A Pilot Study of Electronic Cardiovascular Operative Notes: Qualitative Assessment and Challenges in Implementation

Background: Our objectives are to describe the contents of cardiovascular surgical operative notes and to develop and test a standards-based structured electronic operative note that might be used for secondary purposes. Study Design: Operative notes were selected for patients who underwent primary, isolated coronary artery bypass grafting (n = 33); aortic valve replacement (n = 33); reoperative coronary artery bypass grafting (n = 11); or aortic valve replacement (n = 11). The content was qualitatively assessed and categorized into 3 sections, ie, technical/procedural, anatomic/physiologic description, and judgment/opinion. An electronic operative note was developed using a standards-based approach to categorize the type of operation. Results: Average length ± SD of the operative note was 495 ± 186 words (range 243 to 1,267 words). The procedural category made up a mean proportion of 73% ± 12% (range 32% to 95%). The descriptive category was the second largest category in the operative note; mean percentage 22% ± 8% (range 5% to 43%). The dictation of the judgment portion made up 6% ± 6% (range 0% to 25%) of the operative note. In the pilot electronic note system, 5 surgeons entered 23 procedures performed on 18 patients (14% of eligible patients). Seventeen (74%) procedures entered by surgeons were in complete agreement with the data for the Society of Thoracic Surgeons database collected by professional abstractors. Conclusions: Freeform dictation of cardiovascular notes varied by individual surgeon style and case complexity. Up to 25% of the operative note was dedicated to judgment/opinion, which would be difficult to recreate in a structured data-entry format. An electronic system for entering procedural details can improve efficiency for secondary purposes of data collection but must be carefully implemented to avoid loss of important information.