Stories

D-Lib Magazine
May 1999

Volume 5 Number 5

ISSN 1082-9873

The Virtual Naval Hospital

Lessons Learned in Creating and Operating a Digital Health Sciences Library for Nomadic Patrons

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Michael P. D'Alessandro, M.D. (Corresponding author*)
Department of Radiology
University of Iowa College of Medicine
Iowa City, IA
 [email protected]

Donna M. D�Alessandro, M.D.
Department of Pediatrics
University of Iowa College of Medicine
Iowa City, IA
 [email protected]

CAPT Richard S. Bakalar, MC, U.S. Navy
Telemedicine Department
National Naval Medical Center
Bethesda, MD
 [email protected]

LT Denis E. Ashley, MC, U.S. Naval Reserve
Office of the Chief of the Medical Corps
United States Navy Bureau of Medicine and Surgery
Washington, D.C.
 [email protected]

Mary J.C. Hendrix, Ph.D.
Department of Anatomy and Cell Biology
University of Iowa College of Medicine
Iowa City, IA
 [email protected]

*Correspondence should be sent to:
Michael P. D'Alessandro, M.D.
Department of Radiology
University of Iowa Hospitals and Clinics
200 Hawkins Drive
Iowa City, IA 52242-1009
319-356-3394
Fax: 319-356-2220

 

This project was funded initially by a grant from the United States Navy Space and Naval Warfare Systems Command, Agreement Number N00039-96-2-0001 and is funded currently by the United States Navy Bureau of Medicine and Surgery.

Abstract

To meet the information needs of isolated primary care providers and their patients in the United States Navy, the creation of a digital health sciences library was proposed. The creation of the digital library was heavily influenced by the principles of user-centered design, and made allowances for the nomadic nature of the digital library�s patrons and the heterogeneous access they have to Internet bandwidth. The result is a digital library that has been in operation since 1997, that continues to expand in size, that is heavily used, and that is highly regarded by its patrons. A number of valuable technical, personal, and political lessons have been learned about delivering digital library services to nomadic patrons. The most important of these is that to succeed in the design and implementation of a digital library, regardless of the field of endeavor, one must focus consistently on the population served and what their mission is, and tailor the digital library to their needs. If this is done, the result will be a tool that is heavily used and sincerely appreciated. These lessons learned will become increasingly valuable as society moves towards a ubiquitous computing environment.

Mission

In educational circles, learning is increasingly recognized as a life-long process of apprenticeship [1,2,3,4]. Health care providers commonly generate questions about their patients but rarely have the time to seek answers to the questions because they lack convenient access to authoritative medical information at the point-of-care [5,6]. Similarly, patients require health information to live healthy lives and prevent disease, to learn how to access the health care system when they are ill, and to learn about diseases they may have [7].

The Internet offers the potential to allow convenient access to authoritative information at the point-of-care [8]. However, the majority of the information on the Internet is poorly organized [9], growing rapidly [10] and of questionable authority [11]. Today, emerging Internet digital library technologies hold the promise of bringing order to this chaos, thereby helping the Internet to meet the information needs of medical apprentice learners.

The mission of the U.S. Navy�s Medical Department is to 1) support the combat readiness of the uniformed services and 2) promote, protect and maintain the health of all those entrusted to their care, anytime, anywhere [12].

Navy primary care providers are among the most geographically isolated health care providers in the world, and rarely have convenient access to authoritative medical information. The Navy therefore has a strong interest in using information technology to help provide specialty expertise to primary care providers at sea to enhance diagnosis and treatment of complicated medical problems in order to help maintain combat readiness. From this interest the Navy has introduced telemedicine technology at sea [13] and desired to use digital library technology to provide primary care providers convenient access to authoritative medical information at the point-of-care. The Navy approached digital library researchers at the University of Iowa, who had a history since 1992 of providing digital library services to isolated rural primary care providers and their patients by the Virtual Hospital digital library [14]. The Navy wished to leverage Iowa�s expertise and lessons learned to deliver digital library services to isolated Navy primary care providers and patients at sea.

Thus, the Virtual Naval Hospital (http://www.vnh.org) was born, with a mission of creating and curating a digital health sciences library to make the Internet a useful medical reference tool for Navy primary care providers at the point-of-care and a health promotion tool for Sailors and Marines. The great challenge of this digital library project was to deliver digital library services to a nomadic patron population on the sea, under the sea, in the air, and in the field who have heterogeneous access to Internet bandwidth.

Challenges

Community Served
The U.S. Navy and Marine Corps currently consists of 324 ships and three active and one reserve Marine divisions. At any one time, 33% of these ships are forward deployed at sea, and another 20% are at sea undergoing training. During the 1990�s, the Navy and the Marines have been called upon to respond to an international crisis on the average of once every four weeks [15]. The Sailors and Marines on these ships are men and women from the ages of 17 to 55, but consist primarily of 17-25 year olds who are healthy, active people. The size of the communities in which they live and work can range from 100 Sailors on a submarine to 6,000 Sailors and Marines on an aircraft carrier.

Primary Care Providers
At the core of Navy medicine are its primary care providers who practice on ships, on submarines, with aviation squadrons, in the field with Marine battalions, and in Navy medical clinics and hospitals. Their responsibilities include primary care as well as preventive, occupational, and environmental medicine. Their medical training varies widely; from corpsmen who undergo 12 weeks of medical training and operate under the supervision of a more senior primary care provider; to the Independent Duty Corpsman, a senior corpsman with several years experience who obtains an additional 12 months of medical training and usually operates as the senior primary care provider on smaller ships; to Medical Officers who are physicians who have completed 4 years of medical school and 1-4 additional years of primary care and specialty training and who are the senior primary care providers on larger ships such as amphibious assault ships and aircraft carriers, as well as for aviation squadrons and Marine Corps battalions.

Medical References
All Navy ships, aviation squadrons, and Marine Corps battalions, by regulation, are required to have a standard print medical library. In some instances, shortages of space and funding result in incomplete or out-of-date print medical libraries.

Computer and Communication Capabilities
This highly nomadic force has heterogenous computing assets and access to Internet bandwidth in their medical departments. Most medical departments have personal computers with CD-ROM drives, and many Navy primary care providers purchase their own state-of-the art laptop computers and employ this technology while at sea. Today, at one end of the bandwidth spectrum, approximately 24 ships (amphibious assault and aircraft carriers) have reasonably predictable and continuous access to the Internet and Web browsing while at sea. This access is dependent upon operational theater, mission, and command support. This bandwidth is provided by a satellite link [16] and 1.5 Megabits per second of bandwidth are available. Most of the bandwidth, however, is devoted to "line" or operational use, so, at best, the medical department is given access to 128 kilobits per second of bandwidth, and often they are given no access to bandwidth at all. For the remaining 300 ships and primary care providers serving with Marines in the field, access to the Internet and Web browsing is very limited. Intermittent access to the Internet and Web browsing is available when in port or in barracks, or if they have access to non-standard issue portable satellite telephones such as those from Iridium (Iridium, Washington, DC) or INMARSAT (INMARSAT, London, England). Continuous Internet access and Web browsing capability may be available for these platforms in the future, using a combination of commercial and military satellite links, but it will be many years before all receive access to such bandwidth.

The Approach

Previous work identified a number of barriers to primary care provider use of a digital library [17]. The Virtual Naval Hospital digital library was designed to overcome those barriers by determining what patrons need, building what they want, and delivering a useful tool in a form that nomadic patrons can use anywhere, regardless of their computer or communication capabilities.

User-centered Design
User-centered and learner-centered design principles guided the creation of this digital library [18]. Navy primary care providers' and patients' information needs at sea were determined by a literature-based needs assessment. The 80 most common medical problems encountered at sea were identified, along with the 25 most important health promotion topics applicable to Sailors and Marines. An interview-based needs assessment with Navy primary care providers was then performed as a "reality check" and corroborated the findings obtained from the literature [19].

Content for the digital library was obtained by identifying U.S. Navy and U.S. Government medical manuals which covered the previously defined 80 most common medical problems and 25 most important health promotion topics. Because the manuals were all published by the U.S. Government and contained non-classified information, their content was in the public domain. All manuals, in paper or electronic format, were converted into Hypertext Markup Language (HTML) files.

Content for the digital library was also obtained by identifying authoritative and easy-to-use medical Web sites. The following criteria were used for World Wide Web site selection:

  1. The site was selected by a process of peer review by accreditation, because accreditation models are designed for works that change over time. To become accredited, a site must clearly display four core quality standards:

    1. Authorship, including the author's name, affiliation, and credentials.
    2. Attribution of facts through the listing of references.
    3. Disclosure of site ownership and sponsorship.
    4. Currency of the site, listing dates of content posting and updating.

    5. The site must be free to use, in part or in whole.

    6. The site's information must be primarily in HTML format so that it can be read by patrons with the lowest common denominator World-Wide Web browser.

    The information architecture of the digital library is problem-based, allowing patrons to quickly and easily find answers to their medical questions. A personalized view of the Internet was created for primary care providers (http://www.vnh.org/Providers.html) by linking the 80 most common medical problems seen at sea to the authoritative medical information in the resources previously cited. The primary care provider�s page also contains links to information on health promotion, occupational and environmental health, medical procedure descriptions, MEDLINE, continuing medical education courses and administrative references. A personalized view of the Internet was created for patients (http://www.vnh.org/Patients.html) by linking the 25 most important health promotion topics to the authoritative medical information in the resources previously cited. The patient�s page also contains links to information on first aid and consumer health information references.

    As part of a process of continuous quality improvement, evaluation of the digital library is ongoing. Web server log file records are analyzed using the log file analysis programs Analog 1.2.3 (University of Cambridge Statistical Laboratory, Cambridge, England) and Wusage (Boutell.Com, Inc, Seattle, WA). Patron feedback is encouraged and obtained via electronic mail and an on-line comment form (http://www.vnh.org/cgi/CommentVNH.pl). As part of a formative evaluation, several small groups of primary care providers were surveyed after using the digital library. A larger, summative, longitudinal survey of primary care providers' use of the digital library is currently being performed.

    The day-to-day operation of the digital library is overseen by the digital library�s Digital-Librarian-In-Chief at the University of Iowa (M.P.D.). The Virtual Naval Hospital is hosted out of the University of Iowa�s Electric Differential Multimedia Laboratory. A Specialty Advisory Board composed of U.S. Navy medical specialists provides operational input and review by identifying new authoritative U.S. Navy and U.S. Government medical manuals that should be digitized, as well as new authoritative medical Web sites that should be linked to the digital library. Prioritization oversight regarding content to be digitized comes from a single point of contact in the Office of the Chief of the Medical Corps, U.S. Navy Bureau of Medicine and Surgery (D.E.A.). Strategic planning and operational oversight will be provided by a new review board which is currently being established.

    Digital Library Architecture
    The hardware and software architecture of the digital library is built upon open Internet and World Wide Web standards that allow for scalability, interoperability, and modifiability as the information in the Virtual Naval Hospital is expanded and new computer and communications hardware and software technologies become available. All digital library documents are stored as HTML files, and adhere to a uniform style convention that minimizes the use of graphics to ensure that navigation within the digital library is clear [20], quick [21], and that patrons may have confidence in the information they are reading [22]. Images are stored as GIF and JPEG files. The repository for all these documents is the World Wide Web, where they are indexed and made free-text searchable by the Glimpse search engine (University of Arizona, Tucson, AZ). To ensure redundancy, the digital library has backup sites at the University of Iowa, the Naval Medical Information Management Center in Bethesda, Maryland, and at the Naval Management System Support Office in Chesapeake, Virginia, which currently supports a small but growing number of intranets on Navy ships via the Intranet Web Services program.

    Nomadic Considerations
    To allow access to the digital library when the patron does not have continuous access to the Internet available, a caching strategy was developed that would be technologically durable, readily understandable and easily implementable by patrons who were assumed to have limited computer skills and no access to technical support. A CD-ROM mirror of the digital library was created, which can be used as a locally cached version of the digital library on nomadic patrons� personal computers. Over 4,000 copies of this CD-ROM mirror are produced annually and distributed to every Navy primary care provider.

    The Results

    The project began on October 1, 1996. Five months later, after initial research, design, and creation, the operational prototype of the digital library was launched on March 1, 1997. Since inception the digital library has grown from 1 megabyte of content comprising 1 digital textbook and 525 links to authoritative medical Web sites, to its current size of 80 megabytes of content comprising 40 digital textbooks and 1,094 links to authoritative medical Web sites. The digital library and its CD-ROM mirrors are currently available on every Navy ship, submarine, aviation squadron, medical clinic, hospital, and Marine battalion. During recent conflicts in Southwest Asia and the Balkans, the digital library proved critically useful for care of deployed service members.

    Overall usage of the digital library has grown at a steady rate since launch (http://www.vnh.org/Misc/Statistics.html). The digital library is currently being used by over 1,250 patrons per day, who read over 100,000 pages of information on the digital library each month. Although a broad spectrum of information is accessed, the most commonly read medical reference and health promotion pages in the digital library consist primarily of the most common medical problems seen at sea and the most important health promotion topics. The digital library, therefore, is providing patrons with the information they need. From the server log file data and from analyzing e-mail to the digital library, approximately 56% of patrons are from the U.S. military, 30% are U.S. civilians, and the remainder are foreign nationals.

    The digital library clearly fills a previously unidentified and therefore unmet need for authoritative medical information at the point-of-care. It gives convenient access to such information to populations who have traditionally not had such access before, such as junior corpsman and -- most importantly -- patients. The small size of the digital library on board ship is an added bonus. More importantly, information can be quickly loaded onto the digital library in times of conflict and rapidly disseminated to the fleet. In the case of the conflict with Iraq in the fall of 1997, when there was again fear of chemical weapons being used against U.S. forces, the relevant medical manuals were quickly digitized and loaded onto the digital library. Finally, the digital library can accommodate a breadth of information that is much greater than that which could be accommodated in the confined spaces of the print library onboard ship. This was brought to light in the winter of 1998 when, again facing conflict with Iraq, Navy primary care providers in the Persian Gulf were able to review Combat Stress Control psychiatric information, which was on the digital library but was not part of the regulation print library, to assist in counseling efforts for Sailors and Marines before they faced combat for the first time.

    The digital library receives an average of 13 comment forms per month from patrons. These contain a mix of questions, corrections, suggestions, and praise for the digital library. The praise from feedback forms (http://www.vnh.org/Misc/FanMail.html) as well as independent reviews (http://www.vnh.org/Misc/Reviews.html) express overall satisfaction with the digital library, and demonstrate that the user-centered design technique has placed the digital library squarely "in the ballpark" of being able to meet patrons� information needs.

    Lessons Learned

    Lessons learned are categorized as technical, personal, and political.

    Technical
    1. The Primacy of User-Centered Design - In short, if one does not give patrons what they need, a digital library project is over before it begins. The initial needs assessment led to the development of the problem-based interface that allows digital library patrons to change their usage paradigm of the Internet from one of Web surfing to one of problem solving. The information in the problem-based interface is essentially "pre-surfed" for them; thus they are usually never more than three clicks away from the home page to the answer to their question. This feature -- that it helps patrons quickly and conveniently find answers to questions they otherwise would not have time to pursue -- allows for the seamless integration of the digital library into their work flow and, consequently, gives patrons a compelling reason to use the resource. Knowing patrons� needs initially, and keeping in touch with them by feedback as a form of continuous quality improvement, ensures that the digital library remains accessible to them and relevant to their needs.

    2. Digital Library Architecture for Nomadics: Less is More - Once a digital library had been created to which patrons wanted continuous access, the next challenge became how to deliver it to them, given their highly nomadic nature and the heterogenous nature of the bandwidth available to them. Focus was placed on determining what would be the minimum level of technology needed to support the patrons in accomplishing their mission. The result was a technologically simple digital library architecture, using lowest common denominator Internet standards and information architecture style standards. This simple solution, however, is the digital library�s true power, for the simplicity of the solution allows the digital library to be truly cross platform and machine independent. Caching CD-ROM mirror copies of the digital library locally with patrons that can be copied to any other form of magnetic or optical media, ensured that all patrons have a baseline level of digital library functionality that can be enhanced as they gain access to communications bandwidth. This ruggedized or "Milspec" digital library can be deployed on any computational platform that has a Web browser and allows for the graceful degradation of a patron�s interactions with the digital library. If the patron has continuous access to the Internet, they can access the digital library Web site exclusively; if they have no access to the Internet, they can access the locally cached CD-ROM mirror copy of the digital library exclusively; and if they have intermittent access to the Internet, they have many intermediate options for raising their communications antenna, having a quick look around the Internet for the up-to-date information they need and, once they find it disappearing again off the Internet, using the locally cached CD-ROM copy of the digital library.

    3. From Simple Systems, Powerful and Complex Behaviors Can Emerge - Ultimately, a digital library should be more than an electronic bookshelf -- i.e., what one extracts from a digital library should be far different, and better, than what is put into it [23]. Initially, this digital library served as a digital bookshelf, in that what patrons got out of the digital library -- digital books -- was exactly what had been put into it. Eventually, through the expansion of the problem-based interface, what patrons began to extract from the digital library was far different, and more useful, than what had been put in. The prime example of this is the Medical Planning and Medical Intelligence section. Today, Navy and Marine forward-deployed expeditionary forces may go into action with very short notice. The Medical Planning process is necessarily compressed, with little time to obtain formal classified intelligence. The Medical Planning and Medical Intelligence portion of the problem-based interface (http://www.vnh.org/Providers.html#42) aggregates a large number of informal, unclassified, open source intelligence resources both within and outside the digital library. In many instances, these references are superior in quality and ease of access to their classified counterparts [24]. This simple aggregation of content into a problem-based interface clearly leads to a whole which is much more powerful and complex than the sum of its parts. The value of this content aggregation, the result of careful and considered curatorship, was foreseen in the first article on digital libraries [25] and, with the advent of the World Wide Web, has been rediscovered and reconfirmed [26].

    Personal
    1. Key Intermediary - People, not technology, are the key to making a digital library project work. A digital library project needs a key intermediary to succeed, a multidisciplinary person who can interact with the different constituencies involved and translate between them. In this project, the Digital-Librarian-In-Chief served as the key intermediary. This individual�s background includes computer science, medicine, and digital library research, coupled with a rich knowledge of the history and current state of the U.S. Navy. He was able to quickly assimilate the important issues facing U.S. Navy medicine and was able to establish personal relationships with all the constituencies involved. He meets with them regularly, and serves as the single person accountable to them to solve their problems and implement their suggestions.

    2. Situated Training - Publicity and marketing is crucial if potential patrons are to learn about the tool built specifically for their needs. Convincing patrons to use a digital library in their daily work is very personal. Once they learn of the digital library, a tour of it should be offered that will serve to guide them through how the digital library works (http://www.vnh.org/Misc/Tour.html). This tour should function as a situated training exercise, such as a scenario, to emphasize the relevancy of the digital library to their daily work, thus giving them a compelling reason to return and use it in the future. It is always better for patrons to be pulled, rather than be pushed, into the technology.

    3. The Long View - At the beginning of a digital library project, most participants do not understand what is trying to be accomplished. Patience is a virtue when trying to convince others of one�s vision. What may be clear to you is for others only a hazy light that with time will brighten. Therefore, stick to one�s original ideals and use quality as the guiding principle in all matters.

    Political
    1. Autonomy versus Supervision - One of the reasons for this digital library�s initial success was that it was started by civilians operating outside the standard military chain of command. These civilians had no knowledge of standard military operating procedure, and had no preconceived notions or prejudices. Because of this, they were perceived as neutral players, and quickly became trusted by all involved. This was extremely helpful in recruiting content providers and reviewers, which turned out to be a highly personal and time consuming task. One of the reasons for the digital library�s continuing success is that, once the concept of the digital library was proven, it was assimilated into the standard military chain of command and given appropriate military supervision and oversight, while still retaining some degree of operational autonomy, allowing thinking outside the box to anticipate and quickly respond to new challenges as they arise.

    2. Real World Experience is the Best Teacher - It is better to be an operational prototype than a demonstration project. First, much more is learned from real world operations with an uncontrolled, heterogenous patron population as compared with demonstrations conducted with a controlled, homogeneous patron population. Experience is the phenomena where the test comes first and the lesson comes afterward. Second, it is easier to convince individuals to collaborate and help "do it right from the start" if they see the project has the potential to quickly help a large population, rather than being yet another demonstration that, in all likelihood, will never see the operational light of day.

    3. Sensitive, Not Classified, Information - All of the information on the digital library is non-classified. Nonetheless, some of the information, particularly medical administrative information, was never intended for consumption by non-medically trained civilians and may be regarded as insensitive by civilians not familiar with the standard operating procedures of the military. In order to keep barriers to accessing information low and because nearly half of the Navy patrons of the digital library use it from outside the .mil domain, there is no desire to place this administrative information behind a login / password or access control list. One must be cognizant not only of the target audience but also the peripheral audience that may misinterpret information in a digital library. Therefore, such information requires a higher standard of review for clinical quality and accuracy, timeliness and currency, source reputation and, of course, spelling and grammatical editorial correctness; and also for political sensitivity. Multiple reviewers are required to avoid single source bias. Information selection and regular advisory board oversight are major process requirements of site maintenance and sustainment. Finally, a disclaimer that encompasses both legal and public affairs perspectives is imperative.

    The methodology used in the creation and operation of this digital library is widely applicable to other constituencies inside and outside of the military and medicine. The U.S. Coast Guard has already adopted this digital library and several foreign navies have shown interest in adopting it. Applications in the merchant marine would be a logical next step, and the digital library has already been deployed and tested on a commercial cruise line. The University of Iowa�s digital library team�s next step is, literally to shoot for the stars and apply the lessons learned in this project to the design of a prototype digital library for use on the National Aeronautics and Space Administration�s International Space Station.

    The Future

    Even after continuous access to the Internet is provided to all ships, there may never be enough bandwidth available to the primary care providers at sea; their medical information needs are always secondary to the military operational information needs of the ship, and in times of conflict, such bandwidth may be turned off to reduce the ship�s electronic emissions signature. This simple fact leads to a requirement for continuous refinement and enhancement of the caching strategy under the assumption that patrons can only be expected to have, at best in the future, intermittent access to the Internet. The distribution of a CD-ROM mirror of the digital library will therefore be continued on an annual basis, and methods are being developed for keeping the nomadic patrons� local CD-ROM mirrors of the digital library synchronized and more up-to-date with the main digital library Web site. Investigation is underway of 1) a new generation of off-line-browsers which can automatically subscribe to the digital library and pull updates on a scheduled basis, 2) push technology which can regularly broadcast digital library updates to subscribers, and 3) a quarterly compressed downloaded archive of the entire digital library which can be manually pulled by patrons into their computers and which turns into a self-extracting copy of the digital library upon downloading. The technique ultimately chosen will have to be technologically durable, readily understandable and easily implementable by patrons who are assumed to have limited computer skills and no access to technical support.

    Digital libraries such as the Virtual Naval Hospital will become necessary and integral parts of telemedicine and electronic medical record systems, providing on-line reference information linked to the patient's telemedicine consultation or medical chart. The review of information from digital libraries at the point-of-care will ultimately form the basis of a new generation of Continuing Medical Education (CME) systems that will award CME credit for medical education that is delivered in a clinical context. Work towards fulfilling this vision continues [27].

    Eventually, this digital library may be expanded to include participation by the other Uniformed Services. The digital library can easily adapt to the other services, because the U.S. Naval Services, through its aviation and Marine ground forces, face similar medical issues as does the U.S. Air Force and the U.S. Army. Focused user-centered design work could be done to refine the pre-existing problem-based interface to include their service specific needs.

    Finally, summative evaluations will continue to be undertaken to determine the digital library�s patron satisfaction, efficiency and efficacy, cost effectiveness, and impact on patients.

    Conclusion

    In the 18th and 19th centuries, the Royal Navy dominated the seas, and oversaw the era of Pax Britannica. One important reason for this dominance was the importance the Royal Navy placed on issues now referred to as health promotion (nutrition, personal hygiene) and occupational and environmental medicine (pest control, ventilation, sanitation) [28, 29]. This emphasis led to Royal Navy Sailors and Marines living healthier lives than their antagonists, thus allowing for increased time training at sea. This ultimately led to an enhanced state of combat readiness, which allowed them to successfully accomplish their mission when called upon. Today, the U.S. Navy similarly dominates the seas and oversees this turbulent era of Pax Americana. Now, as in the past, to allow the U.S. Navy to carry out its mission, its Sailors and Marines must be healthy.

    An institution such as the U.S. Navy is a knowledge factory. A digital health sciences library has been created that distributes this medical knowledge more efficiently and more effectively to the people who need it, when they need it. This digital library uses lowest common denominator Internet standards to take a significant first step towards bringing order to the chaos of the Internet by delivering organized, authoritative information to the point-of-care for nomadic patrons, wherever they are. The result is a tool that helps Navy primary care providers and patients prevent disease and, when disease does occur, to correct it, thereby maximizing readiness by continuing medical education to the point-of-care.

    To succeed in the design and implementation of a digital library, regardless of the field of endeavor, one must focus consistently on the population served and their mission, and tailor the digital library to their needs. If this is done, the result will be a tool that is heavily used and sincerely appreciated.

    Today, digital library patrons are stationary in nature, gaining access to digital libraries by fixed workstations with low and high speed wired connections to the Internet. In the future, as society moves towards a ubiquitous computing environment to accommodate an increasingly nomadic lifestyle [30], access to digital libraries will be primarily by mobile workstations or wearable computers with low speed wireless connections to the Internet. Therefore, one of the next grand challenges to digital library research will be determining how to deliver digital library services to nomadic patrons. The lessons learned from this project take a first step in showing the way.

    Acknowledgments

    The authors would like to thank the many members of the U.S. Navy and U.S. Marine Corps and their associated civilian employees who have provided assistance in the form of content, feedback, and administrative and political assistance. They would also like to thank the members of the University of Iowa�s Electric Differential Multimedia Laboratory for their help in creating and operating this digital library.

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    The contents of this article are not necessarily the official views of, nor endorsed by, the U.S. Government, the Department of Defense, or the Department of Navy.

    Two of the authors of this article, CAPT Richard S. Bakalar, MC, USN and LT Denis E. Ashley, MC, USNR, are employed by the U.S. government and therefore their work is not protected by U.S. copyright. © 1999 Michael P. D'Alessandro, Donna M. D'Alessandro and Mary J.C. Hendrix

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    DOI: 10.1045/may99-dalessandro