Integred record system for standard reporting operations in pediatric cardiac surgey and complexity estimation

The Hospital Information System, first developed at our main institute for the integration of clinical, administrative and management resources in Cardiology, has been recently extended for use at our section specialised in Cardiac Surgery. Extension of the electronic medical record (EMR) to the management of patients admitted in Pediatric Cardiac Surgery started with the development of a system for reporting operations in structured form and for estimating their complexity, according to a model set up in a previous study involving our institute and other two pediatric cardiac surgery centers. The international congenital heart surgery nomenclature, promoted in Europe by the Pediatric European Cardiac Surgical Registry (ECSUR) project, was adopted. The ECSUR data set with associated short lists (translated into Italian) of pre-operative risk factors, diagnoses, procedures and complications was implemented in our EMR. Minor coding expansions were suggested by both surgeons and cardiologists. EMR interface was developed to record, for each operation, diagnoses and procedures, patient findings and conditions, operative events and methods. Information on patient history and on follow-up was also recorded. From the combination of underlying diagnosis and procedure each operation was classified in terms of 3-level complexity according to the developed multicenter model. The system is used daily for reporting operations in our Pediatric Cardiac Surgery department. All operations since January 2000 were archived (a total of 547 in two years) and data were periodically exported and submitted to the ECSUR database center. A comprehensive data bank is being developed allowing both clinical management and research as well as risk stratification and outcome analysis. Moreover estimation of operation complexity is useful to evaluate DRG\u27s, often underestimated in Pediatric Cardiac Surgery