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78 © Blackwell Science Ltd 2002 Health Information and Libraries Journal, 19, pp.78–83

Blackwell Science, Ltd

SALUS: online co-operation between South Australian health librariesMary Peterson* & Lindsay Harris†, *Deputy, Library and Educational Information Services, Royal Adelaide Hospital/Institute of Medical and Veterinary Science, †Libraries Manager, North Western Adelaide Health Services, Adelaide, South Australia

Abstract

The establishment of the South Australian Health Libraries Consortium led tothe development of the SALUS project which enabled the online delivery ofcore health, clinical information and bibliographic databases with full-textresources across South Australian government health services. This was thefirst venture of Australian health librarians to create an online consortium.This article discusses the policy and management issues surrounding theimplementation of the SALUS project and its influence on the evolution of thehealth Libraries Consortium over several years. Lessons learned during thisprocess included: the necessity to plan well ahead yet to remain flexible inimplementing those plans, to avoid procedure becoming more important thanimprovization during planning, to be willing to take well judged risks onoccasions, and to be fully aware of changing circumstances in the project’sfunding and political environment. The importance of securing influentialadvocates outside of the participating libraries to support continued projectfunding is also considered.

Introduction

The background to the SALUS project

To understand the evolution of the SALUS onlineproject in South Australian health libraries itis important to describe briefly the social anddemographic conditions under which the projecthas developed since the mid 1990s. The state ofSouth Australia covers a vast area, some 984 000square kilometres, and receives the lowest rainfallof all the Australian states and territories. Overhalf of it is either desert or marginal pastoral land.

The distribution of population is characterizedby very low densities in the rural regions, withlarge areas in the far north and west almostuninhabited, and elsewhere very small townsscattered across great distances. In contrast, over70% of the state’s 1.5 million people are con-centrated in the state capital, Adelaide. Thisdemographic imbalance is underlined by the factthat all other urban centres in South Australiaeach have less than 35 000 residents. Con-sequently, nearly all the major hospitals, principalhealth facilities and tertiary educationalinstitutions are located in the Adelaidemetropolitan area.

In South Australia, there are two Universitymedical schools and seven major public teachinghospitals together with a range of other private

Correspondence: Mary Peterson, PO Box 14, Rundle Mall, AdelaideSA 5000, Australia. E-mail: [email protected]

SALUS: online co-operation, Mary Peterson and Lindsay Harris

© Blackwell Science Ltd 2002 Health Information and Libraries Journal, 19, pp.78–83

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and public hospitals, community health centres,clinics and biomedical research institutions. Allthe public health services, including hospitals,report to the state government’s Department ofHuman Services (DHS), and funding is in mostcases derived from both federal and state govern-ment sources.

A key feature of South Australian health serviceprovision is the overwhelming concentration offacilities, professional staff, biomedical technolo-gies, educational programmes and administrationin Adelaide. In contrast, the sparsely settled andoften distant rural regions have suffered from alack of medical specialists or resident medicalofficers, inadequate advanced diagnostic andintensive care services and poor infrastructure forclinical training. Efforts are now under way toovercome some of these disparities, but this wasvery much the prevailing situation in 1995 whenSouth Australian health libraries first consideredthe feasibility of establishing a state-wide onlinehealth information service.

The vision for health information and the origins of SALUS

The germ of the idea that eventually led to SALUScame from a paper presented at the 1995 Special,Health and Law Librarians Conference in Sydneyby Grace Cheng, the Libraries Director for theHong Kong Hospital Authority. In her paper,Cheng outlined the establishment of servicenetworks supported by Health Centre librariesand the setting up of the infrastructure of theHospital Authority Library Information System(HALIS) of the Hong Kong Health CareAuthority.1 This concept inspired Anne Fricker,then librarian at the South Australian Instituteof Medical and Veterinary Sciences (IMVS), toconsider establishing a similar Wide AreaNetwork (WAN) offering access to electronicinformation to health professionals throughoutthe state. This would be achieved with thecollaboration of Adelaide health libraries in thecreation of a commonly supported operatingplatform and associated online products.

Despite the economic and social differencesbetween the two jurisdictions, there were certainsimilarities in the structure of their health services

that made the Hong Kong model attractive toSouth Australian health librarians. Both operatedBritish influenced health systems with the princi-pal health care units and services concentrated insmall, heavily-populated urban regions dominatedby government-funded teaching hospitals, whichare in close geographical proximity to each otherand the major educational institutions. Bothsystems are controlled by a single official healthauthority with many clinical practices and trainingprograms that are common in content to each. Inaddition, both groups of health librarians wereaccustomed to working closely together and mostwere ultimately answerable to their respectivegovernmental health authorities.

Following the Sydney Conference, a meeting ofhealth library managers was convened in Adelaidein late 1995 to establish a South Australian HealthLibraries Consortium ‘… with the express pur-pose of wide area networking electronic full textand bibliographic health knowledge products’.2

Chaired by Anne Fricker, an eight-person Work-ing Group was formed representing the 16members of the Health Libraries Consortium toprepare a business case for the funding and imple-mentation of a WAN project in health informa-tion. It was envisaged that this WAN would useCompact Discs (CDs) on networked servers basedat one of the participating hospitals.

This project was distinguished, not just by thesignificant technical aim to create a WAN accessi-ble to all health professionals employed in the statehealth system, but also by its intended scope. Thegoal was to provide a readily available onlineservice offering core bibliographic databases like along with seamless access to full-textelectronic publications: quite an ambitious plan,technologically speaking, for that period in themid 1990s.

Weight was given to our aim by the well knownRochester Study3 and supported by several otherstudies including the Canberra Study.4 All of thesedemonstrated conclusively that use of appropriateinformation sources from libraries significantlyinfluenced physicians in their practice of medicineand resulted in better patient outcomes and fewermedical errors.

In brief the stated objectives of the Consortiumproject were:



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1 To provide and improve access at the desktop toa wide range of electronic health products.

2 To promote equity of access to database servicesfor all health professionals.

3 To improve service delivery and informationsharing amongst the staff of all participatingConsortium members.

4 To establish a standard networked system ofinformation sources using existing state govern-ment systems and networks.

5 To improve the development of appropriatetraining programs for all staff in the Consortiumto ensure the effective usage of databases.

6 To achieve economies of scale in the purchase ofhardware and software, negotiating licensingagreements and the installation of databases.5

The promise unfulfilled: the first attempt at networking

In the following year, the Consortium WorkingGroup prepared terms of reference for the projectand wrote several drafts of a Business Case. Thisinvolved complex cost-benefit analysis todemonstrate the value of the proposal over theretention of the status quo of individual healthlibraries operating in an uncoordinated manner.

Extensive reviews of the available products werecarried out, including the various searchingplatforms for the major biomedical bibliographicdatabases. Vendors were invited to give productdemonstrations to the Consortium and interestedclinicians. At this stage of the project, a list of coreproducts was identified based on current sub-scriptions already held by individual Consortiummembers and their availability on CD ROM.

Funding was secured for the employment of aProject Officer, Greg Fowler, who had beenmanager of the state’s Drug and Alcohol ServicesCouncil Library and an inaugural member of theConsortium Working Group. The appointment ofa Project Officer was crucial in permitting thecompletion of a major Business Case report,which would otherwise have been beyond thecapacity of a volunteer Working Group to draft.As well it indicated departmental support for thenetworking concept behind the Business Case.6

The Business Case envisaged a CD based WANbecause of the state of information technology in

the mid 1990s. The roll-out of networked onlineconnections across the South Australian healthsector was incomplete and the Internet at that timewas viewed as too slow and unreliable for thepurposes of the project. A CD based WAN had signi-ficant cost implications for the Consortium.Establishment of the WAN would have requiredthe networking of Compact Discs on a centrallylocated and accessible mainframe computer at ametropolitan hospital. An estimated two and aquarter million Australian dollars was required inboth capital works and recurrent expenditure tofund the WAN. The capital works component wasto fund initial WAN hardware and networkingcosts and the recurrent expenditure component topay for subscriptions to core databases with mostof this amount being committed in the first threeyears of an anticipated five year long project.5

The Business Case was published in May 1997and almost immediately became mired in bureau-cratic delays despite the extensive analysis whichhad attended its drafting. State Treasury requestedfurther clarification of some of the budgetaryestimates, and new layers of formal endorsementof the Business Case, prior to submission to theState Cabinet, emerged in different parts of thepublic service. Despite the best efforts to pushthe Business Case through the various channels ofgovernment, it was April 1998, almost a year later,before the report was ready to proceed to theCabinet Office.7

Failure of the first business case: the lessons learnt

By May 1998 there was a shortfall in the capitalworks budget of the state health authority and ithad no choice but to put to one side the wholesubmission pending the availability of fresh capitalfunds. In June, the project came to a standstill. Thefailure to proceed was a serious disappointmentfor all South Australian health librarians.

In retrospect, it is clear that there were severalreasons why this first Business Case failed. Thesemay be summarized as follows:• In an attempt to ‘get the submission right’, too

much time was spent on refining details in thedocument which could well have been consid-ered after the project had received fundingapproval.



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• Consortium members left too many of theadministrative and lobbying responsibilities toan overburdened Project Officer and thereforedid not appreciate shifts in the decision-makingprocesses within the public service until too late.

• Political events and attendant bureaucraticreorganization obscured the chain of decisionmaking once the Business Case was written. Thesubsequent need for flexibility in gaining neces-sary approvals within a reasonable time framewas not recognized by Consortium members.Procedure took precedence over final outcomes.

• The plan for a CD-based WAN was probablytoo ambitious in the context of the prevailinginformation technology infrastructure in thestate government. The imaginative nature of theconcept militated against its ready acceptanceby all the relevant sections of the public service,not least the sources of funding. The result wasa demand for extensive checking and recheckingof the costs and technical feasibility in order tobe assured of the project’s merits. In turn thiscontributed to the lengthy delays and finaldemise of the first Business Case.

• After the initial phase of planning, the projectlacked influential ‘champions’ outside of thehealth libraries who could have acted as advoc-ates for its implementation. Once fundingbecame difficult, the Business Case was unableto compete against other priorities. The Consor-tium should have given more attention to enlist-ing the support of key clinicians andadministrators once the Business Case wasissued.

Project revival

The situation was not promising. The projectBusiness Case was shelved, and shortly afterwardsa state election, resulted in a reshuffling ofdepartments. A new mega-department wascreated, the Department of Human Services,which was a merger of the health, social servicesand housing portfolios. The Libraries Consortiumfound itself with new members, keen to participatein any venture which would result in cost-benefitto their service, but whose subject emphasisbroadened the definition of ‘health’ akin to that ofthe Alma Ata declaration.8

Three factors were probably important inpreventing the project from falling into oblivion:the creation in January 1999 of the new mergedlibrary service of the Royal Adelaide Hospital(RAH) and the Institute of Medical and Veterin-ary Science (IMVS), the increased robustness andreliability of the Internet as a delivery medium,and the sheer dogged determination of theConsortium members not to give up.

The newly combined RAH/IMVS libraryservice was established with the brief to deliverclinical and research information in an electronicformat. This large library unit, combined withother teaching hospitals and government healthagencies, provided the leadership needed to workwith the major suppliers (Health CommunicationNetwork and OVID) to get a combined service offthe ground. By pooling funds from their recurrentbudgets, a group of six institutions demonstratedthat a consortium project could deliver corelibrary products via the Internet and offer consid-erable benefits in the consolidation of user licencenumbers and the range of products. This provedparticularly true for the smaller members.

Nothing succeeds like success. A member of thecentral DHS library staff was freed to draft a newbusiness case, and this time the case attracted thepromise of central funding for 12 months, with theappointment of a Project Officer, on the under-standing that participating institutions wouldcommit to recurrent funding for a further periodof five years. The project was named after SALUS,the Roman goddess of health and well-being. Thefirst two letters, SA, also marked the project asbelonging to South Australia.

Consolidating the structure

As a centrally funded project, the SALUScommittee structure needed to be formalized tocomply with the Department’s guidelines. AMemorandum of Understanding (MOU) wasdrafted, which was signed by the CEOs of all DHSagencies. The MOU can be viewed at: http://www.salus.sa.gov.au/mou.rtf. A ConsortiumManagement Committee (CMC) was formed tooversee the implementation of the project.Reporting to the CMC a subcommittee, theConsortium Technical Advisory Group (CTAG),



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was created comprising member librarians withInformation Technology expertise. The role ofCTAG is to evaluate both current and potentialnew products as well as answer technical queriesfrom less-well versed members of the Consor-tium. The CTAG Terms of Reference can beviewed at: http://www.salus.sa.gov.au/Documents/CTAG%20terms%20of %20reference.pdf.Consortium members elect the CMC annuallyand membership of other Consortium sub-committees is by self-nomination with theendorsement of the CMC. More informationabout committee structures can be found at:http://www.salus.sa.gov.au/background.html.Regular meeting schedules were set up with cleargoals for members and the Project Manager.

The initial task of the Project Manager was toinvite tenders for the development of a projectwebsite. The website was crucial as not all govern-ments agencies had intranets capable of pointingto the information resources bought by the project.Many DHS staff didn’t work in a traditional officeenvironment. This made the Internet the deliverymechanism of choice and made the establishmentof a project website a high priority.9 Initial projectfunding included provision for the construction ofa website. While the Consortium had a clearpicture of the site’s content, the website design wasoutsourced to a web design company, whoprovided maintenance for 12 months. As the sitewas to be used by DHS workers in remote areas, thedesign of the website was kept simple to ensure asrapid download time as possible. Currently, thewebsite is maintained by members of theConsortium Technical Advisory Group.

Ongoing planning

Rather than leave the running of the project to theProject Manager and the various committees, andgiven that there was a 12-month limit on centralfunding, it was decided to hold regular planningdays for all professional library staff. In practice,that meant nearly all librarians employed by theDHS. This was not as unwieldy as it might at firstseem, as the total number was about 30–35 people.The Planning Days were run in the nature of aretreat and were facilitated by experiencedmeeting leaders who had been thoroughly briefed

in advance and who provided an in-depth reportfollowing the days’ activities.

One of the results of Planning Days was theestablishment of a discussion list to facilitatecommunication between members. This hasproved to be extremely effective, both as a vehiclefor circulating minutes of meetings as well as ageneral communication tool for Consortium-related questions.

Benefits and drawbacks

The benefits and drawbacks of our project can bebest summarized thus:

Benefits

• Cost effective in delivering a wide range ofonline information.

• Has achieved statewide access for DHS staffwith minimum outlay on infrastructure.

• Promoted the concept of health information inelectronic format, facilitating the move awayfrom print.

• Raised the profile of health libraries.• Its formalized structure has encouraged official

DHS recognition of the Consortium as theforum for government health libraries.

Drawbacks

• As a librarian centred project, it has lacked highlevel political influence.

• There is no guarantee of continued fundingbeyond the initial implementation phase.

• Non-DHS groups are excluded as being outsideour remit, for example, metropolitan generalpractitioners and private hospitals.

• The managerial autonomy of some institutionsis restricted by the need to financially supportSALUS.

• Inter-library cooperation is crucial for thecontinuity of the project and depends onthe willingness of the library managers tocollaborate.

Lessons learned

In the initial planning phase of any such project, itis important to secure ongoing commitment to the



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project from the library and managers of allparticipating institutions. The mechanisms forplanning, implementing and evaluating the servicemust be considered, but goals set for the projectmust be realistic and achievable. The involvementof senior managers and clinicians will help securelong-term political support. There must also bethe capacity and willingness to concentrate onoutcomes and not be side-tracked by process. Theavailability of technical and project managementexpertise is crucial in this. If it isn’t available fromwithin the group, it should be brought in.

Project roll-out will be delayed (perhaps stalled)unless implementation takes place in realisticstages. Enhancements can follow after the coreproducts are established. It is important to getsomething up and running quickly to establishthe project’s credibility. Keeping all consortiummembers informed of progress at all times isvital at this stage to ensure that every member feelsthat they are part of (‘own’) the project. Theimplementation phase is also a good time to try tosecure guarantees of commitments to long-termfunding, preferably over and above the libraries’budgets.

Most importantly, the project needs to bewidely and aggressively marketed to potentialusers. Marketing goes hand-in-hand with usereducation, together with the education of alllibrary staff who will be working with the project.This is essential. Unless the users have the neces-sary skills, they will not use the service, and theproject will fail. Training must be integral to anytechnologically-based project to ensure its success.

Any project of this nature is very time demanding.This must be recognized at the outset. It is one ofthe reasons for securing guaranteed commitmentsfrom library managers and for tackling the projectin manageable stages.

Finally, the implementation of a new service,such as our project, requires a shift in philosophy.The move from a paper to an electronic-basedservice is a major change in the way library ser-vices are delivered and perceived. Such a significanttransition requires adaptability from both librarystaff and users.

Conclusions

From the beginning of the project in 1999, theSouth Australian Human Services Libraries’Consortium has resulted in an increasingawareness amongst users of the volume of materialavailable electronically. Many have become awareof their library as a dynamic service in ways theymay not have previously contemplated. The aim ofany health library service is to get information tothe clinician or researcher when they need it, in aform in which it is useful. The SALUS project’scentral achievement has been to ensure equalaccess to clinical information to many healthprofessionals regardless of location.

References

1 1995, Cheng, G. Y. The use of benchmarking in improved library service quality of devolved management. In: Cree, J., ed. Synergy in Sydney. Sixth Asian Pacific Specials, Health and Law Librarians Conference. Proceedings; 1995; Sydney: ALIA & ALLG, 111–21.

2 South Australian Health Commission Libraries Consortium. Health Knowledge for Better Health. Project Proposal. Adelaide: SA Human Services Libraries Consortium, 1999, 11.

3 Marshall, J. G. The impact of the hospital library on clinical decision making: the Rochester study. Bulletin of the Medical Library Association,1992, 80(2), 169–78.

4 Ali, I. Library provided information and clinical decision making; a study of two hospitals in Canberra, the Canberra study. Australian Academic and Research Libraries, 2000, 31(1), 30–45.

5 South Australian Health Commission Libraries Consortium Working Group. Business Case. Adelaide: South Australian Health Commission Libraries Consortium, 1997, 10; 34.

6 Sladek R. The South Australian Human Services Libraries Consortium. Health Inform 1999, 8(2), 5.

7 South Australian Health Commission Libraries Consortium. Business Minutes. Adelaide: South Australian Health Commission Libraries Consortium, 1998.

8 World Health Organization. Declaration of Alma Ata. In: International Conference on Primary Health Care; 1978, 6–12 September, Alma Ata, USSR: World Health Organization, 1978.

9 South Australian Health Commission Libraries Consortium. SALUS: http://www.salus.sa.gov.au.

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