Digital diagnostic head

To date, there is no standardised format for the content and structure of diagnosis headers in discharge reports in Germany. This results in a lack of interoperability between clinical IT systems, which makes cross-sector, digital exchange and automatic data transfer more difficult. Inconsistent documentation, high administrative costs and relevant information that is not available at the crucial moment repeatedly lead to gaps in care.

1. Identification of best practices: Using an AI-supported analysis of discharge reports from different medical facilities, interdisciplinary patterns on the structure and content in the diagnosis header are collected and evaluated.
2. Determination of medical preferences: A survey of physicians in Germany to capture the requirements regarding structure, content and level of detail of the diagnosis headers and adapt them to clinical reality.
3. Disease-specific templates: By agreeing on specific information elements in the diagnostic header, documentation templates for common diseases are created that simplify everyday clinical practice.
4. Programming the digital templates: The templates are converted into the KV-MIO format (the standardised language of the electronic patient file) and made available in a database.

• Funding: The project is funded by the internal research funding of Witten/Herdecke University. Funding reference number: IFF 2024-80.
• Responsible: Chair of Health Informatics & Chair of Internal Medicine I