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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


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Last updated: 04 March 2002