Medication reconciliation using natural language processing and controlled terminologies

Stud Health Technol Inform. 2007;129(Pt 1):679-83.

Abstract

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.

Publication types

  • Evaluation Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Clinical Pharmacy Information Systems*
  • Continuity of Patient Care
  • Drug Therapy, Computer-Assisted*
  • Hospitalization
  • Humans
  • Medical History Taking
  • Medical Order Entry Systems
  • Medical Records Systems, Computerized
  • Medication Errors / prevention & control
  • Medication Systems, Hospital
  • Natural Language Processing*
  • Pharmaceutical Preparations / classification*
  • Vocabulary, Controlled*

Substances

  • Pharmaceutical Preparations