A picture paints a thousand words, and in the field of medicine, images are essential. The recent launch of MIDRIB (Medical Images Digitised Reference Information Bank)  , and the announcement of the Visible Human Dataset UK Mirror, have demonstrated JISC's  determination to provide high quality content in this area for the UK higher education and research community.
Medical images are extremely diverse in both their content and modality, and can range from illustrations of medical equipment, to radiological images, to 3-D objects. Using images in medical and healthcare education allows complex concepts to be conveyed and adds impact that is not present in textual information. As undergraduate teaching moves toward problem-based learning (PBL), it becomes essential that students have easy access to a wide range of relevant images. The rise of technology-based learning brings with it a need for high quality medical images in electronic form. At present this can often only be answered from small collections held by individual lecturers or departments. MIDRIB seeks to harness that effort for the benefit of the entire community; it is about making teaching and learning more effective by creating a comprehensive national resource.
Compered expertly by Geoff Watts of Radio 4's 'Medicine Now' fame, the launch of MIDRIB was held at the Royal College of Surgeons of England on February 27th 1997. The day's proceedings began with a fascinating tour through the history of medical images by Professor Heinz Wolff. He stressed the need to encourage learning, by placing deliberate obstacles in the way - hooks on which information may be attached, so as to create permanent footprints on the mind - otherwise images alone may simply add to the current flood of preprocessed information. We heard throughout the day how MIDRIB plans to build such hooks around the images.
As Alice mused: "what is the use of books without pictures and conversations"; and, indeed, an important part of the eLib Programme relates to the digitisation of images. It fell to Dr Anne Mumford (Loughborough University and the Advisory Group on Computer Graphics) to provide insights into the wider JISC picture - how MIDRIB fits in with the range of eLib Programme  projects and the JISC strategy. In particular, she highlighted how interoperability among the variety of JISC funded projects and services might allow efficient discovery and retrieval of online resources: finding information about a disease such as cholera might involve accessing not just medical images through MIDRIB, but also other networked resources (eg through OMNI and SOSIG) or photographs depicting social conditions (eg through the Knowledge Gallery).
Jill Szuscikiewicz (MIDRIB Project Manager) and Stephen Morris (Director of Information and Computing, St George's Hospital Medical School) introduced the project and illustrated how MIDRIB will be used in teaching, as a resource to support the preparation of lectures, tutorials and handouts, as a reference resource for students, and as an important resource for CAL development. A test version of the CD-ROM distribution interface was demonstrated, illustrating the ease with which it will be possible to generate simple lecture material for storage and reuse either locally or online from the MIDRIB server.
Professor Reg Jordan (Academic Sub-Dean of the Medical School, University of Newcastle-upon-Tyne), drawing on the University of Newcastle experience, discussed the role of IT-based learning in the new medical curriculum. By promoting collaboration and networking, in his vision, MIDRIB's shared resource of tens of thousands of donated images will become not only a source of clip art for CAL, but also an important learning tool for students: both in self-directed learning or revision, and also to incorporate images into projects and presentations, that are increasingly encompassed in active learning.
Distance learning will be an essential part of the medical faculty of tomorrow; already we are seeing an increased reliance on learning away from the teaching hospital, eg in GP surgeries. Images, in their many different forms, will play an important part in supporting and complementing learning at a distance. There can be significant logistical problems in developing and delivering images online, as well as issues of implementation. Projects such as SWOT (South and West of England Obstetrics and Gynaecology Trainees) and VOW (the Virtual Ovarian Workshop), described by Mr Julian Jenkins (Consultant Senior Lecturer, Department of Obstetrics and Gynaecology, University of Bristol), are beginning to explore the use of medical images remotely. Mr Jenkins illustrated how invaluable the availability of image data will be for continuing medical education across the field of medicine and healthcare.
Second-guessing how MIDRIB will be used as a teaching and learning resource and in clinical practice, Susan Gove (Librarian, St George's Hospital Medical School) provided a detailed anatomy of users' current needs, as experienced through enquiries received in the library environment. The trend towards PBL in the new medical curriculum increases the demand for learning resources, including the use of images in essays, projects and student-generated learning materials. Electronic versions of image atlases will be heavily used for revision, especially if self-testing and assessment are available. Teaching staff will use MIDRIB to illustrate PBL scenarios and interactive key cases. Library staff, through their training and expertise, will be well placed to raise awareness about MIDRIB, and to offer training and advice.
Mark Gillett (Technical Consultant, MIDRIB project) provided a fully user friendly account of the building blocks that will make up the MIDRIB system. Developed to support the information needs of the users, the MIDRIB team and the image contributors, it will support each stage from acquisition through to delivery. A rich search and retrieval system is planned so that, through a single interface, it will be possible to search MIDRIB alone or alongside other databases, either local - such as TICTAC (a database of tablets and capsules), or remote - such as other eLib databases (through WHOIS++); it is hoped that the search capabilities will extend even further afield using other remote query technologies, such as Z39.50. Tailored interfaces will also be provided where subject specificity requires this, or to support users at different experience levels. Powerful free text search options will be supported, as well as thesaurus-enhanced searching (using UMLS, the Unified Medical Language System) and browsing (using MeSH, the US National Library of Medicine's Medical Subject Headings). Additional features will include glossaries, simple templates for the creation of teaching sets and online tutorials, and a facility to import or export Powerpoint presentations.
Even digitised, images are of no practical use unless they can be retrieved. This was vividly demonstrated by Jane Williams (Director, Multimedia Research Unit, Institute for Learning and Research Technology (ILRT), University of Bristol) and Margaret Munro (Tropical Medicine Resource (TMR), Wellcome Centre for Medical Science), who described the extensive work of the MIDRIB Cataloguing and Classification Committee. Two text elements will aid retrieval: classification and descriptive information. It is this information, or metadata about an image, that will help to get images out of the slide cabinet and into the community. The metadata that MIDRIB uses will be Dublin Core / Warwick Framework  compliant. A number of different classification and indexing systems are planned to be used in MIDRIB, such that will allow searches to be performed for information about image modalities and media, by geographical location, by medical speciality (using the NHS Management Executive list of medical specialities), and by subject (using MeSH and also, prospectively, UMLS).
Much of the first year of MIDRIB has been concerned with establishing standards in advance of the project being fully implemented. Ethical standards are clearly a major concern: new technology has added a significant factor - yet also provides an opportunity to set new benchmarks, as outlined by Professor Alastair Campbell (Inaugural Professor of Ethics in Medicine, University of Bristol). The use of personal information for teaching and research is regarded as ethical only if specific consent has been obtained. It is important that the use of medical images, dealing with areas regarded as sensitive by patients, does not entail breach of confidentiality or intrusion into patients' privacy, and failure to gain consent would represent such a breach.
Assuring patients that MIDRIB will be utilised only for teaching and research requires safeguards on access to the image bank. MIDRIB is devising a registration system that will ensure that the image bank is not accessible for any purpose other than healthcare education and research. It is proposed that medical and healthcare faculties of UK universities and teaching hospitals will register with MIDRIB, signing an institutional user licence, and individual user registration will be administered locally. Images of especially high sensitivity - for example, in paediatrics - will require additional safeguards, and are planned to be available on CD-ROM only, available only to healthcare professionals or healthcare libraries (with restricted access). Patient information sheets will explain the implication of the new medium and will detail the safeguards that are implemented, so that patient consent is fully informed. An ethics committee with strong lay representation may provide a further safeguard.
While interest has already been expressed from several owners of collections of images, a formal call for contributions to MIDRIB was launched on the day. A key concern for contributors will be that of copyright. MIDRIB will seek to license the images for use specifically in UK medical and healthcare education and research, but ownership of the copyright will remain with the individual or the institution with whom the licence is agreed. Indeed, high quality medical images have a commercial value which the copyright owner might want to protect: as Catherine Draycott (Head of the Wellcome Centre Medical Photographic Library) and Jill Szuscikiewicz (MIDRIB Project Manager) underlined, under such an arrangement it will not be necessary for image contributors to forego potential future income streams.
The day concluded with an overview of how MIDRIB has collaborated so far with OMNI (Organising Medical Networked Information), the subject based information gateway funded as part of the eLib Programme to provide access to high quality biomedical networked information. Betsy Anagnostelis looked forward to future joint initiatives by the two projects in areas such as evaluation, technical interoperability, selection of medical image resources, and promotion and training, that will see MIDRIB and OMNI continuing to work closely together in supporting teaching, learning and research in the networked environment.
MIDRIB will be accessible over the academic network, at http://www.midrib.ac.uk/ . For further information, or to receive a copy of a CD-ROM test version of MIDRIB for evaluation, please contact Jill Szuscikiewicz, MIDRIB Project Manager, MIDRIB, Medical School Foyer, St George's Hospital Medical School, Cranmer Terrace, London SW17 0RE (email: firstname.lastname@example.org, tel: 0181-725 3420, fax: 0181-725 3583).