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Question. For a number of years the Committee has urged the National Library of Medicine to increase its outreach effort to doctors and health practitioners in rural areas. Your budget request includes $6,183,000 for outreach activities, an increase of $650,000 from the fiscal year 1991 level.

How many doctors are now subscribed to Grateful Med and how much has this increased since last year?

Answer. There are 6,698 or 75% of the doctors who have personal accounts for searching NLM's online system that use GRATEFUL MED. The number of doctors using GRATEFUL MED to search has increased 53% since February of 1990.

Question. What has your research shown about what works and what doesn't work to encourage doctors to use your system?

Answer. Early indications are that the special Outreach projects undertaken by individual libraries to introduce doctors and other health professionals in rural and underserved areas to online searching via Grateful Med will be particularly successful. Some 30 contracts were awarded to institutions such as community hospitals to provide innovative training programs. Other approaches that appear to work include: special rates that encourage medical students to begin searching while in medical school, free searching to allow those opening accounts to become familiar with the system, free Grateful Med demonstration disks distributed at the NLM exhibit booth at health professional meetings, toll free numbers for ordering Grateful Med and getting search assistance, and articles by health professionals in local newspapers or professional journals describing the usefulness of Grateful Med searches. Health professionals also appreciate the ability to use credit cards to purchase Grateful Med. Special "master account" billing for all individuals searching from a single institution and flat-rate per code billing experiments have encouraged institutions to obtain large blocks of search codes for the health professional and researchers they employ. We expect NLM's new "Clinical Alert" service to be an added inducement to doctors to become online searchers, but it is too early to assess its impact on system use.

NLM has found that advertisements are not particularly successful in encouraging doctors to use Grateful Med. Distribution of free copies of Grateful Med and designation of specific "free online use days" have not been effective with doctors either.


Question. You have started a new service this year called "Loansome Doc." What is this new service?

Answer. Loansome Doc is a new feature of GRATEFUL MED, NLM's microcomputer based user-friendly system for searching NLM's MEDLARS databases. Through software enhancements to GRATEFUL MED

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.


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.


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

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 recommends 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.

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


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 AI 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 HPCC initiative is an investment that will allow these intramural and extramural programs to reach their full potential.

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. As a result of this agreement, the Library has:






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;

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;

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

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

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.


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. 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.


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.


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?

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


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