West Virginia CONSULT: Enhanced Information Access for Health Care Practitioners in a Rural Environment“ LINDA JACKNOWITZb West Virginia CONSULT West Virginia Universiy Health Sciences Center P.O. Box 901 7 Morgantown, West Virginia 26506-9017 CONSULT AS ACCESS TO BIOMEDICAL INFORMATION
The philosophy that underlies the West Virginia CONSULT network is that all health professionals, whether located in large metropolitan areas or small, rural towns, need access to accurate, timely, convenient biomedical information. It is the cornerstone of quality patient care. The CONSULT mission is to provide West Virginia’s health professionals, especially those practicing in rural environments, improved access to timely biomedical information. CONSULT acts both as a gateway to already established clinical, bibliographic, and administrative databases and as the source of unique locally developed information services. CONSULT users choose either to search the network directly, or to channel their information requests through trained information gatekeepers based at their local hospitals. Although CONSULT was conceived originally as a tool for those who practice at rural hospital sites, the expectation is that health professionals will also want to access CONSULT in their offices and even in their homes. Barriers to Access
A 1987 needs assessment conducted with rural health professionals throughout West Virginia identified three major obstacles to accessing biomedical information. They were (1) inadequate local resources at West Virginia hospitals, (2) West Virginia’s rural environment, and (3) limited computer literacy among West Virginia’s health professionals. I will discuss each of these barriers briefly.
Inadequate Local Resources The 1987 study attempted to identify existing information resources at 27 of West Virginia’s small, rural hospitals and to explore the biomedical information needs of professionals based at those institutions. Results indicated that local resources were often inadequate. The median information resources budget for the 27 hospitals ‘The medical information network described in this paper is supported by National Library of Medicine grant No. LM05047.
’e-mail: [email protected] 163
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(expenditures for books, journals, audiovisuals, interlibrary loans, and databasc searches) was $1,100 annually. The budgets ranged from $0-12,000. Although all of the hospitals owned some books and journals, they were often scattered throughout the facility without any standard method of organization or retrieval. The percentage of monographs five years old or older was always high, whereas very few of the hospitals kept journals for the recommended five years. Only seven of the hospitals subscribed to any standard periodical index, such as the Abridged Index Medicus. Although hospital administrators and health professionals readily acknowledged the importance of current, accurate information, they expressed concern about investing adequate funds to develop local resources. They pointed to ever-increasing book and journal prices and to the short shelf life this information has. Although all but three hospitals had a microcomputer somewhere on their premises, only seven of the 27 had modems. In hospitals with microcomputers, almost all of them were located away from clinical or library areas and were used for administrative or financial purposes. No hospital reported that it currently accessed any remote bibliographic database on site.
Rural Environment of West Virginia
West Virginia is characterized by mountainous terrains and an inadequate road system that often causes meaningful travel distances to be measured in terms of driving time rather than actual miles. According to the latest figures from the United States Census Bureau, West Virginia continues to rank among those states with significant numbers of rural population centers.’ West Virginia has a significantly high incidence of cancer, heart disease, and stroke; these three diseases are leading causes of deaths in the state.* West Virginia is also notable for exceptionally high levels of obesity, sedentary lifestyles, and smoking behaviors.* All of these facts indicate that a significant portion of the state’s population would benefit from access to locally available physicians and other health professionals. Unfortunately, 85% of the state’s 55 counties are medically underserved areas, while 78% of them are areas with health manpower shortages. Although the need to attract additional competent health care personnel to rural areas is evident, influencing them to settle there is often difficult. One reasun practitioners cite for not wanting to set up a rural practice is the fear of professional isolation. Barbara Barnett, in her article on recruiting physicians to small, rural hospitals states, “Physicians have concerns about how they will practice medicine in rural areas. Many fear professional isolation. . . . They are concerned that they won’t be able to consult with other doctors about difficult cases and that they won’t be able to attend continuing education program^."^
Limited Computer Literacy among West firg’niaS Health Professionals
Results from two studies conducted in the late 1980s showed that a majority of West Virginia’s physicians did not use computers for administrative, educational or information-seeking purpose^.^.^ Anecdotal feedback gotten from focus groups assembled to advise CONSULT on program development confirmed these findings. However, there is some optimistic news. Although both studies documented West Virginia physicians’ limited use of computers, one set of researchers concluded,
JACKNOWITZ: WV CONSULT
“. . . physicians recognize the value of
165
medical literature databases once they have
learned about them.”5
IMPLEMENTATION OF A STATEWIDE NETWORK
With a major grant from the National Library of Medicine (NLM), the West Virginia University Health Sciences Center (WVUHSC) formulated a plan to use a combination of technology and training to break through these barriers. The plan was developed with input from the West Virginia Hospital Association, community hospitals, health practitioners, and health sciences librarians. CONSULT also gratefully acknowledges the advice and guidance offered by the Mercer University School of Medicine’s Georgia Interactive Network (GaIN). In particular, Dr. Jocelyn Rankin, Director of the Library, and her Associate Director, Martha Watkins, have been generous supporters of West Virginia’s electronic networking efforts. The plan divided West Virginia into eight geographic information service areas (GISAs), each consisting of a lead hospital and two or three smaller institutions. Lead hospital status is conferred on institutions that have better developed library resources and trained library personnel. These hospitals also have to agree to provide first line information services to selected small, rural hospitals in their GISA. If a lead hospital is unable to supply requested information, or it is more readily available via one of the network’s centralized information services, then the request may be electronically redirected. CONSULT expects to integrate 24-32 hospitals into the network in three stages. Phase 1 began in the fall of 1991; however, services requiring access to CONSULT’S wide area network were unavailable to sites until February 1992. At present six sites are active; they are located in the Parkersburg and Clarksburg GISAs. CONSULT chose to activate these GISAs first for two reasons: (1) Their relative proximity to the WVUHSC meant that the amount of travel time necessary to correct any unexpected on-site problems would be kept to a minimum; and (2) the lead hospitals’ librarians and collections are among the best in the state. The Charleston GISA will be activated next. Each CONSULT test site receives a microcomputer, 2400-baud modem, printer, and telefacsimile machine. Administrators at these sites must agree that the primary purpose for this equipment is to seek and retrieve information. The test site is responsible for on-site preparation, including the installation of any necessary telephone lines. Each site also agrees to identify a minimum of one employee to serve as the institution’s information gatekeeper; to date all of the activated sites have identified at least two such individuals. At all of the small, rural sites, the information gatekeepers are employees who have additional major responsibilities. Gatekeepers at the Phase 1 sites include a pharmacist, a director of nursing, medical records personnel, a licensed practical nurse, data processing personnel, and a director of education. CONSULT believes that the selection, training, and motivation of gatekeepers is critical to the creation and maintenance of a successful network. The existence of locally based, trained gatekeepers is important for two reasons. First, although CONSULT will encourage health professionals to search the system personally, it is anticipated that a number of these individuals will route their information requests through the hospital’s gatekeeper. The gatekeeper will therefore need to be well
166
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aware of how to use all of the CONSULT network components and to understand how CONSULT fits into the overall workings of the National Network of Libraries of Medicine. Second, a well-trained hospital information gatekeeper can be a local resource for end users to turn to when they have questions about how to use the CONSULT system. After considering many different telecommunication options, CONSULT decided to utilize a packet data network (PDN), operated by C&P Telephone, a subsidiary of Bell Atlantic. The PDN provides toll-free access to CONSULT's central computer from almost anywhere in West Virginia and operates under the x.25 telecommunications protocol. The present configuration should enable 14-16 simultaneous users to access CONSULT without any noticeable system degradation. Unlike traditional toll-free access that charges for time on-line, PDN charges are based on the number of data packets users send and receive. During the grant period, CONSULT absorbs all of the PDN-generated telecommunication charges for its test sites. Because the CONSULT wide area network was recently installed, it is still too early to judge whether the PDN option will prove to be the optimum solution for the network's ongoing telecommunication needs. The original plan called for the network's software to be housed on another state agency's VAX platform; however, a generous gift from the Drug Information Association allowed CONSULT to move from this shared computing environment to its own MicroVax 3100. In addition to allowing CONSULT to assume a more independent computing stance, housing CONSULT'S software on its own MicroVax makes estimating computer-related costs more predictable. CONSULT NETWORK SERVICES
At the heart of the CONSULT network are its information services, training program, and user support services. CONSULT'S information services are created in conjunction with several key collaborators. They include the West Virginia Hospital Association, the West Virginia Drug Information Center, the West Virginia University (WW)Health Sciences Library, the Food and Drug Administration (FDA), the WVU School of Medicine, the Mary Babb Randolph Cancer Center at W, continuing education professionals located at community hospitals, and professional associations in the state. A recent collaborator in CONSULT'S development is the Visiting Clinicians Program at WW. Many of the physicians who belong to this program practice in rural West Virginia. They are representative of the population that CONSULT seeks to reach, rural primary care doctors. These physicians have contributed to CONSULT'S development by sharing their insights, suggestions, praise, and criticisms of the system. They have been an excellent reality check for this evolving program. When users choose the "CONSULT Basic Services" option from the network menu, telecommunication software automatically dials into CONSULT, thereby eliminating the amount of keyboarding that users must do in order to log on. Currently the CONSULT Basic Services option offers three choices: Mailman, CE Link, and FDA News. Mailman gives CONSULT users access to private and shared electronic mail services. Users can send confidential mail to selected correspondents or communicate collectively with members of several special interest groups. At present only a limited number of special interest groups exist; however, CONSULT anticipates that more groups will be formed as users begin to recognize the ease with which they are able to communicate shared interest, concerns, and questions with distanced col-
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167
leagues. CONSULT staff will actively promote the establishment of such special interest groups as one means of trying to lessen the sense of professional isolation cited by rural practitioners. CE Link is a statewide continuing education calendar that also contains references to key regional and national meetings. Users can search this database by keyword, specialty, date, location, and accrediting body. It incorporates Boolean logic into its search strategies. FDA News provides users with summaries of significant Food and Drug Administration news releases. Up to 12 months’ worth of summaries are available on-line. In addition, CONSULT serves as a gateway to several established information resources. GRATEFUL MED is a cost-effective, user-friendly interface that provides end users with access to NLM’s MEDLINE and other MEDLAR databases, while LOANSOME DOC is a convenient interlibrary loan tool that allows end users to order copies of full text journal articles identified through a GRATEFUL MED search. Access to DOCLINE is only available through the site’s information gatekeeper. It provides CONSULT users with additional document delivery options and is not limited to items identified through GRATEFUL MED; it is intended to complement the LOANSOME DOC option.
MODULES UNDER DEVELOPMENT
Three additional modules are currently under development. The first is a current awareness database, Primary Care Digest (PCD). Its goal is to help physicians make efficient use of time spent keeping abreast of the primary care literature. Each month selected primary care physicians and drug information experts at the WVUHSC will scan the primary care journal literature in order to identify 20-30 key articles. Along with journal citations, PCD will also offer users the article abstracts, downloaded from the MEDLINE database. Should searchers prefer hard copy of the full text of an article, they will be able to choose that option. The second module under development is being created in collaboration with the West Virginia Drug Information Center and the FDA. It is the Drug Alert Database (DAD). DAD will provide users with rapid, up-to-date information on recently approved drugs, drug recalls, and drug shortages. DAD will also give health practitioners a convenient, electronic way to report serious adverse drug events and drug quality concerns to the FDA. The third module will give CONSULT users access to the WVU Health Sciences Center’s recently automated library catalog. CONSULT anticipates providing access to the on-line catalog during the current year. Future enhancements under consideration include a wide area CD-ROM network, additional drug information components, a cancer information module, and a locum tenens database, and Internet access. CONSULT is also being used to provide communication support for third-year medical students doing their family medicine clerkships at rural practice sites around the state.
CRITERIA FOR END USERS
As previously noted, CONSULT’Send users have the option to search the system personally or to route their information requests through their institution’s gatekeeper. In order to stimulate end users to access CONSULT directly and still
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168
maintain control over the project’s budget and evaluation component, personal access codes will be available at all test sites to the following categories of individuals: 0 0 0 0
0 0
All active admitting physicians, At least one information gatekeeper, All nurse managers, All pharmacists, One administrative staff member, and Five additional wild-card choices to be made at the discretion of each hospital’s administration.
In creating the wild-card category CONSULT acknowledges the uniqueness of each test site, particularly the small, rural hospitals. Frequently employees at these institutions have several responsibilities and function in more than one role. In making their wild-card choices, administrators are asked to refer to the following criteria: 1. Do these individuals have an ongoing need to access timely biomedical information? 2. Would these individuals be given access to CONSULT if network-related costs were being assessed to the administrator’s institution? 3. Do these individuals have the authority to implement action based on information found via CONSULT? 4. Would these individuals be good choices for other compelling reasons? Reports from Phase 1test sites indicate that approximately 500 health professionals will be eligible to search CONSULT directly. It is hypothesized that no more than 1525% of the eligible end users (75-125) will actually do so. To date all training sessions have been held at individual test sites. Past experience has shown that it is unrealistic to expect rural health care workers to have the flexibility to travel regularly for related training; however, CONSULT will also use key state professional association meetings to offer additional training sessions and to convene CONSULT user groups. Other methods to deliver on-site training, including computer-based instruction, are under consideration. CURRICULUM
The CONSULT curriculum is dynamic and based on the current menu of network services and the related information needs of end users and gatekeepers. The following courses are part of the current curriculum: 1. Hardware made Easy
The use and maintenance of CONSULT grant-related equipment 2. Introduction to GRATEFUL MED/LOANSOME DOC The basics of both software programs; geared to end users 3. Introduction to GRATEFUL MED/DOCLINE The basics of both software programs; geared to information gatekeepers 4. Introduction to CONSULT Basic Services Accessing and using Mailman, CE Link, and FDA News 5. GRATEFUL MED Search Strategies Users practice search strategies and learn more about MeSH and advanced search techniques The CONSULT philosophy is to train the hospital’s information gatekeepers first, before teaching end users. This not only helps prepare gatekeepers to be able to
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facilitate information requests that are routed through them, it also gives end users access on site to at least one individual who may be able to help them with CONSULT-related questions. User support is provided via a toll-free telephone line, the electronic mail component, system documentation, and face-to-face site visits. Soon to be activated is a new technique that will enhance CONSULT’S telephone help line. Shadowing is a technique that will allow CONSULT staff to access a user’s screen and thereby see exactly the same information that the user is seeing. A transparent user log audits the following information for evaluation purposes: user’s demographic data, the use of the various modules, and information-seeking patterns. If an information gatekeeper uses CONSULT on behalf of a client, the log also collects similar information about the client, along with whether that individual has had a personal access code assigned to him. CONSULT uses the Department of Veterans Affairs Decentralized Hospital Computer Program (DHCP) software as its primary development platform. The software is available free of charge from the Department, through the provisions of the Freedom of Information Act. DHCP is a hospital information system written in the MUMPS or M programming language. One of its strengths is the availability of FILEMAN, a sophisticated database management system. CONSULT chose this software platform because (1) it has proven successful in comparable applications; (2) it has low procurement costs; (3) some of its applications, like Mailman, were already developed; (4) it is widely accepted and uscd; and (5) there is continuing research and development on the software. The CONSULT staff is a part of the Office of the Vice President for Health Sciences. It consists of a project director, user education librarian/instructional designer, systems analyst, and office manager. The project director and librarian also have appointments in the Department of Family Medicine.
CONCLUSION Although the WVUHSC has had a long tradition of providing service to citizens throughout West Virginia, recently the University has placed even greater emphasis on rural outreach activities. West Virginia CONSULT provides another important link between WVU and the state’s rural health communities. In conclusion I would like to read from a piece of mail that CONSULT recently received. The letter comes from one of our small, rural hospital gatekeepers. She wrote, Our small rural hospital has neither the financial resources nor the storage space to keep a wide varietyof medical literature on hand. Only a few of the more current sources are available to the health care practitioners using o u r small library. Although the system is still new to us and only a small handful of our professionals have taken advantage of its services as yet, all who have done so have expressed sincere delight at the vast information avenues it has opened to us. This program, as a whole, holds great potential for communication and information retrieval that would not otherwise have been so easily available.
The letter says that we have made a good beginning; however, now the real work begins. We believe CONSULT need only be limited by its ability to be creative and to be sensitive to our user’s needs.
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ANNALS NEW YORK ACADEMY OF SCIENCES REFERENCES
M. K., S . MORGAN & N. QUITNO. 1992. State rankings 1992: A statistical view of 1. O’LEARY, the 50 United States. Morgan Quitno Corporation. Lawrence, KS. 2. Premature mortality in West Virginia, 1978-1989. MMWR CDC Surveill. Summ. 1987. 3 6 29,33. B. 1988. Recruiting physicians to small and rural hospitals. South. Hosp. 5 6 18. 3. BARNETT, 4. KRISTOFCO, R. E., S. A. HALL& E. CHICK.1987. CME preferences, practices of West Virginia physicians.WV Med. J. 83: 83. K. 1988. Determining effective promotion strategies for introducing medical 5. HACKLEMAN, literature databases to primary care physicians in West Virginia: Final report.: 30, 31. (unpublished) Southeastern Atlantic Regional Medical Library.
The philosophy that underlies the West Virginia CONSULT network is that all health professionals, whether located in large metropolitan areas or small, rural towns, need access to accurate, timely, convenient biomedical information. It is the cornerstone of quality patient care. The CONSULT mission is to provide West Virginia’s health professionals, especially those practicing in rural environments, improved access to timely biomedical information. CONSULT acts both as a gateway to already established clinical, bibliographic, and administrative databases and as the source of unique locally developed information services. CONSULT users choose either to search the network directly, or to channel their information requests through trained information gatekeepers based at their local hospitals. Although CONSULT was conceived originally as a tool for those who practice at rural hospital sites, the expectation is that health professionals will also want to access CONSULT in their offices and even in their homes. Barriers to Access
A 1987 needs assessment conducted with rural health professionals throughout West Virginia identified three major obstacles to accessing biomedical information. They were (1) inadequate local resources at West Virginia hospitals, (2) West Virginia’s rural environment, and (3) limited computer literacy among West Virginia’s health professionals. I will discuss each of these barriers briefly.
Inadequate Local Resources The 1987 study attempted to identify existing information resources at 27 of West Virginia’s small, rural hospitals and to explore the biomedical information needs of professionals based at those institutions. Results indicated that local resources were often inadequate. The median information resources budget for the 27 hospitals ‘The medical information network described in this paper is supported by National Library of Medicine grant No. LM05047.
’e-mail: [email protected] 163
164
ANNALS NEW YORK ACADEMY OF SCIENCES
(expenditures for books, journals, audiovisuals, interlibrary loans, and databasc searches) was $1,100 annually. The budgets ranged from $0-12,000. Although all of the hospitals owned some books and journals, they were often scattered throughout the facility without any standard method of organization or retrieval. The percentage of monographs five years old or older was always high, whereas very few of the hospitals kept journals for the recommended five years. Only seven of the hospitals subscribed to any standard periodical index, such as the Abridged Index Medicus. Although hospital administrators and health professionals readily acknowledged the importance of current, accurate information, they expressed concern about investing adequate funds to develop local resources. They pointed to ever-increasing book and journal prices and to the short shelf life this information has. Although all but three hospitals had a microcomputer somewhere on their premises, only seven of the 27 had modems. In hospitals with microcomputers, almost all of them were located away from clinical or library areas and were used for administrative or financial purposes. No hospital reported that it currently accessed any remote bibliographic database on site.
Rural Environment of West Virginia
West Virginia is characterized by mountainous terrains and an inadequate road system that often causes meaningful travel distances to be measured in terms of driving time rather than actual miles. According to the latest figures from the United States Census Bureau, West Virginia continues to rank among those states with significant numbers of rural population centers.’ West Virginia has a significantly high incidence of cancer, heart disease, and stroke; these three diseases are leading causes of deaths in the state.* West Virginia is also notable for exceptionally high levels of obesity, sedentary lifestyles, and smoking behaviors.* All of these facts indicate that a significant portion of the state’s population would benefit from access to locally available physicians and other health professionals. Unfortunately, 85% of the state’s 55 counties are medically underserved areas, while 78% of them are areas with health manpower shortages. Although the need to attract additional competent health care personnel to rural areas is evident, influencing them to settle there is often difficult. One reasun practitioners cite for not wanting to set up a rural practice is the fear of professional isolation. Barbara Barnett, in her article on recruiting physicians to small, rural hospitals states, “Physicians have concerns about how they will practice medicine in rural areas. Many fear professional isolation. . . . They are concerned that they won’t be able to consult with other doctors about difficult cases and that they won’t be able to attend continuing education program^."^
Limited Computer Literacy among West firg’niaS Health Professionals
Results from two studies conducted in the late 1980s showed that a majority of West Virginia’s physicians did not use computers for administrative, educational or information-seeking purpose^.^.^ Anecdotal feedback gotten from focus groups assembled to advise CONSULT on program development confirmed these findings. However, there is some optimistic news. Although both studies documented West Virginia physicians’ limited use of computers, one set of researchers concluded,
JACKNOWITZ: WV CONSULT
“. . . physicians recognize the value of
165
medical literature databases once they have
learned about them.”5
IMPLEMENTATION OF A STATEWIDE NETWORK
With a major grant from the National Library of Medicine (NLM), the West Virginia University Health Sciences Center (WVUHSC) formulated a plan to use a combination of technology and training to break through these barriers. The plan was developed with input from the West Virginia Hospital Association, community hospitals, health practitioners, and health sciences librarians. CONSULT also gratefully acknowledges the advice and guidance offered by the Mercer University School of Medicine’s Georgia Interactive Network (GaIN). In particular, Dr. Jocelyn Rankin, Director of the Library, and her Associate Director, Martha Watkins, have been generous supporters of West Virginia’s electronic networking efforts. The plan divided West Virginia into eight geographic information service areas (GISAs), each consisting of a lead hospital and two or three smaller institutions. Lead hospital status is conferred on institutions that have better developed library resources and trained library personnel. These hospitals also have to agree to provide first line information services to selected small, rural hospitals in their GISA. If a lead hospital is unable to supply requested information, or it is more readily available via one of the network’s centralized information services, then the request may be electronically redirected. CONSULT expects to integrate 24-32 hospitals into the network in three stages. Phase 1 began in the fall of 1991; however, services requiring access to CONSULT’S wide area network were unavailable to sites until February 1992. At present six sites are active; they are located in the Parkersburg and Clarksburg GISAs. CONSULT chose to activate these GISAs first for two reasons: (1) Their relative proximity to the WVUHSC meant that the amount of travel time necessary to correct any unexpected on-site problems would be kept to a minimum; and (2) the lead hospitals’ librarians and collections are among the best in the state. The Charleston GISA will be activated next. Each CONSULT test site receives a microcomputer, 2400-baud modem, printer, and telefacsimile machine. Administrators at these sites must agree that the primary purpose for this equipment is to seek and retrieve information. The test site is responsible for on-site preparation, including the installation of any necessary telephone lines. Each site also agrees to identify a minimum of one employee to serve as the institution’s information gatekeeper; to date all of the activated sites have identified at least two such individuals. At all of the small, rural sites, the information gatekeepers are employees who have additional major responsibilities. Gatekeepers at the Phase 1 sites include a pharmacist, a director of nursing, medical records personnel, a licensed practical nurse, data processing personnel, and a director of education. CONSULT believes that the selection, training, and motivation of gatekeepers is critical to the creation and maintenance of a successful network. The existence of locally based, trained gatekeepers is important for two reasons. First, although CONSULT will encourage health professionals to search the system personally, it is anticipated that a number of these individuals will route their information requests through the hospital’s gatekeeper. The gatekeeper will therefore need to be well
166
ANNALS NEW YORK ACADEMY OF SCIENCES
aware of how to use all of the CONSULT network components and to understand how CONSULT fits into the overall workings of the National Network of Libraries of Medicine. Second, a well-trained hospital information gatekeeper can be a local resource for end users to turn to when they have questions about how to use the CONSULT system. After considering many different telecommunication options, CONSULT decided to utilize a packet data network (PDN), operated by C&P Telephone, a subsidiary of Bell Atlantic. The PDN provides toll-free access to CONSULT's central computer from almost anywhere in West Virginia and operates under the x.25 telecommunications protocol. The present configuration should enable 14-16 simultaneous users to access CONSULT without any noticeable system degradation. Unlike traditional toll-free access that charges for time on-line, PDN charges are based on the number of data packets users send and receive. During the grant period, CONSULT absorbs all of the PDN-generated telecommunication charges for its test sites. Because the CONSULT wide area network was recently installed, it is still too early to judge whether the PDN option will prove to be the optimum solution for the network's ongoing telecommunication needs. The original plan called for the network's software to be housed on another state agency's VAX platform; however, a generous gift from the Drug Information Association allowed CONSULT to move from this shared computing environment to its own MicroVax 3100. In addition to allowing CONSULT to assume a more independent computing stance, housing CONSULT'S software on its own MicroVax makes estimating computer-related costs more predictable. CONSULT NETWORK SERVICES
At the heart of the CONSULT network are its information services, training program, and user support services. CONSULT'S information services are created in conjunction with several key collaborators. They include the West Virginia Hospital Association, the West Virginia Drug Information Center, the West Virginia University (WW)Health Sciences Library, the Food and Drug Administration (FDA), the WVU School of Medicine, the Mary Babb Randolph Cancer Center at W, continuing education professionals located at community hospitals, and professional associations in the state. A recent collaborator in CONSULT'S development is the Visiting Clinicians Program at WW. Many of the physicians who belong to this program practice in rural West Virginia. They are representative of the population that CONSULT seeks to reach, rural primary care doctors. These physicians have contributed to CONSULT'S development by sharing their insights, suggestions, praise, and criticisms of the system. They have been an excellent reality check for this evolving program. When users choose the "CONSULT Basic Services" option from the network menu, telecommunication software automatically dials into CONSULT, thereby eliminating the amount of keyboarding that users must do in order to log on. Currently the CONSULT Basic Services option offers three choices: Mailman, CE Link, and FDA News. Mailman gives CONSULT users access to private and shared electronic mail services. Users can send confidential mail to selected correspondents or communicate collectively with members of several special interest groups. At present only a limited number of special interest groups exist; however, CONSULT anticipates that more groups will be formed as users begin to recognize the ease with which they are able to communicate shared interest, concerns, and questions with distanced col-
JACKNOWITZ: WV CONSULT
167
leagues. CONSULT staff will actively promote the establishment of such special interest groups as one means of trying to lessen the sense of professional isolation cited by rural practitioners. CE Link is a statewide continuing education calendar that also contains references to key regional and national meetings. Users can search this database by keyword, specialty, date, location, and accrediting body. It incorporates Boolean logic into its search strategies. FDA News provides users with summaries of significant Food and Drug Administration news releases. Up to 12 months’ worth of summaries are available on-line. In addition, CONSULT serves as a gateway to several established information resources. GRATEFUL MED is a cost-effective, user-friendly interface that provides end users with access to NLM’s MEDLINE and other MEDLAR databases, while LOANSOME DOC is a convenient interlibrary loan tool that allows end users to order copies of full text journal articles identified through a GRATEFUL MED search. Access to DOCLINE is only available through the site’s information gatekeeper. It provides CONSULT users with additional document delivery options and is not limited to items identified through GRATEFUL MED; it is intended to complement the LOANSOME DOC option.
MODULES UNDER DEVELOPMENT
Three additional modules are currently under development. The first is a current awareness database, Primary Care Digest (PCD). Its goal is to help physicians make efficient use of time spent keeping abreast of the primary care literature. Each month selected primary care physicians and drug information experts at the WVUHSC will scan the primary care journal literature in order to identify 20-30 key articles. Along with journal citations, PCD will also offer users the article abstracts, downloaded from the MEDLINE database. Should searchers prefer hard copy of the full text of an article, they will be able to choose that option. The second module under development is being created in collaboration with the West Virginia Drug Information Center and the FDA. It is the Drug Alert Database (DAD). DAD will provide users with rapid, up-to-date information on recently approved drugs, drug recalls, and drug shortages. DAD will also give health practitioners a convenient, electronic way to report serious adverse drug events and drug quality concerns to the FDA. The third module will give CONSULT users access to the WVU Health Sciences Center’s recently automated library catalog. CONSULT anticipates providing access to the on-line catalog during the current year. Future enhancements under consideration include a wide area CD-ROM network, additional drug information components, a cancer information module, and a locum tenens database, and Internet access. CONSULT is also being used to provide communication support for third-year medical students doing their family medicine clerkships at rural practice sites around the state.
CRITERIA FOR END USERS
As previously noted, CONSULT’Send users have the option to search the system personally or to route their information requests through their institution’s gatekeeper. In order to stimulate end users to access CONSULT directly and still
ANNALS NEW YORK ACADEMY OF SCIENCES
168
maintain control over the project’s budget and evaluation component, personal access codes will be available at all test sites to the following categories of individuals: 0 0 0 0
0 0
All active admitting physicians, At least one information gatekeeper, All nurse managers, All pharmacists, One administrative staff member, and Five additional wild-card choices to be made at the discretion of each hospital’s administration.
In creating the wild-card category CONSULT acknowledges the uniqueness of each test site, particularly the small, rural hospitals. Frequently employees at these institutions have several responsibilities and function in more than one role. In making their wild-card choices, administrators are asked to refer to the following criteria: 1. Do these individuals have an ongoing need to access timely biomedical information? 2. Would these individuals be given access to CONSULT if network-related costs were being assessed to the administrator’s institution? 3. Do these individuals have the authority to implement action based on information found via CONSULT? 4. Would these individuals be good choices for other compelling reasons? Reports from Phase 1test sites indicate that approximately 500 health professionals will be eligible to search CONSULT directly. It is hypothesized that no more than 1525% of the eligible end users (75-125) will actually do so. To date all training sessions have been held at individual test sites. Past experience has shown that it is unrealistic to expect rural health care workers to have the flexibility to travel regularly for related training; however, CONSULT will also use key state professional association meetings to offer additional training sessions and to convene CONSULT user groups. Other methods to deliver on-site training, including computer-based instruction, are under consideration. CURRICULUM
The CONSULT curriculum is dynamic and based on the current menu of network services and the related information needs of end users and gatekeepers. The following courses are part of the current curriculum: 1. Hardware made Easy
The use and maintenance of CONSULT grant-related equipment 2. Introduction to GRATEFUL MED/LOANSOME DOC The basics of both software programs; geared to end users 3. Introduction to GRATEFUL MED/DOCLINE The basics of both software programs; geared to information gatekeepers 4. Introduction to CONSULT Basic Services Accessing and using Mailman, CE Link, and FDA News 5. GRATEFUL MED Search Strategies Users practice search strategies and learn more about MeSH and advanced search techniques The CONSULT philosophy is to train the hospital’s information gatekeepers first, before teaching end users. This not only helps prepare gatekeepers to be able to
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facilitate information requests that are routed through them, it also gives end users access on site to at least one individual who may be able to help them with CONSULT-related questions. User support is provided via a toll-free telephone line, the electronic mail component, system documentation, and face-to-face site visits. Soon to be activated is a new technique that will enhance CONSULT’S telephone help line. Shadowing is a technique that will allow CONSULT staff to access a user’s screen and thereby see exactly the same information that the user is seeing. A transparent user log audits the following information for evaluation purposes: user’s demographic data, the use of the various modules, and information-seeking patterns. If an information gatekeeper uses CONSULT on behalf of a client, the log also collects similar information about the client, along with whether that individual has had a personal access code assigned to him. CONSULT uses the Department of Veterans Affairs Decentralized Hospital Computer Program (DHCP) software as its primary development platform. The software is available free of charge from the Department, through the provisions of the Freedom of Information Act. DHCP is a hospital information system written in the MUMPS or M programming language. One of its strengths is the availability of FILEMAN, a sophisticated database management system. CONSULT chose this software platform because (1) it has proven successful in comparable applications; (2) it has low procurement costs; (3) some of its applications, like Mailman, were already developed; (4) it is widely accepted and uscd; and (5) there is continuing research and development on the software. The CONSULT staff is a part of the Office of the Vice President for Health Sciences. It consists of a project director, user education librarian/instructional designer, systems analyst, and office manager. The project director and librarian also have appointments in the Department of Family Medicine.
CONCLUSION Although the WVUHSC has had a long tradition of providing service to citizens throughout West Virginia, recently the University has placed even greater emphasis on rural outreach activities. West Virginia CONSULT provides another important link between WVU and the state’s rural health communities. In conclusion I would like to read from a piece of mail that CONSULT recently received. The letter comes from one of our small, rural hospital gatekeepers. She wrote, Our small rural hospital has neither the financial resources nor the storage space to keep a wide varietyof medical literature on hand. Only a few of the more current sources are available to the health care practitioners using o u r small library. Although the system is still new to us and only a small handful of our professionals have taken advantage of its services as yet, all who have done so have expressed sincere delight at the vast information avenues it has opened to us. This program, as a whole, holds great potential for communication and information retrieval that would not otherwise have been so easily available.
The letter says that we have made a good beginning; however, now the real work begins. We believe CONSULT need only be limited by its ability to be creative and to be sensitive to our user’s needs.
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ANNALS NEW YORK ACADEMY OF SCIENCES REFERENCES
M. K., S . MORGAN & N. QUITNO. 1992. State rankings 1992: A statistical view of 1. O’LEARY, the 50 United States. Morgan Quitno Corporation. Lawrence, KS. 2. Premature mortality in West Virginia, 1978-1989. MMWR CDC Surveill. Summ. 1987. 3 6 29,33. B. 1988. Recruiting physicians to small and rural hospitals. South. Hosp. 5 6 18. 3. BARNETT, 4. KRISTOFCO, R. E., S. A. HALL& E. CHICK.1987. CME preferences, practices of West Virginia physicians.WV Med. J. 83: 83. K. 1988. Determining effective promotion strategies for introducing medical 5. HACKLEMAN, literature databases to primary care physicians in West Virginia: Final report.: 30, 31. (unpublished) Southeastern Atlantic Regional Medical Library.
