U.S. Medicine Donald A.B. Lindberg, M.D. Director, National
Library of Medicine
The U.S. National Library of Medicine:
Expanding Services, Expanding Audiences
The medical library is a key element of infrastructure underpinning
scientific research: using library-based databases a scientist reviews the
latest that has been published before embarking on an experiment, and
publishes the results of that experiment in a journal that finds its way
into that same online database and onto the library shelf. In the health
sciences, the institution that fulfills this role as information
collector, organizer, and disseminator is the National Library of Medicine
(NLM). The NLM maintains two buildings in Bethesda, on the campus of the
National Institutes of Health, to house its unparalleled collections (with
treasures dating to the 11th century). The Library's reading rooms are
open to the public, as are a variety of exhibits and displays. The current
major exhibition is "The Once and Future Web," which explores the parallel
histories of the telegraph and the Internet as two electronic
communications technologies that transformed the world.
The National Library of Medicine continues to evolve from an
institution serving primarily health professionals to a source of
authoritative health information for all. By far the largest medical
library in the world, the NLM is now providing more diverse information to
a wider audience than ever before. Although the Library has been
collecting, processing, sharing, and preserving the biomedical literature
for more than a century and a half, the modern technology employed today
has radically altered how these traditional tasks are done and expanded
their potential for improving the public health.
It is gratifying that the Library's efforts to broaden its services
have been rewarded by widespread acceptance on the part of both the
scientific community and the general public. Polls show that health
information is one of the most popular areas of inquiry by the
Internet-using public, and that NLM's MEDLINE and MEDLINEplus are heavily
used resources. Usage figures for these and other NLM Web-based data
resources continue their steep ascent: the latest statistics show some 400
million searches being done annually, most of them queries to the MEDLINE
database.
MEDLINE is the online file of 12 million references and abstracts to
articles from approximately than 4,600 medical journals. It has been
relied on by the medical community for 30 years as the most authoritative
entry point into an ever-expanding biomedical literature. MEDLINE covers
the period 1966 to the present, and the Library is now converting printed
data from earlier years, back into the fifties.
The sophisticated, yet easy-to-use access system for searching MEDLINE
is called PubMed <www.ncbi.nlm.nih.gov/PubMed>.
Since the launch of PubMed in 1997 continual improvements have been
introduced, and today it offers a high degree of flexibility to users. For
example, there are now Web links to some 2100 of the journals represented
in MEDLINE, allowing users to have access to the full text of articles
referenced in the database. Where such links are not available, users may
avail themselves of the PubMed feature known as "Loansome Doc" to place an
online order for an article directly from a library in the National
Network of Libraries of Medicine. A recent enhancement to PubMed is the
personalized "cubby," which allows the user to store and update searches
between sessions.
The Public Discovers NLM
There was an unexpected consequence of making MEDLINE freely available
on the Web in 1997: what had been a scientific information resource used
almost exclusively by medical librarians, scientists, and health
professionals was discovered by consumers. NLM estimates that 30 percent
of all MEDLINE searching is being done by the public. It is not unusual to
hear of patients who use the database to do research on their condition,
and arrive at the doctor's office with articles from the scientific
literature. In an effort to arm the public with more useful information,
the NLM, in 1998, introduced MEDLINEplus, a source of authoritative,
full-text health information from the NIH institutes and a variety of non-
Federal sources.
MEDLINEplus has grown tremendously, both in terms of its coverage of
health and its usage by the public. As of September 2001, it was being
consulted some 6 million times each month. The original two dozen "health
topics," containing detailed consumer information on various diseases and
health conditions, have been increased to 500. Other information available
through MEDLINEplus includes medical dictionaries, an extensive medical
encyclopedia written in lay language with thousands of illustrations,
detailed information from the U.S. Pharmacopoeia about more than 9,000
brand name and generic prescription and over-the- counter drugs,
information in Spanish, directories of health professionals and hospitals,
and links to organizations and libraries that provide health information
for the public. New additions to MEDLINEplus in 2001 are illustrated
interactive patient tutorials and a daily news feed from the public media
on health-related topics.
The NLM has also learned that health professionals of all kinds are
finding MEDLINEplus to be an excellent source of information. Many
physicians use it to keep up- to-date on medical subjects outside of their
specialty. Others are referring their patients to MEDLINEplus for
up-to-date and authoritative information about their health conditions.
One reason they feel comfortable in doing this is that they trust the
imprimatur of the NIH and NLM. They know that NLM information specialists
follow strict guidelines in selecting Web pages that are appropriate to
the audience level, well-organized, easy to use, educational in nature,
and not selling a product or service. NLM librarians ensure that the
source of the information is dependable, with an advisory board whose
names are listed, and that the site is consistently available and its
links reliably maintained.
The 500 MEDLINEplus health topics have links to a database of ongoing
and planned scientific studies-clinical trials. The reverse is also true:
users of <ClinicalTrials.gov> can also link
to consumer health information relating to the subject of a clinical
trial. ClinicalTrials.gov became available in February 2000 and hosts more
than 5000 visitors daily. The database is a registry of some 5,700 trials
for both federally and privately funded trials of experimental treatments
for serious or life- threatening diseases. Most of the studies are in the
U.S. and Canada, but about 70 countries are represented in all.
ClinicalTrials.gov includes a statement of purpose for each study,
together with the recruiting status, the criteria for patient
participation in the trial, the location of the trial, and specific
contact information.
Databases-New and Expanded
"CAM on PubMed" was announced jointly by the Library and the National
Center for Complementary and Alternative Medicine in February 2001. This
is a popular feature that allows users to limit a MEDLINE search to
articles about complementary and alternative medicine (CAM). The CAM on
PubMed subset currently contains more than 220,000 references to journal
articles related to CAM research. As the field of research in this area
grows and more articles are published in peer-reviewed journals, the
service will greatly expand.
Another online service introduced in 2001 is a Web site aimed at the
special needs of the inhabitants of the Arctic. "ArcticHealth," as it is
called, provides access to evaluated health information from hundreds of
local, state, national, and international agencies, as well as from
professional societies and universities. The new site has sections devoted
to chronic diseases, behavioral issues, traditional medicine,
environment/pollution, and environmental justice. ArcticHealth <arctichealth.nlm.nih.gov>
is the first in what may become a series of health information Web sites
for special populations. Having created the site, the NLM plans to work
with the Regional Medical Library at the University of Washington in
Seattle to have ArcticHealth hosted and maintained by a university already
working with issues important to the Arctic region.
Three Nobel-prize-winning scientists have been added to NLM's website
Profiles in Science <http://www.profiles.nlm.nih.gov/>.
They are biochemist Christian Anfinsen, molecular biologist Marshall
Nirenberg, and geneticist Barbara McClintock. Profiles in Science features
illuminating correspondence, laboratory notes, unpublished manuscripts,
and photographs from outstanding scientific careers. This site, begun in
1998, is now becoming a major online resource for storing the public and
private-and sometimes intimate-papers of this century's greatest
biomedical scientists. There are now seven researchers whose papers are
featured on Profiles in Science.
PubMedCentral, a digital archive of life sciences journal literature,
was announced in 2000 by NLM's National Center for Biotechnology
Information. Publishers electronically send peer-reviewed primary research
articles to be included in PubMedCentral <http://www.pubmedcentral.nih.gov/.
They may also deposit other materials, such as review articles, essays,
and editorials. A journal may deposit material as soon as it is published,
or it may delay release for a specified period of time. NLM undertakes to
guarantee free access to the material; copyright remains with the
publisher or the author. There are at present more than 50 journals in
PubMedCentral, with more soon to come online.
Partnerships
The National Network of Libraries of Medicine (NN/LM) continues to be
the NLM's primary collaborator in outreach to the biomedical community and
to the public. The NN/LM consists of 8 Regional Medical Libraries, 150
resource libraries (at medical schools and other major institutions), and
4500 libraries at hospitals, clinics, and local health institutions. The
goal of the Network is to provide access to accurate and up-to-date health
information for health professionals, patients, families, and the general
public, irrespective of their geographic location. The NN/LM places a
special emphasis on outreach to underserved populations in an effort to
reduce health disparities. In 2001 the NLM competitively awarded new
5-year contracts to eight institutions to serve as Regional Medical
Libraries.
One of the NN/LM outreach efforts involves a telemedicine "connections"
program for Native Americans in the Pacific Northwest conducted through
the Regional Medical Library at the University of Washington. The project
is connecting tribal educational and health facilities to the Internet and
thus reducing the isolation from quality health information and health
care of this vulnerable population. Many of the involved communities (16
villages and tribes in Alaska, Washington, Idaho, Montana, and Oregon) are
in isolated rural areas. In another project, at the University of Alaska
in Anchorage, doctors are using "store and forward" telemedicine
technology to assist health aides in isolated Native American frontier
villages to diagnose ear infections correctly and thus prevent the overuse
of antibiotics. If the village health aide cannot definitively diagnose an
ear infection, a full color digital picture of the eardrum is captured and
sent as an e-mail attachment to the specialist at the hospital. The
specialist makes the diagnosis, determines the course of treatment and
telephones the health aide with the findings.
Early in 2001, the NLM co-sponsored with the Medical Library
Association and the Public Library Association a first-ever meeting to
focus on helping public library patrons find quality health information.
NLM's current emphasis on health information for consumers made this a
natural collaboration between two branches of the library community. At
the 2-day conference, held in Washington, D.C., public librarians were
introduced to health information resources and collection development and
training in how to search health and medical databases. Information about
sources of funding (always welcome by public libraries) was provided.
NLM also has international partners. Since its earliest days in the
19th century, the Library has eagerly sought out for its collection
medical literature from other countries. The published Index Medicus and
the online databases both reflect the international character of medical
publishing. Bilateral agreements between the Library and more than 20
public institutions in foreign countries allow them to serve as
International MEDLARS Centers. As such, they assist health professionals
in accessing MEDLINE and other NLM databases, offer search training,
provide document delivery, and perform other functions as biomedical
information resource centers. The newest International Center, on board in
2001, is the University of Oslo Library of Medicine and Health Sciences in
Oslo, Norway. That Library will provide online search assistance,
training, and document delivery to health professionals and libraries in
Norway and in the Baltic States. They will also translate NLM's
vocabulary, known as Medical Subject Headings, into Norwegian.
Another international partnership in which the NLM is a key player is
the Multilateral Initiative on Malaria. NLM's mandate as leader of the
Communications Working Group has been to leverage partnerships to create a
malaria research network in Africa, enabling scientists there to have full
access to the Internet and the Web as well as access to medical
literature. The aim is to allow researchers, any time of the day or night,
to have instantaneous Internet access that will enable them to send and
receive e-mails, search for literature, interrogate databases, share files
and images with colleagues, and generally move to a new and more efficient
way of doing collaborative research. There are at present 10 installations
in Ghana, Kenya, Tanzania, and Uganda. Pending completion of connectivity
are stations in Burkina Faso, Cameroon, Gambia, Nigeria and Gabon.
Research and Development
The Library remains at the cutting edge of research and development in
medical informatics-the intersection of computer technology and the health
sciences. It does this both through a program of grants to
university-based researchers and through R & D conducted by the NLM's
own scientists. The Library was a leader in the High Performance Computing
and Communications initiative of the nineties and is presently working to
ensure that the health sciences are prepared to take full advantage of the
Next Generation Internet. NLM's Lister Hill National Center for Biomedical
Communications conducts a wide range of research to improve biomedical
communication and also oversees a broad-gauge telemedicine program and the
Visible Human Project.
The Library has used a variety of mechanisms- grant and contract-in the
past several years to fund a variety of telemedicine projects. Some of
them are innovative projects that demonstrate the application and use of
the capabilities of the Next Generation Internet. "A Clinic in Every Home"
is an especially promising telemedicine project with the Iowa Department
of Public Health and the University of Iowa. Building on work successfully
done under an existing contract with NLM, this project is providing a
test-bed for medically underserved rural Iowa residents to provide them
with access to high quality health care. The expectation is that using
such a system will both raise the quality of health care and lower health
care costs. Another example, at the University of Pennsylvania School of
Dentistry, is testing the use of digital dental x-ray for dental
consultation. Digital dental x-rays are taken by the patient's primary
care dentist and sent to university specialists for treatment advice.
Expert consultation results in higher quality care, travel is avoided, and
costs are lowered.
Applications involving the Visible Humans also, in many cases, require
more bandwidth and more reliable service than are currently available. The
Visible Human male and female data sets, consisting of MRI, CT, and
photographic cryosection images, are huge, totaling some 50 gigabytes.
They are being used by scientists around the world in a wide range of
educational, diagnostic, treatment planning, virtual reality, artistic,
mathematical, and industrial uses. Projects run the gamut from teaching
anatomy to practicing endoscopic procedures to rehearsing surgery. One new
aspect of the Visible Human evolution is the project to develop an
extremely detailed atlas of the head and neck in collaboration with the
National Institute of Dental and Craniofacial Research, the National Eye
Institute, the National Institute of Deafness and Other Communication
Disorders, the National Institute of Neurological Disorders and Stroke,
and the National Science Foundation. The application of cutting edge
technologies in this project will allow interactive dissection of anatomic
structure and "fly-through" anatomic relationships, for example, traveling
down the optic nerve and viewing the ophthalmic artery and its
tributaries.
The other major NLM component involved in research and development is
the National Center for Biotechnology Information (NCBI). The Center
designs and develops databases to store DNA sequence information and
creates automated systems for managing and analyzing knowledge about
molecular biology and genetics. With the release of the "working draft" of
the human genome, the global research focus is turning from analysis of
specific genes or gene regions to whole genomes, which refers to all of
the genes found in cells and tissues. To accommodate this shift in
research focus, NCBI has developed a suite of resources to support
comprehensive analysis of the human genome and is thus a key component of
the NIH Human Genome Project. The NCBI is responsible for all phases of
the NIH GenBank database, a collection of all known DNA sequences. GenBank
is growing rapidly with contributions received from scientists around the
world and now contains more than 12 million sequences; it is accessed on
the Web 200,000 times each day by approximately 50,000 researchers <http://www.ncbi.nlm.nih.gov/>.
Scientists use not only the sequence data stored in GenBank, but avail
themselves of the sophisticated computational tools developed by NCBI
intramural investigators, such as the BLAST suite of programs for
conducting comparative sequence analysis. Entrez is NCBI's integrated
database search and retrieval system. It allows users to search enormous
amounts of sequence and literature information with techniques that are
fast and easy to use. Using this system, one can access NCBI's nucleotide,
protein, mapping, taxonomy, genome, structure, and population studies
databases, as well as PubMed, the Web-based retrieval system for
biomedical literature. The publicly accessible "Human Gene Map" is another
example of an important analysis tool developed by NCBI researchers.
GeneMap represents an outline of the draft human genome and contains the
location of more than 35,000-about half-of all human genes.
NLM Extramural Programs have an important role in ensuring that the
nation's biomedical research enterprise has the trained professionals it
needs in computational biology, including mathematical modeling in the
life sciences, advanced imaging, and molecular biology.
This role was brought into focus in the report of the Working Group on
Biomedical Computing, "The Biomedical Information Science and Technology
Initiative." The BISTI initiative directly falls within the scope of the
NLM's medical informatics training program under which the Library
supports 12 training programs at universities across the nation for the
express purpose of training experts to carry out research in general
informatics and in the genome-related specialty of bioinformatics. The NLM
has augmented each of the 12 training programs with a "BISTI supplement"
of $200,000 to strengthen or initiate bioinformatics training within the
program.
Despite the NLM's extensive involvement with computer and
communications technology, the staff is ever mindful of its responsibility
to maintain the integrity of the world's largest collection of medical
books and journals.
Increasingly, this information is in digital form, and the NLM, as a
national library responsible for preserving the scholarly record of
biomedicine, is developing a strategy for selecting, organizing, and
ensuring permanent access to digital information. Regardless of the format
in which the materials are received, ensuring their availability for
future generations remains the Library's highest priority.
U.S. Medicine Vol. 38, No. 1 January 2002 Pages
44-45
First published: 04 March 2002 Last updated: 04 March 2002 Date Archived: 22 April 2004 Metadata | Permanence level: Permanent: Unchanging Content
|