1978 U.S. Senate Appropriations Committee Budget Testimony, 95th Congress 1st Session, March 16, 1977
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DEPARTMENTS OF LABOR AND HEALTH, EDUCATION, AND WELFARE AND RELATED AGENCIES APPRO- PRIATIONS FOR FISCAL YEAR 1978 HEARINGS BEFORE A SUBCOMMITTEE OF THE COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE NINETY-FIFTH CONGRESS FIRST SESSION ON H.R. 7555 AN ACT MAKING APPROPRIATIONS FOR THE DEPART- MENTS OF LABOR AND HEALTH, EDUCATION, AND WEL- FARE AND RELATED AGENCIES FOR THE FISCAL YEAR ENDING SEPTEMBER 30, 1978, AND FOR OTHER ITRI'OSES Printed for the use of the Committee on Appropriations PART 2 (Pages 817-1812) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Secretary's Overview Health Services Administration Center for Disease Control National Institutes of Health Alcohol, Drug Abuse, and Mental Health Administration Saint Elizabeths Hospital Health Resources Administration U.S. GOVERNMENT PRINTING OFFICE 84.877 0 WASHINGTON : 19778407374_000002.txt

Page  2 National Library of Medicine PREPARED STATEMENT Senator Bayh. National Library of Medicine. Dr. Cummings. Budget request for $36.7 million, $1V£ million over last year. Nice to have you here, Dr. Cummings. Do you have any comments before we get started? Dr. Cummings. I would like to make one or two points, Mr. Chair- man, in addition to my statement for the record which I will provide. Senator Bayh. We will print your statement in the record at this point. [The statement follows:] Statement by the Director, National Library of Medicine on "National Library of Medicine" Mr. Chairman and members of the committee: When the forerunner of the National Library of Medicine was established in 1836 as the Library of the Army Surgeon General's Office, its basic role was to serve the needs of military medical officers by providing them with access to medical informa- tion which they needed as practicing physicians. As the mission and services of the Library expanded all civilian practicing health professionals were given access to the Library's holdings, and increasing emphasis was placed on serving the needs of health researchers and health educators as well. Notwithstanding the success which the Library has had in disseminating relevant medical information to all segments of the health community, it is our view that the information transfer process which serves the scientist so well does not respond as effectively to the clinically oriented needs of the health practitioners. Accordingly the Library will devote increasing resources toward the development of information services and the conduct of information activities which assist and enhance health care delivery. Since the passage of the National Library of Medicine Act in 1956 the Library has become a major information resource for the nation's health community. The Library fulfills its responsibilities by collecting, organizing and disseminating the most extensive collection of health science literature and other informational materials in the world. Today the Library's collection is organized in a most efficient manner consistent with facilitating the timely and effective dissemination of medical information. This has been made possible because the Library has continued to pioneer in the application of new technologies to library functions. Such revolutionary library technolo- gy as photoduplication for interlibrary loans and computerized information storage and retrieval systems were developed and applied successfully by the NLM. The impact which these new technologies have had on the ability of the Library to disperse medical information is reflected in the continued growth in utilization of these tools by the health community. For example, the number of computer-based online searches performed has grown from approximately 250,000 in fiscal year 1974 to 566,000 searches generated in fiscal year 1976. In fiscal year 1978 the number of searches will exceed 650,000. Similarly the number of interlibrary loans performed by the Library exceeded 200,000 in fiscal year 1976, and the number of such loans performed by the NLM established regional medical network reached over 1 million in fiscal year 1976. Other more traditional Library services continue to experience high growth rates. For instance, the number of reference inquiries which totaled 32,000 in fiscal year 1976 is expected to reach 50,000 in fiscal year 1978. Similar increases for reader services which totaled 96,000 in fiscal year 1976 are expected to reach 125,000 by fiscal year 1978. NLM which is responsible for operation of a nationwide online computerized biblio- graphic retrieval service including MEDLINE (MEDLARS online), will encourage the use of these services in direct patient care facilities. This is in contrast to the earlier (1617)8407374_000003.txt

Page  3 1618 years of the MEDLINE network's development when the development of MEDLINE centers was concentrated in medical school libraries and their affiliated health care facilities. Currently of the existing 445 MEDLINE centers, approximately one-thira are located in direct patient care facilities. Nearly 50 percent of the new centers established—37 of 75—in 1976 were in hospitals. This trend to expand the networK to include smaller hospitals and community based health oriented training programs, will be accelerated in fiscal year 1977 and fiscal year 1978. In addition to providing services to physicians, dentists, nurses and allied health personnel, the Library has improved access to health care administrators, planners, economists, legislators and others who are playing an expanding role in our nation's health care delivery system. This extension of services to health practitioners is being developed along several lines. A complete restructuring of the Library's "Scope and Coverage policy is under- way to expand our holdings in the field of health care delivery and related areas. This extension plan will be implemented this year. The Library has undertaken a careful review of significant health care periodicals from various sources such as the American Hospital Association, American Medical Association, Association of American Medical Colleges, and other organizations to develop a consolidated list of periodicals to consider for inclusion in our published Index Medicus or in the MEDLINE data base. Indexing of such material was begun early in 1977 and will be fully implemented by 1978. Concurrently the Library has been expanding the controlled vocabulary used in indexing the biomedical literature to make it more responsive to the information needs of the health care community. Combined with the capabilities of the MEDLINE system to search titles and abstracts on any term, the expanded vocabulary will enable more explicit and effective searching of the health care literature. The NLM has been investigating the difficult task of rapidly translating research results into clinical practice, an assignment which it shares with the other Institutes within NIH. Whereas the Institutes assume responsibility for the content accuracy of the information to be disseminated, the Library is responsible for providing suitable communication channels through which the information reaches the practitioners and others who have a need for this information. As a part of this effort to fulfill our responsibility the Library has undertaken a technology transfer study in conjunction with several Institutes and leading academic and specialty societies. It is hoped that the outcome of this project will lead to a new mechanism which is capable of providing medical information in style and format more immediately useful to the health practi- tioner. Such an undertaking could impact on the health practitioner in several important ways. These include: (1) enhancing efforts in continuing education; (2) providing infor- mation about specific clinical problems; and (3) making medical literature and informa- tion less remote from the realities of medical practice. Our goal is to develop new mechanisms and products to identify, organize, and distribute information relevant to clinical problems and to improve the quality of health care delivery. In addition to participating in this innovative effort, the Lister Hill National Center for Biomedical Communications continues to develop and coordinate experimental com- munication networks and systems for the entire biomedical community. Utilizing the Communications Technology Satellite the NLM, in conjunction with other U.S. health agencies, has begun a national experiment to provide information for health education and the delivery of health services to remote areas. Six broadcast and receive stations will be installed this year in sparsely populated areas of the country. NLM's own broadcast studio has been completed. Such stations will facilitate teleconferencing among health agencies and provide professional consultation between academic health centers and professionals in remote settings. The NLM administers a program of grants and contracts to assist medical libraries in developing improved health information services. This program is authorized by the Medical Library Assistance Act of 1965 and its extensions. Based on funds available through this program the Library provides resources to support the maintenance and operation of 10 regional medical libraries which serve as focal points for region- wide planning and information services. In the past the emphasis of the regional medical libraries was primarily on document delivery services—interlibrary loans—however, the NLM and the participating libraries recognize the need to move beyond document delivery activities by having the regional medical libraries act as demonstration and information dissemination centers. Through these efforts more health care practitioners will have local access to the advanced health science information systems available to them. The National Medical Audiovisual Center continues to encourage the use of effective learning materials and innovative educational techniques in support of health science education at the undergraduate and graduate levels. In fiscal year 1978 the Center's major thrust will be to extend its program efforts to all levels of health science education8407374_000004.txt

Page  4 1619 with more emphasis being placed on improving the continuing education of health professionals. In this way the knowledge and skills of the health practitioner can more easily keep abreast of the new medical advances. The Center continued to make audiovisual learning and teaching packages available to the health community through its distribution and sales programs. The 53,000 loans in fiscal year 1976 accounted for an estimated 5 million viewing experiences, and over 4,000 packages were sold through the General Services Administration. The Toxicology Information Program is responsible for collecting and organizing toxicology data from a variety of sources and making it more readily available to its user communities in industry, universities, health care facilities and government agencies. It obtains information from published scientific literature, files of governmen- tal, industrial, and academic organizations in many formats; organizes and enters this information into standardized computerized storage and retrieval systems for easy ac- cess. In fiscal year 1978 the Toxicology Information Program will concentrate its efforts on improving the utility of its various services to its user communities through en- richments and expansion of its data bases. For example, TOXLINE, an online toxicology data base, will be enhanced with special files on drug interference and drug interactions which are of special interest to the health practitioner. During fiscal year 1976 over 30,000 online searches of the TOXLINE data base were completed. This represents over a 30 percent increase over fiscal year 1975 levels. We are proud of the accomplishments of the Library in serving the information needs of the health professional community. We believe the initiatives which have been presented today provide the potential for enabling the Library to continue to fulfill its congressional mandate to assist the advancement of medical and related sciences by fostering the dissemination and exchange of information which is important to the progress of medicine and the public health. In summary, Mr. Chairman, our request for fiscal year 1978 is $36,746,000, an increase of $1,512,000 over the amount available for obligation in fiscal year 1977. The net increase reflects $537,000 for mandatory requirements and $975,000 for addi- tional program related costs. I shall be pleased to answer any questions and supply additional information desired for the record. Dr. Cummings. As I listened to my colleagues testify yesterday and today I realized that the National Library of Medicine in a way is a victim of the success of biomedical research because in the last 10 years the biomedical literature which resulted from the research sponsored by NIH and others has doubled. This has created an enormous new corpus of knowledge and a new collection for us to manage. Paradoxically, we are also the victims of our own technological success because as we have generated new computer systems in our effort to handle this literature, to be able to identify it for physicians, scientists and educators, we are now finding that making this information available to them causes a return in the way of service requests for the full documentation. So, I simply wish to point out to the committee that the Library is sort of the end of the line of research. It is the beginning and end of the research process, and we are doing our best to keep abreast of it. The other point I would like to make is that we believe the practic- ing health community is the segment that we need to address more than any other component of the health community. We believe that the science communication apparatus for scientists is good, and we think it is quite good for education. Our new initia- tives will be to shift resources to better serve the practitioner. REGIONAL MEDICAL LIBRARIES Senator Bayh. Where does the regional medical library system fit into that? I understand the use has gone up 20 percent last year. Could you tell us how that fits in?8407374_000005.txt

Page  5 1620 Dr. Cummings. Yes, sir. We support 10 regional medical libraries throughout the Nation in an effort to share this workload, and it has in fact proved to be in my view a very fine success. Last year the regional medical libraries of the country gave more than 1 million loans to people searching for medical information and they, through our computer system, provided more than a 500,000 computer searches. I think this network shows how one can combine and share resources more effectively and more efficiently than having everyone try to do the same thing. LIBRARY INFORMATION SERVICES Senator Bayh. I had some of my colleagues point out that requests they made at the Congressional Research Service—they had some delays as long as 4 or 5 weeks, which causes me to ask the question beyond that: If that is the kind of response that Members of Congress get, that have to pass on these budgets, what about people out in the field that are not in that position? What is the timelag? How immediate are we able to be as far as responsiveness? Dr. Cummings. I would not want to draw invidious comparisons with the Library of Congress, but I can tell you---- Senator Bayh. This is the response time after they request from you before they get the information. Dr. Cummings. Let me give you the general statistics and then deal with your specific question. We monitor very carefully the turn- around time of all requests made of the National Library of Medicine. 90 percent of all of our services are delivered within a 4-day period. The requests that we get from other large libraries are usually those of extraordinarily difficult or complex issues. Senator Bayh. A specific concern was for copies of articles, this kind of thing that you have at your disposal. That was where the delay has been. Is that the category you are alluding to there? Dr. Cummings. I would say, if there is a delay in delivery of the photocopy of an article, it is due to the fact that that material is not readily available, and not due to the process that has been established to acquire material, photograph it and provide it to the borrowing institution. I am quite willing to look into this statement because I am really quite puzzled by it. Senator Bayh. You might talk to staff about it. I don't know how representative that is. Dr. Cummings. I don't believe it's representative. Senator Bayh. I don't recall them ever bringing that kind of com- plaint to me, but there has been some brought to the committee. If we can do something here, perhaps as far as your loan division, or whatever, might be understaffed, whatever might be the problem, if there is one. Dr. Cummings. I will look into that. Senator Bayh. What is the MEDLARS system? Dr. Cummings. It is a acronym for Medical Literature Analysis and Retrieval System. It's our computered-based apparatus which takes all of the major publications and lists them article by article, indexes8407374_000006.txt

Page  6 1621 them, stores them in the computer for ready retrieval. We have more than 3 million articles compacted in the computer system. About 650,000 searches of that file will be made this year to serve informa- tion queries from outside the library. This system has been put online now to some 455 institutions around the country so that people don't have to come to the National Library but merely search it by a terminal, either in a hospital or medical school, or some other health institution. Senator Bayh. What does one have to do to qualify to have access to that kind of information? Dr. Cummings. The system has been designed to serve the health/professional community. Broadly defined, that includes academia, Federal agencies, health industry, anyone who has a legiti- mate need to know what is available in the National Library of Medicine. We also serve about 30,000 individuals who come to the library for this information. It's a health/professional library. It serves research, education, and practice. LISTER HILL CENTER Senator Bayh. I talked to Chairman Magnuson. He wanted to make certain we had a target date on completion for the Lister Hill facility. Do we have a target on that? Dr. Cummings. Yes; as Dr. Fredrickson pointed out, the bids have been opened. There was a technicality involved in how the contractors listed their subcontractors, so we have been delayed 90 days. We expect construction to start in June of this year and to be completed at the end of 1979. Senator Bayh. Thank you. I have had a call to be elsewhere to mark up a bill, at the HUD committee, where they need me for a quorum. Mr. Schwartz, why don't I ask a couple of questions and then you can answer them and staff can advise me as to what the answers are so I don't keep this other committee waiting? We would like to have any comments you might care to make about your particular responsibilities there and also the articles that have appeared about the plans for Ft. Detrick, genetics research. You might tell us this, because I am sure that several members of the committee will be interested. Also, the child health building, plus there are some other questions here I think you could answer for the record, after which, we will be in recess until 2 p.m. tomorrow afternoon, when we will meet to markup the supplemental appropria- tions bill. Mr. Schwartz. At the current time, we don't have in our buildings and facilities budget a request for authorization for this project. The funding is available in several of the Institutes, but it has not been proposed as a specific building facility project. It might be more convenient to express that as a specific project in the buildings and facilities areas, though. Senator Bayh. For several years, the new child health building has been talked about. What are your plans for this? Mr. Schwartz. We are looking at long-range plans for all of NIH. At this time it appears that perhaps the more important facility8407374_000007.txt

Page  7 1622 problem is the need for refurbishment of the entire NIH facility, not just the need for additional facilities. We are currently considering the possibility of using the proposed site for the child health building, incorporating some of the child health needs, but using it as tur- naround space for refurbishing several of our aging buildings. Also in our long-range plan, there are a number of buildings scheduled for destruction. This would allow us to do that. This will probably be part of our fiscal year 1979 buildings and facilities pro- gram. IMPACT OF FISCAL YEAR 1978 BUDGET Senator Bayh. Before leaving, though, Dr. Newell, I notice, in look- ing over this budget of yours, that there is only a $4 million increase. Is that accurate? Dr. Newell. Yes, sir. That is earmarked. Senator Bayh. In a $814 million base. How in the world will you keep operating at the level in which you are operating now with that small of an increase? Dr. Newell. Well, what we had to do is, try to do some reprogram- ing within the dollar amounts we have. The $4 million is actually earmarked for us to do research related to the Toxic Substances Control Act. We have already met with the EPA to lay out some plans for that. What I have done in order to have a little degree of flexibility is, refuse the construction category and, having done that, I added some dollars to the prevention area and some dollars to the clinical treatment area. But it has all been internal reprograming of dollars. Senator Bayh. In my real quick shorthand math here, you had about a $48- or $50-million inflationary impact. Dr. Newell. That's correct. Senator Bayh. With all your reprograming, if you get $4 million extra, you are still better than $40 million in the hole. I don't neces- sarily want to pursue this right now, but I assume the rest of the committee is interested in it. If not, I would like for you to personally provide for me, if you will, please, where you see the impact of this burden falling. If you had your druthers, what do you think you really could use, either to maintain services at the present level or to expand them into those areas that show the greatest amount of promise? You had some real breakthroughs at the National Cancer Institute that I am personally aware of, and I think that is one of the reasons you had that amount of money. Have we stopped having breakthroughs, or are their opportunities to continue to make the kind of progress in the next year we made in the past few years? I wish you would be specific on that if you could, would you please? Dr. Newell. Yes, sir. I'll provide a thorough answer for the record. [The information follows:]8407374_000008.txt

Page  8 1623 Impact of 1978 Budget Request and Required Funding The 1978 funding request of $818,936,000, is an increase of approximately $4.0 million over the FY 1977 appropriation. This increase is for carcinogenesis research in conjunction with the Environmental Protection Agency as a result of the Toxic Substances Control Act. The impact of this level of funding is: In our traditional research grant program, NCI would be able to fund approximately 36 percent of the grants approved by the National Cancer Advisory Board. This represents an increase of three percentage points from the level which could be funded at the FY 1977 appropriation level. Intramural research will be kept at approximately the same operating level. There will be reductions of up to 10 percent in extramural (both grant and contract) activities of the Institute. Full implementation of the new drug synthesis program could not be accomplished. This program would involve establishing centers for drug synthesis having the capacity to identify, design, screen, redesign, retest and develop drugs which could be fed into ultimate clinical trials. This program would be the heart of the scientific base of the Drug Development Program for Cancer Treatment. The biochemical screening program would be funded at a reduced level of effort. These are efforts to look at new ways of identifying compounds with activity against cancer. The ultimate effect of this action, as with the synthesis program reduction, is to reduce the number of new anticancer agents going to clinical trials. Combined modality approach in the treatment of large bowel and stomach cancer will be restricted. Studies utilizing new chemotherapy regimens immediately after surgery in patients with advanced metastatic disease have been promising. It had been planned to expand these studies to include the use of immunotherapy in addition to chemotherapy. At the present time steps have been taken to develop a multidisciplinary character for the Clinical Cooperative Groups and to encourage the establishment of new, smaller, geographically oriented groups. These efforts would be curtailed. Epidemiological studies to identify those factors, including environmental, responsible for clusters of high risk communities in the United States will not be expanded as planned. Studies required to determine steriod-binding characteristics of breast cancer with epidemiologic risk factors will not be able to be initiated. Efforts to initiate studies relating smoking and alcoholism as high risk factors in head and neck cancer, as well as determining the effectiveness of anti-smoking and anti-drinking clinics in the reduction of risk will not be possible at the budget request level. Studies related to the identification of populations exposed to known and suspected occupational environmental bladder carcinogens will be modified. Some areas of research related to viral induction of cancer would be adversely affected. For example, a comprehensive survey of human tissues for herpes simplex in an attempt to determine etiologic significance of these viruses to cancers of man will be delayed. Fund8 to determine the basic mechanisms by which normal cells are transformed to cancer cells and the relation of viruses to this process will be limited. Nutrition studies to define the interrelationship between host-tumor competition for nutritions would not be initiated. Also, laboratory studies of certain implicated dietary componenets in carcinogenesis cannot be pursued. Included would be the role of carbohydrates in carcinogenesis.8407374_000009.txt

Page  9 1624 Efforts in Cancer Control would be maintained: Cancer centers support would have to be carried on at the FY 1977 level. There could be no expansion of the support at the 1978 budget request level. Required Funding In order to maintain the momentum of the National Cancer Program and allow for exploitation of research and control opportunities, the Institute in its Budget Estimate to OMB requested a level of $955,000,000 for 1978. This is the level recommended by both the National Cancer Advisory Board and the President's Cancer Panel. Areas where additional funding would be utilized include: Breast Cancer Recent research into breast cancer has produced exciting leads in each phase of the disease process — early diagnosis, better ability to choose the best treatment course for each individual woman and new treatments resulting in delayed recurrences and less disfiguring surgery. We would certainly welcome the opportunity to expand our efforts in this area. Carcinogenesis Research including Viral-chemical Co-carcinogenesis Present evidence indicates that apparently normal human cells may contain genetic information related to RNA viruses which enables the cells to become malignant when provoked. This information may be released when triggered by an abnormal stimulus, such as exposure to certain environmental chemicals. The viral - associated material acts as the initiating agent in carcinogenesis here, whereas the chemical acts as an enhancing agent or co-carcinogen. Testing Chemicals There is an increasing urgency to identify those chemicals in the environment that cause cancer. There is reason to believe that 80 to 90 percent of cancers are extrinsically induced, probably by chemicals. It is most important, therefore, that faster, more inexpensive and more accurate methods of testing chemicals for cancer-causing properties be developed. Preclinical Treatment Research Preclinical treatment research includes the synthesis, acquisition, screening, and further evaluation of compounds, including pharmacology and toxicology studies with compounds selected for development toward clinical trial. New leads have been developed that require further investigation including preclinical efforts in reverse transcriptase, further studies of biological markers and natural products acquisition. Clinical Trials The realization that many cancers - even those which are seemingly localized - are disseminated upon initial detection and diagnosis has set the stage for development and application of multi-modal cancer treatment. Technical advances in surgery, radiotherapy, chemotherapy and immunotherapy provide the basis for tailoring treatment to meet the specific needs of cancer patients It is necessary to extend the use of clinical trials required to explore and exploit the most effective use of combination therapy in diseases such as cancers of the breast, colon-rectum, ovary, prostate, head and neck, and bladder. Epidemiology There is a critical need to determine the distribution of cancer in the population in relation to environmental factors and occupational exposures ,nH to identify the factors that increase the risk of populations and ind vlduals for development of cancer. "*"8407374_000010.txt

Page  10 1625 Computerized Axial Tomography Development The development of Computerized Axial Tomography (CAT) is a major advance in noninvasive diagnostic techniques for cancer and other diseases as well. There is need to determine as rapidly as possible how to best exploit its potential for early detection of cancers. CAT provides the ability to "see" organs and structures in the body never "seen" before, such as the brain, pancreas, adrenal glands, lymph nodes, and lungs, without having to inject anything into or remove anything from the patient. For example, the diagnosis of brain tumors previously required the injection of air into the brain - the most painful diagnostic procedure known to man. Use of CAT scanners can potentially reduce the need for this procedure by 70 percent. Funding Approved High Priority Grants Currently, NCI can only fund 33 percent of approved high priority regular research grants. Additional funding would be provided for regular research grants, larger and more coordinated research programs—cancer centers, organ sites (large bowel, bladder, prostate and pancreas) and training. We are thus not able to sustain the momentum and enthusiasm which has existed among the scientific community. It is research resulting from this very momentum that has produced many of the scientific leads described above. Nutrition The study of nutritional aspects of cancer both in terms of etiology and treatment is a new field of cancer. It is thought by some that nutritional factors (diet) play a contributory role in some of the common cancers of man. It is also believed that nutritional factors may play an important part in regulating the immune status and in enhancing the effects of some chemotherapeutic drugs. These are important new leads which have direct implications for prevention and treatment. Community Activities The Cancer Control Program is developing extensive involvement with community hospitals in educating physicians about cancer prevention, early diagnosis and treatment. This is extremely important because approximately 80 percent of newly diagnosed cancers are first seen by practicing physicians in community hospitals. These, in short, are the areas in which additional funding is needed and could be readily and efficiently utilized. Regarding breakthroughs, the future holds great promise of continuing success in the cancer field. It is not possible to predict which areas will produce the most promising results. In the short range, emphasis will be concentrated on providing for the cancer patient. Our longer range goal is, of course, the prevention and elimination of the cause of cancers. In summary, to maintain our programs at their present level this Institute would require $888,236,000. In order to expand those areas indicated above a level of $955,000,000 would be required.8407374_000011.txt

Page  11 1626 Senator Bayh. I am just going to have to go. I apologize for rushing in and out, but let me say, I, for one, am grateful to all of you for the services you provide the country in performing your duty. We want to help you. Tell us how we can. I am sure I speak for the whole committee. SUBMITTED QUESTIONS Senator Bayh. Thank you very much. I appreciate your trouble and patience. I'll give you the remaining written questions to be an- swered for the record. [The following questions were not asked at the hearing, but were submitted to the Department for responses subsequent to the hearing:]8407374_000012.txt

Page  12 1627 LISTER HILL FACILITY QUESTION* I am sure Lister Hill is wondering how his building is coming. What can we tell him? When is the completion date? ANSWER* The bids for construction of the Lister Hill Center Building were opened in January 1977, however, because of technical errors in the submissions, GSA has decided to rebid the construction contract. It Is now anticipated that bids will be reopened in June 1977 with the actual awarding of the contract scheduled for July. Completion of the building Is planned for late 1979. QUESTION* I imagine we should start to think about the needs for this building—people and equipment. What are your plans? ANSWER* The Library plans to utilize the latest In computer and communications technology to improve and expand upon its existing programs in Information dissemination. It is our judgment that in order to properly utilize these new specialized facilities and laboratories in the new Lister Hill Building, some 60 highly trained professionals will be required during the period 1978 to 1980. Staffing is the key to progress in biomedical communication experimentation. The need for new equipment is also important. Approximately $4.5 million is required to procure the specialized communications equipment necessary to fully utilize this new facility. We anticipate having sufficient construction funds available to cover the cost of most fixed equipment. INFORMATION DISSEMINATION QUESTION* When we think of information dissemination at the NIH, the Library always comes to mind. Give us some examples of new programs you have started in the past three years. ANSWER* Early in 1975 the Lister Hill Center component of the Library initiated a new program of satellite communications exploration on behalf of the Public Health Service (PHS) using the Canadian-American Communications Technology Satellite (CTS). Since that time planning, design, and Imple-8407374_000013.txt

Page  13 1628 mentation of a PHS Experimental Network consisting of six ground stations has been undertaken. These six ground stations are located in Fairbanks, Alaska; Seattle, Washington; Bozeman, Montana; Denver, Colorado; Lexington, Kentucky; and, at the Library in Bethesda, Maryland. Early in 1977 the Library began test transmissions using CTS from a new television studio and transmitter located in Bethesda. The entire network should be operational by mid-summer. Programs to be broadcast utilizing CTS in continuing education for health professionals are being developed with the cooperation of several federal agencies, universities and professional societies. Exploratory development has already been started on what will be one of the Library's highest priority programs for FY 1979--expanding the Library's information services to meet the needs of those concerned with the delivery of health care. The Library will develop and test new mech- anisms capable of providing information in a language, format, and time frame more immediately useful to the health practitioner. This will involve experimental development of one or more processes by which information relevant to clinical problems can be identified, organized, and distributed-- informatlon which will Improve disease outcomes in meaningful and measurable ways. The Lister Hill Center staff has begun to develop and test a model of one such process for one disease entity, infectious hepatitis. In September, 1976 the Library completed its Learning Resource Laboratory. This Laboratory provides an environment for the development and demonstration of computer applications in the broad area of biomedical information processing, with emphasis on library systems and computer-based education. In addition to the developmental environment, the Laboratory serves as a demonstration center where representatives of the health community can view the many possible innovative applications of modern computer technology. In 1975 the Library implemented a greatly improved successor to its MEDLARS system. This second generation system, known as MEDLARS II, enabled the NLM to develop new and expanded services based on the system's greatly expanded capabilities, including the extension of MEDLINE and other on-line8407374_000014.txt

Page  14 1629 services to a much broader spectrum of the health and health-related community. One of the newer capabilities has permitted the inclusion and searching of abstracts of articles which makes the data base much more useful. The implementation of MEDLARS II was coupled with a major upgrading of our computer system which has enabled us to keep abreast of rapidly increasing demands for our on-line services. These new capabilities have also enabled us to accommodate requests for operation of additional on-line data bases from other Institutes within the NIH. We currently provide access for our network's users to two data bases generated by the National Cancer Institute, CANCERLINE and CANCERPROJ, and to the EPILEPSYLINE data base of the National Institute of Neurological and Communicative Disorders and Stroke. CANCERLINE contains citations and abstracts dealing with cancer therapy and chemical, physical and viral carcinogenesis. CANCERPROJ contains summaries of ongoing cancer research projects which have been provided by cancer researchers in many countries. EPILEPSYLINE contains bibliographic citations with abstracts to articles on the subject of epilepsy that have been abstracted by Excerpta Medica. Cooperative undertakings, as illustrated by these examples, are important steps in assuring that the medical community is provided with useful information in a timely manner. The Library is also building an on-line, multimedia data base for audiovisuals called AVLINE. The AVLINE system is designed to provide rapid access to comprehensive information on biomedical audiovisuals in much the same way the NLM's MEDLINE system does for printed materials. The materials cited in AVLINE are acquired for reference and direct loan or duplication in our efforts to strengthen the undergraduate and continuing education process within the health community. The Toxicology Data Bank is an on-line, interactive data retrieval service that contains evaluated data on chemical, toxicological, pharma- cological, manufacturing, usage and ecological properties of potentially hazardous substances to which populations are exposed. Data In text segments are extracted from monographs, reviews or criteria documents.8407374_000015.txt

Page  15 1630 Data records are reviewed by a committee of experts in toxicology andrelated fields. A file containing some 1,000 compound records will bemade available for limited public testing this summer. Full public accessby users of other NLM on-line services is planned for the end of FiscalYear 1977. In collaboration with the DHEW Committee to Coordinate Toxicology, NLMinitiated TOX-TIPS, a monthly announcement bulletin containing informationon planned or ongoing long-term biological testing of chemical substances.The bulletin is intended to help eliminate unknowing replication of suchtests, which are expensive. Input for TOX-TIPS is obtained by solicitingvoluntary contributions from industry, academia, and Government agencies.In addition to announcements of tests, TOX-TIPS carries cumulative indexesby compound, species, route of administration, duration of the tests andand testing organization. At this time, TOX-TIPS is distributed to over3,000 administrators and scientists in industry and government. QUESTION* Is your budget request large enough to accommodate even moreemphasis in this area? ANSWER* There are some areas in the information transfer methodologyprogram and in the technology programs which could utilize additional funding,assuming that this was accompanied by an increase in personnel. QUESTION* Explain your MEDLARS System to us. ANSWER* MEDLARS (Medical Literature Analysis and Retrieval System) isthe acronym used to cover the computer based system which provides NLM'spublications (such as Index Medicus) as well as its on-line data bases suchas MEDLINE, TOXLINE, CHEMLINE and CATLINE. Domestically there are some500 centers located throughout the U.S. which provide on-line searches V upon request. During FY 1977, it is estimated approximately 600,000reference requests will be processed by these centers. QUESTION* Do you feel this program has reached peak capacity? ANSWER* NLM's present computer capacity is projected to be adequate8407374_000016.txt

Page  16 1631 for the present and near future. A Request for Proposal for a new computer system has been developed and a new computer system will be acquired for installation in the new Lister Hill Center Building scheduled for completion in the fall of 1979. NLM has provided on-line access to most of the major research institutes, medical schools, VA hospitals and other large hospitals in the U.S. NIM is also encouraging access to community hospitals and other organi- zations providing direct health care by expanding our network to include hospitals in rural and smaller communities. DOCUMENT DELIVERY QUESTION* The Congressional Research Service, we are told, must wait four to six weeks for copies of articles from NLM. If we get that kind of service, I'm afraid to guess what people in the rest of the country get! Why is this--is your Library Loan Division that understaffed? ANSWER* It is difficult for me to understand this delay in service, but I can assure you that we will thoroughly investigate these assertions. Eighty-eight percent of our interlibrary loans are filled within a four day period and 100 percent are filled within ten days. Because NLM is the national backup library of last resort, those requests which are difficult to identify are subjected to more extensive searching in an effort to locatethe document. In addition, there may be extended delays in the mail service or in the requesting organization to and from NLM. This is beyond our control. The Regional Medical Library network similarly processes requests in ten regions across the country. Approximately 80-85 percent of the requests sent to Regional Libraries are filled; 90 percent in four days or less, and 100 percent within ten days. The remainder are referred by TWX to NLM for processing. The preponderance of requests for photocopy documents clearly are filled in a short period of time. When requests are received by telephone or other direct communication from the Congress or the Congressional Reference Service (CRS), they are handled on a high priority basis.8407374_000017.txt

Page  17 1632 However, It is true that it has become increasingly difficult during the past year to maintain rapid and high quality basic library services because of a shortage of personnel. Interlibrary loan requests have doubled from 126,000 in 1971 to 263,000 in 1976. On-line service requests have risen from 250,000 in FY 1974 to an estimated 600,000 in FY 1977. At the request of the Congress, we are expanding our literature coverage and service communication to the rapidly expanding health care delivery com- . ponents of medicine. More manpower will be required to carry out existing library functions which include acquisitions, processing, indexing, on-line services, maintenance of the collection and automation services. Upon looking Into the allegations made by the Congressional Research Service we have In fact found that requests from this organization have taken approximately thirty days to reach the National Library of Medicine. The requests were processed at NLM and mailed within a period, of three to five working days. For example, four recent requests from CRS dated between November 24 and December 1, 1976 were received at NLM on December 28. Despite the long holiday weekend and an unusually high year-end leave experience, these requests were processed and mailed between January 3 and 5. We presume that the thirty days required to reach NLM resulted from processing at the Library of Congress or as a result of mail delivery delays. We have there- fore suggested to CRS that requests for documents be made by telephone to expedite processing. REGIONAL MEDICAL LIBRARIES QUESTION* Dr. Cummings, every year the use of Regional Medical Libraries goes up by 15-20 percent. Explain the program a little and why it is so popular. Has your budget kept up with all the costs? ANSWER* The National Library of Medicine has long recognized that it should not assume total fiscal responsibility for the Regional Network's document delivery program; to attempt to do so would raise serious concerns about the efficiency of the operation. Already a very wide base of support8407374_000018.txt

Page  18 1633 ons has been established and our contracts with the ten Regional Medical Libraries currently provide for only approximately 507. of the total volume of business. Continuing efforts for a fiscally stable network are being made at two different levels: 1) geographically proximate health instituti are being encouraged to coordinate their acquisition of materials and exchange among themselves, those resources which are in heavy demand, and; 2) NLM and the other major institutions in the Network are presently engaged in a dialogue to determine appropriate and equitable shares of Federal and non- Federal responsibilities. Through these partnerships it is fully anticipated that we will be able to continue to promote an uninhibited growth and development of the document delivery system. PERSONNEL REQUIREMENTS QUESTION* Every year we increase your budgets, but many times you don't get new positions to go along with this. Frankly, let me know if you have position problems at NIH. Have you enough people to do a good job of monitoring grants or clinical care and research? How do your position levels for 1978 compare to 1976? ANSWER* The FY 1978 budget request provides for 470 positions, a reduction of two positions under the FY 1976 level. Our original request for FY 1978 was 553 positions, an increase of 81 positions over the FY 1976 and FY 1977 level of 472. Although we believe we have sufficient positions to monitor our grants program, the NLM public service activities and research and development programs are understaffed. The great preponderance of the 81 positions requested in FY 1978 is to maintain high quality basic library services. During the period FY 1976 through FY 1978, service demands will increase by approximately 18 percent. Specifically, our workload statistics indicate the need for manpower to meet increasing demands for interlibrary loans, for cataloging and indexing new materials, for responding to increased demands for on-line services and for basic maintenance of the Library's collection.8407374_000019.txt

Page  19 1634 If the NLM is to continue to improve biomedical Information transfer, it must have the necessary in-house expertise to apply the latest advances in computer and communications technology. Positions are needed in FY 1978 to aid in the dissemination of research results, to explore the potential value of computer technology In assisting in biomedical information transfer, and to develop and evaluate institutional materials for health professional education. QUESTION* What in your professional judgment is needed to satisfy your training needs? ANSWER* The Library has identified an urgent need for research in the field of information service that is clearly lagging because of the small number of professional personnel trained to conduct such research. It is obvious that the Library must return to a program of research training for both information scientists and the supporting professional staff who can contribute to their research effort. It is our best judgment that both individual awards and institutional training grants should be used to train fifty carefully selected trainees, requiring $1,000,000 in FY 1978. PROGRAM PRIORITIES QUESTION* Because your budget has been so static over the past few years, has this had an impact on programs which you would like to initiate but can't? Which ones? ANSWER* Although the FY 1978 budget increase of $1,512,000 will only cover mandatory and other increased costs of operations, the National Library of Medicine did receive approximately a 20 percent program increase in FY 1977. Despite these increases, NLM is experiencing difficulty in coping with its expanded mission to adequately serve the total health care delivery community. The development of library resources and delivery of services requires a large manpower commitment. The Library has been struggling with personnel ceilings which have seriously impeded our ability to provide the greatly-expanded workloads resulting from our increased on-line and document delivery systems. We have been able to cope with thi*8407374_000020.txt

Page  20 1635 to some extent by introducing new technical and maintenance pro^-uures which have enabled us to increase productivity. We have, hoover, approached the limit of benefits in this direction. In order to expand our functions in the fields of health care delivery to include important areas of health economics, medical sociology, the financing of health care, etc., we will need to recruit highly specialized technical staff to enable us to provide the resources for selecting and acquiring the important scientific and scholarly literature, and for providing meaningful and timely reference and bibliographic services to many user groups who currently do not have easy access to this growing body of information. In addition, the anticipated increase in workloads will require further staff for processing documents acquired and for delivery of those requested. It has been said that people never die from lack of books and journals. In fact, this is not correct. People may die because of a lack of information and communication. There are many examples of this throughout the medical annuals. For instance, lack of knowledge about antidotes for poisons is clearly preventable. Emergencies in rural areas may be assisted by rapid communications. Our satellite communications program in Alaska demonstrated this.