There is not a single best workflow to recommend for SNOMED CT translation. The workflow most suitable to a country’s needs depends on what part of SNOMED CT is likely to be used, the resources (including translators) available and the order in which translation principles are prioritised.

4.1 Team selection

It takes a village to translate SNOMED CT, that is to say a group of people with different roles and expertise:

• Terminologists ensure the semantic correctness of the translations: to check whether the translations convey and imply the exact same meaning as the concepts expressed with the FSN and concept relationships. The NRC should contact SNOMED International in case of discrepancies between descriptions and definitions, between English descriptions, and to report duplicate concepts (see chapter 4.5). SNOMED International can facilitate translation by providing text definitions.
• Healthcare professionals, as the target users of the translations, should indicate which translations are most frequently used and recognizable in the healthcare environment. 

SNOMED CT contains many concepts that refer to procedures or disorders that are highly specialised, have become obsolete, or convey the same meaning through entirely different descriptions. No single healthcare professional or terminologist can interpret them all. You will need a team of specialists from the relevant healthcare disciplines, who can indicate what an obscure term means, how it is referred to in your language and whether it is relevant for your country or not. If you translate a use case specific reference set, you may be able to limit your team to a single specialty. In that case, the terminologist will need to ensure that the translations are not interpreted into a too specific context, which would render them unsuitable for other use.

• Linguists are required to ensure consistent, concise, grammatical translations that are free of spelling errors. They are more likely to notice and avoid standard (non-medical) translation pitfalls that a healthcare professional new to translation might fall into. Linguists are often trained to use text corpora for translation purposes. Translation, especially in such huge quantities, is a profession in itself: a group of healthcare professionals simply will not make as neat a job of it. By preference, the translators should be specialised in medical translation or assisted by a medical linguist.

Some of these skills may be combined. For example, the Netherlands found it useful to train young Medical Doctors in the use, purpose and structure of SNOMED CT, so they can check both semantic correctness and recognizability of the translation, increasing efficiency. Alternatively, translators can be trained as terminologists, or healthcare professionals with a linguistics background can be found. However, combining multiple skills or expertise in a single person will make it harder to find suitable people and increase the cost of their labour.

4.2 Prioritise translation principles

The Guidelines for Translation of SNOMED CT discuss the translation principles that are vital to know when translating SNOMED CT, including the idea of concept-based translation. Translations should be unambiguous, linguistically correct, consistent and both recognisable and acceptable to healthcare professionals. Unfortunately, these requirements conflict. In order to resolve these daily dilemmas most quickly, you should prioritise them and let this priority influence your workflow. If you rate recognisability and acceptability highest, then the healthcare professional should have the final say over each translation. If on the other hand you value consistency and linguistic correctness more, then a medical linguist or translator should have that honour. This prioritisation should be done in close collaboration with the editorial board and made available in the national language guidelines for translation. 

In difficult cases an editorial board can ensure consensus about the best possible translation (or compromise). The use of synonyms can be used to support different jargons between specialist groups, spelling variants or even patient-friendly terms. To distinguish translations that adhere to all principles from those that deliberately violate some (e.g. contain spelling errors, are meant for patients rather than medical professionals, or are ambiguous) you can choose to create multiple language reference sets. Please note that adding synonyms or language reference sets does increase the burden of maintenance.

You should also decide in advance how to handle obsolete or erroneous concepts. Do you want to translate them anyway (which leads to an imperfect result), ignore them (which leads to an incomplete translation) or resolve them with SNOMED International (which leads to a large amount of work both for you and for SNOMED International) However, it is highly recommended to submit obsolete and erroneous concepts to improve the quality and reduce the burden of future translations into other languages. The time spent on discussion regarding bad concepts will multiply for each new translation unless they are resolved by Snomed International. 

4.3 Determine the workflow

There is no single best workflow. The choices you have made above restrict the number of workflows that are suitable to your situation. However, some principles hold true in all cases:

• Each translation should be concept-based. Concept-based translation is explained in chapter 4 in “Guidelines for Translation of SNOMED CT”.
• Each translation should be viewed by at least two team members, and any change made, however trivial, should be reviewed by a colleague.
• You will need an editorial board to maintain linguistic guidelines, correcting any translations that do not comply, and resolve difficult cases.
• You should be able to track the process of each translated concept through the workflow.
• You need some kind of quality assurance (described in “A methodology and toolkit for evaluating SNOMED CT translation quality”).

Different member countries have translated using very heterogeneous workflows. The previous version of this document recommended the workflow in Figure 4-1, based on the experiences of Sweden and Denmark.

Figure 4-1: Translation process recommended after Swedish and Danish translation

Conversely, the Netherlands adopted a complex workflow where each expertise owned its own workflow status (see Figure 4-2). This made it easier to find suitable team members, but increased the amount of time needed per translation and required abundant and careful communication to coordinate the different expertise groups. 

Figure 4-2: Translation process in the Netherlands

Figure 4-3: Translation process in Belgium

Figure 4-4: Translation process in Norway

4.3.2  Pro’s and con’s of different workflows

Table 4-1: Pro’s and con’s of different workflows

4.4 Progress monitoring and follow-up

The following issues related to the translation process should be monitored and considered:

• regular adjustment of the linguistic guidelines;
• adjustment of the resources in the translation processes in order to continuously optimise the process;
• workflow statistics;
• correction of translations that do not comply with the linguistic guidelines. This includes changing older translations to comply with a new guideline.

The following issues of project progress should be monitored:

• follow-up on quantity, e.g. the number of approved translated concepts, the number of unresolved problem concepts sent to the editorial board, the number of errors made by the translators;
• follow-up on quality, e.g. how well the translation complies with the linguistic guidelines, how well the translation complies with language corpora and concordances of respected medical journals and other relevant sources;

follow-up on costs;

• follow-up on deviations from goals;
• follow-up on translation service provider issues;
• follow-up on performance of IT tools.

4.5 Content enhancement during translation

The translation process provides an excellent form of quality assurance for SNOMED CT, both in terms of a review of existing content, and also the identification of SNOMED CT concepts which could be added to the release, either as international content additions or by addition to national extensions where these exist. Guidance for content requests can be found here - SNOMED CT Content Request Service. 

If promoting national concepts to the international edition, the FSN and PT have to be translated into English (US). This requires in depth knowledge of the Editorial Guide and naming conventions related to the hierarchy the concepts belong to.

Regarding all requests, whether to the International or National Release, should be supplied with a detailed description of the problem, along with a statement of requirements to inform the resolution. In the case of requests originating from translation activities, this should include details of the problem related to translation with a description including concept/description translations to provide additional clarity.

An NRC may use their own tool, such as JIRA, to collect and filter requests for SNOMED International; or they can use a tool that SNOMED International provides: https://be-rmp.snomedtools.org/fr/. This latter tool is convenient because it can be used to escalate an issue to SNOMED International.

The Translation User Group (TUG) uses a JIRA environment to signal and discuss translation issues among translating countries. This is a good venue to ask how other countries have solved a particular translation issue. When the group agrees that the issue is with the international edition and warrants a change request, the group can submit the request through CRS using the TUG’s project code. 

4.6 Collaborating with other NRCs

The Translation User Group meets regularly with a dual purpose: to create and update guidelines such as these, and also to share experiences and expertise. When you encounter a particular translation dilemma, such as an ambiguous source concept or term, you can raise an issue in our JIRA project: https://jira.ihtsdotools.org/projects/SCTF/summary.

We invite every organisation or professional developing a SNOMED CT translation to join the group. Details can be found on https://confluence.ihtsdotools.org/display/TRANSLATIONUSERGROUP/Translation+User+Group+Home .

4.7 Translation to multiple languages or dialects

Performing translation and validation to a target language which is official in several countries potentially involving different NRCs will normally require a different approach, such as Spanish, French and German. However, a language being shared across borders, may present differences regarding spelling or lexical choices which have to be taken into account. This section will present some experiences of multiple languages and dialects.

4.7.1 The Swiss Experience

The Swiss Extension includes German, French and Italian. The following are the experiences and workflows of the Swiss NRC.

The concepts are initially translated by the internal translation service of the Federal Office of Public Health (FOPH). eHealth Suisse then checks whether the initial translations comply with the guidelines and the translation guides of the respective language of SNOMED International. If necessary, the translations are additionally validated by experts.

Depending on the language, a different process is initiated.

The German translations are compared with existing translations from Germany or Austria and supplemented if necessary. Subsequently, the German translations are submitted to the German Translation Group (GTG). The translations are checked again by the GTG and, if necessary, supplemented with further synonyms. After review, the translations are published in the German Community Browser of SNOMED International and a public commenting phase is started. During this phase, anyone can comment on the translations. Once the commenting phase has been completed and evaluated, the translations will be incorporated into the joint German edition of the GTG.

French translations that are not already in SNOMED's "Common French Translation" will be submitted to the French Translation Collaboration Group and included in the "Common French Translation". Unlike the German-language group, the French-language group does not provide for public comment.

Italian translations do not go through an International Working Group, as none currently exists. Italian translations are validated by appropriate subject matter experts after the initial translation, if needed, and then imported directly into the Swiss Extension.

Based on the Swiss experience, there are advantages and disadvantages of a sequential and a parallel translation process: