GP Dr Harry Brown continues his exploration of the use of IT in general practice by mapping the trend away from print-on-paper prescribing support.


Dr Harry Brown GP Leeds

I would guess that virtually all of us have been brought up on and still use the paper edition of the British National Formulary – or simply BNF as most of us call it – as a valued and trusted source of prescribing and therapeutic advice. It has certainly evolved over the years, generating web versions, apps and sister publications (BNF for children), and it also appears on that modern showcase Wikipedia - see http://en.wikipedia.org/wiki/British_National_Formulary. But most of us probably still depend on and use the printed edition, which is refreshed twice a year. Not only is the content updated but often the booklet gets battered and tatty due to its constant use, so it’s nice to get a fresh, new printed copy. 

However in this ever-changing technological climate, the paper edition may now no longer be our main source of information. Until now, free copies of the BNF have been landing on our desks twice a year, in March and September, something that many of us have taken for granted. But there was no free version of the BNF available in March 2014. From now on, distribution will be annual, with the next free paper update from NICE appearing in September 2014. (Note that this policy change does not affect the current distribution of the BNF for Children.) 

Although many of us (and I would guess the majority of GPs) probably use the BNF on a daily basis, maybe we should not be that surprised. Paper-based distributions of any book are expensive and we are living in the digital age where most publications are migrating or have already switched to an electronic platform. Not only is this more cost effective for the publisher, but updates and new information can be added more regularly, searches can be faster and more accurate, and even multimedia could be included.

Prescribing in the digital age(1)

How do we adapt? 

If you really cannot manage without a print edition and still want the full print cycle then you can buy it from the publisher http://www.pharmpress.com/BNF. Or you can wait for the annual free version – but bear in mind that your current paper edition may be out of date. I suspect that many of us will move either online or to a digital version. For those of us in the UK, we do have some cost-free options. I would recommend spending some time reading http://www.nice.org.uk/mpc/BritishNationalFormulary.jsp, which gives NICE’s thoughts about the free distribution of the BNF both for adults and children and provides links to free digital resources. 

The adult BNF online can be found from here: http://www.evidence.nhs.uk/formulary/bnf/current. The good news is that there is no password, no registration and it is regularly updated. In fact this resource is open to anyone including patients as well as health care professionals, and I applaud its ease of use and accessibility. At the bottom of the page there are links to some excellent therapeutic and prescribing resources. Of course, being a website, there is no limitation on the volume of information that can be made available, though of course there is a risk that the user can be overwhelmed. You can see the attractions of withdrawing partial funding for the paper edition and switching to a free and accessible digital resource. Similar comments apply to the BNF for Children website accessible from here: http://www.evidence.nhs.uk/formulary/bnfc/current. Rather than trying to remember the addresses or follow the links from the NICE website home page, I would strongly suggest bookmarking these sites on your browser.

GP systems

Some GP clinical systems have electronic prescribing support bundled from within them. Other benefits of an electronic clinical system include alerts about drug interactions, sensitivities and easily accessible information about past prescribing patterns. 

In the case of a home visit, where there is no access to the electronic medical record, lack of access to these support and safety services can make prescribing a little trickier, although some clinical systems can allow access via a secure laptop over a mobile network. This can be time consuming, potentially clunky and relatively slow, unless of course you use an internet-enabled smartphone or tablet to navigate to the BNF online – and provided that you have fast internet access. But there are some pretty good apps available, and a launch pad can be found at www.nice.org.uk/aboutnice/nicewebsitedevelopment/NICEApps.jsp, which allows access to free apps to qualifying NHS staff in England, Wales and Scotland. If you don’t have a NHS Athens account, then the NICE webpage just mentioned has signposts on how to register. Apps are available for both Apple and Android systems, and once downloaded, they do not require internet access and can work offline, until they need updating. 

Incidentally, the same webpage that gives access to the apps also provides a link to the NICE guidance app, again available for both Apple and Android, and gives you access to a substantial and useful resource which can be updated

Other kids on the block 

Of course, there is more to electronic prescribing support than NICE guidance and the BNF. The long established MIMS is also available online at http://www.mims.co.uk/. Interestingly, the paper publication has recently gone from monthly to quarterly for reasons broadly similar to those for the changes to distribution of the BNF. 

MIMS too has spawned apps for both Android and Apple products offering off-line use, available from http://www.mims.co.uk/mims_specialist/article/1119541/ MIMS-app/. In this case, there is a cost to access, although the price is relatively modest. 

There is also the hugely detailed Medicines and Healthcare Products Regulatory Agency website http://www.mhra.gov.uk/, which provides a wealth of prescribing information. To save having to return regularly, you can subscribe to its email alerts. There is a GP microsite at http://www.mhra.gov.uk/ Safetyinformation/Healthcareproviders/ Generalpractice/index.htm which I would also recommend as helpful for GPs who find that not everything on the main site is relevant to them. Similarly, residing within the NICE main site is another easy to miss microsite, http://www.nice.org.uk/mpc/, another great launch pad with a whole wealth of prescribing and therapeutic information of use to a GP or primary health care team. 

Of course, you don’t have to restrict your search to the United Kingdom; on the internet the world is your oyster. Do bear in mind that regulations and prescribing culture vary from country to country and not all the data will be applicable to UK practice. Even so, such publications can make useful reading and one good example is Australian Prescriber at http://www.australianprescriber.com/.

Conclusion

The change in the paper distribution of the BNF may trigger an adjustment in the culture of the prescribing reference materials you may use. For some this may precipitate a switch to digital resources and this article has hopefully given a flavour of what is available.