Formulary decision support

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Formulary decision support (FDS) is a facet of clinical decision support (CDS) designed to improve formulary compliance in clinicians by guiding them towards formulary preferential options over non-formulary ones.(1)


With the cost of drugs rising, hospitals and pharmacies use formulaties to promote appropriate, safe, and cost-effective drug therapy. By increasing adherence to formulary guidelines, more cost-effective drug therapy can be employed. In April, 2004, two Massachusetts insurers began providing FDS as part of their e-prescribing system to community-based practices. In an 18 month period, they served 1.5 million patients and filled 17.4 million prescriptions. The FDS showed a 3.3% increase in tier 1 prescriptions with an estimated savings of up to $845,000 per 100,000 patients.(2)


There are several methods of formulary decision support.

Limited formulary medications in CPOE order catalog

The first method of formulary decision support is to only include a limited number of formulary medications in the CPOE order catalog.


  • Only formulary medications can be chosen


  • Prescription of non-formulary medications has a high chance of being delayed without a way to enter it into the CDS.

Mark non-formulary or restricted options in CDS

The second method is to mark the non-formulary options in the clinical decision support module.


  • Inobtrusive


  • Lowest compliance rate

Pop-up alert when non-formulary option is chosen

The third method is to have a pop up alter when a non-formulary option is chosen.


  • High compliance and allows most options to continue (eg. override, search for more information, suggest alternatives)


  • Highly interruptive


Poor compliance to FDS was most often due to a lack of an offered alternative or strong provider beliefs about the medication, even if those beliefs are not widely supported by available evidence.(1)

Recommendations For Implementation

There should be an educational program that accompanies the implementation of the CDS system. Users will ignore prompts they do not understand or do not agree with if they do not understand the reasons that the prompt is provided.(1)

Other key aspects in FDS implementation include but are not limited to

  • Consider FDS for medication substitution only after addressing decision support for patient safety and clinical quality needs
  • Strong personnel and training support, and good communication
  • Screen recommendations with expert local clinicians first
  • Alert screen should include a link to information describing institution-specific guidelines for restricted medications
  • Pharmacists should frequently personally review the ignored formulary alerts, including interviews with clinicians to understand why
  • Formulary alerts should be monitored and modified or removed if the desired outcome is not being achieved
  • Formulary-related alerts can sometimes best achieve a desired outcome by educating users, for example:
    • Formulary changes for a drug class, e.g., H2 blockers
    • Medication shortages
    • New safety alerts issued by the FDA


  1. Kuperman GJ, Bobb, A, Payne TH et al. Medication-related Clinical Decision Support in Computerized Provider Order Entry Systems: A Review. J Am Med Inform Assoc. 2007; 14(1):29-40. Epub 2006 Oct 26
  2. Fischer M, Vogeli C, Stedman M, Ferris T, Brookhart T, Weissman J. Impact of Electronic Prescribing with Formulary Decision Support on Medication Use and Cost. Archives of Internal Medicine. 2008;168(22):2433–2439.

Submitted by Mike Steinfeld