Darmoni S J [a], Dufour F [b], Massari P[c], Arnoudts S [a], Dieu B [c],
Alizon B [d], Hantute N [d ] and Baldenweck M [a]
[a] Direction du Système d'Information et de l'Informatique, CHU de
Rouen, 1 rue de Germont, 76031 Rouen Cedex, France,
[b] OVP, Editions du Vidal, 11 Rue Quentin Bauchart, 75384 Paris Cedex 08 France
[c] Département de l'Information Médicale, CHU de Rouen
[d] Pharmacie Centrale, CHU de Rouen
Medical documentary information systems, integrated into the Hospital Information System, have been defined as a necessity and a priority in the Rouen University Hospital. Information about drugs is essential to patient care and management. Computerised access to the French drug information reference "Dictionnaire Vidal" has been chosen as the first step of our medical documentary system. The aim of this application is to provide on-line access to drug monographs with queries and displays as close as possible to the printed edition of the Vidal Dictionary. Headings specific to the Rouen University Hospital were included : availability of a drug in the pharmacy and its cost. Electronic Vidal is operational on IBM and BULL mainframes and on Unix platforms. In the Rouen University Hospital, Electronic Vidal has been in use since November 1992 on the 800 terminals and microcomputers located in care units. In 1993, daily, 150 accesses are performed and 270 drug monographs are displayed ; in 1998, figures are nearly doubled (294 accesses and 481 drug monographs) . The next step will be the development of the access to drug interaction data. Electronic Vidal will become the core of the drug documentary information system.
Key-words
databases, factual; drug information services;
The constant provision of up-to-date information in an hospital is of crucial
importance for good clinical practice but dissemination of relevant medical reference
material is an expansive and time consuming activity.
Availability of reliable and frequently up-dated information and knowledge is necessary to
improve directly patient care and management. It can also acts indirectly by avoiding time
loss due to information search. Recent improvement in the information management
technology have provided new opportunity to face the challenge.
The achievement of computer-based 'information and knowledge banks' was defined as a
priority in our hospital.
'Information and knowledge banks' are necessary when:
1) this information is of limited access on existing information materials such as books
and reviews;
2) this information has to be frequently searched and consulted by a large population of
end-users;
3) the information and knowledge update have to be easily, quickly and simultaneously
updated on all sites of consultation; Implementation of an 'information and knowledge
banks' implies:
1) the previous creation of a scientific and technical committee in charge of
organisation, evaluation and decisions about the 'information and knowledge bank';
2) the choice of information and knowledge sources and suppliers; it have to be admitted
as a reference for all the end-users;
3) a fast information search and retrieval system as convenient and simple as possible,
optimising the recall and not the fallout;
4) an ergonomic design allowing an easy and reliable screen consultation.
Among the information searched daily, drug-related topics are particularly important
because of the growing complexity of drug-management and the number of critical changes in
drug specifications that may occur at any time. Frequency of updating is a key-feature in
this field.
The drug-related information are checked several times a day by a large population of
end-users in care units, such as physicians, nurses, students, secretaries, etc. In
France, the most used reference document is the Vidal dictionary. It compiles the
regulatory texts of drug characteristics which are released along with the marketing
authorisation given to pharmaceutical companies and validated by the French Ministry of
Health (at least for the drug monographs released after 1979). One monograph is released
for each drug and all the monographs have the same headings pattern which complies with
the European guidelines for drug monographs (EEC. Directive 83/570 art. 4bis). The
monograph sequence is shown in table 1.
Table 1
Monograph sequence
____________________________________________________________________________
1. Brand name
2. Pharmaceutical form and presentation
3. Composition : - actives substances and excipients
4. - dosage and unit dose
5. Pharmacokinetics
6. Pharmacological properties
7. Indications (efficacy mentions)
8. Contra-indications
9. Warnings
10. Precautions of use :
11. - use in pregnancy
12. - nursing mothers
13. - drug interactions
14. Vigilance and driving
15. Side effects and adverse reaction (frequency and gravity)
16. Dosage and administration
17. Storage (exceptional condition)
18. Overdosage
19. Legal category
20. Product licence number and year marketed
21. Public price
22.Manufacturer
_________________________________________________________________________________________
Usually, the topic of a single consultation of a drug monographs in the printed edition
is limited to one heading. Therefore it is easy to display it on a computer screen.
The compliance of this kind of information to the previous enumerated criteria was
obvious. That is why the computerisation of information and knowledge about drug became
the first step of our 'information and knowledge bank'.
The choice of the Vidal dictionary as the drug reference book led to a partnership with
the editor of the Vidal dictionary, the OVP company. The rules of this partnership are the
following:
1) the drug text must be exactly as it could read in the printed edition of the Vidal
dictionary; no information could be add to the original text;
2) the source files of drug monographs and indexes are provided and updated by OVP;
3) the computerisation of the Electronic Vidal is performed by the Information System and
Informatics Department of the Rouen University Hospital;
4) the marketing of the data and the retrieval software is ensured by OVP.
Additive headings were included, allowing each hospital to link specific information to
the monographs e.g. availability of a drug in the hospital pharmacy and its hospital cost
per unit.
The software of Electronic Vidal was developed with Pacbase (workbench of the CGI
company). In Rouen, it is operational on a IBM mainframe 3090 (MVS). Bull DPS 7 version
(TDS and GCOS7), IBM ES 9000 (VSE/ESA) version and Unix version are also available.
Document indexes was performed by Vidal scientific group which also realised the text
formatting specific to the screen lay-out, taking into account the screen limitations (25
lines x 80 rows, fixed space font, 16 colours or monochrome brightness levels). This
formatting was realised to preserve as far as possible the look and spacing of the
original printed document.
In Rouen, the computer network with 800 terminals and microcomputers located in care units
provides an easy access to the Electronic Vidal.
The menu-driven software offers three ways of access : trade name, substance name and
therapeutic classification. Regardless of the way of access, the end-user is offered the
display of the 24 headings of the Vidal Dictionary.
Only the first letters of the names of drugs or substances need to be keyed in. If the
keying is non ambiguous, the corresponding monograph is displayed, otherwise the list is
displayed starting from the first matching name. The user may display any part of the
monograph by vertical scrolling, one page or one line at a time. The current monograph
title is repeated on every screen together with the indication of the availability of the
current drug at the hospital pharmacy.
One key-press gives access to the list of the other drugs containing the same active
substance as the current drug. Another key-press give access to a short list of those
which are available at the pharmacy and shows the hospital cost for each.
The way of access by the therapeutic classification requires only the three first letters
of any therapeutic class or sub-class. The entire list is also available on a key-press.
The corresponding list of drugs is available for each class.
Headings specific to the university hospital are accessed from the screen which displays
the monograph content. This heading contains the list of the corresponding drugs available
in pharmacy, their hospital cost, the last updating date and is author. A comment may be
linked with each drug.
The monograph and their indexes are updated quarterly by OVP. The hospital-specific
information is updated by the hospital pharmacist. The access to the Electronic VIDAL is
available only for authorised health professionals: each and user has to enter his
identification and his password.
The Electronic Vidal is in usable in the Rouen University Hospital since November 1992.
Reactions to implementation of this first data base have been remarkable. From that
moment, the printed edition of the Vidal dictionary have not been available in any
locations of care unit, excepted for those which where not equipped with terminals,
specially the outpatient rooms.
Several statistical indices was included in the software design. This numeric data
emphasise the quantitative importance of consultation.
Since the availability of the electronic dictionary (between November 23rd 1992 and
October 31st 1993), 52760 accesses were performed and 90635 monographs were displayed. An
average of 155.2 daily accesses are performed, corresponding to the daily consultation of
266.6 monographs; an average of 1.72 drug text is displayed per connection. During the
second trimerster 1998, the numbers have nearly doubled: an average of 294 daily accesses
are performed, corresponding to the daily consultation of 481 monographs; an average of 1.63
drug text is displayed per connection
Each month 40% of overall monographs are displayed. After one year, three quarter of
monographs are displayed at least once.
The access by trade name is the most frequent (91%), followed by the access by substance
name (5.8%) and the access by therapeutic class (3.4%). The accesses are spread out in the
60 departments of the hospitals (median of 79 monthly accesses with a maximum of 288 and a
minimum of 2). The three biggest consumer departments of our hospital are : intensive care
unit, pneumology and cardiology.
The typology of end-users are the following: in the absolute: nurses (36.7%), residents
(19.3%), physicians (13.7%), medical students (9.8%), secretaries (9.5%), pharmacists
(5.1%), informaticians (3.4%),and midwives (2.5%). Divided by their respective number in
the hospital, the pharmacists are the biggest consumers of the Electronic Vidal with 25
accesses per month and per pharmacist followed by the residents (3.4 accesses per month
and per resident), the medical students (1.8 accesses per month and per student), the
physicians (1.6 accesses per month and per physician) and the nurses (1.4 accesses per
month and per nurse).
During the first year of utilisation, the four most displayed monographs are
Mopral(omeprazole) with 337 accesses (0.4% of the overall accesses), Augmentin
(amoxicilline and clavulanic acid) with 317 accesses, Prozac (fluoxetine) with 315
accesses, and Depakine (valproic acid) with 307 accesses. Sorted by active compound
regardless of multi active compound drugs, the three most displayed active compound are:
paracetamol (1600 accesses and 2% of the overall accesses), ascorbic acid (1386 accesses),
and amoxicillin (940 accesses). The most frequently displayed monographs belongs to the
following therapeutic classification: cardiology (10655 and 17.6% of the overall
accesses), infectiology (8204), and neurology & psychiatry (7532). The five most
frequently displayed therapeutic classes are : antihypertensive agents (5351 and 6.6% of
the overall accesses), antianginal drugs (3225), drugs of cardiac failure (2305),
penicillins (2045) and anxyolitics (1938).
The typology of the displayed headings are the following: composition (47%), indications
(19.1%), posology (18.3%), contra-indications (9,1%), public cost and name of the
manufacturer (3.9%), and overdosage (2.7%). The end-users are consulting the hospital
specific headings in 3.9% of the connections. The average number of connections of
Saturdays and Sundays are representing respectively 53% and 34% of the average number of
connections of a weekly day. On the nyctohemeral period, there are two maximum of
consultation: one at 11am (with 54 connections in an hour) and the other at 15pm (32
connections in an hour).
Several textbooks and dictionaries contain information about drugs, including
properties and management guidelines. Data have in some occurrences better structure than
in the Vidal Dictionary which helps to an easier computerisation. However, the health care
professional end-user do not know them well, their update is less reliable and the
information is not validated by any official committee. That is why the Rouen University
Hospital has chosen the Vidal Dictionary as the reference as the electronic textbook about
drugs.
More generally, the achievement of 'information and knowledge banks' in hospitals is far
from easy: it is difficult to index and maintain information and knowledge, there is a
lack of a normalised medical language [1]. Documentary information
systems must overstep these problems; some research projects are under way : UMLS project [2], natural language processing.
Information about drugs are consulted every day. Several drug information banks already
exist in France and in the world : BIAM (French acronym for automated drug information
bank) since 1984 [3], French THERIAQUE [4],
both accessible by videotex (Minitel), Drugdex [5], Electronic PDR [6], Europharm, CD-ROM containing several European drug dictionaries,
such as the German Rote Liste, the Italian Farmadisco, the English Martindale, the Swiss
Compendium and the French Vidal. Outside Vidal CD-ROM, Vidal Dictionary is also available
on Data Discman, ideal tool for attending health care professionals.
At the contrary, Electronic Vidal is implemented in an hospital computer network. Its
exploitation cost is independent of number of connections. It contains only officially
validated information. Its index have nonetheless several limits. It is not possible for
the moment to use full-text or Boolean queries, using key-words (e.g. searching of all
drugs which are contra-indicated in "myasthenia" using the word
"myasthenia" in the heading contra indication). Electronic Vidal has few other
limits : some French drug are not included in the Electronic Vidal, drug-drug interactions
are not yet available. Some of these limits will be fulfilled in 1994.
Vidal electronic dictionary shows many advantages. Using the network facilities with many
terminals, it can be accessed simultaneously on 800 screens instead of 220 printed
editions. This limited number was responsible of the use of old versions. Quarterly
updates released by OVP give access to fresh information. Headings specific to the
university hospital extent the range of information with data that where not of easy
access before. This information may help the prescriptor in adapting therapy to the
available commercial products in the pharmacy. To be aware of the drug price may incite
the prescriptor to consider the cost of a prescription.
These advantages may explain the importance of the impact and the number of daily
connections realised by health care professionals of our hospital although the
functionality's of Electronic Vidal are certainly not optimally utilised; particularly the
elementary access by trade name is the far most frequent. The foreseen evolution will
increase the coverage and treatment of drug-related information.
The Vidal electronic dictionary will be the nucleus of true 'information and knowledge
bank' which will associate official information and information specific to the hospital,
helping to disseminate each other in a synergistic process.
The authors thank Nicole Pantin for her secretary assistance
[1] Degoulet P and Fieschi M. Banque d'informations Médicales. In: Traitement de
l'information médicale. Méthodes et applications hospitalières. Degoulet P, Fieschi M
(eds). Paris: Masson, 1991:241-248.