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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.


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.

It is

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. 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 library, 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

GRATEFUL MED user and a network library, allows electronic ordering of documents.

Demonstration projects in the Rio Grande Valley of South Texas and Meharry Medical College in Tennessee to identify impediments to use and test innovative strategies for improving access among health professionals in geographically isolated areas, including the use of a circuit librarian (Rio Grande Valley) and training residents in GRATEFUL MED use, who will go on to train their preceptors (Meharry). A total of 18 outreach projects have a minority focus.

Continuing efforts to publicize the programs and services of the Library. Publicity activities are targeted both to health professionals and to general audiences, and include exhibits at meetings as well as training kits, press releases, videos, and a campaign to inform dental professionals about the benefits of GRATEFUL MED.

These institutions that are collaborating with us now represent the most needy, and the projects are now being undertaken.


Question. What is NLM doing to ensure the participation of biomedicine in Federal high performance computing and networking initiatives?


Answer. NLM has taken a leadership role for medicine in the Presidential High Performance Computing and Communications Program. A part of this multi-agency initiative is to develop the National Research and Education Network, a sort of computer superhighway. High performance computers and high-speed computer networks are key technologies for the future of biomedical science and its applications. Within the Department of Health and Human Services, the focal point of the HPCC program is the NLM. NLM is the only biomedical element in the initiative; its role is to provide applications for this advanced technology and to help the biomedical research and medical practice communities prepare for the major changes that this initiative will bring to their medical practices, to the expectations patients will have for up to date modern treatment, and for the actual improvements in care that the new network will make possible.

Question. What will be the potential impact on health care for the Nation?

Answer. Activities already underway at NLM which would benefit greatly from association with this initiative include molecular biology computing, creation and transmission of electronic images, the linking of academic health centers via computer networks, the creation of "intelligent gateways" to retrieve information from multiple life sciences databases, and expanded training in biomedical computer science.

Question. The President's Budget contains three million for this initiative, but how much did the Federal Coordinating Council for Science, Engineering, and Technology actually recommend?

Answer. The FCCSET budget recommends a $16.5 million increase for these programs in FY 92 and $19.5 million in FY 93.


Question. The Congress is pleased to see that the NIH has instituted a clinical alert system whereby the medical community is notified of major results of clinical trials prior to formal publication.

What is NLM's role here?

Answer. Once an NIH Institute director and the NIH Director's Office have determined that expedited release of findings from a clinical trial could affect morbidity or mortality, NIH employs a variety of mechanisms to announce the findings including press conferences, press releases, and use of the National Library of Medicine's online services and the Regional Medical Library Network. The responsible Institute provides NLM with a several page statement of the important findings as well as a short summary of the key points. NLM immediately puts the summary "clinical alert" message on its online system, giving a telephone number that users may call to request a copy of the complete statement. The Library also faxes or electronically disseminates the complete text of the "clinical alert" to 138 major medical libraries and mails the complete text to more than 3,000 Regional Medical Library Network members, including libraries in hospitals nationwide. These libraries in turn disseminate the "clinical alert" to other clinical care facilities, research centers, and professional groups in their geographic areas.

These NLM actions in disseminating clinical alert information are, of course, in addition to the other dissemination means selected by the relevant institute; for example press conferences, mailing of letters to professional societies when appropriate, etc.

Thus far, NLM has received uniformly encouraging reports from the field. In many cases the medical librarians have reported that they were able to contact the appropriate clinicians in their medical centers, and often reported that the clinical alert information was useful to the clinician and had not reached him or her by other means.


Question. In our report last year we indicated our serious concern with the proposed Paperwork Reduction Act provisions that could have jeopardized NLM's cost recovery mechanisms and the quality of the databases. Has that matter been adequately resolved?

Answer. The matter is not resolved, and it continues to be a major concern.

Question. If not, what is needed to protect NLM's reasonable


Answer. Before Congress adjourned, the last version of the Paperwork Reduction Act proposal did contain a specific exclusion for the NLM. The proposal did not pass, however, we understand a new bill will be introduced in this Congress.

To protect NLM's reasonable prices and ensure the quality of its databases, the NLM needs either an exclusion in the Paperwork Reduction Act itself, or specific authority in the basic NLM Act to enter into license agreements that provide for quality control and full recovery of access costs.


Question. What is the status of NLM collaboration with the Agency for Health Care Policy and Research (AHCPR) to provide information services in the field of health services research? How are these activities being funded?

Answer. In response to the December 1989 legislation that created the AHCPR, AHCPR and NLM have entered into an interagency agreement to improve information services in the field of health services research. 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

(2) -begun to enhance coverage of health services research in the NLM collection, its Medical Subject Headings, and its online databases of indexed citations;


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 Unified Medical Language System
(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.

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.

Under the terms of its legislation, AHCPR is authorized to support NLM's health services research information program through FY 1992. AHCPR is providing support to NLM at the level of about $1,000,000 per year.



Question. Three million dollars of your 1992 budget have been earmarked for advancements in the National Research and Education Network (NREN) efforts of NLM, one-quarter of which is to be spent on connecting medical institutions with the NREN network

and the rest of which is to be "apportioned among other performance computing projects."

Would you please specify what some of these "related" projects are?

Answer. 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. Three million dollars has been made available to NLM for this High Performance Computing initiative in FY 1992. The National Research and Education Network (NREN) is one component of the overall FCCSET plan. NLM's related HPCC 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.

Question. Do any of these planned projects involve the medical or health science libraries or librarians in the NREN network?

Answer. A major portion of NLM's HPCC effort will be in assisting and encouraging biomedical and health care institutes to attach to and use new high speed networks and additional national information resources. In the case of major medical centers, the medical librarians are already central to the institutions planning for information systems. The IAIMS grant sites are examples of this. We also plan for experimental sites in rural areas and areas serving minority or otherwise underserved populations. In such cases, NLM will continue to work through the Regional Library Network realizing that most hospitals do not have medical librarians on staff.

Question. NLM's budget proposal expresses the clear intention to use the NREN network to improve health care practitioners' direct access to GRATEFUL MED. While this effort is laudable, it appears to have certain limitations, as practitioners are sometimes intimidated by the technology and may not use it to its fullest capacity. In order to maximize the NREN program's capabilities, what steps are you taking to involve health science libraries and librarians in your NREN efforts?

Answer. The DeBakey Outreach Panel calls for the Regional Medical Libraries to serve as NLM's "field force" for introducing health care practitioners to the products and services available through the NLM.

Question. What will be the impact of this expanded outreach effort on health sciences libraries and librarians?

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