Practitioner commentary on Garfield E. The impact of health information delivery on the quality of patient care: whither medical information science? Health libraries review 1985, 2 (4), 159–169*


  • *

    Paper given at the Medical, Health and Welfare Libraries Group Conference, Coventry, 5 July 1985. Reprinted in this supplement, pp. 52–62.


This wide-ranging essay touches on some aspects of health library and information service practice that today's librarians will recognize and some that will provide a jarring note, considering changes in practice since 1985.

Despite the US setting of Garfield's perspective, many in the UK can relate to the topic of library services under threat. It may not be the direct threat as described in the article, with the removal of a legal obligation to provide library and information services (LIS); in the UK the familiar Health Services Guideline HSG (97)471 still requires that NHS staff have access to effective library services. However, LIS in this country are susceptible to the same financial pressures that affect all health-care organizations.

Meeting information needs

Garfield begins with the ‘key question’ of whether hospital libraries are necessary for health-care professionals to keep up with current medical trends. He suggests that the exponential growth of information, of itself, does not justify hospital libraries. It is the ‘need for more specific information that makes libraries, indexes and especially librarians more relevant’ (p. 160).

This rings true in 2008 where access to information is no longer the specialist province of library professionals. Routes to the knowledge base are made easier with summary resources such as systematic reviews and guidelines. The National Library for Health (NLH)2 is just one provider of customized and personalized portals to information.

Garfield describes a range of service delivery methods to meet the need for specific, patient-related research information, including models such as Clinical Medical Librarianship (CML) and similar outreach services, well established in the US in 1985 and gaining acceptance in the UK in more recent years.

His essay illustrates how such outreach services are adapted to best fit clinical requirements. Variation in practice occurs based on the urgency of the information need or the profession of the information-seeker. This reflects the multidisciplinary approach and the widening user base in UK outreach services.

Garfield's description of CML services extending their practice to meet the information needs of patients and families illustrates ‘recognition by the medical community of the consumer's growing participation in health care and the individual's right to make informed decisions about care and treatment’ (p. 165). In an information literate society, providing information on treatments to patients often feels like a new phenomenon but clearly it is not.

Divergence from the US prototype to match UK needs is explored by Garfield, referring to early NHS projects. More recently a UK 2005 survey3 of such services identified 25 such practitioners, probably an underestimate of the current position in 2008. The recent Review of NHS Library Services4 links the Clinical Librarian role to that of ‘Team Knowledge Officer’ which it recommends to ensure that the research evidence base is embedded in everyday practice; an opportunity for libraries to be central to the ‘flow of information from the research front’ (p. 160).

An interesting commentary on our role as librarians is that we provide a balanced perspective on medical issues. As clinical librarians we are aware of differences in clinical opinion and can act as ‘honest brokers’ of information to guide final decisions.


Inevitably, it is in the area of information technology (IT) where Garfield's essay seems the most dated. The use of personal collections of references as an ‘auxiliary memory’ feels like an anachronism. A personal file might contain research that has been superseded and online access provided for NHS staff should make such a resource redundant.

Garfield expected a slowly increasing use of computers for organizing information. He refers to librarian ‘fears of automation’, reassuring the profession that physicians training in literature searching are better clients for literature search services. We would agree and our experience is that training end-users and also offering literature search services can work successfully in tandem.

We now know that the use of personal computers (PCs) and other technologies has dramatically expanded. Further, librarians have taken a lead in using IT and exploring, for example, mobile technologies such as Personal Digital Assistants (PDAs)5 to take research evidence to where it is needed.

What Garfield does not identify is the expansion of computers to include multimedia and the influence of e-learning on continuing education. Librarians are combining their knowledge of IT systems and software with their educational role in developing online learning (e-learning) for teaching and learning.6

Online social networking, blogs and RSS feeds make current awareness alerts (referred to as ‘SDIs’ in the article) not only easier for the end-user to set-up but, with tightly focused content output, they can fulfil the need for specific information identified in 1985.

Garfield does however, foresee the advent of native language searching, the interaction between clinical and information specialists, and the capturing of organizational data (i.e. knowledge management). He also describes the creation of ‘expert systems’ predicting decision support systems such as Map of Medicine.7

Value and impact

Garfield makes no reference to the term ‘evidence-based’, which was not used in a published article until 1992.8 But he was clearly aware of the concept and the thrust of his essay is about the importance of getting research evidence to the frontline and proving the value of LIS in bridging the research–practice gap.

He identified the need in 1985 for LIS to provide regular quantitative evaluations of their services and supplies us with useful references that could support current funding bids. He specifically describes the need for evidence of effectiveness, cost-effectiveness and cost–benefit. This is a target that is equally relevant9 (and equally difficult to achieve) today.

Evidence-Based Library and Information Practice (EBLIP) encourages librarians to extend evaluation, using methodologies which provide stronger evidence. Such evaluations have proved a formidable task considering the role of confounding factors in influencing outcomes10 and the problems with recruitment to LIS studies.11,12

Recent reviews repeat Garfield's messages and encourage us to include the direct effect for patients among the outcome measures13 while re-emphasizing the need for value and impact studies.14

We hope that the NHS Libraries Review recommendation that ‘Library’ should figure within the naming of NHS LIS will mark the end of what Garfield calls the ‘semantic problem of calling an information-switching centre a library’ (p. 160). This is still a problem today with librarians aware that funding decisions may be made based upon outdated models of LIS.

Marketing our services and justifying LIS has risen up our agenda. Comparing research questions suggested by librarians in 2001 and in 2006,15 the domain of marketing/promotion ranked higher in 2006 (18.5%, equal second with education) than in 2001 (1%) when it ranked lowest.

The messages in Garfield's essay still resonate strongly today. We have made some progress but most of the issues remain.

Conflicts of interest

LW, SS, PD and LH have declared no conflicts.