Integrating a PCT formulary with GP computer systems
| Although many PCTs now have agreed
formularies, adherence to those formularies depends on accessibility
of information and ease of use. Dan Thomas reports on work in Cornwall
to integrate a paper formulary with GPs' computer systems, and
to involve pharmacists in promoting formulary compliance |
Dan Thomas is medicines management
facilitator for West of Cornwall PCT
|
In Cornwall we have a joint formulary, produced as a venture between
secondary care and the three PCTs in the county as a means of promoting
consistent and cost-effective prescribing choices. Despite almost universal
support from GP practices for the use of the formulary as the cornerstone
of prescribing strategy, adherence to the formulary has historically
been variable.
When West of Cornwall PCT asked GPs what caused prescribing outside the
formulary, these were some of the responses:
“Locums tend to be less aware
of the formulary, and it is hard to reverse their decisions.”
“The paper copy of the formulary is only updated every 18 months or so,
so may be out of date.”
“In a short consultation, it is very hard to look things up in a book,
or on the intranet.”
In order to promote greater use of the formulary, West of Cornwall PCT
decided on a two-pronged approach. First, it was decided that it would
be helpful if the information contained in the paper copy could be integrated
with GP computer systems.
Secondly, it was perceived that community pharmacists could play a role
in highlighting non-formulary choices.
The first step was to integrate the formulary with the GPs’ computer
systems, so up to date formulary information would be available to prescribers
without having to interrupt the routine of a consultation. However, the
software functionality of all the GP clinical systems was fairly limited.
Fiddly and annoying to use
Dr Nick Gibson, a GP in Hayle and the PCT prescribing
lead, tried to integrate the formulary with his system. “All we could do was
add all the drugs in the formulary into the ‘practice formulary’ on
the computer. Although this was better than nothing, it caused several
problems. There was no way of differentiating first and second line
choices. If you typed a drug name not in the formulary you found yourself
in a dead end and it was difficult to escape from the formulary when
you needed to. These problems made the system fiddly and annoying to
use, and many GPs simply turned the ‘practice formulary’ off
to avoid them,” he explained.
The PCT then contacted Microtest, who supply computer systems to the
majority of GP practices in West Cornwall. Although all GP system suppliers
are under constant pressure to keep up with the new functionality required
by the Department of Health, Microtest agreed to work on some software
changes specifically to address these problems.
Microtest created a simple PC-based tool that allowed the PCT data analyst
to put together the first and second line formularies from a drug. This
tool produces output in the XML format that should become standard in
all GP systems, allowing the sharing of formularies with practices using
non-Microtest systems.
Microtest then made some specific changes to the functionality of their
system’s prescribing screen. The first major change was the ability
to store and display multiple formularies in
order, so that a prescriber would be presented with drugs in order (first
line, second line, practice choices, etc) on a colour-coded screen.
The second major change was the facility for the computer system to redirect
a prescriber to a higher formulary choice if one were available.
A prescriber who types the name of a second line or non-formulary choice
(eg ‘pravastatin’, a second line choice) will be offered
the option of changing to a higher formulary choice (eg
atorvastatin or simvastatin, first line choices) by the system.
These two changes allow the Cornwall Joint Formulary to be
integrated almost completely with the clinical system, and mean that
prescribers will have to reach for the paper copy much less often. Consider ease of use
Georgina Thomas, pharmaceutical adviser for West of Cornwall
PCT, said “A
lot of work has gone into creating the Cornwall Joint Formulary, but
it is important that we consider how easy it is for GPs and other prescribers
to access the information. There is no point in producing an excellent
formulary if it is not used, and for those reluctant to refer to the
formulary we must make it as easy as possible. Although it is still important
to refer to the paper copy on occasion for specific guidance, if GPs
are shown which drugs are first and second line choice through the normal
routine of selecting a drug from their computer system, that could be
valuable.”
The software is now being used in practices throughout Cornwall, and
is proving popular with GPs. The content of the formulary is constantly
being refined, and will be updated on a quarterly basis after the Cornwall
and Isles of Scilly Prescribing Committee approves new drugs for inclusion.
Future developments are planned to include changes in the display, and
the facility to update the formulary remotely across the NHS Net without
the need for floppy disks. Engage with community pharmacists
The next stage in the PCT’s strategy is to engage with local community
pharmacists, and encourage them to play a part in promoting formulary
compliance. When the latest version of the formulary was produced a copy
was sent to every pharmacy, but feedback from the pharmacists showed
that it generally went onto a shelf or into a drawer and was rarely used.
The PCT team has now turned its attention to this, and hope to develop
relationships between pharmacies and GP surgeries to facilitate formulary
promotion.
A pharmacy intervention scheme is already up and running in several locations
around the PCT, and some practices are already using non-formulary choices
as a possible intervention that is payable through this scheme. Where
arrangements are not so formal, pharmacists are being encouraged to highlight
incidences to the relevant GPs when patients are prescribed non-formulary
choices without a clear indication. It is important that a method of
communication, which suits both the pharmacist and the GP, is agreed
in advance to ensure that communication is effective.
Dr Gibson said “All GPs appreciate constructive advice from their
local pharmacist, but it is important that that advice comes at the right
time and in the right way.”
The PCT is hosting an open evening for pharmacists and a workshop for
GPs, that will focus on these initiatives. It is hoped that by developing
the IT systems in the surgery and the support provided by community pharmacists,
the Cornwall Joint Formulary will become even more widely used and accepted
as the cornerstone of consistent and cost effective prescribing. |
