Information in practice

National electronic Library for Health (NeLH)

J A Muir Gray, programme director ^a,  Simon de Lusignan, director of primary care library ^b. 

^a National electronic Library for Health, Institute of Health Sciences, Oxford OX3 7LF, ^b Hunter Wing, St George's Hospital Medical School, London SW17 0RE

Correspondence to: S de Lusignan slusignan{at}drs.desk.sthames.nhs.uk

Modern healthcare professionals have to resolve the information paradox; they are overwhelmed with information but cannot find particular information when and where they need it.¹ The internet and its associated technologies, especially the world wide web, have the potential to both exacerbate and reduce these problems. Simply providing access to the world wide web per se may exacerbate the problems of information overload, since every web browser has access to hundreds of millions of pages of information. However, the cost effective provision of access to timely, current, and high quality information is what internet technology potentially offers. Creation of the National electronic Library for Health (NeLH) should be seen as an attempt to harness internet technologies to solve this information paradox.

Sir Edward Waine, regius professor of medicine in Glasgow, who invented Waine's thyroid index, an early, pre-computer, decision support system, used to teach about "la maladie du petit papier." This described the patient who, somewhat nervously, took a little bit of paper out of his jacket pocket towards the end of the consultation and used this paper to remind him of the questions that he knew he was bound to forget in the stress of the consultation. Many clinicians have now found that le maladie du petit papier is now but a fond memory as they face daily "la maladie du grand print-out," an altogether more daunting challenge. The world wide web has blown away the walls and doors of medical libraries, which once shielded medical knowledge from the public gaze. Members of the public can now have access to almost all the information that professionals have.

	Internet tools

Top Internet tools NHS information strategy Aim of the National... Metaphorical architecture of... Access to the NeLH Conclusions References

Internet technologies potentially provide the tools to solve the knowledge paradox. At the most basic level, the web browser and hypertext link provide easy to use tools to view documents and to move between them. Hypertext links allow rapid movement from document to document in a way that is not possible with printed material. This hopping from place to placeknown as "surfing the web"is often enjoyable but can also be frustrating and time consuming.

Search engines go some of the way towards targeting the information that you require. A search engine can either search a single site or search across many. It can be constructed so that it either searches comprehensively or across a limited range of knowledge sources. The "EBM search" located on the Doctors Desk home page² is an example of the latter: a simple search term produces a small number of hits. The aim of this search engine (created by Dr Adrian Brown, St George's Hospital Medical School, London) is to produce the right volume of review articles for a busy general practitioner who does not have the time for a more extensive literature review. EBM search can also be launched from within a general practice clinical computer system, which means that once a diagnosis has been entered on the computer the search engine can be launched. This approach will help ensure that the target times of 15 seconds for accessing knowledge will be met.

User definable alerts can ensure that you receive an email whenever a journal article is published on a subject you are interested in. The BMJ website offers this facility to users (www.bmj.com).

Lastly, a range of commercial products allow personalisation. These are usually referred to with the "my" prefix. The "my Yahoo" internet page³ is a good example of how personalisation interfaces currently operate.

	NHS information strategy

Top Internet tools NHS information strategy Aim of the National... Metaphorical architecture of... Access to the NeLH Conclusions References

At the end of 1998 the new information strategy Information for Health was published, the culmination of an intensive project led by Frank Burns.⁴ The information strategy is wide ranging but has one simple central message, that investment in computing should benefit clinicians and patientsa radical departure from previous strategies, which have focused on the financial and managerial benefits of investment in information systems. Part of this strategy was a proposal that there should be a National electronic Library for Health.⁵

	Aim of the National electronic Library for Health

The mission of the NeLH is to deliver information to improve patient care. Obviously, knowledge alone will not achieve these objectives, but without easy access to good knowledge decision makers face an impossible barrier to providing high quality health care.

The NeLH will be developed on the following principles:

• It will be obsessed with the quality and not simply the quantity of the information
• It will contain both "know how" and knowledge
• It will be equally open to patients and clinicians, to the public and managers
• It will exist only in electronic form; there will never be a building called the NeLH
• It will involve its users in decision making as well as delivering a service to them.

The knowledge links to the site will be comprehensive, but its search engines will retrieve data only from sites that have met quality criteria.

	Metaphorical architecture of the NeLH

Top Internet tools NHS information strategy Aim of the National... Metaphorical architecture of... Access to the NeLH Conclusions References

The atrium
New entrants to the library will have access to a number of help desks, these will either be for discrete groups of users (such as for occupational therapists or orthopaedic surgeons) or to aid use of specific tools (such as Medline or the Cochrane database). The library is planned as a multidisciplinary source of knowledge and know how, but it is recognised that each professional group will have its own needs. It is envisaged that royal colleges and societies will become "cybersocieties," delivering services to all members electronically; the Royal College of Surgeons of Edinburgh has already gone some way down this road.⁶

Know how
In future more care can be managed through the development of healthcare systems with guidelines and audit. We are entering an era when guidelines will proliferate and the number of effective computer decision support systems will increase. One of the missions of the National Institute of Clinical Excellence (NICE) will be to introduce order into this rapidly growing subject,⁹ and the NeLH will look to NICE as a key supplier of know how. Prominence will be given within the NeLH site and its search engines to material from NICE. It may also remain a mandatory part of any personalised interface that a user develops with the library.

Knowledge
The need for decisions to be based on best current knowledge is now unquestioned. Those who have questioned it perhaps did so because they were unclear about the part that knowledge played in decision-making. The figure shows the model on which the NeLH is based, illustrating that knowledge always has to take into account the patient's condition and the patient's values, or, in the case of decisions about groups or populations, the needs and values of that particular population.

View larger version (16K): [in this window] [in a new window]   Model for decision making

NeLH knowledge platform
Researchers collect data and produce information, but for many users the information that is published in scientific journals, written primarily for other researchers, is not particularly helpful: it is often biased,¹¹ with the bias being very difficult to detect,¹² and the quality of the information may be difficult to discern and may not be expressed in the way that is most useful to users. For example, results may be presented as relative risks only, whereas many users would also like to know absolute risk and benefit. The NeLH will therefore give priority to systematic reviews of knowledge that are regularly updated, such as the Cochrane Database of Systematic Reviews.¹³

NHS Direct Online
Informed patients will be a major driving force for change in the 21st century. Although the main impact of the world wide web at present is to make patients amply informed, the aim of the NeLH is to ensure that they are not only informed but also well informed through NHS Direct Online, which will complement the telephone service NHS Direct.¹⁴

• How can I stay healthy, feel better, and reduce the risk of disease?
• Do I need to see a doctor for this problem?
• How can I learn more about my condition, contribute to my care, and make the best use of health services?

Knowledge management
Hitherto, libraries have been knowledge warehouses. Even if library users restricted their choice to secondary publications and distilled knowledge they would still be overwhelmed by information. Knowledge management can help mitigate this problem through better training of users and better presentation of knowledge.

• Doers of research
• Users of researchpatients, clinicians, and managers
• Teachers and trainers of healthcare professionals
• Librarians and information specialists.

	Access to the NeLH

Top Internet tools NHS information strategy Aim of the National... Metaphorical architecture of... Access to the NeLH Conclusions References

Standards have been set for access to information in the NeLH in different circumstances (see table). However, accessibility has other challenges: an NHS that operates throughout the day needs a 24 hour knowledge service, and much study and most accessing of medical internet information happens from home.¹⁵ The NeLH must meet these needs.

The final issue of access relates to locality. This can mean different things to different people, and the architecture of the NeLH must take account of this. National guidelines require local adaptation if they are to used effectively, and the construction of NeLH must facilitate this process while making the local changes explicit.¹⁶ An open architecture that will allow the linking of knowledge to patients' medical records is also a vital long term issue.

Virtual branch libraries
Branch libraries flourish because they are close to communitiesprovided, of course, that they meet the needs of the community. Three different but related types of virtual branch libraries are planned for the NeLH:

• Clinical branch libraries will be primarily for patients and clinicians and relate to a specialist subject in medicine
• Complementary branch libraries will focus on populations
• Health improvement libraries are designed to meet the needs of those who make decisions about groups of patients or whole populations.

	Conclusions

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The NeLH must be seen in the context of the global information society. Nationally, the Department of Health's commitment to public information and involvement is reflected in the Centre for Health Information Quality.¹⁷ There is unprecedented investment in training and development in the public library servicenow called the People's Network¹⁸and there is considerable investment in education and the National Grid for Learning.¹⁹ Health is not a single sector issue, and the NeLH will integrate with these initiatives. Many stable building blocks are already in place in the medical arena, from the Cochrane Collaboration to the BMJ's web presence.

Few countries have a better healthcare library service than Britain, but there is no room for complacency. The plan for the NeLH envisages that existing libraries will become part of the NeLH as soon as they are connected to the web and the NHSnet. Their most valuable resource, the librarians, will play a central part in the development and delivery of the NeLH's aims and objectives. The NeLH is fortunate in being able to learn from and work with other important institutions, notably the National Library of Medicine. The NeLH will have no large buildingit will be a virtual library, and its users will also be involved in its construction in a way that would be impossible if it were built of bricks and mortar. The NeLH will be a virtual organisation, connecting both sources of knowledge and users, who are all too often too isolated; were it to have a motto, it would be difficult to better E M Forster's oft quoted "Only connect."

	Footnotes

   Competing interests: Both authors have academic sessions funded by the NHS Information Authority, the funding body of the NeLH.

	References

Top Internet tools NHS information strategy Aim of the National... Metaphorical architecture of... Access to the NeLH Conclusions References

1.	Muir Gray JA. Where's the chief knowledge officer? BMJ 1998; 317: 832-840[Free Full Text]. (www.bmj.com/cgi/content/full/317/7162/832, accessed 10 Nov 1999.)
2.	The Doctors Desk. EBM search. drsdesk.sghms.ac.uk (accessed 10 Nov 1999).
3.	Welcome to My Yahoo! my.yahoo.com/?myHome (accessed 10 Nov 1999).
4.	NHS Information Authority. Information for health: contents. www.nhsia.nhs.uk/strategy/full/contents.htm (accessed 10 Nov 1999).
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6.	Royal College of Surgeons of Edinburgh. www.rcsed.ac.uk/ (accessed 10 Nov 1999).
7.	GP-UK. www.schin.ncl.ac.uk/gpuk/gpuk_home.htm (accessed 10 Nov 1999).
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9.	National Institute for Clinical Excellence. www.nice.org.uk (accessed 10 Nov 1999).
10.	Department of Health. Research and development. www.doh.gov.uk/research/index.htm (accessed 10 Nov 1999).
11.	NHS Information Authority. National electronic library for health (NeLH) prototype. Bias. www.nelh.nhs.uk/bias.htm (accessed 10 Nov 1999).
12.	NHS Information Authority. National electronic library for health (NeLH) prototype. Results may be impossible to appraise. www.nelh.nhs.uk/imposs.htm (accessed 10 Nov 1999).
13.	Cochrane Collaboration. Cochrane Library. Oxford: Update Software, 1999(www.cochrane.org/cochrane/cdsr.htm, accessed 10 Nov 1999.)
14.	NHS Information Authority. National electronic library for health (NeLH) prototype. NHS Direct Online. www.nelh.nhs.uk/nhs_direct_online.htm. (accessed 10 Nov 1999).
15.	Health On the Net Foundation. Surveying the internet usage for health/medical purposes. www.hon.ch/Survey/analysis.html (accessed 10 Nov 1999).
16.	Williams JG. Guidelines for clinical guidelines should distinguish between national and local production [letter]. BMJ 1999; 318: 942[Free Full Text]. (www.bmj.com/cgi/content/full/318/7188/942/a, accessed 10 Nov 1999.)
17.	Centre for Health Information Quality. www.chiq.org.uk/ (accessed 10 Nov 1999).
18.	Library and Information Commission. New library: the people's network. London: Library and Information Commission, 1997(www.ukoln.ac.uk/services/lic/newlibrary/, accessed 10 Nov 1999.)
19.	Department for Education and Employment. National Grid For Learning. www.dfee.gov.uk/grid/ (accessed 10 Nov 1999).

(Accepted 13 October 1999)