Integrating CD-ROM Medline with Electronic Mail: First Step in lmplementing New Strategy for Online Reference Library Ron Ribitzky, M.D. Boston Children's Hospital, Information Services Department Harvard Medical School, Medical Infonration Science Program, Dept. of Medicine (Pediatrics) 300 Longwood Avenue, Boston MA 02115 Tel: 617-735-6915 Medline [1-21. Seeking to provide users with direct, free access to Medline and convenient, local printing we have installed BRS/Onsite in spring of 1988 [3]. The product contained three most recent years and current month subsets of Medline. Our results of BRS/Onsite use profiles generally matched NLM's data [2].
Abstract Simultaneous ACCESS to and DISSEMINATION of electronically available PROFESSIONAL KNOWLEDGE, in a productive, Cost-of-Ownership effective, and affordable manner are now achievable. Emerging MANAGEMENT-OF-INFORMATION and SYSTEMS-INTEGRATION disciplines are essential contributingfactors to devising and implementing NEW STRATEGIES for ONLINE
REFERENCE LIBRARIES. Bringing integrated information closer to the ultimate user and RESHAPING the electronic databases andfull-text management systems MARKETPLACE are the most significant outcomes. Key technology attributes are advancements in CD-ROM, Networking, and office automation . We have proven this concept by developing an INTERFACE between MEDLINE from COMPACT CAMBRIDGE and ALL-IN-I from DIGITAL EQUIPMENT CORPORATION. Saved search results are automatically routed to the individual's ALL-IN1 account where further DOCUMENT MANAGEMENT and electronic mailfunctions may be performed. A 486Ware system from Logicraft and a five-members VAX-Cluster (respectively), are linked in a DECNet environment that is the foundation of Children's Integrated Hospital Information System. !n phase one of the project up to 8 SIMULTANEOUS USERS may access the 8 RECENT YEARS, from any one of 1500 ACCESS POINTS (local and remote), and utilize any one of 150 NETWORKED PRINTERS.
Opportunities are now within reach to expand the electronic library services while utilizing progressive methods and taking advantage of the best available technologies. Introduction Hundreds of users at Clhildren's, the majority of which are physicians have used a remote access, subscription based 0195-4210/91/$5.00 © 1992 AMIA, Inc.
578
In retrospect, BRS/Onsite at Children's had some critical shortfalls. First, from a cost-of-ownership standpoint, BRS/Onsite was an expensive solution. It was installed on an IBM 3090 mainframe on a VM/MVS and consumed close to 4 GB of storage. Additionally, the product did not meet our connectivity expectations. Attempts made by a multidisciplinary team to integrate BRS/Onsite with networked printers over SNAGate and DECNet were unsuccessful. Further, transferring search results from the IBM/MVS to DEC's VAX/VMS environment for document processing and distribution involved a cumbersome, manual process of manipulating screen dumps to SNAGate files. Furthermore, generating daily use statistics required a data-center operator's intervention, and was lacking key asset-monitoring features. Finally, BRS/Colleague was eventually perceived an inferior user interface compared to other Medline products that have since emerged in the market.
Mission and Strategies Children's Hospital has revisited its library service in the context of securing its leadership position in pediatric patient care, research, and education. Quality of service, wide and free access to knowledge assets, and achieving economies of scale were identified as key objectives by the library committee. It was apparent that full text electronic databases rapidly either substitute or complement traditional, paper based sources of bio-medical knowledge [1, 2, 4-13]. Children's experience in utilizing diverse information technologies [3], combined with our awareness to the context of which Medline ought to be used were instrumental in devising a new strategy for the hospital's electronic reference library.
The strategic plan defines three categories of online reference library services, emphasizing source and access as key differentiating factors. First category is remote-access, subscription-based databases. High costs and relatively inferior communication technology are substantial adverse features. The pay-as-you-use practice was in direct conflict with our fundamental philosophy that access to knowledge assets in the context of patient care and generating new medical knowledge ought to be free [1-2,6-7,15-16].
Second category is vendor provided databases that may be installed on premises. CD-ROM technology rapidly emerges as the superior cost/benefit solution in this category. Industry offerings in terms of types and numbers of different databases is rapidly growing [17-19]. Connectivity of low cost personal computers with large scale, network based enterprise information system is extensive and relatively mature [3,20-23]. However, capacity and performance problems were anticipated. Further, asset monitoring is a severely lacking feature since these PC databases have been traditionally designed for a single user as opposed to being part of institutional, shared asset [17,19,24]. Third category refers to internally developed databases that utilize full text management systems technology, seeking to capture, maintain and grow 'MEDICAL CORPORATE KNOWLEDGE'. Databases that contain patient specific, medical-knowledge intensive documents such as discharge summaries and operative reports introduce significant new benefit to clinicians, researchers, educators and students. Consulting with electronic documents of the emerging Computerized Medical Record is substantially more cost effective and strategically justiried alternative than provided by paper based record [3, 25-26]. Further, site specific manuals and policy books may be converted to electronic format.
Change Management Medline's popularity, the extensive experience in the industry regarding its use, and the richness of competing vendor offerings suggested that Medline be the focus of a pilot project in the context of the new strategy for online library. Additionally, prior expectations not fully satisfied, Medline was the most pressing service for us to deal with. Driven directly by concrete users' demand and prioritizing, we have set out to devise a new solution for
Medline that will provide more than three years worth of backfiles, that has a better user interface than BRS/Colleague, that may fully utilize any networked printer on campus, and which automatically interfaces with Children's office automation and electronic mail
system (ALL-N-1). The service ought to have been less costly to the institution than its BRS/Onsite predecessor, and provided free of charge to users.
Defining and prioritizing the new functional requirements were done by users, while the Information Department staff acting as facilitators and internal consultants for technology assessment and implementation. Preliminary interaction with individual, dedicated users have evolved to forming a voluntary, ad-hoc steering committee of clinicians, researchers and librarians. ALL-IN-I was almost exclusively and very effectively utilized to distribute information and exchange opinions with the users community in between the committee meetings. We concentrated initially on educating users in opportunities that are created by a rapidly changing information technology, and how they may be translated to practical reality. The evaluation of alternative solutions included demonstrations, functionality review, use profie studies at Children's and elsewhere, technical feasibility assessment, cost-of-ownership analysis and strategic justification method. Introducing New Technology The library committee, headed by a senior staff physician and a core group of librarians, clinicians and researchers (the pilot group) was instrumental and essential to the process. Since Compact Cambridge Medline was first introduced, the pilot group tested the entire installation and provided extremely valuable insight, and directions for
further development. In order to ensure proper management of users
expectations, the system was initially introduced to individuals and small groups. Lessons learned while implementing discharge summary and operative report applications were key to constructing our technology introduction strategy [25]. We have emphasized reasons for change (functional, operational, and fiscal) from BRS/Onsite to Compact Cambridge Medline, the experimental nature of the newly integrated solution, and brought to users awareness issues of UNLEARNING other familiar systems concurrently with the need to LEARN a new system. An interactive, online tutorial effectively substituted the need to distribute paper based documentation. Experienced users increasingly became
579
active in assisting new users utilize the system, as benefits became apparent. ALL-IN-1 was instrumental in managing complementary instructional communication and problem management. We have developed a use monitoring software that helped us in capacity planning during the pilot phase, while setting the foundation for asset management during the production phase. The Enabling Technology CD-ROM was the technology of choice for its significantly low cost of ownership. Compact Cambridge Medline was selected for its high rating [181 and vendor's commitment to collaborate with us on implementing our new srtegy. Such collaboration was strategically and tactically essential, since unprecedented effort to fully integrate the product with Children's technically complex environment was anticipated. Further, asset monitoring feature had to be developed prior to releasing the product for general use and required working in partnership with all parties involved.
Compact Cambridge Medline stores one year per platter. Two Hitachi optic readers having four drives each, thus providing 8 years of data were daisy chained into a Logicraft 486Ware computer running MS-DOS. Logicraft's technology emulates DOS in DEC's VAX/VMS environment, and supports up to 16 simultaneous users. We have used DEC's PC integration product (PCSA) for its seamless integration capability at the file transfer level. We have later abandoned the PCSA component of the project's network architecture in order to simplify the integration with Children's office automation system (DEC's ALLIN1) and to eliminate the need for reentering user's passwords. Children's prior experience with DEC's ALLIN1 is phenomenal, and was reported elsewhere [3]. Our strtegy was to save Medline search results to user's ALLIN1 account in order to facilitate further editing and sharing of interesting abstracts with colleagues, as well as integrating search results with emerging ALLIN-1 based, patient care speciric documents. An ALLIN1 document transfer utility is available to end users. However, this manual option requires a minimal knowledge of directory structures and file transfer process in a VAX/VMS environment. We have assumed that the average user neither possess this technical knowledge nor he or she will want to devote extra time and key strokes to achieve results that may be automated in the first place. So we have utilized ALLINI provided development tools that read files written by Compact Cambridge Medline via
580
Logicraft 486Ware to the user's root directory on the VAX/VMS. These files are then copied to user's ALLIN1 directory, and posted to a MEDLINE folder in ALLINI. The file transfer is initiated by user's logout from Medline, and is followed by starting ALLIN1 and displaying the index of its Medline folder to the user. Destination file names and source files named by the user are exactly the same. The file's display and print format is completely identical across Medline session, DOS, VAX/VMS, and ALLIN1. Capacity and Performance Starting Compact Cambridge Medline across the network added up to 10 seconds, while the execution of search transactions was comparable to a standalone configuration. Response time was subject to performance fluctuations of the underlying hospital information system. Some degradation noticed as the number of simultaneous session reaches the maximum. Transferring saved search results to and starting ALL-IN- I is a known resource intensive process that in the case of our system consumes about 3045 seconds, at the END of the session. Upgrading access and performance was subject to results of a detailed use monitoring system that we have developed, combined with subjective input from users. Cost Analysis Comprehensive COST-BENEFIT, COMPARATIVEANALYSIS of BRS/Onsite and Compact Cambridge was complicated by the need to account for dynamic use of numerous sharable resources that comprise the underlying system, network, and application architecture of the integrated solution. Capital, depreciation, licensing, and operational accounting for various elements required extra, costly resources by itself Competition on resources needed for other information services in the near term added yet another dimension to the analysis. We have decided to reduce this complexity by making certain assumptions and approximations. At the direct operating (licensing) cost component we were able to deliver substantially better service to our users at 80-90% savings. We estimate that additional savings could have been identified had we invested in further analysis.
The Future of Children's Online Library In the time of writing this article, Compact Cambridge Medline gradually migrates from experimental to operational phase. Demand and performance are closely monitored. Data compression techniques are expected to
integrating online reference libraries in the context of hospital information systems [15-24]. Unfortunately, and contrary to its historical initiative [1-2], the National Library of Medicine has counterproductively responded to this positive trend of cost reduction by restructuring its licensing practices that resulted in INCREASING its fees.
yield more than one year per platter, thus allowing us to support 12 rather than 8 years online in the near future, and the entire Medline database eventually.
Successful CD-ROM Medline service will set the stage to installing additional CD-ROM products such as CANCERLIT, drugs interaction, AIDS database and others. Growth in database offerings at Children's will require upgrading of the systems architecture, mainly adding more powerful computers and seamlessly integrating a heterogeneous access devices. Our technical achievements in integrating Medline with ALLINI leverage our position in exploring further opportunities with the industry.
Discussion Physical, operational, and media constraints of TRADITIONAL LIBRARIES have increasingly FAILED to provide ACCESS to PROFESSIONAL KNOWLEDGE IN SUPPORT OF CLINICAL CASE MANAGEMENT, WHEN, WHERE, and HOW CLINICIANS NEED IT [1-2,4,6,8-12]. Books and magazines are confmed to facilities, the access to which is provided within preset, restrictive schedule. In most cases, only one copy of the paper based information is available. Unfortunately, the need for this information in the context of clinical case management is commonly out of sync with its availability. The dissemination of hundreds of networked access devices throughout the campus to affordable, electronic databases containing abstracts and full-text of professional publications, in an integrated information fashion is the emerging alternative. The National Library of Medicine has made a major step toward addressing this service shortcoming by developing Medline, an online database containing citations and abstracts of biomedical articles published worldwide[1-21. Initially introduced on a mainframe platform, and accessible via dial-up method this service was and still is costly and decreasingly effective. Hundreds of professional and scientific databases that utilize full text management systems were introduced in the course of the past two decades [5,15, 18]. More than a dozen of software vendors specialize in the biomedical publications segment. Librarians emerged as experts in conducting cost effective searches for end users [2,7,10,11,14]. Economies of scale made possible by advances in technology, and growing exposure to end users have created opportunities to
The most pressing, competitive issues for providers of CD-ROM databass such as Medline in the next few years is the ability to compress the entire database into a manageable, small number of CD platters; developing multi-database products; migrating from citations only to full-text and multimedia; providing industry standard compliant GRAPHIC USER INTERFACE and INTERAPPLICATIONS COMMUNICATION facilities; and reducing the complexity of networking solutions in the context of large-scale, network-based, multi-vendor information systems environment. Vendors of the information technology infrastructure will contribute to this trend by offering higher capacity products that cooperate seamlesly. The key challenge facing SYSTEMS INTEGRATORS is to intelligently incorporate rapidly expanding electronic SOURCES of PROFESSIONAL KNOWLEDGE within the INFORMATION INTENSIVE WORKING ENVIRONMENT of the USERS, in a CREATIVE, PRODUCTIVE, and AFFORDABLE manner.
Acknowledgement Children's library committee clinicians and researchers, Compact Cambridge people, Logicraft staff, and my colleagues in the information systems departnent were instrumental in helping me implement yet another essential component of the vision for new ways of disseminating knowledge to healthcare professionals. References [1] A World of Knowledge for the Nation's Health: the US National Library of Medicine. RB Mehnert, Am J Hosp Pharm, 43(12):2991-7, December 1986 [2] Bibliographic Retrieval: A Survey of Individual Users of Medline. Karen T. Wallingford et al., MD Computing, 7(3):166-171, 1990 [3] An Integrated Hospital Information System at Children's Hospital. D Margulies, M.D. et al.
581
Proceedings of the 14th Annual SCAMC, 699-703, November 1990, Washington D.C.
[161 Online and OMine Print Costs in Medline. BR Boyce, Bull Med Libr Assoc, 72(2):177-9, April 1984
[4] Searching the Literature: Index Medicus or Medline?. HA Olafsson, Br J Hosp Med, 37(2):161-2, February 1987
[5] New and Noteworthy: Directory of Online Health Care Databases. Medical Data Exchange., MC Computing, 6(5):310,315, 1989
[6] Clinical Computing in a Teaching Hospital. HL Bleich, N Engl J Med., 312(12):756-64, March 1985 [7] Searching Medline at the University of Michigan. Suzanne Grefsheim, M.S.L.S., M.E.D. et al., MD Computing, 8(1):32-36, 1991
[17] CD-ROM Medline Use and Users: Information Transfer in the Clinical Setting. PW DaLrymple, Bull Med Libr Assoc, 78(3):224-32, July 1990
[18] Grading the Vendors of CD-ROM. Richard Harris et al. (letter), MD Computing 6(6):322-323, 1989 [19] An Evaluation of CD-ROM Medline Use in Thailand. A Chamchuklin, Bull Med Libr Assoc, 78(4):395-9, October 1990 [20] LANs and CD ROM: The Quest for a Sane, Elegant Solution. Barry Gerber, PC Week, p. 48, September 4, 1989
[8] A Residency Based Information System. JW
Murphy et al., Ann Intern Med, 112(12):961-3, June 15, [21] New and Noteworthy: Network Access to CD-ROM Databases. Aries Systems Corp., MC Computing, 6(5):310, 1989
1990 [9] How to Keep Up with the Medical, Literature: IV. Using the Literature to Solve Clinical Problems. RB Haynes et al., Ann Intern Med, 105(4):636-40, October 1986
[22] How to Keep Up with the Medical Literature: V. Access by Personal Computer to the Medical Literature. RB Haynes, Ann Intern Med, 105(5):810-6, November 1986
[10] Morning Report: Role of the Clinical Librarian. GL Barbour et al., JAMA, 255(14):1921-2, April 11, 1986
[23] Application of the Office or Home Computer to Searching the Medical Literature. SS Scheidt, J Am Coll Cardiol, 8(5):1211-7, November
[11] Online Access to Medline in Clinical Settings: Study of Use and Usefulness. RB Haynes, Ann Intem Med, 112(1):78-84, January 1990
1986
[24] Monitoring Patron Use of CD-ROM Databases Using Signln-Stat. H Silver et al., Bull Med Libr Assoc, 78(3):252-7, July 1990
[12] Computerized Literature Searching in the Ambulatory Setting Using PaperChase. BK Wolffing, Henry Ford Hosp Med J, 38(1):57-61, 1990 [13] Citation Analysis of the Field of Medical Decision Making: Update, 1959-1985. KI Pyle et al., Med Decis Making, 8(3): 155-64, July-September 1988 [14] User Attitudes Toward End User Literature Searching. L Ludwig, Bull Med Libr Assoc, 76(1):7-13, January 1988
[15] An Evaluation of Four End User Systems for Searching Medline. MD Bonham, Bull Med Libr Assoc, 76(2): 171-80, April 1988
582
[25] Use of a Text Retrieval System to Automate Discharge Summaries and Operative Reports. R Ribitzky, M.D. et al. Proceedings of the 14th Annual SCAMC, 370-374, November 1990,
Washington D.C.
[26] Cost of Implementing and Maintaining a Hospital Pharmacy Based Online Literature Search System. PF Souney et al., Am J Hosp Pharm, 42(11): 2496-8, November 1985
Abstract Simultaneous ACCESS to and DISSEMINATION of electronically available PROFESSIONAL KNOWLEDGE, in a productive, Cost-of-Ownership effective, and affordable manner are now achievable. Emerging MANAGEMENT-OF-INFORMATION and SYSTEMS-INTEGRATION disciplines are essential contributingfactors to devising and implementing NEW STRATEGIES for ONLINE
REFERENCE LIBRARIES. Bringing integrated information closer to the ultimate user and RESHAPING the electronic databases andfull-text management systems MARKETPLACE are the most significant outcomes. Key technology attributes are advancements in CD-ROM, Networking, and office automation . We have proven this concept by developing an INTERFACE between MEDLINE from COMPACT CAMBRIDGE and ALL-IN-I from DIGITAL EQUIPMENT CORPORATION. Saved search results are automatically routed to the individual's ALL-IN1 account where further DOCUMENT MANAGEMENT and electronic mailfunctions may be performed. A 486Ware system from Logicraft and a five-members VAX-Cluster (respectively), are linked in a DECNet environment that is the foundation of Children's Integrated Hospital Information System. !n phase one of the project up to 8 SIMULTANEOUS USERS may access the 8 RECENT YEARS, from any one of 1500 ACCESS POINTS (local and remote), and utilize any one of 150 NETWORKED PRINTERS.
Opportunities are now within reach to expand the electronic library services while utilizing progressive methods and taking advantage of the best available technologies. Introduction Hundreds of users at Clhildren's, the majority of which are physicians have used a remote access, subscription based 0195-4210/91/$5.00 © 1992 AMIA, Inc.
578
In retrospect, BRS/Onsite at Children's had some critical shortfalls. First, from a cost-of-ownership standpoint, BRS/Onsite was an expensive solution. It was installed on an IBM 3090 mainframe on a VM/MVS and consumed close to 4 GB of storage. Additionally, the product did not meet our connectivity expectations. Attempts made by a multidisciplinary team to integrate BRS/Onsite with networked printers over SNAGate and DECNet were unsuccessful. Further, transferring search results from the IBM/MVS to DEC's VAX/VMS environment for document processing and distribution involved a cumbersome, manual process of manipulating screen dumps to SNAGate files. Furthermore, generating daily use statistics required a data-center operator's intervention, and was lacking key asset-monitoring features. Finally, BRS/Colleague was eventually perceived an inferior user interface compared to other Medline products that have since emerged in the market.
Mission and Strategies Children's Hospital has revisited its library service in the context of securing its leadership position in pediatric patient care, research, and education. Quality of service, wide and free access to knowledge assets, and achieving economies of scale were identified as key objectives by the library committee. It was apparent that full text electronic databases rapidly either substitute or complement traditional, paper based sources of bio-medical knowledge [1, 2, 4-13]. Children's experience in utilizing diverse information technologies [3], combined with our awareness to the context of which Medline ought to be used were instrumental in devising a new strategy for the hospital's electronic reference library.
The strategic plan defines three categories of online reference library services, emphasizing source and access as key differentiating factors. First category is remote-access, subscription-based databases. High costs and relatively inferior communication technology are substantial adverse features. The pay-as-you-use practice was in direct conflict with our fundamental philosophy that access to knowledge assets in the context of patient care and generating new medical knowledge ought to be free [1-2,6-7,15-16].
Second category is vendor provided databases that may be installed on premises. CD-ROM technology rapidly emerges as the superior cost/benefit solution in this category. Industry offerings in terms of types and numbers of different databases is rapidly growing [17-19]. Connectivity of low cost personal computers with large scale, network based enterprise information system is extensive and relatively mature [3,20-23]. However, capacity and performance problems were anticipated. Further, asset monitoring is a severely lacking feature since these PC databases have been traditionally designed for a single user as opposed to being part of institutional, shared asset [17,19,24]. Third category refers to internally developed databases that utilize full text management systems technology, seeking to capture, maintain and grow 'MEDICAL CORPORATE KNOWLEDGE'. Databases that contain patient specific, medical-knowledge intensive documents such as discharge summaries and operative reports introduce significant new benefit to clinicians, researchers, educators and students. Consulting with electronic documents of the emerging Computerized Medical Record is substantially more cost effective and strategically justiried alternative than provided by paper based record [3, 25-26]. Further, site specific manuals and policy books may be converted to electronic format.
Change Management Medline's popularity, the extensive experience in the industry regarding its use, and the richness of competing vendor offerings suggested that Medline be the focus of a pilot project in the context of the new strategy for online library. Additionally, prior expectations not fully satisfied, Medline was the most pressing service for us to deal with. Driven directly by concrete users' demand and prioritizing, we have set out to devise a new solution for
Medline that will provide more than three years worth of backfiles, that has a better user interface than BRS/Colleague, that may fully utilize any networked printer on campus, and which automatically interfaces with Children's office automation and electronic mail
system (ALL-N-1). The service ought to have been less costly to the institution than its BRS/Onsite predecessor, and provided free of charge to users.
Defining and prioritizing the new functional requirements were done by users, while the Information Department staff acting as facilitators and internal consultants for technology assessment and implementation. Preliminary interaction with individual, dedicated users have evolved to forming a voluntary, ad-hoc steering committee of clinicians, researchers and librarians. ALL-IN-I was almost exclusively and very effectively utilized to distribute information and exchange opinions with the users community in between the committee meetings. We concentrated initially on educating users in opportunities that are created by a rapidly changing information technology, and how they may be translated to practical reality. The evaluation of alternative solutions included demonstrations, functionality review, use profie studies at Children's and elsewhere, technical feasibility assessment, cost-of-ownership analysis and strategic justification method. Introducing New Technology The library committee, headed by a senior staff physician and a core group of librarians, clinicians and researchers (the pilot group) was instrumental and essential to the process. Since Compact Cambridge Medline was first introduced, the pilot group tested the entire installation and provided extremely valuable insight, and directions for
further development. In order to ensure proper management of users
expectations, the system was initially introduced to individuals and small groups. Lessons learned while implementing discharge summary and operative report applications were key to constructing our technology introduction strategy [25]. We have emphasized reasons for change (functional, operational, and fiscal) from BRS/Onsite to Compact Cambridge Medline, the experimental nature of the newly integrated solution, and brought to users awareness issues of UNLEARNING other familiar systems concurrently with the need to LEARN a new system. An interactive, online tutorial effectively substituted the need to distribute paper based documentation. Experienced users increasingly became
579
active in assisting new users utilize the system, as benefits became apparent. ALL-IN-1 was instrumental in managing complementary instructional communication and problem management. We have developed a use monitoring software that helped us in capacity planning during the pilot phase, while setting the foundation for asset management during the production phase. The Enabling Technology CD-ROM was the technology of choice for its significantly low cost of ownership. Compact Cambridge Medline was selected for its high rating [181 and vendor's commitment to collaborate with us on implementing our new srtegy. Such collaboration was strategically and tactically essential, since unprecedented effort to fully integrate the product with Children's technically complex environment was anticipated. Further, asset monitoring feature had to be developed prior to releasing the product for general use and required working in partnership with all parties involved.
Compact Cambridge Medline stores one year per platter. Two Hitachi optic readers having four drives each, thus providing 8 years of data were daisy chained into a Logicraft 486Ware computer running MS-DOS. Logicraft's technology emulates DOS in DEC's VAX/VMS environment, and supports up to 16 simultaneous users. We have used DEC's PC integration product (PCSA) for its seamless integration capability at the file transfer level. We have later abandoned the PCSA component of the project's network architecture in order to simplify the integration with Children's office automation system (DEC's ALLIN1) and to eliminate the need for reentering user's passwords. Children's prior experience with DEC's ALLIN1 is phenomenal, and was reported elsewhere [3]. Our strtegy was to save Medline search results to user's ALLIN1 account in order to facilitate further editing and sharing of interesting abstracts with colleagues, as well as integrating search results with emerging ALLIN-1 based, patient care speciric documents. An ALLIN1 document transfer utility is available to end users. However, this manual option requires a minimal knowledge of directory structures and file transfer process in a VAX/VMS environment. We have assumed that the average user neither possess this technical knowledge nor he or she will want to devote extra time and key strokes to achieve results that may be automated in the first place. So we have utilized ALLINI provided development tools that read files written by Compact Cambridge Medline via
580
Logicraft 486Ware to the user's root directory on the VAX/VMS. These files are then copied to user's ALLIN1 directory, and posted to a MEDLINE folder in ALLINI. The file transfer is initiated by user's logout from Medline, and is followed by starting ALLIN1 and displaying the index of its Medline folder to the user. Destination file names and source files named by the user are exactly the same. The file's display and print format is completely identical across Medline session, DOS, VAX/VMS, and ALLIN1. Capacity and Performance Starting Compact Cambridge Medline across the network added up to 10 seconds, while the execution of search transactions was comparable to a standalone configuration. Response time was subject to performance fluctuations of the underlying hospital information system. Some degradation noticed as the number of simultaneous session reaches the maximum. Transferring saved search results to and starting ALL-IN- I is a known resource intensive process that in the case of our system consumes about 3045 seconds, at the END of the session. Upgrading access and performance was subject to results of a detailed use monitoring system that we have developed, combined with subjective input from users. Cost Analysis Comprehensive COST-BENEFIT, COMPARATIVEANALYSIS of BRS/Onsite and Compact Cambridge was complicated by the need to account for dynamic use of numerous sharable resources that comprise the underlying system, network, and application architecture of the integrated solution. Capital, depreciation, licensing, and operational accounting for various elements required extra, costly resources by itself Competition on resources needed for other information services in the near term added yet another dimension to the analysis. We have decided to reduce this complexity by making certain assumptions and approximations. At the direct operating (licensing) cost component we were able to deliver substantially better service to our users at 80-90% savings. We estimate that additional savings could have been identified had we invested in further analysis.
The Future of Children's Online Library In the time of writing this article, Compact Cambridge Medline gradually migrates from experimental to operational phase. Demand and performance are closely monitored. Data compression techniques are expected to
integrating online reference libraries in the context of hospital information systems [15-24]. Unfortunately, and contrary to its historical initiative [1-2], the National Library of Medicine has counterproductively responded to this positive trend of cost reduction by restructuring its licensing practices that resulted in INCREASING its fees.
yield more than one year per platter, thus allowing us to support 12 rather than 8 years online in the near future, and the entire Medline database eventually.
Successful CD-ROM Medline service will set the stage to installing additional CD-ROM products such as CANCERLIT, drugs interaction, AIDS database and others. Growth in database offerings at Children's will require upgrading of the systems architecture, mainly adding more powerful computers and seamlessly integrating a heterogeneous access devices. Our technical achievements in integrating Medline with ALLINI leverage our position in exploring further opportunities with the industry.
Discussion Physical, operational, and media constraints of TRADITIONAL LIBRARIES have increasingly FAILED to provide ACCESS to PROFESSIONAL KNOWLEDGE IN SUPPORT OF CLINICAL CASE MANAGEMENT, WHEN, WHERE, and HOW CLINICIANS NEED IT [1-2,4,6,8-12]. Books and magazines are confmed to facilities, the access to which is provided within preset, restrictive schedule. In most cases, only one copy of the paper based information is available. Unfortunately, the need for this information in the context of clinical case management is commonly out of sync with its availability. The dissemination of hundreds of networked access devices throughout the campus to affordable, electronic databases containing abstracts and full-text of professional publications, in an integrated information fashion is the emerging alternative. The National Library of Medicine has made a major step toward addressing this service shortcoming by developing Medline, an online database containing citations and abstracts of biomedical articles published worldwide[1-21. Initially introduced on a mainframe platform, and accessible via dial-up method this service was and still is costly and decreasingly effective. Hundreds of professional and scientific databases that utilize full text management systems were introduced in the course of the past two decades [5,15, 18]. More than a dozen of software vendors specialize in the biomedical publications segment. Librarians emerged as experts in conducting cost effective searches for end users [2,7,10,11,14]. Economies of scale made possible by advances in technology, and growing exposure to end users have created opportunities to
The most pressing, competitive issues for providers of CD-ROM databass such as Medline in the next few years is the ability to compress the entire database into a manageable, small number of CD platters; developing multi-database products; migrating from citations only to full-text and multimedia; providing industry standard compliant GRAPHIC USER INTERFACE and INTERAPPLICATIONS COMMUNICATION facilities; and reducing the complexity of networking solutions in the context of large-scale, network-based, multi-vendor information systems environment. Vendors of the information technology infrastructure will contribute to this trend by offering higher capacity products that cooperate seamlesly. The key challenge facing SYSTEMS INTEGRATORS is to intelligently incorporate rapidly expanding electronic SOURCES of PROFESSIONAL KNOWLEDGE within the INFORMATION INTENSIVE WORKING ENVIRONMENT of the USERS, in a CREATIVE, PRODUCTIVE, and AFFORDABLE manner.
Acknowledgement Children's library committee clinicians and researchers, Compact Cambridge people, Logicraft staff, and my colleagues in the information systems departnent were instrumental in helping me implement yet another essential component of the vision for new ways of disseminating knowledge to healthcare professionals. References [1] A World of Knowledge for the Nation's Health: the US National Library of Medicine. RB Mehnert, Am J Hosp Pharm, 43(12):2991-7, December 1986 [2] Bibliographic Retrieval: A Survey of Individual Users of Medline. Karen T. Wallingford et al., MD Computing, 7(3):166-171, 1990 [3] An Integrated Hospital Information System at Children's Hospital. D Margulies, M.D. et al.
581
Proceedings of the 14th Annual SCAMC, 699-703, November 1990, Washington D.C.
[161 Online and OMine Print Costs in Medline. BR Boyce, Bull Med Libr Assoc, 72(2):177-9, April 1984
[4] Searching the Literature: Index Medicus or Medline?. HA Olafsson, Br J Hosp Med, 37(2):161-2, February 1987
[5] New and Noteworthy: Directory of Online Health Care Databases. Medical Data Exchange., MC Computing, 6(5):310,315, 1989
[6] Clinical Computing in a Teaching Hospital. HL Bleich, N Engl J Med., 312(12):756-64, March 1985 [7] Searching Medline at the University of Michigan. Suzanne Grefsheim, M.S.L.S., M.E.D. et al., MD Computing, 8(1):32-36, 1991
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