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and DOCLINE, NLM's automated interlibrary loan request and referral system, individual health professionals can place an order online for a photocopy of the full article for any reference retrieved in a GRATEFUL MED search. Loansome Doc provides a valuable link between the GRATEFUL MED user and a medical library. From the GRATEFUL MED menu, a user may select the Loansome Doc function, perform a search, select items to order, and send the orders to a previously designated medical library. Each user can select one of three delivery methods for receipt of his or her documents (mail, fax or pickup). Through a new DOCLINE function, a library receives the requests, fills them if the items are available, or transfers the requests to DOCLINE where they will route to a library that reports owning the requested documents.

Loansome Doc is intended to serve all health professionals, not just those currently affiliated with a medical library. It will be available to all GRATEFUL MED (IBM) users by January 1992. A phased implementation will occur beginning in May 1991 when Loansome Doc disks will be sent to all GRATEFUL MED users in the two western regions. Additional institutions will have Loansome Doc by late summer or fall, 1991.

NEW REGIONAL LIBRARY STARTED IN 1991

Question. I understand you have decided to increase your regional libraries from seven to eight. Why was this necessary? Why was the new regional library put in the Northeast?

Answer. The decision to increase the number of regions and regional medical libraries from seven to eight was made in direct response to the request of the Congress that NLM expand its outreach efforts and to a recommendation of the Outreach Planning Panel chaired by Dr. Michael DeBakey. The regional medical libraries (RML) are a key element in NLM's strategy to reach all U.S. health professionals, and particularly those in rural and Inner city areas. In the seven region configuration, the Northeast region contained 10 states, served both large urban centers, such as New York City, and isolated rural areas, for instance upstate Maine, and had the largest number of physicians, dentists, and nurses of any of the seven regions. Dividing this area into two smaller regions will enable NLM and the RMLs to intensify efforts to reach these health professionals. Contracts for the new eight region configuration are expected to be awarded on May 1, 1991.

HIGH PERFORMANCE COMPUTING PROGRAM

Question. Your budget includes a requested increase of approximately three million dollars for a new program for high performance computing. I understand this is the biomedical component of the High Performance Computing and Communications initiative proposed by the President's Office of Science and Technology Policy.

How will this program assist the medical community?

Answer. The Office of Science and Technology Policy (OSTP), and its Federal Coordinating Council on Science, Engineering, and Technology (FCCSET) Committee on Physical, Mathematical, and Engineering Sciences has formulated a Presidential initiative for

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High Performance Computing and Communications (HPCC), which is to begin in FY 1992. There is a growing impetus for strengthening the capabilities of the biomedical community in high performance computing and networking. Grand Challenges in biomedicine, such as the analysis of the human genome, prediction of biological structure and function from genetic code, and rational drug design, will require new and faster computers, advanced software, a national research and education computer network, and expanded training of scientists in the use of computer-based tools. The overall FCCSET plan recomiends additional resources for NLM to address these Grand Challenges in biomedicine as part of this multi-agency coordinated initiative. NLM's plans include applications in molecular biology computing, creation and transmission of digital electronic images, the linking of academic health centers via computer networks, the creation of advanced methods to retrieve information from life sciences databases, and training in biomedical computer sciences. In years to come the HPCC and what it creates will be of enormous importance to medicine. At the moment, medicine is a tiny part of the HPCC.

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Specifically, NLM will expand its grants program to connect medical institutions to the high speed network and to train scientists in the use of new computer capabilities. The Library will proceed with a "Visible Human" project that will result in the ability to compute, display, and transmit the enormous amount of digital information that comprise three-dimensional images of the human body at millimeter-level resolution. The availability of such a tool will have significant implications for medical education, research, and practice.

NLM will also make its databases available over the evolving high-speed research network. In order to facilitate linkages between dissimilar databases, the Library will accelerate development of the Unified Medical Language System, a research effort to build computer systems which "understand" medical concepts and overcome differences in terminology.

Lastly, NLM will expand its development of advanced software and biotechnology Information retrieval methods and the implementation of the "backbone" sequence database of molecular structure that will contain key linkages to the scientific literature and to existing biological databanks. This database, called GenInfo, will be made available to researchers over the high-speed computing network being expanded under the HPCC Initiative.

Question. Why should it be located at the National Library of Medicine?

Answer. Within the Department of Health and Human Services, the focal point for the HPCC Program is the National Institutes of Health and, specifically, NLM. The NLM has a long and productive history of innovation in the use of computers and computer networks. In 1964, NLM created MEDLARS to automate Index Medicus. MEDLINE (MEDLARS On-Line) was the world's first large-scale successful online bibliographic system, and the first international telecommunications -based science information network. The success of MEDLARS and MEDLINE was a milestone in the evolution of modern libraries.

The work currently underway in NLM's Lister Hill National Center for Biomedical Communications and National Center for Biotechnology Information in artificial intelligence, digital imaging, high speed networking, and computational molecular biology is equally progressive today. In addition, NLM's grants program supports the acquisition of sophisticated computer resources needed to conduct research in artificial intelligence (AI), as well as the research of individual investigators applying these al tools to the development of medical decision-support systems. The Integrated Academic Information Management System (IAIMS) Program is a forward looking NLM innovation that supports the development and testing of alternative models for linking diverse computer resources and databases on the campuses of the nation's academic health science centers. The need for personnel to carry out the above research and to staff the IAIMS institutions, for example, individuals cross-trained in biomedicine and contemporary information technology, is addressed by NIM's medical informatics training grants program. Additional funding for NIM through the IPCC initiative is an investment that will allow these intramural and extrainural programs to reach their full potential.

AGENCY FOR HEALTH CARE POLICY AND RESEARCH

Question. Under Section 6103(a) of the Omnibus Budget Reconciliation Act (OBRA) of 1989, Congress directed NLM to provide for the timely dissemination of information and to establish an information center on health care technology assessment. What progress have you made in the accomplishment of these directives, and what needs to be done to fully achieve this directive?

Answer. In response to this legislation, NLM has entered into an interagency agreement with the Agency for Health Care Policy and Research (AHCPR) to improve information services in the field of health services research, including technology assessment. result of this agreement, the Library has:

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(1)

established a new Office of Health Services Research Information that is currently providing special literature searches and back-up document delivery service for the AHCPR panels charged with developing practice guidelines;

(2)

begun to enhance coverage of health services research, including technology assessment, in the NLM collection, its Medical Subject Headings, and its online databases of indexed citations and abstracts;

(3)

initiated a research and development project to make
the full-text of approved guidelines available to users
of NLM's online services;

(4)

begun expanding the UMLS Knowledge Sources to make them more useful to health services researchers;

(5)

developed a special workshop and training materials designed to inform health services researchers of the utility of NLM's current online services;

NLM and AHCPR have established a joint working group of experts in the field of health services research to assist NLM with some of these projects. The Institute of Medicine is assisting NLM and AHCPR by conducting a study of information needs related to health services research, including technology assessment, and by recommending new or expanded services that NLM should provide to meet these needs.

NLM is making good progress toward the goals outlined in the legislation at the level possible with the funding (two million dollars per year) provided by AHCPR under interagency transfer.

PAPERWORK REDUCTION ACT

Question. What is the current status of discussions over possible changes to the Paperwork Reduction Act that you have felt would have an adverse impact on quality control of your databases?

Answer. Before Congress adjourned in the fall, the Senate included the House-passed changes to the Paperwork Reduction Act that concerned us, but added a specific exclusion for the NLM. The exclusion would have permitted the NLM to continue licensing arrangements that provide for important quality controls. The proposal did not pass, however, we understand a new bill will be introduced in this Congress.

Whether the new bill will contain an exclusion for the NLM is unknown. This continues to be a major concern for us. Without appropriate controls, the integrity of the MEDLARS databases will be compromised, and the quality of a remarkable medical resources will suffer.

INFORMATION SYSTEMS

Question. Information Systems are becoming increasingly sophisticated and more accessible, with a move to full-text retrieval in many areas. Do you encounter policy disputes with the medical publishing industry over access to and payment for their material?

Answer. NLM does not currently provide full-text retrieval of commercially published books and journals. Our current projects in this area are limited to collaboration with one commercial and one university publisher in the development of systems for creating, updating, and searching online textbooks and experimentation with online retrieval of the full-text of clinical practice guidelines that are in the public domain.

CHEMICAL EMERGENCIES

Question. You have a number of databases relating to . chemical, environmental, and hazardous substances information, and some of them are quite complex in their format. How easy is it for individuals and organizations to access this information, particularly those who may be dealing with hazardous chemical emergencies?

Answer. NLM, in collaboration with the Agency for Toxic Substances and Disease Registry, has developed a special microcomputer workstation to facilitate retrieval of critical

information in chemical emergency situations. Locally stored files on emergency medical treatment and the properties of hazardous chemicals, as well as specially developed search software make information retrieval from the workstation easy after a minimum amount of training. NLM has collaborated with the Agency for Toxic Substances and Disease Registry to provide "train the trainers" courses in 36 states.

To simplify searching for the untrained or occasional user., NLM is developing menu searching for some databases on its TOXNET system. Also, PC-based tutorials and other training aids have been developed for new users. This is not yet by any means perfect.

While NLM's popular PC-based access software GRATEFUL MED has been developed primarily for MEDLINE, it should also be improved to facilitate searching chemical and toxicological databases such as ChemID, CHEMLINE, TOXLINE and TOXLIT. We have not had sufficient resources to allocate these improvements. We hope to find the means in the next 1-2 years.

OUTREACH

Question. Last year this Committee added substantial funds to expand NLM's outreach initiative, particularly in rural areas. Has this increased access to health professionals in remote areas, and what plans do you have to improve services?

Answer. It has become evident that large numbers of health professionals do not have easy access to biomedical information--because of geographic isolation, non-affiliation with a hospital or medical school library, or lack of information about NLM's products and services.

With the increased funding available for outreach, we have identified institutions and individuals to help us reach out to these underserved health professionals. Libraries in our own Regional Medical Library hetwork as well as other institutions have stepped forward in response to NLM solicitations for help. It is clear that within the population of health professionals in underserved areas, there is a sub-group of health professionals serving minority populations who have a special set of problems in accessing information. NLM has geared a special set of initiatives to these minority communities. Results of these outreach initiatives include:

Extensive efforts to train physicians and other health professionals on the use of GRATEFUL MED in 50 communities in 32 states. For example, health professionals residing in 15 non-urban southern Iowa counties that do not contain a health science 11brary, are being trained in the use of GRATEFUL MED at their local community hospitals by an NLM-funded trainer. This project, and others like it, are being accomplished through special demonstration projects at the Regional Medical Libraries and awards to individual small-to-medium sized libraries in the network, with an emphasis on libraries in rural and inner city areas.

Faster and easier access to documents identified in online searches. For those health professionals who are not affiliated with a medical library. LOANSOME DOC, NLM's new link between the

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