Dog-eared and stuffed into the pocket of a white coat, the British National Formulary is a British institution.
The BNF turns 60 this year. But far from retiring, it is taking on a new lease of life with several new digital platforms either up and running or planned for next year.
The drugs bible
The BNF is an unusual beast. It is basically a guide for prescribers that is consulted more than half a million times every weekday by the NHS staff in the UK alone.
It is used across the entire health community, from primary to secondary care. It is used for adults and children (since the launch of a dedicated children’s formulary six years ago). And these days it is used by supplementary prescribers, such as nurses and physiotherapists.
Yet it is also used in primary care trusts, for monitoring the cost of drugs prescribed, in Parliament and even in court cases.
It is a commercial venture. But it is published on behalf of the British Medical Association and the Royal Pharmaceutical Society by their respective publishing houses. Its mission is to “improve the health of patients by being the authority on the use of medicines”.
It is entirely independent of both the government and the pharmaceutical industry. But it was commissioned by the Ministry of Health in 1948 and updated at the request of the Department of Health and Social Security in 1976. It also takes information from industry as one of its sources.
It is widely regarded as the authoritative source of medicines information in the UK if not the world. In compiling its regular updates, the BNF takes in an enormous range of information sources and expert advice.
As publishing director Duncan Enright says: “A considerable amount of thought and discussion is given to every phrase and sentence that appears in the BNF.”
In digital form
There has been an electronic version since 1995, with an intranet version available since 1999. Each month, 3m pages on the bnj.org site are viewed. But as of this year – and into 2011 – the BNF is going digital in a major way.
Cornelia Schnelle, managing editor for digital development and delivery at the BNF, admits that many users are still wedded to their paper copies.
The reality of life in many acute NHS trusts is that they are not fully web-enabled and even getting access to an intranet version is sometimes tricky.
But she adds: “We believe that the book will lose importance at some time in the future. Users are moving more and more towards digital devices for access to medical information and we know that even doctors are using Google now. That is very unsafe.
“We want to make sure that in this changing environment, the BNF – as the authoritative source – is available and answering users’ needs.”
BNF has developed a range of decision support modules that will be familiar to anyone who has even a passing acquaintance with e-prescribing – allergy checking, drug interaction checking, duplicate therapy checking, contra-indication checking and dose range checking.
It has also developed a number of “knowledge modules” – datasets that allow integration of referential material and dose information into clinical workflows and to aid the cataloguing of medicines.
For example, the NHS dm+d to BNF/BNFC linking file means clinical system users can navigate to information within BNF publications.
An intranet and local formulary tool allows hospitals to integrate their own local formulary guidelines into their own intranet BNF. Medication order sentences offer prescribers the option to pre-populate prescriptions for common drugs.
A BNF content hierarchy file helps PCTs with cost monitoring. So far, most of these are not yet commercially available but they have been developed – and tested – through work with trusts and suppliers.
For example, clinical decision support data sets are available for integration into Cerner’s NHS Millennium application and will be in use over the next year or so.
And BNF is working with EMIS in primary care, with McLeron Computers in pharmacy, and with Ascribe to create contextual links from their e-prescribing systems to relevant information in the BNF.
On trial in Birmingham
The BNF has also been working with University Hospitals Birmingham, which has developed its own e-prescribing and electronic records solution, PICS.
This has incorporated BNF decision support tools so that prescribers receive an alert when drugs they are prescribing are contraindicated. Users can link directly from the system to reference material in the BNF, without having to reach for a book or log out of the system.
A study presented at a conference earlier this year showed that it is possible to link trusted authoritative sources to electronic prescribing systems to provide real-time warnings that enhance safe prescribing.
It also showed how doctors react to these warnings. In the 30-month period studied, the system generated over 1.9m warnings; in only 7% of these cases did users then refer to eBNF for more detail.
Dr Jamie Coleman, senior clinical Lecturer in clinical pharmacology and medical education at the University of Birmingham, says it is interesting how few doctors check the detail behind warning.
He suggests that the mere sight of the BNF logo is enough for them to accept it. “When they see the brand information warning, they feel reassured that they are getting the right information for the patient at hand,” he says.
However, the lack of reaction could reflect alert fatigue among doctors. This is, after all, one of the acknowledged drawbacks of e-prescribing systems.
Schnelle says: “It is very difficult for systems to know who is using the system and what background knowledge they have.
“Some systems have gone down the route of ‘if in doubt, send an alert’ and while that can be perceived as safest, in a day to day environment it can lead to a situation where prescribers receive a lot of alerts that are either not relevant or not serious.
“So instead of acting on them, they start to ignore them altogether or switch off the alerting system, which defeats the object.”
Dr Coleman thinks over-alerting is not the problem in Birmingham. For one thing, the numbers checking references when they receive an alert is increasing month on month as users become more familiar with PICS.
Electric future
BNF is now planning a study to test how doctors react to warnings with Newcastle upon Tyne Hospitals NHS Foundation Trust, which is a Cerner Millennium user. This will look at how many alerts they receive, how many are heeded and lead to clinical change and how many are overwritten or ignored.
As the BNF goes digital, book users need not fear for its future. However, those switching to digital systems may soon find that they have an empty pocket where their trusty hard copy once sat.