Authors: Tricia Scolaro and Helen Archer
The Library and Information Service of the Western Australian Women's and Children's Health Service (WCHS) was responsible for the redevelopment of the Intranet. The Intranet is a one-stop shop for the broad range of information required to support the day-to-day activities of the WCHS. This paper outlines the strategic management of the redevelopment and the challenge of maintaining the currency, accuracy and relevance of the information. The provision of interactive training packages and the use of scripted journal passwords to provide wider access to electronic journals while complying with publishers' licensing restrictions will be examined.
While on long service leave in 1996-1997, I visited various hospitals and health facilities in Europe and the United States. I recognised the vast potential of the Intranet and the Internet as a powerful decision support, marketing and communication tool and as a one-stop shop for information to support the day-to-day activities of the hospitals and the practice of evidence-based health care.
I returned from my travels resolved to create a web site for the library and for King Edward Memorial and Princess Margaret Hospitals . The hospitals operate 24 hours a day, seven days a week and an Intranet is an effective way of ensuring staff have access to the information and services they need at all times. The hospitals are situated two kilometres apart and were amalgamated as a government initiative in 1992. In January 2002 King Edward Memorial and Princess Margaret Hospitals and associated institutions became the Women's and Children's Health Service (WCHS) and this is the name that will be used for the organisation throughout this paper.
Soon after my return from the United States we had a staff vacancy in the library so I rewrote the job description to include experience in web page design as one of the selection criteria. We were fortunate to recruit a qualified librarian who had developed an open learning web site in a previous position.
A small Internet site was developed for a fundraising auction that took place during the 1994 visit of Prince Charles to Princess Margaret Hospital. The WCHS is part of a wide area network connecting almost all organisations within the Western Australian Government Health Service (WAGHS) and is protected by a firewall. As the WAGHS encourages the purchase of compatible hardware and software by its organisations, there was a ready made platform for the development of web sites for communication within the WAGHS. The initial Intranet site for King Edward Memorial and Princess Margaret Hospitals was developed by a few enthusiasts from Information Systems, mainly in their own time.
In 1996 Library and Information Services began work on the development of the library web pages. Library staff attended training sessions on the use of Microsoft Frontpage, the software package that was compatible with other software used across Health in WA. In 1998 the library web pages were launched both on the Intranet and the Internet.
The library web pages included:
The library web pages were very well-received by WCHS staff and they raised awareness of the potential value of an Intranet. Staff generally began to discuss the need for the existing Intranet to be redeveloped.
In response to staff pressure in 1999 the Chief Executive asked the Manager of Information Services to look for a company to redevelop the Intranet and later that year a contract was let. A member of Information Systems, a member of the library staff, who was eventually appointed Intranet/Internet Manager, and I worked closely with the software developer to develop the concept plan, design, graphics, navigation and functionality of the Intranet site. The software developers interviewed key personnel throughout the hospitals. An Intranet Committee, which was formed to act as a reference group for the developers, met during the early stages of the project.
The library vision for the Intranet was for a constantly evolving medium that would accommodate ongoing growth and development, where content and accessibility is continually reassessed to meet the changing needs of the WCHS. The Intranet would support decision making and the practice of evidence-based health care and professional practice by providing a platform to distribute WCHS policies and procedures; facilitate access to evidence-based guidelines from recognised organisations and institutions; provide links to key international databases and information sources; link to electronic journals; and provide access to evidence-based resources such as the Cochrane Collaboration.
The Intranet was designed to be self-managing. The Chief Executive had not envisaged that staff would be required to manage the Intranet once it was established and staff had been trained to add material. However, it became clear that staff would be required for the ongoing development and management of the site, so Library and Information Services developed a business case proposing the appointment of an Intranet Manager and Intranet Support Officer. The positions were initially approved for six months and were subsequently made permanent.
The redeveloped Intranet consists of two sections, the web pages and a document management system known as the Document Publishing and Management System (DPMS). As the Intranet is housed on the wide area network, information on the web pages of the Intranet is available to all institutions connected to the wide area network, including almost all hospitals and health services in the WAGHS. The Executive decided that documents in the document management system would be restricted to WCHS staff. Generally the contents pages of policy and procedure manuals are available on the web pages but individual policies are stored in the document management system. It was decided that, as most policies and procedures were hospital specific and were designed for the particular resources and environment of the WCHS, it may not be appropriate to use them in another institution. Procedures considered appropriate for use outside the WCHS, such as Evidence-Based Clinical Guidelines (Obstetrics), are not restricted.
An excellent working relationship was established with the manager and staff of the Information Systems department who provided technical support for the redevelopment of the Intranet. Input was received from the Manager of Information Systems on the development of the business case and job descriptions and the Manager was a member of the interview panel.
Policies and procedures
An Intranet Policy and an Internet Publishing Guide were developed for the WCHS. The Intranet Policy defines primary and secondary clientele; accountability; page owners for the web pages; workgroups for documents stored in the document management system; availability of information; and accuracy, currency and standards for information published on the Intranet.
The Intranet Publishing Guide defines and sets standards for content; the role of the page owner of web pages and workgroups for documents in the document management system; procedures for both web page publication and the addition of documents to the document management system; accuracy, currency and linking; style guides; the thesaurus; and promotion and training.
Keywords in the thesaurus were taken from the National Library of Medicine Medical Subject Headings, Library of Congress Subject Headings and other relevant thesauri. The National Library of Medicine Medical Subject Headings is a standard tool for indexing and is classified as a level three tool by Darmoni . Health professionals use keywords from the National Library of Medicine Medical Subject Headings to search Medline, so they are familiar with the terminology. The thesaurus also incorporates local terminology, eg: hospitals, departments and wards. The software for the Intranet does not allow retrieval under the proposed metadata standard the Dublin Core Metadata Element Set but this should be considered for the redeveloped Internet site .
A copyright and disclaimer statement are added to every page. An initial draft was written, based on the wording used by other Australian sites. The draft was forwarded to the Crown Solicitor for approval and changes suggested by the Crown Solicitor were incorporated. A link is provided to the Copyright Act 1968 .
Regular updates on the progress of the redevelopment of the Intranet and calls for content were e-mailed to Heads of Departments and placed in the monthly New Resources booklet published by Library and Information Services. Presentations were made to the Executive and upper management. At launch the Intranet Manager and I addressed the regular staff lunchtime forums.
Under the contract with the developer, training was provided to staff designated as publishers. Training was later taken over by the Intranet/Internet team.
A news ticker runs across the top of all Intranet pages. The library uses the news area to announce the addition of new electronic books, journals and databases to the Intranet.
Directories available on the Intranet include conferences, consumer information, journals, National Health Data Dictionary, Pathology Test Directory, and the internal telephone directory.
The library maintains the conference pages, which publish details about major Australian and international conferences in areas of interest to staff of the WCHS. A one month archive is maintained.
Journals are listed alphabetically by title and include the holdings for WCHS libraries and a link to the Internet site for the journal. The list is annotated to indicate whether the electronic copy of the journal is available at work-stations across the WCHS, or available in the library only. As more publishers offer electronic access, and the accessibility of electronic journals tends to increase demand, libraries have a growing number of clients requesting electronic access from their work-stations [4-8]. To meet the demand from its clients for both print and electronic journals within tight budgets, the library provides electronic journal access as an enhancement to the print collection. Access is facilitated by print subscriptions that bundle electronic access at no additional cost, free access, and consortium access to BMJ journals.
Managing access to electronic journals
The biggest hurdle the WCHS library faces in the management of its electronic journal collection is the provision of secure hospital-wide access. Of the 148 electronic journals currently accessed free of charge through print subscriptions, over half use Internet Protocol (IP) authentication to control access, with the rest providing access by username and password. The WCHS is prevented from using IP authentication to provide hospital-wide access to electronic journals because it accesses the Internet via a Health Department of Western Australia proxy server, which is unable to provide a unique IP address range reflecting the locations of the WCHS sites. Using the proxy server address would allow all metropolitan and regional health services to access the journals sites, contravening publishers' usage agreements. The assignment of five fixed IP addresses to the library has provided a partial solution to the problem, with access to IP authenticated electronic journals now available in the library.
As publishers show an increasing preference for IP authentication due to its convenience, the access problems experienced by the WCHS and other organisations are unlikely to be resolved unless publishers rethink their usage agreements . Although the model of username and password access promises more opportunities for institution-wide access, the reality is that most publishers place restrictions on how passwords can be distributed, prohibiting their publication on Intranets and web pages. Owing to the difficulty of distributing passwords securely within the WCHS, clients are still required to visit the library to be logged on to many password-controlled journals.
One solution introduced by the library is automatic log-on scripting which provides seamless access to electronic journals across both hospital sites. Scripting is a commonly used procedure for concealing passwords. It involves embedding the log-in information, in this case the journal username and password, in a scripting program which will launch and log-in automatically when the desired electronic journal link is selected. Access is restricted to users logging in from the WCHS Intranet. The log-on process is seamless and users are unable to read the authorisation password. Bishop  concludes that if users are presented with barriers when accessing electronic resources, such as difficult registration and log-in procedures, they will soon lose interest in using the resource.
To determine whether a publisher would be likely to allow scripting and therefore institution-wide access to a journal, library staff consulted the publishers' usage agreements. Generally, the usage agreements were difficult to interpret and most required a request for further information from the publisher. As Edwards 11 notes, 'there seem to be as many definitions of an 'institution' and a 'site' as there are electronic publishers.' Publishers were contacted individually and asked if they could provide a username and password access option and for permission to script the username and password to provide institution-wide access.
The majority of publishers gave permission to script the username and password. The main obstacles encountered included the inability of most publishers using IP authentication to provide a username and password alternative. Some publishers reserve username and password access for personal subscriptions. Those publishers who were willing to provide us with a personal username and password were concerned with security issues as their system would allow any user to access administration information on their site and change the password. Journal web sites where the log-in did not appear on the first page proved unsuitable for scripting because the URL was unstable.
Of the 70 journals currently accessible in the library by username and password, only 14 have been scripted to date. Fortunately these are some of the journals in high demand. Publishers' preference for IP authentication and rigid username and password access control prevents the library from providing institution-wide access to all electronic journals. Furthermore, as Edwards  notes, most publishers are still failing to meet users' early expectations of electronic journals, which is the ability to access them from home.
Online sevices available on the Intranet include an online request facility for engineering services, forms, online learning, library electronic services, and room bookings
The forms area on the Intranet contains over 80 forms including accident/incident reports, admission of a new drug, leave applications, and a staff excellence nomination form. Most forms must be printed off and then completed and submitted. Forms for library services can be completed and submitted online.
Online inter-library loan requests
The library reviewed the procedures for online inter-library loan requests used by other libraries and followed the Australian Library and Information Association (ALIA) guidelines, Electronic signature and library-user requests for document supply . Staff wishing to request inter-library loans online must complete and sign an inter-library loan registration form. They are then issued with a randomly generated PIN that they collect in person from the library on the presentation of their WCHS identification badge. The procedures were approved by the hospital Executive and advice was sought from the Crown Solicitor. The recommendation from the Electronic Commerce Expert Group, Electronic Commerce: Building the Legal Framework  indicates that 'a detailed legislative electronic signature regime is not required at this stage'. The ability to request inter-library loans online has been very well received by WCHS staff.
Library electronic services
Health and medical databases and information sources
As many staff within the WCHS do not have Internet access it is essential that the key health and medical databases and information sources are provided locally. The databases and information sources are housed on a UNIX server within the wide area network so access to the Internet is not required. Three other hospitals within WA have access to the network. The local message area indicates whether a journal is held by one of the libraries in the co-operative. WCHS staff find this very helpful as they know which articles can be obtained quickly. The provision of links from the databases to electronic journals held by the libraries in the co-operative is under investigation.
Access to a number of electronic books is provided to all WAGHS organisations by the Department of Health through their Clinical Information Access Online (CIAO) web site . The library provides scripted access to these electronic books.
The WCHS is a member of the WAGHS co-operative and the online library catalogue is available through the Intranet.
There are three web-based tutorials on the WCHS Intranet: an Intranet Tutorial, an Emergency Learning Package and an OSH Manual Handling eWorkbook. Electronic tutorials enable staff to learn at their own convenience and at their own pace rather than having to book a training session during office hours. This is particularly helpful for staff who regularly work evening or night shift.
The library has commenced a project to translate its paper-based user guide Health and Medical Databases and Information Sources (Ovid) Search Guide into an electronic learning package. Evidence is accumulating that electronic learning can increase access to library education programs, encourage clients who otherwise would not ask for help and accommodate a broader range of learning styles [15-16]. The Ovid software is ideally suited to a web-based interactive tutorial because it allows learners with differing levels of computer skills to progress in a step-by-step linear manner at their own pace .
Prior to the development of the online learning package library staff examined a number of Ovid tutorials available on the Internet  and consulted with staff development personnel to identify:
Carbonaro  states the learning process should be 'individualised, self-paced, and adaptive to the learners' needs.' The tutorial was divided into sections based on the major learning objectives to allow clients with different levels of experience to access only the parts of the tutorial relevant to them . It was agreed that instructions would be sufficiently detailed to ensure the client understands them but not so detailed that the client loses interest. Agreement was also made on the type and extent of graphics and interactive elements to be used. A standardised layout was also determined.
Library staff are in the process of preparing the tutorial in Power Point so it can be evaluated by both library staff and staff development personnel before being transferred to web-based software. The completed tutorial will then be tested on the target audience. Users will be asked to complete an evaluation form at the end of the tutorial so library staff can assess whether the user feels they have met the stated learning objectives.
This area provides annotated links to many significant health science sites of interest to WCHS staff. The links area is maintained by Library and Information Services staff using the guidelines stated in the library publication Selection Criteria for Evaluating Health Related Web Sites. It is our policy to list sites that are from an authoritative source, are regularly updated and provide information which will further the activities and professional development of WCHS staff. Ensuring the quality of links to Internet sites is an ongoing challenge. Library and Information Services staff continually monitor the links for broken links and to ensure the sites listed maintain their quality and relevance.
While Pandolfini and Bonati  concluded from their systematic re-evaluation that the quality of public health information published on the Internet had improved over the last few years, they pointed out the need for ongoing monitoring of the quality of Internet sites. Eysenback, Powell, Kuss and Sa  analysed 79 studies that evaluated the quality of health information on the Internet. Most studies (70 per cent) concluded that quality was a problem on the web, 22 per cent were neutral and only 9 per cent came to a positive conclusion. Criteria used to measure quality included authority, accuracy, readability, comprehensiveness and comparison of information contained on the Internet with that provided by other sources. In a two-year study, the Detwiler Group  discovered that information on health Internet sites is frequently more than a year old and in many instances is several years out-of-date.
Departments and wards
Departments and wards may structure their pages however they wish but are restricted by the software to ten areas. Many wards and departments include a profile, feedback, news services, forms and departmental policies and procedures. The Library and Information Services pages include a Library A-Z, Borrowing, Databases, Journals, Document Delivery, eBooks, Conferences, Intranet/Internet and New Resources.
The policies section contains frequently used policies affecting the majority of WCHS staff, including HDWA policies, Human Resources policies, KEM/PMH Infection Control Manual and an Occupational Health and Safety Manual. Policies relating to specific departments or wards are usually housed on the Policies pages of the department or ward.
The procedures section provides direct access to frequently used procedures affecting the majority of WCHS staff, including the Clinical Practice Manual, Evidence Based Clinical Guidelines (Obstetrics), the KEMH RMO Handbook and the PMH Emergency Preparedness Manual. Procedures relating to specific departments or wards are often housed on the Procedures pages of the department or ward.
The Australian Council on Healthcare Standards (ACHS) is an independent, not-for-profit organisation, dedicated to improving the quality of health care in Australia through continual review of performance, assessment and accreditation. Accreditation with the ACHS is achieved through the EQuIP process. EQuIP is a four-yearly cycle of events with an emphasis on continuous improvement. The WCHS was accredited in March 2002 and in the self-assessment conducted in June 2001 the ACHS commended the management of the Intranet.
Barriers to the use of the Intranet
There are a number of barriers within the WCHS to the use of the Intranet:
In November 2000 Library and Information Services obtained approval to redevelop the Internet site to promote the WCHS as centres of excellence and to be the site of choice for information on women's and children's health. Focus groups were conducted at each site and after extensive consultation with WCHS staff a feasibility study was produced by the Intranet/Internet team and endorsed by the Executive Group in January 2002. Work commenced on a requirements statement for the redeveloped Internet.
In February 2002 the Acting Chief Executive of the WCHS moved the management of the Intranet/Internet team to Information Systems. An Intranet/Internet Working Group was established and the Head of Department Library and Information Services was appointed Chair. The Intranet/Internet Working Group is responsible for the content of the Intranet and the Internet. This arrangement has only recently been formalised and so it is too soon to evaluate its effectiveness.
The Intranet brings together existing WCHS policies and procedures, links to evidence-based guidelines from recognised organisations and institutions, information from the key international databases and information sources such as Medline and from evidence-based resources such as the Cochrane Collaboration. This information coupled with the experience and existing knowledge of the clinician supports evidence-based clinical decision making but accessing and processing this information at the point of care is a very time consuming process. There is some evidence that the practice of evidence-based health care and thus improved patient outcomes can be facilitated by the integration of clinical decision support tools with the electronic patient record [23-24]. The electronic patient record is not widespread in Australia but the work being undertaken in this area may be the next step forward in the evolution of the Intranet.
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18. Ovid Internet tutorials analysed:
Blinn College Ovid Tutorial [http://www.blinncol.edu/...]
Dartmouth: Introduction to Ovid MEDLINE
Duke University Medical Center Library
[Glenfield Medical Library]
Monash University Library
University of Michigan
University of Missouri-St. Louis: Interactive Ovid Tutorial
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