Senior Pharmacist – Medicines
Drug formularies are essential to any hospital. They list the recommended drug choices within the hospital from the many potential options that are on the market to support cost-effective prescribing.
Historically, paper has been the only way to disseminate such knowledge, usually in the form of a booklet that is published periodically. The updating and distribution of such booklets is invariably time-consuming and costly, which leads to delays in producing updated versions. Hence they are never fully up to date, and with over 2,300 different drugs to manage (not to mention the various forms of each drug – tablet, injection, and so on), and changes being made on a continual basis, a live, easy-to-access intranet-based version of the data is clearly a superior option.
The intranet-based formulary
The intranet-based formulary system that is running at the Sherwood Forest Hospitals in Nottinghamshire has been in use now for over two years. All the hospital computers link into the system, and all doctors, nurses and pharmacists have access.
In practice, while pharmacists took to the programme very quickly, it has taken longer to gain acceptance among some doctors and nurses, depending on whether or not they “like” computers. New doctors are given a demonstration of the system as part of their “hospital induction”, and a training programme for nurses is about to commence.
The formulary software was developed inhouse by the Information Services Department, using Visual Basic 4.0, “Internet Database connector” (IDC and HTX) and SQL scripts. The system runs under Microsoft Internet Information Server V4.0 running on Windows NT4.0, backed by a Microsoft SQL server 6.5, again running on NT4.0. The client uses a standard web browser to post queries and view the results from any intranet-ready PC.
Any site that already has an intranet server and SQL server could run this software without any additional costs – the only requirements are some basic programming skills and a knowledge of SQL, ODBC and HTML/IDC. The only real costs for implementing this system were time and Visual Basic Professional, as this was not already used on site. The required servers were already in place from other projects.
The intranet drug formulary is very straightforward to use – you simply type in the name of a drug on the ward computer and it shows you whether the drug is classified as “formulary”, “formulary 2nd line”, or “nonformulary”. It also shows a list of all similar drugs, and their respective formulary status.
In the UK, the British National Formulary (BNF) groups all similar drugs together. For example, section 1.3.5 contains all the proton pump inhibitors. If you ask the intranet drug formulary about one of the drugs, it will tell you the classification of all the drugs in the group. In the example shown (see Figure 1), pantoprazole has been searched for, which locally is nonformulary, but it also lists the other related drugs, which shows that lansoprazole is the formulary choice.
A very useful feature of the intranet drug formulary is the ability to offer additional support or related information. First, there is a section for short notes next to each drug, giving such information as whether there is a syrup available, and second, it will link to pages of more detailed
information (see Figure 2). For example, if you search for “pantoprazole” it will offer a link to pages such as:
- The hospital guidelines on acid-related disease.
- Price comparison graphs of the drugs.
- Relative efficacy tables of the drugs.
- Independent reviews of the drug.
These pages of further information can be intranet- or internet-based pages.
The information pages can be printed out and inserted into patient’s notes or drug charts if required.
The data is updated via a simple program that is available only to selected individuals in the pharmacy (see Figure 3). The updating process is instantaneous. As the data is changed on the pharmacy computer, it is immediately available on the ward computers.
The next step is for the local general practitioners (GPs) to be given access to the system. This will ensure that the most cost-effective drug choices and the best advice is available to the GPs in the local community. Such collaboration will help patients crossing the hospital–GP interface by encouraging use of the same drugs throughout the whole of the hospital’s catchment area.
The hospital pharmacy organises the supply of drugs and information to the doctors and nurses of the hospital. A computer system, such as the one described, is a very powerful tool for increasing the effectiveness of the pharmacy department in achieving this.
It also helps keep drug costs down by advising doctors to use the drugs that the hospital’s specialists have decided are the most cost-effective. It saves pharmacy time in policing formularies, because as the data are so accessible doctors are more willing to check first rather than guess at what may be the best choice.
The unexpected bonus of the system is that it helps to support effective and cost-effective prescribing by providing an index to drug-related guidance. Most hospitals will already have many guidance documents. The intranet drug formulary provides the perfect central index for them all. It is always available, always up to date, does not require distribution and has no printing costs.
The author would like to acknowledge John Whistler for his help with the technical aspects of this article.