1. Introduction

1.1. Background

SNOMED CT terminology provides a common language that enables a consistent way of indexing, storing, retrieving, and aggregating clinical data across specialties and sites of care.

SNOMED International maintains the SNOMED CT technical design, the content architecture, the SNOMED CT content (includes the concepts table, the descriptions table, the relationships table, a history table, and ICD mappings), and related technical documentation.

1.2. Purpose

This document provides a summarized description of the content changes included in the October 2022 release of SNOMED Clinical Terms^® (SCT) International Release.

It also includes technical notes detailing the known content or technical issues where the root cause is understood, the fix has been discussed and agreed to, but has yet to be implemented.

The SNOMED International Release Notes are available alongside the October 2022 International release.

1.3. Scope

This document is written for the purpose described above and is not intended to provide details of the technical specifications for SNOMED CT or encompass every change made during the release.

1.4. Audience

The audience includes National Release Centers, WHO-FIC release centers, vendors of electronic health records, terminology developers and managers who wish to have an understanding of changes that have been incorporated into the October 2022 International release.

Please note, you may have to register for a Confluence user account in order to access the links included in these release notes.

2. Content Development Activity

2.1. Summary

Continuous quality improvement and enhancement of existing content is an ongoing process undertaken by SNOMED International in preparation for every release. The October 2022 International Release has seen a continuation of the work driven by contributions from: Kaiser Permanente i.e. Convergent Medical Terminology (CMT), Global Medical Device Nomenclature Agency (GMDNA), Orphanet and other domain specific collaborations as well as requests received via the Content Request System (CRS). 

Additionally quality improvement activities are advanced via project driven initiatives summarized below.  Additional work items impacting every release are updates to the SNOMED CT derived maps such as ICD-10 and ICD-O; details are included in these release notes.  

Information about editorial decisions may be found in the SNOMED CT Editorial Guide; mapping guidance for ICD-10 can be found here

2.2. Quality Initiative

The Quality Initiative (QI) project is the implementation of the Quality Strategy. After a successful pilot project for the July 2018 release the next stage has been implemented for subsequent releases including October 2022. 

Quality improvement tasks are being deployed to improve internal structural consistency and ensure compliance with editorial policy related to the stated modeling of content. Additionally, correction or addition of defining relationships is being carried out to accurately reflect current clinical knowledge and ensure the semantic reliability of descriptions associated with a concept.

2.2.1. Intellectual Disability

110359009 |Intellectual disability (disorder)| has been remodeled and is now sufficiently defined. The 505 subtypes have been also been updated to align with the new model.

2.2.2. Drug Withdrawal 

The model and descriptions for 363101005 |Drug withdrawal (disorder)| and child concepts have been updated to reflect the associated meaning.

2.2.3. Drug Dependence

The descriptions for concepts including the term "drug dependence" have been updated to reflect "substance dependence".

The word “drug” in the existing descriptions is ambiguous and does not have a universal definition or a consistent international representation; it can refer to illicit drugs and/or prescription medications. Additionally, dependence can occur with the use of substances such as ethanol, which are not considered an illicit drug or a prescription medication.

2.2.4. Poisoning Caused by Organism

Concepts of the type 'poisoning caused by organism' have been reviewed.  The model for these concepts has been updated including the following subhierarchies:

• 275390005 |Toxic effect of plant (disorder)|
• 44400004 |Toxic effect of venom (disorder)|
• 75258004 |Food poisoning (disorder)|
• 26033009 |Toxic effect of mycotoxin (disorder)|
• 1149327007 |Poisoning caused by Clostridium botulinum toxin (disorder)|

2.3. Body Structure 

2.3.1. New Concepts for Tooth Socket

Approximately 45 new body structure concepts have been created to represent tooth socket, entire tooth socket and subtypes. Approximately 10 procedure concepts have had their modelling changed to reflect the new concepts available. In addition to this, 335901003 |Gomphosis structure (body structure)| now subsumes 80541002 |Cementum structure (body structure)|, 46141003 |Structure of alveolus dentalis (body structure)| and 245775004 |Structure of periodontal ligament (body structure)|, and 786880003 |Structure of jaw region within part of mouth (body structure)| has been inactivated as a duplicate to 28035005 |Tooth, gum, and/or supporting structure (body structure)|. 

2.3.2. Zygomatic Structure

The subhierarchy of 13881006|Zygomatic bone structure (body structure)| has been reviewed and updated. Content in the procedure and disorder hierarchies have been updated to align with this new anatomy model with approximately 20 concepts being revised.

2.3.3. SEP and Laterality Anatomy Reference Sets

The release file for the lateralizable body structure reference set has been updated and validated.

The release file for the SEP reference set has been updated and validated.

2.4. Procedure

2.4.1. Diagnostic Procedures

Work has been completed on the inactivation of procedures stating intent as diagnostic in descriptions. 126 concepts have been inactivated. The exceptions to this approach have been procedures that differ in what is actually done depending on whether the intent is diagnostic or therapeutic. 171 concepts have been retained on this basis. Work will now commence reviewing therapeutic procedures.

2.5. Qualifier Value

2.6. Substance

2.7. Pharmaceutical/Biological Product

2.8. Physical Object

2.9. Collaboration/Harmonization Agreements

2.9.1. Convergent Medical Terminology (CMT)

125 CMT concepts have been added for the October 2022 release with a focus on injury and skin ulcer content.

2.9.2. Orphanet

Working in collaboration with Orphanet (http://www.orpha.net/consor/cgi-bin/index.php), content development is ongoing for rare disease concepts in SNOMED CT. Content in scope for this project is published in the annual update of the SNOMED CT to Orphanet Maps.

All of the concepts added for the Orphanet project have been mapped to ICD-10.

2.9.3. ICD-11 Update

The October 2022 release has seen continued addition of content for this project.

2.9.4. Cancer Synoptic Reporting

Cancer synoptic reports are used by many member countries to record pathology examination of cancer specimens including the College of American Pathologists (US and Canada), Royal College of Pathology (UK), Royal College of Pathology Australasia (Australia, New Zealand), PALGA (The Netherlands), Swedish Society of Pathology, and others.

For more information about this project, please see Cancer Synoptic Reporting Clinical Project Group 

2.9.5. Social Determinants of Health - Gravity Project

11 concepts have been added for the October 2022 release with a focus on health literacy findings and procedures relating to substance use treatment programs.

2.9.6. International League Against Epilepsy (ILAE)

The October 2022 release includes changes and improvements to generalized onset seizure and seizure structural grouper content within the << 313307000 |Epileptic seizure (finding)| hierarchy.

Further details of these changes are available here. 

2.10. Internal Quality Improvement

2.10.1. Machine Readable Concept Model (MRCM) Changes

There have been no changes for the October 2022 release.

Please see early visibility notification for details of future changes to the MRCM.

2.11. SNOMED CT derived products

2.11.1. ICD-10 map

The SNOMED CT to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (© World Health Organization 1994) 2016 Version map (SNOMED CT to ICD-10 Map) is included in the SNOMED CT International release as a Baseline. The SNOMED CT to ICD-10 Map was created to support the epidemiological, statistical and administrative reporting needs of SNOMED International member countries and WHO Collaborating Centers.

The SNOMED CT to ICD-10 Map is released in Release Format 2 (RF2) only. It is located in the file der2_iisssccRefset_ExtendedMapFull_INT_20200731.txt, which is in the Map folder under Refset, in each of the three RF2 Release Type folders. 

The SNOMED CT to ICD-10 Map is released as Refset 447562003 |ICD-10 complex map reference set (foundation metadata concept)|.

2.11.2. Content development activity summary

The map is a directed set of relationships from SNOMED CT source concepts to ICD-10 target classification codes.  The SNOMED CT source domains for the MAP are limited to subtypes of 404684003 |clinical finding|, 272379006 |event| and 243796009 |situation with explicit context|.  The target classification codes are ICD-10 2016 release. 

Mapped content for October 2022

The map provided for the Octoberr 2022 release has been updated, and now represents a complete map from SNOMED CT International release to ICD-10 2016 version.

• 481 newly authored concepts have been added and mapped.

• The SNOMED to ICD-O (morphology) map has one additional concept added as a result of the ICD-O 3.2 review or added due to CRS requests.

We would welcome feedback on any issues that users of the map may detect when using the map. Issues should be submitted via mapping@snomed.org

2.11.3. Technical Guide Exemplars

The Technical Guide Exemplars document has now been moved from the International Edition release package to a Confluence page.  This page can be found as part of the ICD-10 Mapping Technical Guide (see Appendix B), which is hosted here:  http://snomed.org/icd10map

2.11.4. SNOMED CT to OWL conversion and classification

The repository containing the toolkit enabling simple SNOMED CT to OWL conversion and classification can be found here, including documentation on its use: https://github.com/IHTSDO/snomed-owl-toolkit

Please contact SNOMED International at support@snomed.org if you would like to provide any feedback on ways to extend and improve the new toolkit.

3. Technical notes

3.1. Known Issues

Known Issues are content or technical issues where the root cause is understood, and the resolution has been discussed and agreed but has yet to be implemented.  This can be due to a number of reasons, from lack of time within the new monthly editing cycles, to the risk of impact to the stability of SNOMED CT if the fix were to be deployed at that stage in the Product lifecycle.  

For the current SNOMED CT International edition, the following Known Issues were identified, and agreed to be resolved in future editing cycles:

3.2. Resolved Issues

Resolved issues are Known Issues which were not fixed as part of the previous release lifecycle, but which have now been resolved in the latest release.  They can also be issues found during testing of the current release, which were resolved before the final deployment of the Production release.  Finally they can be issues which were reported or found during the testing phase, but which have been closed without any action taken.  

The Resolved Issues for the current SNOMED CT International edition can be found here:

3.3. Technical updates

3.3.1. RF2 package format

For future reference, the RF2 package convention dictates that it contains all relevant files, regardless of whether or not there is content to be included in each particular release.  Therefore, the package contains a mixture of files which contain both header rows and content data, and also files that are intentionally left blank (including only a header record).  The reason that these files are not removed from the package is to draw a clear distinction between files that:

• have been deprecated (and therefore removed from the package completely), due to the content no longer being relevant to RF2 in this or future releases, and 

• happen to contain no data in this particular release (and are therefore included in the package but left blank, with only a header record), but are still relevant to RF2, and could therefore potentially contain data in future releases.

This allows users to easily distinguish between files that have purposefully been removed or not, as otherwise if files in option 2 above were left out of the package it could be interpreted as an error, rather than an intentional lack of content in that release.

Configuration file in the RF2 package, containing Release Metadata 

A new file has been included since the July 2020 International Edition, containing metadata about the Release package itself.  This has been created in conjunction with feedback from the community, and as such initially contains the following fields:

• effectiveTime
  

• previouslyPublishedPackage

• languageRefset(s)

• licenceStatement

The file is in .JSON format, to ensure that it is both machine-readable and human-readable, and is named "release_package_information.json".

The metadata will be extended and refined going forward, in order to ensure that it contains the most useful information possible. If you have any ideas about any other useful information to include, please send them to info@snomed.org, along with a business case explaining how the information would benefit stakeholders.  Please be aware that this use case will then be assessed by SNOMED International, and the new metadata will only be included in the configuration file if the business case is strong enough.  

3.3.2. New Association References

In order to support the Content changes above in section 2.3, the following Association Reference set members have been added to the International Edition from the April 2022 release onwards:

• 1186921001|POSSIBLY REPLACED BY association reference set
  
• 1186924009|PARTIALLY EQUIVALENT TO association reference set

3.3.3. Early visibility of impending changes in the upcoming 2022 Monthly International Edition releases

Please see the following page for details of all upcoming changes planned for 2022: 

•  https://confluence.ihtsdotools.org/display/RMT/2022+Early+Visibility+Release+Notice+-+Planned+changes+to+upcoming+SNOMED+International+Release+packages