RX for Medical Libraries

Last March 17 in the New England Journal of Medicine, two articles posited the future of medical libraries. I expected MEDLIB to buzz about them, yet no one even started a chat thread. By one reading, in 2015 there will be large libraries with fantastic techno-goodies, e-resources, and lovely space. My big medical library brothers and sisters will be around, but what about the little libraries in community hospitals or small university-affiliated hospitals? In the past two years I've seen dozens of libraries closed or outsourced, five go to reduced hours, four combined, over a dozen librarian positions eliminated, and the birth of the Super Library Tech—who runs the library but doesn't need to have an MLS. I'm worried that Thomas Lee's “Quiet in the Library” (one of the articles) forebodes the quiet wake of the small medical library.

There are now approximately 2900 hospital libraries and an estimated 4000 staffers working in them, and they are at risk. As I see it, there are four main threats to medical libraries: deprofessionalization, a failure to do outreach, a shift in the culture toward McInformation, and ongoing budget crunches. We must cope with all of these now to ensure the survival of small medical libraries and the well-being of healthcare itself.

The biggest factor placing these libraries in danger is deprofessionalization. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, a.k.a. the Joint) does not require a professional librarian to oversee the provision of information services or the library itself. It just says that a hospital must have information service available. Yet the Joint expects the hospital to provide effective services for other departments with someone from those fields. For example, the head of nursing must be a nurse practitioner with experience in the field. Guess what? Because the Joint expects this standard to be met, it is. If management knows it can get accreditation without a degreed librarian or an actual library in place, then it has no incentive to provide either.

Librarians have the time to keep up with the information explosion—especially uncontrolled in the medical field. They know which resources are out there and can tune in to the needs of the hospital and its staff. Doctors and other staff don't have the time or specific training to do their own reference work. Also, many online titles are embargoed—not available until certain dates. What if your online package doesn't have the journal a doctor needs? You'll need to have it loaned from another library that has it. If libraries do not exist to do this work and to take advantage of the power of joining a consortia, the doctor may go without the requested journal.

Outsourcing information services, a popular stopgap, does not guarantee quality or that the service will always be there when needed. Librarians must make management realize that online packages that bundle books and journals on one web site, like MDConsult—no matter how attractively promoted—are not on a par with complete information services. They are one size fits all and do not address local needs.

As information professionals, we should expect and ask that when JCAHO comes to review the hospital, they visit the library. Then we can illustrate how necessary the library is to the hospital. We can let the Joint and hospital management know that with our expertise, we can bring information services to hospital staff better than any outsource option and with a better budget.

Budgets pressures are bad, but we are worse at justifying them to management. We need to talk in terms of “return on investment.” Detail how your service saves the hospital money. Show how your information services reduced cost of care with a better drug or procedure, prevented a patient adverse event, or saved staff time. One search, for example, reduced “length of stay” by two days, saving $1000 in hospital costs. The legwork of one librarian saved 40 minutes of staff hours at X cost per hour and freed up 40 minutes of patient care time. A patient understood his instructions and condition better, so one visit instead of two was required, freeing up 30 minutes in the clinic for patient care. Using MS Excel and MS Access, start generating regular cost distribution reports on library work, showing savings to the clinical departments.

Don't stop at gathering this information, however: report back to management on how the library helped. Give a library value statement to management such as, “I saved you $X” or generated specific revenue, or satisfied a need that would have “cost” you X in dollars or time. Tell management in their language why they need you.

Outreach is where librarians have the most control over the positive impact on services to patients, staff, and management. Medical librarians tend to sit in their offices on their search thrones and say, “I work only with the doctors.” Well, this mindset needs to change, now. There's a consumer health revolution out there, backed by a National Library of Medicine National Institute of Health directive to meet patients' health information needs. Librarians, you must connect with patients. An informed patient has less stress, complies with instructions, and heals better than an uninformed one. They also become less of a tort risk if they feel they are involved in the healthcare process.

To get patients into the library, have hospital staff get the word out that there is a library and that patients are welcome to use it. Suggest to the doctors or nurses that they write up an InfoRx referral for a visit to the library to talk to the librarian and hand them a sample of what one might look like. Some patients think the library is only for the doctors. Visit patients in the waiting rooms or hospital rooms and ask what they need to know. Use the free consumer health resource MedlinePlus to provide consumer health information.

You can market library services with bookmarks on trays, attached to prescription bags, or in envelopes with letters to patients. Tie these efforts in with health observances on conditions, like May for Mental Health Month. Put up posters, flyers, and bibliographic lists on related topics in specific clinics, like cardiology. Have your hospital's phone message system or in-house television system note there is a library with staff there to help. Participate in community-oriented hospital programs and family support groups. Would it hurt to have a coffee hour from time to time? How about a paperback swap? A real winner, this draws patrons in and gives you an opportunity to ask the important question, “Can I help you?” People readily bring in what they have read to exchange for something new. And if you run low, you can usually get free books from what's left over from the local public library book sale.

Consider yourself the part of the healthcare team that is in charge of consumer health information services and act accordingly. Have a holistic family outlook to providing information, by helping patients' families with some of their questions. Make it standard practice that for each visit with a patient to provide consumer health information, a chart note goes into the medical record as a “consumer health information consult.”

Don't forget to network and be a resource for the local public library's consumer health collection. In turn, have the public librarians refer their patrons back to you for specific help. Consumers need an experience other than that of a stuffy medical librarian who only works with doctors. Always let management and the chief of staff know your contact hours in this area.

Outreach to clinical and nonclinical staff is more important than ever. Expand the library beyond the library space. Create face time with your customers in their arena. Send a welcome letter telling each new staff member what services are available. Start doing document delivery to their offices with a friendly, “Hello, need anything else?”

Your presence at meetings around the hospital provides a personal face to the library. Be sure to read minutes and peruse the hospital intranet to see what is going on, and visit each department as often as possible. Again, be proactive, and whenever you see an opportunity to fill an information need, go for it. Participate in medical center goal sharing and in-house activities whenever possible.

Be there for grand rounds or morning report to deliver search expertise or articles. Remember LATCH–Literature Attached to Charts? This can be tooled into SSATCH–Search Strategy Attached to Charts. Execute SDI's, library lingo for a regularly run literature search, on a doctor's favorite topics or trends.

Extend these efforts to programming. Establish a “Search Clinic—The Librarian Is In,” every Friday, when folks are winding down and catching up. Have periodic search classes with PubMed, and market interlibrary loan service at the class. Host a search blog or Wiki seminar for staff to discuss difficult searches and solutions.

To meet staff where they need the library most, keep in touch by pushing hot topics with RSS feeds from web sites about specific medical conditions. Or, scan WebMD's free daily email for popular medicine articles and forward them with a personal message that tells them to stop in for more.

As with management, be proactive with the clinical staff, especially those who are involved with quality patient care issues. Often the clinical staff is so busy putting out daily fires they don't have the time to be preventative. Your expertise and assistance can be most beneficial here. Provide information on FDA warnings, best practices, the ORYX performance measurement, standards, guidelines, patient incidents or sentinel events, and torts. Free web sites to use are firstgov.gov, fedstats.gov, www.cdc.gov, www.patientsafety.gov, psnet.ahrq.gov, and www.fda.gov. Don't forget to check web sites of your local state health department, specific organizations, or accreditation agencies that deal in these areas.

We must redesign the medical library experience for the customer. Librarians can shine as the techno-geek resource for computer questions. Your databases, Internet, MS Office, citation manager software, and PDAs, just to name a few, are tools you can use to be invaluable as a “hotline” for help. Establish instant messaging for people to ask questions without coming to the library. Send them messages on their handhelds. Be a resource for techno-poor staff by loaning out PDAs, laptops, or handheld mobiles. Try answering some nonmedical questions for staff, or their children, using a few free Internet resources like refdesk.com, lii.org, ipl.org, or the reference section of www.yahoo.com.

Are you doing periodic information audits in both the clinical and administrative services? Don't just buy recommended titles on a list without checking to see what folks need. If the hospital is trending toward outpatient care, then so should your collection. The library will die if no one is using it.

Librarians can take advantage of other opportunities for a different kind of outreach by creating collateral duties working with the hospital web, satellite services, continuing medical education support, grants writing, public relations, patient representative, or projects with the director's office. These extras show that you are not isolated, stuck in the book world. Remember, team players are not usually let go with a budget cut. You can do much of this work in the library, which will in turn help keep it open.

McInformation has the hardest impact. Customers want information delivered as fast as their burgers. The Internet is touted as the infinite ultimate library, though uncataloged, uncontrolled, and often unquality. And there doesn't seem to be the mindset to read and research these days. Often I hear from clinical staff, “I don't have time,” or from students, “Hey, I can just cut and paste this section into my paper.” McInformation, express research, is a dangerous practice. The word to senior staff is, get them into the habit of lifelong learning: read, write, publish.

So librarians, reach out and give people a place to be with resources and a friendly environment. Be proactive. Show them you are the portal to the information world. I fear, if you don't, the prognosis for small medical libraries is terminal