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As the National Library of Medicine expands access to its products and services by making them available on the Internet, more accurate information about current and future access in medical libraries is needed. The National Network Office of the National Library of Medicine conducted a survey of all network member libraries to determine the extent of connectivity and the barriers preventing 100% connectivity. Respondents called a toll-free number and, using interactive voice technology, answered questions concerning Internet access in their library. Seventy-eight percent of the network member libraries responded. Four percent of academic libraries, 27% of hospital libraries, and 10% of "other" libraries reported that they were not connected. Computer cost, lack of in-house expertise, and lack of management support were the highest ranked barriers to connecting. The National Library of Medicine and the Regional Medical Libraries will use information from this survey to develop strategies to help all member libraries achieve full connectivity.

Community hospitals in rural and isolated areas have had little access to the Internet. In 1992, the National Library of Medicine funded a pilot project to be conducted by the University of Washington and seven community hospitals in the northwestern United States. The goals of the project were to connect the hospitals to the Internet and study the uses made of this resource. A number of administrative, technical, financial, and organizational problems were dealt with in the attempt to establish the Internet connections and introduce this resource to these health care settings. This paper examines these issues and presents conclusions drawn from the experiences of the project team.

In 1992, as part of its high-performance computing and communications initiative, the National Library of Medicine decided to provide health sciences institutions with Internet connection grants similar to those offered to universities by the National Science Foundation. Although library involvement is not required, librarian and library uses have been the most common category in the applications received.

Network connectivity is critical in Arizona, where travel distances are great, academic programs dispersed, and health care practitioners often geographically isolated. Accordingly, the University of Arizona (UA) applied for $50,000.00 in National Library of Medicine/National Science Foundation (NLM/NSF) Connections Program funding to promote statewide collaboration in supporting UA's health sciences education and research programs by expanding network connectivity to hospitals and other health-related institutions. The proposal outlined three strategies: Each major nonuniversity teaching hospital would secure and maintain a leased communications line dedicated to network connectivity, and NSF funds would be used to buy some necessary hardward. NSF funds would be used to establish a modern bank for dial-up Internet access by rural practitioners and teaching sites. Co-principal investigators of the project would promote and support the use of this new statewide connectivity and foster its continued expansion. The proposal was based on a conservative philosophy: familiar technologies and, where possible, existing networks and equipment would be used. The proposal was approved, and NSF funds hastened creation of an expanded health information network in Arizona. Once that network was in place, participants moved quickly from managing the mechanics of connectivity to planning for a computing and communications platform with services. Private funds were obtained to help organize the Arizona Health Information Network to direct these expanded services.

Integration of multiple information systems of a medical center will change the way physicians work and practice medicine in the future. Several major steps must be taken by an institution to make this a reality. Since 1983, Georgetown has been engaged in an Integrated Academic Information Management System (IAIMS) project to bring together multiple sources of information that reside on different computers and database systems. Georgetown is developing a Biotechnology and Biomedical Knowledge Network that includes informational and clinical databases, scholar workstations, instruction on computer use, a campuswide network with local area network nodes, and a modular approach to systems integration. The IAIMS project, spearheaded by the medical library, has enabled a broad spectrum of health professionals to benefit directly from new, dynamic information services. The network is heavily used; in 1991, more than 2,100 individual users conducted more than 148,500 computer functions and more than 104,000 searches. There is economy of scale in high-volume use. Overall, the average search cost is $1.57; for high use databases the cost is $0.38, and for low use, it is $9.41. As described in this paper, IAIMS offers a cost-effective means of enhancing patient care by improving information services to physicians. At Georgetown, IAIMS has advanced the concept of integration, accelerated use of computers in education, increased user acceptance of advanced technologies, and established cost factors for providing information resources. While progress made in improving the transfer of medical information is impressive, it is clear that IAIMS requires several more years of support to achieve full implementation.