical Audio- visual Center in developing an On-line data base of selected biomedical audio- visual materials (AVLINE). Audiovisual material will be cataloged according to NLM standards and MEDLARS indexing rules, and an abstract describing the material will be provided. In addition a printed catalog of audiovisual citations will appear as a section of Current Catalog.8407002_00057.txt

Page  57 1310 NATIONAL INSTITUTES OF HEALTH National Library of Medicine Program Purpose and Accomplishments Activity: Toxicology Information (Public Health Service Act, Title III, Part I, Sec. 381) _______________1976________________ I975 Budget Estimate p08# Amount Authorization Pos. Amount 16 1 830,000 Indefinite 16 1,846,000 Purpose: The Toxicology Information Program (TIP) is responsible for collecting and organizing toxicology data from diverse sources and making the relevant information more readily accessible. Explanation: TIP obtains information from the published scientific literature and the files of governmental, industrial, and academic organizations; organizes and enters the information into computerized storage and retrieval systems; and provides products such as literature searches in specific areas of toxicology. Accomplishments in FY 1975: In FY 1975 TIP continued to operate and maintain TOXLINE, its on-line bibliographic retrieval service. The system achieved a file size of over 350,000 searchable citations, index terms, and abstracts derived from the published literature on topics such as pesticides, pharma- ceuticals, and environmental toxins. A fee of $15 per hour was charged for TOXLINE service, which in FY 1975 produced over 20,000 on-line searches and 145,000 pages of off-line print. TIP also made significant progress in building a Toxicology Data Bank covering hazardous chemicals to which people are presently being exposed. The program completed the basic design for this on-line retrieval system, began extracting evaluated data from the literature, and entered records on 1,000 chemical compounds into a computer file. TIP continued to provide input for the monthly abstract journal and companion tape service, Abstracts on Health Effects of Environmental Pollutants, and maintained support for the Toxicology Information Response Center at the AEC's Oak Ridge National Laboratory. The Center, which partially recovers its operational costs by charging $50 per search, performed over 400 biblio- graphic literature searches and sponsored several state-of-the-art reviews on topics of particular current interest in toxicology. The reviews were prepared by selected experts and published in Environmental Health Perspectives or other journals. As part of the DHEW Committee to Coordinate Toxicology and Related Programs, TIP has helped develop special toxicology information activities for the Department. One of these is a feasibility study for developing a data bank on base-line responses in laboratory animals. The collaborative effort also has led to several interagency agreements under which TIP provides information services to other agencies.8407002_00058.txt

Page  58 1311 NATIONAL INSTITUTES OF HEALTH National Library of Medicine Program Purpose and Accomplishments Activity: Research Management and Program Services (Public Health Service Act, Title III, Part I, Sec. 381) _______________1976_________________ 1975_______ Budget Estimate Pos. Amount Authorization Pos. Amount 79 4,653,000 Indefinite 79 4,711,000 Purpose: This activity provides the overall program management and administrative support necessary for the National Library of Medicine. It also manages NLM's international activities funded by the Scientific Activities Overseas Appro- priation and provides for NLM's payment to the NIH Management Fund. Explanation: Primary functions include the preparation and processing of crant applications for review committees and NLM's Board of Regents; public infc - mation and publications management; financial and personnel management; program analysis and contracts management; administrative services; and coordination of NLM's equal employment opportunity activities. Accomplishments in FY 1975: NLM has developed an on-line computerized infor- mation system containing data on all of its grant awards. In FY 1975 the data was used for general reporting of program activity and for detailed analysis. NLM categorized each grant by program objectives to acilitate evaluation of performance. In addition, it undertook formal evaluation of the Regional Medical Library program and grants for training and for Medical Library Resource Improvement. NLM also conducted a workflow study for the Library; performed a major analysis of NLM computer operations; and reorganized the operational arrangements of NLM's biomedical communications network. Objectives for FY 1976: The data contained in NLM's computerized information system, combined with recommendations from public advisors, will be used to refine grant program objectives. In particular the evaluation of Medical Library Resource Improvement grants will continue in order to determine the advisability of modifying the program. NLM will process in excess of 400 grant applications.8407002_00059.txt

Page  59 1312 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE NATIONAL INSTITUTES OF HEALTH National Library of Medicine Amounts Available for Obligation Appropriation........... Total, obligations. Estimate $28,815,000 Interim Period $6,572,000 28,815,000 6,572,000 8407002_00060.txt

Page  60 1313 Obligations by Activity 1976 Interim Period Pos. Estimate Pos. Estimate Medical Library Assistance Total............................. — 6,333,000 — 870,000 Direct Operations Lister Hill Nat'l Center for Biomedical Communications: (a) Project Contracts.............. — 2,025,000 — 495,000 (b) Other Direct................... 23 685,000 23 170,000 Nat'l Medical Audiovisual Center: (a) Project Contracts.............. --- 325,000 — 75,000 (b) Other Direct................... 100 2,656,000 100 670,000 Library Operations: (a) Project Contracts.............. — 1,920,000 -— 480,000 (b) Other Direct................... 250 8,314,000 250 2,130,000 Toxicology Information: (a) Project Contracts.............. --- 940,000 — 250,000 (b) Other Direct................... 16 906,000 16 225,000 Research Management and Program Services: (a) Project Contracts.............. --- --- --- --- (b) Other Direct................... 79 4,711,000 79 1,207,000 Subtotal................. 468 22,357,000 468 5,702,000 Total Obligations 468 28,815,000 468 6,572,0008407002_00061.txt

Page  61 1314 Obligations by Object Total number of permanent positions......... Full-time equivalent of all other positions. Average number of all employees............. Personnel compensation: Permanent position........................ Positions other than permanent............ Other personnel compensation.............. Subtotal, personnel compensation..... Personnel benefits.......................... Travel and transportation of persons........ Transportation of things.................... Rent, communications, and utilities......... Printing and reproduction................... Other Services: Project contracts......................... Payment to NIH Management Fund............ Other....................................... Supplies and materials...................... Equipment................................... Grants, subsidies and contributions......... Total obligations by object............ 1976 Interim Estimate Pe riod 468 468 40 40 527 527 8,506,000 2,120,000 529,000 131,000 117,000 32,000 9,152,000 2,283,000 844,000 209,000 160,000 41,000 24,000 4,000 2,307,000 603,000 369,000 99,000 5,160,000 1,300,000 1,696,000 424,000 1,307,000 402,000 298,000 72,000 1,040,000 265,000 6,458,000 870,000 28,815,000 6,572,000 8407002_00062.txt

Page  62 1315 NARRATIVE 1976 Interim Budget Period The 1976 Interim Budget estimate of $6,572,000 is a reflection of the National Library of Medicine's commitment to maintain its on-going programs at the FY 1976 level for the same period. The elements of the budget estimate were developed accordingly.