MANUFACTURING AND THE NII Summary of Comments Committee On Applications and Technology Information Infrastructure Task Force September 8, 1994 Mark Mandell National Institute of Standards and Technology Although the informal feedback on the white paper: Manufacturing and the NII, has been uniformly positive, there has been surprisingly little response in the way of formal, substantive comments. On the positive side, neither the content, structure, nor vision articulated in the paper has been called into question. On the negative side, there has been virtually no comment on or response to the questions and issues raised in the last section of the paper. Despite that fact, the comments received to date have been valuable in illuminating and reemphasizing some key issues. Generally, these comments focused on the need for us to pay more attention to the non- technical barriers to the implementation of NII applications to the manufacturing setting. For example, one respondent wrote: "The report does not adequately address cultural barriers to implementation which are major. . . . [M]uch of the infrastructure to use modeling and simulation for concurrent engineering exists and has for some time; yet a relatively small number of advanced companies are systematically putting the technology to use. Why not? The fact is that manufacturing is by nature very conservative and cautious with respect to change. There are many who believe in intuition and lessons from the past rather than technology guiding us into the future, and they do not put their trust in new paradigms until they become proven lessons." Dealing with cultural and organizational barriers to change and human factors is certainly necessary if the nation is to reach its goals in manufacturing, and the IITF needs to consider these issues more rigorously. As pointed out in another response, manufacturers "have little ambition to change" and are burdened by "economic baggage" in the form of legacy hardware and software systems, industrial "inertia," and the need to justify investments to the last penny. The result is that, "It takes a long time to impact manufacturing technology." Perhaps more to the point, another respondent highlighted the fact that the problem is getting smaller manufacturers to adopt what are considered to be today's "leading edge" technologies rather than do nothing or try to adopt "bleeding edge" technologies. NII pilot projects, therefore, should focus on demonstrating the real world impact of today's technology, for in short, "We can always demonstrate the technical leading edge; it is deployment to the mainstream that is critical in making fundamental change happen." One final theme in all of the comments received to date has been the need to focus better on education, training, and other work force issues, in particular ease of use. One respondent cited the need to make the "NII available to small companies with limited skills and resources . . . . providing standardized training programs for users staying away from the need for the specialist . . . [and] making sure that data output is user friendly and current as opposed to too much data too late." Another emphasized the need to provide "appropriate display technologies," "appropriate human-machine interfaces," and "easy-to-use applications," as well as the need to have in place adequately educated management (and management structures) and a skilled work force. Request for Additional Comments: Below are listed the eight "Issues and Questions to be Addressed" that were first posed in the Manufacturing and the NII white paper. We still believe that these are the "right" issues and questions to be addressed, but would like to take this opportunity to ask you if, in fact, we are looking at the important issues and are asking the right questions. Your responses will help us develop informed and effective policies that are in tune with your needs and concerns and in concert with your actions. o The continued modernization of manufacturing processes, in particular through incremental investment by small- and medium-sized manufacturers in appropriate manufacturing technologies, is fundamental to building a strong, competitive, sustainable industrial base in the U.S. Early indications show that programs such as the Manufacturing Extension Partnership (MEP) and other state and local efforts are successful at helping manufactures make investments and adopt appropriate manufacturing technologies, including communications equipment and computer hardware and software applications for the NII. Should the federal government, building on the successes of the MEP, broaden the scope and reach of the MEP, turning it into a national program capable of assisting small- and medium-sized manufacturers throughout the U.S. in their preparation for the use NII for manufacturing? o In the new manufacturing paradigm, the factors that determine competitiveness -- flexibility, responsiveness, time-to-market, cost, and quality -- all depend on the efficient manipulation, control, management, and use of information. For this reason, information is a company's key strategic asset. While many companies want to modernize their equipment and processes, they often find difficulty in procuring, installing, and configuring new equipment to work with old equipment and in thinking about short-term investments in new equipment and capabilities in the context of a long-term, enterprise- wide investment strategy. To facilitate the investment process, should the Federal government increase the scope of the MEP to assist small- and medium-sized companies with their long-term strategic planning and investment decision-making activities? o Standards for product data exchange, electronic commerce, and interoperabilty are essential to the development and use of the NII in manufacturing. Currently, however, there is no generally accepted methodology or data format standards to allow easy exchange of data (both engineering and business) between U.S. companies within the same industry or across industries. In addition, information technology advances for manufacturing systems occur at very frequent intervals and there is concern that the standards development process as it is today cannot keep pace with the needs of the manufacturing industry. The federal government can accelerate the standards development and acceptance process by providing strong technical support for standards development and by demonstrating the soundness of technical ideas through rapid prototyping, demonstration of feasibility, and other implementation and validation activities. In which areas are the development and demonstration of the technical underpinnings of manufacturing-related standards for the NII most needed? Does continued federal investment product data standards (STEP), electronic commerce standards (EDI), and interoperabilty standards (OSE) make sense? Is there a need for an overarching standards framework that ensures that manufacturing applications for the NII are compatible? o The Committee on Civilian Industrial Technology (CIT) of the National Science and Technology Council (NSTC) has identified several areas as critical to the manufacturing infrastructure. These areas include: Agile Manufacturing, Manufacturing Systems Integration, Manufacturing Technology Deployment, Intelligent Sensors and Controls, and Rapid Prototyping. In addition, the Committee on Information and Communications (CIC) of the NSTC oversees R&D for the Information Infrastructure more broadly. What are the specific technical requirements that industry needs to develop, implement, and use manufacturing applications for the NII? Which areas of R&D will stimulate the development and use of applications for the NII in manufacturing the fastest? What are the best candidates for federally sponsored demonstration projects and testbeds? Which federal agency or agencies should coordinate and lead the effort to build and test manufacturing applications for the NII? o While the federal government performs a great deal of R&D and provides demonstrations and testbeds, it is the private sector that turns the results of both public and private R&D into commercial products and processes. In the capital intensive, pre-production, latter stages of R&D, however, capital markets often find it difficult to properly assess the risk-return ratio (i.e., expected value) of further investment in product or process development and therefore often do not provide resources to test the commercial viability of high risk products and processes. To what extent is this a problem in manufacturing? Is there a government role in helping capital providers to accurately determine the risk-return ratio of investment in the latter stages of high risk product and processes development? o In the information age, a highly skilled, flexible, restrainable workforce is essential to economic competitiveness. The NII can be used to provide just-in-time, remote, tailored, multi-media education and training applications. (See, for example, "A Transformation of Learning: Use of the National Information Infrastructure for Education and Lifelong Learning"). The dynamic nature of the manufacturing sector necessitates the existence of adequate mechanisms for the identification of current and future trends and needs of U.S. manufacturers, assessment of the skills required to perform new tasks and use new manufacturing equipment, and development and delivery of focussed education and training programs directly to workers on the shop floor in a timely and effective manner. To what extent should the federal government play a role in developing mechanisms for the education and training the U.S. workforce to meet manufacturing needs? Should the federal government guarantee that all U.S. manufacturers, regardless of size, have access to adequate education and training resources? Which federal agency or agencies should be responsible for these activities? o For manufacturers to use the NII they must be assured that their transactions will be secure, timely, verifiable, and unaltered. To what extent is the safety, reliability, security, and maintenance of the NII a federal responsibility? ELECTRONIC COMMERCE AND THE NII Summary of Comments Committee On Applications and Technology Information Infrastructure Task Force September 8, 1994 Chuck Chamberlain, USPS David K. Jefferson, NIST Comments on the Scope of Electronic Commerce Comments indicated that Electronic Commerce must support other applications. For example, these comments suggest that Electronic Commerce must support the Manufacturing and Government Services applications: "Design and development of products should get more attention in this section (page 26). It is a manufacturing issue as well, but this is a significant opportunity and it is tied to Electronic Commerce and the NII. . . . Many of the technologies required (such as distributed simulations, networked virtual environments, high performance computation, large scale storage management, interactive visualization systems, and virtual reality presentation) are addressed by other sections for different applications but could be coordinated here. . . . Technology . . . could also eliminate proximity as an element of the traditional office working environment for all the application arenas. The notion of a virtual workplace probably deserves more focus." "The Government oversees vast quantities of data that are not readily accessible by the public. An objective of the NII should be to make these data available. Private use of these data using data mining tools, future parallel search engines and other tools could enhance service delivery. . . ." "In the introduction it discusses Business to Business communications. It does not identify that the same basic capability can be applied to link Business to Consumers and the reverse. The same applies to linking government to individual citizens." Comments on Issues Raised in the Report (quotations in bold are from page 39 of the Report) Security/integrity The Report proposed that "Government and industry cannot accept Electronic Commerce unless electronic transactions are secure. There are clear requirements for authentication of the source of a transaction, verification of the integrity of the transaction, prevention of disclosure of the transaction to unauthorized users, and verification of receipt of the transaction by the intended trading partner. . . ." Many comments supported the importance of the issue; some comments mentioned specific solutions, such as "Premenos, a value-added EDI services provider, is now offering in a test mode with several Fortune 500 clients, public key services for securing electronic transactions." Interoperability/scalability The Report proposed that "We must develop technologies, measurement tools, testing services, interoperability demonstrations, etc., to ensure that components satisfy the current and future requirements of government and industry. . . ." Most comments supported the importance of the issue (i.e., interoperability), but did not propose specific programs for achieving that goal. The CALS-ISG, among others, has this as a major thrust of their national and international mission as well as the creation and publishing of business cases. The comments included the following: "How can NII accommodate requirements for reliability, response time, interoperability, and security of EC?" "Need cost-effective security combined with cost-effective interoperability, plus performance matching existing proprietary and/or private networks" "Concerns about interconnectivity and information discovery are being replaced by concerns about interoperability and security" ". . . how can its widespread use be facilitated. We feel that the best way is for the government to be a role model to industry by educating its own managers on the technology and processes, and implementing electronic commerce for its own purposes with as broad a constituency as possible, both within the government and with affinity groups. By doing so, the government, because of its size, and the number of affinity groups with which it works, can provide important seed money required by vendors and businesses to build the infrastructure and transaction volumes necessary to achieve critical mass for this market." Non-technical issues The Report proposed that "Successful resolution of technical issues will be insufficient to ensure the widespread use of Electronic Commerce; economic, cultural, regulatory, and legal barriers to Electronic Commerce must be identified and removed. . . ." The comments expressed general concerns related to problems of providing universal access to Electronic Commerce, and specific concerns about how small business can economically participate in Electronic Commerce. One comment stated that "As the sophistication required to compete increases, the cost to compete will also rise. This could potentially put small businesses with limited investment capital at a disadvantage. Some consideration should be given to the NII impact to the competitive balance in the marketplace. There should be a discussion of potential undesired effects and ways that these can be mitigated without slowing the collective competitiveness of American Industry. One approach might be an expansion of the Electronic Commerce application discussed on page 32 to provide a forum for the use of small business to post its services, qualifications, availability and other relevant information. Such a service could be accessed by other small businesses, prime contractors and the agencies themselves. This could become a forum where small businesses might use the NlI to broker their services." Another comment suggested additional services related to the Government Services application: "Reduced time in accessing government statistics and information such as regulations which assist businesses in decision making and manufacturing. Ability of small businesses or companies in accessing and transferring data which is currently limited to well funded corporations." Important questions raised in the comments included the following: "How will EC affect small business?" "How will small business input their EC requirements into the builders of the NII?" "How will use of the NII for EC affect urban and regional development? Do urban and regional planners discuss EC requirements with small business and builders of the NII?" "How will EC in the NII coordinate requirements and progress with EC in the GII?" HEALTH CARE AND THE NII Summary of Comments Committee On Applications and Technology Information Infrastructure Task Force September 8, 1994 J. Michael Fitzmaurice, Ph.D. Ellen Rossman Agency for Health Care Policy and Moshman Associates, Inc. Department of Health and Human Services INTRODUCTION In early 1994, eight authors were asked by the White House Information Infrastructure Task Force, Committee on Applications and Technology, to write an introduction and white papers on applications of the NII in seven specific areas. The seven areas are: education, electronic commerce, environmental monitoring, government services, health care, libraries, and manufacturing. The goal was to focus public attention on a national vision of the opportunities for the public to receive the benefits of advanced computing and communications technologies through NII applications in these areas. Another target was to improve public policy by identifying how the Federal government can bring these benefits to the forefront when it is in the public interest. In Putting the Information Infrastructure to Work , the papers were published with a call for public comment. This paper summarizes the public comments received for "Health Care and the NII." As of August 19, 1994, 81 groups and individuals provided comments on "Health Care and the NII," one of eight chapters in the document entitled Putting the Information Infrastructure to Work: A Report of the Information Infrastructure Task Force Committee on Applications and Technology. Of these commenters, approximately 40 percent represented health care and information management associations, foundations, and advocacy groups; 15 percent were members of the academic community; 15 percent were federal government personnel; and the remaining 30 percent were providers of health care, information management, and legal services. Commenters clearly believed the health-care chapter to be an important vehicle for presenting the NII-related needs and views of health professionals to policy and decision makers. Many of the comments submitted were two or more pages in length and some as long as six pages. The comments were characterized by their thoroughness, thoughtfulness, and attention to detail. They addressed issues ranging from the technical, theoretical, and philosophical to the grammatical. They documented the critical importance of the National Information Infrastructure (NII) to the health care provider and health care information management communities and the commitment of the members of these communities to play an active role in NII's development and implementation. To provide a relatively short synopsis of the extensive number of comments received, this summary will focus primarily on comments addressing those topics which appeared to be of most significance to the commenters. After a brief discussion of the commenters' response to the overall vision presented in the chapter, this summary will condense comments on 13 topics that were addressed by six or more individuals. (These topics and the number of commenters mentioning each are listed in Exhibit 1.) Finally, it will discuss briefly comments that targeted the special NII-related interests of particular groups. RESPONSE TO THE OVERALL VISION PRESENTED IN THE CHAPTER There is interest in the extent to which the comments indicated agreement (or disagreement) with the overall vision presented in the paper, i.e., how health care providers and institutions can exchange and pool information in order to improve the quality and contain the costs of health care. None of the commenters expressed disagreement with this overall vision. Rather, the vision appeared to be accepted as a "given" by commenters, whose remarks served to flesh out and expand upon components of the vision as it was presented in the chapter. While the comments documented some disagreement on the details of the exact process for ultimately achieving the vision, it was clear that this diverse group of commenters are committed to achieving a similar goal. ISSUES OF PRIMARY INTEREST TO COMMENTERS Far and away, the topic of standards development received the most attention: issues related to standards were mentioned by 32 commenters. Other frequently mentioned topics included the role of the federal government in developing and implementing a health care NII (23 commenters); issues pertaining to privacy, confidentiality, and security (22 commenters); and discussion related to research, demonstrations, and evaluation (19 commenters). Brief summaries of key points raised by the commenters on these topics are provided below. Development of Standards The following summarizes the variety of issues raised by the 32 commenters who mentioned standards. %The need for acceleration of standards development was expressed by four commenters. The federal government was urged to play a role in the acceleration process. %While five commenters indicated their support for the facilitation by the federal government of a public-private partnership for the development of health care information standards, six others stated their support for efforts of the American National Standards Institute's (ANSI's) Healthcare Informatics Standards Planning Panel (HISPP) in this area. One of the latter group expressed concern that the federally facilitated partnership might duplicate the efforts of HISPP. %Two commenters suggested specific types of standards that should be developed, including standards for data communications, data storage, and data encryption/security; standards for data compression for electronic imaging; and universal standards for information exchange. %Two commenters offered differing opinions on whether the federal government should mandate the use of standards. One stated that, while the private sector should not be required to use standards, the public sector should have this mandate. The second believed both the public and the private sector should be mandated to use the same standards. %Differing opinions were also offered by two individuals who suggested priorities for standards development. While one believed that standards for nomenclature, coding, structure, and the content of data sets should receive the highest priority, the other suggested standards for medical administrative transactions be given top priority, in order to reduce health care administration costs. The latter also believed that standards for clinical transactions should be a "close second," in order to improve health care quality. %Two commenters mentioned issues to be considered once standards have been developed. These included creation of "trading partner agreements" and "implementation guides" and regular updating of standards, to address changes in technology. Commenters also discussed the role of the federal government in the standards development process. Representative comments include the following: %The single most important role of the federal government in expediting the development of medical information flow is to foster the development of universal standards for information interchange. Any such effort must include major input from industry and the medical profession, but must be led by the federal government. Any other organization leading such efforts will be seen as potentially self-serving and be suspect by other participants. %Information standards should be developed within the current accredited standards committees with oversight and coordination by an ANSI panel or board which includes both the public and private sectors. The federal government should participate and then commit to accepting the developed standards or recommendations. Past experience shows that the government may participate but not commit to consensus recommendations and may resort to other techniques or not change the way its business is conducted. Any decision by the government for federal programs has a monumental impact on the private sector. %The federal government should not develop standards, it should promulgate and mandate the use of standards developed by ANSI HISPP. It may also be helpful to have the federal government facilitate the development of treaties among the feuding standards groups. Role of the Federal Government Twenty-three individuals mentioned various aspects of the role of the federal government in the development and implementation of the health care NII. As noted above, issues related to the government's role permeated commenters' discussion of standards and also were introduced into their discussion of many of the other topics related to the health care NII. As relevant, these comments are incorporated into the summaries on these topics which follow. In addition to standards, the two topics mentioned most often by commenters as areas in which the government has an important role to play included addressing the issue of privacy, confidentiality, and security and funding research, demonstrations, and evaluations. Privacy, Confidentiality, and Security Ten of the 22 individuals who commented on the issues of privacy, confidentiality, and security stated their support for national legislation to achieve uniformity in the way that uses of personally identifiable patient data are restricted. Only two of the 22 commenters were dubious about legislative solutions and questioned the assumption that new legal structures could deal with these issues adequately or completely. Seven commenters suggested strategies to be used along with or instead of legislation. Among these strategies were: %Ensuring that examples of benefits to patients resulting from increased sharing of information are available before attempting to enact the legislation, so that legislative efforts will not be derailed by fear; %Offering patients the choice of consenting to expanded use of their medical information by others; %Developing model legislation for use by states in revamping their privacy laws and offering fiscal encouragement to promote uniformity over time; and %Educating the public to be more realistic about the difficulty of eliminating all risk of disclosures. Finally, two commenters argued that privacy may not be as "thorny" an issue as it is perceived to be. One suggested that members of the public may not be aware of all of the issues involved and might be willing to sacrifice aspects of privacy now protected, if they understood this would achieve a better quality of health care at a lower cost. The other believed the issue may become less important once certain aspects of health care reform are implemented and penalties such as health-based insurance exclusion and job discrimination are eliminated. Research, Demonstration, and Evaluation All of the 19 individuals who mentioned research, development, demonstration, and evaluation of integrated health care information systems indicated their support for a federal program funding such activities. The vast majority of comments on this topic offered suggestions or support for particular types of research, demonstrations, or evaluations that should be funded. These are summarized in Exhibit 2. Two of the 19 commenters mentioned specific activities they believed the government should not fund, but were otherwise supportive of a federal funding program. Universal Patient Identifier Eleven commenters mentioned the concept of a universal patient identifier, many of whom pointed to the controversial and difficult nature of this issue. Of the three who commented on the possible use of the social security number as the identifier, two disagreed with the option because of its controversial nature and the relatively high likelihood of breach of confidentiality. The third believed the social security number was appropriate for identifying records, but not for authorizing access. Another commenter found a unique identificationnumber to be a more pragmatic and viable solution to identification than other options mentioned in the chapter (e.g., retinal scan, DNA blood typing) which would be more costly, both in resources and time. Public Access to Health Information Public access to health information was discussed by ten commenters. Four commenters had positive views on this subject and believed that NII will promote the distribution and access of health-related information to the public; support consumers' informed decision making about health; and redress the balance of power existing between the health care professions and the laity. However, four commenters were less optimistic about the benefits of increased access. They noted that the public is already overloaded with information received via the media and questioned consumers' ability to understand and use health information appropriately. One of these commenters, while agreeing that informed consumers will be a key benefit of NII, believed that substantial education will be necessary to have an effect on national health expenditures. Another concern of three commenters was that NII could increase the health status gap between the "haves" and the "have-nots," who may not have access to information technology. Finally, one commenter was concerned that the chapter's presentation of this issue suggested consumers could get the necessary information on their health care problems from computers, which would be a substitute for primary care. Data Repositories and Data Ownership Of the ten commenters who mentioned health care data repositories, six agreed there should be federal involvement in efforts to establish repositories. However, one of these believed successful pilot projects would eliminate the need for further federal funding of repositories, because communities and health care organizations would "scramble" to adopt information systems shown to have positive cost utility. The one commenter indicating disagreement with federal involvement believed such involvement would not be worthwhile because the private sector is already spending a good deal of money in this area. Commenters also noted that analysis, translation, and dissemination of depository data need to be addressed and that federal support of research and education regarding the usage, use, and impact of repositories would be of value. In addition, five of the 10 commenters believed the issue of data ownership must addressed before repositories can become a reality. Use of Existing Systems Eight commenters suggested that greater emphasis be placed on using, refining, linking, and making universally available existing systems and technologies. The following are examples of comments representing this view: %The federal government should not make a major investment to create an integrated health care information system, when such systems are already in place in private sector health care settings and the financial arena. Benchmarking and using or improving on existing systems would be a worthwhile place to start, rather than starting over. %Instead of focusing on development of sophisticated new technology, it would be more realistic to describe a future in which existing applications are universally available, such as easy access to lab data from other sites, immediate and rapid access to the National Library of Medicine data bases from office or hospital computer, and automatic checks of all prescriptions for potential drug-drug interactions. %Disseminating proven applications should be emphasized, such as the HELP system at Latter Day Saints, Indiana University's intelligent order entry system, and numerous commercially-available applications on such topics as literature searching and patient and professional education. We do not need to wait for futuristic developments. Data Quality The issue of data quality was raised by eight commenters. Most of their comments focused on the detrimental impact poor quality data could have on the perception of NII and on its usefulness for clinicians, researchers, and policy makers. Examples of key points made include the following: %Data that are of poor quality, antiquated state, or low relevance will increase uncertainty in information generated and decrease credence of decisions made from the system. Given the repercussions that incorrect data could have on quality of care and programmatic alternatives identified for policy makers, an ongoing program for improving and documenting the "wellness" of data is more than justified. %If studies are conducted using medical record data derived from many sources, there needs to be assurance that these data reach a certain and known level of accuracy. Lack of quality standards would decrease the value of the data bank, perhaps to the extent of making it meaningless. Data from fewer centers evaluated for accuracy would be of greater value than data from many sources of unknown accuracy. %Claims data have a reputation for some "creativity." Bias creeps into clinical data towards more favorable financial and administrative outcomes. There is a need for an audit system to assure data validity. However, two commenters suggested that features of an integrated information system themselves could lead to improved data quality. They noted that longitudinal data systems and uniform data structures standardizing data collection over a number of hardware platforms will increase data validity and reliability and that point-of-service data collection also will increase the probability of obtaining reliable and valid data. Coordination of Federal Agency Activities Eight commenters remarked on the need for coordination of federal activities to reduce unnecessary duplication of effort and to coordinate data and information requirements among various federal programs. Of these, six explicitly stated their support for establishing a federal work group for such purposes. Only one questioned the creation of the work group, noting that, while coordination and sharing across segments of the government is desirable,the benefits accrued may not exceed the energy required to establish the group, especially if there are no "teeth" in the requirement that agencies coordinate and avoid duplication. Development of the Computer-Based Patient Record Eight commenters remarked on the computer-based patient record (CPR). All were in support of the development of the CPR and three described the CPR's development as "high priority," "the foundation for everything else," and "essential for the US healthcare system." Training in the Use of NII The need for training in the use of NII was addressed by six commenters. These comments focused primarily on training health care providers. The commenters noted that proper use of electronic aides will require revision of work patterns taught in medical and nursing schools as well as reorientation of current practitioners. They believed the federal government should fund training programs to address these needs. The programs should target community-based practitioners as well as those in academic settings. Liability and Regulatory Issues Six commenters addressed liability and regulatory issues other than those related to privacy, confidentiality, and security. Five of these mentioned state "quill pen laws," one of whom commented that "until a standard for electronic signature exists, we will be stuck with a paper trail." Another noted that digital signatures are much more secure and reliable than hand written signatures. Two commenters identified liability and regulatory issues related to NII that will need to be addressed, including insurance coverage for teleconsultation, state regulations allowing practitioners from rural areas to engage in telemedicine with their urban counterparts, and the adequacy of current laws and legal precedents on issues of malpractice, ownership, contracts and torts, and privacy. Two others suggested the NII may result in reductions in malpractice suits and physicians' malpractice insurance, as practice guidelines are developed and comprehensive standards of medical practice emerge. SPECIAL NII-RELATED INTERESTS OF PARTICULAR GROUPS In addition to addressing the specific issues raised in the chapter, a number of the commenters emphasized the need for the NII to embrace the entire health community. These commenters urged that NII address not only the information needs of providers of ambulatory and hospital-based medical care and their patients, but also those in other settings, including consumers with chronic medical problems and the providers who care for these consumers in their homes. Commenters representing professionals in such disciplines as dentistry, preventive medicine, health promotion, mental health, and pharmacy described the importance of the NII to their fields and the consumers whose needs they address. Although many commenters praised the chapter for the comprehensiveness of its presentation of current activities related to health care information, 22 commenters, including many of those representing the particular groups mentioned above, provided additional examples of NII-related activities in which they or other groups were involved. These examples and comments are further evidence of both the great interest and the capacity ofthe many facets of the health professional community to be involved in developing and implementing the NII for health. In summary, the vision presented in "Health Care and the NII" represents desirable goals. Commenters remind the reader that important issues for health care policy makers, health care providers, and consumers must be addressed for progress to be made. Further, commenters believe that much of the vision has begun in the private sector and that reality must accompany the vision. The expected costs as well as benefits must be delineated, and the private sector must be recognized for what it has done and for what it will be called upon to do. The Federal government must provide leadership and partnership to the private sector. Consumers must be supported in their quest for increased healthiness as well in their decisions about treatments for acute illness. Exhibit 1 Topics Mentioned by Six or More Commenters Topic # of Commenters Development of Standards 32 Role of the Federal Government 23 Privacy, Confidentiality, Security 22 Research, Demonstration, Evaluation 19 Universal Patient Identifier 11 Public Access to Health Information 10 Data Repositories/Data Ownership 10 Use of Existing Systems 8 Data Quality 8 Coordination of Federal Activities 8 Computer-Based Patient Record 8 Training in the Use of NII 6 Liability and Regulatory Issues 6 Exhibit 2 Types of Research, Demonstrations, and Evaluations Mentioned in Comments %Model development for small institutions and local networks, including field demonstrations and planned pilot tests %Research on creative methods to ensure security and privacy of information in repositories %Community trials %Research to identify specific applications and systems where benefits exceed costs %Determination of costs and benefits of nationwide networks %Model development for health care information %Research to identify potential administrative and clinical cost savings %Identification of changes in health care service utilization and in the process of health care %Studies on uses, usage, and impact of longitudinal data in repositories %Determination of savings from access to medical effectiveness information %Research and analysis of legal and judicial aspects of a health NII, including the adequacy of current laws and legal procedures to address issues of malpractice (medical and other), ownership, contracts and torts, and privacy %Creation of open systems development test beds, including interoperability testing with other domain infrastructures %Research and development related to the information infrastructure as a mechanism for teaching and learning activities %Determination of whether standards promote cost-effectiveness %Demonstrations of community health information networks ENVIRONMENTAL MONITORING AND THE NII Summary of Comments Committee On Applications and Technology Information Infrastructure Task Force September 8, 1994 Ernest Daddio National Oceanic and Atmospheric Administration Department of Commerce Following is a summary of comments received on the "Environmental Monitoring and the NII" white paper which appeared as one of seven NII applications papers in the publication "Putting the Information Infrastructure to Work." The comments are the result of a direct mailing to more than 800 individuals as well as posting on electronic bulletin boards. The survey targeted individuals with interest and/or expertise in environmental matters and information technology and spanned the gamut of private industry, academia, professional associations, interest groups, and federal, state, and local governments. In general, the comments received reinforced issues and considerations identified in the Environmental Monitoring white paper. A number of reviewers expanded upon the issues and helped to clarify and better define some of these issues. For the purpose of summarizing the comments, they are grouped below into four general categories: interoperability and standards, universal access to information and network services, intellectual property rights/data pricing, and Government versus non-Government role. Interoperability and Standards Most reviewers of the Environmental Monitoring white paper touched upon issues of interoperability of information systems. One reviewer stated: "...the most important part of the entire document is... coordination among the various Federal agencies. In my experience, and in the experience of many other scientists...the recent history of un-coordination among the agencies has been not only time-comsuming, frustrating and inefficient from our perspective, but it has also been a clear waste of money in terms of duplicated efforts, failed projects, and simple turf-protecting...when a specific environmental data set, managed by a specific agency, is available only via asingle data system, and (as has happened) that particular agency refuses to adopt a better system, access to that data set is effectively squelched. The current situation, with environmental data sets...provides a variety of examples of this problem." A technical manager at an internationally based corporation with environmental science and technology interests noted: "...the central theme of the paper should be that the NII is more the incentive than the means for the agencies to do better with their data and information. Interoperability is the key concept, with vitual access to the data as needed. Therefore, the big push from the agency side should be standardization of data, data system access, and quality assurance." Universal Access to Information and Network Services Issues of access and particularly access to appropriate levels of bandwidth were expressed by several individuals. Certainly a goal of the NII should be a democratization of access; inevitably one is confronted with questions of how to best distribute a limited resource. A University of Colorado scientist stated: "Much has been written about commercial cable companies and/or telephone companies providing coaxial-level Internet service to every household in the country. Such speculation may be useful from a political perspective...It scares the daylights out of those of us who depend on the Internet for our ability to do environmental science. We have enough problems with bandwidth as it is...future use of the system by institutions working on critical national environmental problems may be hampered by the public's using the system for games, gossip, and catalog orders. A priority system may be necessary." Another reviewer made a point that environmental databases may be enormous in volume and therefore how does one determine who gets access to the databases and how much of the databases should be allowed to be transported over the telecommunications infrastructure. His comments follow: "...care should be taken to avoid 'information overload' on this system. To this end, there should be a concerted effort to 'filter' and/or 'prioritize' environmental information on the NII." A corporate executive for an environmental information technology firm raised the issue of what level of user understanding should be targeted considering theenvironmental monitoring application is a highly technical one: "On the NII we will find extreme levels of sophistication of users. Certainly something like MOSAIC can address the 'friendliness' issue, but as the variety and complexity of the data grow, the user interface must adapt accordingly. We believe this is non-trivial." Intellectual Property Rights/Data Pricing Several respondents to the request for public comments on the "Environmental Monitoring and the NII" paper raised issues related to intellectual property rights to information, charging for data, and how much to charge. As one may anticipate, the opinions fell on either side of the fence depending on whether one is the consumer or the provider of environmental information. An individual in a private weather consulting firm complained that he and others like him will not be able to compete with the federal agencies distributing similar products for free; nor could he compete with universities whose weather products distribution is, in effect, subsidized through research grants from the federal and state governments and private foundations. On the other hand, a university researcher pointed to reduction in remote sensing research in the 1980s that resulted from the privatization of LANDSAT satellite imagery and the consequential increase in cost to the user. Another university researcher posed the issue: "We need to debate data worth and ownership. In the past, the data and information was the property of those collecting it. They then turned the data and information into valuable rewards (publication, salary, tenure, etc.)...How about the scientist who is not the primary data gatherer but is the synthesizer? ...Whose credit?" Government Versus Non-Government Role Several reviewers of the Environmental Monitoring white paper emphasized the importance of the partnership between the Government and non-Government sectors in implementing NII plans and in implementing the environmental monitoring application. One reviewer affiliated with an internationally based information technology corporation observed: "more emphasis needs to be placed on the interface with the private sector groups and their application of environmental data...although it is true that federal agencies hold most of the environmental data in repositories, the majority of the data needs (and the decisions made) are at the state and local levels." Still another reviewer from a Department of Energy laboratory stated: "the value of the NII in the context of servicing decision support systems for the Federal Government, Industry, Public Interest Groups, and Academe is profound and should receive more emphasis in the paper..." A corporate executive in environmental information research and technology pointed out that the environmental monitoring as an application on the NII is significantly constrained in the context of today's federal agency budgets. It is not clear that the private sector has enough profit motive to invest heavily in the application. Her assessment follows: "Budgetary constraints are a significant reality...while the technology/capability and motivation are present, the federal government continues to face a deficit, and funding priorities are the norm...recommend that the private sector be encouraged to invest and develop this aspect of the NII, however, it is not clear that the business case can be effectively made at this juncture." In a more general context, beyond the environmental monitoring application, several comments stressed the importance of the partnership between government and the private sector in realizing the NII vision. Each has a critical role to play and each depends on the other. For example, a technologist at a large international information technology corporation commented: "Commercialization of technologies will follow the identification of the sustainable marketplace but often lags the leading edge requirement. Some of the necessary technologies will progress without Government guidance. Slow progress in other technologies may inhibit realization of the NII vision...Where there is significant risk in bringing technology to market, a proactive Government role could make the difference. The U.S. Government should define the highly leveraged technologies to accomplish its vision, look for areas of significant risk to business and areas where a sustainable marketplace will lag the Government's need, and step in." LIBRARIES AND THE NII Summary of Comments Committee On Applications and Technology Information Infrastructure Task Force September 8, 1994 Herb Becker Library of Congress Following is a summary of the comments received for the "Libraries and the NII" section of Putting the Information Infrastructure to Work: Report of the Information Infrastructure Task Force Committee on Applications and Technology Report of the Information Infrastructure Task Force Committee on Applications and Technology. Comments have been arranged according to the section of the draft paper to which they are applicable. PART I: What Is the Application Arena? DESCRIPTION OF LIBRARIES The Role of Libraries in the NII. The definition of libraries should include the following: A library includes the selection of materials, organization, preservation, and service to a named constituency. Key to the concept of "library" is a service goal and an ongoing responsibility to a set of users. The physical distribution of materials is not relevant. Library, therefore, is not an accurate term for a database site or gateway. A database is not a library. The role of libraries as agents of democratic and equal access to information must continue. It must be recognized that libraries and librarians train the public, aid businesses in their economic development, support health care and education--all of the other areas discussed in the first set of IITF papers. The library community brings to the information infrastructure the perspective of information professionals from politically neutral institutions charged with ensuring public access to diverse information sources and viewpoints, regardless of a user's economic status or information seeking skills, and regardless of information format. In the emerging electronic age, this requires equal, ready, and equitable access to the nation's telecommunications infrastructure to avoid widening the gulf between the information rich and poor. By serving as a common repository from which businesses, schools, and households draw and share information, libraries reduce the need for individual business, schools, and households to spend resources for duplicate information resources that are shareable. Libraries are already beginning to fulfill the role of network guide for those who do not lack equipment but rather need guidance about what can be retrieved. Similarly,libraries provide efficiency of access--not all homes are likely to have the full set of technology required to access and receive all of the various types of information projected to be available in the next ten years. The role of special libraries and librarians and research and university libraries and librarians are major constituencies which must not be forgotten as the NII looks for links to the world of users. Caution is advised in defining the role of the public library : those who can afford to pay for information will do so; the vision of the NII is that everyone else will be brought to the door of the public library, which is already underfunded and understaffed. The Role of Librarians. Librarians are information leaders. Because of this expertise they are crucial to the future of the NII. Librarians have spent centuries refining knowledge about storage and retrieval of information. From the clay tablet to the digital world, this knowledge has and will continue to be crucial. The Application. Libraries are a central node in the country's educational system. Additionally, they provide access to information which is vital to the community and economic development. Benefits of Applications in This Arena The NII should assure that government information is more accessible. Library as physical repository should diminish as libraries become electronic gateways to information resources. PART II: Where Are We Now? Funding: Footnote 6 is important. Start-up costs for implementation of government databases are likely to be significant and budgets must help support the development of electronic databases. Research and Development. Public libraries may be at a disadvantage in applying for grants or responding to proposals due to limited resources. Smaller libraries, if they are to have a role in the NII, should be targeted by programs. If libraries are necessary to assure equitable access to NII information, then specific government programs should be implemented to encourage both connectivity and education of existing staff. Cryptography, Security and Privacy. The confidentiality of library circulation records must continue. In the network environment, the possibility of tracking readership patterns at the level of the individual could have chilling repercussions on the perception of individual freedom and privacy with negative impacts on the use of network information. Additionally, electronic signatures must be developed. The ability of librarians and the public to cite electronic sources as "official" through an electronic signature would allow libraries to increasingly rely on electronic information. PART III No comments were received for this section. PART IV: How Are We Going to Get There? The Government's Role Funding. Governments at all levels must help fund those areas that are not being addressed by the marketplace, but which nonetheless provide an overall social benefit. This would include, but not be limited to, the digitizing of certain collections, the provision and maintenance of access through libraries, and the education of and provision of access to underserved groups. Facilitation of Standards Development. As a community interested in technical standards, should there be a lead agency for NII library-useful standards? Providing a Testbed: Depository Library Program. The Depository Libraries are an excellent test group for government information projects. They provide a testbed for intergovernmental information for state, local, regional and federal databases as depository librarians already deal with multiple levels of government and its information. Policy Setting: Copyright. The discussion of intellectual property is excessively focused on the print model. A broader discussion of the issues and trends would have been useful. For example, the trend to licensing rather than sale of digital material is important in this area even any conclusions may be premature. Industry Regulation. It is recommended that the federal government be responsible for assuring free public access to government information. The Depository Library Program should be key in promoting and providing public access to government information. Education. University libraries should be added to the statement on education. The term "primitive" should be removed from the statement on access. For the NII to be a successful component of education, schools and libraries must be equal to other entities in accessing information. Digital Conversion It is critically important to focus on content. Access to a vast and diverse array of resources supports education, protects productivity and competition, stimulates R&D, and public awareness. Availability of such resources will make connectivity meaningful and is key to the vision of the NII. It is not enough to convert and collect electronic material, however. The issues of access, organization, and preservation must also be considered. It is important that the various projects listed in the report be coordinated, information shared, and considered as a whole so that progress towards the digital library can be made efficiently and in the most timely manner. One model to build on is the National Endowment for the Humanities (NEH) 20-year plan to preserve three million brittle books. The NEHprogram has established a collaborative, multi-institutional program that includes standards development, selection of resources, training in preservation and technology, preparation and conversion of resources, and maintenance and provision of access to these resources. In any effort as major as the conversion of core materials for the NII, no single institution should be expected to take on an effort of this scope. Such an effort should be a cooperative effort involving many institutions. OTHER COMMENTS The remainder of this summary discusses comments received that were not directly related to the draft, but still considered important by reviewers. Additional Issues Which Must be Addressed. Civil Liberties. Intellectual freedom, censorship, and privacy issues are important issues not fully treated in the document. Resolution of these issues could fundamentally impact the content of the NII. Semantic Gateways. Whether manually created or digitally generated, semantic gateways will be a necessity in the world of massive databases being discussed in conjunction with the NII digital libraries. Organization of Data. Similarly, the role of organization of data for successful retrieval must not be ignored. Only 7 percent of the data on the Internet today is text; the remaining data are graphics, multimedia, and computer programs. These latter types of data do not self-identify as easily as text and, therefore, some type of searchable organizations must be imposed before retrieval can take place. Preservation. Digitization is not a panacea for preservation. Digital technologies are changing rapidly; materials stored on a digital medium today may not be readable by the equipment used even five years from today. Digitization for preservation requires a program that guarantees migration of the digitized materials to new technologies on a continuing basis. Other Industry Players. The expanding role of electric utility companies should not be overlooked and should be added to the list of "key industries." Equity of Access. What does equity of access really mean. What kind of investment are we talking about for the nation? What is feasible? Further equity of access studies must be undertaken if the goal of equity of access to information is to be achieved. Those studies underway should be coordinated and the data shared with any studies which follow. All Digital? It would be a mistake to assume that the goal of libraries is to become entirely digital. Most users continue to show a preference for paper particularly when reading long documents but also for short ones. It may be appropriate to digitize factual material, but leisure reading material is likely to continue to be delivered inpaper for sometime. Library as Publishers? Similarly, it would be inefficient to assume that libraries will become printers or publishers for any information but low use materials. Algorithmic Retrieval. The probability of purely algorithmic retrieval for most formats may be simple in the near term. For text, such indexing and retrieval may be possible before the end of the century. For image, audio, video materials, such capability is unlikely. It must be assumed, therefore, that some human intervention for identification and organization of such materials will be a necessary, if costly, alternative for some time. Are Libraries Facing an Identity Crisis. Libraries are suffering from an identity crisis. There are disparate views of the future role of libraries and librarians. The demographic and economic factors that shaped the public library movement in the nineteenth century U.S. are gone. The invention and widespread use of telecommunication systems--telephones, televisions, computer data networks--make libraries appear less useful. Libraries are facing competition--competition in conjunction with private investment are the underpinnings of the Administration's NII program. Questions We must Ask. What are libraries roles by sector? Should libraries divide between public and private sector? Should the library community divide itself along public and private spheres or should it serve both spheres? What does competition mean for libraries in the NII? Should libraries retreat from areas in which the private sector declares it intends to serve? Does the growth of unpublished and unauthenticated materials on the network suggest that the role of libraries is diminishing or becoming more targeted as part of the general, interdependent evolution of libraries, information services, publishers, and navigation and information services? Does this suggest that the role of libraries, particularly public, will be primarily as information providers for the information poor?