<span class="padlock_text"></span> v23 #6 Immersed in Patient Care: Mission Critical Decisions for Hospital Libraries

by | Feb 13, 2012 | 0 comments

by Patricia A. Hammond (Health Sciences Librarian, Sentara Potomac Hospital)

Since World War II, healthcare in the U. S. has improved dramatically. Successful public health initiatives, like a clean water system and widely available vaccination programs, have added years to our life expectancy.  So much so that Eric Plasker promotes his book and seminars about “the One-Hundred Year Lifestyle.”  Medical research, both government and privately sponsored, plus advancement in technology have led to earlier diagnosis and more accurate treatment options.  With improved health of the population, growing governmental regulation of the healthcare industry, and the managed care approach to cost reimbursement, the role of the hospital in the healthcare delivery system has evolved.  No longer just a “healing place” for the critically ill, hospitals offer a gamut of inpatient and outpatient services.


In the U.S., the National Library of Medicine (NLM) coordinates an organized network of biomedical libraries to help fulfill its mission to collect, organize, and make available biomedical information for scientists, educators, health practitioners, and the public.  Within NLM, the National Network of Libraries of Medicine (NN/LM) office is charged with advancing medicine and improving public health by providing all U. S. health professionals with access to biomedical information.1  Through contracts with eight regional medical libraries, the NN/LM promotes and delivers NLM products and services.  The eight regional programs invite participation in a nationwide network of biomedical libraries.  The library networks are formal and well-organized.  A participating library or organization completes a membership form and must agree to fulfill the responsibilities of members.  Four types of network memberships are outlined.  One type is “primary access libraries.”  “Primary Access Libraries include hospital libraries and all other Network member libraries that generally represent the health professional’s first point of access into the Network.  These libraries serve health professionals who plan, manage, and provide health care as well as teachers and students in these areas.”2  These libraries are not affiliated with academic medical centers.  The collection development function in hospital libraries is greatly influenced and supported by NN/LM network infrastructure.

There is no consensus about the definition of a hospital library.  They are more varied in size and scope of services than most academic libraries.  They are found in major research hospitals, specialty hospitals, military hospitals, veterans’ affairs hospitals, healthcare systems, and community hospitals.  Their core clientele are hospital staff and medical staff (physicians and surgeons).  The two largest user groups are medical staff and nurses.  Some libraries also provide service to medical residents, health professions students, researchers, patients, and/or the general public.  Hospital librarians’ expertise includes the medical and related literatures, medical terminology, and a working knowledge of the healthcare delivery system.  They must relate as readily to a patient with mental illness as to a surgeon performing a procedure when their patient experiences an unexpected outcome.  Many hospital libraries are staffed by one person.  Solo librarians are literally responsible for all library operations — and more.

Flying Solo

The sense of urgency in patient care drives the fast pace in hospitals.  Since direction and operating goals in the hospital setting change rapidly, assessing user need and prioritizing daily tasks are daunting.  Librarians in a one-person shop are accomplished jugglers.  Some solo librarians have organizational responsibilities in addition to library services.  These nontraditional library roles may include coordination of the continuing medical (physician/surgeon) education (CME) program, information technology, health information management, hospital archives, patient education, or management of medical media.3  A survey of hospital librarians done in March 2011 revealed that they served on 122 types of hospital committees.  The committees listed on the survey were divided into nine categories — administration, clinical, education, facilities, human resources, nursing, research, support services, and technology.  Not only do librarians provide valuable input and support for these committees which maintain the relevance of the library, but they glean information from their colleagues that contribute to resource selection decisions.4

Collection Development

Collection management in this environment is a delicate balancing act between planning for the acquisition of the necessary basics and providing other resources just-in-time.  Providing the right combination of purchased print and online resources while staying “on budget” is a formidable task.  In the hospital environment, the revenue-generating departments and services tend to get greater financial support.  Since libraries are not revenue-generating, financial support is usually minimal.  As with other types of libraries, hospital libraries do collection-use surveys and strive to convert print subscriptions to the pricier online version whenever possible. “Virtualization” of library services is the most important trend.  Because the libraries are embedded within the hospital environment, the most frequently encountered barrier to expansion of library services are restrictive Information Technology (IT) policies and practices. The barriers range from a lack of IT staff familiarity with educational needs and applications to an overly protective firewall and network security system based on concerns about privacy of patient records.  Another barrier is medical and hospital staff reluctance to use online resources. Some hospital librarians hesitate to proactively convert their collections to an online format because of negative feedback from their clientele.  Most medical and nursing staff leaders finished their terminal degree before online library resources were commonplace.  Also, private practice physicians are independent businesspeople who manage their own offices.  There are still physicians in our community that have no office fax machine and do not use email for business purposes.  In 2011 it became a requirement that all Sentara Potomac Hospital (SPH) employees receive and use a Sentara email account.  It is a new requirement for SPH nurses to check their work schedules and other work-related information via their hospital email account.  Hospital-wide use of computer systems for work-related activities and information sharing is new for many staff at our hospital.  Realizing the situation in hospitals and physician practices, the federal government established funding through the Health Information Technology for Economic and Clinical Health (HITECH) Act to encourage and support use of Electronic Health Record (EHR) systems.  Implementation of EHR systems is propelling forward computer usage by health care providers and providing a mechanism for linking online library resources within the patient record.5

For many years, a mainstay tool for collection development in the health sciences was the Brandon-Hill lists.6-8  The three lists contained book and journal titles by specialty.  After these lists ceased publication in 2003, Doody’s Core Titles (http://www.doody.com/dct/) filled the gap for a recommended book list when it began in 2004.  In addition to this commercial service, many sections, including the Collection Development Section, of the Medical Library Association offer recommended core lists on their Website (http://www.mlanet.org/sections/sections.html).  Some of the topics covered are consumer health, dentistry, chiropractic medicine, and pharmacy/drugs.  When selecting journal titles, the Institute for Scientific Information (ISI) Impact Factor is a consideration.  Typically in health sciences libraries, 75-80% of the budget is spent on journals, and only 20-25% is spent on monographs.  Hospital user demand is for the most current patient care information.  Because of this need and limited physical space, many hospital libraries keep back issues of journals for no longer than ten years, which makes a good argument for converting to online subscriptions when possible.  Many do not bind journal issues.  To ensure access in the NN/LM Southeastern/Atlantic Region for member libraries to older materials, the Print Collection Retention and Access Ad-hoc Committee was formed to coordinate an organized approach as libraries downsize their physical space.  Through DOCLINE, NLM’s automated interlibrary loan (ILL) request routing and referral system, members of the NN/LM network have a fast and effective document delivery system.9  A boon for small libraries is FreeShare, a cross-regional library group for DOCLINE libraries that participate in free, reciprocal lending.10  Related is an Electronic Transfer of Funds Service (EFTS) from the University of Connecticut Health Center Library for DOCLINE members when charges are incurred for interlibrary loan.11  EFTSmember libraries open a deposit account that other members can draw down when an ILL charge is assessed.  This service eliminates the need for local processing of invoices.

In hospitals, justifying large expenditures for online resources is difficult, and shepherding license agreements through the approval process is challenging.  In a recent survey of NN/LM Southeastern/Atlantic Region (SE/A) hospital libraries, 51.6% of the respondents said that they participate in a consortium or group purchasing arrangement to acquire access to electronic resources.  Consortia are comprised of local, statewide, or regional heath sciences libraries that band together for a group buying discount.  Another type of discount purchasing arrangement is available through a hospital’s affiliation with a multi-hospital health care system.  Hospital librarians are interested in group purchasing arrangements that save both time and expense.

In most hospitals, online resources are purchased from more than one vendor and a variety of approaches are used.  One approach is to subscribe to aggregated databases.

The NN/LM SE/A survey of hospital librarians revealed that 94.9% of the respondents subscribed to the Cumulative Index to Nursing and Allied Health Literature, making it the most popular online resource.  When possible, subscribers also opt for the version that includes full-text journals.  Another type of approach is to purchase a packaged collection of books or journals.  The second most popular resource identified in the survey was Wolters Kluwer’s OVID E-journals.12  OVID offers several packages of online biomedical and nursing journals.  Subscribing to a package is convenient to manage, but too often titles that are not needed are included, which is not economical.  Smaller libraries often opt for the “a la carte” approach which allows for the flexibility of selecting specific titles but takes more time to manage.  Multiple invoices must be paid, and Internet connectivity with several publishers must be maintained.

Members of the hospital and medical staffs frequently submit requests for new books, journals, or other online resources.  Most requesters are unaware of the large “institutional” subscription rate that libraries must pay.  Library Journal reported the average price for a journal subscription in the Health Sciences to be $1,398 in 2010.  Librarians frequently explain the “cost benefit analysis” concept to requesters.  A reality is that if a medical subspecialist requests a journal title, it is unlikely that the library will add the subscription if only a handful of staff will use it.  On the average, nursing books and journals are much less expensive.  Ready access to vendor COUNTER (Counting Online Usage of NeTworked Electronic Resources) statistics is essential for renewal of online resources.  At urban and suburban community hospitals, it is not uncommon for the physicians and surgeons to be on staff at more than one hospital.  Referring them to a librarian at another hospital where they are on staff is another facet of cooperation among biomedical libraries.  This practice enhances the medical staff’s access to online library resources.  It can also influence collection development decisions.


The key to success in deploying changes in library services is a proactive, comprehensive user education program.  Regularly scheduled group presentations can be done by the librarian during CME events, nursing orientation, and nursing skills fairs.  Departmental, leadership, and committee meetings are excellent venues for linking discussion items to relevant library resources.  Participants in employee health fairs and hospital support groups appreciate information about consumer health resources.  In hospitals, the path to user education is more closely aligned with that in the public library than in academics.  Hospital staff is encouraged to use library resources, but clearly this is not an expectation.  Because some staff rarely use library services, it may be efficient for the librarian to do searches for them.  The trend in hospitals toward 100% productivity of the patient care staff means that it is more cost-effective for the librarian to spend time finding, summarizing, and reporting requested information.

Looking forward, converting to online subscriptions whenever possible is necessary.  Integrating these resources with the EHR will provide instant access to relevant medical literature for health care providers.  Increasingly, hospital library users carry handheld devices and request access to library resources via mobile platforms.  Subscribing to resources that offer mobile applications provides bedside access for busy clinicians.

In today’s health care climate, it is difficult for small community hospitals to survive independently.  A mode of survival is to merge with a larger, multi-facility healthcare system.  The process of a merger presents many new challenges and opportunities to a solo librarian.  Melding computer networks and resources with a new organization is akin to starting over with a new employer.  The individual hospital’s Web presence disappears, and Web pages must be integrated within the new health system’s existing Web portals.  Careful deliberations transpire to design the best fit for a new Web presence.  Working with librarians at remote locations to decide what to keep and what to cancel is a different approach to collection management.  Selection of resources that are best for the whole healthcare system, while maintaining essential resources for local clientele, adds a new dimension to collection development.


1.  Sandra M. Wood, ed., Introduction to Health Sciences Librarianship (New York: Haworth Press, 2007), p. 18.

2.  National Network of Libraries of Medicine Southeastern/Atlantic. “Network Membership,” http://nnlm.gov/sea/services/membership.html (accessed on July 11, 2011).

3.  Sandra M. Wood, ed., Introduction to Health Sciences Librarianship (New York: Haworth Press, 2007), p. 357.

4.  Rebecca A. Birr, Kathy Zeblisky, April Aguinaga and David Drachman, “The T-shaped Librarian Rethinks Librarians’ Roles in Hospital Settings,” Poster presented to the Annual Meeting of the Medical Library Association, Minneapolis , MN, May 17, 2011.

5.  Patricia A. Hammond, “Hospital Library Summit Addresses Challenges and Solutions,MLA News 51, no. 4 (April 2011): pp. 16 -17.

6.  Dorothy R. Hill and Henry N. Stickell, “Brandon/Hill Selected List of Print Books and Journals for the Small Medical Library”, Bulletin of the Medical Library Association 89 no. 2 (April 2001): 31-153.

7.  Dorothy R. Hill and Henry N. Stickell, “Brandon/Hill Selected List of Print Books and Journals in Allied Health”, Journal of the Medical Library Association 91, no. 1 (January 2003): 18-33.

8.  Dorothy R. Hill and Henry N. Stickell, “Brandon/Hill Selected List of Print Nursing Books and Journals”, Nursing Outlook 50, no. 3 (May-June 2002): 100-13.

9.  U. S. National Library of Medicine. “DOCLINE System,” http://www.nlm.nih.gov/docline/ (accessed July 12, 2011).

10. National Network of Libraries of Medicine, “FREESHARE – Free Reciprocal Interlibrary Loan Group,” http://nnlm.gov/rsdd/freeshare/ (accessed July 12, 2011).

11.  University of Connecticut Health Center, “EFTS the DOCLINE Billing Component,” https://efts.uchc.edu/Common/index.aspx/ (accessed July 12, 2011).

12.  National Network of Libraries of Medicine Southeastern/Atlantic. “A Recent Snapshot of Hospitals’ Electronic Purchasing Habits in the Southeastern Atlantic Region,” SEA Currents http://nnlm.gov/sea/newsletter/2011/07/a-recent-snapshot-of-hospitals%e2%80%99-electronic-purchasing-habits-in-the-southeastern-atlantic-region-2/#more-5325 (accessed July 27, 2011).

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