Toxicology and Environmental Health Information Resources: The Role of the National Library of Medicine (1997)

An important component of expanding the use of toxicology and environmental health information resources is increasing the awareness of these resources in the health professional and other interested user communities. Potential users of online toxicology and environmental health databases must be cognizant of the existence of the databases and of their content, must be computer literate (assuming that the user will perform his or her own search), and must have some familiarity with toxicology and environmental health data in order to interpret the retrieved information correctly.

Government agencies traditionally are not involved in marketing their products or databases. However, in 1987 an amendment to the NLM Act added to NLM's mission the function of publicizing the availability of NLM's products and services (Public Law 100-202, section 215). Furthermore, in 1988 the Senate Committee on Appropriations recognized that

This direction toward increased dissemination has led to the expansion of NLM's outreach and training programs, which are discussed throughout this chapter. Additionally, this chapter makes recommendations aimed at increasing

the awareness and utility of not only the TEHIP databases but also other toxicology and environmental health information resources.

For health professionals to efficiently search toxicology and environmental health databases and effectively use the information in those resources, there are several educational requirements. Health professionals need a working knowledge of computers, especially online searching skills, and an understanding of the strengths and weaknesses of the information available in this field.

As discussed in Chapter 4, computer use is largely a matter of demographics. Younger health professionals are more likely to feel comfortable with computer use and to have become accustomed to retrieving information through computers. There is, however, a continuing need to train health professionals about specific databases and the use of health-related information resources.

Koschmann (1995) categorized computer training into three types: (1) learning about computers, (2) learning with computers (i.e., computer-assisted instruction and the use of computers as specialized tools for instruction), and (3) learning through computers (i.e., incorporating computers into student's work and assignments on a daily basis). The author concluded that although there is a place for each of these in the educational process, it is learning through computers that is most effective in preparing for lifelong learning.

A 1984 report by the Association of American Medical Colleges recommended the introduction of computer training into medical education (AAMC, 1984; Matheson and Lindberg, 1984). Although most medical schools now teach basic computer skills (e.g., literature searching and word processing), a survey of 1992 medical school graduates found that 39 percent believed that the computer training that they had received was inadequate (Anderson, 1993; Hersh, 1992). Medical, nursing, and other health professional schools use a number of computer-assisted instruction programs for tutorials and computer simulations of clinical decision points (Hoffer and Barnett, 1990). Additionally, recognizing the vastness of the biomedical knowledge base and the necessity of lifelong learning, many health professional schools are using approaches, such as problem-based learning, that focus on independent learning and that incorporate learning through computers by emphasizing the frequent use of information resources, such as online databases, to solve clinical problems (Earl et al., 1996; Rankin, 1992; Schilling et al., 1995). Approaches to computer training vary between institutions. Some medical schools require an informatics or literature-

searching practicum, whereas in many medical schools this training is available only through noncredit classes (Florance et al., 1995; Ikeda and Schwartz, 1992; Pao et al., 1993). Responsibilities for computer training are often shared between departments of medical informatics (where available) and the health sciences library.

Online database searching, particularly MEDLINE searching, is often incorporated into continuing education courses, and evidence-based medicine continues this emphasis by using the biomedical literature to inform clinical decision making throughout the physician's career.

Answering questions and making proper diagnoses of exposure-related illnesses pose challenges for any health professional. As discussed in Chapter 1, the complexities of interpreting toxicology and environmental health data are substantial. Although no health professional can be expected to know the toxic effects of all chemicals, it is critical that health professionals be informed about the issues and familiar enough with the field to consider environmental and occupational exposures in assessing a patient's symptoms, making a diagnosis, answering a patient's questions, and counseling patients about environmental health risks.

However, health professionals, especially clinicians, receive limited education and training in toxicology and environmental health in part because of an overcrowded and increasingly specialized curriculum (Graber et al., 1995; Snyder et al., 1994). One study concluded that medical students receive fewer than 6 hours of occupational and environmental medicine during 4 years of medical school (Burstein and Levy, 1994). A survey of 89 departments of internal medicine found that 51 (57 percent) did not offer programs or clinics in occupational and environmental medicine and that only 20 programs (22 percent) offered clinical occupational medicine experience to residents, in most cases this training was elective (Cullen, 1987). A survey of 423 accredited baccalaureate schools of nursing found that while most of those responding included occupational and environmental health content in their curricula, fewer than half offered course content in epidemiology, toxicology, industrial hygiene, and occupational health nursing concepts and practice—related fields of knowledge essential to the understanding and management of such problems (Rogers, 1991). A 1994 study of graduate nursing programs in public health or community nursing found that only 17 percent required a course in environmental health (Ostwalt and Josten, 1994). Several recent IOM studies have focused on strategies for enhancing the environmental health content in health sciences curriculum and continuing education courses (IOM, 1988, 1995a,b), and this committee supports the recommendations of those reports (Box 5.1).

Current efforts to increase training in environmental health include the addition of occupational and environmental health questions on certification examinations, the awarding of curriculum grants for environmental health training by the National Institute of Environmental Health Sciences and by the Agency for Toxic Substances and Disease Registry, and the establishment of task forces by the Children's Environmental Health Network to develop training materials and training guides for pediatric residency faculty and other health professionals.

There is a continuing need for individuals cross-trained in computers and telecommunications, information sciences, and biomedicine. Individuals specializing in medical informatics use basic research in cognitive science, decision science, logic, statistics, computer science, and a number of other fields to develop and deploy applications that are specific to the needs of health professionals (Greenes and Shortliffe, 1990). Additionally, they are involved in planning and policy development and work to integrate information technology in health care and medical education. One of the emerging areas in this field is public health informatics, which will incorporate environmental health information issues.

NLM offers institutional training grants and individual fellowship to promote interdisciplinary training in medical informatics. Of those individuals completing the training programs, it is estimated that most are working in research environments, with approximately two-thirds in academic medicine and one-third in health-related research and development (Wallingford et al., 1996).

To assist in strategic planning on outreach issues, the NLM Board of Regents convened an Outreach Planning Panel in 1988 that was mandated to identify opportunities for improving the access to and dissemination of NLM's information resources (NLM, 1989). The initiatives proposed by that panel have been implemented into what is now an extensive outreach effort. NLM has established an Office of Outreach Development that works with its interdivisional Outreach Coordinating Committee to plan, develop, and evaluate NLM's outreach program. Recently, NLM conducted a 5-year review of its outreach efforts, which noted the expansion from 16 outreach projects in 1989 to approximately 300 projects (involving more than 500 libraries and other institutions) in 1994 (Wallingford et al., 1996).

NLM's outreach efforts are primarily conducted through the National Network of Libraries of Medicine (NN/LM), a nationwide network of more than 4,500 local medical libraries (primarily hospital libraries), more than 140 Resource Libraries (primarily at medical schools), and eight Regional Medical Libraries (RMLs) (Figure 5.1). The medical librarians and information specialists at each NN/LM member library play an integral role in educating, training, and providing access to NLM's resources.

Within each geographic region, the RMLs manage outreach activities that focus on connecting unaffiliated, rural, and minority health professionals with their local medical libraries and with NLM products and services. NLM supports Grateful Med demonstration and training projects through NN/LM, and since 1994, RMLs have awarded American Medical Association Category 1 Continuing Medical Education credits to those attending Grateful Med training sessions. Through the National Online Training Center sponsored by NN/LM, health professionals can register online for classes that are held regionally.

The current NLM contracts with the eight RMLs emphasize public health outreach programs. Each RML develops projects targeted for populations in its geographic region, and RML-sponsored outreach activities have been developed to reach a range of health professionals including physicians, nurses, dentists, pharmacists, therapists, and health administrators (Wallingford et al., 1996).

One of NLM's major outreach initiatives is a program that provides extramural grants to hospital libraries and other health science libraries for the purposes of introducing and expanding computer and telecommunications technologies. Four grant mechanisms have significance to outreach efforts:

• Information Access Grants provide assistance, primarily to small hospital libraries, for introducing computer technology.

• Information Systems Grants (ISGs) provide funds for improving or expanding access to information technologies and are primarily targeted to larger hospitals and academic health centers (e.g., an ISG provided funds for the establishment of a statewide network in Alaska that links rural hospitals and the medical library at the University of Alaska in Anchorage [Wallingford et al., 1996]).

• The Integrated Advanced Information Management Systems (IAIMS) initiative is designed to encourage the integration of multiple computerized

FIGURE 5.1 National Network of Libraries of Medicine. SOURCE: Adapted from NLM (1986).

information systems located throughout a hospital or medical center. IAIMS grants provide institutions with funding to plan and develop institution-wide computer networks that may include clinical, research, and library resources; administrative systems; and other computer functions such as word processing and email (Broering, 1992; Fuller, 1992; NLM, 1989; Roderer and Clayton, 1992).

• Internet Connection Grants are available through NLM. They enable health science libraries and other organizations to initiate Internet connections or to extend existing connections to outlying institutions (Corn and Johnson, 1994).

NLM offers a workshop on searching ChemID, CHEMLINE, TOXLINE, TOXLIT, and the TOXNET databases. These 2-day workshops are free-of-charge and are frequently held in conjunction with MEDLINE training courses. The TOXNET workshop is conducted by Specialized Information Services Division (SIS) staff and is held at the National Institutes of Health (NIH) campus in Bethesda, Maryland. The workshop features hands-on searching of the databases and provides extensive documentation and sample search printouts for the students to take back to their workplace. This class is a specialized module in NLM's entire training program that features introductory and advanced classes on MEDLARS searching.

Although these courses are available, there is only limited attendance. In FY 1995, 14 classes were offered on the ChemID, CHEMLINE, TOXLINE, TOXLIT, TOXNET databases, and of those, 6 classes were canceled. Sixty in

dividuals received training in the 8 classes that were held. The reasons for the limited attendance may include the length of the course, location, limited publicity, or lack of awareness of the utility of these databases.

NLM is developing a microcomputer-based toxicology courseware program that will provide an introduction to the fields of toxicology and environmental health for undergraduate students (NLM, 1995). It would be beneficial for this courseware, when it is released, to go beyond a stand-alone program and to be available on the World Wide Web as a case-based learning resource.

In addition to working with NLM-wide outreach activities, SIS has been active in targeting outreach activities to those populations particularly interested in environmental health information. Authoritative toxicology and environmental health information is of particular importance to underserved populations, those communities and locales where medical care is not readily or thoroughly available. These are often the same low-income or minority communities that are disproportionately exposed to hazardous environmental conditions at work and in the home (Averill and Samuels, 1992; Benson, 1995). One of the objectives set forth by the U.S. Department of Health and Human Services' Subcommittee on Environmental Justice, which is examining strategies to address environmental injustice issues and the associated adverse human health and environmental effects, is ''to make environmental and occupational health data more available to the public" (DHHS Subcommittee on Environmental Justice, 1995). SIS sponsors several outreach programs that provide information to the general public, to underserved communities and the health professionals who serve them, and to other health professionals who are not affiliated with a health sciences library.

In 1991, SIS implemented a pilot Toxicology Information Outreach Project with the objective of strengthening the capacity of Historically Black Colleges and Universities (HBCUs) to train medical and other health professionals in the use of NLM's toxicology and environmental health information resources. Nine HBCUs currently participate in the pilot program: Drew University School of Medicine and Science, Florida A&M University, Howard University, Meharry Medical College, Morehouse School of Medicine, Texas Southern University, Tuskegee University, University of Arkansas at Pine Bluff, and Xavier University. The program provides a workstation with computer-based tutorials, Grateful Med software, instructional materials, and free online access to the NLM

databases. Training is offered at each institution to researchers, instructors, and students, and in some cases health professionals in neighboring communities have attended training sessions.

Additionally, NLM collaborates with the Agency for Toxic Substances and Disease Registry (ATSDR) to train members of other HBCUs and minority institutions that offer environmental and occupational health programs. Three-day training classes have been held at the Oak Ridge Institute for Science and Education and at Howard University and have been attended by members of 44 additional HBCUs and minority institutions.

The Toxicology Information Outreach Project has had a significant impact on the curriculum and on outreach programs (Box 5.2). Use of the NLM databases has been incorporated into a number of courses at the undergraduate and graduate levels. Additionally, several universities have initiated their own outreach efforts involving educating junior high and high school students, college undergraduates, and local health professionals in accessing and searching NLM's toxicology and environmental health databases (Wallingford et al., 1996).

SIS is actively involved in a collaborative project between NLM and the Health Information Center (HIC) of the Wheaton Regional Library of the Montgomery County (Maryland) Department of Public Libraries. This project pro

motes access to information resources on environmental health and HIV/AIDS. NLM supplies free access to the relevant online databases on these topics (including AIDSLINE, AIDTRIALS, HSDB, and TRI), in addition to other services, such as developing presentations for community groups; providing books, periodicals, and other documents; and providing assistance in linking the HIC World Wide Web homepage with other Internet sites on environmental health and HIV/AIDS. Through this collaborative effort, environmental health information is being disseminated to several interested user communities including the general public and health professionals (such as school nurses) who are not affiliated with a health sciences library.

NLM and NN/LM staff exhibit the MEDLARS databases and new NLM products and services at a number of national, regional, and local health professional meetings and conferences. Additionally, SIS and NN/LM staff schedule a number of exhibits specifically to demonstrate the TEHIP databases at relevant national and regional meetings and conferences for health professionals. In FY 1996, the TEHIP program exhibit schedule included the annual conferences of the American Industrial Hygiene Association, the National Environmental Health Association, and the Society of Toxicology and the American Occupational Health Conference. To ensure that TEHIP program resources and databases are featured at all relevant regional and local meetings and conferences, communication and collaboration is essential between SIS and NN/LM staff and health professional organizations at the national, state, and local levels.

The committee believes that the user profile analysis recommended in Chapter 4 will be particularly helpful in outreach and training efforts. That analysis will allow NLM to set priorities and will provide information on the databases of greatest use to specific groups of health professionals. Thus, outreach and training efforts can be targeted so that resources are used most efficiently. As will be discussed in Chapter 7, an evaluation component, incorporated into the initial planning stages for each project, is critical in assessing the impact of training and outreach efforts.

As discussed in Chapter 3, the committee believes that the TEHIP program can make significant contributions to health professionals by providing information on the broad spectrum of databases and other information resources available in toxicology and environmental health, including but not limited to the TEHIP databases. By using the traditional expertise of libraries in providing reference services, outreach and training efforts could provide health professionals with information on the scope of relevant information resources and their available access points.

Outreach and training efforts are most effective when they are focused on the specific interests of the audience. A number of methods of incorporating this approach are available. Careful examination of the user analysis (see Chapter 4) could assist NLM in focusing its outreach and training efforts on those databases that best meet the needs of the user community. Focus group participants and the committee members believe that case studies are particularly effective since they can incorporate the use of relevant toxicology and environmental health information resources into clinical situations dealing with a particular topic (e.g., birth defects and cancer) of interest to the audience. Similarly-focused efforts can be used in continuing education programs and would be effective in the growing use of the World Wide Web to provide continuing education courses.

NLM and NN/LM staff currently exhibit the MEDLARS databases at a number of health professional conferences. Focus group participants indicated that they would be interested in having NLM conduct workshops or do teleconferences using search scenarios relevant to the topics at specific conference (e.g., environmental exposures of children at pediatrics conferences). These workshops would be ideal places to provide health professionals with information on the wide range of relevant toxicology and environmental health information resources.

Although most health professionals do not require intense specialized training on the TEHIP databases, such as the training currently provided through NLM's National Online Training Program, this training is useful for certain individuals including librarians and scientists who may be performing in-depth searches of the TEHIP databases. The committee believes that the key to effective outreach and training is to focus those efforts by demonstrating the utility of the TEHIP databases and other similar information resources to health professionals.

To reach the wide range of health professional user communities who can benefit from toxicology and environmental health information, it is important to use already-existing dissemination networks and current environmental health efforts. Committee members are aware of a number of dissemination mechanisms, including those described below, and encourage NLM to use these and other methods. Efforts should focus on those information resources that will be most useful for the targeted audience.

Information is currently disseminated by EPA to local emergency planning committees which have a strong interest in environmental health issues. Tying into that network to disseminate information about relevant TEHIP and other information resources would be advantageous. Environmental justice efforts are another focal point for outreach at the regional and community levels. Additionally, the NN/LM is an extensive existing network that is readily available. Since a large focus of NN/LM's outreach efforts is on Grateful Med training, incorporating searches involving the TEHIP databases into Grateful Med search examples would be a low-cost yet effective means of training. As seen in SIS's current cooperative project with the Wheaton Regional Public Library, public libraries are very effective in reaching many groups interested in environmental health issues, including patients, the general public, and health professionals such as school nurses who are not tied into other library networks. Local public health departments and poison control centers are also resources that would benefit from close ties with the TEHIP program. Publishing articles or informational advertisements in health professional publications is another way of reaching a large audience; these resources include scientific journals, and professional society newsletters and Web sites. These are only a few examples of networks and activities that are in place and that can be used to inform health professionals about toxicology and environmental health information resources that are relevant to their work.