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Health Information Forum: Working together to improve access to reliable information for healthcare workers in developing and transitional countriesHIF13: Access to reliable drug information: adapting information to the needs of the end userVenue: British Medical Association, Tavistock Square, London, WC1H 9JR Date: Tuesday 5 September 2000 Contact: Neil Pakenham-Walsh Telephone: 01865 249909 E-mail: [email protected] The objective of the meeting was to inform and exchange views and experiences with a specific focus on ADAPTATION of reliable drug information for different target audiences. Many of the issues are generic. These notes will therefore be of interest to ALL those involved in improving access to appropriate health information. Chair: John Hudson (Publisher, BMJ Books) Participants
Andrew Chetley announced that DFID had approved funding for the UK Health Communications Partnership, which will be called Health Communications Exchange, or Exchange for short, a networking and learning programme on health communications for development. Exchange will work in close cooperation with INASP-Health/Health Information Forum. Further details at < www.healthcomms.org > EMAIL CONTRIBUTIONS TO THE MEETING (extracts) EMAIL CONTRIBUTION 1: Mariam Cassimjee, KwaZulu-Natal Pharmacy and Therapeutic Committee, Addington Hospital, Durban, South Africa. < [email protected] > KZN PTC is looking at the best methods of disseminating decisions of the committee to all prescribers and pharmacists. E-mail, intranet, printed copy for those areas which have not the electronic facility? In S Africa, there are Primary Health facilities which do not have a telephone. Primary Care Nurses are now dispensing and their training is being enhanced through distance learning. Whilst the importance of the correct data and decisions reaching all in the health team for enabling the rational use of medicines cannot be overstressed, the level of information and a user friendly approach are the tricky bits. All the team members have a different level of Pharmacology. No doubt it is a challenge and can be done but it does need some hard work. The other aim is to develop a culture of seeking drug information for better outcomes. The KZN PTC is looking at developing this aspect as well and to date has acquired the computer together with internet facilities. The S African Essential Drug Programme offices are equipped to assist and are an e-mail away. EMAIL CONTRIBUTION 2: Natalia Cebotarenco, DRUGS Pharmacological Information Centre, Moldova < [email protected] > Report of the Networking meeting on Essential Drugs in New Independent States, Association DRUGS, Moldova, June 2000, Chisinau, Moldova. This conference brought together representatives of religious organizations, community and NGOs from Moldova, Ukraine, Russia, Armenia and Tadjikstan. The report covers three main areas:; Humanitarian Drug Assistance; and Drug Information. 1. Essential Drugs and Rational Drug Use. 'Practically all drugs are available either on the internal market of the country or in the neighbouring countries, and what is more, without prescription. It is difficult to talk to a physician about rational choice of drugs in conditions of boundless freedom' 2. Humanitarian Drug Assistance. There are multiple deficiencies in the operation of many drug donation programmes, but 'When it comes to any assistance . . . many recipients remember the saying “Do not look the gift-horse in the mouth”.' 3. Drug Information. 'Notwithstanding the abundance of pharmaceutical advertising, unbiased drug information is not fully accessible to the majority of drug consumers. The printed sources of information are not numerous and they become obsolete very quickly. Often they are expensive to most of the physicians and pharmacists.' EMAIL CONTRIBUTION 3: Randal Franzen, STAT!Ref Electronic Medical Library, Teton Data Systems, USA. < [email protected] > '... the computer has changed the way the entire world exchanges information. One only has to look at the existence of HIF-net at WHO to see that we are at an age where people from around the world are communicating with each other in an entirely new way. Our STAT!Ref software provides accurate and current drug information in an electronic library . . . We at Teton Data Systems are here to support the Health Information Forum, the World Health Organization or any group that seems to take the lead in the electronic distribution of information. We are open to help in building custom libraries for locally relevant information, support training and negotiate with publishers to provide information at discounted levels for those people of the world that need help. I would be happy to supply anyone with a free trial of our STAT! Ref Electronic Medical Library upon request.' EMAIL CONTRIBUTION 4: Stein Lyftingsmo, Manager, The Hospital Pharmacy of Elverum, Norway. < [email protected] > It was in Bosnia I really discovered the importance of an internationally used and accepted drug classification system. In the UN forces in Bosnia there were personnel from at least 20 nations, and after a while they were supposed to have their medical supplies through the UN system. UN did not have a drug classification system (nor a pharmacist!) of their own. Neither did NATO. And neither of them used the system chosen by WHO, but tried to do it with the alphabet. Russia, US, UK, Germany and France all had their own national classification systems. Imagine making a drug inventory under these circumstances. Take as an example a strong analgesic, fixed combination of acetaminophen and codeine. The only common system is the alphabet, and should we place the product under A, P, C or K? (Acetaminophen has the generic name paracetamol in Europe, and codeine is written as kodein in many languages.) Imagine purchasing medicines (nationally) in countries with poorly developed health systems. Imagine building up drug supplying systems, and drug information systems in such countries. Imagine making a pharmaco-epidemiological study in more than one country. Try to find any drug database (that tries to be international) that has a drug classification system that is used by more than its home nation. The drug authorities in some large, rich and well established countries are doing much harm to the rest of the world (and to themselves) by not looking beyond their own borders in this matter. Drug information is a vital component in sustainable and safe health services; therefore the different drug information functions must be outlined in the national drug policy and be based on the essential drug concept. They must also be resourced. At a national level every country needs access to information that is global, normative and standard setting: to use for central functions; and to assess and process for national and sub-national uses. National drug regulatory authorities must have access to quality information of different kinds to fulfill their many responsibilities. In addition to the core regulatory functions of registration, licensing and regulation they must:
They must therefore have access to adequate finance and know-how as well as technical drug information and market information. Since health sector reform was adopted during the past decade, many national responsibilities have been decentralised - without resources or support - and liberalisation has increased the availability of drugs in the private sector. Therefore drug information functions at the local level (district and below) are much more complex - and echo many central responsibilities: managers now handle budgets for procurement and manage the district pharmaceutical services. Ensuring that drugs are used correctly by prescribers and consumers is only one aspect of ensuring sustainability and safety in the pharmaceutical sector. It is often impossible to meet the national and local responsibilities because understanding of the importance of the drug information functions is lacking. There are few quality sources of information to work with, little technical support, and even where good work is done - for example Sri Lanka - they do not have the money to up-date and sustain progress. How, therefore, could we help? 1. Promote the cause of drug information as a necessary component of health services through an advocacy plan addressed to governments and donors (raise the profile of specialist pharmacists capable of undertaking these complex tasks, and the economic benefits of supporting them in national and district drug information services). 2. Ensure that expensive books are available at an affordable price – and that at least national authorities and drug information services receive the newest versions.. Subsidise the prices if necessary 3. Challenge the publishers to produce a CD-ROM which includes a selected list of the most essential texts. 4. Encourage international discussion and support networks, such as the International Network of Drug Information Services (INDICES) to broaden their support to include training and distance learning modules. 5. Ensure wide distribution of excellent free materials such as 'Practical Pharmacy'..which can be adapted to local needs, and publish 'Where there is no Pharmacist'. SPEAKER 2: DINESH MEHTA: Reliable information on medicines for healthcare workers Much of what I have to say is based on our experience of constructing a prescribing manual (British National Formulary) for the UK and a very limited experience of some of the issues relating to the construction of a resource suitable for use in resource-poor areas. I will first talk about what I believe are the information needs of the healthcare worker - in relation to medicines. Then I'll describe the important features of a resource on prescribing information. The main part of the presentation will be a discussion about getting good information to the healthcare worker. This then leads to some issues that need to be considered when constructing information for a resource-poor area. We have done some work with the WHO to construct a model formulary. I'll be able to tell you just a little bit about this. Finally I hope to mention issues other than information sources, which play a crucial part in any policy to promote rational use of medicines. And we will look at some criteria by which to judge a prescribing information resource. A. What the healthcare worker wants to know about medicines
First, the healthcare worker needs to be able to quickly identify the best drugs or drug groups for a given condition. Second, the healthcare worker needs to match the drug to the patient and the patient's condition. This may mean further refining the choice. Side-effects and warnings about the medicine need to be considered on an individual basis. The healthcare worker will also need some practical information - such as who the medicine is available from, how much it costs and what the legal restrictions on its use are. Finally, we need to remember that healthcare workers who do not prescribe or dispense the drug may also want to learn about any medicine that a patient is taking. B. What are the requirements of a good prescribing resource? A good prescibing resource needs to be:
C. Getting information to the healthcare worker We first start with the existing influences on the prescriber (see graphic 1). Many of these influences might exert their effect in a way that antagonises rational use of medicines. The promotion of medicines by the industry is not always consistent with policies on rational use of medicines. Similarly, the strong expectations of the patient may also make it difficult to use medicines effectively. The cost of medicines may also occasionally force the prescriber to opt for a less effective or a less safe option. Three influences that might perhaps help include what the healthcare worker might find in a good textbook or in a properly-constructed summary of product characteristics or advice from an informed expert. But none of these influences take account of what is now regarded as the proper basis for practising clinical medicine - I mean good evidence. In order to offer patients the most effective treatment, practice must be moulded on the result of good research and systematic reviews of the literature. At the risk of upsetting some people I would suggest that it is best to use experts to interpret the knowledge and to work out what impact any new evidence has on the local clinical practice. That expert assessment should take on board not only the evidence but also the views of expert clinicians, regulatory information and local traditions about the use of medicines. The result of all this analysis - as authoritative practical advice - is then passed to healthcare workers at the sharp end. The dissemination could take the form of bulletins, guidelines or formularies. The prescriber thus receives practical, authoritative and up-to-date information to use in the clinic. The healthcare worker can use this information to counter any biased information. D. What are the special needs of resource-poor countries?
E. WHO Model Formulary The WHO is constructing a Model Formulary. It takes on board some of the principles mentioned here. The formulary is constructed around the list of essential drugs. The essential drugs list is arranged by conditions - the formulary will follow the same classification. It recognises that there may be few other alternative sources of reliable information and therefore the information about each drug will be fairly comprehensive. The WHO expects that the Model Formulary will be adapted to local needs. However it hopes that the formulary will not only provide reliable core information on the drugs on the Essential Drugs List but it will also provide a template for the construction of local information. F. How do you make rational drug usage work? The availability of good information about medicines is not enough. Other elements need to be in place in order to achieve a good standard of prescribing:
Robust legislation and effective enforcement are very important in the implementation of a programme for rational prescribing. G. How do you judge an information resource? First, who produces it and to what end? To sell a product or to cut down the prescribing cost? To inform about new/unorthodox treatments or to provide the best evidence-based information? How does it marry the evidence base with grass-roots clinical practice? How up-to-date is it? Even the best evidence-based guidelines become dated. Does the resource take into account all the changes to licensed information as well as any emerging safety concerns? How widely is it used? Is the resource shared by doctors, pharmacists, nurses and other health professionals? By primary care and secondary care? Does it cover the widest spectrum of prescribing circumstances? Can the source be used independently of other sources? Does it for example include appropriate non-licensed doses? Does it include information about prescribing? Such as how much of a cream to prescribe, how to work out children's doses. Finally, what scope do the practitioners have to influence the content of the medical resource? SPEAKER 3: ANDREW HERXHEIMER: Information for different groups: the Chinese box model The aim of producing and distributing information about drugs is to encourage their appropriate use. Appropriate use involves the people who take medicines, and those who administer them to others, or sell them, or prescribe them. Each of these four groups needs its own set of essential information about a medicine to handle it correctly and to communicate effectively about it with people in the other groups. Each set can be regarded as a different selection from the set of 'complete' information about the medicine - i.e. all that is known and believed about it. Doctors need to know most, patients least; the needs of pharmacists, nurses, drug sellers come in between. These different sets of information must be consistent or even congruent in terms of content. But they will often differ in size, form, emphasis and vocabulary because they must be adapted to the recipients' level of education and understanding. Consistency cannot be checked if an information set is developed for only one target group. Ideally congruent sets for all target groups should be developed concurrently. The small groups looked at three different 'levels' of target audience: those with minimal, moderate, and high levels of medical/prescribing knowledge. The groups were asked to focus particularly on the basic information needs of end users in 'resource-poor settings'. GROUP A. Adapting drug information for prescribers with minimal or no medical knowledge – eg (some*) community health workers, drug sellers, and family members/consumers. (Note: * The word 'some' is used in all categories, in recognition that there is a large variation within each subgroup and overlaps across the groups. Some pharmacists, for example, may have more background knowledge than most doctors.) The group considered how people get information on drugs. Oral traditions, radio, TV and audiotapes, other media, drug sellers, local pharmacies, drug distributors, schools and teachers are all used as channels for information dissemination. Despite this, people's beliefs continue often to be based on myth. Key messages:
GROUP B. Adapting drug information for prescribers with some medical knowledge - these prescribers might include (some*) nurse prescribers and pharmacists. Some district health workers get lists of selected drugs - others nothing at all. Private medicine is flooded with proprietary information, which is often biased. Key messages:
GROUP C. Adapting drug information for prescribers with substantial medical knowledge - these prescribers might include (some*) doctors. The group focused on adaptation of content rather than the medium or distribution. Key messages:
Initial discussion centred around the breakdown of health and drug information systems in newly independent states as well as developing countries - thus leaving millions unprotected from "the dangerous rubbish from the market place". Major concerns were expressed about the number of unregulated drugs circulating in developing, transitional and 'new' countries. It had, for example, been estimated that 75% of the drugs in Nigeria were 'fake'. It is important that drug information is seen as central to an efficient health system and there is a need to find individuals in each country who can play this central role, and for their work to be supported both financially and technically. Where possible, local health workers should have an influence on the content of drug information materials, as part of a cyclical process of materials development, distribution, use, feedback, and development of new and better materials. The importance and problems of producing a CD-ROM with information that has been updated regularly was discussed in some detail. The problems are finance, copyright and the costs of distribution. It was suggested that a CD-ROM with training material and best-evidence information might be attractive to a wide range of support. 'HIF-net at WHO' could be used as a vehicle to mobilize for this, and a small group of interested parties might be encouraged to take the matter forward to appropriate donors. Regarding 'in-kind' support, the organization STAT!Ref has the technology to make an easily searchable CD-ROM of essential drug information texts. The systems and structures should use the networks (e.g. health systems and libraries) that are already in place. These could be expanded and would ensure that any system was in touch with what people wanted for themselves. The situation varies enormously from country to country. Finally it was pointed out that Drug Information was a 'case study' and hence relevant to other types of health information. The lessons learned in one area can be transferred to another, and this might open up the discussion on 'HIF-net at WHO' to good practice whatever the subject of the information. Acknowledgement: INASP-Health is grateful to the British Medical Association for the provision of complimentary room facilities for Health Information Forum meetings. The Health Information Forum is run as an activity of INASP-Health, a cooperative network for organizations and individuals working to improve access to reliable information for healthcare workers in developing and transitional countries. Participation is free of charge and without obligation. INASP-Health is supported by the BMA, Danida, ICSU-Press, and WHO. INASP is a programme of the International Council for Science (ICSU). |
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