Side-by-side, but from different worlds: service and resource provision by academic health sciences libraries to their affiliated hospitals

The nature of the affiliations between large, academic health sciences centers and their teaching hospitals vary tremendously from institution to institution. During the past few decades, many university-run teaching hospitals have shifted governance to the private, corporate sector [1]. The sometimes complex governance and organizational structure among these institutions can complicate the library's provision of services and online resources. For example, since the 1997 merger of the university-governed hospital at the University of Nebraska Medical Center with a privately owned hospital, the university's McGoogan Library of Medicine has made great strides in extending services and resource access to the hospital. However, access to online resources such as electronic journals and other bibliographic and clinical tools remains a challenge. 
 
The authors searched the literature in hopes of finding guidance for navigating these challenges but found a substantive lack of journal literature regarding the relationship and resource sharing arrangements between the academic library and its institution's clinical partners. Information can be pieced together from articles about education, staff sharing, Integrated Advanced Information Management Systems (IAIMS) projects, and consortia licensing among libraries and governments, but information that focuses on the academic health sciences library–hospital partnership and its challenges is lacking [2–8]. The 2006–2007 Association of Academic Health Sciences Libraries (AASHL) annual statistics addressed library service to affiliated hospitals, asking many similar questions, but the AAHSL survey and data were not available until after this study was conducted [9].

The nature of the affiliations between large, academic health sciences centers and their teaching hospitals vary tremendously from institution to institution. During the past few decades, many university-run teaching hospitals have shifted governance to the private, corporate sector [1]. The sometimes complex governance and organizational structure among these institutions can complicate the library's provision of services and online resources. For example, since the 1997 merger of the university-governed hospital at the University of Nebraska Medical Center with a privately owned hospital, the university's McGoogan Library of Medicine has made great strides in extending services and resource access to the hospital. However, access to online resources such as electronic journals and other bibliographic and clinical tools remains a challenge.
The authors searched the literature in hopes of finding guidance for navigating these challenges but found a substantive lack of journal literature regarding the relationship and resource sharing arrangements between the academic library and its institution's clinical partners. Information can be pieced together from articles about education, staff sharing, Integrated Advanced Information Management Systems (IAIMS) projects, and consortia licensing among libraries and governments, but information that focuses on the academic health sciences library-hospital partnership and its challenges is lacking [2][3][4][5][6][7][8]. The 2006-2007 Association of Academic Health Sciences Libraries (AASHL) annual statistics addressed library service to affiliated hospitals, asking many similar questions, but the AAHSL survey and data were not available until after this study was conducted [9].

METHODOLOGY
The purpose of this research was to provide an overview of the prevalence and types of academic health sciences libraries' involvement with their institutions' affiliated teaching hospitals and to identify challenges (and interventions) that academic libraries encounter when providing services and online resources to affiliated hospitals. In May 2007, a twenty-fiveitem questionnaire was created using the online survey software, SurveyMonkey. Services, outreach, and on-line resource issues were the prevailing survey themes. Questions pertained to institutional governance, library or liaison support to the hospital, traditional library service provision and charges, access to online resources such as bibliographic databases or clinical tools, and resource authentication and licensing. Respondents were asked a series of open-ended or multiple-choice questions, which offered a selection of common characteristics or scenarios from which to select.
The AASHL membership, which was used as sample of convenience, represents 144 institutions, the largest group of academic health sciences library directors in the United States. The authors sent an email message in May 2007 to the AAHSL email discussion list, with instructions to forward the email to persons most familiar with hospital library services or licensing, if necessary. An optional form allowed potential participants to provide the names of their academic institutions. This information was later used to track participants and generate a list for follow-up reminders, which were sent in June 2007. The survey closed on June 30, 2007.

RESULTS
A total of 63 individuals responded to the survey. Several surveys were excluded due to incomplete data (2) or ineligibility due to a lack of relationship with an affiliated hospital (6). In at least 2 cases in which more than 1 individual at the same institution completed the survey, both responses were included in the analysis. The final analysis contained answers from 55 individual respondents, with the majority (n526, 48%) representing libraries that had a different governance structure than that of their affiliated hospital (Table 1). It should be noted that multiple affiliated hospitals were not differentiated. Survey data were analyzed with SurveyMonkey crosstab and answer-specific filters, which allowed investigators to pull out sets of data, based on respondents' answer to specific questions, and to compare their answers to other questions.

Services and outreach
All 55 of the respondents' libraries provided support to their hospitals, even in instances in which the hospital had its own independent library (29%, n516) ( Table 2, online only). Regardless of the presence or absence of a hospital or academic-satellite library, however, 53% (n529) of respondents indicated that a library staff member was designated as a primary contact or liaison to the hospital. Of the 29 respondents whose hospital did not have a library or satellite, 45% (n513) had a liaison. Additionally, of the 17 respondents whose library had a clinical medical librarian program (CML), 77% (n513) served nonacademic and academic clinicians.
The survey also asked about traditional library services to affiliated hospitals (Table 3, online only). The overall level of services provided to hospital personnel was strong, particularly for reference and interlibrary loan (96%, n553). When asked about Supplemental Tables 2 and 3 are available with the online version of this journal. remote access to online resources such as bibliographic databases, 78% (n543) of respondents indicated that access was available to their hospital. When charges for services or resources were involved (n525), the range of pricing structure differences between academic and hospital customers was minimal, although 16% (n54) of those libraries that offered remote access to online resources had different pricing structures for their hospitals.

Online resource issues
The survey also collected information on the prevalence of online resource and cost sharing, license negotiation, and network authentication issues (Table 1). The majority of respondents (87%, n548) indicated that the licensing of some or all of the libraries' online resources was shared with the hospital. Of this group, 40% (n519) of the respondents' hospitals contributed to licensing costs, mirroring a trend reported in the AAHSL statistics. Financial support from hospitals to academic library affiliates more than doubled from 20% in 1998-1999 to 49% in 2006-2007 [9,10]. However, the remainder of respondents' libraries (n529, 60%) paid for all of the shared licenses. When asked if the hospital had a license negotiator, respondents (n545) indicated that some did have their own license negotiators of some kind (n516, 36%), but that the libraries still either ''always'' or ''sometimes'' (n541, 91%) obtained new resource quotes that included the hospital.
Though 33 respondents' libraries and hospitals shared the same computer network authentication system, 57% (n519) shared all resources, regardless of governance. Among the different governance and authentication combinations, respondents indicated that hospital patrons who experienced the most confusion were from hospitals whose library did not share governance with the hospital. This confusion stemmed largely from the lack of resource availability due to licensing limitations in which access was available to the hospital or academic sides, but not both; different authentication systems; hospital network security barriers; and the unavailability of some resources (e.g., UpToDate) from off-campus or out of the hospital.

DISCUSSION
Based on these results, it is apparent that an educational institution's primary teaching hospital does not often go without support from a library, though the degree of support varies. However, most libraries (91%) investigated and negotiated online access for all. Additionally, CML support to nonacademic clinicians was high (n513, 77%), illustrating that academic libraries bear a good deal of responsibility for hospitals' information needs.
Library liaisons to the hospital can provide a consistent face and voice for the library, as well as facilitate communication about licensing and authentication issues [11]. The low number of libraries that had no library in the hospital but had a hospital liaison (n513, 45%) was surprising, because liaison programs are a staple in academic libraries, and hospital staff may be one of the largest populations of library patrons. However, one respondent noted that a relationship with the hospital was not initiated until the hospital itself perceived the need, based on endeavors such as nursing Magnet programs and electronic medical records. Conclusions regarding the benefit of a library liaison cannot be drawn here, and further investigation into this issue is warranted.
In terms of shared licensing and authentication issues, most respondents reported the usual frustrations and confusion, varying from a lack of hospitalbased access to networking barriers. Complications arise in the hospital-academic affiliation when the hospitals are not viewed as affiliates by vendors and publishers. One respondent noted, for example, that as their affiliated hospital grew, ''vendors see big bucks there and don't want to continue to see [the hospital] as part of the College.'' Another frustration faced by respondents was regarding the commitment and procurement of funds from the hospital: There is no one person at the hospital to deal with. I have had limited administrative support for developing a relationship that would involve compensating the library Other comments indicated that in situations in which some licenses were not shared, hospital affiliates often wondered why they could not access the same resources as academic personnel and requested off-campus access to all resources and a single log-in for clinical applications and library resources. Users were sometimes unaware of licensing limitations and restrictions, such as off-campus access to UpToDate, and needed to be educated about the reasons behind access discrepancies.

CONCLUSION
Academic health sciences libraries and their affiliated teaching hospitals operate under many different systems of governance, and libraries differ considerably in the services and resources they offer their affiliated hospitals. However, several basic tenets were echoed in surveyed respondents' experiences and advice. Perhaps these points represent best practices in establishing relationships and negotiating online resources' licenses for access for affiliated hospitals: & maintain a good working relationship with primary stakeholders & be aware of politics & understand organizational infrastructure & develop formal proposals and pricing models for services and resource packages to affiliated hospitals & educate administrators regarding licensing procedures and limitations & pilot-or beta-test hospital services and resources to identify problems The results of this survey describe the current state of the academic library-hospital relationship, but further research is needed in areas such as work with vendors and publishers in the complex organizational structures that often exist between hospitals and academic institutions and the types of resources that are best suited to joint licensing ventures with clinical and academic cohorts. The authors also recognize that the results of this survey may not be fully representative of the entire academic health sciences library population due to the nonrandomness of the sample. Providing services and resources to affiliated hospitals can be complicated. Open communication and positive relationships are central to overcoming these challenges and securing mutually beneficial partnerships for providing library services and resources to affiliated hospitals.