1973 U.S. Senate Appropriations Committee Budget Testimony, 92nd Congress 2nd Session, May 1, 1972
Page  1

DEPARTMENTS OF LABOR AND HEALTH, EDUCATION, AND WELFARE AND REUTED AGENCIES APPRO- PRIATIONS FOR FISCAL YEAR 1973 HEARINGS BEFORE A SUBCOMMITTEE OF THE COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE NINETY-SECOND CONGRESS SECOND SESSION ON H.R. 15417 AN ACT MAKING APPROPRIATIONS FOR THE DEPARTMENTS OF LABOR AND HEALTH, EDUCATION, AND WELFARE AND RELATED AGENCIES, FOR THE FISCAL YEAR ENDING JUNE 30,1973, AND FOR OTHER PURPOSES Printed for the use of the Committee on Appropriations PART 3 U.S. GOVERNMENT PRINTING OFFICE 74-MI O WASHINGTON : 19728410522_000002.txt

Page  2 NATIONAL LIBRARY OF MEDICINE Appropriation Estimate To carry out, to the extent not otherwise provided for, section 301 with respect to health information communications and part I and J of title III of the Public Health Service Act, [$24,086,000] $28,104,000 of which [$2,102,00] $2,902,000 shall remain available until June 30, {J97JJ 1974. Justification Amounts Available for Obligation 1972 1973 Appropriation.................................... $24,086,000 $28,104,000 Unobligated balance start of year................ 45,550 --- Unobligated balance lapsing...................... - 26,000 --- Total obligations........................... $24,105,550 $28,104,000 ____________________________Obligations by Activity____________ 1972 1973 Appropriation Estimate Pos. Amount________Pos. Amount Medical Library Assistance: Training................. — 1,200,000 — 1,500,000 Special Scientific Projects............... — 95,000 — 95,000 Research................. -- 650,000 -- 900,000 Library Resources........ -- 2,505,000 -- 2,705,000 Regional Medical Libraries.............. r- 2,147,550 -- 2,902,000 Publications Support..... 340,000 -- 390,000 Subtotal............... -- 6,937,550 -- 8,492,000 (2645) Increase or Decrease Pos. Amount + 300,000 + 250,000 + 200,000 + 754,450 + 50,000 +1,554,4508410522_000003.txt

Page  3 2646 1972 Estimate 1973 Estimate Increase or Decrease Direct Operations: Lister Hill National Center for Biomedi- cal Communications: (a) Project contracts.. -- 1,375,000 (b) Other direct....... 19 480,000 National Medical Audio- visual Center: (a) Project contracts.. — (b) Other direct....... 108 2,350,000 Library Operations: (a) Project contracts.. — 2,091,000 (b) Other direct.......249 6,390,000 Toxicology Information: (a) Project contracts.. -- 564,000 (b) Other direct....... 20 754,000 Review and Approval of Grants................. 32 710,000 Program Direction........ 56 2,454.000 Subtotal............... 484 17.168.000 Total obligations........484 24,105,550 « 2,475,000 24 597,000 110 2,677,000 1,891,000 249 6,779,000 715,000 20 933,000 32 746,000 56 2.799.000 — +1,100,000 +5 + 117,000 +2 + 327,000 - 200,000 — + 389,000 — + 151,000 — + 179,000 — + 36,000 — + 345.000 491 19.612.000 +7 +2.444.000 491 28,104,000 +7 +3,998,450 Obligations by Object Increase 1972 1973 or Appropriation Estimate Decree ;e Total nuaber of permanent positions..... 484 Full-time equivalent of all other positions............................. 18 Average number of all employees......... 495 Personnel compensation: Permanent positions................... $ 6,906,000 Positions other than permanent........ 203,000 Other personnel compensation.......... _____89,000 Subtotal, personnel compensation.... 7,198,000 Personnel benefits...................... 599,000 Travel and transportation of persons.... 167,000 Transportation of things................ 33,000 Rent, communications, and utilities..... 1,704,000 Printing and reproduction............... 468,000 491 25 508 +7 +13 $ 7,362,000 317,000 87,000 + 456,000 + 114,000 2.000 7,766,000 665,000 176,000 30,000 1,732,000 478,000 + 568,000 + / 66,0'JC + 9,000 3,000 + 28,000 + 10,0008410522_000004.txt

Page  4 2647 1972 1973 Increase or ---------------------------_________________Estimate______Estimate Decrease Other services: Project contracts..................... 4,030,000 5,081,000 +1,051,000 Payment of NIH Management Fund........ 1,062,000 1,119,000 + 57,000 0ther................................. 934,000 1,544,000 + 610,000 Supplies and materials.................. 310,000 363,000 + 53,000 Equipment............................... 663,000 658,000 - 5,000 Grants, subsidies and contributions..... 6,937.550_______8,492.000 +1,554,450 Total obligations by object............ 24,105,550 28,104,000 +3,998,450 Summary of Changes 1972 estimated obligations................................................... $24,105,550 1973 estimated obligations................................................... 28,104,000 Net change................................................... + 3,998,450 Base________ Change from Base Pos. Amount_____Pos.______Amount Increases: A. Built-in: 1. Annuallzatlon of new positions In 1972..... 2. Wage board pay increases................... 3. Within grade pay Increases................. 4. FTS rate increase.......................... 5. Annuallzatlon of commissioned officers quarters allowance.......t............... 6. Non-competing continuation grant Increases. Subtotal, built-in Increases.......... B. Program: 1. Training grants............................ 2. Research grants............................ 3. Library Resources grants.................... 4. Regional Medical Libraries grants.......... 5. Lister Hill National Center for Biomedical Communications................ 6. National Medical Audiovisual Center........ 7. Library Operations......................... 8. Toxicology Information..................... 9. Upward Mobility Program.................... 10. Program Direction.......................... Subtotal, program Increases........... C. Payment to "National Institutes of Health Management Fund" for centrally furnished services..................................... Total, Increases................. -jcraases: ■>. Built-in: 1. Two days less pay In FY 1973............... 2. Annuallzatlon of savings from employment reduction in 1972........................ Total, decreases................. Total, net change.................................... — _ — 105,000 — — — 5,000 -- -- -- 270,000 " " " 5,000 _ .. .. 5,000 — .. — 700,000 " " " +1 ,090,000 1,200,000 .. 100,000 — 650,000 -- 200,000 -. 2,505,000 — 100,000 — 2,147,550 " 499,450 19 1,855,000 5 1 ,125,000 108 2,350,000 2 265,000 249 8,481,000 -- 105,000 20 1,318,000 — 250,000 .. — — 138,000 56 2.454.000 — 125,000 " " +7 +2 ,907,450 1,062,000 + 57,000 +7 +4,054,450 - 50,000 j^____ 6,000 56,000 +7 +3,99.-, 4508410522_000005.txt

Page  5 2648 Explanation of Changes .uilt-in Increases — These increases will provide $105,000 for the annualization of seven new positions requested in fiscal year 1973, $5,000 for pay increases for wage board personnel, $270,000 for within grade pay increases and also includes $5,000 for the annuallzatlon of commissioned officers quarters allow- ance increase authorized In fiscal year 1972. $5,000 is provided for increased costs In fiscal year 1973 of the Federal Telecommunications System. $700,000 is for increases associated with the sustaining of non-competing continuation grants awarded under the Medical Library Assistance Extension Act of 1970. Training grants '-- A program increase of $100,000 will permit the funding of three additional grants bringing to twenty the number of active grants used to sup- port approximately one hundred forty individuals studying the applications of medical science information. Research grants — A program increase of $200,000 will allow the awarding of five additional grants bringing to twenty-six the number of grants supporting the development of new methods of processing biomedical knowledge. Library Resource grants — A program increase of $100,000 will be used to support 47 additional awards with emphasis being placed on using the funds to stimulate local community support for upgrading medical library resources and services. Regional Medical Library grants — A program increase of $499,450 will permit the support of the increased number of interlibrary loans that will result from the new on-line bibliographic retrieval system, MEDLINE. Additionally, new services and methodology to improve existing services will be supported through the grant mechanism. Lister Hill National Center for Biomedical Communications ~ A total of $3,072,000 and 24 positions is requested in 1973, a program Increase of $1,125,000 and 5 new positions. The increase will provide for: (1) Additional communication costs which will be incurred in providing access to an expanded user population on the new MEDLINE system; (2) planning and hardware costs of the new satellite communication experiment; (3) training of health personnel in techniques of providing health care and education via cable television; and (4) expanding the New England Interactive Network. National Medical Audiovisual Center — A program increase of $265,000 and two new positions is requested in 1973. This increase will permit a modest expansion in Che development of multimedia instructional packages which will aid medical «jJu .icors in restructuring curricula and condensing the educational process by using novel pedagogical techniques. Library Operations — A total of $8,670,000 and 249 positions is requested in 1973, a program increase of $105,000. This increase will aid in maintaining th> Library's literature resources and allow for the continuance of the Gap F lling Program for missing materials, particularly in the heavily used periodica} collections. , Toxicology Information — A program increase of $250,000 will be directed towards the continuation and expansion of the on-line toxicology information and data system through the creation of additional software modules. This increase will also permit the preparation of additional state-of-the-art reviews and improved information evaluation services furnished to the biomedical community. Upward Mobility Program — A program increase of $138,000 is to fund the costs of NLM employees participating in the DHEW's Upward Mobility Program. Program Direction — A program increase of $125,000 is to fund the support of in- ---creased efforts In developing, coordinating, and evaluating a national biomedi- cal communications network.8410522_000006.txt

Page  6 2649 Significant Items in House and Senate Appropriations Committee Reports Item 1972 Senate Report Lister Hill Center for Biomedical Conw.uni cat ions 1. Committee stated that, "As the success of the Center's efforts will ultimately depend on their acceptance and support by the medical and scienti- fic communities, the Director of the National Library of Medicine and the staff of the Lister Hill Center should prepare an informative report on its prototype experiments--such as the satellite communications link with remote regions in Alaska and the two-way television network in New England-- and its plans for the future. One of the purposes of the report should be to stimulate awareness of and interest in ways in which modern communications techniques can be adapted and expanded to serve all facets of health services, biomedical research, and the training of health professionals." (pages 65-66 of Senate Report). Acrion taken or to be taken 1. The Director of the NLM and the staff of the Lister Hill Center are preparing for submission the subject report to the Senate Appropriations Committee. Authorizing Legislation 1973 Legislation Public Health Service Act Section 371 - Purpose and Establishment of Library............................ Section 394 - Grants for Training in Medical Library Sciences.............. Section 395a - Assistance for Special Scientific Projects.................. Section 395b - Research and Development in Medical Library Sciences and Related Fields........................ Section 396 - Grants for Improving and Expanding the Basic Resources of Medical Libraries and Related Instrumentalities..................... Section 397 - Grans for Establishment of Regional Medical Libraries......... Section 398 - Financial Support for Biomedical Publications............... Authorization Requested Indefinite 2,000,000 500,000 3,000,000 4,500,000 3,500,000 1,000,000 Appropriation Requested 19,612,000 1,500,000 95,000 900,000 2,705,000 2,902,000 390,0008410522_000007.txt

Page  7 2650 Y^ar Budget Estimat to Congress e House Allowance Senate Allowance Appropriation 1963 $ 3,335,000 $ 3,335,000 $ 3,335,000 $ 3,335,000 1964 4,074,000 4,074,000 4,074,000 4,074,000 1965 3,678,000 3,858,000 4,058,000 3,958,000 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 20,769,000 1972 21,981,000 22,781,000 25,086,000 24,086,000 1973 28,104,000 Personnel compensation 1972 Appropriation Pos. Amount 484 $ 7,797,000 16,308,550 1973 Estimate Pos. Amount 491 $ 8,431,000 19,673,000 Increase or Decrease Pos. Amount +7 +$ 634,000 — + 3,364.450 Total. 484 24,105,550 491 28,104,000 +7 + 3,998.450 General Statement The National Library of Medicine, the world's most important resource for bio- medical documents, facilitates the application of biomedical information to the treatment and prevention of diseases by acquiring, organizing and disseminating informational materials to health professionals. The NLM actively explores ways in which technological advances in the communications field can be applied to organi- zing that knowledge and making it available where and when it is needed. For example, the Library is experimenting using a NASA satellite to make the expertise of local hospitals available for the health care of remote Alaskan villagers with no professional health personnel. Also, it is making its computerized bibliogra- phic data base available to users in biomedicine throughout the country through the use of on-line computer terminals, linked by a commercial land wire network. The NLM has a congressional mandate to coordinate the development of a National Biomedical Communications Network (BCN) which, when fully established, will further enhance the flow of information to health professionals. The individual programs of the Library which are described herein are all facets of the Library's Efforts to fulfill this charge. For library services, such a network already exists with selected participating institutions serving as major Regional Medical Libraries throughout the country to facilitate document delivery and reference services. Numerous smaller local libraries in hospitals and schools of the health professions are also linked into the network. These libraries receive support from the NLM through direct financial assistance and by interlibrary loans and specialized ref- erence services which the NLM, as the Nation's central biomedical resource, pro- vides as backup to the system. Implementation of a complete communications network is currently In its formative stages. Projects will be continued to determine what new communications technology can be utilized most efficiently and effectively to encourage and coordinate networking efforts of medical schools, hospitals, and other components of the Nation's health-care system to expand the overall coverage of the network.8410522_000008.txt

Page  8 2651 The FY 1973 budget request provides some of the funding necessary to usher in a modern era in biomedical , ommuric. rion. An increase of over $1,200,000 has been asked for the innovative program of the Lister Hill ( ei lr. cr Pionedical Commu- nications. Also $1,554,450 additional has tstr. re-.iuesttc lor the giai i:r:—ams authorized by the Medical Librarv Assistance Act (as am=n..td). .. i:~- M'rmsi v-1 enable the extramural participants of the nationwide health ir.forrr.itici network tr provide expanded and more timely service to the Nation's health professionals. Construction of the Lister Hill Center building that will house the new comm- unications programs of the NLM is still in the planning stages. However, an impor- tant step forward recently occurred with the apportionment of planning funds for this Important facility. GRANTS The programs authorized by the Medical Library Assistance Act of 1965 (Public Law 89-291) and the Medical Library Assistance Extension Act of 1970 (Public Law 91-212) are designed to meet national needs for better health information services through improved health library resources and facilities, trained manpower, and improved health communications technology. Specifically, the Act authorizes support of projects to develop resources and techniques necessary to collect, pre- serve, store, process, retrieve, and facilitate the dissemination and use of health science information. Training and Fellowships Non-competing continu- ation grants........ New grants............ Total............. 1972 Appropriation No. of Awards Amount $523,463 676,537 1973 Estimate No. of Awards Amount 13 7 17 1,200'T000" $972,598 527,402 Increase or Decrease No. of Awards Amount +3 +$449,135 - 149,135 20 1.500.000 +3 + 300.000 This program helps meet the Nation's need for medical librarians, information specialists and biomedical personnel trained in the utilization of computer tech- nology for health education and patient care. The emphasis is on training for creative leadership in positions of major responsibility. In FY 1973 an increase of $300,000 is requested to support 20 projects, 13 of vhich will be continuations. Training programs in computer technology will be stressed as the necessity for making computer technology a.part of the armamen- tarium of tomorrow's health personnel becomes clear. The more information at the immediate disposal of the physician, the better the diagnosis and the more rational the treatment. The computer is ideally suited for providing data to the knowledge- able health professional. Support of programs which provide further and specialized training for indivi- duals already possessing the basic library degree will be expanded and modified. Ph.D. programs, rather than master's degree and non-degree programs, will be stres- sed in FY 1973 with a strong emphasis on training for management. These training :':iiLi and fellowships are one of the most productive extramural programs supported by the TJLM. Many graduates occupy leadership positions in major medical libraries which are becoming active centers for biomedical communication. The increasing complexity of library practice brought about by the introduc- tion of advanced technology and b:.cmedical nemarking arrangements requires that librarians acquire these new communication skills and apply them to facilitate the rri c>; health information. Similarly, health professionals must learn to use . rra.:i - technology in education and patient care. The $300,000 increase in TY 19.73 will provide some of the resources required to produce the medical librari- ans and information specialists trained in modern methods of information transfer.8410522_000009.txt

Page  9 2652 Special Scientific Projects Non-competing continu- ation grants........ New grants............ Total............. 1972 Appropriation No. of Awards Amount $95,000 1973 Estimate No. of Awards Amount Increase or Decrease No. of Awards Amount 95.000 $80,000 15,000 +3 -2 95,000 +$80,000 - 80.000 The 1973 request of $95,000 for Special Scientific Projects is the same as 1972. These grants are intended to support outstanding scholars in the full-time analysis and documentation of major advances in the health sciences. The results are published as monographs. Health science information is available from a bewildering number of sources and usually without post-publication review. Scholars, eminent in their fields, critically review the literature and present the state-of-the-art. These reviews are usually in broad fields and therefore require a competence not usually availa- ble in specialty areas; thus these grants serve to make more accessible selected areas of biomedical Information. Research 1972 Appropriation No. of Awards Amount 1973 Estimate No. of Awards Amount Increase or Decrease No. of Awards Amount Non-competing continu- ation grants........ New grants............ Total............. 12 9 $434,265 215,735 10 16 $340,000 560.000 -2 +7 21 650.000 26 900.000 -$ 94,265 + 344,265 +5 + 250.000 In 1973, the Library is requesting $900,000 in new obligational authority which will support approximately 16 new or competing renewal research projects and continue the support of 10 non-competing continuation projects, a total of 26 awards. The continuing high level of the national effort in health-service educa- tion and research produces a constantly growing amount of biomedical information. More effective transmission, storage, and retrieval of this information at realis- tic cost-benefit ratios Is imperative. Projects will be supported In (1) defining information-seeking practices of health professionals, (2) improvement of the bio- medical vocabulary for written and mechanized information handling, (3) improved Information systems, and (4) development and testing of various information media. The increase in funds will make it possible to support research and develop- ment projects involving complex technologies. For example, studies in retrieval of information often involve experimental machine-readable data bases. Transfer of information for educational purposes often involves electronic circuitry as well as extensive evaluative testing. Certain developmental activities, concerning medical library operations, have been successful and will be appropriate for sup- port as demonstration projects.8410522_000010.txt

Page  10 2653 Library Resources 1972 Appropriation No. of Awards Amount 1973 Estimate No. of Awards Amount Non-competing continu- ation grants......... New grants............. Total.............. 167 240 $ 859,109 1,645,891 101 353 $1,205,000 1.500.000 Increase or Decrease No. of Award8 Amount - 66 +$345,891 +113 - 145,891 407 2,505,000 454 2,705.000 +47 +200.000 The 1973 request of $2,705,000 for Library Resource Grants represents an in- crease of $200,000 in the level of support from 1972. The-Increase will be used to sward 20 grants to establish basic collections and 10 grants -to improve local library services. The total request will permit the library to support 101 non- competing continuation grants and to make 353 new awards. Medical Library Resource Grants are designed to assist In the establishment, improvement, and expansion of the Nation's health science libraries, and to encour- age increased community support for the local library. Grants for a one-year period are made to health institutions which demonstrate a need to establish basic collections and services. Grants are also made to institutions with existing health science libraries for the support of projects designed to make the growing scien- tific literature more rapidly accessible to health professionals throughout the United States. Funded applications include cooperative programs In which a strong resource library undertakes to provide training, consultation and loan services for the small community hospitals, clinics and other health facilities; projects which seek to speed the delivery of services through the use of modern communication devices and automation techniques; and projects which simply increase the infor- mation resources of an institution after an assessment of needs of the health professionals. This program is also important in complementing the service activities of the Regional Medical Library Program. The Regional Medical Libraries and the major resource libraries which participate in the network can operate most efficiently in a backup role for regional informational needs rather than as prime sources for all needs. Only if local library resources and services are selectively improved can the network function effectively and the full benefits of the Regional Medical Library Program be realized. Regional Medical Libraries 1972 1973 Increase or Appropriation Estimate Decrease No. of No. of No. of Awards Amount Awards Amount Awards Amount Non-competing contlnu- 9 $2,147,550 10 $2,302,000 15 600,000 + 1 +$i:'+,450 +15 + 600.000 9 2.147.550 25 2,902.000 +16 + 754.450 The FY 1973 request for $2,902,000 represents an increase of $754,450 over the 1972 level. This amount will allow the Library to maintain the contract i'tpoort for ti e 10 active regional medical libraries (RML's) and will cover the -ddltibr.al costs of operations caused by increased user service demands. In iccition, 15 r.ew grants will be awarded for projects which, (1) analyze existing -ethods, (2) establish new services or methods, (3) and improve and expand existing services.8410522_000011.txt

Page  11 2654 The goal of this program is to develop a national network of regional medical libraries with the necessary depth and scope to supplement the services of other medical libraries in their designated region. Backup library services in the form of interlibrary loans and sophisticated reference services are now available. In FY 1972 the mechanism of support for the service components of the RML's was com- pletely converted from grants to contracts. In FY 1973 an increase in service demands is expected due primarily to two factors: 1. Health professionals are becoming increasingly aware of the availa- bility of lnterlibrary loan service from these regional libraries now that they are fully operational. (From FY 1969 to FY 1972 the average yearly increase in these loans has been 35 percent). 2. The initiation of the NLM's new on-line bibliographic retrieval ser- vice, 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 and will cause an acceleration In lnterlibrary loans at the RML's. The new competitive grant program to be fully launched In FY 1973 will be available to all institutions participating in the network service plan. Improve- ments in service resulting from these grants should benefit operations in the respective regions and the network as a whole. Permitting ready access to biomedical literature by health professionals is vital to the well-being of the citizens of the U.S. The Regional Medical Library Network can make a large contribution to this goal. In FY 1972 it is estimated that 500,000 lnterlibrary loan requests will be filled by the RML's and 600,000 in FY 1973. Publications Support 1972 1973 Increase or Appropriation Estimate Decrease No. of No. of No. of Awards Amount Awards Amount Awards Amount 6 $142,660 9 $214,000 +3 +$71,348 9 197.340______8 176.000 -1 - 21,348 15 340.000 17 390,000 +2 + 50.000 The 1973 request of $390,000 will allow the continued support of nine projects and will support 10 new or renewal projects. The development of selected publica- tions to help American health professionals digest and utilize the tremendous output of new information in the biomedical sciences contributes to the NLM's overall effort to facilitate biomedical communications. Such publications include abstracts, bib- liographies, handbooks, and critical reviews, as well as monographs and translations which condense, synthesize, evaluate, or otherwise repackage information for health scientists, educators, and practitioners. Only products that are commercially not feasible are undertaken. Among the projects funded in 1972 is a periodically appearing atlas on inter- national molecular structure of proteins which is of value to researchers in areas such as inborn metabolic defects and protein replication in cancer. Also included are a translated book on ecology providing to U.S. scientists the first view of Russian thought on this important field, and a handbook condensing the large mass of data on experimental pathology of the chick embryo, of value to studies on drug effects and congenital malformations in the human fetus. Non-competing continu- ation grants........ New grants............ Total8410522_000012.txt

Page  12 2655 In FY 1973 the program will continue to support selected publication projects that are directed to meet major reference information needs for U.S. health profes- sionals and also to encourage the production of reference tools needed by and useful to librarians and information specialists in the health sciences. DIRECT OPERATIONS 1972 1973 Increase or Appropriation Estimate Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits.......... 484 $7,797,000 491 $ 8,431,000 +7 +$ 634,000 Other expenses.......... 9,371,000 -- 11,181,000 -- + 1,810,000 Total............... 484 17,168.000 491 19.612.000 +7 +2.444.000 Lister Hill National Center for Biomedical Communications 1972 1973 Increase or Appropriation Estimate Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits.......... 19 $ 370,000 24 $ 497,500 +5 +$ 127,500 Other expenses.......... 1,485,000 — 2,574,500 — + 1.089.500 Total............... 19 1,855.000 24 3.072.000 +5 + 1.217,000 The Lister Hill National Center for Biomedical Communications is the focal point for coordinating biomedical communications systems for the entire Department of Health Education, and Welfare and is responsible for developing'a Biomedical Communications Network. It has provided' an experimental service (AIM-TWX) to over 65 hospitals and libraries using teletypewriter terminals to access bibliographic citations from 100 leading English language medical care journals in an on-line time-sharing computer. This successful service cutting retrieval time from weeks to minutes at reduced costs has encouraged a series of modifications for improving the system. The impro- ved system called MEDLINE has already become operational on the computer at the NLM. It will provide access for many more users to a data base of over 1,000 journals. MEDLINE is being connected to a commercial data communications network which will provide access on a toll-free basis in at least 35 cities throughout the Nation. The inauguration of the MEDLINE network makes it practical and economically attrac- tive to expand this service to a broader range of users among both the academic community and health-care practitioners. Therefore, additional computer-based data sources will be brought on-line which can eventually serve medical schools, schools of dentistry, many nursing schools and most other institutions that train allied health professionals. The augmentation provided by Congress in the 1972 budget is being used to bring into the network additional data bases to provide, for example, computer assis- ted instruction and diagnosis. These experiments are designed to evaluate the effectiveness of computer/communications technology in relieving the critical health manpower shortage by providing a means for students to learn at their own pace aid permitting faculty to handle a larger student population of diverse backgrounds. A, nedical network linking 26 native villages with service unit hospitals and medical centers is now operating seven days a week in Alaska using the NASA Appli- cation Technology Satellite (ATS-1). This network provides reliable daily voice consultation between village health aides and physicians thus improving the primary8410522_000013.txt

Page  13 2656 health care in remote areas of the State. Further efforts have been initiated to explore the use of two-way voice communication via satellite for community health and education. Further experiments are planned which include the transmission of electrocardiograms; and slo^'-scan TV to experiment with transmission of facsimiles such as simple x-ray pictures. With the cooperation of NASA, the Lister Hill Center plans to carry out tests of two-way TV satellite communications for health care delivery and education In other areas where health services are scarce. The satellite is the Application Technology Satellite-F (ATS-I) to be launched in May 1973. This effort is a logical conse- quence of the experiments presently being conducted in Alaska and extends the range of services presently being explored. Funds provided in 1972 will be used to design and develop a two-way satellite terminal and to provide the start of detailed plan- ning and scheduling of experiments required to be ready for operation when the sate- llite is made available in June 1973. This satellite will provide an opportunity to explore the utility of a variety of interactive health programs, to bring the expertise of major medical centers to rural communities in several western states. This is part of a larger DHEW program to define the public service functions of satellite communications and establish the needs for shared and/or dedicated domes- tic communication satellites. Some of the 1972 funds have been used to speed devel- opment of a medical microwave network linking medical schools and hospitals In Vermont and New Hampshire. This New England Interactive Network brings the exper- tise of the Dartmouth and University of Vermont Medical Schools to community hospitals. Further experiments will explore the use of a mobile van to extend the network to institutions where a valid need exists for better care, but where expensive fixed installations are not justifiable economically. This network will eventually link some 15 hospitals and 3 university health centers in a mutually reinforcing program of improved health care delivery and education. The Center also has begun to explore the use of cable television (CATV) as a means of reaching the impoverished urban dwellers who, in part because of inadequate communications, suffer from poor health care and health education. One plan involves a two-way interaction between a sophisticated metropolitan hospital and the resi- dents of low cost public housing in an effort to educate them in their own personal health and to bring them more actively into the health care system. Another possi- bility is to determine the usefulness of CATV in providing better service by making available the expertise in medical schools and hospitals to health care centers and to provide a learning experience for doctors, nurses and other health professionals in community care through participation in such a program. At the request of Congress a report is being prepared on the Lister Hill Center's prototype experiments and its plans for the future. The 1973 budget request represents a continuation of the programs outlined above and provides for the rapid development of these communications technologies to an operational state. New programs included are communication costs for the MEDLINE network; procurement of satellite terminals and other hardware in order for instal- lation and checkout to be completed in time to perform the ATS-F experiments; de- tailed planning, program development, and hardware procurement for the CATV programs; and expansion of the New England Interactive Network. The Center is becoming recognized as the major technology transfer element be- tween the computer and communications communities and the medical community. Effec- tive accomplishment of this role requires a balance of contractual efforts' and in- house expertise.8410522_000014.txt

Page  14 2657 National Medical Audiovisual Center 1972 1973 Increase or Appropriation Estimate Decrease Poa. Amount Pos. Amount Pos. Amount Personnel compensation and benefits.......... 108 $1,631,000 110 $1,738,500 +2 +$107,500 Other expenses.......... _zz_______719.000 _______938.500 — + 219.500 Total............... 108 2.350,000 110 2,677,000 +2 + 327,000 The National Medical Audiovisual Center (NMAC) in Atlanta, Georgia, administers programs to improve the quality and increase the use of biomedical audiovisuals in schools of the health professions and in the continuing education of health profes- sionals. In FY 1972 the NMAC acquired and organized selected medical audiovisual materi- als and distributed them through a variety of methods. It provided advice and con- sultation on health instructional systems, media, and facilities. NMAC also develo- ped prototype modulated instructional media units and provided training to medical school faculty through workshops and seminars. Finally, NMAC catalogued and shared reference material in efforts to stimulate and facilitate the use of audiovisual materials by health professionals. In carrying out these tasks NMAC collaborated with the Bureau of Health Manpower Education (BHME) on furthering mutual objectives in health manpower education. During FY 1972, NMAC is conducting an active program of cooperation with national professional medical organizations to make ussful instructional media available to the medical community. This program has two components: location and peer evaluation of existing instructional media and the development and production of pilot instructional units. Those latter units are based upon instructional ob- jectives identified by cooperating groups and are designed in modules to permit economical modification. NMAC also is supporting a "unlversity-on-loan" program where experienced medical educators, supported by their universities, are encouraged to participate in developing these prototype multi-media systems. These innovative teaching devices use voice, vision, and touch to give a live three-dimensional immediacy to a learning experience. New multi-media technology holds great promise for more efficient and less time-consuming medical education. In 1973 the Center will modestly expand: (1) its acquisition and distribution activities, (2) production and field-testing of educational materials in cooperation with health professionals, and (3) experimentation with self-instructional technology and modular audiovisual units which are valuable for their ease of updating and flexibility of use. Additionally, it will implement more fully its "university-on- loan" concept through inauguration of a program of acquiring, cataloging, and dis- tributing to the biomedical community highly selected collections of slides and other audiovisual materials for use in the continuum of medical education. Audio- visual instructional packages will be produced In cooperation with the BHME and health-sciences instructional centers located in universities throughout the country. The Center will utilize the MEDLARS system of NLM to disseminate infor- mation on the availability of evaluated audiovisual instructional materials, thereby serving a much needed clearinghouse function. Library Operations 1972 1973 Increase or Appropriation Estimate Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation and benefits.......... 249 $3,850,000 249 $4,048,000 — +$198,000 Other expenses.......... 4,631,000 — 4,622.000 — - 9.000 Total............... 249 8.481.000 249 8,670.000 — + 189,0008410522_000015.txt

Page  15 2658 Library Operations selects, acquires, catalogs, and preserves biomedical pub- lications; indexes and provides access to the material through manual and machine produced bibliographies; furnishes reference and loan services; prepares and pub- lishes indexes, catalogs and other publications for the use of the biomedical commu- nity; and manages the Library component of the Biomedical Communications Network. In FY 1972 Library Operations will provide approximately 260,000 services to the public in its capacity as a component of and a backup for the National Library Net- work. In addition, regional libraries funded by NLM will provide more than 327,000 document delivery and MEDLARS services. The Library also will index 220,000 articles from biomedical periodicals for inclusion into the MEDLARS data base from which the NLM prepares and publishes a monthly Index Medicus and a yearly 9,000 page, eight volume Cumulated Index Medlcus. In addition, the MEDLARS system produces over 21 specialized bibliographies in the field of medicine in collaboration with federal agencies and professional medical societies, and the Abridged Index Medicus. which has been developed for the indivi- dual practitioner and small hospital libraries. The Library also collects and catalogs books and monographs and through the MEDLARS system produces and publishes semi-weekly, monthly, quarterly and annual cumulations of cataloged material for the use of medical libraries in carrying out their cataloging and acquisition functions. During FY 1972, an eight volume sexennial publication of the NLM catalog since 1965 was produced. The Library also negotiated a contract to provide for the com- mercial production and distribution of NLM catalog card sets to other libraries at moderate cost. The Library plans to publish, in collaboration with the American Public Health Association, a new publication called Current Bibliography of Epidemiology, which has been previously published on an experimental basis by the American Public Health Association. This represents the only index of its kind and will contain vital references to epidemiologic aspects of all diseases. NLM has implemented a new on-line bibliographic service called MEDLINE with a data base of more than 1,000 of the world's leading biomedical journals containing up to 500,000 citations. This access will be backed up by retrospective retrieval capacity for the entire machine-based data file at NLM which currently contains about 1,500,000 citations. This will represent an expansion of accessibility from the 11 MEDLARS centers to about 200 major installations and provide the base for ultimate plans for even more widely disseminated access for hospitals and directly to health science practitioners. A communications network has been established by the Lister Hill Center to make this data available to most major medical schools, hospitals, and research institu- tions on a toll free or low toll basis. This development r^'-ld replace the needs for a major portion of the MEDLARS bibliographic searches and provide more timely service by its on-line access to the system by a large proportion of the user population. It is thus proposed to phase out most of the MEDLARS centers. This phase out will provide the operational costs for maintaining the MEDLINE communication network. j In late FY 1972 the capability of searching more than one data base will become available in the programs operating MEDLINE. The Library is building two additional data bases available In its computerised files for serials and for monographs. During FY 1973, these will become available on-line to all users in the MEDLINE network and will provide access to the catalog and serial files available at NLM. The serial files will also include information on the availability of publications in about 100 major medical libraries in the Regional Medical Library Network and will improve document delivery services. As a by-product of these efforts, the Library will be able to publish a series of library reference tools which should reduce greatly the efforts of libraries In Identifying and locating items.8410522_000016.txt

Page  16 2659 The emergence of the Library as the backup for a large network cf libraries has required more critical attention for the need to build its physical resources to maintain the collection, fill gaps in the collection and for preserving the deterio- rating portions through microfilming. The FY 1973 increase in resources will be utilized to maintain the Library's collection at a level capable of providing this critical backup function in the face of rapidly rising costs for acquisitions. The request for Library services in 1973 Is $5,099,000 and 197 positions. These funds will allow the processing of 100,000 lnterlibrary loan requests; 18,000 domestic computer-generated demand searches, 84,000 reader requests (direct use of the collection), indexing of 220,000 articles, publication of 21 recurring biblio- graphies, acquisition of 130,000 serial pieces and 14,000 monographs, binding of 28,000 volumes and microfilming of approximately 1,000,000 pages of deteriorating documents. Development and Implementation of a Second-Generation MEDLARS (MEDLARS II) The National Library of Medicine began the development of a second-generation Medical Literature Analysis and Retrieval System (MEDLARS II) in 1968 through a major contract which included responsibilities for a system conceived as c three to four year project of development and incremental upgrading. However, due to the increasing need for the planned interactive capability and the great difficulty which the original contractor experienced in implementing the system, the project was given major redirection in April 1971. A proprietary software package which had already been in use' by the Library was purchased for a nominal sum and a contract let to rebuild the MEDLARS II system around it. This current phase of MEDLARS II development, which consists of an improved. file generation/maintenance system, a new set of programs to produce output for photocomposition and additional search capability is expected to be completed in 1973. In full operation, MEDLARS II will incorporate the following technical elements: increased processing capability; on-line storage devices.permitting direct access to the data base; multi-programming capability which will permit several tasks to be performed by the computer simultaneously; and on-line access to data bases from r - mote terminals. Translated into program capabilities, the new features will prov.de for: a greatly increased file capacity to allow the maintenance of abstracts, summaries, and bibliographic service requests; the processing of more current data through direct input and on-line updating of the file; and automated acquisition end cataloging system with availability of cataloging data to and from medical libraries; and development of specialized Information files to support the Library's Toxicology Information Program through the addition of chemical name and structure search capa- bilities. Experience with the development of the MEDLARS II system indicated that althoug the 360/50 computer then in use was adequate for development work, production oper- ation and particularly che requirements of the on-line interactive system (MEDLINE) would require a more powerful computer. Consequently, permission to upgrade to an IBM 370/155 was obtained and the computer was installed in December 1971. The programming and analytical staff specialize in the field of information storage and retrieval. Because of the recent Implementation of the on-line interac- tive portion of MEDLARS II (MEDLINE), increasing emphasis has been placed on the design of interactive time-sharing systems and on the interface of the computer with communications systems. The 1973 budget request includes $3,571,000 and 52 positions to continue the development, implementation and operation of MEDLARS II and the operations of MEDLARS I.8410522_000017.txt

Page  17 2660 Toxicology Information 1972 1973 Increase or Appropriation Estimate Decrease Pos. Amount Pos. Amount Pos. Amount Personnel compensation -'"' and benefits.......... 20 $ 435,000 20 $ 490,000 — +$ 55,000 Other expenses.......... _=I______883,000 — 1.158.000 — + 275.000 Total............... 20 1.318.000 20 1.648.000 — + 330.000 The mission of the Toxicology Information Program (TIP) Is to select, analyze, and organize Into automated storage and retrieval systems toxicologlcal information now available only from numerous diverse sources. The effective implementation of the program requires close collaboration with other government agencies and the creation of a capability to respond to requests for information. This in turn re- quires access to toxicology information from scientific literature and the files of government and Industry. Collaborative Activities with Other Organizations The TIP is participating in a joint effort with several federal agencies to en- hance the capabilities of an Interactive computer system (STIMS/RECON), originally developed by NASA and kept in the public domain by this Interagency effort. TIP' 3 data banks are being stored on this sytem. TIP, in collaboration with FDA, also is working on the storage in the on-line system of data from the handbook Clinical Toxicology of Commercial Products. Literature searches in various areas of toxico- logy are being performed by TIP routinely for over 20 government organizations. TIP has also started a contractual effort with a large chemical company through which the toxicology information of that company's products will be extracted from company files and added to TIP's data banks. TIP's efforts to extract toxicology data from pesticide petitions submitted to FDA and EPA continues. In 1973, efforts to support other agencies with toxicology information and data on request will be expanded. TIP will also Initiate activities with other organi- zations to obtain toxicology data from their files. Development of Specialized Files and Products Based on the Published Literature In 1972 TIP completed the preparation of several publications and other infor- mation services including: a drug interaction bibliography; a thesaurus of toxico- logy terminology; a new abstract journal and companion computer tape service on the "Health Effects of Environmental Pollutants"; and the "Common Data Base", a compu- terized file containing structural and nomenclature information as well as Chemical Abstract* registry numoers for some 35,000 biomedlcally Important compounds, which is being maintained and regularly updated In collaboration with FDA. Plans for 1973 include the publication of a supplementary volume on Drug Inter- actions- continuation of the publication of several state-of-the-art reviews in various'toxicology subject areas; initiation of a continuing bibliography on drug metabolism; and publication of a supplemental volume listing compounds newly^ added to the"Common Data Base" since 1968. Automated Systems In 1972 the TIP has Initiated an on-line interactive computer system containing t-o*icoloKV information and data which will be available to users at a minimum cost «?« remote terminals. The system uses government owned computer software and a ernmant leased communications network. During the initial period of operation, the svstem has contained citations and abstracts primarily from the published litera In 1973 efforts will be directed towards enlarging tne scope of the sys~ implement, ac hiji "» ____ _.„„.-► K„t-h vreriTARS and the TIP data bases. to system iases.8410522_000018.txt

Page  18 2661 Toxicology Information Response System A toxicology information analysis and response center established by TIP via an NLM-AEC interagency agreement at the Oak Ridge National Laboratory (ORNL) became operational in 1972. The Center has been performing literature searches in various areas of toxicology for government agencies, industry, universities, and private individuals, such as physicians, on a request basis. The Center also has initiated and sponsored state-of-the-art reports, mostly on the health effects of environmental toxicants, by well-known experts. These reviews are being published in review journals or through the National Technical Information Service, Department of Commerce. The ORNL computer center is working with TIP on software development and data file building. Plans for 1973 include the development of additional review articles, expansion of the literature search services, and the creation of computerized data banks on the toxicology of pesticides and other environmental toxicants, hazardous household products, and chemicals posing a threat to occupational and public health. Review and Approval of Grants 1972 Appropriation Pos. Personnel compensation and benefits.......... 32 Other expenses.......... -- Total............... 32 Amount $581,000 129.000 1973 Estimate Pos. Amount 32 $618,000 128.000 710,000 32 746,000 Increase or Decrease Pos. Amount +$37,000 - 1.000 + 36.no This activity provides the administrative staff and program direction for aix grant programs authorized by the Medical Library Assistance Act of 1965 and its Extension Act of 1970, as well as for the international activities of the National Library of Medicine which are funded by the Scientific Activities Overseas appro- priation. The funds requested for this activity will provide the resources required to process, review and manage approximately 950 grant applications received per yea.;. This office provides staff assistance In the areas of grants management, direction,. program review and evaluation of applications and travel. Administrative support is also provided to the NLM Board of Regents and the various grant review committees. Program Direction 1972 Appropriation Pos. Amount 1973 Estimate Pos. Amount Personnel compensation and benefits.......... 56 Other expenses.......... -- Total............... 56 $ 930,000 1,524,000 56 $1,039,000 1,760.000 2.454.000 56 2,799.000 Increase or Decrease Pos. Amount +$109,000 + 236.000 + 345,000 This activity provides the program leadership and centralized administrative support necessary for the coordinated operation of the various NLM programs. It provides support for the Immediate Office of the Director, the Office of Administra- tive Management, and payment to the National Institutes of Health Management Fund foi services furnished centrally. In 1972 efforts have been directed towards the devel- opment of new and the improvement of current systems for the dissemination of bio- medical information. Specific emphasis has been placed on systems design for the distribution of toxicity information utilizing MEDLARS II and the Lister Hill Center's Biomedical Communications Network. Additional emphasis also has been placed on providing overall program evaluation and analysis for the Library's pro- grams. Included under this activity for 1972 and 1973 is $66,000 for program evalu- ation. In 1973 the above activities will continue to receive emphasis, and In addition the Library's current efforts in coordinating and developing biomedical8410522_000019.txt

Page  19 2662 communications systems and network prospects for the entire Department will be assigned higher priority. This activity will also support the costs associated with the participation of NLM employees In the Upward Mobility Program. Program Purpose and Accomplishments Activity: Training Grants (Medical Library Assistance Extension Act of 1970, P.L. 91-212, Section 394) ________________1973_______________ Budget *972______ Estimate Po»» Amount Authorization Pos. Amount $1,200,000 $2,000,000 --- $1,500,000 Purpose: The objective of the training program is to help meet the Nation's need for medical librarians, information specialists, and biomedical personnel trained in the utilization of computer technology for education and patient care. Recent data indicate that most librarians in health-related libraries (75%) have had little or no work in sciences related to health. Only 35% have had medical library training in the form of one course. These deficiencies impair infor- mation transfer and must be remedied. Explanation: Grants may be made to non-profit institutions qualified to conduct the proposed training activities. Grants may also be made to individuals in the form of fellowships. Accomplishments in 1972: A total of 17 grants which supported 123 trainees were active in Fiscal Year 1972; 4 new or competing renewal awards were made. In addition, three fellowship awards were made to individuals. These awards will upgrade the skills of personnel engaged in medical librarianship and the transfer of health information. Objectives for 1973: An increase of $300,000 over'the Fiscal Year 1972 level will support 3 additional training programs. This will permit the Library to support 20 projects, 13 of which will be continuations. Emphasis will be placed on train- ing health professionals in the health applications of computer technology. Support of current programs which provide further and specialized training for individuals will also be continued and expanded. They will be modified to empha- size doctoral programs rather than Master's degree and on-the-job training Including training for management. Activity: Special Scientific Project Grants, Medical Library Assistance Extension Act, Section 395 1973 Budget 1972 Estimate Appropriation" Authorization . $95,000 $500,000 $95,000 Purpose: Special Scientific Project grants support outstanding scholars In the full-time analysis and documentation of major advances in the health sciences; Explanation: Project grants are awarded to scholars and public or non-profit institutions on behalf of such scholars. Accomplishments in 1972: Three new project grants were awarded in 1972. Objectives for 1973: This program will be funde 1 at the 1972 level which will allow the support of 4 projects.8410522_000020.txt

Page  20 2663 Activity: Research Grants (Medical Library Extension Act of 1970, PL 91-212, Section 395b) ________________1973_________________ Budget Estimate_______ Authorization Pos. Amount $650,000 $3,000,000 — $900,000 Purpose: The purpose of the Research Grants program is to develop new methods of processing information and making accessible the rapidly growing body of bio- medical knowledge. Explanation: Grants are awarded to investigators and public or non-profit private institutions on behalf of such investigators. Accomplishments in 1972: There were 21 grant awards in this year; 12 were non- competing continuations, and 9 were new or competing renewal projects. Of these, 3 had to do with medical library operations and techniques, 12 with biomedical communications, and 6 with history of medicine. Objectives for 1973: The Library will make 26 awards, of which 10 will be non- competing continuations and 16 will be new projects. The projects will include studies to evaluate effectiveness of library services, Information-seeking behavior patterns of health professionals, and information services for clinical needs. Also included will be historical projects on themes relevant to current American health problems. Activity: Library Resource Grants (Medical Library Assistance Extension Act of 1970, P.L. 91-212, Section 396) _________________1973________________ Budget _______1972__________ Estimate Pos. Amount Authorization Pos. Amount $2,505,000 $4,500,000 — $2,705,000 Purpose: The purpose of the grants is to provide financial assistance and incen- tive for improving the basic materials, equipment, and services of local medical libraries. The emphasis is on upgrading medical libraries in hospitals, educational institutions, and medical societies by supplementing rather than supplanting local resources. There are two types of resource grants. The first is a 1-year non-renewable award for the purpose of establishing a basic collection. The second type is of a project nature and is awarded for a 1-3 year period to improve medical library services. This latter program complements the service activities of the Regional Medical Library Program. No resource grant may exceed $200,000 for any fiscal year. Explanation: Applications are submitted by a health science library or by an in- stitution for its library. They are evaluated by the Biomedical Library Review Committee and the Board of Regents of the National Library of Medicine using criteria which reflect the requirements of the legislation. Priority scores are assigned each approved application. Accomplishments for 1972: The Library made 407 awards in 1972, 167 were contin- uing projects and 240 were new grants. These grants will be awarded not only on the basis of local need but more importantly in consideration of how the Improve- ment, of local services will strengthen not only local services but the regional medical library area as well and, by extension, the entire RML network. 1972 Pos. Amount8410522_000021.txt

Page  21 2664 Objectives for 1973: In 1973, the Library expects to support 101 continuing grants and 353 new ones for a total of 454 awards. The new awards in 1973 will raise the total to 667 institutions receiving support under the Extension. Five hundred of these awards will be for establishing basic resources in first level libraries. The balance of the awards will be to primary and secondary resource libraries for improving services. Activity: Regional Medical Libraries Awards, (Medical Library Assistance Extension Act, Section 397) ________________1973 Budget 1972 Estimate Appropriation Authorization $2,102,000 $3,500,000 $2,902,000 Purpose: Regional Medical Library (RML) awards (grants and contracts) provide funds to support a national network of medical library services. Contracts sus- tain the regional operations of 10 Regional Libraries. Competitive Grants com- plement the contradts by providing support for projects which analyze existing methods, establish new services or methods, and improve existing services in the RML's. Explanation: The regional services of the Regional Medical Library contracts include lnterlibrary loans, on-line literature searches, and other reference services. The 10 prime contractors were selected because of the scope of their collections and the potential strength of their regional service components. Grants are available to Institutions within each region for improving or ex- panding the regional contracted services and are reviewed and evaluated by the Biomedical Library Review Committee and the Board of Regents of the National Library of Medicine. Accomplishments in 1972: The Library awarded three new contracts and six renewal contracts in 1972. Approximately 500,000 lnterlibrary loans will be made in FY 1972. Additionally access to MEDLINE, the on-line bibliographic retrieval system, will be afforded to all the RML's. Objectives for 1973: In 1973 the Library expects to renew 10 contracts and 15 new grants for a total of 25 awards. These grants and contracts will support: (1) the provision about 600,000 lnterlibrary loans; (?.) 50 continuing library education workshops for small hospitals; and (3) access to MEDLINE. Activity: Publications Support Grants, Medical Library Assistance Extension Act, Section 399 1973_______________ Budget Estimate 1972 t . , Appropriation Authorization $340,000 $1,000,000 $390,000 Puroose- The Publications Support Grants provide support for the preparation and/ or publication of secondary tools such as abstracts, bibliographies, handbooks, JLi critical reviews, as well as monographs and translations which condense, syn- thesize! evaluate, or otherwise repackage information for health scientists, educators, and practitioners. rrants are made to individual scientists or to public or non-profit S£gS£ of Serration on behalf of such scientists. Publications sorted £ the program are those of need and merit which cannot be financed by commercial publishers.8410522_000022.txt

Page  22 2665 Accomplishments In 1972: Fifteen grants were awarded in 1972; 6 were continuing projects and 9 were new or competing renewal projects, including a comprehensive bibliography that will combine in one volume the references to the massive, widely dispersed literature on Chayas disease, one of the major diseases of the Western Hemisphere; a critical review on the controversial issue of the hereditary impor- tance of non-chromosomal substances, which is of major importance to the developing field of human genetics. Objectives for 1973: In 1973, the Library will continue the support of 9 continu- ation projects and will support 8 new or renewal projects. New projects in 1973 will stress reviews, especially critical reviews, as well as reference tools needed by and useful to librarians and information specialists in the health sciences. Activity: Lister Hill National Center for Biomedical Communications ________________1973_____________ Budget ______1972 Estimate Pos. Amount Authorization Pos. Amount 19 $1,855,000 — 24 $3,072,000 Purpose: The Lister Hill Center applies communications and computer technology to improve health care delivery, medical education and biomedical research. Explanation: The Center matches high priority needs with technological capabili- ties to develop experimental services and evaluate their effectiveness. Proof of utility and acceptance of costs by the consumer is justification for incorporation into an operational biomedical communications network. Accomplishments in 1972: The Center initiated a national network providing access to bibliographic citations to current medical information stored in an NLM computer. This network called MEDLINE (MEDLARS On-Line) contained an expanded data base and served more than 60 hospitals, libraries and medical research facilities. New data bases have been added to the MEDLINE network to provide experiment- computer assisted instruction and diagnosis. This powerful tool could eventually permit interchange of data bases between medical schools and other schools of the health professions (totaling approximately 2,300) permitting students to learn at their own pace and increasing the capabilities of their faculties. An experimental network linking native villages, service unit hospitals, and major medical centers is now operating seven days a week in Alaska utilizing a communications satellite. This network provides reliable daily voice consultation between village health aides and physicians. An operational network could signif- icantly upgrade the primary health care afforded the 55,000 natives in the remote reaches of Alaska. The network also indicates whit could be done for millions of others in geographically isolated regions of the United States. DHEW and NASA have agreed to explore the use of the powerful Application Technology Satellite (ATS-F) to provide two-way TV for health and education experiments. The Lister Hill Center has been designated to lead the health- oriented effort which could impact on the well-being of some 40,000,000 Americans in scarcity areas. In 1972 emphasis has been on the detailed planning and schedul- ing of experiments and design of an inexpensive tw6-way satellite terminal. The Center has supported a television microwave network linking the Medical Schools of Dartmouth College and the University of Vermont with community hospitals. In addition, construction of a mobile van was begun to extend the network to insti- tutions where a valid need exists for better care and education but where it .s not economically justifiable to provide expensive fixed installations. The overall network will eventually link 15 hospitals and three university health centers in a mutually reinforcing program of improved health care delivery and education.8410522_000023.txt

Page  23 2666 The Center undertook two planning efforts to explore the use of cable television (CATV) to reach millions of urban dwellers who suffer from poor heali:h care and health education by virtue of their socio-ecomic situation. At the request of Congress a report is being prepared on the Lister Hill Center's prototype experiments and its plans for the future. It has responded to the Congressional request for development of a program of requirements for con- struction of the Lister Hill Center building. Objectives for 1973: The budget estimate for 1973 provides for the continuation of the programs described above. The approximately 1,200,000 funding increase in 1973 will support the following: (1) Communication costs which will be incurred in providing access by an expanded user population to the new computer data bases placed on the MEDLINE network. (2) Initiation of ATS-F satellite terminal procurement; testing to determine equipment required to transmit information on patient needs, physiological data, and video transmission when necessary; and initiation of training for participating health personnel in the use of communication equipment. (3) Training of health personnel in techniques of providing health care and education via CATV. (4) Expansion of the New England Interactive Network. The five new positions will be utilized for the monitoring of the contracts efforts described above. Activity: National Medical Audiovisual Center _______________1973____________ Budget ______1972 Estimate Pos, Amount Authorization Pos. Amount 108 $2,350,000 --- 110 $2,677,000 Purpose: The National Medical Audiovisual Center (NMAC) administers programs to improve the quality and increase the use of biomedical audiovlsuals in schools of the health professions and in the continuing education of health professionals. Explanation: NMAC acquires and distributes audiovisual Instructional materials which have been reviewed by peer professional organizations for direct relevancy to contemporary education in the health professions; provides educational research and consultation on audiovisual systems and media; develops prototype instructional media units; supports education through workshops, seminars, training programs and site surveys; and catalogs and shares reference information on audiovisual Instructional media. Accomplishments in 1972: In 1972, NMAC provided about 90,000 units of educational service or assistance to over 35,000 health-science Individuals or Institutions. The services Included: 68,000 film loans; 17,150 Instructional media reference search requests; over 300 educational consultations; workshops and seminars attended by over 900 health professional students, faculty and practitioners; about 1,581 videotape professional teaching programs duplicated and furnished to schools. In collaboration with BHME's Office of Audiovisual Education Development, NMAC accomplished about 40 health education projects relating to medicine, dentistry, nursing and allied health professions. Cooperative evaluation programs with 12 national health professional organizations resulted in peer review of approximately 2,000 medical films and videotapes. More than a dozen prototype units of multi- media Instruction were developed and tested in collaboration with schools of the8410522_000024.txt

Page  24 2667 health professions, national medical organizations, and other Federal health programs. The Center also initiated a "University-on-Loan" program, under which 30 medical educators, supported by their 28 universities, came to the NMAC to participate in cooperative programs to plan and develop media instructional applications. Objectives in 1973: In 1973, NMAC will provide an estimated 115,000 units of health educational services to 36,000 health science professionals and institutions an increase of 25,000 over 1972. Of this total, there will be about 85,000 film loans; 23,000 instructional media reference searches; and 1,800 professional-level videotape replications distributed to schools and organizations. The NMAC also anticipates modest expansion of the media resource data collection and the develop- ment of a visual abstracting mechanism to meet teacher's needs in media selection. The "University on Loan Program" activity will expand slightly as will the utilization of peer professional groups in screening and selecting instructional media to be placed in the NMAC collections. Collaborative projects with the SHME will be continued on health education projects that satisfy mutual program goals. Activity: Library Operations 1973 Budget 1972 Estimate Pos. Amount Author ization Pos. Amount 249 $8,481,000 --- 249 $8,670,000 Purpose: Library Operations provides bibliographic, reference and loan service as a central resource for a nationwide network of regional and local medical librar- ies. In addition, it compiles and publishes catalogs, indexes, and bibliographies of materials pertinent to biomedicine. - Explanation: This activity of the Library acquires and catalogs materials and indexes biomedical literature for incorporation into MEDLARS, the Library's com- puterized medical literature analysis and retrieval system. From the MEDLARS data base the Library publishes Index Medicus. 21 specialized bibliographies in the field of medicine, Abridged Index Medicus. and the Current Catalog of current books and technical reports. The Library also manages and coordinates a network of domestic and foreign MEDLARS stations and Regional Medical Libraries. The History of Medicine Division acquires, organizes and maintains historical source materials related to biomedicine. Accomplishments In 1972- NLM provided 260,000 services in its dual capacity as a central backup to the Regional Medical Libraries and as one of the components of the network. In addition, through the regional libraries it has provided more than 327,000 document deliveries and MEDLARS services. A 9,000 page, eight volume annual Cumulated Index Medicus. the 1,300 page Bibliography of the History of Medicine (1965-69), and the 7,000 page, eight volume Cumulated Current Catalog (1965-70) were published.------------------------ 1972 saw the initial implementation of the Library component of the Biomedical Communications Network with a new on-line bibliographic service called MEDLINE. A communications network will make the data available to 200 major medical schools, hospitals, and research institutions on a toll free or low toll basis. The data base will contain 607. of the MEDLARS data base or citations to 1,000 of the world's leading biomedical journals. During the year a contract was negotiated to provide for the commercial production and distribution of NLM catalog card sets at a moderate cost. Objectives in 1973: Plans for 1973 call for full implementation of the MEDLINE system with a gradual phasing out of the present MEDLARS Search Centers. Con- ventional retrospective MEDLARS searches will be processed solely at NLM as a backup resource for the MEDLINE Operation.8410522_000025.txt

Page  25 2668 Other conventional library operations will continue at approximately the same level of activity as in FY 1971 and FY 1972. Specifically, the Library will process 100,000 lnterlibrary loans, publish 21 recurring bibliographies; acquire 130,000 serial pieces and 14,000 monographs, bind 28,000 volumes and microfilm approximately 1,000,000 pages of deteriorating documents. Activity: Toxicology Information ________________1973 _______ Budget _1?I2 Estimate PoSf. Amount Authorization Pos. Amount 20 $1,318,000 — 20 $1,648,000 Purpose: The Toxicology Information Program (TIP) is responsible for developing and operating a computer-based toxicology information storage and retrieval system. It also Issues publications and other information packages and services to satisfy the needs of the scientific cosssunity, Industry and other federal agencies. Explanation: The TIP services as a national resource for toxicological information by organizing data from diverse sources into computer-based files. It also provides state-of-the-art reviews, annotated bibliographies and literature search services. Accomplishments in 1972: In 1972 the TIP continued to support a Toxicology Infor- mation Response Center at the Oak Ridge National Laboratory, to provide expert con- sultation as necessary in specific areas of toxicology. The TIP continued to em- phasize collaborative efforts with other federal agencies as well as academic and industrial organizations, as part of its efforts to coordinate toxicological data from a wide variety of sources. In the development and maintenance of its data files, the TIP emphasized adverse drug reactions, pesticides, and environmental pollutants. These efforts resulted in several new publications and computer ser- vices, Including the testing of an on-line Interactive toxicology data system. Objectives for 1973: The on-line toxicology information system will be expanded through the addition of more terminals which, when the system is fully operational, will permit remote access to the centralized computer files by other federal agencies, universities, and industrial organizations on a "pay-as-you-use" basis through a government-leased communications network. The capabilities of the system also will be enhanced through the creation, in cooperation with other government agencies, of additional computer software modules. The Response Center at Oak Ridge will expand its services through the preparation of additional state-of-the-art reviews and other evaluation services. The TIP also will continue to build a computerized link between the NLM'a MEDLARS data base and the computerized files of Chemical Abstracts Services. All of these activities are Intended to provide an effective toxicological Information component for the emerging National Biomedical Communications Network whose development the NLM is responsible for coordinating. Activity: Review and Approval of Grants (Public Health Service Act, Title III, Part I) 1973_____________ Budget 1972 . Estimate Amount Authorization Pos. Amount 32 $746,000 Purpose: This activity provides support for staff to manage the six grant programs authorized by the Medical Library Assistance Act of 1970, as well as international activities of the NLM funded by the Scientific Activities Overseas appropriation.8410522_000026.txt

Page  26 2669 Ey?Sanation: The functions of this office include the processing of approximately 9j0 grant applications and their review by program officers, staff assistance to reviewing committees and the Board of Regents of the National Library of Medicine, grants management and direction, and program review and evaluation. There are 3 Biomedical Library Review Committee meetings and 3 Board of Regents meetings a year. Accomplishments in 1972: In 1972 this activity provided the administrative support and program leadership necessary for a coordinated approach to the review of library and information oriented grants. Administrative support was also provided for the approximately 470 awards made in fiscal year 1972. Objectives for 1973: This activity will continue to provide administrative support to the NLM's expanded grant-in-aid program. Approximately 550 grants will be awarded in FY 1973. This includes support of research and development of new methods of making accessible biomedical Information. In the training area intern- ships, continuing education, and programs which lead to the Ph.D. will be strersed. Activity: Program Direction (Public Health Service Act, Title III, Part I) ________________1973_____________ Budget ______1972 Estimate Pos. Amount Authorization Pos. Amount 56 $2,454,000 --- 56 $2,799,000 Purpose: This activity provides the program leadership and centralized adminis- trative support necessary for the coordinated operation of the various NLM activities. Explanation: Program Direction provides support for the immediate Office of the Director, Office of Administrative Management, the Office of Public Information and Publications Management, and payment to the National Institutes of Health Management Fund for centrally furnished services. Accomplishments in 1972: Efforts in 1972 are being directed towards the develop- ment of new and the improvement of current systems being utilized in the dissemi- nation of biomedical information. Specific emphasis is being placed on the systems design for the distribution of toxicity information utilizing MEDLARS II and the Lister Hill Center's Biomedical Communications Network. There will be an additional emphasis on providing overall program evaluation and analysis for the Library programs. Objectives for 1973: This activity will continue to provide the overall scientific and administrative management of the NLM programs.- Emphasis will be placed on conducting meaningful program analysis and evaluation of the impact of NLM support as well as publications management and program planning activities. Current efforts in coordinating and developing biomedical communications systems and network pro- spects for DHEW will be expanded and assigned high priority in FY 1973. Additional- ly, the costs of NLM employees participating in the Upward Mobility Program will be funded in this activity. Included under this activity for 1972 and 1973 is $66,000 for program evaluation.8410522_000027.txt

Page  27 NEW POSITIONS REQUESTED Fiscal Y»«t 1973 Annual Grade Number Salarjr Lister Hill National Center for Biomedical Communications GS-14 1 Engineer $ 21,960 Communications Specialist GS-13 1 18,737 Electronics Technician GS-13 1 18,737 Computer Programmer GS-12 1 15,866 Engineer GS-H 1 13,309 National Medical Audiovisual Center Medical Officer GS-15 1 25,583 Audiovisual Educational Specialist GS-12 1 15.866 Total, New Positions 7 $130,058 \,8410522_000028.txt

Page  28 National Library of Medicine STATEMENT OF DR. MARTIN M. CUMMINGS, DIRECTOR, NATIONAL LIBRARY OF SCIENCE ACCOMPANIED BY: DR. ROBERT Q. MARSTON, DIRECTOR, NATIONAL INSTITUTES OF HEALTH DR. G. BURROUGHS MIDER, DEPUTY DIRECTOR, NATIONAL LIBRARY OF MEDICINE DR. LEROY L. LANGLEY, ASSOCIATE DIRECTOR, EXTRAMURAL PROGRAMS, NATIONAL LIBRARY OF MEDICINE KENT A. SMITH, EXECUTIVE OFFICER, NATIONAL LIBRARY OF MEDICINE DR. ROBERT W. BERLINER, DEPUTY DIRECTOR OF SCIENCE, NATIONAL INSTITUTES OF HEALTH LEON M. SCHWARTZ, ASSOCIATE DIRECTOR FOR ADMINISTRA- TION, NATIONAL INSTITUTES OF HEALTH LELAND B. MAY, ASSISTANT DIRECTOR OF FINANCIAL MAN- AGEMENT, NATIONAL INSTITUTES OF HEALTH CHARLES MILLER, DEPUTY ASSISTANT SECRETARY, BUDGET BUDGET REQUEST Senator Fong. Next, the National Library of Medicine. The budget request is $28,568,000, an increase of $4,441,000 over the 1972 appropriation of $24,127,000. Dr. Martin Cummings, Director of the Library, will present the request. Dr. Cummings. PREPARED STATEMENT Dr. Cummings. Thank you, Mr. Chairman. I will present a summary of the statement- Senator Fong. Your testimony will be received in full and you may highlight it. (The statement follows:)8410522_000029.txt

Page  29 2672 Mr. Chairman, Members of the Committee: The National Library of Medicine is responsible for acquiring, organizing, and disseminating informational materials in the health sciences. In carrying out this mission, the Library has built up the most important collection of biomedical literature ever assembled, now numbering over 1,300,000 items. In recent years the Library has been faced with an ever-increasing workload as it strives to keep pace with the information explosion that has occurred in the health sciences. When the NLM began in 1836 only 11 medical Journals were being published in the United States. Those 11 have multiplied to the more than 6,000 U.S. medical journals published annually today—a staggering increase. More new and useful medical knowledge has been acquired in the lifetime of the NLM than in all other ages of the past. Whereas the cost of acquiring the medical literature has increased steadily at 10-12 percent for several years, the rate more than doubled in calendar year 1971. This causes some concern not only because of the increase in acquisition costs but also because requests for loan of books and monographs tuve doubled during the last six months. It is much more costly to loan books than photocopies of journal articles. I am pleased to report that the National Library of Medicine met its production goals and objectives last year. We have continued to provide competent and efficient library services to a constituency of users which includes health science practitioners, educators and scientists. In addition, we have continued to implement the specialized medical informa- tion and communications programs which we described last year. MEDLINE Specifically, our n*w on-line reference retrieval system MEDLINE has been operating efficiently since December 1971. It replaces the earlier version called AIM-TWX which was us^d successfully by more than 80 insti- tutions' throughout the country. Whereas AIM-TWX contained citations to little more than 100 journals, MEDLINE win cover approximately 1,000 periodi-8410522_000030.txt

Page  30 2673 l cals which provide more than one-half of the entire MEDLARS file. A MEDLINE search costs approximately $9 as compared to $60 for the MEDLARS search which it replaces. Searches are completed in 10 to 15 minutes in contrast to 10 to 15 days required by the older system. A commercial communications network will make MEDLINE available to major medical schools, hospitals and research institutions at low cost. Approximately 200 insti- tutions can join the network during fy 1973. Whereas the Library fully subsidized all domestic MEDLARS searches, the user pays the line charges for MEDLINE. This development should reduce the need for the longer MEDLARS searches. Thus most of the MEDLARS centers in the United States will be phased out and the funds that have supported their operations will be used to maintain the ttEDLINE communications network. We would emphasize that this network will be available to transmit data other than bibliographic citations and in time should encourage dissemination of other information in a variety of other computerized data bases. As I informed this committee last year, the Library is actively engaged in redirecting the development of the new system MEDLARS II. It will be completed by the end of fy 1973. LISTER HILL CENTER FOR BIOMEDICAL COMMUNICATIONS The Lister Hill Center's satellite communications project has been critically tested and found to be most useful in improving medical com- munications to remote villages in Alaska. On at least two occasions it provided information which proved to be life-saving. It has served to bring medical assistance to persons who previously could not be reached by telephone or radio communications. It has helped physicians determine when patients need to be evacuated to district or regional hospitals for emergency care. On the other hand, it has cut down on unnecessary bush plane evacuation when the patient could be managed by a health aide or local nurse after satellite consultation with a physician. We are pleased with the accomplishments and plan to extend the system to other regions of our nation where great distances and rugged terrain make patient-physician contact difficult.8410522_000031.txt

Page  31 f\v 2674 The National Aeronautics and Space Administration plans to launch a sophisticatedjBatellite late in fy 1973. The staff of the Lister Hill National Center for Biomedical Communications has been working closely with NASA to define a series of experiments using the new satellite to test the utility of interactive programs in improving health =are. The experiments are being designed to meet the needs of a number of selected locales. I Experience with r.he interactive television system operating successfully in New England strongly indicates the desirability of expanding that network through Vermont end New Hampshire tnd conducting similar studies via the new satellite in other parts of the country. The medical literature continues to grow at a rate of 6 percent a year. At this rate of growth our facilities will be overflowing by 1975. It is therefore essential that the building authorized by Congress for the Lister Hill Communications Center be completed by that date so that we may move personnel and communications activities into the new facility and restore the space they presently occupy to conventional library functions. NATIONAL MEDICAL AUDIOVISUAL CENTER The National Medical Audiovisual Center continues to serve American medicine by acquiring, producing, cataloging and distributing audiovisual materials which are used in the teaching and practice of medicine, dentistry and the allied health professions. It makes its resources available to professional societies and academic health centers through collaborative arrangements. The Center offers a variety of highly successful workshops through which it teaches the fundamentals of audiovisual technology utilization. One of the most significant developments of the past year has been the merging of interests in advancing the education of health professionals by the Bureau of Health Manpower Education and the National Library of Medicine. The Bureau interacts constantly with a variety of educational interests, has intimate knowledge of curricular content, and closely monitors educational trends. The Library, on the other hand, has estensive expertise in the development of audiovisual materials which enhance the learning process and8410522_000032.txt

Page  32 2675 tt^ome increasingly important in restructuring of the academic experience. Moreover, the Library has long experience with development and management of computerized 1iles and has developed the concept of networking to increase utility and cost-effectiveness. The melding of these different skills on the basis of mutual interests should create a more progressive and cohesive program than could possibly result from each organization going its separate way. MEDICAL LIBRARY ASSISTANCE ACT Through the Medical Library Assistance Act we have been able to improve significantly library and information services at local and regional levels. BeLter library resources for community hospitals, teaching hospitals and academic health centers have been made available to more than 600 institutions in the 50 states. The Regional Medical Library network is fully operational and now provides 500,000 lnterlibrary loans annually. Several hundred young medical librarians have been trained to fill the gaps within the profession and to assume.its leadership in the very near future. The training program is being strengthened by phasing out support for training in conventional librarianship to emphasize the specialized needs of medical libraries and communications science and to develop management capabilities. TOXICOLOGY INFORMATION PROGRAM The Toxicology Information Program collaborates extensively with other Federal agencies, such as the Food and Drug Administration and the Environ- mental Protection Agency, to collect, organize, and automate toxicology data from diverse and previously uncoordinated sources. It is developing a Toxicology Information Query Response Center at the Oak Ridge National Laboratory (AEC), which draws as needed on the capabilities of their scien- tists to provide special analyses and evaluations of toxicological data for Federal agencies, industry, and the scientific community in general. The increase of over $300,000 in fy 1973 for this program will be utilized primarily to pla>:e this Query Response Center into full operation.8410522_000033.txt

Page  33 2676 Toxicologist.s generally prefer to use abstracts as alerting systems. Therefore, the Toxicology Information Program has negotiated with such organizations as Chemical Abstracts Service and Biosciences Information Services (BIOSIS) to purchase abstracts at modest costs and repackage them to suit the needs of toxicologists. In collaboration with BIOSIS a new abstract journal, "Health Effects of Environmental Pollutants," has been issued in experimental format and will begin regular publication this year. An on-line interactive toxicology information system will be expanded through the addition of more terminals and the creation of additional data bases. SUMMARY As we prepare for the future, we remain sensitive to the information and communications needs of American medicine. A library can only be responsive to its clients through an intimate understanding of their requirements. We believe that the progress of medical science is reflected in our enlarging information base and we are committed to share this information rapidly and efficiently with all those who have a need to know. In summary, our request for fy 1973 is $28,104,000 an increase of $3,998,450 over the amounts available for obligation in fy 1972. The net increase reflects program increases of $2,907,450 and $1,091,000 for mandatory increases, such as within-grade increases, additional NIH Management Fund assessments for centrally furnished services, and increases associated with non-competing continuation grants supported under the Medical Library Assistance Extension Act of 1970.8410522_000034.txt

Page  34 2677 COMPETENT AND EFFICIENT LIBRARY SERVICES Dr. Cummings. I am pleased to report that the National Library of Medicine met its production goals and objectives last year. We have continued to provide competent and efficient library services to a con- stituency of users which includes health science practitioners, educa- tors, and scientists. In addition, we have continued to implement the specialized medical information and communications programs which we described last year. MEDLINE Our new on-line reference retrieval system Medline has been operat- ing efficiently since December 1971. Searches are completed in 10-15 minutes in contrast to 10-15 days required by the older system. A com- mercial communications network makes Medline available to major medical schools, hospitals and research institutions at low cost. Ap- proximately 200 institutions will join the network during fiscal year 1973. LISTER HILL NATIONAL CENTER FOR BIOMEDICAL COMMUNICATIONS The satellite communications project has been critically tested and found to be most useful in improving medical communications to remote villages in Alaska. On at least two occasions it provided infor- mation which proved to be life-saving. We are pleased with the accom- plishments and plan to extend the system to other regions of our Nation where great distances and rugged terrain make patient-physician con- tact difficult. Experience with the interactive television system operat- ing successfully in New England strongly indicates the desirability of expanding that network through Vermont and New Hampshire and conducting similar demonstrations in other parts of the country. Centeb Repobt to Congress These and other activities are in our report to Congress. Senator Fong. That will be received as part of the record. (The report follows:) 74-334 O—72—pt. 3----238410522_000035.txt

Page  35 2678 PREFACE On August 3, 1968 the President of the United States signed into law the Senate-House Joint Resolution 193 of the 90th Congress supporting a proposed center for biomedical communications and designating it as the Lister Hill National Center for Biomedical Communica- tions. On September 18, 1968, the Secretary, DHEW, established the Center as an organizational entity of the National Library of Medicine implementing that Resolu- tion. The purpose of the Center is to adapt existing techniques and develop new computer and communica- tion technologies for incorporation into operational biomedical communications networks in support of health care delivery, education and research. In recognition of the importance of the Center's services, the following statement was included in the Report of the Committee on Appropriations of the July 29, 1971, hearings on the DEPARTMENTS OF LABOR, AND HEALTH, EDUCATION, AND WELFARE, AND RELATED AGENCIES APPROPRIATION BILL, 1972: "As the success of the Center's efforts will ultimately depend on their acceptance and support by the medical and scientific communities, the Director of the National Library ot Medicine and the staff of the Lister Hill Center should prepare an informative report on its prototype experiments—such as the satellite communica- tions link with remote regions in Alaska and the two-way television network in New England-and its plans for the tuture. One of the purposes of the report should be to stimulate awareness of and interest in the ways in which modem communications techniques can be adapted and expanded to serve all facets of health services, biomedical research and the training of health professionals." This Report to Congress is forwarded in response to this direction, and is an accounting of our stewardship to date—of what has been accomplished in three years.8410522_000036.txt

Page  36 2679 THE LISTER HILL NATIONAL CENTER FOR BIOMEDICAL COMMUNICATIONS Report to the Congress of the United States Rapid expansion of medical knowledge and advances in technology have led the public to expect and demand more accessible and better health care. To meet these expectations will place an increased demand on all components of the health system and will require more efficient utilization of manpower and facilities to keep down and, hopefully, reduce the costs of achieving the goal. Technology will be called upon more and more to assist in improving efficiency and extending the capabil- ities of the limited and already strained manpower resources. The Congress early recognized the importance of communication and the need for a national center to give impetus and direction to a national program of biomedical communications. Its development was under- taken on the recommendation of the House and Senate Appropriations Committees and the House Special Sub- committee on the Investigation of the Department of Health, Education, and Welfare (1966). This subcom- mittee recommended that the National Library of Medicine establish a research center in biomedical communications, and establish a national' biomedical clearinghouse and referral service. On August 3, 1968, the President signed Joint Resolution 193 into Public Law 90-456 creating this center as the Lister Hill Naiioiial Center for Biomedical Communications. On September 18 the Secretary, DHEW, established that Center as an organizational entity of the National Library of Medicine within the National Institutes of Health. The Lister Hill Center is concerned with the use of computer and communication technologies to meet biomedical needs. The technologies involved-com- puters, communication satellites, computer and com- munication networks, microwave and cable television- are not new. They have required over thirty years and billions of research and development dollars to reach their present level. But these dollars were spent for defense, for space exploration, for business profits, not for health care delivery. A comparatively modest invest- ment of the Center's time and money is required to modify, adapt, blend and apply these existing technolo- gies to meet the Center's objectives: 1. To assist the development of new knowledge and to speed new knowledge to application; 2. To improve training at all levels of health professional education: undergraduate, graduate, and continuing; 3. To facilitate and reduce costs of health services delivery; 4. To improve the public's understanding of pre- ventive medicine and healthful living. In anticipation of establishment of the Lister Hill Center, the Associate Director for Research and Devel- opment of the National Library of Medicine published a Technical Development Plan for the period 1969-1974, which contains- the basic concept of a Biomedical Communications Network as an interrelating complex of five basic components: A. The Library Component B. The Specialized Information Services Com- ponent C. The Specialized Education Services Component D. The Audio and Audiovisual Component E. The Data Processing and Data Transmission Component The Biomedical Communications Network provides the mechanism, the organizational structure, and the management vehicle for the informational and educa- tional service responsibilities of these components. It is also the means for the transfer of technology into applications within medical information and education systems. As such, the Network represents a combination of operational services, of experimental services and procedures, and of design and engineering of new improved communication services and techniques.8410522_000037.txt

Page  37 268u During the intervening yean the balance of effort has shifted as procedures, services, and systems pass from the development phase to the operating phase. What has remained constant are the responsibilities of the Center to: 1. Design, develop, implement, and provide tech- nical management of a Biomedical Communica- tions Network; 2. Assist the biomedical community in identifying and developing products and services for dissemi- nation over the network; 3. Develop petwodu and information systems to improve health education, medical research, and the delivery of health services. The programs of the Lister Hill Center axe planned to explore the application of communication and computer system technologies to health needs. They are designed to determine the modalities of information (voice, data, video) and kinds of service best supported by various combinations of propagation media and communication technology. They will also define the bounds (geo- graphic, demographic) within which each configuration provides the maximum cost/benefit ratio. Those applica- tions which provide a useful, cost-effective service will be incorporated into the Biomedical Communications Network. SATELLITE NETWORKS Satellite Projects Some areas of the United States receive inadequate health service because of isolated geographic or severe climatic conditions. Short-wave radio waves can go from a ground station to a communication satellite and back to another ground station with far more reliability than normal transmission routes parallel to the earth's sur- face. A communication satellite can reliably connect these isolated communities' with physicians, thus pro- viding sorely needed consultation and direction. Such an experimental network has been installed in Alaska utilizing the National Aeronautics and Space Administra- tion's Application Technology Satellite, ATS-1. This Satellite is located in stationary orbit over the equator at approximately 150° West Longitude. Thus, it is visible 24 hours a day to more than a third of the earth. The Alaskan network consists of simple inexpensive termi- nals in villages, field service unit hospitals, and medical centers interconnected with a voice link operating through the satellite. Medical traffic is carried two hours per day, seven days per week and has been functioning successfully since August 1971 with very little time lost from the ionospheric interference which makes conven- tional radio useless, frequently and for long periods of time. The network is credited thus far with saving two lives in medical emergencies. The services provided are: 1. Voice consultation between community health aides and physicians at Native Health Service Hospitals, and between physicians and consultants at Medical Centers; 2. Continuing education of health aides, nurses, and physicians; 3. Education of villagers in personal health matters; 4. Communications between hospitalized patients and their families in native villages. The purpose of the Alaska Experiment, is to deter- mine which useful services can be provided by voice communication. Scientists and engineers at Stanford University, the University of Washington, and the University of Wisconsin are experimentally transmitting computer-generated data, receiving print materials from unattended terminals, and transmitting x-rays, other forms of pictures, electrocardiograms, and other physio- logical data via the satellite. When the quality is judged adequate and all interfaces between equipments defined, additional services will be incorporated into the Alaskan network to ascertain their contribution to the health care and education of the native population. A similar network is being planned for Micronesia, the Trust Territory of the Pacific Islands, and American Samoa. Ground stations on at least three islands will be linked to the major medical, educational, and library resources of the University of Hawaii via the ATS-1 satellite. ATS-F Satellite Project ATS-1 is a low-powered satellite and therefore cap- able only of transmitting narrowband information. To attempt to receive television would require large, com- plex, and very costly terminals. However, to evaluate the optimally useful services which could be carried via satellite, a full video capability is essential. In 1973, NASA will launch another in the ATS series bf satellites, ATS-F. The ATS-F is the sixth in a series of experi- mental satellites designed to explore communications, navigation, and scientific phenomena in space. NASA has recently added a receiver/transmitter specifically for8410522_000038.txt

Page  38 2681 experimentation b> (he health and educational commu- nities This satellite is sufficiently powerful to provide quality television with simple, cheap ground terminals. Planning for its use is already underway by the health community with technical guidance from the Lister Hill Center. The new experiments will explore the benefits of television as well as narrowband transmissions in support of health care delivery and education. Because of the total capability which can be provided by ATS-F, and recognizing that needs will vary from region to region, it is planned to include experiments in the Northwest (including Alaska) and the Rocky Mountain states in order to gather information which is applicable to as broad a cross section of the country as possible. The particular experiments have not yet been developed in detail but will probably be drawn from the following: I. Medical consultation for remote health pro- fessionals: physicians and other health profes- sionals serving remote Indian populations, and nurse practitioners and physician assistants in remote sites; 2. Programmed instruction between medical schools, and between medical schools and remote field sites to explore the feasibility of sharing faculty to provide a well-balanced program across all disciplines. Specifically, one experiment will involve the education of students in Fairbanks, Alaska by faculty located at the University of Washington. Training students in their local set- tings may increase the percentage of health profes- sionals retained in their native states. A second experiment will explore continuing education of physicians and other health professionals through a regularly scheduled video link with faculty at the medical school; 3. A combined education and health program for migrant workers and their families using a mobile terminal; 4. Continuation of the Alaskan experimental med- ical services to remote villages with the addition of video, and hopefully the provision of a 24-hour emergency medical call-up service from remote villages. In addition to the obvious benefits accruing to health education and delivery of health services, a very impor- tant objective of this extensive satellite experimentation is to develop a base of experience and knowledge to support the formulation of biomedical communications CABLE TELEVISION NETWORKS During 1971 national attention was focused on cable television (CTV). Federal agencies directly concerned with health care delivery systems and health professional education were directed to develop programs and plans for application of this communication medium to the improvement of the public's health. The Lister Hill Center supported efforts to establish useful pilot proj- ects in which CTV is incorporated into health care delivery systems and educational programs. Millions of people living in urban ghetto areas do not receive adequate health care. It is unlikely that the present pattern of health care delivery will appreciably alter the isolation of these individuals who often are as remote from proper medical care as are the natives in outlying Alaskan villages. The causes of this problem are varied and numerous. It is difficult to get trained professionals to live and work in urban ghetto areas. Distrust and fear of the existing system combined with ignorance of available diagnostic and treatment facilities contribute to the failure of many individuals to seek medical care. In many instances language barriers aggra- vate the problem. Since these people depend so heavily on television for information and entertainment, there should be no difficulty in getting them to relate to the TV monitor. Programs directed at improved patterns of self care of the chronically ill and disabled should greatly diminish associated discomfort and disability. Educa- tional programs dealing with personal and community health should increase the feeling of "belonging" to society. Participation in an educational endeavor will make entry into the medical care system less difficult and much more rewarding both to the patient and to the health professional who provides the care. Several possible sites were carefully examined for the trials of CTV because of the urgent need for improved services to the people in urban ghettos. Ethnic back- ground, population densities, existing health services, and other factors influencing health care were studied. Rather than attempt to establish new health care delivery systems that utilize cable television, the com- munications system will initially be introduced and evaluated in existing health care/educational settings where acceptance is already established.8410522_000039.txt

Page  39 2682 Denver, Colorado Cable TV Project Neighborhood health centers in Denver have proven valuable in the delivery of health care to the lower socio-economic strata of the city. The role of and need for telecommunications in the delivery of health care and education have been documented and consist of the capability for voice and visual interaction between two or more health professionals located at remote points in the system; e.g., physician and nurse, or physician and allied health personnel. The Colorado Medical Center (the University of Colorado Medical School complex), the Denver General Hospital (City Hospital), the neighborhood health clinics and other organizations and institutions are involved in the total program of health care for ghetto areas. While the primary function of these organizations is the provision of health care, education of health professionals is given high priority in planning. Medical students at the University of Colorado will be involved in the system at all points. House staff training will be carried on throughout the system in order that proper emphasis can be placed on the delivery of medical care in the context of the needs of the individual as a part of a total community. Allied health professionals, who will provide a major portion of the primary care, will have 24-hour access to information and consultation via the broadband cable TV communication system. Current trends in health planning and manpower training indi- cate that a considerable portion of primary care will be provided by personnel other than physicians in the near future. A variety of applications tested elsewhere appear to be applicable to the Denver project. Real time consulta- tion concerning health care problems is of utmost importance. Transmission of physiological data (electro- encephalograms, electrocardiograms, etc.) is also impor- tant, and connecting neighborhood health centers with a central computer will provide access to information that is a part of the total patient record. Two major health clinics provide medical and admin- istrative support to six neighborhood health centers. The cable system will provide particulady valuable support to these small clinics or centers which may depend for primary care principally on allied health professionals. The communications network for the Denver project will consist of the personnel and devices to provide interactive audio and video information and the channels which connect the Colorado University Medical School and Hospitals with Denver General Hospital, the East and West Side Clinics, and with the smaller clinics or centers that depend on the East and West Side Clinics for support. Mt. Sinai-East Harlem Cable TV Project The Mt. Sinai-East Harlem project presents an oppor- tunity to develop a unique patient and public inform*. tioo and education system. Mt. Sinai Medical Center has accepted responsibility for the health care of that segment of New York City known as East Harlem, an area almost completely composed of low income minor- ity groups. Historically, the Mt. Sinai Medical School has developed its programs and policies by considering the three elements: health care delivery, medical education, and research. They have now included a fourth ele- ment—representation from the consumer or user popu- lation—to broaden support for the community-oriented health care system. East Harlem has a population of approximately 200,000 people of whom 90% are black or Puerto Rican in almost equal numbers: the balance of the population is white. A substantial portion is elderly and confined to their homes. Almost one third of the people live in public housing. This poverty area suffers from almost all the inherent inner city problems: poor housing, inade- quate education, high dependence on welfare, high crime rate, and high incidence of illness. The generally poor quality of health care available to ghetto residents add to those difficulties resulting from advanced age, physical disability and ignorance of the health system-ignorance that is often due to recent removal from previously familiar neighborhoods. These individuals depend to a large degree on commercial television for information about the world in which they live. Therefore, Mt. Sinai anticipates that two-way interaction between the Medi- cal School and residents of apartment complexes in the East Harlem area via Cable TV will greatly improve their ability to provide the improved services that are needed. Programs designed to increase the individual's ability to provide self care as well as educational programs for general health education will be emphasized. The two- way capability of the system will allow individual users to access special information services and programs. It also will provide constant feedback of information necessary to update and restructure the system. As the system becomes more familiar to the health professional, it will have increasing value in continuing education of all components-physicians, nurses, licensed practical nurses, physicians' assistants, and others.8410522_000040.txt

Page  40 2683 Evaluation of the effectiveness of Cable TV in providing a higher quality of health care or education will occur in three stages. The first stage will be to determine "popularity," that is, the percentage of potential users, either health professional or public, who use the system as a learning resource, the number and nature of patients who obtain health care more rapidly, and their expressions of satisfaction with the services performed. The second stage will test the knowledge gained by the health professional and ascer- tain the effect the information transferred has on the particular community served in terms of changes in patterns of health care utilized and the development of new or improved services. The third stage will be to determine how rapidly corrective health care has been made available with the aid of the cable system. Technical evaluation will consist of determining cost effectiveness based on the cost of the system as compared with cost for equal service using other media. NEW ENGLAND MICROWAVE NETWORK Impediments to effective continuing medical educa- tion efforts by medical centers for those who deliver health care in mountainous rural areas is formidable. The harsh climate and rugged terrain of New Hampshire and Vermont resulted in the development of a patchwork of small communities and small community hospitals served by health professionals largely isolated from major medical resources. The difficulties imposed by these physical realities on those who deliver care in these communities are compounded by heavy service de- mands, resulting in little opportunity for participation in educational efforts which are not directed at immediate and relevant patient problems. Younger physicians fear professional isolation and shun service in the smaller communities.1 University Medical Centers must find appropriate means to extend their educational resources to those who deliver health care in relative isolation without compromising or seriously diverting the limited manpower of the educational institutions. 1 Sec, for example, "Health Care in the Northern Counties of New Hampshire and Vermont," a report to the Northern New England Health Advisory and Planning Committee, New England Regional Commission, and Medical Care and Education Founda- tion, Inc.. April 1969. Full, two-way interactive television is the best, and perhaps the only technology available today for bringing the medical school classroom to the small community hospital and, simultaneously, bringing the busy commu- nity health professional to the university classroom. Doctors in the community hospital can now participate in grand rounds with their university colleagues. Nurses in coronary care units can share instruction and experi- ences in patient care. University faculty members can teach nursing students at the University Hospital and a small local vocational school simultaneously. All these activities are underway with an experi- mental microwave television link connecting Dart- mouth's Medical School and University Hospital in Hanover, N.H. with Claremont General Hospital in Claremont, N.H. 30 road miles away. The link was originally started under the sponsorship of the National Institute of Mental Health to provide psychiatric consul- tation by Dartmouth psychiatrists to general practi- tioners and their patients in Claremont. Since the Lister Hill National Center for Biomedical Communications assumed sponsorship of the project in July 1970, users of the television link have grown and expanded until there are now ten hours of regularly scheduled opera- tions, six days a week—with programs ranging from surgical rounds on Saturday mornings to a pharmacology course for licensed practical nurses and actual psychi- atric consultation and therapy. Construction is sched- uled to start this spring on a mountaintop microwave network, extending ISO miles to the northwest, linking Dartmouth with the medical school of the University of Vermont in Burlington. Another community hospital, Central Vermont Hospital in Berlin, Vermont will join the network at the same time. Plans are already underway for residents at the University of Vermont to do some of their training at Central Vermont, while retaining their ties to the University via television. Beginning in Fiscal Year 1973 television service will be extended to other institutions, including hospitals too small to be able to take advantage of television seven days a week. A van-mounted microwave unit is being designed to provide television service to several small hospitals and clinics within line of sight of one of the network's relay points. The van will carry the television equipment to connect these small hospitals to the network on a regularly scheduled basis. This innovative approach should make it possible to provide needed services in areas which do not justify the expense of a fixed installation.8410522_000041.txt

Page  41 2684 WIRELINE NETWORKS MEDLINE Service In October 1971 the National Library of Medicine initiated a new service, MEDLINE (MEDLARS On- Line), to provide an on-line bibliographic searching capability for libraries at medical schools, hospitals, and research institutions throughout the country. MEDLINE allows almost instantaneous searching of the medical literature. Development of MEDLINE has been spurred by the success of AIM-TWX (Abridged Index Medicus via the Teletypewriter Exchange Network), an experi- mental service inaugurated by the National Library of Medicine eady in 1970. AIM-TWX itself was the result of three years' development by the Lister Hill National Center for Biomedical Communications. The AIM-TWX service demonstrated the value of on-line retrieval, particularly in hospitals. For AIM-TWX, citations to articles published during the last five years in over one hundred journals in clinical medicine were stored in the large, time-sharing computer of the System Development Corporation, Santa Monica, California. The journals covered include those in NLM's new Abridged Index Medicus (AIM). The Toxicology Information Program, NLM, has also added a limited number of clinically relevant serials containing toxicol- ogy information. These additional journals, with their article citations and Medical Subject Headings (MeSH) indexing terms, are now also available in the AIM-TWX data base. The larger MEDLINE data base consists of about 400,000 citations to articles from more than 1,000 journals indexed for MEDLARS since January 1, 1969. MEDLINE operating on the National Library of Medi- cine's IBM 370/155 computer can support many simul- taneous users. The service can be called from com- munications terminals connected to the commercial telephone network. The user can search the vocabulary to find appropriate search terms or enter directly subjects, subheadings, dates, authors' names, language or other search terms. The computer informs him of the number of documents for each subject. He can combine terms to pinpoint his interest. Finally, the bibliography can be printed at his terminal or it can be mailed to him. The Library supports and manages a nationwide data communication network to facilitate access to the service by authorized users. Access is achieved, via telephone lines, teletype, TWX, and other terminals operating at 100, 148, or 300 words per minute. The communications network enables users in more than thirty-five major cities (nodes) to reach the computer at the cost of a local telephone call; users elsewhere pay only the charges to the nearest node. Eleven Regional Medical Libraries provide the mana- gerial and document delivery backbone of the MEDLINE network. Other medical libraries will be provided access to ensure availability of service to all health professionals. Libraries desiring access to MEDLINE must provide evidence of a previous service record to biomedical scientists and practitioners within their communities, both within and outside their own institutions. They must pay their own terminal and telephone costs. Analysis performed to determine the relative costs of providing service using the existing MEDLARS I and MEDLINE approaches has been made and shows a substantial saving in favor of MEDLINE. MEDLINE service is just the beginning of the service to be provided via the Data Communication Service. In early spring, the AIM-TWX service will be available from the same telephone numbers. By mid-summer a variety of diagnostic systems and computer-aided instruction as described below will be available. Thus, medical stu- dents, physicians, and allied health professionals will have access to an increasingly sophisticated repertoire of information services and aids through our Data Commu- nication Service. Computer Simulation Projects The computer has become a medical school faculty assistant, not as a clerk, accountant, or librarian, but as a patient, tireless colleague, ready 24 hours a day, seven days a week to teach, to review, to give and score examinations and to simulate patients with various common or obscure diseases. This new service consti- tutes the Biomedical Data "Network portion of the larger Data Communication Service. Until the advent of the Lister HiB Center's Biomedi- cal Data Network, such computer programs were, by and large, mostly used only on the campuses,where they were developed. In November 1970 the Board of Regents of the National Library of Medicine recom- mended the "organization of a biomedical communica- tions network fundamentally conceived as providing the8410522_000042.txt

Page  42 2685 mechanisms by means of which inter-institutional coop- eration and sharing of resources will be used to meet some of the needs of medical education and medical practice." Three centers are notable in the application of computers to undergraduate and continuing medical education: Ohio State University Medical Center; the University of Illinois Medical Center in Chicago, Illinois; and the Laboratory of Computer Sciences of Massa- chusetts General Hospital and Harvard Medical School in Boston, Massachusetts. Each of these centers has its own computer, its own unique sets of teaching routines and each is willing to share its resources with others. Ohio State University Medical School has specialized in the application of computer aided instruction to the first two years of undergraduate medical education. Much of the teaching is done through computer consoles with the students allowed to spend the time they need to master thoroughly the subjects. The University of Illinois Medical Center is best known for the CASE programs. These are simulated clinical encounters in which the computer acts the role of the patient and the student diagnoses and records therapy prescribed on the basis of the computer store of symptoms. CASE is particularly applicable to the second two years of undergraduate education, with applications for continu- ing medical education. Massachusetts General Hospital offers a wide variety of computer simulations of varying disease syndromes, of biochemical models and of various clinical encounters. The Massachusetts General Hospital programs are expected to be of interest for a wide variety of applications from undergraduate education to actual use by the practicing physician. Plans are now well underway to connect the com- puters at each of these centers to the network which also carries MEDLINE, and to make the services of these computer centers available for improved medical educa- tion across the nation.* Further expansion^ is planned for the future. The present system for examining physicians for their quali- fying "Boards," by assembling candidates and examiners in the same place at the same time is costly both in time and money. The National Board of Medical Examiners and a number of specialty boards, including the Ameri- can Board of Internal Medicine have been exploring the problems of giving these examinations by computer to candidates at remote sites. Consideration is being given to the Center's Biomedical Data Network as a means for developing and transmitting examination materials. It is also planned to include instructional materials of value to dentists, nurses, and allied health professionals. IMPROVED LEARNING TECHNIQUES Are notebooks and handwritten lecture notes obso- lete? Can today's medical students learn more effectively through the use of a tape recorder instead? Does one have to spend 45 minutes listening to a play-back of a 45-minute lecture? These are some of the questions posed in an experiment being carried out at the George Washington University College of Medicine. Two devices have made this experiment possible: the inexpensive, durable, battery-operated cassette tape recorder, and the "speech compressor," a machine that can cut the time required to play back a recorded lecture by half. Last fall each entering medical student was loaned a tape recorder, and encouraged to use it as if it were his own. Lectures of cooperating faculty are being recorded, and duplicated on cassettes at either normal or com- pressed rates. Students can borrow these tapes, together with sets of slides. The experiment is still underway. The short term results are good and the students are enthusiastic about this new technology. Only time will tell whether we are training a new generation of doctors who will use the tape recorder for recording and learning as freely as their fathers did the pen and notebook. CONSULTANT PROGRAM The Council of Academic Societies (CAS) of the Association of American Medical Colleges (AAMC) undertook an investigation of the needs and capabilities of medical schools in order to make recommendations regarding specific areas of content development, and of the means by which the academic community and health care practitioners should be involved in the planning of services to be provided by the Lister Hill Center. The report of that committee was published in July 1971,7 and contained the following recommendations for im- mediate action by the Lister Hill Center: 1. Development of catalogs and indices of relevant computer programs; 2Stead, EG.; McC Smythe, C; Gunn, C.G.; Littlemeyer, M. H. "Educational Technology for Medicine: Roles for the Lister Hill Center." Journal of Medical Education, p. 46, July 1971, Part 2.8410522_000043.txt

Page  43 2686 2. Strengthening the staff of the Lister Hill Center; 3. Development of distribution systems for exist- ing educational programs and materials; 4. Organization and administration of a system to involve medical school faculties in the definition of priorities and programs, and design of specific educational materials; S. Development of specific educational aids de- signed to fall into the two general categories: those which promote practice in the acquisition of skills and those which promote new ways of accompUsfcuig tasks; 6. Devetopsneat of approximately tea regional centers directed at computer applications for health science education, nrniprrwei traping and health services. The AAMC report also noted that. The health science educational communities must accept a continu- ing responsibility for expressing their needs and offering advice and support to the Lister H21 Center__" The development of a Consultant Program was recognised as an efficient and effective way to implement many of the recommendations of the AAMC committee and thus promote the development of biomedical communica- tions systems and services for the health professional communities. The Consultant Piogtem is designed to provide the greatest mutual benefit to the Lister Hill Center, to the individual consultant, and to the academic community. Tasks for the consultant are designed specifically to provide a learning opportunity in technology in medical education. The consultant per forms specific tasks for the Center and provides invaluable aid to the Director and his staff. Specific areas of need in the user community are identified and organizations and institutions having a special capability for the production of educational materials are encouraged to cooperate with the Lister Hill Center and/or other components of the National Library of Medicine in providing support for programs of medical education. Close liaison is maintained with the Association of American Medical Colleges and many of its member institutions. Whenever programs or materials of special interest are identified, recommenda- tions concerning their use or inclusion in the program of the Center will be made. EPILOGUE The first three years of the Lister Hill National Center for-Biomedical.Communications were a'rime for planning, for limited experiments, and pilot projects. Now the plans are maturing, the experiments becoming the basis for operational services. The technologies the Center was created to exploit—satellite communications, cable, microwave television, on-line computer networks-are - being used. Experimental and operational networks now serve the Nation in small and large part. The networks connect sources of medical knowledge with those who need that knowledge; the swift and certain transmission of electrical messages is substituted whenever and wherever possible for the slow, expensive, and even hazardous movement of people. The Center was founded to give impetus and direc- tion to a national program of biomedical communica- tions. This report is an accounting of our stewardship to date-of what we have accomplished in three years. It is only the beginning.8410522_000044.txt

Page  44 2687 LISTER HILL BUILDING Dr. Cummings. The medical literature continues to grow at a rate of 6 percent a year. At this rate of growth our facilities will be over- flowing by 1975. It is therefore essential that the building authorized by Congress for the Lister Hill Communications Center be completed by that date so that we may move personnel and communications activities into the new facility and restore the space they presently occupy to conventional library functions. NATIONAL MEDICAL AUDIOVISUAL CENTER The National Medical Audiovisual Center continues to serve Ameri- can medicine by acquiring, producing, cataloging, and distributing audiovisual materials which are used in the teaching and practice of medicine, dentistry, and the allied health professions. It makes its re- sources available to professional societies and academic health centers through collaborative arrangements. The Center offers a variety of highly successful workshops through which it teaches the fundamen- tals of audiovisual technology utilization. MEDICAL LIBRARY ASSISTANCE ACT Through the Medical Library Assistance Act we have been able to improve significantly library and information services at local and regional levels. Better library resources for community hospitals, teaching hospitals, and academic health centers have been made avail- able to more than 600 institutions in the 50 States. The regional Medi- cal Library network is fully operational and now provides 500,000 interlibrary loans annually. Several hundred young medical librarians have been trained to fill the gaps within the profession and to assume its leadership in the very near future. TOXICOLOGY INFORMATION PROGRAM The toxicology information program collaborates extensively with other Federal agencies such as the Food and Drug Administration, the Environmental Protection Agency, and the Atomic Energy Commis- sion to collect, organize, automate, and disseminate toxicology data. Senator Fong. How do you disseminate this information that you get? Dr. Cummings. It is disseminated in several different forms—such as a document or a manuscript. We actually provide a copy of that document through a lending procedure which goes to the nearest local library, and through that library to the individual who makes a request. In some cases we provide information in contrast to a document, such as information dealing with the toxic effects of a pesticide or a drug. Generally, the information we provide is in a textual form, or in an audiovisual format. There might be a videotape, a motion pic- ture, a slide sound series pertaining to a particular medical subject. Senator Fong. And how do you tell people that you have this? Dr. Cummings. We have been a national library for many years, and hopefully most of the health pr fessional community know that8410522_000045.txt

Page  45 2688 we are available to serve them. But we do provide brochures, pamph- lets and, through articles in professional journals, continue to an- nounce the availability of new services. Senator Fong. Thank you. INCREASE OVER 1972 Dr. Cummings. In summary, our request for fiscal year 1973 is $28,568,000, an increase of $4,395,450 over the amounts available for obligation in fiscal year 1972. The increase of $464,000 above the orig- inal congressional justification is requested to provide for the effects of the 1972 pay raise in 1973. Senator Fong. How will you be using the remaining $4 million increase ? Dr. Cummings. The remainder of the increase will be used for pro- grammatic purposes. About $iy2 million will be used to augment our extramural grants program, and $2.5 million will be distributed among the various direct operations of the NLM. SATELLITE COMMUNICATIONS IN ALASKA Senator Fong. How is experimental docking for satellite commu- nications in Alaska working out ? Dr. Cummings. We are very pleased with the results of this experi- ment, Mr. Chairman. We have 26 terminals located in isolated villages of Alaska through which a health aide reports daily to a physician in a distant, but more sophisticated health center, on the problems of health in that small community. Senator Fong. There is no doctor in that community ? Dr. Cummings. There is no doctor in any of these villages. In fact, there often is n6 nurse. A person is selected by the community to be trained as a health aide and this health aide reports on the various difficulties and the medical problems as they occur daily. It makes it possible, for example, for people to be evacuated when they need hospitalization. Or, importantly also, it makes it possible to give local care to an individual through consultation, and thereby reduce the need for evacuations. So it works both ways. Senator Fong. The communication system is run by you ? Dr. Cummings. The satellite was put up many years ago by NASA for other purposes. When it completed its use, we were then allowed to use the satellite for these health communications. And in fact, it is managed jointly by the University of Alaska, which provides the engineering services, and by our staff which arranges for the health information services. Senator Fong. I understand, health personnel in Alaska, Stanford University, University of Washington, and University of Wisconsin were going to try experiments in communication by satellite, including pictures, electrocardiograms and so forth. Were these experiments conducted, and with what results ? Dr. Cummings. Yes. These experiments have been conducted and have been successful. The University of Wisconsin, the LTniversity of Washington and Stanford University have all taken a piece of the8410522_000046.txt

Page  46 2689 overall problem of communications to determine whether, for example, through this small satellite a Polaroid photograph of an individual, say, with a wound, can be transmitted. This is not a powerful satellite that allows for two-way video. Therefore, we are searching for very simple ways to elaborate on its capability. We have been able to transmit electrocardiograms that can be read in a sophisticated medical center, and most recently we have been able to transmit texts of documents. We don't do this as a matter of routine because it takes a great amount of the bandwidth, but it can be done under emergency circumstances. Senator Fong. Are you expanding this to Hawaii, American Samoa, Micronesia, and the Trust Territory of the Pacific? Dr. Cummings. Yes, we just contracted with the University of Ha- waii to test the same applications on behalf of the health needs of the South Pacific territories. TWO-WAY COLOR TELEVISION NETWORK Senator Fong. Along similar lines, what is the status of the two- way color television network in hospitals and university medical centers ? Dr. Cummings. We are involved in only one such experiment and that connects the Dartmouth Medical College with Claremont Hospi- tal in New Hampshire, and is now being expanded to other hospitals and the University of Vermont. The status of that project is as fol- lows : we have active, on-going telecommunications between the Dart- mouth faculty and physicians at Claremont Hospital. We are mount- ing, on Mount Acushnet, a relay station so this may be extended to the other communities. Importantly, I'd like to say that we are devel- oping a mobile van that will allow a transmitter to be moved into the parking lot of a community hospital so that they may engage in the two-way teleconferencing as well. MEDLARS SYSTEM Senator Fong. Exactly how would the working health community go about using the computer-based Medlars system or the newer Med- line system? Dr. Cummings. We now have a network which comprises most of the large cities of our Nation which are joined to a computer located at the National Library of Medicine and a computer located at Santa Monica, Calif. A physician, or scientist, or educator may sit at a remote terminal, either in his local library or in his hospital and query the file that is located in one of these two computers, asking for informa- tion on a particular subject. The response comes in one of two forms. It comes as a printout immediately on the teletypewriter which gives him the leading references to that subject, or if he wants an extensive or more elaborate bibliography, it may be printed out at night when the line time is cheaper and be mailed to him from the nearest regional library. Senator Fong. You mean a man in Alaska can contact the computer and the computer will answer his questions? Dr. Cummings. Unfortunately, a man in Alaska cannot do this yet because the telephone network that we use does not extend to Alaska. \8410522_000047.txt

Page  47 2690 He would have to call Seattle, which is our nearest node, and would get that service from Seattle. Senator Fong. The Seattle man would be talking to—— Dr. Cummings. He would be talking to somebody in the regional library in Seattle, and the regional library would than do the search for him at the nearest computer in California. Senator Fong. The computer would answer him ? Dr. Cummings. Immediately. Senator Fong. There's a rollcall in progress and I'll be back in about 15 minutes. (A brief recess was taken.) TOXICOLOGY INFORMATION CENTER Senator Fong. We will resume our hearing. Doctor, what is the Query Response Service at Oak Ridge? Give us an example of how it works. Dr. Cummings. The Toxicology Information Response Center Serv- ice at the Oak Ridge laboratories is a specialized information service operated under contract to the National Library of Medicine to pro- vide in-depth information dealing with drugs, chemicals, and other materials. It provides to industry, to physicians, scientists, and educators de- tailed listings of substantive information on these various toxicologi- cal agents. It is a new service only recently effected, and is a service which will be paid for by the users because it is something over and beyond a normal library service. Senator Fong. I see. Why was it established at Oak Ridge ? Dr. Cummings. We chose Oak Ridge for two reasons. First, they have an outstanding professional staff with long-standing interest in this professional field. Second, Oak Ridge established the first large- scale series of information analysis centers in other fields, so the man- agement at Oak Ridge was very much interested in providing this kind of service. Senator Fong. When you speak of an information explosion, are you talking about new information or merely a proliferation of litera- ture for dispensing it ? Dr. Cummings. That's a very profound question. I must say that I think we "are talking about both. First, there is undoubtedly a mass of new knowledge that is generated by research programs of our Nation and abroad, and this leads to the publidation of new information, principally through books and journals. However, new information is also provided in technical reports and in other format, so I would say that we are really talking about new knowl- edge which is articulated in written form primarily that we consider the information explosion. I must immediately add that there is a redundancy in this litera- ture. There are now more than 60,000 scientific journals published throughout the world, a phenomenal number, and in medicine alone, more than 6,000 medical journals. We have the responsibility to ex- amine these, to index them, an announce to the profession at large what has been published each month, and this is an awesome task. Senator Fong. Do you evaluate it ?8410522_000048.txt

Page  48 2691 ur. IfMMixos. We do not attempt to evaluate the quality of the work. We do attempt to describe very carefully what the content of each particular article is. CONSTRUCTION STATUS OF LISTER HILL CENTER Senator Fong. I see. What is the current status of the proposed construction for the Lister Hill National Center for Biomedical Communications? Dr. Cummings. As you know, the Congress provided to NIH and the Library, funds for planning this new facility some 2 years ago. The program of requirements has been written and approved at NIH and approved by the Department. I am informed that the Department will select an architectural and engineering firm sometime during the month of May to begin the detailed design, and as I indicated in my opening statement, we hope to be able to come back to the Congress, through the Department, with a request for the building funds in the near future. Senator Fong. How would a health professional at the local level make use of the library service supported by the National Library of Medicine ? Dr. Cummings. The health professional at the local level merely goes to the nearest medical library, which may be in his community or near his community and makes a request for the information he seeks at that level. If they do not have it locally, it is then transmitted to one of 11 regional libraries that are in the network. They are usually able to respond to about 85 percent of all such queries. However, if the regional library does not have this material, the more difficult material, it is then transferred to the National Library of Medicine and sent back to the requestor directly. . Senator Fong. All these regional libraries are under you? Dr. Cummings. All of the regional libraries exist in freestanding academic settings or in private libraries. They are not part of NLM, but we fund their regional services. We provide support to them to give local services. INFORMATION FOR ENVIRONMENTALISTS Senator Fong. What is the NLM doing to provide an information base for use by environmentalists ? Dr. Cummings. We are very proud that last year we were able to develop a new monthly alerting service which announces all of the health related aspects of the environment. Dr. Mider was responsible for this development and with your per- mission I would like him to elaborate on that. Mr. Mider. Mr. Chairman, we suddenly realized that we have a lot of information that environmentalists needed, and while medical people know about our publications, many environmenalists did not, so we went through our files and found those items which seemed to be of most interest to environmentalists, and we put out a publication which was called Selected References on Environmental Quality as it Relates to Health. We provide the Government Printing Office camera-ready copy each month, and it is sold by subscription for $4 a year. Within 10 months we had 700 subscriptions. We don't give it away. In developing the Toxicology Information Program we built a file of8410522_000049.txt

Page  49 2692 some 3,000 or 4,000 toxicologists which defined their attributes, their interests, their background and in doing this we queried them as to what their needs were. They said we need more abstracts. We're not in the abstracting busi- ness, but Biological Abstracts is, so recently we have teamed up the Medlars System with the abstracts available from Biosis to provide an abstract journal called the Health Effects of Environmental Pollut- ants. This is also sold. We underwrite a part of the cost of this and it has to become self- supporting within 2 years or that is the end of it. We are building a computer-based file with access over the same commission network over which Medline operates. We hope that this will become available in June or perhaps a little later in the summer. This will include the two items I told you about plus the toxicity bibliography which has been active since 1966 and the Health Aspects of Pesticides Abstract Bulletin which was started by the Food and Drug Administration and is being continued, with our help, by the Environmental Protection Agency. Senator Fong. How many subscriptions do you need to balance out ? Dr. Mider. I don't know how many it will take to keep Health Aspects of Environmental Pollutants going because this is run by Biosis. It sells for $95 a year, in a printed version, $500 a year if you want to run the tapes on your own computer. Toxicon, which is the computer based file I talked about has several different elements, will be operated commercially, and we anticipate that the cost will be about $45 an hour. If our experience with this system is similar to what we've already had with Medline, it should take about 15 minutes to produce the search. Toxicon has been demonstrated at two national meetings al- ready, and there is substantial interest and enthusiasm for it. FUNDING OF LISTER HILL CENTER Senator Fong. An increase of over $1,200,000 has been asked for the innovative programs of the Lister Hill National Center for Bio- medical Communications. Will all of this be used for satellites ? Dr. Cummings. No, sir. It will not all be used for satellite communications. In our report to Congress we have outlined several areas of health information transfer that we believe are important. Among them is a project to demonstrate the utility of cable television to bring health information to the underprivileged in certain selected areas of our Nation. We have, for example, an arrangement with the Mt. Sinai Medical School in New York City which will provide information services to a group of some 250,000 people in the inner city of New York. We have a similar development taking place in Denver, Colo., where they will be providing clinical services through small outposts in the pe- riphery of that city. In addition, some of these funds will be used to further elaborate on the computer based information services which we talked about earlier. The funds will not all go toward the satellite communications effort.8410522_000050.txt

Page  50 2693 Senator Fong. Thank you, Doctor. I don't think I have any more questions for you. Dr. Cummings. Mr. Chairman, with your permission, I would like to have the record show that this is the last time that Dr. Mider, my deputy, will be appearing before this committee. He has appeared for almost two decades as a senior scientist at NIH and more recently as the Deputy Director of the Natonal Library of Medicine, and I would be remiss if I did not attempt, at least, to have the record show that those of us who have been privileged to work with him recog- nize the very enormous contributions he has made to American medi- cine, and broadly, to American science. Senator Fong. Well, Doctor, listening to the very fine testimonial you have given to your retiree here, I join you in commending him for the very fine work he has done, and hope that his retirement will be very peaceful and ioyful, and I wish for him a very long, long life. Dr. Mider. Thank you. Senator Fong. Thank you, gentlemen.