Prescription compliance with National Formulary restrictions: Evaluation and information system–based strategies in an Indonesian tertiary hospital

The National Formulary plays a critical role in promoting rational drug use and controlling healthcare costs within Indonesia’s National Health Insurance system. Ensuring compliance with formulary restrictions, including prescriber authorization criteria, is essential to maintain prescribing quality, patient safety, and financial sustainability. However, evidence regarding compliance and system-level implementation challenges in tertiary hospital settings remains limited. This study aimed to evaluate prescribers’ compliance with National Formulary restrictions, including prescriber authorization requirements, and to identify system-level barriers and potential digital-based improvement strategies in an Indonesian tertiary hospital. A mixed-methods case study was conducted in a Ministry of Health Class A tertiary hospital. The quantitative phase analyzed 16,725 outpatient prescriptions issued between January and July 2025, comprising 705 drug items subject to formulary restriction criteria. Compliance was assessed based on formulary inclusion and prescriber authorization requirements. The qualitative phase involved focus group discussions and in-depth interviews with physicians, pharmacists, information system personnel, and hospital administrators. Quantitative data were analyzed descriptively using Microsoft Excel, whereas qualitative data were analyzed using inductive thematic analysis supported by NVivo version 14. Overall compliance with National Formulary restrictions was high (98.4%), with only 11 of 705 drug items (1.56%) classified as noncompliant. Evaluation of prescriber authorization restrictions demonstrated an extremely high compliance rate, with only one drug item (0.14%), sildenafil, prescribed by a physician without the authorized specialty. Qualitative findings identified key system-level barriers, including limited integration of formulary information into electronic prescribing systems, reliance on individual clinician knowledge, lack of structured monitoring mechanisms, and absence of real-time formulary decision support. Recommended improvement strategies included strengthening digital formulary integration, implementing automated reminder systems, incorporating recommendatory clinical decision support features, and integrating formulary restriction information into physician dashboards. Compliance with National Formulary restrictions was very high, reflecting effective institutional governance and prescribing oversight. However, sustainable formulary compliance requires strengthening digital integration, automated monitoring, and clinical decision support systems. Integrating flexible, patient-centered digital formulary tools into routine prescribing workflows is essential to promote rational drug use, enhance medication safety, and support the long-term sustainability of Indonesia’s National Health Insurance system.