Cornerstones for the new millennium
Defining our terms
Cornerstone is defined by rhe Oxford English Dictionary as "one of the stones forming the salient angle of a building" , and notes that it is used figuratively "in respect to its function in consolidating the building". Cornerstones are symbols of permanence and their special durability lends cost-effectiveness to the whole edifice as cheaper materials can be used as in-fill; they define boundaries. As we approach the start of the third millennium, how appropriate are such things to the health information profession? How well will we be served by each of these qualities?
Permanence is a traditional library virtue: apart from the Papacy and two parliaments, all the enduring institutions of our culture are universities - each with a library as its heart. And the librarian as unimaginative, hawk-eyed guardian of The Collection is a staple of English-language culture, at least. This quality is still an important element of what we contribute to the scholarly process, and this paper will return to it below, but we have to incorporate our traditional regard for the immutable into our management of change.
The pace of change in medical information is a cliché but its reality is never more clearly evident than at biennial conferences such as CRICS, where we find that a huge proportion of the professional context has changed during the two-year cycle and where most of from the preceding proceedings has the same familiar but distant atmosphere of a novel written 25 years ago. Torrential change is irrigating the social context in which we operate as well as our professional lives. A couple of examples:
-. The 24-hour society: The concept of "normal office hours" is beginning to seep away in the UK. Banking and other retail financial services are becoming phone-based and open all hours and the consumer expectations raised by these information-based services are permeating into commodity-based retailing, with internet shopping already commonplace at least among the information-rich.
-. Life-long learning: A broad social phenomenon doubly relevant to us as information workers active in medicine. Lifelong learning is a key element in the UK government's modernisation of the UK economy; and in medicine it is being helped along by the evidence-based medicine movement and its policeman cousins clinical audit and recertification of qualifications.
-. Distance-independent services: The telecommunications revolution has already changed the economics of all transactions that do not require face-to-face contact , making geographical separation a minor or irrelevant consideration. This is particularly true of information delivery, and we can expect it to spread (for example in telemedicine) into areas where previously the assumption was that such contact was essential.
-. Niche markets: The economics of information and production technology are running in favour of products and services tailored to specific and relatively small groups of users. One size fits all national services are increasingly under pressure from small, nimble and perhaps not individually very long-lasting competitors.
One of the most important implications of these changes is that the traditional filters (wealth, intellectual merit, plausibility, etc) no longer regulate access to worldwide publishing, and that the contextual quality cues have to be relearned and are anyway much less straightforward than in print. Everyone who uses the net can produce glorious examples of the flexibility of human understanding, but most of us have probably also been fooled at least for a time.
As professional information workers we also face new problems from artificially raised expectations among our users. "The Information Revolution" is an easy route for journalists with a column to write and a deadline to meet, and our users are constantly fed more or less fanciful pictures of a world where every item of information they want or need is available on the web, easily and instantly findable by any sensible literate person, and free. Perhaps more worrying is that electronic information systems foster a largely fallacious illusion of competence on the part of the untutored user. It is a rare library user who appreciates how difficult it is to conduct a thorough, effective literature search, and doctors may be particularly poor at appreciating that what they have retrieved is a small and probably slewed subset of the available information. The BMA's Medline Plus search service opens with a Health Warning on this very issue.
However, in some important respects the speed of change itself, and the consequent fluidity of the information environment, make the traditional library virtues of permanence and continuity more important than ever. Who has not turned to a familiar and trusted web resource and been greeted with the dreaded Error 404 - denoting that the information is no longer available either at this address or anywhere. Publishers have always been the worst people to trust to maintain their own archive, and the fact that the availability of most web information is ultimately dependent on whether the originators have paid the annual rent for their web space only makes this more acute. One of the key strengths of most research libraries, and certainly of the BMA, is the cumulative and cumulating knowledge amongst the professional staff of what is available and what can be found. It is obvious that, while the nature of the web makes this more difficult and time-consuming to maintain and develop, it becomes more valuable as an asset to the library and its parent organisation. Finally, the plastic nature of electronic information resource raises issues of document integrity which simply did not arise in print media. The continuation of the conventions of academic life make it essential that proper audit records be kept as "published" documents change and evolve:
-. increasingly documents on discussion lists develop a life of their own through the modern equivalent of Socratic dialogue
-. there is an increasing danger of meddling, by the authors or others, with the "standard" text, perhaps to update, backdate or merely correct data, or maliciously or mischievously to discredit them
-. there is also the danger of formats and standards, for example the resolution and colour registration of embedded graphics might be crucial in supporting the document's conclusions and when viewed on a workstation unable to support these elements may give rise to incomprehension or entirely wrong conclusions.
However, impermanence is a fact of contemporary life, and one which we must ride in order to ensure that our profession survives. It is a commonplace to say that we are in a situation of paradigm shift, and one which is a considerable understatement. The situation is more one of a paradigm grand prix: every three minutes or so another 22 paradigms come flying past, it all happens too quickly for people to take it in, the paradigms always seem to be more or less the same - and if you carry on watching for long enough you begin to see patterns emerge and develop a veneer of understanding what you see.
No Clear Destination
It is the contention of this paper that the process of change is too new for us to predict the outcome. The switch from steam to electric power in manufacturing industry gives a very good analogy. When factory machinery was powered by steam, the only viable methodology was to have one large steam motor located centrally, and to power the workbench equipment by an elaborate system of drive shafts, pulleys and belts. For mechanical efficiency the drive shafts had to be as near to the machines as possible, which created cluttered, dark, low-ceilinged workshops. When the conversion to electric power took place, what happened was simply that the large steam motor was replaced by an equally large electric motor and the drive paraphernalia stayed in place. It was only over decades that it was realised that the best way of utilising electric power was to have a small electric motor on each machine, thereby opening the way to lighter, airier factories and orders of magnitude growth in the flexibility and mobility of manufacturing processes within the workshop. The change was not technological, it was an evolving understanding of the implications. In terms of information publishing, we are still at the stage where we are trying to tweak better performance out of the impressive new large electric motor we have installed. Although it is safe to predict that the evolution will not take five or six decades to bring about truly fundamental change, we are no better able than those early electrical engineers to predict the fundamental implications of the change process we are so enthusiastically fuelling.
Some things are becoming clearer, for example the fundamental changes to the cost structure of library services, with the marginal cost of service provision approaching zero in many cases. But the dilemma remains: it is not easy to plan a journey when the destination is undiscovered and the means of transport have not yet reached alpha testing?
Stage one is to seek to define the destination, even in vague conceptual terms. For medical librarians, this has been nicely encapsulated by Jeremy Wyatt into what he calls The Thing: "An electronic system designed to combine the recording and retrieval of clinical information with the delivery of best evidence to the clinician's desk top in real time as part of the consultation". Clearly, our profession's contribution will only be a part of what is required; equally clearly, without our putting our profession's expertise behind the development the end result will be either impossible, much delayed or far less effective than it could have been. So how do we start:
-. As with a major home improvement enterprise, we start with what's easy, with what we know we can do.
-. Adopt sensible planning horizons: in the present situation we should have a good idea what our development plan is for one year ahead, some working hypotheses for the 1-3 year period and perhaps a general outline for 3-5 years. Our working plans should reflect this state of affairs and not look into the unknowable with artificial and insupportable omniscience.
-. It is important not to move so radically that you travel out of sight of your users' understanding of what a library should be. Few things damage confidence in a library more than a reputation for out-of-control wildness.
-. Plans should keep technological and service options open. Nimbleness of mind and action is a prime virtue in our professional environment.
-. Collaboration is utterly essential, both at a tactical level with libraries combining their resources to serve their readers better and at a strategic level where our professional institutions are essential in the political and legal battles with vested interests that the paradigm changes will throw up.
The second element in the meaning of cornerstone is that of the definition of boundaries. We need to define, for example, the components of The Thing that are the responsibility of our profession: the organisation and presentation of knowledge, its safeguarding, some components of the identification of quality in information, in-depth follow-up documents.
Methods and technologies change, but values and professional ethics persist. As a profession we have an impressive record of achievement and our collective virtues and strengths have a lot to offer as familiar conceptual landmarks slip out of sight behind us.
-. First among these is a largely unthinking integrity and honesty in our approach to our work; librarianship embodies what is most admirable about the publlic service ethic.
-. Librarians are exceptionally receptive to their users' needs and preferences, exceptionally non-arrogant about our place in the health care delivery process.
-. We are unusually collaborative in major projects and minor everyday detail: for example the amazing, and amazingly effective worldwide network for document identification, location and delivery.
-. As a profession we also tend to be inexpensive. Sadly.
Neither the publishing nor the computer industries can compete with us on these grounds.
We can and should seize the moral high ground in developing the future of medical information services; we can and should use our professional ethics as a survival tool. We can do this by continuing to behave and plan in our users' best interests. We can develop the already thriving cooperative spirit and work to strengthen our professional bodies, making them more aware of their role in change management. Above all we should shun the restrictive practices which vested interests so often seek to transfer across technology boundaries and which are such a feature of many electronic publishing ventures. We must work against the hobbling of technology in the commercial interest, for example to "protect" our libraries as physical entities and our technology-determined function as information gatekeepers. Our role will develop and mutate as information itself mutates: uncertainty is a road to travel, not a barrier to cower from.