We aimed to develop an efficient surveillance approach for childhood diabetes. We analyzed EHR data from two independent US academic health care systems. Presumptive diabetes cases were identified as those having >1 of the five diabetes indicators in the past 3.5 years. EHRs of the presumptive cases were manually reviewed. We developed a stepwise surveillance approach using billing codes-based pre-specified algorithms and targeted manual EHRs review. The sensitivity and positive predictive value in both systems were approximately >90%. This stepwise surveillance approach resulted in a >70% reduction in the number of cases requiring manual validation compared to traditional surveillance methods.