JMIR Publications

ABSTRACT

Background:

The diagnosis section of electronic hospital discharge summaries, akin to a problem list, offers a concise summary of the patient’s medical condition and is essential for continuity of care and clinical information exchange. However, the lack of condition-specific documentation standards contributes to unstructured, inaccurate, or incomplete documentation and limits the potential for structured data exchange and secondary use of diagnostic data.

Objective:

This study aimed to (1) develop and demonstrate a replicable methodology for developing consensus-based templates for electronic diagnosis documentation and (2) apply this methodology to pneumonia, chronic obstructive pulmonary disease (COPD), and lung cancer.

Methods:

A two-round Delphi study was conducted between November 2024 and January 2025. A panel of 60 pneumologists from the German Respiratory Society and the Association of Pulmonology Clinics evaluated proposed documentation elements for inclusion or exclusion and classified them as mandatory, required, or optional until consensus was achieved. Consensus for inclusion was defined as more than 75% agreement, with strong consensus defined as greater than 95% agreement.

Results:

A replicable methodology for developing consensus-based diagnosis templates was established and effectively applied to pneumonia, COPD, and lung cancer, achieving consensus (>75% agreement) on 9, 21, and 31 data elements, respectively. For pneumonia, strong consensus (>95% agreement) was reached on data elements such as cause, location, and microbiology findings. For COPD, data elements with strong consensus included substance use, interventions, and disease severity as per GOLD staging. For lung cancer, 17 data elements reached strong consensus, all classified as mandatory. Visualized templates were developed to support hospital implementation in electronic discharge summaries.

Conclusions:

This study established and applied a replicable consensus-based methodology for developing condition-specific structured diagnosis documentation templates for electronic discharge summaries. The established methodology and resulting templates provide a foundation for future implementation in electronic clinical documentation systems. Future work will extend the approach to other conditions and validate the templates in clinical practice.