[PDF][PDF] Medication reconciliation using natural language processing and controlled terminologies

JJ Cimino, TJ Bright, J Li - Studies in health technology and informatics, 2007 - Citeseer
Studies in health technology and informatics, 2007Citeseer
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 …
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.
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