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Since its launch in 1949, the British National Formulary has developed
enormously. Almost all of that development has taken place in the latter
half of its life, starting with its transition from a book of standard
formulations to a prescribing guide in 1981 and, most recently, to the
introduction of handheld digital versions in 2003.
The BNF’s first venture into the digital age was in 1995 when an
electronic format was launched to provide immediate support for electronic
prescribing systems. This was followed, in 1999, with CD versions that
could be used on stand-alone PCs or via an intranet and, in 2000, by
its launch on the internet with free public access in the UK.
PDA (personal digital assistant) versions first became available in 2003
and can now be obtained from two different suppliers — Medhand
and Skyscape — in formats that can be used on almost any hand-held
device.
But developments in the digital realm for the BNF do not end there. The
BNF has been available as part of the EMIS system for some time and work
is under way to make it possible to integrate BNF information seamlessly
with other NHS clinical systems using accepted standards, such as the
NHS dictionary of medicines and devices (dm+d) and SNOMED-CT (systematized
nomenclature of medicine — clinical terms).
A pilot project with the Microsoft Common User Interface used by the
NHS is also under way. This will make it possible to access BNF data
direct from a deskbar that sits at the bottom of computer screens without
having to launch an application first. Links to BNF data from within
Microsoft Office documents will also be possible.
Dominic Vaughan, BNF publishing director, says that steps to integrate
the BNF with core NHS systems have been under way for some years.
“Research suggests that, in its various formats, the BNF is used
more than three million times a week. So having it on the desktop, and
being
able to click through to it seamlessly, should be a tremendous advantage
to the NHS,” he said. “Digital access is a key part of our
commitment to provide excellence at the point of care.”
Commenting on the deskbar, Saul Marmot, a GP in Tower Hamlets, London,
said: “This is really good. I just type a phrase and it brings
up lots of references. … I also like the fact that you can misspell
a word and it will have a good guess at what you are looking for. That’s
very useful if you are working quickly or a drug name has changed recently.”
Another feature under development makes use of the research pane available
in Microsoft’s Office suite of applications. Using this, drug names
can be highlighted so that the research pane displays relevant information
from the BNF and BNFC, sourced via the internet.
Why do we need the British National
Formulary
Some people might wonder why the BNF range of products is needed
at all, given that medicines in Britain are subject to the rigorous
licensing systems operated by the Medicines and Healthcare products
Regulatory Agency and the European Medicines Agency.
The answer to the question is provided by the existence of the
BNF for Children.
Produced under the authority of the Paediatric Formulary Committee
and published jointly by the Royal Pharmaceutical Society, the
British Medical Association, the Royal college of Paediatrics and
Child Health and the Neonatal and Paediatric Pharmacists Group,
the BNFC describes how medicines are used in practice, which can
be very different from their licensed uses. One of the drivers
behind the BNFC is the fact that licensed indications frequently
do not cover the clinical needs of children.
In the same way, the licensed indications and usage of medicines
for adults frequently lag behind actual clinical practice.
This means that editorial processes have to be particularly rigorous — which
they are. And the expertise of the BNF editorial team is such that
the World Health Organization used them to produce its model formulary.
Recent research conducted by TN Healthcare shows that the BNF and
BNFC are the first place most health care professionals look for
authoritative, practical and up-to-date information on the selection
and clinical use of medicines in a safe, clear, concise and accessible
manner. |
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Smaller and lighter than the book, the BNF is
now available on PDAs
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Users’ views
Cecilia Tse, formulary and medicines management pharmacist at London’s
Northwick Park Hospital, is a great fan of the intranet version of the
BNF. “We use it a lot,” she said. “It has facilities
to link the electronic BNF to our trust guidelines. That means it’s
a one-stop reference.”
But she adds that the system does not allow multiple links to be created,
which she sees as a drawback.
Mr Vaughan says that when the intranet version was first brought there
were a number of requests for multiple linking. “These have been
developed and it is now possible to include any number of hyperlinks
within a BNF record to external resources,” he said.
The trust can also give GPs access to the BNF on its intranet by giving
them extranet links.
Another enthusiast for the digital formats is Sarah Sutton, clinical
librarian at Leicester Royal Infirmary.
Describing the PDA version available from Medhand, she said: “The
idea of carrying the BNF around in your pocket [in a version] smaller
than the book is excellent. And you can access it on the same device
as you keep your diary, contacts, and even your e-mail. I also like the
idea of carrying it around with you in the latest version, which you’ve
always got if your subscription is current. Often, when you’re
on a ward the only paper version available is out of date.”
Malcolm Furnell, senior pharmacist at Royal Sussex County Hospital, Brighton,
shares Ms Sutton’s view of the benefits of having the BNF in portable
digital form.
“It’s a handy electronic version that’s easier to carry round
than the book,” he said.
Plus, the Medhand PDA version comes on an SD (secure digital) card that
can be inserted into the USB port of a laptop computer, as well as fitting
into a PDA.
“It was OK,” he said. “The links were fast, although I had
issues with the icons and how to access past information and my bookmarks.
I’m quite pleased with it. It’s just different from online
and the book, which means its another version to get used to.”
But Ms Sutton, an information professional, warns that the current electronic
formats, both on the internet and PDA, are not without their limitations.
“The interface of the electronic formats doesn’t take advantage
of all the benefits of being electronic. It takes you off to some parts
of the data and you can’t work out how you got there. I hear comments
from doctors and pharmacists who find it difficult to use electronically.
Clinicians won’t wrestle with it — they will give up and
go away.”
As a result, Ms Sutton says, a lot of doctors don’t access good
drug information. “They’re Googling for it instead. That’s
scary!”
Ms Sutton also believes strongly that add-ons, like dose calculators,
should be built into the electronic versions. These could ask for the
appropriate figures for the drug, such as weight or height, to be entered
and then give the dose. They could even warn if the result was outside
the expected dose limits if someone entered the wrong data.
“If the BNF says what the calculation should be for any drug, why not
put it in? That could be in the online version as well.”
Mr Vaughan said: “We are working with systems suppliers to provide
dose-range checking functionality at the point of prescribing. This will
be based on patient details (age, height and weight) from the clinical
system that interacts with the BNF dose information via SNOMED-CT codes
that identify the indication and NHS dm+d codes that identify the medicine
or preparation required. Development of a dose calculator, initially
for BNFC, is also at the planning stage.”
A brief history of the BNF
What is now known as the British National Formulary started life
as a palm-sized hardback book issued by the British Medical Association.
The National Formulary for National Health Insurance Purposes was
published in 1929 on behalf of the then National Insurance Defence
Trust.
Intended for use by both doctors and pharmacists,
it contained 79 pages of standard recipes for commonly prescribed
medicines.
Its pages were interleaved with blank lined pages on which users
could add their own notes. That slim volume lasted almost 20 years
before a joint committee of the BMA and the National Pharmaceutical
Service decided that a new joint committee of the medical and pharmaceutical
professions should compile a standard prescribers’ formulary.
The resulting National Formulary was published jointly
by the BMA and the Pharmaceutical Society of Great Britain under
the guidance
of the Joint Formulary Committee in 1949. That committee endures
to this day and still guides publication of the BNF.
The idea behind the 1949 National Formulary was that it should
be “a volume of convenient size that may be carried in the
pocket”. The current series of the BNF still manages to achieve
the same objective despite the huge increase in the number of drugs.
Its
first issue, in 1981, contained 341 editorial pages, plus a 40
page index and, from personal experience, fitted comfortably
in a lab-coat pocket. However, after only a few six-monthly issues,
its increasing size and weight meant that it was starting to become
inconveniently bulky.
The most recent issue, published last week — BNF
54 — has 893 pages and a 41-page index. It still manages
to fit in a lab-coat pocket, and has managed to keep its weight
down to a mere 572g by being printed in small type on bible-thin
paper. |
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The
Pharmaceutical Journal