With the installation of the Med-Base CD-ROM (MEDLINE on Compact Disc-Read-Only-Memory) database search services have been greatly improved at the Boston University Medical Center Library. The focus of this paper is the implementation of the Med-Base system. Med-Base is the producer's name for its MEDLINE file. CD-PLUS is the name of the Med-Base system software.

It is not within the scope of this paper to illustrate sample searches or enumerate specific search mechanisms. The emphasis is with the application of the system, its reception by library users, and the overall importance of CD-ROM in medical library reference 'work. I shall also survey the benefits and disadvantages of Med-Base, along with its implications for librarianship. Personally, I have great faith in this particular CD-ROM system. It is a powerful research tool, enabling us to manage vast amounts of information. It is to our advantage to examine the benefits and disadvantages of Med-Base because we place this CD-ROM product in realistic perspective.

The views expressed in this paper are those of the author. They should not be taken to represent the views of an institution with which he is associated.

The purpose of this paper is to contribute to the literature on database searching, and the impact of CD-ROM technology. I believe that librarians and information providers should advance new technologies and work to improve the effectiveness of information services. Our profession is dynamic, it is not static. It is imperative to master our environment and prepare for the challenges of the next century.

2. DATABASE SEARCHING AND ITS RELEVANCE TO THE MEDICAL CENTER

Database searching is a marvelous aspect of the post-1945 world. Enormous amounts of information are stored on databases and compact discs. This has enabled librarians and recently non-librarians, the ability to manipulate large databases through the formulation and execution of complex search strategies. With the advent of CD-ROM medical specialists are able to access biomedical literature without troublesome telecommunciations delays. These optical discs have had a positive impact on the methods of biomedical information management (Wertz, 1986).

Throughout the past ten years the health care industry in the United States has experienced a period of tremendous change. To put it simply, these changes have created new demands for accurate information. The management and delivery of information has become a larger issue for librarians. As a result of these changes libraries now serve a broader clientele of users (Hafner, 1986).

Database searching has become an essential activity of medical center employees. All health professionals rely on the availability of accurate information to make informed health care decisions. One searcher has written that the information received from journal literature has had a direct positive impact on patient care (Dabanovic, 1985). Another health care provider has reported that the use of the MEDLINE database has played a key role in the treatment of clinical problems (Haynes, et al., 1986). Because of the new demands for current information, health care professionals now write about database searching in the major medical journals. These users are knowledgeable, and sophisticated in the use of various online systems.

The value of the health professional espousing the virtues of database searching cannot be overstated. One could cite dozens of articles that have appeared in the medical, pharmaceutical, dental, and nursing literature. Database searching has truly been popularized. Naturally the arrival of CD-ROM technology is a part of this trend. The drawback to this" popularization" of searching is that many end-users may not exploit their chosen databases to the fullest potential. They may ignore other databases and other retrieval methods. The librarian remains an expert and consultant for many health care end-users. The popularization of searching is a welcome development. Users have developed a greater appreciation for the information process.

CD-ROM, as Garfield stated, is "another step on the way to the World Brain" (Garfield, 1988). This technology has not yet fully been realized. Naturally the information you are reading in this paper will become dated in a short time. We should welcome the development of the "World Brain" for several reasons. The need for international cooperation, cross-cultural understanding, and resource exchange is important not only for the world scientific community, but also for the relaxation of international tensions. The role of information in this regard is so important that its accessibility and storage is possible only through more improved technologies. The importance of well-informed decisions based on powerful systems is crucial to the survival and welfare of our societies.

3. A BRIEF OVERVIEW OF THE HISTORY OF MEDICAL LITERATURE IN THE USA

Throughout the past 150 years the National Library of Medicine (NLM) has played a leading role in the dissemination of medical and health related information. A cause for this vanguard role was the change that medical practice experienced during the last half of the nineteenth century. Physicians began to look at their world differently. The tradition oriented profession transformed itself into one that questioned everything, and sought solutions through experimentation. A scientific revolution had already occurred in Europe and returned to the United States with new ideas (Davies, 1986).

Medical education began to model itself on the German system. Practical instruction was emphasized in contrast to didactics. Books and journals became a component in this process. The educator William Osler stated that: "A physician who does not use books and journals, who does not need a library, who does not read one or two of the best weeklies and monthlies, soon sinks to the level of the worst cross-counter prescriber..." (Osler, 1897).

During the post-1945 period it became apparent that published information was not reaching the health care practitioners. In 1965 the U.S. Congress passed the Medical Library Assistance Act. It was from 1965 onward that the NLM became a "proactive" rather than "reactive" institution. The Assistance Act, signed by President Johnson, provided for the development of medical library programs, the application of new technologies, and the creation of the Regional Medical Library Network. As a direct result of this Assistance Act, more than 4,000 health science libraries are now utilized by health professionals and others (Davies, 1986). The NLM and its Regional Medical Library Network have become "the central nervous system of American medical thought and research" (Bean, 1982).

The NLM has also developed an impressive international reputation. It serves as a catalyst for projects, a role model to be emulated, and a supporter of international libraries and institutions (Smith & Janson, 1986). As of 1987 there were MEDLARS centers in 16 foreign countries (Mehner & Leiter, 1988). The MEDLINE file has enjoyed both national and international success. Naturally the MEDLINE file became an early candidate for optical storage on Compact Disc. In 1988 there were at least five producers of MEDLINE on Compact Disc.

This is the historical context within which MEDLINE on CD-ROM evolved. It is important to consider this history because it enables us to place Med-Base in context. The commitment to quality medical information has a solid history, involving many different people.

4. HOW AND WHY MED-BASE WAS CHOSEN BY BOSTON UNIVERSITY

Because of an increased demand for online searching, and the desire by librarians to offer a search system at no charge, the library purchased a subscription to the Med-Base system in the Fall of 1988. One may ask: why no fee for the user? American society has always been committed to the principle of an informed citizenry. Libraries have offered "free" services to fulfill this end. Libraries do not exist to make profit. In fact they are unprofitable enterprises. Hence, the application of this technology in a library that serves schools of dentistry, medicine and public health is obvious. The informed library user makes better decisions about patients and the general work environment.

The Med-Base system was selected for several reasons. The eight discs represent the entire MEDLINE database since its inception in 1966. There are two search levels: menu and command driven. Additional features include save search options, downloading onto floppy discs, and special administrative features. The producer, Online Research Systems, Inc., provides monthly updates of MEDLINE under the subscription agreement.

The implementation of this technology has been a success. Success is defined by user satisfaction. Physicians, students, nurses, dentists, faculty, and others have used the system with skill and satisfaction. In some cases those who once distrusted computers now return with friends and colleagues to demonstrate their new computer skills.

As a librarian involved in public services it has been satisfying to listen to users compliment the system, and to observe their enthusiasm. New technology has not meant the "death of the library;" on the contrary, users now return to the library staff for assistance and new reference questions. End-users will require even more assistance in gaining access to information (Aveney and Conneen, 1986). CD-ROM is a positive development for libraries.

5. HOW MED-BASE OPERATES

The Med-Base (CD-Plus) operates on an eight disc system. The entire MEDLINE database is covered since 1966. Discs are updated each month to coincide with the National Library of Medicine's monthly update schedule. MEDLINE covers over 2,500 serials from the biomedical, dental, and nursing subject areas. This is the world's premier biomedical database because of its superior indexing with the Medical Subject Headings (MeSH). The entire MEDLINE database consists of approximately five million citations.

Med-Base allows users to execute searches on two levels: menu or command. Users are able to search abstracts, sort, merge, and save their searches. Another popular function is the downloading of information onto DOS formatted floppy discs. Thus users may create their own mini-databases in their offices, laboratories, or homes.

Searches may be executed by subject or natural language. The CD-Plus software has been structured so that natural language is mapped to proper MeSH headings. Author, title word, unique identifier code, journal name, and chemical registry number searches are also available. The producer of this CD-ROM product has done a commendable job in creating a software that enables users to understand MEDLINE without sacrificing advanced search features.

The CD-Plus software executes searches in less than 15 seconds. This software supports all CD drives currently on the market. In addition to this CD-Plus also supports the new generation of faster and smaller "half height" CD drives. With these new drives it is possible to equip a standard PC XT or PC AT with one floppy drive, a fixed disc, and one or two internal CD-R0M drives.

Obviously the first item of importance is the CD-ROM drive. The first general CD-ROM drives such as the Phillips CM100 or Hitachi 1502 have an average access of l.4 seconds. The second generation drives such as Phillips CM 121, CM 201, CM 131, Sony 510 or 6100 series, or Toshiba 2100 are almost three times faster than the first generation drives

A second important item is the RAM disc. The RAM disc board plugs into an expansion slot inside the computer. This board usually contains l to 8 megabytes of memory and can imitate a hard disc. The CD-Plus software will use a RAM disc (it must possess at least two megabytes) for temporary storage. Here one may perform such functions as print to disk, explode MeSH terms, and standard Boolean operations.

The CPU is also an important consideration. On the low end is the 8086 or 8088 CPU found in the IBM XT or XT clone, with a relative speed index of 1. At the high end is the PC based on the 80386 chip with an index of 15 or higher (15 times faster than a PC XT). The 80386 CPU used in the CD-ROM workstation has an index of 18 (18 times faster than a PC XT). It is important to remember that these numbers relate only to CPU processing. Overall searching speed is determined by the relative speed of all components.

The producer of this product assisted us with a great amount of advice to insure proper installation.Questions have been answered by the software developer directly over the telephone. Service has been satisfactory. When we encountered the problem of a scratched (malfunctioning) disc, a replacement was sent without charge within three days.

6. THE SUCCESS OF MED-BASE IN OUR MEDICAL LIBRARY

After daily use for a sixth month period it is safe to assert that the Med-Base CD-ROM research tool has greatly enhanced the bibliographic retrieval process. Users have signed up for virtually all available time slots and have continued to remain enthusiastic about this system. Because of the power, speed, and overall flexibility of Med-Base, it is easy to understand its popularity. Since CD-ROM is time-shared, all telecommunications delays have been eliminated. Med-Base usage has become so popular that users now sign up for time slots a week in advance. In the future the library may wish to purchase a "jukebox" to enable several users to search at one time, thereby decreasing heavy demand during peak usage periods.

7. THE END-USER AND MED-BASE

Med-Base is currently free of charge to all students, faculty, technicians, and other institutional personnel within the medical center and the university. The medical center consists of two teaching hospitals, schools of dentistry, medicine, and public health. A mental health center is also affiliated with the university, as well as several other area hospitals. It is no exaggeration to state that the library is a very busy place in which to work. The diverse array of users allows for many challenges.

All users may schedule an online database search appointment with a reference librarian. During these sessions the librarian formulates and executes the search for the client. The total cost of the search, plus a 20% surcharge is passed on to the client.

Despite the installation of Med-Base, this service is still in great demand. The implementation of Med-Base has alleviated some pressure from the librarians to perform database searches. Greater order has been introduced into the work environment.

As stated above, users schedule themselves for use of the MedBase system. Users may reserve a thirty minute time period on a first come basis. Because of this, many users have become aware of time constraints and the need to construct logical and efficient search strategies. Librarians, expert in the use of the system, are often consulted for assistance.

Through the continued use of this powerful research tool, users have developed various degrees of sophistication. In all cases, users have acquired an appreciation of searching, and view the library from a new viewpoint. The library is perceived as an information provider.

Sophisticated or experienced users present librarians with new challenges. Those who require intricate explanations of NLM indexing policies provide intellectual stimulation. Both librarians and users develop new levels of mutual respect and cooperation. The search process is realized for what it has always been: a dynamic interactive process. The end result is usually user satisfaction.

Initially most first-time Med-Base users require a brief introduction to the Med-Base system. During a five to ten minute period the librarian acquaints the user with the search process and structure of Med-Base. Naturally instruction varies depending on the sophistication of each user. Users are almost highly elated with the system, and return again to conduct searches. Because of a small reference staff it has not been possible to offer formal classes on the use of Med-Base. Individual demonstrations are always provided to the first time user. Individual sessions are very effective because of the diversity of users, and the logistical impossibility of assembling a group of people together for a class or demonstration. The individualized session can become time consuming for the librarian; however it allows genuine two-way communication between user and librarian. In an individualized session the user is free to ask specific questions relating to his research.
 

8. THE DISADVANTAGES OF THE APPLICATION OF MED-BASE

As with any research tool, certain disadvantages are associated with the Med-Base system. The system itself is not in error. Its application and usage does present the library with some questions to be resolved. Fortunately the disadvantages of the system are not serious. With an increased awareness of the library's overall services, some disadvantages shall be overcome.

Because we live and work in a period of increasing economic difficulty and change within the health care system, the demand for accurate and effective information has increased. Health sciences librarians are under pressure to provide services to an expanded clientele (Hafner, 1986). Librarians and information specialists are sensitive to the information requirements of their clientele.As stated above, the application of a time-shared system such as Med-Base has augmented the information retrieval process. With the "atomization" of information, users have developed a better understanding of the electronic information process. (Aveney & Conneen, 1986).

This CD-ROM product performs very well. Through successful performance, user expectations have greatly increased. Users are already anticipating greater enhancements. However, some users actually expect too much from CD-ROM. This technology has become "the" resource to consult. This is a somewhat dangerous development. The CD-ROM is still only one tree within the library forest. To focus solely on one resource at the expense of others obscures the real goals of information retrieval. Librarians are able to access hundreds of databases through the BRS, DIALOG, MEDLARS (NLM), and STN online services. Obviously not all of the additional databases have been placed on CD-ROM. For example the sister files of MEDLINE (TOXLINE, POPLINE, BIOETHICSLINE, etc.) are not available on CD-ROM. Perhaps it will be some time before they appear on optical disc. These are smaller files and have not been as widely used as MEDLINE. Nevertheless, these sister files are extremely important to health sciences researchers.

It has been the author's experience to discover, in conversation with many experienced library users, the ignorance over the definition of MEDLINE. Many have been led to believe that MEDLINE is the only search system available to the biomedical community! This is unfortunate because the user is cheated. He pays the price through ignorance. My point here is to identify a problem that has a solution. To ignore the vast number of additional databases handicaps the library user and underutilizes our excellent array of resources. To conclude this point, one must remember that a wealth of information exists in books, audiovisual materials, and within indexes that cover the pre-online periods. The reliance on one particular tool is unproductive for various users. For example, a medical geneticist may need to examine the sociological literature in addition to the biomedical literature. As information providers we must be aware of all conventional and unconventional research strategies to assist our clients. Since each client has different needs the intellectual challenges become greater for the information provider.

9. ADDITIONAL CONSIDERATIONS FOR LIBRARIANS

An additional problem encountered as a result of the Med-Base implementation has been the secondary user. Should secondary (non-institutional affiliated) users be allowed access to this system when competition for time slots is already very intense? Outside users do use the library; on occasion they consume considerable reference staff time with their requests. One medical school branch library survey showed that 51% of reference transactions involved institutional non-affiliates (Landwirth, Wilson, Dorsch, 1988)

With increased societal demands for information, the growth of the secondary user will continue to be considerable. Librarians and administrators need to be aware of the conflicts between primary and secondary users. Policies and guidelines should be developed to allocate services based on institutional realities and the local role of the institution.

Librarianship is an intellectual enterprise combining physical resources, communications systems, and people. The impact of CDROM technology on our profession has been positive largely because we control and advice this resource. As Erika Love noted: "we need to determine not what is technologically practicable, sensible, economic and humane." Furthermore, if we are to remain a profession we must "...control and advance the state-of-the-art" (Love, 1987).

The challenges posed by the information age require us to remain current and keep abreast of new developments. In order to remain an effective profession we must master our world. Our command of resources and our knowledge will enable us to accomplish this task.

10. CONCLUSION

With the acquisition of Med-Base my library has renewed its commitment to quality information retrieval. To put it simply, the library has gained "great face" within the institution. The library has returned to its role as information provider. CD-ROM users have realized that librarians care very much about their research. The success of the health care professional is mutually dependent on the success of the librarian. Cooperation is essential. It is exciting and rewarding because knowledge is increased on a daily basis.

The utilization of this CD-ROM system has obviously been a great success for many reasons. A larger group of library users now appreciate the power and flexibility of database searching. Perhaps the greatest evaluation of the system came from an experienced faculty member involved in the preparation of a comprehensive review article for publication: "This is a God send. It is so flexible, and it saves me so much time!" The Med-Base (CD-Plus) CD-ROM system is a great asset to reference services. The advantages of its application far surpass any disadvantages.

I trust that this paper has provided the reader with additional insight into the benefits and drawbacks involved in the implementation of a CD-ROM system in a medical center library.

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