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1986-2006: Two Decades of Progress


A Brief Report: Major Elements of NLM’s
Work Since its Long Range Plan of 1986

The 1986 Long Range Plan stimulated a variety of expanded responsibilities for the National Library of Medicine. Some of these required action by the U.S. Congress. Others are the result of recommendations by the Library’s Board of Regents and various advisors. One gauge of this expansion is the increase in the NLM budget, from $57.4 million as reported in the 1986 annual report, to $323 million in 2006.

Some highlights from the past 20 years:

Internal Library Processes.
Twenty years ago, NLM relied primarily on mainframe computers and commercial telecommunications networks. The Library Operations staff already used relatively sophisticated systems to carry out acquisitions, cataloging, indexing, preservation, and document delivery tasks, but the 1986 plan emphasized the need to rationalize, integrate, and greatly expand automated support for basic library processes. There were no electronic journals in the NLM collection. All MEDLINE citations and abstracts were keyed in from print journal issues, although NLM was talking to publishers about their ability to supply this information electronically. NLM’s Reading Room patrons filled out document requests by hand, copies of articles provided in response to inter-library loan requests were delivered by surface mail, and the majority of offsite reference and customer service inquiries came by telephone to several different service points. In 2006, NLM’s computers are connected to the world via the Internet. 82% of the now more than 600,000 citations and abstracts are received electronically from publishers. The rest are captured via a precisely tailored scanning and optical character recognition system developed by the Lister Hill Center. Onsite patrons generate document requests as a by-product of searching NLM’s online catalog or PubMed, but only if the material they are seeking is not available in electronic full-text. NLM fills 96% of roughly 274,000 annual interlibrary loan requests electronically. The Library’s now consolidated customer service operation receives 67% of its requests via email and the Web.

MedlinePlus Materials MEDLINE.[2]
In 1986, NLM enabled users to use personal computers to connect to MEDLINE via GratefulMed (now MEDLINE via PubMed). There was a modest fee for searching to cover commercial telecommunications charges and there were slightly more than 3 million online searches that year. In the 1990s NLM reinvented its legacy computer systems and was supported by Congress in making Web access to NLM services free via the Internet. The reinvention effort also supported efficient use of NLM data by external computer systems. The current rate of searching is almost one billion searches annually.

National Network of Libraries of Medicine. National Network of Libraries of Medicine.[3]
What was formerly called the Regional Medical Library Network was renamed and enlarged. Funding for the network increased from $2.2 million to $12 million annually. The NN/LM now has some 6,000 member institutions that cooperate to equalize and improve access to information in universities, hospitals, and communities across the nation. The Network has broadened its responsibilities to serve the general public as well as health professionals, researchers, and information specialists and is a major part of NLM’s strategy to reach minority groups and underserved communities.

Human Genome Project. National Center for Biotechnology Information.[4]
The NCBI, created by act of Congress in 1988, has become an international leader in assembling, organizing, and making available the kinds of biological and genomic data that drive modern life sciences research. The Center works closely with researchers and institutions at NIH and around the world who contribute sequence and other data to GenBank and other molecular biology databases. In recent years, the NCBI has been tapped to develop PubChem databases that store and link data about biologically active small molecules. This is a key element in the trans-NIH Roadmap Initiative.

Outreach Materials. Outreach.[5]
Prompted by a special-focus Long Range Planning report in 1989, the NLM launched a vigorous program of outreach to ensure that health professionals and the public were aware of the information resources available from NLM. Early efforts focused on letting physicians know that they could search MEDLINE from their home or office via personal computer software developed by NLM and on alerting the HIV/AIDS community to several free data resources. Today NLM and the NN/LM support hundreds of community outreach demonstrations, events, and projects every year, with special emphasis on groups with major health disparities, such as African Americans, Native Americans, and Latinos. Since 1996, the Library’s major historical exhibitions and their accompanying Web sites, K-12 educational materials, and touring versions have also helped to introduce NLM’s collections and health information services to wider audiences.[6]

NIH MedlinePlus Magazine. Consumer Health Information.
When MEDLINE became free on the Internet in 1997, the general public arrived at NLM’s online door, and the Library began to create a series of health information resources expressly for this audience. MedlinePlus[7], the largest and most prominent of NLM’s consumer health services, is used by millions each month. MedlinePlus has free health information, in both English and Spanish[8], from the NIH Institutes and other reliable sources of health information. Thanks to the efforts of health sciences librarians across the country and their state and local partners, many users can “Go Local” to find neighborhood health services related to topics they view on MedlinePlus. As of 2006, 15 MedlinePlus Go Local sites were operational, with more in the pipeline.

PubMed Central.[9]
In February 2000, NLM launched PubMed Central, a digital archive of full-text articles from biomedical and life sciences journals, on behalf of the NIH. Starting from just two journals and a few thousand articles, PubMed Central now provides free public access to more than three quarters of a million articles cited in PubMed/MEDLINE. PubMed Central has had a major impact on policy and technical developments related to electronic biomedical journals. It is the repository specified in the NIH public access policy and by other major research funders in the U.S. and other countries. Its standard electronic format for archiving articles has been endorsed by the Library of Congress and the British Library and widely adopted by publishers. A modified version of the PubMed Central system is being used to establish similar cooperating archives in other countries.[10]
In response to a mandate in the FDA Modernization Act of 1997, NLM worked with NIH and FDA to develop to allow prospective patients and their doctors to locate ongoing human research studies in which they might participate. First released in 2000 with 4,000 NIH-funded studies, the site now contains information on more than 33,000 federally and privately supported trials in more than 130 countries. The number of trials registered received a boost from a decision of the International Committee of Medical Journal Editors in September 2005 to require, as a precondition for subsequent publication of results in their journals, that clinical trials be registered before they begin.

Toxicology and Environmental Health Information.[11]
In the past 20 years, NLM’s toxicology and environmental health services have broadened their focus from toxicologists, chemists, and pharmacologists to provide services more usable by health professionals, emergency responders, and the public. Innovative services released within the past few years include: the Household Products Database, which provides information for consumers about potentially harmful substances in widely purchased products; ToxMap, which allows communities to determine what toxic substances have been released in their vicinity; and a hand-held hazardous substance information resource used in the field in the aftermath of Hurricane Katrina.

High Performance Computing and Communications.[12]
The multi-agency HPCC program was established by Congress in 1991 to advance computing and communication and provide a platform for a national information infrastructure in the US. NLM was the initial federal representative for biomedicine and health, and the NLM Director was appointed the first Director of the HPCC National Coordination Office by the President’s Science Advisor. With substantial additional HPCC funding beginning in 1993, NLM has funded competitive research contracts for prototype advanced biomedical and health applications of computing and communications, initially focusing on telemedicine and more recently on scaleable networks and disaster information management. The Indianapolis Network for Patient Care,[13] now a national model for regional health information exchange among independent hospitals, pharmacies, laboratories, physician practices, and public health departments, was originally funded by this NLM program. Currently funded projects are looking at self-healing networks and smart triage tags for use in coping with casualties in large-scale emergencies.

Visible Human Project. Visible Human Project.[14]
Initiated by the 1990 long range plan for electronic imaging, this widely publicized Lister Hill Center program generated two large and totally novel datasets of highly detailed anatomical information, created by MRI, CT, and cryosection imaging of male and female cadavers released in 1994 and 1995 respectively. Licensed at no charge by 2,000 individuals and institutions in some 50 countries, the Visible Humans have enabled a wide range of educational, diagnostic, treatment planning, virtual reality, artistic, and industrial applications. An NLM-sponsored partnership between university and industry research groups produced the open source National Library of Medicine Insight Segmentation and Registration Toolkit (ITK) for use with the Visible Humans and other image datasets. ITK is heavily used in imaging research, including work by two of the NIH-funded National Centers for Biomedical Computing.

Unified Medical Language System. Unified Medical Language System.[15]
In 1990, NLM released the initial experimental version of the UMLS Metathesaurus, including 64,000 concepts and 125,000 unique terms from less than 10 biomedical vocabularies, and the UMLS Semantic Network, a high level representation of medical common sense. The intent of the UMLS effort was to provide structured electronic knowledge sources that would aid the development of computer programs that would behave as if they “understand” medical meaning. Today, the UMLS Metathesaurus contains more than 1.3 million concepts and 6.4 million unique terms from 119 vocabularies in 17 languages. NLM is now the designated central coordinating body for clinical terminology standards within the Department of Health and Human Services (HHS). The Library funds, licenses for U.S.-wide use, and builds three core clinical vocabularies, and the UMLS Metathesaurus is the official distribution vehicle for U.S. standard administrative code sets, required to bill electronically for health services, and vocabulary standards for electronic health records. The full set of UMLS components, which also includes advanced lexical tools, is used in most serious natural language processing, data mining, and ontology research and applications in the biomedical domain. Many NLM services, such as PubMed,, and Genetic Home Reference, use UMLS knowledge to enhance retrieval, and the UMLS is integral to the system that provides automated assistance to NLM’s expert human indexers.

Grants for Research and Resource Development.[16]
The NLM has had a program
of grants since 1965. NLM’s grants today are awarded primarily for projects in biomedical informatics, information management, and artificial intelligence. Resource grants now focus on a broad variety of knowledge management projects that utilize telecommunications and computers to improve information access and utilization by professionals and consumers. Approximately half of NLM’s grant budget is expended in support of informatics research projects and research infrastructure such as databases and tools. Clinical informatics, the predominant theme of NLM’s research grants in earlier years, continues to receive strong support, but a significant portion of NLM’s informatics research budget is now allocated to bioinformatics and computational biology as the importance of computing to basic and translational science increases. NLM’s grant programs are also heavily involved in such pan-NIH initiatives as Roadmap and the Biomedical Information Science and Technology Initiative (BISTI), programs designed to address the burgeoning needs of clinical and basic science for computation and for computationally sophisticated scientists. NLM has program responsibility for one of the seven National Centers for Biomedical Computing supported by Roadmap grants.

National Information Center on Health Services Research and Health Care Technology.[17]
Congress first assigned NLM special responsibility for improving information services and resources for health services research and technology assessment in 1989 and established a formal Center at the Library in 1993. In response, NLM developed databases including the full-text of clinical and public health practice guidelines and evidence summaries, information about health services and public health research in progress, and information about research datasets and tools. The Center coordinates NLM’s activities related to health services research, including health data standards, and also many of its services for the public health workforce. In 1997, NLM worked with the Center for Disease Control and Prevention (CDC) to establish the Partnership in Information Access for the Public Health Workforce to bring federal agencies, the National Network of Libraries of Medicine, and public health associations together to improve information services for public health workers. Since that time, the Library has worked with the Partners to develop a range of new information services, training programs, and outreach projects directed at the public health sector and has promoted greater public health participation in existing funding and training opportunities.

Education and Training Materials. Education and Training.[18]
The NLM has greatly expanded the training opportunities it offers—in biomedical informatics (for example, the course given at the Marine Biology Laboratory at Woods Hole, Massachusetts), biotechnology (through the NCBI), and for medical librarians and information specialists. There has also been an emphasis on increasing, through training grants, the cadre of biomedical informaticians. In 1986, NLM supported five academic sites training a total of 29 students; two decades later, the Library supports 18 sites around the nation, with 270 students. The NLM/AAHSL (Association of Academic Health Sciences Libraries) Leadership Fellows Program has been focused since 2002 on preparing emerging leaders for director positions in academic health center libraries. Grant support is available for informationist fellowships as well.

The Library’s innovations and achievements of the past 20 years have helped to inspire the visions of a positively transformed future for medical practice, public health and research. A new climate for change has been fueled by the power of electronic communications, the embrace of the World Wide Web by health professionals and consumers alike, and some deficiencies. These include inadequate health care safety and quality, the need for better disaster response capabilities, increased political support for the electronic health record, and the promise of individualized treatment building on genomic research.

The centrality of NLM to the biomedical sciences - and to health information delivery - will not change. This plan for 2006-2016--the next decade--is organized around four key goals that will help NLM to enable the desirable future:

  1. Seamless, Uninterrupted Access to Expanding Collections of Biomedical Data, Medical Knowledge, and Health Information
  2. Trusted Information Services that Promote Health Literacy, Improve Health Outcomes, and Reduce Health Disparities Worldwide
  3. Integrated Biomedical, Clinical, and Public Health Information Systems that Promote Scientific Discovery and Speed the Translation of Research into Practice
  4. A Strong and Diverse Workforce for Biomedical Informatics Research, Systems Development, and Innovative Service Delivery


FIGURE 1. NLM Budget Chronology

Chart of NLM Budget from 1986 to 2006