How can medical libraries become more relevant in the age of digital information?

Jennifer Dismukes
Syracuse University
School of Information Studies
Syracuse, NY, United States

Library Student Journal,
July 2009

Abstract

All libraries are undergoing changes in the digital age, but medical libraries face additional issues that are unique to the health care system. For example, medical research is creating enormous amounts of information. Also, HMOs are changing the face of health care. Furthermore, technology is separating health-literate patients from patients with low health literacy. These special issues require unique practices that will allow medical libraries to enjoy a more prominent place in health care. This paper recommends three such practices: (1) bringing information to the user via social networks; (2) training practitioners throughout their careers; and (3) reaching out to all patients, regardless of health literacy level, by creating knowledge tools and partnering with other organizations.

Introduction

In 2005, Woolf et al said, "[a]mong the great ironies of the modern health care system is how poorly it delivers knowledge at a time when society enjoys unprecedented access to information" (p. 293). To be fair, the medical field is undergoing drastic changes that would test any industry. Also, medical libraries may be excused from this wholesale judgment because many would consider them to be peripheral players in the health care field. Moreover, medical libraries are found in such varied environments as hospitals, universities, and pharmaceutical companies. Their mission, budget, resources, and patrons are different, so this prevents the effective application of blanket solutions. Nevertheless, their position in the industry and their diversity belie the prime position that medical librarians hold: their unique expertise and access to resources will enable them to capitalize on these changes and become indispensable to patients, practitioners, and researchers. This paper will explain key contextual elements that currently affect the medical field, obstacles faced by medical libraries in realizing their potential as key players in the medical industry, and suggested solutions to those obstacles.

The Present Situation

The vast quantity and quality of information available to patients and medical professionals is reshaping the landscape. For example, "a huge volume of administrative and clinical information from a wide variety of disparate data sources is generated by the roughly 33 million hospital admissions, 505 million outpatient visits, 2.8 billion prescriptions, and 4.8 billion insurance claims made annually in the United States." (IFTF, 2005b, p. 21).

Another influx of information comes from the nearly 10,000 clinical trials which are conducted each year (Chassin, 1998).

Likewise, current research projects, which were almost unfathomable without our current level of technology, are generating a level of data never before seen. These include the Human Genome Project, bioengineering of plants and animals, and disease cures through genetic manipulation. This information must be managed in a way that makes it available to more types of people than ever before (Funk, 1998).

As more and more medical and health-related information becomes available, it has effects on both consumers and care providers. For example, consumers' interest in their own health and well-being has been stimulated by access to information (Shipman, 2004). In addition, new quantities of information in conjunction with the prevalence of HMOs and their business practices have changed the dynamics between doctor and patient.

As has been mentioned, medical information is now readily available to consumers, which piques their interest in their health and wellness. Also, spectacular anecdotal failures of the health care system have been highlighted in the media, which raises consumer interest even more (Shipman, 2004). Consumer awareness has also been created by the continuing recognition of new chronic conditions in need of self-management. Treatment of these conditions becomes more complicated as new drugs are introduced and biotechnological advancements show promise, so doctors and patients will need complete information in order to make informed decisions from a range of options (Woolf et al, 2005).

Three increasingly common behaviors are signaling a sea of change in consumers' approach to health care. The first is self-agency, which eliminates middlemen and allows individuals to act on their own behalf or someone else's. The second is self-customization, which is a self-directed tailoring of services. The last is self-organization, or proactively finding others in order to meet needs; this behavior dramatically increases the importance of social networks (IFTF, 2005a).

These behaviors will be clearly demonstrated by the baby boomer generation, who not only will expect their distinctive needs to be met, but will test the medical field with an unheard of increase in geriatric patients. Unlike previous generations, boomers are embracing "lifelong learning," by "continuously acquiring new skills and knowledge to provide a base for reinvention and change, and to reduce risk in the face of an uncertain present and future. [Thus] as boomers age and have more leisure time, the strategy of leveraging lifelong learning is going to become even more visible (IFTF, 2003, p. 35). This concept will have enormous effects on the approach boomers take with their health care. They will demand to be educated in the format that suits them. They will also expect to have information like hospital rankings and clinical trial results easily available. Finally, they will use or create opportunities to develop information-sharing relationships (IFTF, 2003). Although these changes in consumer behavior will most significantly impact the health care industry as a whole, the effects will certainly be felt by medical libraries as well.

These information-related developments in consumers' behavior and doctors' workload have brought about complications that will require the attention of medical librarians so that they can maneuver into more important positions in the changing world of the medical field.

What is the New Role of the Medical Library?

Considerable obstacles are encumbering medical librarians and the medical community. One major issue is financial pressure placed on patients and providers. Also, the pace of transition to an electronic information management environment has been unusually slow in the medical field. Lastly, a widening divide exists between the health-illiterate and the health-literate.

First of all, increasing financial pressures placed on patients by their HMOs and their employers are prompting them to locate as much free health information as possible, especially online (Shen, 2005). There are a great many ramifications to consider: for example, the digital divide will continue to inhibit equal access to information (Scherrer, 2004). Also, acting on inaccurate health information can be dangerous; at the very least, it is time-consuming for practitioners to correct (Scherrer, 2004). Further, the locus of clinical decision-making has moved from the doctor's office to the home and elsewhere (Shen, 2005); making those decisions outside of a clinical facility adds an emotional component that can adversely affect an otherwise clear-headed process (Woolf et al, 2005). Add to these the realities of steadily declining retiree benefits and the unsure future of Medicare (IFTF, 2003), and one may ask: will medical libraries address this knowledge gap and provide useful and factual information, thereby becoming the critical resource they strive to be for their users?

Financial pressures affect not only patients, but health care providers as well. No longer do they have time to devote to keeping current on the literature. There is too much literature for a single practitioner to address, and heavily increased patient loads leave little time for perusing medical journals (Shipman, 2004). What can medical libraries do to manage the flood of information so that health care providers can be as current as possible on new discoveries?

Beyond the burden of economics, however, the medical field is also contending with exponentially increasing amounts of information. This would seem to make the industry an excellent candidate for the implementation of new methods and repositories for information storage and retrieval. Indeed, Masys (2002) argues that the medical field performs only two main functions: medical procedures and management of the information life cycle. Therefore, because fully half of the industry's function is information-related, it should spend at least an equivalent amount on IT that other information-intensive industries do. However, the medical industry averages 2-3% of budget expenditures when similar industries devote 10-15% of their budgets to IT (Masys, 2002). If the studies he cites prove there is no reason for the medical industry to be so slow to change, what role will medical libraries play in promoting the shift to support electronic information management?

Another major obstacle is health literacy. As Woolf et al(2005) mention, patients with low literacy or language skills have a much harder time understanding a body of terminology that is not only unique to the medical field, but also seems to increase in size and complexity as new discoveries are made. Andrews (2003) says, "although we are often talking about the same thing, we do so in confusing dialects, with seemingly interchangeable phrases" (p. 56). How will medical librarians tackle varying degrees of medical understanding in order to make the provision of health care efficient and thorough for all?

At the same time, the new electronic culture has spawned the rise of patients who sometimes have more information at hand from a simple online search than the medical professionals do (Shen, 2005). This phenomenon has been "shaped by a number of social and economic trends: the growth of the knowledge economy and knowledge work, higher education levels, lifelong learning, and wide exposure to the self-help movement" (IFTF, 2003, p. 46). How can medical librarians ensure that the information obtained by such patients is accurate and timely?

Although many of these problems are not novel, they have so far proven difficult to resolve. The remainder of this essay lays out some possible answers to these questions.

Suggested Solutions to the Issues Raised

Though much of what works for a nonprofit hospital library will not be as beneficial for a pharmaceutical company library, the solutions below are applicable to many different kinds of medical libraries because they face many of the same issues: overcoming economic constraints; transitioning to an electronic environment; and promoting effective patient care.

First, financial pressure on patients will continue to increase. Consumers are being forced to spend more and more money on health care as their premiums go up and employer coverage wanes (IFTF, 2005a). As a result, point of care is progressively shifting away from the doctor's office toward the consumer's home, so consumers will "look toward the marketplace for tools that enable them to self-diagnose, self-monitor, self-test, self-treat, and so on" (IFTF, 2005a, p. 5). With this in mind, Scherrer (2004) recommends "taking the library to the users' point of need" (p. 226). This is an opportunity for medical libraries to enter the consumer's field of vision and another strong reason to offer sound information.

Librarians can assist patients in more profound ways now that patients are independently seeking information that can be tailored for a particular lifestyle, either for themselves or on behalf of a loved one. Librarians can connect with consumers through tried-and-true methods like bibliographies and reading guides, but also through techniques that were not possible before the Internet, like current awareness services and social networks. An example of a current awareness service is an e-mail alert sent to interested parties when their topic of interest shows up in a scientific database, or when the table of contents to the newest issue of a topical periodical is published. Social networks are also popular sources of information. What consumers glean from social networks may be risky though, (IFTF, 2005a) so this is all the more reason for medical librarians to monitor and participate in them. What's more, these services will increase in importance as the boomer generation ages: "boomers have long been identified as a well-educated cohort that is hungry for information. This, as much as any other factor, will redefine how the new seniors will interact with health and health care" (IFTF, 2003, p. 4). For this reason, Huwe (2006) recommends that librarians maintain a strong familiarity with social networking tools by learning about new tools on a regular basis and teaching patrons about them. In fact, medical libraries can be proactive with these tools by using their expertise to focus on conditions that will likely receive growing attention in the future, like mental health, strokes, and geriatric issues (Shen, 2005). Scherrer (2004) goes further and proposes the creation of personalized Web sites that predict resources to match a patron's interest. Amazon.com is the most obvious example of this, as seen in the "You may also be interested in" and product recommendations based on past purchases. Other features may include the ability to customize website features and appearance, in the same manner as iGoogle.

It is also important to note that the economic constraints faced by patients are also borne by providers, due to the continuing consolidation of the health care industry into the hands of a decreasing number of healthcare networks (Funk, 1998). Furthermore, the rapid growth of medical information renders untenable the traditional health service model, in which "an individual practitioner's accumulated personal experience and judgment are the pinnacle of medical effectiveness" (Masys, 2002, 'Groans of a collapsing paradigm' section, para. 1). However, consumer awareness and the rise of the Internet have modified the doctor-patient relationship in ways that produce new employment opportunities for librarians (Masys, 2002). One of those opportunities is training mid-career practitioners who may not be proficient in information searching (Masys, 2002). Because some authors recommend Web 2.0 training as part of required professional development (Sandars & Schroter, 2008), it is an excellent opening for medical librarians to expand their expertise and patron base.

Librarians can also help doctors who are already comfortable in the current digital landscape. According to a recent Manhattan Research, LLC, survey (2008), 83% of physicians make use of online video. Furthermore, one-quarter of physicians are contributing user-generated content to medical blogs, drug rating sites, and message boards (Manhattan Research, 2009). One way librarians can help such practitioners stay on top of the latest literature is with what Atreja, Messinger-Rapport, Jain, and Mehta (2006) call an "online evidence-based information portal" (p. 847). This portal combines an RSS feed of current articles from high impact medical journals with a blog feature which physicians can use to critique those articles. Another exciting way RSS feeds can benefit medical professionals is by creating a daily "PubMed query tailored to match specifically the current awareness needs of that patron" (Estabrook & Rothman, 2006, p. 60). Estabrook and Rothman (2006) also note that these solutions offer a good balance between current awareness and time management: "RSS feeds generated from custom search queries seems to be one of only a few available means of staying informed without being buried in the growing information avalanche" (p. 64).

Medical librarians should extend their reach beyond those already well-established in the medical field, too. Lemley and Burnham (2009) note that "medical librarians will be faced with a golden opportunity to train faculty, students and practitioners in the use of" Web 2.0 tools, because their study shows that 53% of nursing schools and 47% of medical schools are already using Web 2.0 tools in the classroom. These students are the next generation of medical professionals, so as stated before, it is important to meet the patrons where they are.

The second obstacle to address is inadequate IT infrastructure. Because library budgets may not soon see the needed increase in IT spending to convert medical records, research data, and library holdings to digital format, librarians will need to develop their own expertise in both leadership and technology in order to give the medical library a place at the table where IT decisions are made (Funk, 1998). Unfortunately, Abram (2008) details the standard next-generation librarian with a description that would intimidate many. S/he is someone who: "combines e-resources, visual media, and print formats and is container- and format-agnostic;" is "device-independent and uses and delivers relevant results to everything from laptops to smartphones and iPods;" "combines nontraditional and traditional tools invisibly and seamlessly in the interests of clients;" and "touch[es] everyone with the communication mode of their choice - telephone, Skype, IM, SMS, email, virtual reference, and more" (p. 47-48). Nevertheless, once medical librarians learn these skills, they can be key team members in the creation of new central "institutional knowledge centers that formalize responsibility for monitoring, sorting and communicating medical evidence" (Badgett & Morrow, 2005, p. 220).

The third issue is the continuing burden of health literacy. Medical librarians "face the difficult job of providing often complex (yet reliable) information in language that is linguistically, culturally, and age-appropriate so that patients and their families can understand" (Blaine, 2008, p. 20).

In regard to health literacy, Woolf et al (2005) thoroughly analyze the possible solutions. For instance, patients with low health literacy may look online for information about their conditions if they have Internet access. However, their list of results probably has thousands of hits, and they have no way to effectively sort the biased information from the unbiased. But is the better solution to offer a one-size-fits-all decision aid or face-to-face counseling? If it is the latter, who should be the counselor and what kind of training should be required?

Decision aids are balanced, consistent, and can be perused at the patient's leisure, but rarely take into account local resources and cultural barriers. Clinicians could rectify these disadvantages of decision aids, but they are operating at low profit margins and are too time-constrained to give proper counseling. Also, the results of clinician counseling would vary in consistency and quality (Woolf et al(2005)), though those problems could be largely resolved by licensing requirements (Masys, 2002).

Third-party counselors, however, can address all aspects of a condition, from emotional fears to the risk-benefit ratios of various treatments. Woolf et al(2005) recommend that the high-quality information in decision aids be combined with counseling by well-trained third parties. Based on a culture of service and a high level of expertise, medical librarians could be these third-party counselors and play an important role in the creation and maintenance of decision aids (Woolf et al, 2005). Masys (2002) calls this counselor a Personal Health Advocate: someone who offers "services targeted at providing tailored education for an individual's unique combination of health problems and concerns" (New Occupations section, para. 3).

One way in which this health advocate concept has materialized is with the Journey Project at Virginia Commonwealth University, a two-year fellowship that combines the expertise of a social worker with that of a health service librarian. The premise of the project is that health literacy is attained not only with the delivery of medical information but also by assuring that patients and their caretakers understand the information given. The time spent explaining the information is also a chance to make sure everyone involved is handling the situation well, so emotional energy can be directed toward the health issue instead of on fears of the unknown (Leisey, 2009). This project offers another insight into the places medical librarians can use their knowledge.

Another way to increase health literacy is to form cooperative partnerships with other organizations within the medical field (Shen, 2005). One example would be for libraries to become key players in health information seminars and other services offered by pioneering enterprises like Pharmaca (IFTF, 2003), an integrative pharmacy with a mission that meshes well with the educational goals of medical libraries. Pharmaca provides "easy access to credentialed pharmacists, naturopathic doctors, nutritionists, herbalists and more so you can achieve good health without an appointment, insurance or headache" (Pharmaca, 2009, 2). Pharmaca locations offer regular events on mental health, weight loss, pharmaceuticals, and physical wellness, just to name a few. In fact, it is recommended that medical libraries "learn about the work of other academic health centers, nonacademic health organizations, and non-health care institutions to identify best practices that may be usefully incorporated into their own activities" (Commonwealth Fund, 2003, p. 42). In this way librarians can use the best practices identified in other industries to increase health literacy in their own field.

There are other benefits to 'cross-pollination' with other organizations. Not only will medical libraries garner useful procedures to enrich their own level of service, but they can establish connections with other libraries in order to help more librarians enrich their services, too. It would especially behoove medical librarians to connect with public and school libraries so that those libraries may better address the many health-related questions they will be asked. Since the average American does not have unfettered access to a medical library, this presents a fine opportunity to extend the service of medical libraries to more users.

On the opposite end of the spectrum from health illiteracy is the proactive, digitally connected patron. As Connor (2006) notes:

"[s]ince secondary schools and colleges have already capitalized on Web 2.0 technologies and adapted teaching and learning techniques to appeal to digital natives, these adaptations will eventually trickle down to the training of scientists, physicians, and allied health professionals, and ultimately affect medical library operations and facilities" (p. 14).

Medical librarians can effectively guide these patrons to the best information by using Web 2.0 resources, which include social bookmarking, streaming video, podcasts, tagging, instant messaging, and mash-ups, among many others. This paper will focus on four of the most popular and easy-to-use Web 2.0 tools: wikis, RSS feeds, blogs, and social networking sites like MySpace and Facebook.

The database-driven, quick-to-update, collaboration-inspiring wiki can be a useful tool to keep patrons up to date on the latest discoveries and library offerings (Boeninger, 2007). It can also function as a knowledge center for library staff by storing policies, procedures, and much more (Chimato, 2006). A wiki can serve as an organization and communication space for inter-departmental projects, or keep the whole library informed of activities in particular departments. One wiki page that is especially relevant to this paper is Evidence Based Web 2.0, administered by Dean Giustini at the University of British Columbia Health Library(Evidence-Based Web 2.0, 2009). UBC Health Library Wiki, 2009). Arguments are given for Web 2.0 tools in general, but also for wikis in particular. The list of advantages includes the suggestion that active learning through online collaboration is more beneficial than passive learning. Also, online collaboration helps teams of dispersed people do better work. Most importantly, however, medical students and patients will come to expect information through a medium such as a wiki.

RSS feeds, which were referenced earlier to help doctors keep current on literature, can help patients, too. They allow for announcements of library services and content feeds, and can even be customized to be dynamic and topic-specific features on library webpages (Law, 2007). RSS content feeds can be generated directly from any journal website that offers feeds, but feeds can also be generated from online databases. Current awareness via RSS feeds is better than e-mail because the subscriber does not need to plumb through the depths of an e-mail box to find the content, and RSS feed subscribers are anonymous. Further, RSS feeds that are embedded on a web page update more quickly than change requests sent through a webmaster, and RSS-embedded websites allow for "a continually updated page of news on any and every medical specialty" (Estabrook & Rothman, 2006, p. 62).

As Kim and Chung (2007) mention, "understanding how blogs are used can allow information providers to better understand the impact blogs can have on" patients and their loved ones (p. 446). For example, Kim and Chung's study found that most current cancer blogs are used for emotional support and encouragement, not for the sharing of hard research, but that the future holds promise for making blogs a medical information delivery medium. They even recommend analyzing blog messages to see how they could be "beneficial in providing subject categorization to unorganized blog contexts" (p. 449).

The last Web 2.0 tool that will be discussed here is social networks. MySpace has a huge market share, so librarians frequently use it to market the library and upcoming events (Rethlefsen, 2006). Facebook is also exceedingly popular. Hendrix, Chiarella, Hasman, Murphy, and Zafron (2009) found that libraries already use Facebook for pushing announcements, providing chat reference, and marketing. Some libraries even purchase ad space on Facebook and other social networking sites to promote upcoming events (Rethlefsen, 2006). Hendrix et al (2009) recommend maximizing the utility of Facebook by posting tutorials, providing research applications, broadcasting multimedia, and creating online study groups. Rethlefsen (2006) recommends reading user profiles to see what they are looking for, and taking that opportunity to either provide instruction or complement the library collection with new acquisitions. Hospitals also find that social networks assist in collaboration, knowledge sharing, and locating experts (Rethlefsen, 2006).

Though none of these solutions is a cure-all, they represent genuine opportunities for medical libraries to help to bypass budget problems, integrate new technology, and further improve patient care.

Conclusion

The issues of changing technology, information explosion, and paradigm shifts in patient care, accompanied by the financial and literacy obstacles they create, can be effectively addressed to allow medical librarians to adopt a stronger, more forward-looking role in the field of medicine. Three things make medical librarians a valuable asset. First, they have access to the highest quality and most diverse sources of information. Second, they have the service orientation to make that information available to patrons. Third, and most important, they have the singular education and experience to process and distill the information so that it is useful to the end user, whether the end-user is a patient, provider, or researcher. No one else in the field can lay claim to all three qualities, and with the medical field in metamorphosis, the time is ripe for medical librarians to redefine their position within it.

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Author's Bio

Jennifer Dismukes is earning her MLIS degree at Syracuse University. She works as a Research Assistant at a law firm in Washington, DC.

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