Medication reconciliation using natural language processing and controlled terminologies.
Medication reconciliation (MR) is a process that seeks to assure that the medications a patient is supposed to take are the same as what they are actually taking. We have developed a method in which medication information (consisting of both coded data and narrative text) is extracted from twelve sources from two clinical information systems and assembled into a chronological sequence of medication history, plans, and orders that correspond to periods before, during and after a hospital admission. We use natural language processing, a controlled terminology, and a medication classification system to create matrices that can be used to determine the initiation, changes and discontinuation of medications over time. We applied the process to a set of 17 patient records and successfully abstracted and summarized the medication data. This approach has implications for efforts to improve medication history-taking, order entry, and automated auditing of patient records for quality assurance.
Cimino
James J
JJ
Department of Biomedical Informatics, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA. jjc7@columbia.edu
Bright
Tiffani J
TJ
Li
Jianhua
J
D016303:Clinical Pharmacy Information Systems; D003266:Continuity of Patient Care; D004360:Drug Therapy, Computer-Assisted; D006760:Hospitalization; D006801:Humans; D008487:Medical History Taking; D050316:Medical Order Entry Systems; D016347:Medical Records Systems, Computerized; D008508:Medication Errors / Q000517:prevention & control; D008510:Medication Systems, Hospital; D009323:Natural Language Processing; D004364:Pharmaceutical Preparations / Q000145:classification*; D018875:Vocabulary, Controlled
D004364:Pharmaceutical Preparations