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.

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

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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.

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. 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.

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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 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.

HIGH PERFORMANCE COMPUTING PROGRAM

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

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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.

CLINICAL ALERT SYSTEM

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.

PAPERWORK REDUCTION ACT

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

policies?

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.