eDrug: a dynamic interactive electronic drug formulary for medical students

Abstract

What is already known about this subject

• Delivering education about an ever-increasing number of prescribable drugs to medical students represents a major challenge.

• Drug names are generally not logical or intuitive, and many students find learning them akin to learning a foreign language.

• Pharmacology and therapeutics teaching is struggling for visibility in some integrated medical curricula.

What this study adds

• Development of electronic tools allowing web delivery of a restricted student formulary facilitates dynamic access to core learning materials, improves the profile of this aspect of the curriculum and is highly appreciated by students.

Aims

Prescribing drugs is a key responsibility of a doctor and requires a solid grounding in the relevant scientific disciplines of pharmacology and therapeutics (PT). The move away from basic science disciplines towards a more system-based and integrated undergraduate curriculum has created difficulties in the delivery of PT teaching in some medical schools. We aimed to develop a web-based strategy to overcome these problems and improve the PT learning experience.

Methods

We designed and introduced ‘eDrug’, a dynamic interactive web-based student formulary, as an aid to teaching and learning of PT throughout a 5-year integrated medical curriculum in a UK medical school of 1300 students. This was followed by a prospective observational study of student-reported views about its impact on their PT learning experience.

Results

eDrug was rated highly by students and staff, with the main benefits being increased visibility of PT in the curriculum, clear identification of core drugs, regular sourcing of drug information via direct links to accredited sources including the British National Formulary, prioritization of learning, immediate access and responsiveness. It has also served as a focus of discussion concerning core PT learning objectives amongst staff and students.

Conclusions

Web-based delivery of PT learning objectives actively supports learning within an integrated curriculum.

Introduction

Prescribing is a core competency required of all doctors from graduation onwards. Safe and effective prescribing is based on a sound knowledge of the disciplines of pharmacology and clinical pharmacology and therapeutics (CPT) [1]. These skills are at a premium because of a number of important trends, including: increased use of medicines both in secondary and primary care; more rapid throughput of patients; new drug developments extending medicines use into novel areas; increasing complexity of drug use; older patients, who are more vulnerable to adverse effects of drugs; and increasing litigation [2]. These pressures explain, in part, the apparently rapid increase in harm from adverse events related to drug therapy and medication errors [3]. Yet these trends also coincide with widespread concerns about the extent to which graduates are prepared by medical schools to assume their responsibilities as prescribers [2, 4, 5].

The publication of Tomorrow's Doctors by the General Medical Council (GMC) in 1993 heralded a significant change in emphasis in undergraduate education, with a move away from teaching individual scientific disciplines towards a more integrated curriculum [6]. The main goals were to reduce factual burden with the development of a core curriculum, to improve integration with system-based learning and to eradicate the disciplinary and preclinical/clinical divide. For many schools, this prompted a radical redesign of the medical curriculum. An inevitable consequence of the seamless integration proposed by Tomorrow's Doctors was the loss of dedicated courses in a variety of established disciplines, including basic pharmacology and CPT. Indeed, the guidance stated explicitly that it ‘avoided all reference to traditional subjects and disciplines. … urging the advantages of interdisciplinarity’ (paragraph 42). This position substantially weakened the support for retention of pharmacology and CPT as recognizable disciplines in many medical schools. In consequence, many abandoned assessed courses or modules in pharmacology and CPT that tackled generic issues relating to the use of drugs in a variety of clinical settings. Instead, learning about drugs has been devolved to system-based components of the medical curriculum.

At the University of Edinburgh, Pharmacology & Therapeutics (PT) was designated as a ‘vertical theme’ in the new curriculum, i.e. it would be integrated into and delivered within a series of ‘horizontal’ modules across the 5-year curriculum. While this seemed logical, it produced many practical difficulties. Being charged with the responsibility of overseeing and coordinating the delivery of PT learning objectives, we found ourselves trying to liaise with scores of colleagues. Ensuring that the learning objectives were delivered logically, without repetition and with appropriate integration within others' programmes, proved to be unmanageable. Furthermore, as a small group responsible for teaching PT we were unable to respond to the invitations to deliver teaching concurrently across a wide variety of modules. We considered that without specific protected time for our discipline, and identified assessments of its core material, it was virtually impossible to meet our objectives.

Our perception that we were failing to deliver a satisfactory course of learning opportunities in our discipline was confirmed by feedback from the medical students, who identified a number of specific problems:

• low visibility of PT within the curriculum;

• too many different drugs being mentioned within clinical modules;

• no clear prioritization (and occasional disputes) as to what constitutes core learning about drugs;

• lack of coordination between basic science and clinical teaching;

• no source of concise information about the core drugs.

Objective feedback from our local pre-registration house officers showed that they felt inadequately prepared to prescribe, and similar concerns have been expressed elsewhere by students and teachers [4, 5, 7, 8]. The GMC published a revised version of Tomorrow's Doctors[9] in July 2002, which provided rather more direction about teaching and assessment of therapeutics [10], and similar guidance concerning learning about drugs has also been produced in Scotland [11].

Although there is a clear consensus that graduates must be safe prescribers, it is less clear how that outcome can best be achieved. Little support exists for the re-emergence of pharmacology or therapeutics as specific courses in the Edinburgh medical curriculum. The real challenge now is to deliver these learning objectives within the framework of an integrated discipline-free curriculum. The Clinical Section of the British Pharmacological Society (BPS) recently published some guidance on this matter [12] and highlighted the importance of both prioritizing learning around a core list of commonly used drugs (a ‘student formulary’) and enthusiastic leadership (Table 1).

Table 1.

Key principles concerning the delivery of relevant knowledge, skills and attitudes within the framework of an integrated discipline-free curriculum published by the Clinical Section of the British Pharmacological Society [12]

Prescribing and therapeutics should be identified as an important ‘theme’ throughout the medical curriculum

Core learning objectives should be clearly identified

The factual burden posed by the increasing number of prescription drugs should be eased by prioritizing learning around a core list of commonly used drugs (a ‘student formulary’)

Leadership from enthusiastic teachers would be necessary for coordinating learning about drugs

Methods

Development of the concept of ‘eDrug’

The aim of our project was to translate the BPS principles into an effective teaching programme within our integrated curriculum (Table 2). We were fortunate in being able to take advantage of the Edinburgh Electronic Medical Curriculum (EEMeC), an established virtual learning environment (VLE) used in our Medical School since 1998 [13, 14]. In this way we planned to deliver an on-line learning resource, to be known as ‘eDrug’, which would be continuously accessible to students from any computer connected to the worldwide web. As well as coordinating and enhancing the learning and teaching of PT across all 5 years of the MBChB curriculum, we wanted it to remain accessible into the early Foundation training period. eDrug would be a collaborative exercise between the leaders of the PT theme (D.S.M. and S.R.J.M.) and the Learning Technology team (R.E.). The two main tasks would be to provide effective learning materials and then to deliver them in a user-friendly format within EEMeC.

Table 2.

Major objectives in the creation of eDrug

1	To improve the visibility of the PT theme across all 5 years of undergraduate medicine
2	To develop a cost-effective dynamic solution to the problem of maintaining and developing knowledge of PT horizontally within individual years and vertically across all 5 years of an integrated medical curriculum
3	To facilitate integration and coordination of PT teaching within the many other modules in the curriculum
4	To collate generic information on pharmacology, clinical pharmacology and therapeutics, and clinical toxicology
5	To reduce the factual burden (information overload) imposed by the large number of medicines mentioned throughout the course by identifying a ‘core’ list of exemplars, ‘the student formulary’
6	To provide students and staff with clearly identified learning goals via a user-friendly web-based interactive tool
7	To provide enhanced learning and teaching opportunities for PT within existing manpower resources by giving concise information (mode of actions, indications, adverse effects) relating to the core drugs in an enjoyable user-friendly efficient manner
8	To enable users to access lecture presentations, notes and CALs relating to PT dynamically, by maintaining links to current lectures and associated CALs
9	To use established accredited databases such as BNF and search engines such as Answers.com to provide additional focused up-to-date learning material
10	To answer student queries relating to PT material via lecturers and eDrug editors (e-Tutors). This might be done via individual e-mail replies, or more efficiently by posting the reply on the year Discussion board within EEMeC, so that all users can benefit from the information
11	To design a visually attractive interface for users and editors, with simple intuitive navigation
12	To adopt the drug classification used in the BNF, the standard National Health Service formulary, to facilitate transition from undergraduate to postgraduate studies
13	To improve the safety and effectiveness with which our graduates prescribe drugs as junior doctors in a busy NHS environment. Ensure that medical graduates can continue to access eDrug during their Foundation training.
14	To sustain and enhance the system by online objective feedback from users

PT, Pharmacology and therapeutics; CAL, computer-assisted learning; BNF, British National Formulary; EEMeC, Edinburgh Electronic Medical Curriculum.

After careful review, we concluded that the main focus of the resource would be a local ‘Student Formulary’ consisting of a limited list of drugs to be considered as core learning objectives throughout the course. This would be a dynamic resource which would replace the static formulary list that had been in existence for a number of years. Within eDrug we intended to embed other facilities such as direct links to lecture notes and PowerPoint presentations, computer-assisted learning (CAL) packages and external sources of information, including the British National Formulary (http://www.bnf.org/bnf/) and local hospital drug formularies. In this way, eDrug aimed to be a progressive learning hub for the PT theme: knowledge of basic medical science in early years would be complemented by applied material relating to the therapeutic use of drugs in later years of medical education. Junior students would be able to see the relevance of the basic learning and foundation building to their future work as doctors and to make and retain their own notes within eDrug.

Core drug list (student formulary)

The first requirement was to identify a list of drugs that would be core learning within the local curriculum. The general criteria were that these drugs should be (i) in common use, (ii) prescribed or supervised by recently qualified doctors and (iii) ideally act as exemplars for other drugs. For each exemplar graduates would be expected to:

• understand the mechanism of action;

• recognize the indication for use;

• know the common route of administration;

• appreciate the important contraindications and unwanted side-effects.

The student formulary was created by a process of iteration, the starting point being the example list produced by the BPS [12], which was then amended in line with the local NHS formulary [15]. Feedback was obtained from local teachers with reinforcement of the key objectives of eDrug. Not surprisingly, some teachers saw eDrug as a potential constraint to their own academic objectives. However, by a process of negotiation it was possible to reduce the total number of suggestions down to a list of 170 exemplar drugs. This was achieved because it was usually possible to group suggested drugs within the information provided for a single exemplar. A simple example would be the inclusion of fentanyl under the entry for morphine.

Drug information

The core list was then organized to provide relevant information for each of the drugs, using a common format (see Figure 1). We adopted the British National Formulary (BNF) system for classifying drugs, because it is the most widely used source of drug information in postgraduate medical training throughout the UK. Familiarity with the BNF classification was intended to facilitate the transition from medical student to independent prescriber. For each drug, concise information would be provided on: pharmacological mechanism of action, clinical indications and effects, adverse effects, dose and route of administration, interactions and further comments. The latter was used to try to facilitate learning by mentioning similar drugs and illustrating important generic principles with respect to that drug (e.g. digoxin as an example of a drug that is cleared by the kidney). Teachers were asked, where possible, to use the eDrug formulary when extending learning to more specialized drugs. For example, if introduced to the short-acting opioid remifentanil, teachers were asked to highlight the advantages or disadvantages with respect to the class exemplar, morphine. Relevant teachers were requested to provide or review the information relating to the core drugs.

Figure 1.

eDrug front page and drug review, as seen by users

Other features

In addition to listing core drugs and supporting information, eDrug was supplemented with sections on generic aspects of pharmacology, clinical pharmacology, therapeutics and clinical toxicology (Figure 1). These were based on general principles such as mechanisms of drug action, pharmacokinetics, adverse drug reactions, etc. Users could access lecture presentations, notes and CALs relating to PT which are available as links from the appropriate drugs. There were also links to other web resources such as the BNF, Lothian Joint Formulary and Answers.com. In this way, eDrug was based on dynamically reusing learning objects and services.

Technical aspects

eDrug was constructed within EEMeC (https://www.eemec.med.ed.ac.uk/visitors/), a well-established VLE facilitating rapid access to information and learning materials relevant to all 5 years of Edinburgh's undergraduate medical curriculum. EEMeC is an entirely on-line system and can therefore be accessed from any Internet-enabled computer in the world. The speed and facility of the construction of eDrug was enabled by the highly abstracted and object-oriented architecture of EEMeC. The main step in instantiating eDrug in EEMeC was to create ‘drug’ as a new type of system object with a combination of general and pharmacology-specific properties, allowing them to be handled as unique and addressable entities within the system. As a result, drug ‘objects’ could then be dynamically associated with on-line tutorial packages, lectures (as both events and supporting documents) and individual users.

From a user perspective, eDrug is dynamic and interactive, with an attractive interface and intuitive navigation, facilitating access to drug information, and links between drugs and other system objects. eDrug's layout allows year 1 and 2 students, learning about basic pharmacology of drugs, to appreciate their clinical applications, while those in later years can easily refresh their earlier learning. The eDrug editors have instant access to change the entry for any drug, allowing them to add new drugs and other information at any time, with any such changes being immediately available to eDrug's users. This can sometimes be a daily process. In addition, individual students can make and modify notes in their personal ‘My Formulary’, which remains accessible to them beyond graduation.

Results

eDrug was introduced midway through the 2004–2005 academic session and publicised to all 5 years of the MBChB curriculum by demonstrations during lectures, information on academic discussion boards and the presence of the eDrug icon prominently on each student's individual EEMeC front page. It was important to involve users to ensure that eDrug met their needs. This was achieved by soliciting and gathering feedback on the pilot versions of eDrug from both staff and students and using this to drive interface improvements.

eDrug has been heavily used by students, particularly those in the earlier years, who were shown the system during PT teaching sessions; use in the later clinical years was more limited (see Figure 2), probably because of dispersal of attachments (less teaching contact with the editors) and greater familiarity with the learning material. The eDrug editors spent several weeks on developing the content but, once eDrug was established, maintenance has been confined to adding or deleting drugs and making minor corrections on line, amounting to about 1 h per week. IT staff also update links to revised material (e.g. notes, PowerPoint presentations) provided by lecturers, which involves about 1 h of work per week. Users can e-mail individual lecturers with specific queries about particular drugs, and the editors respond to requests from staff and student for amendments, deletions or additions to the formulary.

Figure 2.

Data illustrate the extensive use being made of eDrug by students in years 1 and 5 of the Edinburgh MBChB curriculum during May 2005, following introduction of this learning aid in April 2005. Year 1 averaged 300 hits every day, including weekends; year 5 averaged 114 hits; both classes have approximately 240 undergraduates. eDrug was demonstrated to the whole of first year, but this was not feasible for fifth-year students, who were on clinical rotations, and they were briefed by e-mail

eDrug has also enabled students to interact with fellow undergraduates via academic discussion boards within EEMeC. Students ask or answer PT-related questions, with staff contributing as required. Because all students can see the questions and answers, dissemination of knowledge and resolving misunderstandings occur more effectively through these discussion boards than they do via individual student–staff e-mailing. Contributions by PT teachers to e-discussions help maintain student–teacher contact, which is otherwise difficult to sustain for 1300 students across a 5-year curriculum.

eDrug has also stimulated unprecedented dialogue between teaching staff in the University, associated teaching hospitals and general practice centres concerning appropriate PT learning objectives and the list of core drugs within a busy integrated MBChB curriculum. The eDrug editors are in regular contact with year directors, module organizers and individual lecturers, who may identify new evidence or important changes in prescribing practice that necessitate revisions. Similarly, students may highlight ‘new’ drugs that are mentioned, or areas that need to be covered in more detail. In these ways, eDrug has served as an early indicator of discrepancies concerning learning objectives identified within the vertical theme of PT (run by the editors) and those identified by the numerous individual teachers, and by the examiners.

Objective feedback

Objective feedback was obtained from all five MBChB years in May 2005 by on-line questionnaire. An encouragingly good response rate of 50% was achieved from this voluntary questionnaire, which was circulated near end of year assessments. The responses from all 5 years suggested that eDrug had achieved its primary aim of facilitating learning of PT (see Figure 3). In addition, there was support for the views that it helps to highlight the PT vertical theme in the curriculum, helps to integrate material from different courses, is easy to access and the layout is clear and user-friendly. Features that were particularly appreciated were the electronic links between the PT material in eDrug and horizontal system modules, which helped to remind students of PT learning objectives throughout the curriculum. eDrug has also promoted more dynamic accessing of information about drugs and encouraged web-based support, rather than reliance on static text books. The first-year students made more use of this new facility than did the final year cohort (Figure 2), but many final-year students, who were approaching their finals, also appreciated the educational value of eDrug.

Figure 3.

Upper panel shows the mean score (as percentage of maximum achievable = 100) obtained from on-line questionnaires completed during May 2005. Lower panel shows the pooled values for years 1–5 as a box and whisker graph (median, range and quartiles are shown). The score for each question was high, with a tendency for year 1 to score slightly higher than year 5, who were near to finals. The responses were normalized to allow for the lower response rate from years 2–5. The response rates for individual years (each ∼ 240 students) were: Year 1 (63%) (□), year 2 (43%) (), year 3 (50%) (), year 4 (), year 5 (46%) (▪)

Discussion

We set out to overcome the difficulties we faced as leaders of a continuous 5-year theme of PT learning which, whilst theoretically integrated with most horizontal modules of learning, was struggling for visibility in the curriculum. We decided that supporting PT lectures and problem-based learning sessions by a web-based delivery of learning materials, based around a student formulary, eDrug, was the only realistic way of responding to the problems given our limited resources. In addition, this approach offered the advantages of constant access and the flexibility to respond to changes in curriculum delivery and content, or the use of drugs in clinical practice. The integration with the Edinburgh MBChB's virtual learning environment added significant advantages by using its dynamic architecture to link and extend the impact of the formulary beyond that of the application itself and to draw on the support of the staff who develop and maintain the system as a whole. Our experience, backed by objective student feedback, suggests that the development of eDrug has met most of our original objectives (Table 2). Students and staff are now able to prioritize their learning and teaching around identified core drugs, to link with appropriate learning material in lectures, CALs and accredited web databases, including the BNF. In this way, eDrug has not only raised the previously nebulous profile of PT in our revised integrated medical curriculum, but has also stimulated more interest in accessing up to date and even ‘breaking’ information about drugs.

Some issues arising from the introduction of eDrug

It is, perhaps, inevitable in a busy curriculum that our efforts to define core learning have been greeted by some students as a clear definition of the limits on teaching and assessment. Some teachers have also become concerned that we are attempting to impose limits, a view occasionally reinforced by student attitudes. Our position is that eDrug represents core knowledge, but is not exhaustive in terms of what might appear in teaching and assessment. A further concern is that eDrug might have made the students lazy by providing their learning ‘on a plate’. Our objective feedback, however, seems to suggest that although the concise information is welcomed, students have increased their recognition and pursuit of internal and external links and sources of data. We believe that this is appropriate at a time when doctors increasingly expect to get information about drugs delivered via electronic means, including handheld computers [16].

Developments elsewhere

Similar developments in electronic aids for teaching PT have occurred in other institutions, and the use of problem-based, computer-aided, and web-based teaching and learning in other countries has been discussed elsewhere [17]. A few years ago, interactive case-based and evidence-based prescribing modules, adapted for computerized learning, were introduced into Australian teaching programmes for senior medical students [8], funded by the National Prescribing Service, and following the tenets laid down in the World Health Organization's Guide to Good Prescribing [18]. It included the establishment of local student formularies as a teaching tool, a concept that could be extended to the training of junior hospital doctors. eDrug is the embodiment of that principle. Others have looked towards electronic solutions to improving the profile of PT in the curriculum [19], but we believe eDrug is the first truly interactive example.

Wider application

The introduction of an eDrug-like system requires two key elements: (i) enthusiastic leadership by individuals with time to develop structured learning materials and update them regularly, and (ii) an established VLE or other learning management system. The latter must be easy to adapt and augment, and all of its materials, users, events and other system objects must be uniquely identifiable and associable with other objects. The core learning materials are then added to the system's database, allowing them to be associated with other kinds of course objects. The resulting information structures are then made available to the system's users via the appropriate graphical user interfaces. The requirement for system abstraction to allow for such developments as eDrug is a key component of any modern VLE [20]. eDrug could be made available for use in other circumstances, either by porting the database and tools or by instantiating it as a shared web service [21], although it would need to accommodate local control and content and would still require a local VLE (or equivalent client system) within which it could be rendered.

An important caveat should be noted. Although we have provided evidence that our work is valued by many students, this does not necessarily translate into improved undergraduate or postgraduate performance. While demonstrating either outcome would be the ultimate ‘proof of concept’ for eDrug, designing a rigorous study would present many problems. The ever-changing academic environment, amongst other confounders, would make it difficult to choose controls even if a suitable test of ability could be established.

We believe that the eDrug approach may be particularly suited to the delivery of other traditional scientific disciplines (e.g. anatomy) that have lost their lecture courses in favour of the ‘seamless’ learning experience advocated by Tomorrow's Doctors [6]. In these circumstances, teachers often find themselves struggling to raise the profile of their subject, clarify and deliver learning objectives and interact successfully with students. In the case of PT, eDrug has helped to overcome such problems and is rated highly by students. These benefits required an early investment of manpower but are now maintained without additional resources.