Summary
Please see the attached briefing note. This topic will be discussed at the April SNOMED CT Editorial Advisory Group and CMAG meetings. Comments prior to support the discussion at the meetings would be very welcome.
Relevant documents
Actions:
Date | Requested action | Requester(s) | Response required by: | Comments |
|---|---|---|---|---|
| 23 March 2022 | Review and comment As raised on the April CMAG meeting please post comments by 25 April 2022. | Please post your comments in the Country response table below. |
Links
Initial Country Comments
Country | Date | Response |
|---|---|---|
| USA | 23MAR2022 | Proposal seems reasonable and will provide consistency across SNOMED CT findings. No specific comments or reservations. |
| Australia | 20220427 | We have no specific objections to the proposal. |
| Ireland | 27042022 |
From a haematology perspective I am unclear on the last concept on a measurement or level that is abnormal and on that basis am unclear as to whether accept or reject this final concept proposal. |
| Member countries without a CMAG rep |
8 Comments
Daniel Karlsson
"Decreased", "Increased" could also possibly mean trending down/up, i.e. decreased/increased in relation to previous measurement results.
Paul Amos
Hi Daniel Karlsson, Thank you for your comment.
We considered this as a possibility but there are a few reasons why we felt that this was unlikely:
Clearly it is difficult to be absolutely certain, but in your opinion, given these issues, how likely is it that the increased/decreased concepts have been used to mean a change in level that is more or less than the previous measure?
Feikje Hielkema-Raadsveld
Hi Daniel Karlsson and Paul Amos, We had this exact same discussion while translating SNOMED to Dutch: how to interpret 'increased', and noting that it was usually but not always defined as 'above reference range'. Our conclusion was that, while 'above reference range' was the most likely interpretation and usecase, we could not exclude an interpretation as 'raised compared to previous measurement', for instance in patients with chronic conditions. So we deliberately translated literally to the equally vague 'verhoogd', thus distinguishing them from concepts with FSN ... above reference range.
Replacing instead of changing these 400 concepts seems drastic but I do have to agree with Daniel that these concepts are ambiguous and changing them to 'above reference range' does change their meaning. Consider for instance the concept
95899007 |Drug action increased|; on the surface it has the same pattern, but in this case the meaning really is 'increased compared to previous measurement'.
Daniel Karlsson
Hi Paul Amos
The discussion arose in the X-eHealth project when we were considering observation interpretation value sets. I would not know how likely it would be for users of SNOMED CT to disagree on the meaning of "increased" (in relation to "normal" or in relation to previous result) but it was a source of at least some concern among the lab specialists. E.g. in the HL7 value set for observation interpretation, the word "increased" is used (not as a display term) in the definition to describe change over time. https://build.fhir.org/valueset-observation-interpretation.html
Matt Cordell
I agree with Daniel about the trend/relative to previous, but I think the proposal is reasonably pragmatic for the reasons Paul describes.
I am a little concerned though about the view that "Abnormal" is considered ambiguous. An "abnormal level" is simply "outside the reference range".
I've noticed this trend in recent years where some concepts are being retired as "ambiguous" when they're arguably just "non-specific". If non-specific is to be considered ambiguous, then all intermediate concepts could could be retired as such...
Amputated lower limb - could be left or right ...
Amputated left lower limb - could be above or below the knee ...
Feikje Hielkema-Raadsveld
I agree with Matt Cordell. I would question why someone would report a result 'outside reference range' and exactly what the recipient is supposed to do about it, but the meaning seems perfectly clear: the opposite of 'within reference range'.
Paul Amos
An interesting question. Yes, the meaning is clear, it is outside the reference range. But in practical terms and in the context of a measurement finding, surely that means it is either above or below the reference range OR all we know is that it is outside the reference range, but we don't know whether it is above or below the reference range.
However, if we know the actual result of the test, the only logical answers are either above or below reference range. Which I think in the context of a reported result from the laboratory is what would be returned. So if we don't label this as ambiguous, what would you suggest?
Disorder groupers however do more than represent ambiguity, by which I mean they represent more than just their subtypes. They are also a logical and clinically accepted stage in the diagnostic pathway. We are expressing the stage in which we know this is some sort of "X disorder" but we don't yet know which sort of "X". This is an appropriate and useful statement to make in the clinical record.
Matt Cordell
I agree this value (probably*) wouldn't be reported on a patient record, but that's only one context...
Perhaps I want to identify all patients that have a result outside the reference range for some analytics purpose.
Perhaps I want to make a result bold, or and "report level" flag if some result(s) is outside the reference range.
*It might not be visible on the record, but might be used in the background.
AmbiguousLess specific concepts are obviously useful for disorders where the full details aren't immediately known (if ever) e.g. infections.But that's only a portion of the "disorder groupers".
There's 9 concepts between 404684003|Clinical finding| and 816114007|Amputated left lower limb above knee|
I'm not convinced any of those are stages in a diagnostic pathway.
There's 19 concepts between 64572001|Disease| and 74400008|Appendicitis| ...
Sometimes clinicians might not be as specific as they could be, but removing groupers forces them to be more specific than they might need or want to be...
And in some contexts groupers are useful, even if they could be emulated through post-coordination.
If it's not wrong (ambiguous) does anything even need to be done?