Hospital Libraries Matter

Libraries impact clinical decision-making, support hospital functions.

Guest post by Basia Delawska-Elliott and Donna Belcinski, medical librarians serving hospitals in Oregon and Connecticut.

Recently there have been a number of messages going out to medical library discussion lists announcing the unfortunate closing of yet another hospital library. It seems that, in this era of for-profit medicine, libraries are looked upon as luxuries. Yet those of us who work in them know our services are not only needed but valued by the physicians, nurses, and other health professionals who regularly call on us to answer their questions.

Anyone who doubts the need for information professionals in a hospital probably doesn’t understand what we do.

Many people think everything is on Google, and it might be, but it’s not easy to find. Medical literature is found in databases that often require time, patience, and skill to search, and a subscription to access.

Furthermore, someone has to assess the information needs of the hospital community, negotiate pricing for and purchase the resources that best fit those needs, work with vendors and the institution’s IT department to set up access to the resources, and then navigate the resources to retrieve what is in them.

Searching databases takes time, patience, and skill. While it is certainly possible for medical professionals to have the patience and skill, do they really have the time? How many nurses and physicians, in the course of a busy 12-hour shift, can find the time to search the medical literature?

A point-of-care tool can give a quick answer, but if something in-depth or out of the ordinary is required, those tools aren’t usually helpful. More specialized skills and knowledge of how information is organized are needed to answer complex clinical questions. Hospital librarians have not only the educational background, but also the experience to navigate databases and retrieve hard-to-find information.

symbols representing different types of medical information hover over a laptop on which a doctor typesMany people don’t seem to understand what a librarian does, why it’s different from a Google search, and that the “information bubble” is as real in medicine as it is in other disciplines. They may also be unaware that googling can lead to selective retrieval of information and confirmation of bias. The groundbreaking 1992 Rochester study (Marshall) and the 2013 follow up (Marshall) showed the vast majority of physicians changed the course of patient treatment based on library-provided information—80% in 1992, 75% in 2013. This telling statistic confirms that librarian-mediated searches and resources curated by hospital librarians do make a difference.

Every time a hospital library closes, we send out a call to arms and vow to stem the tide of attrition in our ranks. Yet the task of saving hospital libraries has become increasingly difficult. Once mandated by law, requirements for hospital libraries have been dropped by regulatory agencies—first by the Health Care Financing Administration in 1986, then The Joint Commission in 1993. In the climate of expense cuts, this shift has made hospital libraries an easy target. Point-of-care products, which synthesize current evidence in support of decision-making regarding tests, interventions, or diagnosis, have also made it more difficult to convince administrators that other information resources are still needed—and oftentimes more reliable. And with health systems increasingly consolidating, health system administrators—now  removed from everyday hospital concerns—may see the library only as an expense and not as an asset their hospital staff value and rely upon.

Although hospital librarians have primarily concentrated on providing patient-care information, we also support a number of different important hospital functions and initiatives including research, information literacy training, graduate medical education, undergraduate and graduate nursing and allied health education, continuing education, Magnet preparation, evidence-based nursing practice, and hospital administrative and competitive intelligence research. Cuddy (2005) described a similar assessment of the breadth of library contributions in the Fuld Campus study.

The value of a hospital librarian has been proven. And with doctors and nurses asked to practice evidence-based medicine, is it really wise to close hospital libraries and dismiss the professionals best equipped to find that evidence?

What steps can we take to ensure the latest announcement of a hospital library closing is the last?

Sources cited
Cuddy, T.M. (2005). Value of hospital libraries: The Fuld Campus study. Journal of the Medical Library Association, 93, 446-449.

Marshall, J.G. (1992). The impact of the hospital library on clinical decision making: The Rochester study. Bulletin of the Medical Library Association, 80, 169-17.

Marshall, J.G., Sollenberger, J., Easterby-Gannett, S., Morgan, L. K., Klem, M. L., Cavanaugh, S. K., . . . Hunter, S. (2013). The value of library and information services in patient care: Results of a multisite study. Journal of the Medical Library Association, 101(1), 38-46.

Photo credit (top): Flickr | New Jersey Library Association (CC BY-NC-ND 2.0) | cropped

From One National Library to Another—Similar, Yet Different

Strategic planning underway at two national libraries

Guest post by Dianne Babski, Deputy Associate Director for Library Operations at NLM.

The United States doesn’t have a single national library like other countries. Instead, we have five—the Library of Congress (LC), the National Library of Medicine (NLM), the National Agricultural Library, the National Library of Education, and the National Transportation Library—with LC and NLM the two largest. All five libraries are in the Washington, DC area.

Last month NLM Director Dr. Patricia Flatley Brennan, Dr. Mike Huerta, Associate Director for Program Development, and I took advantage of the proximity and headed to the Library of Congress for a strategic planning conversation. We were joined by LC staff from the Strategic Planning and Performance Management office, including Dianne Houghton, Director, and Emily Roberts, Management and Program Analyst.

Together we celebrated our new directors: Carla Hayden, the 14th Librarian of Congress, and Dr. Brennan, NLM’s 19th leader. Each the first woman appointed to her position, they were sworn in within days of each other last September—and took the helm of two national treasures on the verge of major planning initiatives.

Founded in the early 1800s, both libraries have long histories and serve unique roles. LC is a research service for the US Congress, home of the Copyright Office, a national library for the blind and physically handicapped, and sponsor of the Poet Laureate. It develops its collection based on the Jeffersonian ideal that all subjects will be of interest and value to Congress, scholars, and researchers, as well as the public. In contrast, NLM, the world’s largest biomedical library, builds upon its vast collections in biomedicine, health care, and the history of medicine to further health care practice, support life sciences research, and enhance personal and public health.

The trio poses in front of an ornate fireplace
Dianne Babski, Dr. Mike Huerta, and Dr. Patricia Flatley Brennan visit the Library of Congress to discuss strategic planning.

While our collections, roles, and customers differ, the two libraries face similar challenges, including shifting budgets, dwindling space for growing collections, an evolving publishing landscape, ever-expanding digital and IT footprints, and the need to recruit, train, and retain an educated workforce. These core similarities gave us much to talk about as we discussed our respective strategic planning efforts.

LC is in the early stages of “Envisioning 2025,” its planning initiative designed to chart the course for the Library’s next decade. In-house “tiger teams” comprised of LC staff are formulating questions and raising issues that will help set priorities for future strategic planning activities. LC expects to have a full set of priorities established by the end of the fiscal year and, if all goes well, will start to implement them in 2018.

Meanwhile, NLM is quite far along in its planning process. We have solicited input from our broad stakeholder community, brought together experts to discuss challenges and opportunities around four key themes, gathered ideas and suggestions from NLM staff, and collected and synthesized public comments. This input has been sorted, analyzed, debated, and refined, and together it will inform the recommendations report set for release in late 2017. Those recommendations will, in turn, shape the priorities for NLM’s next decade.

It’s an exciting time at both libraries.

We expect to build on that excitement through ongoing collaboration, sharing experiences in risk management, digitization and preservation, and workforce development.

With more in common than different, we have much to learn from each other, and our two dynamic, new leaders are ready to guide us into a promising future.

There Is an Internet in Space

Guest post by Vint Cerf, vice president and chief Internet evangelist at Google.

In a recent blog, Dr. Brennan correctly identified a future issue: access to medical information from a Mars colony, should one be established. In her summary, she said there was no internet in space.

Actually, there is.

It uses a protocol suite other than the terrestrial TCP/IP originally designed by Bob Kahn and me beginning in 1973 and which has evolved over time thanks to the work of the Internet Engineering Task Force and many researchers and internet practitioners around the world.

The Interplanetary Internet (sometimes called the Solar System Internet by the UN’s Consultative Committee on Space Data Systems) adopted a suite of protocols known generally as the Bundle Protocols. The prototypes of these protocols are on board the Mars rovers, Spirit and Opportunity, the Mars Science Laboratory, and the International Space Station.

The rovers and Science Laboratory use the Bundle Protocols to deliver their data to Earth by way of re-programmed orbiters initially sent to Mars to map the surface of the planet. In essence, the rovers and Science Laboratory capture sensor data, which they beam to the orbiter(s) as the orbiter(s) become visible. The orbiters then hold that data until they can be transmitted to Earth by way of the Deep Space Network (DSN), which was put into operation in the early 1960s to support manned and robotic space exploration. This transmit-and-hold approach of the Bundle Protocols is representative of Delay and Disruption Tolerant Networking (DTN).

The Deep Space Network has three 70-meter dishes located at Canberra, Australia; Madrid, Spain; and Goldstone, California. There are also several 34-meter dishes at these same locations. The DSN is operated by the Jet Propulsion Laboratory  in Pasadena, California, under the oversight of the California Institute of Technology. These large dishes allow the Jet Propulsion Laboratory to receive very weak signals from spacecraft very distant from Earth. The Voyager spacecraft, Voyager 1 and Voyager 2, are now respectively 20.7 billion kilometers and 17 billion kilometers away from Earth and into interstellar space. The DSN can still read the very, very weak signals from both spacecraft.

If a plan does indeed emerge to assure that relevant information from the National Library of Medicine is available to Mars astronauts and perhaps colonists, the natural preparatory step would be to outfit the NLM online systems with Bundle Protocol capability. But don’t expect any kind of real-time, interactive World Wide Web-like service for Mars residents. The light speed round-trip times between Earth and Mars vary from 7 minutes to 40 minutes, and the data rates between Earth and Mars currently run less than 1 Mb/s using conventional radio communications. Experiments have been conducted using laser communications between Earth and the Moon at 600 Mb/s, so one might hope for significant data rate improvements in the future.

If humanity is to become a space-faring species, it will need continuing access to the scientific and medical advances cataloged in the NLM’s systems. We can certainly imagine putting up local data servers on Mars for rapid local interaction while updating these local archives from Earth NLM periodically.

More Information
InterPlanetary Networking Special Interest Group

Image source (top): NASA: Mars Explorers Wanted Posters | modified

Is NLM Building a Library on Mars?

Safe, productive human space travel requires more than sophisticated spacecraft. From environmental conditions to the physiological and psychosocial impacts, NASA’s astronauts face unique challenges while living in space.

To help address those challenges, NIH and NASA established a research partnership in January 2016. The research opportunities arising from this partnership and through NASA’s Human Research Program are expected to improve health both for the population on Earth and for those who travel to Mars and beyond.

What’s the Library’s role?

Well, we’re not getting ready to build an NLM outreach-to-Mars program (yet!), but we are involved in issues related to informatics and health information technology.

We’re expanding our collections and the standard health care terminologies (MeSH, SNOMED, LOINC, RxNorm) to address new environments (i.e., space) and the health concerns faced there (e.g., long-term muscle wasting, bone loss, space radiation exposure). MeSH, for example, already includes terms related to space flight, such as hypogravity and weightlessness; PubMed offers a subset of content focused on space life sciences; PubMed Central houses peer-reviewed papers resulting from NASA-funded research; and our History of Medicine Division holds a unique collection of scientific studies, technical reports, books, and pamphlets received from NASA in 2015.

We’ll also work to fully identify the information and resources needed to support biomedical research and to deliver health services to humans who may be light years away. We can potentially build upon NLM’s current work with machine learning and image recognition to speed diagnosis, and enhance our telemedicine efforts to account for an interplanetary communications delay approaching 42 minutes between Earth and Mars. We’ll further refine our emerging data science methodologies to accelerate discoveries in real time during manned missions. And perhaps most important to me, we’ll imagine—and plan for—a future without the internet.

No internet?!

Astronaut and moon reflected in the window of the space stationCurrently the internet is essential for the delivery of NLM’s most-used services, but there is no internet in space. We need to anticipate an independent technological infrastructure that will allow us to support research and medical care without it.

Such foresight, planning, and commitment can yield great results. Indeed, because of NLM’s leadership of the High Performance Communication and Computing Program 24 years ago (1992), we had satellite communication services in place to support the long-distance conversation between NIH Director Francis Collins and Astronaut Kate Rubins last October (2016).

But thinking systematically about how to deliver scientific knowledge in space will yield benefits long before the Orion spacecraft sets course for Mars.

While we don’t expect the internet here on Earth to go away, we must be prepared to deliver 24/7 access to NLM resources in the event of an interruption in internet service, whether due to natural disasters, construction failures, cyberterrorism, or even solar flares.

So, the next time you hear that NLM is working on human space exploration, remember that, while we’re planning for an information-rich future, we’re also ensuring an information-available present.

The library on Mars will come later.

Co-authored by Dianne Babski, Deputy Associate Director for Library Operations, who serves as the NLM representative to the NIH/NASA Biomedical Research Partnership.

Photo credit (Mars in space, top): Composite NASA Hubble Space Telescope Image (October 19, 2014) | cropped

Sharing Small Data Files for More Analysis Power

Guest post by Ashley Hintz, curator for NLM NCBI’s Sequence Read Archive.

Imagine the rows upon rows of books in the stacks of a research library. Then imagine how much information is stored in those books.

An organism’s entire genome is the equivalent of that large library with its multiple floors of loaded shelves. It is densely packed with information.

Just as reference librarians specialize in locating specific information within the library, bioinformaticians specialize in working through, analyzing, and understanding genomes.

And as librarians determine how best to search the online catalog to locate a specific item within the library, bioinformaticians write computer scripts to filter the massive amount of genomic data and identify the parts most relevant to particular research questions. Such filtering creates smaller data files that are easier to analyze, visualize, and share with colleagues.

Unfortunately, many researchers don’t start with the smaller, filtered genomic data sets.

These researchers are stuck believing they must always begin their analysis from the full genome, even though most of the genome’s elements have nothing to do with their research questions.

The idea that you must have the original raw sequence data to analyze the data correctly means that large amounts of data (sometimes terabytes) get moved on a regular basis, or, given the data’s large size, they never move, so access to them is limited.

It’s the equivalent of checking out the whole library when a couple books will answer your questions.

Genomes can be filtered by SNPs (or single nucleotide polymorphisms) from a vcf file, collections of genes, or read counts for gene expression data. All of these smaller data files have practical-use cases and deliver what researchers are commonly interested in.

Current technology also makes sharing these filtered data files incredibly easy. Given their small size (mere gigabytes), it’s more on the scale of sharing pictures of your children or pets.

Sounds good, but what can one accomplish with these filtered genome datasets?

One example: perinatal screening for genes and/or SNPs that can potentially cause disease. Once the entire genome or exome is sequenced, the doctor can examine a vcf file of SNPs, filter that file further using data about the family’s medical history or the infant’s clinical symptoms, and then transfer the data files easily to a specialist for a second opinion. In these cases, the smaller data file becomes a powerful diagnostic tool.

A second example: gene expression data used in research. Instead of each scientist recalculating read counts (such as FPKMs), one researcher can share smaller analysis files with others. The smaller files can then be used to identify and visualize meaningful differences in expression between genes or samples. This sharing is not only more efficient; it also facilitates the collaboration necessary to tackle such significant and complex medical issues as obesity, Alzheimer’s, and autoimmune diseases, all of which show differences in the expression levels of certain genes.

These examples just scratch the surface of the power behind filtering genome data for data analysis, visualization, and sharing.

With genome sequencing growing more affordable, the amount of sequence data is expected to grow more rapidly, so we need to change the mindset that we must start with the whole library to see results. Think “focused” instead of “complete,” or, as the librarians like to say, “precision over recall.”

It’s one more example of where less, most definitely, can be more.