Medication concepts, records, and lists in electronic medical record systems

Abstract

A well-designed implementation of medication concepts, records, and lists in an electronic medical record (EMR) system allows it to successfully perform many functions vital for the provision of quality health care. A controlled medication terminology provides the foundation for decision support services, such as duplication checking, allergy checking, and drug-drug interaction alerts. Clever modeling of medication records makes it easy to provide a history of any medication the patient is on and to generate the patient's medication list for any arbitrary point in time. Medication lists that distinguish between description and prescription and that are exportable in a standard format can play an essential role in medication reconciliation and contribute to the reduction of medication errors. At present, there is no general agreement on how to best implement medication concepts, records, and lists. The underlying implementation in an EMR often reflects the needs, culture, and history of both the developers and the local users. survey of a sample of medication terminologies (COSTAR Directory, the MDD, NDDF Plus, and RxNorm) and EMR implementations of medication records (OnCall, LMR, and the Benedum EMR) reveals the advantages and disadvantages of each. There is no medication system that would fit perfectly in every single context, but some features should strongly be considered in the development of any new system.

(cont.) A survey of a sample of medication terminologies (COSTAR Directory, the MDD, NDDF Plus, and RxNorm) and EMR implementations of medication records (OnCall, LMR, and the Benedum EMR) reveals the advantages and disadvantages of each. There is no medication system that would fit perfectly in every single context, but some features should strongly be considered in the development of any new system.