Reinventing the Library

Association Seeks to Improve TMA Library Services, Efficiency

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Information Management Feature -- July 2001  

By Laurie Stoneham
Contributing editor

A family practitioner in Cuero identifies a case of Hansen's disease. He needs to know more about leprosy and how to treat it. Quickly. A general surgeon wants to review articles on laparoscopic colon surgery. An orthopedic surgeon is interested in learning more about an extracorporeal shock wave device recently approved by the Food and Drug Administration for treating fasciitis. And an endocrinologist needs a literature search on the benefits of a low-carbohydrate/high-protein diet to treat diabetes.

These are the types of reference research requests the Texas Medical Association Library receives and fills routinely. They are inquiries and answers that can and do save lives, help physicians pinpoint diagnoses, assist research scientists to expand the base of medical knowledge, and help clinicians improve the quality of patient care.

These services also are expensive to offer and are undergoing dramatic shifts because technology is altering library science as it is transforming the storage, management, and distribution of all information.

TMA is in the process of reinventing its library as it continues the process of looking at all member services to deliver value while providing -- in bottom-line terms -- the biggest bang for the buck.

Industry in transition  

The Internet and electronic data transmission have changed the way information is accessed forever. But that's not the only change-driver for libraries.

Florence Mason is a management library consultant who has been working with TMA since last fall to examine its tremendous library resources and repackage them in a way that serves the current and future needs of association members.

Ms. Mason explains that the library industry is shifting because of three trends. A tremendous increase in the prices of medical periodicals and databases is placing enormous pressure on library budgets. In the scientific segment, annual price jumps of 30 percent are expected. Second, libraries used to be prized for their acquisitions. Today, this "real estate" means nothing to information seekers who are more concerned with the application of knowledge. They want to get their hands on the information as quickly and efficiently as possible, and the Internet is offering that convenience. Finally, more choices, not only in terms of materials but also in the formatting (electronic, audiovisual, and print) of the information are available.

In very real terms, then, libraries are changing physically to expand electronically. The transition is complex.

Today's TMA Library  

Formed in 1922, TMA Library currently is the state's 10th largest medical collection, with 44,000 bound volumes and 740 clinical journal subscriptions. It serves as the only health science library in Central Texas, with the closest physical collection housed at the Briscoe Library at The University of Texas Health Science Center at San Antonio. The Richard D. Haines Medical Library at Scott & White Hospital in Temple also offers comparable resources.

In addition to and perhaps even more important than the physical materials stored in 8,368 square feet in the association's headquarters in Austin is the personal assistance and service provided by the library's eight full-time employees, four of whom hold advanced degrees in library and information science. These are experts in the gathering and culling of medical and clinical information.

"I call them for literature reviews and give them a general idea of what I'm looking for and they then expand or pare down the list that I've given them," said Josie R. Williams, MD, medical director for the Texas Health Quality Alliance and recently elected member of the TMA Board of Trustees. "They're much more knowledgeable in gathering the information I need, and they do it much more rapidly than I do."

Any TMA member can take advantage of these reference services that include completing searches on PubMed, the National Library of Medicine's online medical literature database (records from MEDLINE and PREMEDLINE consisting of 9 million bibliographic records from approximately 3,900 current biomedical journals). Copies of full-text articles owned and borrowed by the library can be e-mailed, faxed, mailed, or delivered by overnight courier. Rush services can be completed typically within 24 hours and often the same day of the request.

This level of service is difficult to match anywhere in the state and even the nation. TMA is one of only a few state medical associations that maintain a library.

A major challenge being addressed is that the library is one of the association's most cost-intensive services. Print journal subscriptions cost $204,020 in 2000. Typical health science subscriptions run $800, according to Ms. Mason, with TMA's most expensive journal subscription being the American Journal of Industrial Medicine at $2,875 a year. Electronic resources often are even more expensive to acquire and maintain.

Ms. Mason says it's critical to preserve this powerhouse of expertise regardless of the direction the library takes for the future. "You have a staff that adds value to the library through the speed of service delivery, commitment to providing the very highest level of services, and many years of experience. We must be very cautious to ensure that whatever changes are made do not disturb the quality of these services, because once lost, it's very hard to re-create."

Library patrons  

While library resources and services are available to all TMA members, not all physicians are even aware that the association has a library, and a majority of members don't use the services at all. Less than 10 percent of TMA members use the library on a regular basis. Not surprisingly, a recent survey found that the majority of those users come from Central Texas. Physicians in rural areas also rely heavily on the library as their only convenient source of medical information.

Houston internist William J. Osher, MD, hasn't used the library in about 10 years." I work at the medical center, and I use the Jones Library there or I use the Web."

Amarillo obstetrician-gynecologist Brian Eades, MD, says he has used the library in the past but doesn't so much anymore. "I have found other ways to obtain the information I need more conveniently," said Dr. Eades, who turns to the Internet more and more for research.

But for Clifford Moy, MD, clinical director of the Austin State Hospital, the TMA Library is critical. "Because I live in Austin, it is my medical library. The hospital has a membership with the TMA Library so it is an essential component of physician medical information resources in Austin," Dr. Moy said.

Dan Dugi, MD, a family practitioner in Cuero, has considered the TMA Library a lifeline to current medical information for more than two decades. He has called on expert librarians to help him prepare for some 200 lectures he's delivered in that time and to zero in on the latest treatment options, including how to deal with ancient diseases such as leprosy.

The chair of TMA's Committee on Rural Health, Dr. Dugi also uses the Internet to do his own research. "I think the Internet has helped, but I don't think it will ever replace the library. There are so many specialty items you can't get. Because the librarians are experts and professionals, they can shorten search time dramatically, especially for a physician who doesn't have time to play on the Internet for hours and hours. And even if you have the time," Dr. Dugi added, "you frequently can't find what you want. When you have a professional search staff at your fingertips just a phone call away, you can't beat that service." 

Future options  

A number of opportunities exist to maintain library services and member benefits and achieve greater efficiencies. In a report of initial findings, "Creating the TMA Library of the 21st Century," Ms. Mason, in association with library management consultant Louella Wetherbee, outlined several key directions to be explored.

The basic choices are for TMA to: 

  • Consider getting out of the business of providing clinical information altogether;
  • Move cautiously and consciously into providing more electronic access while creating partnerships to save money and generate income to pay for and deliver these services; and
  • Become a totally electronic-based service, dramatically altering the existing library "real estate." 

Ms. Mason will continue to work with TMA to explore what she calls a "hybrid" scenario, in which the library is neither totally print nor electronic-based. This will include ferreting out all cost efficiencies without sacrificing the quality of services, while moving to convert as much as possible to electronic access.

Knowledge management center  

Under this middle-ground approach, the library would become more than just a housing of clinical data. It would serve as a core of information services both to members and association staff. As such, the library would offer a scientific discipline to more effectively manage the explosion of medical information and knowledge.

Dr. Williams says this makes infinite sense. "We have to develop some information or knowledge management. We have gone from 4,000 to 5,000 randomized trials in a year to more than 13,000 randomized controlled trials in a year. There is no way for physicians to manage that kind of knowledge impact without having a reliable source they can call upon to retrieve and scan through the material very rapidly."

Austin pediatrician Stephen Barnett, MD, concurs: "TMA needs to find a way to help people with this new information age. We are overwhelmed -- totally overwhelmed -- with the amount of information that's available. We need to be able to address this situation by having an information management section of the association for which the library is maybe a core component."

Potential partnerships  

A critical direction for the library is to join with other entities to extend its reach and buying power. Developing strong collaborative relationships will accomplish three goals, according to Ms. Mason: reduce costs by pooling purchasing power with other organizations, improve visibility and perception of TMA Library services and capabilities, and offer additional services by becoming a portal or conduit for accessing expanded resources.

To this end, TMA urged the filing of House Bill 3591 by Rep. Bob Hunter (R-Abilene) that passed during the most recent session of the Texas Legislature. At press time, the bill was awaiting the signature of Gov. Rick Perry. The enactment of this bill will allow TMA to become eligible to participate in TexShare, a lending and purchasing consortium of academic and public libraries throughout the state. The Texas State Library and Archives Commission administers the program that allows Texans to share materials from participating libraries around the state.

Through TexShare, the library could offer TMA members the benefits of the library's access not only to millions of print books and journals, but also to electronic databases that offer full-text article retrieval. TexShare currently offers the Gale "Health Reference Center-Academic," which contains some 400 clinical journals, many of which offer full-text articles. The consortium also has almost 6000 e-book titles through its "netLibrary," many of which address health topics, along with numerous newspaper, business, almanac, encyclopedia, and general periodical databases.

"The mission of TexShare is to improve library services to all Texans and provide participating libraries greater resources to offer their constituents, thereby maximizing their effectiveness," said Beverley Shirley, director of library resources sharing with the Texas State Library and Archives Commission. "This is an interweaving of resources, a sharing that increases the resources available to everyone."

Along with increased resource access and availability, as a participating member of TexShare, the TMA Library would be eligible to apply for grant funds through the state's Telecommunications Infrastructure Fund.

Ms. Mason indicated that the TMA Library would explore the possibility of establishing partnerships with the health science center libraries around the state and affiliating with the South Central Academic Medical Libraries regional library organization.

Cost sharing  

Another recommendation of the consultant was to clearly identify the library's current and future customer base -- those members who use it the most -- and then develop appropriate usage, marketing, and fee packages that are equitable for all association members.

C. Bruce Malone III, MD, of Austin, a member of the TMA Board of Trustees, has been part of a group of association physician leaders examining future directions for the library. "We've got to figure out ways that we can maintain the services that our members want," Dr. Malone said. "Then we have to determine how we're going to reorganize those services so that the members who use them help us pay for them, and the members who don't use them don't have them as a cost."

The evolution under way  

Ms. Mason indicates that the change process will take place over several years. Planning the transition will occur within the next six months to a year.

Dr. Malone summarized the evolutionary process: "What we have to look at is how to continue to fulfill the library's mission in a way that is relevant to our members, cost effective, and consistent with the changes that are going on in information technology. Many libraries are going through this same thing, so the answer may not even have been invented yet." 


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