Evaluating the completeness of perioperative outcome metrics in electronic medical records: Insights based on the proposed Perioperative Clinical Outcomes Registry framework

Abstract

Electronic medical records (eMRs) could support perioperative outcomes registries, but the completeness of routinely collected data remains uncertain. This study evaluated the availability of perioperative data within a large Australian hospital eMR against the Perioperative Clinical Outcomes Registry Extended (PCOREx) dataset. A retrospective audit of all elective inpatient procedures involving anaesthetists at Westmead Hospital (Sydney, New South Wales) in June 2022 was performed. Records were reviewed in Cerner^® PowerChart (Cerner Corporation, Kansas City, MO, USA) and completeness was defined as the presence of PCOREx variables across Baseline Risk, Intraoperative Risk, Process of Care, In-Hospital Outcomes and Post-Discharge Outcomes. A total of 405 patients met inclusion criteria. Overall completeness was 63%; excluding post-discharge variables, inpatient completeness was 77.5%. Demographic, procedural and intraoperative physiological data—mostly structured or automatically captured—were consistently recorded (>90%). Comorbidities, frailty indices, intraoperative temperature, and fluid balance were less complete (<50%). Post-discharge outcomes were recorded in only 7.9% of patients, limited to those who re-presented to hospital. Missingness reflected both structural gaps (absence of fields, siloed intensive care unit systems) and clinical behaviour (selective documentation, variable pathology ordering). While routine eMR data capture many perioperative variables, significant gaps remain, particularly for post-discharge outcomes and selectively documented fields. Mapping completeness within the Clinical Adoption Meta Model framework highlights barriers at system and clinical levels. Standardised data capture, linkage with external databases, and improved interoperability are needed to realise the potential of eMRs for perioperative outcomes registries.