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Report of
  Panel
Long Range Plan
National Library of Medicine
Assisting Health Professions
Education Through
Information Technology
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Report of
   Panel
Long Range Plan


           National Library of Medicine
Assisting Health Professions
Education Through
Information Technology
U.S. Department of Health and Human Services         December 1986
Public Health Service
National Institutes of Health 
Members  and Staff of Panel 5
Assisting  Health Professions
Education Through
Information Technology
Chairperson
G. Octo Barnett, M.D.
Professor of Medicine
Harvard Medical School
Massachusetts General Hospital
Boston, Massachusetts

Members
Phillip C. Anderson, M.D.
Professor and Chairman
Department of Dermatology
University  of Missouri School of Medicine
Columbia, Missouri

Marion Ball, Ed.D.
Director, Academic Computing
Associate Vice-Chancellor
Information Resources  Management (Ad Interim)
University of Maryland at Baltimore
Baltimore, Maryland

Richard  Friedman,  M.D.
Vice Chairman
Department of Medicine
University of Wisconsin Medical School
Madison, Wisconsin

Paul F. Griner, M.D.
General Director
Strong Memorial Hospital
University of Rochester Medical Center Director
University of Rochester School of Medicine and
Dentistry
Rochester, New York

Edithe J. Levit, M.D.
President  and  Chief Executive Officer
National Board of Medical Examiners
Philadelphia, Pennsylvania

Phil R. Manning, M.D.
Associate  Vice President
Associate  Dean for Postgraduate  Education
University of Southern California  School of
Medicine
Los Angeles, California
Victor Neufeld, M.D.,
Associate Dean (Education)
Faculty of Health Sciences
McMaster University
Hamilton, Ontario, Canada

Gerald J. Oppenheimer, M.A., M.S.
Director
Health Sciences Library and Information Center
University of Washington
Seattle, Washington

Sholom Pearlman, D.D.S.
Denver,  Colorado

Thomas Piemme, M.D.
Assistant Dean for Continuing Medical Education
George Washington University
Washington, D.C.

Barbara Redman, Ph.D.
Executive Director
American Association of Colleges of Nursing
Washington, D.C.

M. Roy Schwarz, M.D.
Assistant Executive Vice President for Medical
  Education and Science
American Medical Association
Chicago, Illinois

John N. Sheagren, M.D.
Associate Dean
University of Michigan Medical School
Ann Arbor, Michigan

John F. Sherman, Ph.D.
Vice President
Association of American  Medical Colleges
Washington, D.C.

Edward J. Stemmler,  M.D.
Dean
School of Medicine
University of Pennsylvania
Philadelphia, Pennsylvania

Marjorie Wilson, M.D.
 Senior Associate Dean
 School  of Medicine
 University of Maryland at Baltimore
 Baltimore, Maryland 
Consultants to Panel  5
NLM Staff
Elliot R. Siegel, Ph.D.
Executive Secretary

William G. Cooper, Ph.D.
Resource Person

John A. Starkweather, Ph.D.
Resource Person
Stephen Abrahamson, Ph.D.
Director
Department of Research and Medical Education
University of Southern California School of Medicine
Los Angeles, California

James Adelstein, M.D.
Dean of Academic Affairs
Harvard Medical School
Boston, Massachusetts
William G. Cooper, Ph.D.
Cooper and Associates
Houston, Texas

Leonard D. Fenninger, M.D.
Attending Physician
Northwestern Memorial Hospital
Chicago, Illinois

Robert A. Greenes, M.D., Ph.D.
Radiologist and Director
Computer Science Division
Brigham & Women's Hospital
Boston, Massachusetts

Susan J. Grobe, Ph.D.
Associate Professor of Nursing
The University of Texas at Austin
Austin, Texas

Nelson Logan, D.D.S.
University of Iowa
Iowa City, Iowa

Joseph F. Volker, D.D.S., Ph.D.
Professor
University of Alabama at  Birmingham
Birmingham, Alabama
Rita Zielstorff, M.S.N.
Laboratory of Computer Science
Massachusetts General Hospital
Boston, Massachusetts 
 
Contents
Report of
     Panel
Long Range Plan
1 Background and  Context
  Knowledge Base of Health Sciences 6
  Education of Health Professionals 7
  Information Technology and  Health Sciences Education 7
  Examples of Innovation in Use of Information  Technology in
    Education 8
  Examples of Computer-Based Education Programs 9
  Bibliographic Retrieval 10
  Knowledge Management 10
  Developments in Computer Technology 10
  Future Role for NLM 11
2 NLM Programs and Recent Accomplishments
  Historical Role of NLM 12
  Mission of the Lister Hill National Center for Biomedical
    Communications 12
  Mission of the Extramural Grants and Contracts Program 13
  Intramural Activities of the Lister Hill Center 13
  Extramural Programs of NLM 14
12
3 A Vision of the  Future

4 Major Issues  and  Future Directions
  Unified Medical Language System 19
  Centers of Excellence in  Health Sciences Informatics 21
  Knowledge-Management  Systems for Practicing Health-Care
    Professionals and Students 23
  Educational Technology 26
16

19
5 Recommendations
  Unified Medical Language System 29
  Centers of Excellence 30
  Knowledge-Management Systems 31
  Educational Technology 32
29
References 34
Appendix A
  NLM Planning Process 36 
Background and
Context
Panel Five had  as a topic assisting health
professions education through information
technology. The Panel was charged with
considering the issue of how information
technology might  be used to promote and
facilitate  the education of health profes-
sionals to meet  the needs of the 21st cen-
tury.

"Information technology"  may be broadly
defined as encompassing the full range of
computer-based aids to learning, including
computer-assisted  instruction, case simula-
tions, bibliographic retrieval  systems, elec-
tronic textbooks and knowledge-base sys-
tems, self-testing and appraisal programs,
and  personal file management tools.

The  American systems  of health care and
of education of health professionals  are
considered among the best in the world.
By and large, our professional schools pro-
duce knowledgeable, compassionate,
responsible, and technically competent
individuals. Why,  then, should there be
any concern with  the content and methods
of education of health professionals?
Knowledge Base of Health
Sciences

Within the last few decades, powerful
forces have radically changed the scope
and complexity of the health sciences and
the delivery of health care. These forces
are continuing to influence the shape of
health care, increasing and altering the
body of medical knowledge, changing the
way health professionals practice their
craft,  and modifying the  system of health-
care delivery.

It can be argued that we are in the begin-
ning stages of a new age of health care.
Recent advances in medicine, particularly
in molecular and cell biology,  immunol-
ogy, and neurobiology, have opened new
paths  to  preventive, diagnostic, and  cura-
tive strategies  of astonishing power and
subtlety.  Progress in the fields of  dentistry,
nursing,  pharmacy,  and other health
professions have yielded new strategies for
maintaining health and dealing with illness.

This explosion of knowledge has combined
with multiple factors to change the way
that health professionals function  today.
The aging of the population, the  shift
from acute illness toward  chronic  disease,
the emphasis on cost containment, the
increasingly corporate nature of health-
care delivery, and the availability  of
information-processing technology are all
exerting powerful influences. These factors
will surely alter even more radically the
way that  health professionals of the 21st
century practice.

One obvious effect of the expanded knowl-
edge base is that any single individual
can master only a decreasing fraction of
the total  spectrum of the available infor-
mation. As a result, there has  been a
rapid  growth in the number of health dis-
ciplines,  and of specialties within dis-
ciplines.  This  has produced an increas-
ingly fragmented clinical  practice. 
Education of Health
Professionals

Despite these major advances  in the
science and technology of health care, as
well as the new challenges to the field, the
education of health professionals remains
grounded in the past. The methods used
to train physicians, for example, differ lit-
tle today from those of a half-century ago.
For all of the health disciplines, the struc-
ture of education still primarily consists of
lectures, in which a procession of teachers
relates large  quantities of scientific mate-
rial to a passive student audience.  Current
methods of instruction in the health
sciences cannot meet the challenge of the
exponentially increasing flow of new dis-
coveries.

The explosion in medical knowledge has
placed impossible time demands on the
curriculum, and has far outstripped the
ability of our students to memorize, let
alone retain, the quantity and  complexity
of scientific knowledge. Despite exhorta-
tions from many national organizations in
the private and public sectors, the  trend
toward narrow specialization continues to
increase, and  the duration of professional
education, particularly at the graduate
level, tends to lengthen. We  cannot
depend on traditional continuing educa-
tion to fill this  gap.

Traditional continuing education consists
of general reading, attending courses, and
informally discussing medicine with col-
leagues. It helps keep medical practi-
tioners abreast of the state of the art as
viewed by medical experts. The goals  of
traditional continuing  education, however,
are often diffuse, diverse, and may  not be
directly applicable to practice.

Traditional continuing education may be
only the tip of an iceberg of possibilities
Traditional CME
 General
Information
 Transfer
   y"^      Problems Confronting
  /        Physician In Daily Practice

PrWice-Based CME
for effective learning (see figure). The
body of the iceberg, which encompasses
learning from real events in practice,
offers many more possibilities. The next
decade will bring advances in methods
that will permit linking education more
directly to  actual patient problems.

The new continuing education, made pos-
sible by the computer  and current
telecommunication technologies, will be
more individualized  and better related to
practice.1 Refinements  of existing software
and the development of methods to  imple-
ment the new continuing education in
practice are required to achieve  maximum
benefit.

Information Technology and
Health Sciences Education

One very promising  response to  the  prob-
lem of information overload is to take
advantage of information  technology to
facilitate learning and  to provide easy
access to appropriate information sources
for the practicing health professional at
the time and place  most needed.
Computer-based educational applications
can help these professionals acquire essen-
tial knowledge  and  master problem-solving
skills. Comprehensive training and
experience  with modern methods of infor- 
• •
mation management during the students'
formative years will greatly enhance their
effective functioning as health-care practi-
tioners and professionals committed to
lifelong learning.

In emphasizing the importance of infor-
mation technology in the education of the
health professional, we recognize the
inherent tension between the changing
and unchangeable aspects of health care.
Information technology has the potential
to address the ever-changing  and  ever-
broadening mass of knowledge concerning
the etiology, prevention, and treatment of
disease, as well as the maintenance of
health. This use of technology, however
important, must not distract from the fun-
damental human aspect of care: the rela-
tionship of an individual health profes-
sional to an individual patient.

The role of information technology
includes the teaching of content, but  even
more  important, concerns the method of
education. Students should be given fewer
answers and more tools—tools for  self-
teaching and for synthesizing, framing,
and revising knowledge. They should have
the opportunity  to practice, from  the earli-
est days of professional education, skills of
seeking out information,  testing hypothe-
ses, and solving problems. The underlying
objective in the  use of information tech-
nology in health sciences education is not
so much the transfer of current informa-
tion, but more importantly, providing an
environment that encourages  the student
to take increasing responsibility to become
an independent learner, with  emphasis
upon understanding and application of
knowledge.

The use  of information  technology in
health sciences education is not new. Sig-
nificant advances have  occurred since the
early applications of drill-and-practice,
computer-aided instruction  two decades
ago, and a number of institutions have
developed prototype projects in the  use  of
information technology in health sciences
education. Advances in the  educational
applications of information  technology
have been made possible by a number of
factors: improved  understanding of the
learning  process and of the potential roles
for the use of computer technology; more
detailed specification of the information
requirements in the academic and clinical
settings;  more  powerful  tools for  creating
computer programs; and advances in tech-
nology that were undreamed of 20 years
ago. As  a result, there are now very useful
applications that support bibliographic
retrieval, education, information manage-
ment, and clinical decision  making.

Examples of Innovation in
Use of Information Technology
in Education

Various medical and nursing  schools have
been pioneers in the application of infor-
mation technology in the education of
health  professionals. Ohio State has had a
major computer-based  medical educational
emphasis some for years. Other schools
such as the University of Illinois, Cornell,
Georgetown, the University of Washington,
Dartmouth, and Massachusetts General
Hospital have  made significant innovations
in the  educational applications of com-
puter technology.2 
Perhaps the most novel experiment at present
is a new curriculum at Harvard Medical
School that involves a basic restructuring
of medical education. This program (referred
to as the New Pathway) emphasizes prob-
lem solving and independent learning. A
major element of the new curriculum is the
use of the computer as an integral tool for
education and information management.3
Each  student and faculty member has a
personal computer workstation connected
to a communications network and a  cen-
tral computer data base. Basic tools  such
as electronic  mail, word processing, and
personal filing systems are all parts  of the
program. Computer applications also include
bibliographic retrieval access, self-teaching
and self-assessment modules, simulations
of biological  systems, and patient simula-
tions. The intent is to graduate students
who have developed skills in managing
their own learning and are  capable of
utilizing information technology for  the
management of  scientific and clinical
information, clinical practice, and  continu-
ing education.

The IAIMS (Integrated  Academic Informa-
tion Management System) initiative taken
by NLM is an important model of how the
Library can initiate  change. Initially,
IAIMS was defined as a planning and
development  effort for establishing an
institution-wide computer-based integrated
information system and a new role for
health science librarians.4 The IAIMS sites
are now evolving to become multidisciplin-
ary centers that  bring together experts  in
medical informatics, knowledge  organiza-
tion, library science, decision-assistance
systems, education, and health-care
administration. Through IAIMS, NLM is
fostering dynamic, real-world laboratories
for dealing with the broad issues of
health-care information  management.
Examples of Computer-Based
Education Programs

The increasing interest in the  development
of clinical decision-assistance programs
offers a major opportunity for applications
of information technology that comple-
ment the more traditional modes of medi-
cal education. These programs range in
complexity from simple  "IF-THEN" rules,
which remind clinicians in cases where
prespecified protocols are violated, to pro-
grams that are at the forefront of artificial
intelligence research and whose perfor-
mance can rival expert clinicians in well-
specified,  limited challenges.5 6 7 8 9 One
of the more exciting aspects of this
research is the range of new insights that
are being  provided  into  the nature and
process of clinical reasoning.

Another promising application of com-
puter technology in medical education  is
the simulation of complex biological sys-
tems.  Prototype computer-based simula-
tions can facilitate the introduction of clin-
ical medicine to the student and may
include the simultaneous interaction of a
number of variables and closed-loop feed-
back control. These programs use methods
that range from simple random assign-
ment of patient  "states" (such as the
value  of the blood sugar in a simulation
of diabetic ketoacidosis) to complex model-
ing of physiological systems such as cardio-
vascular regulation.10 n  Coupling these
models with high-resolution graphic dis-
plays and  computer-controlled  video disk
presentations greatly enhances the teach-
ing potential.12
9 
Bibliographic Retrieval

NLM has been a pioneer in promoting
easy and inexpensive access to the pub-
lished literature. The advances made pos-
sible  in bibliographic retrieval by NLM
have  affected more members of the health-
care community than any other single
application of information technology. The
development of the  MeSH (Medical Sub-
ject Headings) indexing system and the
MEDLARS (Medical Literature Analysis
and Retrieval System) accessing system
have  contributed enormously to the
advancement of education at all  levels and
in all settings—undergraduate, research,
and practice. Decreasing cost and increas-
ing availability of personal  computers,
together with reasonably priced MED-
LARS services, have placed online biblio-
graphic assistance within the reach of the
average practitioner and brought closer
the goal of each professional having ready
access to any desired medical  knowledge
independent of the  time and place of
need.

Knowledge Management

NLM has been one of  the most important
institutions in making  information readily
available to the  health  science profes-
sional. Although in  the past,  this role has
been  considered to be  primarily  one of
storage, indexing, and  retrieval of paper
documents, it is both relevant  and timely
for NLM to assume a more dynamic role
in terms of knowledge  management.

Knowledge management may be defined
as a set of methods for the acquisition,
organization, and maintenance of a knowl-
edge  base to  facilitate  retrieval of specific
information. Depending on the specific
application defined, the user  of the knowl-
edge  may be  a clinician, a  student, a
researcher, an  educator, or an
administrator.
The knowledge maintained by a
knowledge-management system may be of
two general types. The first is a concep-
tual framework or schema that defines
organization and relationships within
domains of knowledge. NLM's MeSH
vocabulary is one example  of an organiza-
tional framework: the hierarchical organi-
zation of the MeSH  terms  defines an
explicit  relation  among the different terms
in the nomenclature.

The second type of knowledge-
management system  provides access to
content  knowledge in either structured or
unstructured form. Structured knowledge
is information stored in a form that can
be easily accessed by key ideas or con-
cepts. In a book the  chapter headings and
index represent a primitive  form of struc-
tured knowledge. Much more sophisticated
examples of structured content are elec-
tronic textbooks  such as the Hepatitis
Knowledge Base which was the subject of
active experimentation by NLM.13 Struc-
tured knowledge can also exist in the  form
of procedures or methods for accomplish-
ing specific tasks. Unstructured content,
on the other hand, includes narrative  text
found in traditional textbooks  and in the
archival journal  literature, as well as pic-
tures, graphs, and other forms.

Developments in Computer
Technology

After a slow start, developments in com-
puter and communications  technology
have proceeded at an astounding  pace in
recent years and show no sign of slowing
down. There is general optimism that  even
the  most ambitious potential applications
of information technology to education in
the  health professions will soon become
both technically  feasible and economically
possible. 
At the present time, available technology
enables routine data collection; informa-
tion storage, manipulation, and display;
and a variety of forms of automated rec-
ord keeping. In many settings, students,
faculty,  and practicing physicians have
access to convenient, compact, and power-
ful personal  computers. Network communi-
cation between individual workstations and
institutional  computer resources is  becom-
ing less expensive and more versatile.
Powerful, easy-to-use authoring languages
make it easier for the programming novice
to create exciting educational programs for
the health  professional. The display of
information is becoming increasingly effec-
tive with higher resolution graphics and
the use of  color.
Radically new forms of user interaction
are made possible by innovations such as
"pull-down windows" and various types of
pointer devices (the  "mouse" being one
popular example.) Computer-controlled
video disks allow easy manipulation and
display of either  still images or scenes
with coordinated sound and motion.

These  developments represent the technol-
ogy of the present; to try to predict the
possible technologies of the future is
extremely difficult. It is safe to  predict,
however, that there will be much more
powerful,  smaller, and less expensive  com-
puters, with graphic displays of much
higher resolution and much better commu-
nication capabilities. The limiting factor of
educational applications for the health
professional will not be primarily hard-
ware, but rather a paucity of easily available
and appropriate applications.
Future Role for NLM

This report outlines  a vision of the future
and details several windows  of opportunity
for attaining  this vision.  We strongly sup-
port  the view that, indeed, there are real
and exciting  potential applications of
information technology that can revolu-
tionize the education of  health profes-
sionals. Indeed,  some of the most  critical
weaknesses of present health sciences edu-
cation, and more importantly, some of the
most important opportunities for the
future, can only be met through the
imaginative and comprehensive use of
information technology.  NLM  has  had a
dynamic role in the  past in facilitating the
storage and  dissemination of medical
knowledge. This Panel is deeply persuaded
that in the future, the role of NLM can be
even more important in supporting the
application of the full range of informa-
tion technology to the education of the
student in health sciences and to  the sup-
port  of the practicing health professional.
11 
NLM Programs

and  Recent

Accomplishments



Historical Role of NLM

Through  the years,  NLM has been
involved in various  ways in assisting health
professionals in carrying out their respon-
sibilities as educators and enhancing the
environments for  learning by students in
the health professions. Historically, these
activities  have been carried out
intramurally by the  LHNCBC (Lister Hill
National  Center for Biomedical Communi-
cations) and the NMAC (National Medical
Audiovisual Center), which in 1983 was
officially  merged  with the Lister Hill Cen-
ter. Extramural support to the health
professional community has been provided
by the  Library's Extramural Grants and
Contracts Program.

Mission of the  Lister Hill
National Center for
Biomedical Communications

First established in  1969 as the research
and development  arm of NLM, the Lister
Hill Center's organizational mission is
closely  tied to the goal of assisting health
professions education  through the timely
and efficient exploitation  of new informa-
tion technologies. The Lister Hill Center's
annual  budget in  FY1986 was $9,042 mil-
lion. Specifically,  the Center:

■   performs research  and development to
   create and improve biomedical commu-
   nications systems,  methods, and net-
   works  to enhance information dissemi-
   nation and utilization among health
   professionals;
■  collaborates with members of the
   health professions community and
   studies, defines, and develops needed
   information technology materials and
   services;
■  develops audiovisual and other infor-
   mation systems to improve health
   professions education, research, and
   the delivery of health services;
■  encourages and performs research and
   development in the  production, dis-
   semination, use, and evaluation of
   audiovisual, computer-based,  and other
   educational materials and systems;
■   trains health educators in methods and
   technologies supporting biomedical
   communications; and
■   plans and administers a national pro-
   gram to improve the quality and the
   use of biomedical and audiovisual
   materials in schools of the  health
   professions and the  biomedical com-
   munity. 
Mission of the Extramural
Grants  and Contracts Program

NLM's Extramural Programs, authorized
by the MLA Act (Medical Library
Assistance Act of 1965) and its extensions,
support improvements in health informa-
tion services  and biomedical communica-
tions by providing grants to develop and
extend library services, strengthen infor-
mation resources, conduct research in  ways
of improving communication and knowl-
edge transfer, train health information per-
sonnel, and produce critical reviews and
other publications on important health
topics.

During FY1986, awards totaling $2,347
million were made  for 37 new grants,  and
$9,545 million for 62 contining  grants sup-
porting activities begun in prior years.

In addition, contracts provide for a
national network of RML (Regional  Medi-
cal Libraries) with the necessary resources
and services to give backup support for
local health science libraries. In particular,
the RML  Network is  an important  agency
in organizing  activities leading to com-
puter literacy among  health professionals.
It promotes habits  relative to the access
and use of data bases and health-related
literature,  which tend to lay the  ground-
work for lifelong learning; it is an outlet
for acquainting health professionals with
new hardware and (interactive) software;
and it helps to stimulate an awareness of
pertinent  NLM programs and products.
Intramural Activities of the
Lister Hill Center

The TIME (Technological Innovations in
Medical Education) Project was begun in
late 1983. The primary goal of TIME is to
address the potential application of the
new technologies of microprocessor, inter-
active video disk and speech recognition
to the  education of health professionals.
The new techniques  offer unprecedented
capabilities for interactive and visual
presentations of educational material.  The
TIME  Project is exploring  these capabili-
ties by developing  a  series  of problem-
based patient-related clinical simulations.

With planning begun in  1984, the
National Learning  and Demonstration
Center is to provide  an environment and
demonstration site  for state-of-the-art tech-
nologies in computer-based education in
the health sciences. The  Center will allow
health  science educators  to have access to
a spectrum of computer-based educational
materials. In  addition to  offering  demon-
strations, the Center will  serve as a labora-
tory for comparative studies and evalua-
tion of such materials.

Begun in  1982, the Computer-Assisted
Curriculum Delivery Program consists  of a
series of experiments utilizing video disk
and microcomputer technology. Through
collaboration with  relevant  professional
societies, prototype disks  under micro-
computer  control have been produced in
radiology, pathology, and most recently,
orthopedic surgery. Studies are currently
underway  to assess the value of these tools
in a variety of educational  settings.
13 
In 1985,  NLM staff, including research
staff from the Lister Hill Center, examined
the feasibility of developing a Unified
Medical Language System. This examina-
tion revealed that the technology and
knowledge needed to support the research
and development  of such a system are
now, for the first  time, becoming available,
and that this fundamental problem in
medical informatics can be successfully
addressed under NLM leadership.  With
substantial resource support secured for
1986, NLM  has launched  this effort, which
will seek to  link the vocabulary used to
access the basic science and  clinical litera-
tures to the  vocabulary used  in clinical
practice for  the recording of  patient
records, in health science  education, and
in health-care administration.
Extramural Programs of NLM

The  NLM's grants and  contracts activities
consist of the  following  programmatic
areas that support health  professions
education:

■  Research Grants support investigations
   of the generation, organization, and
   utilization  of health  knowledge. At the
   Latter Day Saints  Hospital-Deseret
   Foundation in Salt Lake City, for
   example, a project is underway to
   assist physicians to draw upon medical
   knowledge  through computer-based
   decision logic.
■  Medical Informatics  Research and
   Training Program  encourages research
   into fundamental issues of health
   knowledge, including the impact of
   advanced computer and communica-
   tions technology on  knowledge
   representation systems. Besides the
   usual investigator-initiated research
   grants, there are New Investigator
   Research Awards and Research Career
   Development Awards for promising
   younger scientists.
■  Medical Library Resource Grants are
   of two types. The  Resource  Improve-
   ment Grant assists single institutions
   and consortia in developing basic  col-
   lections. The Resource Project Grant is
   directed toward established health
   science libraries and enables them to
   undertake new services or expand
   existing ones. At the  Dahlgren Memorial
   Library of  Georgetown University
   Medical Center, for example, a library
   computer information service is being
   established to provide  a learning
   laboratory  environment where students,
   faculty and staff may obtain guidance
   in the use  of microcomputers and in
   data base development. 
 The IAIMS Program follows an NLM-
 supported study by the Association of
 American Medical Colleges that identi-
 fied the need for academic health
 science centers and hospitals to take
 immediate steps to use new information
 technologies to facilitate the flow of
 recorded biomedical knowledge through-
 out the institution in as direct and use-
 ful a form as possible. The study
 recommended the development of proto-
 type network systems, as well as pro-
 grams that encourage the rapid integra-
 tion of information technologies in the
 learning and practice of the health
 professions. In response to the  study's
 recommendations, NLM launched the
 IAIMS  Program, which uses computer
 and communications technologies to
 bring together operational  and aca-
 demic  information in  support of health
 research, education, patient care, and
 management. At the present time,  some
eight institutions have  IAIMS planning
or implementation awards. 
A Vision of
the  Future
The teaching and learning environment
for health professionals will have changed
considerably in the year 2006. The centers
of excellence and IAIMS will produce
widely adapted curriculum models for
integrating technology into the teaching
and learning process. The  educational
emphasis in the 21st  century will be
primarily on individual and small-group
interactions, supplemented only  occasion-
ally by traditional lectures  to large groups.
The focus of professional education in all
the health science curricula will be on
training  students in problem solving, criti-
cal thinking, and analytical skills. There
will be equal emphasis on helping the stu-
dent gain experience  in how to  use tech-
nology for acquiring, storing, and manag-
ing information.

Computer-based patient simulations will be
used extensively to  facilitate the student's
acquisition of skills in clinical problem
solving; to help the student learn to deal
with the  inherent uncertainty, ambiguities,
and  contradictions in  clinical data;  and to
challenge the student to learn how to col-
lect and  interpret data in the most effi-
cient fashion. All of the computer-based
learning  activities will be available to the
student at any time and from the most
convenient location, whether it be within
or remote from the institution.
In contrast to the  present, much less cur-
ricular time will be spent on delivering
purely factual information. Students will
become highly skilled in retrieving perti-
nent information from computer-stored
data banks for particular  educational
issues or specific clinical  problems.
Teachers will routinely use information
technologies and computer simulations,
including high-resolution graphics, anima-
tion, and video images, to challenge stu-
dents during the development of their
basic science laboratory and clinical
patient-care skills.  The capacity  to evaluate
student performance will be greatly
enhanced by  new techniques  that focus on
problem solving rather than on  short-term
memory recall. Electronic mail will be
widely used  in information transfer and
information sharing among the students
and between the students and faculty.
Electronic networks make it possible for
the students and faculty to engage in a
continuing dialogue in an "intellectual
network" of frequent  communication,
questioning, and sharing.

Extramural evaluation programs  for pur-
poses of licensure, specialty certification,
recertification, and other forms of creden-
tialing will be accomplished using com-
puter and other advanced technologies to
assess educational  achievement,  diagnostic
acumen, management skills, problem solving,
decision making, and  other measurable
aspects of professional competence. These
new technologies will  have completely
replaced traditional paper-and-pencil testing
for credentialing in the health professions.
The  introduction of computer-based tech-
nology as the  evaluation methodology for
licensure and  certification will have a
profound influence on the speed with
which the educational system introduces
similar technology for both education and
intramural evaluation. 
Integrated information systems in regional
medical libraries, in academic medical
centers, and at NLM will permit faculty to
draw liberally  from local, regional, and
national computer-based resources in
developing their curricular offerings. The
world's biomedical literature will be easily
available in computer-stored books and
journals, and  a wide variety of knowledge
bases,  visual images, and expert systems
will reside  in  multiple national computer-
stored  data banks that may be accessed at
any time by a few keystrokes, from any
location. The  different professional socie-
ties and medical publishing organizations
will have adopted a Unified Medical Lan-
guage  System for indexing and abstracting
to make the different information sources
more readily available via automated
retrieval systems. Extensive development in
computer-assisted  knowledge management,
using the unified  language as a  concep-
tual framework, will guide the  information
seeker  in taking advantage of these
resources.
There will be a substantial cadre of well-
trained library, information, and health
science specialists who are trained  by the
academic departments and training pro-
grams sponsored by NLM. Many faculty
will have been trained by NLM-sponsored
faculty development programs; they will
have made significant contributions to the
development of computer-based educa-
tional  programs and expert systems. These
programs will be made available through
NLM resources, published by medical pub-
lishing firms, or circulated through consor-
tia of professional schools. The programs
will be indexed in standard literature refer-
ence files and routinely cited in the litera-
ture. These  contributions  to computer-
based  educational materials are seriously
considered in the faculty  reward system
and the faculty promotion process.
NLM will have  encouraged the develop-
ment of operational medical information
systems that combine and integrate a
number of important information manage-
ment resources, including support  for the
recording of clinical information in routine
care, access to appropriate knowledge
resources and continuing education pro-
grams, and routine quality-assurance capa-
bilities. Clinical data are recorded  by
health-care personnel using computer-
supported interactive dialogue and the
Unified Medical Language System. The
successful development of this language
17 
will have evolved through a long period of
collaboration between NLM, the  NLM-
supported centers of excellence and IAIMS
programs, academic investigators, medical
librarians, professional societies, medical
publishers, certification boards, and the
insurance industry. The use of a Unified
Medical Language System in the opera-
tional medical information systems permits
the integration of the descriptors used  in
health records, the diagnostic terms
required for reimbursement, and the tex-
tual description of scientific conclusions in
the medical literature.

Computer-based continuing education pro-
grams will have been developed as  part of
an overall scheme to provide information-
management resources to practicing
professionals in  all of the different  health
professions. NLM  will have  made major
progress in assuring that  such programs
are fully available to the practicing health
professional, making a reality of  the con-
cept of  "lifelong learning"  and the "con-
tinuum  of medical education." The
knowledge-management systems and expert
consultation resources that assisted the
practitioner's learning process during the
student years will  become an indispens-
able tool throughout his or her career  as
a practicing health professional. Extensive
communication networks will provide the
capability for easy and rapid electronic
consultation  and  sharing of clinical infor-
mation between different professionals.
Personal computers and communication
networks will provide access  to online data
bases, knowledge bases, and  expert consul-
tant services. The ready and early availa-
bility of research findings, together with
automated access to a huge  pool  of data
on health and disease of a large popula-
tion through computer-stored data banks,
will permit great  strides in describing dis-
ease states, identifying  causes of disease,
and  selecting optimal treatments.  The
value of information in these data banks
will have been greatly enhanced through
the widespread adoption of a system of
recording  clinical information using the
Unified Medical Language System.
18 
Major Issues and
Future Directions
 It became evident during the course of
 the deliberations of this  Panel that the
 subject of information technology in the
 education of health professionals is  both
 broad and complex.

 For many years, the limitations of the
 technology (e.g., expense, unreliability, dif-
 ficulty of use),  prevented both clinicians
 and  educators from transferring even rou-
 tine  tasks to the computer. The technology
 has developed dramatically in recent years,
 and  we now find that the major problem
 is lack of applications and methods of dis-
 semination to take full advantage  of cur-
 rent  capabilities.

 It also became  obvious to us that certain
 aspects of the application of the technol-
 ogy will  need to be expanded even further
 to meet the needs of  tomorrow. Without
 proper expertise and  organizational
 resources, this Nation will jeopardize the
 quality of education and practice of its
 health-care providers,  and consequently,
 the quality of its health care.

 Our  deliberations narrowed to  four areas
 that  seem fundamental to assisting future
 education in the health professions
 through information technology. These
 four  areas are:  the Unified Medical  Lan-
 guage System, centers of excellence  in
 health sciences  informatics, knowledge
 management systems  for practicing health
 professionals and students, and educa-
 tional technology itself.

 The  first two are necessary prerequisites
 to exploiting today's technological capabil-
 ities, and are vital to  meeting future
 needs. The last two push the boundaries
 of today's capabilities; they pave the way
 for providing the environment that will be
 needed for the  health-care community of
2006.
Unified Medical Language
System

Current Situation and Needs
A major impediment to widespread adoption
of computer-based information systems in
health care has been the absence  of a
standard vocabulary for  describing health-
care phenomena pertaining to patient
care, results  of biomedical  research, and
the managerial and business transactions
of ambulatory care and hospital activities.
Each vocabulary has evolved separately
from noncommon origins:  clinical  from
direct observation of signs  and symptoms;
research from basic biology and chemistry;
and managerial from accounting and business.

In order to integrate computer-based infor-
mation systems in the health sciences, the
vocabulary used in the clinical setting
must be linked to that used for indexing
scientific, clinical, and behavioral litera-
ture; this vocabulary must  also be compat-
ible with the terminology used in health
science education, in health-care adminis-
tration, in medical  reimbursement, and in
health-related social and engineering dis-
ciplines.

At the same  time, the increasing use of
automated information systems increases
the need for common terminology. A
major resource commitment will be
required to develop  methods wherein a
unified language can be easily used in a
professionally acceptable fashion in all the
health disciplines. Leadership will  be
required to overcome habitual recording
practices that do not consider integrated
uses of documents. 
 A major accomplishment in the develop-
 ment of a unified  medical  vocabulary is
 the worldwide adoption of  NLM MED-
 LARS (based on the MeSH indexing sys-
 tem) for access to  bibliographic citations
 of scientific literature. NLM and profes-
 sional librarians in schools and hospitals
 have exerted considerable leadership in
 developing extensions and  enhancements
 to the MeSH vocabulary and in promoting
 the use  of this example of  a standardized
 vocabulary. However, MeSH is insuffi-
 ciently detailed for use in clinical care,
 specialty areas, and many of the health
 professions outside of medicine.

 Windows of Opportunity
 Professional groups, academic  organiza-
 tions, librarians, academic  investigators,
 and medical publishers have increasingly
 recognized the need for common terminol-
 ogy and are growing more  interested in
 collaborating to develop such a common
 terminology. The proposed  NLM centers
 of excellence and the IAIMS Programs
 should provide excellent opportunities to
 collaborate in  projects aimed at the
 incremental  development  and evaluation  of
 a common language for the different dis-
 ciplines, professional schools, clinical-
 classification needs, and reimbursement
 requirements.

 Improvements in computer  technology pro-
 vide new methodologies for research into
 the language used  for  all facets of health
 care.  For example, it is now possible to
 retrieve entire documents  and to search
 and  analyze the full text of documents
 and  reference files.  This creates an oppor-
 tunity to undertake  a comprehensive defi-
 nition of the vocabularies and terms used
 in the different clinical  areas, to examine
the role  of syntax and  context in determin-
ing the meaning of the terms used in  any
vocabulary, and to discover  methods of
language unification or linkage.
 Developments in computer-based patient
 record systems in a number of academic
 centers have made it possible  to assemble
 large  collections of computer-stored medi-
 cal records. Much  of the data  in these
 computer-stored records exists  in the form
 of predefined, controlled vocabularies or
 in machine-readable text. This creates an
 opportunity to consider the relationship of
 clinical vocabularies to vocabularies used
 in scientific literature  and the  MeSH
 vocabulary.

 NLM's experience  and leadership in
 development of the MEDLARS system and
 the MeSH vocabulary  are enormously
 valuable as a  foundation for undertaking
 development of a Unified Medical Language
 System. The insights and experiences that
 have been generated in the Library's
 previous work can offer a sound foundation
 for extending  the concept of a controlled
 vocabulary into other areas.

 Impediments
 A common language must be derived ulti-
 mately within a common conceptual
 framework. Reconciling existing frame-
 works  will be  difficult; accommodating the
 language  from those disciplines that have
 not yet identified a common framework
 will make this task even more difficult.

 The language  developed in specialized
 areas  is resistant to change by  outside
 pressures. The proposed development of  a
 unified language  requires a major col-
 laborative project among NLM,  the differ-
 ent professional societies, academic organi-
 zations, professional boards, credentialing
 and licensing boards, reimbursement  agen-
 cies, editors of professional journals, and
 relevant Government agencies. Collabora-
tion on this scale will be very difficult to
orchestrate. Each group and subgroup will
have interests to protect, both professional
and financial.  Those who have  invested 
the most in prior standardization may
have the most to lose. Many clinicians will
display inertia and  overt resistance to
changing long-standing habits of expres-
sion. The need for international interchange
of information adds to the complexity. The
utmost dedication, imagination,  and leader-
ship on the part of NLM will be required.

Centers  of Excellence in Health
Sciences Informatics

Current Situation and Needs
Informatics in the health sciences is a
developing field of  applied  science that
has made admirable progress in the past
decade. A  major factor in this progress is
related to the leadership  of NLM  and a
few individual academic laboratories (often
sponsored  by NLM research grants). In
addition, private industry has become more
aggressive  in developing and marketing
information technology support  systems,
such as  those for hospital information,
bibliographic reference, electrocardiographic
analysis, and the like. However,  the
promise  of information technology in
medical  applications  has only begun to be
tapped. There is a  pressing need  to
support  and promote work  in this field.

Many of the significant advances in medi-
cal informatics have come about in com-
bined academic/clinical environments
characterized by a combination  of
administrative support, substantial stable
funding, and expert human resources.
Such environments, however, are unusual.
Many of these units have evolved  more as
a result of the combination of the
individual initiative of a few creative
individuals and fortuitous circumstances,
rather than planning. In  order to promote
more rapid advancement in the field of
medical informatics, well-planned centers
of excellence  for research  and training are
needed. These will  provide the necessary
combination of academic/clinical environ-
ments, stable material resources, and con-
centrated expertise.

Windows of Opportunity
Health science informatics is attracting
many bright young individuals from the
health and engineering professions, as well
as from medical library science and aca-
demic  administration, who have the poten-
tial to  advance  the field. Without
advanced training and opportunities for
research, this talent pool will probably not
be tapped to its full potential. Establish-
ing centers of excellence would enable the
Nation to develop and expand a highly
skilled cadre  of researchers in informatics
for all the health specialties; the centers
would  provide long-term  career support
and job opportunities in order to keep
talented individuals in this highly impor-
tant field.

Several of the IAIMS projects, as well as
other existing centers (including NLM's
own Lister Hill National Center for Bio-
medical Communications), can serve as
models for the centers needed in health
professional schools and teaching hospi-
tals. In addition, there are currently a
number of health professionals who, by
virtue of education and experience, have
amassed considerable expertise in the
application of computers  to health-care
problems. With  appropriate funding, their
expertise might be tapped for these
centers to further research and  training in
health science informatics. 
Establishing centers of excellence may be
the most rapid and effective means of
promoting medical informatics in this
Nation. Such centers will provide a highly
visible critical mass of individuals,  capable
of exploiting and expanding computer
technology for the ultimate goal of high-
quality, cost-effective  education and health
care.

Impediments
A major impediment to establishing
centers of excellence  is the  requirement  of
long-term, stable support. NLM must have
sufficient funds  and an appropriate fund-
ing mechanism to provide such support.

Since the expected outcomes of this project
may not be  realized for several years, it
will be  critical to select for initial funding
those institutions that have high potential
for  producing results. The requirements
should include  demonstrated leadership, a
well-documented track record of accomplish-
ments, an obvious potential for continuing
excellence, and the unambiguous support
of the local  administration.  There  are only
a few institutions at present that meet
these criteria. There is, therefore, a need
to  promote this concept and to encourage
schools to develop their resources so  that
they may compete for these awards.
22
There are several major reasons to provide
a high level of stable support for  the pro-
posed centers of excellence. Such  funds
would encourage the  evolution of  institu-
tional role  models for the field and also
support the development of applications in
medical informatics that can be readily
disseminated. In addition,  a  fundamental
component of the  center concept  is a high
level of collaboration  among different
institutions. However, there is no strong
precedent for the dissemination of com-
puter applications in  medical informatics,
and true institutional collaboration is rare. 
NLM must develop review and funding
mechanisms that foster  such  an attitude
and, in addition, NLM will need to main-
tain  close surveillance of the centers and
implement an evaluation program that
measures performance in terms of institu-
tional acceptance and support. At the
same time, performance would be assessed
in part by  the extent of collaboration and
successful dissemination.
Knowledge-Management
Systems  for Practicing Health-
Care Professionals and Students

Current Situation and Needs
There is general acceptance of the claim
that practicing health professionals could
benefit from greater  accessibility to cur-
rent information about optimal diagnostic
and treatment strategies and appropriate
therapy. However, few specific data are
available on the  details and frequency of
the clinical problems  and  the decisions
that a health-care provider is required to
make  in the course of his or her daily
practice. Even less is  known about
whether, and to what extent, better acces-
sibility of relevant information would
improve the quality of health care  or
make  its delivery more cost-effective.

Descriptive research  is needed to delineate
the information needs of the practitioner
in various settings. Demonstration  projects
are required to gain experience in utiliz-
ing computer technology in knowledge-
management systems  that guide  and serve
the practitioner.  Evaluative research is
needed  to determine  the utility and effec-
tiveness of these systems in clinical practice.

A knowledge-management system should
be tightly linked  with a computer-based
medical record system so  that the  informa-
tion activities of clinical practice can  be
integrated with decision support and con-
tinuing education. This requires a well-
designed interactive  computer system  that
would both support routine information-
handling needs and  provide ready access
to appropriate knowledge  bases (e.g., drug
information data bases, data bases on
appropriate use  of specific tests, informa-
tion on effective  diagnostic strategies, etc.).
23 
A knowledge-management system has the
potential to integrate clinical records with
quality-assessment and quality-assurance
activities that are fully under the control
of the  user. There is a pressing need for
clinical information  systems that allow the
systematic  analysis of practice patterns.
Such a system should be capable of
providing feedback and reminding  the
user when  he or she deviates from prede-
fined quality-assurance protocols. To gain
the full support and  participation of
individual  practitioners  in this activity,  it
will be  important to assure each one that
feedback on  individual performance will
be provided confidentially,  as a learning
experience. Care should  be taken to assure
them that  this activity is in no way per-
ceived  as one with punitive implications.

A knowledge-management system should
support the following uses:

■  Targeted  Information Retrieval.  This is
   the  mode  in which a user seeks to
   retrieve knowledge to support a
   specific problem-solving task. As was
   pointed out in a recent study of physi-
   cian needs for information in office
   practice,13 problems frequently  occur
   in daily practice  that require informa-
   tion that  is not usually provided by
   available  print sources.  Not only is
   such knowledge retrieval  important for
   making the decision  itself, but  learn-
   ing  tends to occur best in a problem-
   solving context,  i.e.,  when the need  for
   information is urgent.
24
■  Browsing Knowledge Retrieval. This is
   the mode in which the user is
   interested in how a particular fact
   relates to other facts and is attempting
   to learn more about  the context of a
   particular issue in order to understand
   more about it. The equivalent function
   in using a book is scanning adjacent
   paragraphs  or looking through the
   table of contents. For example, if the
   user of the  knowledge-management sys-
   tem were looking up the side  effects of
   a particular drug used  to treat hyper-
   tension,  the user might also be
   interested in other facts about the
   drug, e.g., the pharmacologic class  to
   which it belongs or  its  mode of action.
■  Decision Support. A  knowledge-
   management system developed with
   assistance from  professional societies
   should help in identifying the data
   that are  critical for a particular clini-
   cal situation. For example, clinical data
   bases can be developed that would
   provide such important information as
   the recommended work-up for a
   specific clinical problem or the predic-
   tive value of specific  signs, symptoms,
   and laboratory tests.  Nursing research,
   for instance, shows that nurses often
   "lack effective cognitive strategies for
   processing data."14
■  Personal Reference System. The con-
   ceptual framework used in  a
   knowledge-management system will
   usually be devised by experts. This will
   provide a logical schema for  filing
   observations that reflect the user's  own
   unique combination of concerns and a
   personally selected bibliography.
■  Topic-Specific Bulletin Boards. The
   conceptual framework of the
   knowledge-management systems can
   likewise  serve as the  organizing princi-
   ple for informal, topic-specific bulletin
   boards. Users with targeted interests 
   could inquire  about (or add informa-
   tion on) research in progress,  prelimi-
   nary findings, generalizations  from
   clinical experiences, or specific clinical
   or management topics. This would sig-
   nificantly extend to a  much wider
   community the existing practice of
   consulting with peers  on problems or
   topics  of interest.

Two overriding design considerations  are
that the knowledge-management systems
(a) be affordable by both  the self-employed
health-care practitioner and by organiza-
tions that employ health-care practitioners,
and (b) be relatively simple to access and
use.

Windows of Opportunity
The increasing complexity of medical care,
the continuing knowledge explosion, and
the importance of considering costs in
diagnostic and  therapeutic decisions  make
it more necessary than ever for health-care
providers  to access and utilize the most
current and reliable information  in making
decisions  about  their patients. Health-care
practitioners are  becoming increasingly
aware that they  cannot rely on memory
alone;  they need the  ability to obtain
problem-specific knowledge, to appraise  it
critically,  and to utilize it appropriately. In
medicine, the need for such orientation is
one of the major tenets of the Report of
the Panel on the General Professional
Education of the Physician and College
Preparation for  Medicine (the GPEP
Report) of the Association of American
Medical Colleges,15 and the report of the
American Medical Association's Council
on Medical Education, Future Directions
of Medical Education.16
As an aid to both clinical decision making
and education in the health professions,
computer technology can play an impor-
tant role in  knowledge management  and
knowledge retrieval.  The traditional role of
NLM  has been in the cataloging, storage,
and indexing of paper documents. The
availability of electronic storage of such
information  now offers a radically new
opportunity for NLM to make clinical and
scientific  information much more available
and accessible to the health-care profes-
sional. The  mission  of NLM can and
should evolve from being primarily one of
document storage to one of knowledge
management.

Impediments
The design  of useful knowledge-
management systems for health-care
providers depends in large part on three
factors:

■  the size, completeness,  and quality of
   the knowledge bases available;
■  the availability of effective tools to
    allow  easy and timely access to
    appropriate portions of the knowledge
    base;  and
    the implementation  of  appropriate
    methods of generating, updating, and
    controlling the quality  of the informa-
    tion.
25 
Creation of such knowledge bases will not
proceed actively until there is reasonable
expectation on the  part of authors and
software publishers that health-care  practi-
tioners will find computer-based
knowledge-management systems attractive.
On the other  hand, practitioners will not
be tempted to employ such systems until
there is a critical mass of content, in
terms of scope and inclusiveness,  that is
both available  and  easily  accessible.

Furthermore, unless appropriate mechanisms
are in place to assure confidentiality,
individual  users may  perceive that the
record of their performance could lead to
punitive judgments by other parties.
Whether real  or wrongly  perceived,  this
would greatly diminish the voluntary par-
ticipation that will  be needed.

A similar limitation is that administrators
of health-care organizations and financial
reimbursement agencies are unlikely to
provide  financial support  for access to
knowledge  bases for health-care profes-
sionals until their impact  on effectiveness
of decision  making and utilization of
resources has  been  demonstrated.

Prototype, exploratory developments, and
initial evaluation efforts are essential to
overcome these barriers.
Educational  Technology

Current Situation and Needs
Technology exists to provide students with
a wide  variety of tools and aids to learn-
ing, including computer-assisted instruc-
tion, computer-based simulations, word
processing, bibliographic retrieval, self-
testing  and appraisal,  electronic textbooks,
personal file management, and electronic
mail. Many professional schools currently
make at least some of these tools available
to their students, and  increasingly stu-
dents are acquiring personal hardware and
software for facilitating schoolwork.

Enlightened educators and students sense
the potential of this technology, but are
frustrated because the current  piecemeal
approach prevents its full realization.  They
envision a curriculum  where technology is
fully integrated into  all coursework, and
where all faculty  and students  have access
to similar, compatible  resources. These
educators also recognize the added flexi-
bility that modern information  technology
provides to accommodate individual varia-
tions in interests, ways of learning, and
uses to  which knowledge is put. The vastly
increased capacity to extract materials
selectively tailored to a very special learn-
ing purpose from multiple sources allows
much greater  individualized use of curric-
ulum content  than could any set of stan-
dardized textbooks.

As the costs of higher education continue
to rise,  faculty productivity and effective-
ness have become crucial issues. CMI
(Computer-Managed Instruction) provides
the technology to facilitate the  administra-
tive aspects of student progress through a
curriculum. CMI  can coordinate course
objectives, maintain syllabuses  and bibliog-
raphies, and keep track  of course grades
and  evaluation notes. It  can schedule  stu-
dents for  courses, labs, and clinical practi-
cum requirements in proper sequence. Its 
promise as a technology for improving
faculty productivity and efficiency should
be further developed and evaluated for the
complex requirements of education in the
health sciences.

Windows of Opportunity
The Association of American  Medical Col-
leges' Steering Committee on the Evalua-
tion of Medical Information Science  in
Medical Education has concluded that
advances  in information technology
applied to the educational process have
progressed sufficiently for  medical infor-
matics to  be an "obligatory component of
modern medicine."17 18 Increasingly,
health science educators recognize that it
is important to provide the student with
control over his or her education through
the encouragement of personal initiative,
self-directed learning, and  frequent oppor-
tunity for self-assessment.  Students are
generally  comfortable in using the com-
puter and react positively  to its use in
instruction. Schools in the near future will
probably  require students  to acquire  com-
puter equipment,  just as they now require
microscopes  and stethoscopes; at the same
time, many students  will enter professional
training with considerable experience
gained from elementary, high-school, and
college computer  courses.

The introduction  of computer-based test-
ing by the National Board of Medical
Examiners in 1988—initially in the Part
III examination and  subsequently in  the
Part I and II examinations, as well as the
Federation Licensing Examination—will
provide a significant impetus to  students
and medical schools  to utilize advanced
technologies in educational settings.  This
initiative  will have a  profound impact in
the United States, since every physician
licensed to practice medicine in  this  coun-
try is evaluated by an examination devel-
oped or prepared by the National Board
of Medical Examiners.
Increasingly sophisticated students and
instructors  will be able to take advantage
of expanded technological capabilities,
such as interactive video disk, animated
graphics, physiological and epidemiologi-
cal modeling programs, and networked
student/faculty workstations.

The comprehensive use of information
technology in  the education of health
professionals can have far-reaching effects.
The student who uses the computer as an
indispensable  tool during the  formative
educational years will undoubtedly find it
an indispensable partner in future practice.

Impediments
As is true  in other developing fields, a
lack of standardization in educational
technology inhibits the sharing of
materials and  methods. Indeed, a built-in
conflict exists  between the goals  of
developing exciting and stimulating  proto-
types and  the standardization of  methods.

Efforts to  standardize professional curric-
ula or resources have not met with great
success. Only  minimal progress has  been
achieved in standardizing computer  equip-
ment and  software. 
In the case of computer programs relevant
to educational technology, standardization
is inhibited by the inertia of the many
and diverse users  who cannot individually
justify conversion  to a standard that
arrives after they have invested  their
scarce resources in their own  application
programs on their unique operating sys-
tems.  In only  a  few situations are pro-
grams available  that allow conversion of
old systems to new systems without
extraordinary cost.

Faculty efforts to develop and use educa-
tional technology  are fragmented  and
insufficiently supported either by  local
institutions or external funding. This limi-
tation is particularly true with regard to
the development of computer-based
materials, since  such  activity is  very time-
consuming  and  is rarely considered a
research contribution.  In  addition, publica-
tions  in  educational or information tech-
nology journals  do not offer the same
recognition for promotion purposes as  do
papers in traditional research journals.

A number of health science schools have
developed  audiovisual  departments with
varying success. However, only rarely will
an institutional  organization already in
place assist with the development of
computer-assisted  instructional software. At
any given school individual faculty mem-
bers maybe interested  in  this  activity, but
even  so,  the development is often  frag-
mented,  with little overall plan, integration
of either software  or hardware, or sharing
of resources or support personnel.
Similarly, there is no comprehensive
cataloging of instructional software, and
very little interchange of  materials from
one institution to another or indeed, even
among disciplines within  a single institu-
tion. An  example of what is needed to
remedy this is Patient Management Simu-
lations: A Resource  Catalog, recently
produced by the  Office of Educational
Resources and  Research of the University
of Michigan Medical Center.19 Based on a
national  survey, it lists information about
more than 70  simulations from 64 sources.
Another  example  is the Index to
Computer-Based Applications in Dental
Education, published by the American
Association  of Dental Schools.20

The effectiveness and cost-benefit of new
educational  technology  in the health
sciences  have not been clearly demon-
strated. Such evaluation is very important,
but it is  difficult because of our very
limited ability to  measure  the effectiveness
of current educational methods.
28 
Recommendations
Unified Medical Language
System

 We  Recommend That NLM Support
Development and Use of a Unified
Language For All the of the Health
Sciences

More specifically, NLM should do the
following:
(1) Sponsor a consensus-seeking conference
and  subsequent periodic working confer-
ences that would bring together represen-
tatives from  all appropriate  concerned sec-
tors  for joint consideration of the
problems involved in the development, dis-
semination, and utilization of a unified
language system for the health sciences.
Representatives of professional societies
and  licensing organizations  in  all areas of
health care should  be  involved, as should
representatives of the insurance industry,
relevant  Government agencies,  and  pub-
lishers of literature and software  oriented
toward the health-care  community.

(2) Use the extensive experience of  MeSH
development  and usage to begin  at once
to develop extensions of MeSH to index
health system clinical information and pro-
vide  nomenclatures for health professions
other than medicine. Furthermore, NLM
should continue to  identify new terms and
relationships  between terms  by automatic
monitoring of the full text of citations
stored in the NLM  computer-stored data
bank.
(3) Investigate as an intramural project the
relationships  between the vocabulary used
in MeSH and word usage in the test  ques-
tion  banks of the different certification
organizations (e.g., the  National Board of
Medical Examiners  and the  various medi-
cal specialty  and subspecialty boards.)
NLM should  also apply this process to
question banks developed by credentialing
boards in other health professions in order
to provide direction for both expanding
MeSH and developing the Unified Medi-
cal Language.
(4) Develop collaborative efforts with spe-
cialty societies and other health profes-
sions  to extend the MeSH thesaurus into
clinical care records, connecting terms
used in these fields to broader, narrower,
and related terms in the existing thesau-
rus. Professional societies in all areas of
health care should be involved, as should
representatives of the insurance industry,
relevant Government  agencies,  and editors
and publishers of literature and software
oriented toward the health-care commu-
nity.
(5) Promote and support extramural
projects that focus on the use  of a Uni-
fied Medical Language in interactive,
computer-based clinical information sys-
tems.  NLM should give a high priority to
gaining experience with such standardized
vocabularies in operational  medical  infor-
mation systems used in a variety of set-
tings  by the full spectrum of health
professionals.

(6) Support extramural projects to develop
standard vocabularies modeled on MeSH.
These vocabularies must take  into account
the specific concerns of the various health
disciplines and the subspecialties. The
necessary support utilities must be  devel-
oped, (e.g., dictionaries of terms, a thesau-
rus, cross-indices, automatic classification
and indexing assistance tools,  and com-
puter programs to validate  the literature
and medical records  that use the vocabu-
lary).  This should be followed  by auto-
mated indexing and  classification of clini-
cal records and literature by these
standard terms. 
(7) Encourage the development of
computer-based instructional programs
that  utilize the Unified Medical Language.
The  Panel strongly believes that it is
essential to inculcate  in the health science
student from the  start the  need for and
usefulness of a common language. We fur-
ther  recommend  that NLM provide finan-
cial start-up support for model educational
programs that include a major focus on
the use of a uniform  vocabulary.
(8) Undertake and sustain long-term  initia-
tives and collaborative efforts to promote
the use of the Unified Medical Language
by editors and publishers  of journals,
books, computer  programs,  and other
media produced for health professionals.
(9) Promote and support both intramural
and  extramural projects that explore and
develop effective  methods of knowledge
retrieval  from  full text.

Centers of Excellence

We Recommend that NLM Establish
Centers  of Excellence For Research
and Training in Medical Informatics
Technology as  Applied to the Health
Sciences.

These  centers of  excellence  should have
the following characteristics:

(1) Each  center of excellence should  have  a
strong research focus and significant
educational and training components. In
addition,  each center should be a leader
in introducing information technology into
health professions education and in
stimulating the introduction of health
science informatics content  in the curric-
ula of  the different professional schools.
(2) Each center of excellence should incor-
porate a true multidisciplinary approach.
In particular, each center should develop a
substantial relationship with the opera-
tional health delivery system, practicing
professionals from all health disciplines,
and the health science library community.
The geographical location of a center,
although important,  is not as critical as
that a proposed center provide a core of
educational, technological, and research
resources that will have an impact beyond
the local area.
(3) In each center, NLM  should support
training of highly skilled career investiga-
tors, provide adequate core research fund-
ing, and support career development pro-
grams for experienced researchers
(including individuals visiting  from non-
center institutions.)
(4) Additional criteria for an award should
be a willingness of the proposed center to
collaborate with other center awardees in a
consortium arrangement  so that each cen-
ter can benefit by and build upon each
other's experience. One of the most
important criteria is  the  proposed center's
capacity to aid in  disseminating its accom-
plishments and contributions to other
professional schools  and  the practicing
health professional—locally, regionally, and
nationally.
(5) Funding of a center should be for a
minimum 5-year period, at a level of
approximately $1 million each year for
each center. This is  needed to  fulfill the
training and dissemination functions and
provide the  necessary commitment to
build  and support a  center's research
infrastructure and  ensure continuity for
productive research and development. 
(6) Funding would support staff resources
and core project activities. Each center
would also compete, along with other
investigators not affiliated with a center,
for the available funds NLM has in its
budget base to conduct additional
investigator-initiated research projects out-
side of the center's core research. Center-
based investigators  would of course be
encouraged to seek funds from other Fed-
eral and  private sources.
(7) In order to  assure productive  outcomes,
a number of preconditions should be met
by the applicant institutions/organizations.
These should include evidence of adminis-
trative support  and support of academic
leadership, a minimum  required level of
salary support commitment by the institu-
tion, pre-existing resources such as com-
puter equipment and space, a core staff
who has  demonstrated previous achieve-
ments in medical informatics, evidence of
support for the conversion of the institu-
tion's library into an information-
management center able to participate
fully in medical informatics programs, and
evidence  of the willingness of the curricu-
lum committees to  integrate training  in
medical informatics with other parts of
the professional curriculum.
Knowledge-Management Systems

We Recommend  That  NLM Develop
an Extramural Research Support
Program For Development,  Use  and
Evaluation  of Prototype Knowledge-
Management Systems.

More  specifically, NLM  should:
(1) Stimulate  the development of function-
ing prototype knowledge-management sys-
tems and make them available to selected
users; gain experience with the use of
these  prototypes; and obtain feedback
about problems, limitations, and needed
capabilities. These systems should  be
designed to be used directly by health
professionals  in daily practice and  should
integrate routine clinical information
processing  with knowledge retrieval. In
addition to scientific medical knowledge,
information that instructs  the health
professional on how to  gain access to com-
munity  resources (e.g., extended care facili-
ties) should be  included. They should
include  user-interface methods and tools  to
facilitate targeted knowledge retrieval,
browsing, and decision support. In addi-
tion, NLM  should seek to  establish col-
laboration with Federal reimbursement
agencies and private health insurance
companies  to establish mechanisms so that
agencies could  share the costs of develop-
ing operational prototypes from which they
would directly or indirectly benefit.
(2) Undertake programs that would lead to
a critical mass  of content  for inclusion in
a knowledge-management  system. As part
of the effort to evaluate quality of content,
NLM  should  undertake  to establish active
collaboration with other organizations, par-
ticularly professional societies and  creden-
tialing,  licensing, and reviewing boards, to
develop  mechanisms to support the acqui-
sition and organization of the  expert 
knowledge base. NLM should also  seek
active collaboration with such organiza-
tions in studies directed at evaluating the
dissemination  and utilization of specific
applications of knowledge-management sys-
tems.
(3) Fund research aimed at resolving
potential problems and issues related to
the development and maintenance  of
knowledge-management systems,  including:
■  improved understanding of the
   information-seeking behavior  and the
   access needs of practicing health-care
   providers;
■  consideration  of the different behavior
   involved in targeted, problem-solving
   knowledge  retrieval versus browsing
   versus decision support;
■  development of alternative strategies
   for transforming information  pertain-
   ing to health  sciences  into  an "elec-
   tronic textbook" format and  considera-
   tion of mechanisms for content update
   and revision as needed;
■  consideration  of problems of  individual
   versus communal authorship; and
■  delineation of software engineering
   issues involved in computer storage
   and access of large and complex
   health science knowledge bases.
(4) Support research aimed at determining
to what extent  a practice-linked, knowledge-
management system could facilitate cost-
effective  decisions and more judicious use
of available resources.
Educational Technology

We Recommend  That  NLM Under-
take a Series of Projects Aimed at
Developing Educational Applications
of Computer Technology and
Integrating These Applications Into
Health Sciences Curricula.

More specifically, NLM should:
(1) Support development of novel forms of
applications of information technology that
have the potential for significant educa-
tional impact.  Possible examples include:
■   the use of  computer models that can
   interact with the  student in  a consulta-
   tive or explanatory fashion;
■   programs that provide  realistic  simula-
   tions of patient cases that could help
   the student learn about diseases that
   might not be encountered in his or
   her clinical rotations; and
■   simulations of physiological  systems
   that provide students the opportunity
   of learning  the interactions and feed-
   back that exist among biological varia-
   bles in complex systems.
(2) Promote access to computer-based
educational resources by undertaking the
following:

■   publicize the availability of resources
   that have been cataloged;
■   support improvements  to the National
   Learning Demonstration Center as a
   location where visiting scholars can
   explore  existing materials in a variety
   of health-related subject areas and use
   various  computer and  video educa-
   tional technologies;
■   support the development of extramural
   demonstration centers  where faculty
   can observe and  use computer-based
   educational applications; 
■  promote increased awareness among
   health sciences faculty and librarians
   about the use  of educational technol-
   ogy by supporting training in medical
   informatics and by sponsoring fellow-
   ships. Such training would be an
   appropriate part of the proposed
   centers of excellence program; and
■  support annual conferences,
   "tradeshows,"  seminars, and demon-
   strations where the new developments
   in  educational applications of informa-
   tion technology can be reviewed and
   evaluated by invited decision-makers in
   medical education.
(3) Seek external consultation about how
to promote  the development  of "stan-
dardized"  authoring  languages and
programming tool kits to facilitate national
dissemination. An analysis of existing tools
should be undertaken. These languages
and  tool kits would enable the production
of educational software at a  sufficiently
high level of abstraction to match different
educational philosophies  and specific tech-
nologies.
(4) Explore  the adaptation of computer-
based  methods developed by the National
Board  of Medical  Examiners. Although
developed for testing purposes, these
simulations demonstrate strategies that can
be usefully  modified  to meet instructional
needs  of individual schools of medicine.
(5) Develop mechanisms for specific review
and  documentation of the available  educa-
tional  software, as well as a system of
cataloging transferable programs. This
software should  be indexed in the
appropriate health science indexes (Index
Medicus, Cumulative Index to Nursing
and Allied Health Literature,  etc.) so that
it is  as accessible  as journal articles.
(6) Promote the publication of reviews of
computer-based educational programs  by
professional journals. NLM  should work
with appropriate professional societies to
develop techniques and standards for
review of computer-based programs.
(7) Initiate, promote, and support collabo-
ration with professional societies  in
developing lists of topics to be taught in
specific subject areas. These topic-area
lists  would serve as a guide to indexing of
materials and for developing new
computer-based educational materials.
(8) Work through the Regional Medical
Libraries to advance and coordinate utili-
zation of new technologies as they become
available. The professional staff of the
Regional Medical Libraries  would be
trained to provide  an interface between
potential users of technology and the
NLM resources that might facilitate  such
use.
(9) Support the development of model cur-
ricula where  information technology is
fully integrated into the  design, manage-
ment,  and  delivery  of a particular health
science educational area.
■  Accredited schools in the various
   health sciences  would be eligible to
   apply for grants for planning,
   implementation,  and  evaluation  of  the
   proposed curriculum. NLM should
   assure representation of the major
   health professions in a model curricu-
   lum project.
■  NLM should provide support  for
   faculty  time devoted  to integrating
   computer technology into coursework,
   including development of course-
   related  instructional programs where
   needed. Support should also be
   provided  for the acquisition of hard-
   ware and software and for preparation
   of the academic health sciences  library
   to  serve as a participating unit. 
References
Applicant institutions would be
selected based on the following: (1)
prior accomplishments  in  the  field of
computer-based education and/or
computer-managed  instruction; (2)  evi-
dence of administrative support,
including necessary changes to the
institution's library; (3) allocation  of
space and existing  hardware; and  (4)
evidence of collaborative  arrangements
with  recognized experts in the field of
computer-aided education.
At the  end of a specified period,
independent evaluative  studies should
be carried out to  gauge the effective-
ness  and impact of the curricula on
student learning and  faculty produc-
tivity and efficiency.
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9. Kingsland LC, Lindberg DAB, Sharp  GC.
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12. Harless WG, Zier MA, Duncan R. A voice-
activated interactive video disk case study for use
in the medical  school classroom. / Med Educ (in
press).

13. Bernstein LM, Siegel ER, Goldstein CM. The
Hepatitis Knowledge Base: a prototype information
transfer system. Ann Intern Med 1980;93(pt2):
169-81.

14. Grier MR.  The need for data in making nurs-
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information systems.  New York: Springer, 1981;21.

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20. Tira DE, Tharp LBK,  Beard MW. Index to
computer-based applications in dental education,
2nd ed. Washington DC: American Association of
Dental  Schools, 1985.
35 
Appendix A:
NLM Planning Process
In January,  1985 the Board of Regents of the
National Library of Medicine resolved to
develop a long range plan to guide the Library
in wisely using its human, physical, and finan-
cial resources to fulfill its mission. The Board
recognized the need for a well-formulated plan
because of rapidly evolving information technol-
ogy, continued growth in the literature  of
biomedicine, and the need to make informed
choices of intermediate objectives that would
lead NLM toward its strategic, long range goals.
Not only would a good plan generate goals and
checkpoints for management, actually a map of
program directions, but it would also inform the
various constituencies among the Library's
users about the future it sought and could help
to enlist their  support in achieving that future.

At the Board's direction, a broadly based proc-
ess was begun involving the participation of
librarians, physicians, nurses, and other health
professionals; biomedical scientists; computer
scientists; and others whose interests are inter-
twined with the Library's. A total of 77 experts
in various fields accepted invitations to serve on
one of the five planning panels. Each panel
addressed the  future in one of the five domains
that encompass NLM's current programs and
activities.  The domains, which provided the
panels, a framework for thinking about the
future are:

1. Building and organizing the Library's
   collection
2. Locating and gaining access to medical and
   scientific literature
3. Obtaining factual information from data
   bases
4. Medical informatics
5. Assisting health professions education
   through information technology

The Library chose a planning model with three
components. First, it incorporates a general,
somewhat indistinct vision of the future 20 years
from now in medicine, library and information
science, and computer-communications technol-
ogy. That environment  cannot be forecast pre-
cisely, but we can speak of a "distant" goal.
That goal is seen as a societal objective whose
attainment involves  many organizations and
agencies. NLM has a major role to play in
achieving the goal and must plan its part. Sec-
ond, while the 20-year goals are indistinct, there
are opportunities for and impediments to
achieving them. The opportunities and impedi-
ments can be more clearly envisioned because
they appear to lie roughly 10 years away. Third,
the specific steps that should be taken to
remove the impediments and take advantage of
the opportunities should be programmed for
3 to 5 years.

The planning process also involved participation
within the Library. The Director provided his ver-
sion of the future in the form of a "Scenario:
2005," which was distributed to panel members
and Library staff. NLM staff prepared back-
ground documents that reported NLM achieve-
ments in the five domains, and reviewed current
planning. Senior NLM staff members also acted
as resource persons to the planning panels.

At the end of the planning  process, each panel
formulated recommendations and priorities for
future NLM programs and  activities in the
domain under its purview. The five panel reports
were reviewed by the Board of Regents in June
1986. The Board then asked the NLM staff to
analyze  and reconcile their findings, eliminating
any duplications and consolidating the recom-
mendations. Together with the planning panel
reports, this synthesized plan presents the official
Long Range Plan of the Board of Regents of the
National Library of Medicine.
Photographs were obtained from the
several Bureaus, Institutes, and Divi-
sions of the National Institutes of
Health (including the Office of the
Director, NIH, the Warren G. Magnuson
Clinical Center, and the National In-
stitute on Aging), the Uniformed Serv-
ices University of the Health Sciences,
the World Health Organization, and
William A. Yasnoff, M.D., Ph. D.. 
 
December 1986