Date: 2022-02-23
Time:
1700- 1830 UTC
0900 -1030 PDT
Zoom Meeting Details
Topic: SNOMED Editorial Advisory Group
Time: Feb 23, 2022 09:00 AM Pacific Time (US and Canada)
Join from PC, Mac, Linux, iOS or Android:
https://snomed.zoom.us/j/96728596672?pwd=aXF2TzJZNVp3enRVRWR1UEJ0RytOQT09
Password: 078363
Attendees
Chair:
AG Members
- Alejandro Lopez Osornio (ex officio)
- Keith Campbell
- Monique van Berkum
- James R. Campbell
- Jeffrey Pierson
- Paul Amos (ex officio)
Invitees
Meeting Files:
Objectives
- Obtain consensus on agenda items
Discussion items
| Item | Description | Owner | Notes | Action |
|---|---|---|---|---|
| 1 | Call to order and role call | This meeting is being recorded to ensure that important discussion points are not missed in the minutes. The recording will be available to the SNOMED International community. Joining the meeting by accepting the Zoom prompt declares that you have no objection to your comments being recorded |
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| 2 | Conflicts of interest and agenda review | None stated. | ||
| 3 | Combined procedures | A question submitted via Freshdesk asked the proper way to represent "Combined procedures". These often represent two or more atomic procedures performed during the same encounter or surgery. E.G. 16180003 |Laryngotomy with removal of tumor (procedure)| 78165004 |Take-down of arteriovenous shunt with creation of new shunt (procedure)| Many procedures of this type involve endoscopy of some type. SNOMED no longer allows for combined disorders where there is no common causal relationship between the two, except in rare instances where two concepts are generally temporally associated with a potential underlying cause (e.g. diarrhea and vomiting). For procedures, SNOMED has good coverage of the atomic procedures involved in such combined procedures . However, there are potentially many hundreds of these types of concepts that could be added based on the current modeling of these as a Procedure with two relationship groups representing the two different atomic procedures. As Alejandro Lopez Osornio has pointed out in the Freshdesk response, these can also be represented simply as a post-coordinated expression using the "+". e.g. 61561005 |Incision of larynx (procedure)| + 370612006 |Excision of neoplasm (procedure)|. Due to the relatively unbounded set of combined procedures that can be modeled, what should be the editorial policy related to future requests for combined procedures? The requester expressed a desire to not have to record two separate procedures as they are temporally linked. Discussion: Disorders are events of nature but procedures are man-made. Combined procedures often have an association focused on a single focus. E.g. "incision and drainage of joint". If they can be sufficiently defined then they should be added. There is a benefit for clinicians to have these combined procedures in finding the proper procedure. What are the criteria that should be applied to allow for these? If the multiple procedures done in sequence related to a single focus for the set of procedures, that are usually done during the same encounter, then they should be added. Not a random collection of procedures. Decision: Consensus is that these types of procedures should be added given the constraints discussed above. Editorial guidance to be drafted to represent the decision. | Jim Case to work with Monica Harry and Krista Lilly to develop editorial guidance for combined procedures | |
| 4 | Malignant neoplasm redesign | Discussion: The current mechanism for defining primary malignancy and metastatic in SNOMED CT is through the 116676008 |Associated morphology (attribute)| relationship with the following morphology concepts as the value: Subtypes of 367651003 Malignant neoplasm of primary, secondary, or uncertain origin (morphologic abnormality): See attached document above.
Discussion: The CSRWG has been made aware of this and based on the direction, we will discuss this with them. This does not impact work with the WHO ICD-O. The problem with primary and metastatic has been recognized for a long time. Challenges with options 2 and 3 are based on the fact that the meaning of a concept is based on the FSN. Changing the name is "changing the meaning". Changing the FSN should be carefully looked at. The overall model is an improvement. The consensus of the group is that the options related to renaming of FSNs is not an optimal solution. Current concepts with "primary" or "metastatic" should not be inactivated. Concepts that do not specify primary of metastatic should be remodeled as agnostic. The challenge is that we do not know how these have been used and recreating the same FSN. This is constrained by the current tooling and editorial rules (cannot create an identical FSN). Decision: No renaming of FSNs. Concepts will be remodeled according the term in the FSN. New concepts representing primary and metastatic will be created as necessary. Proposal to go out to CoP for comment. |
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| 5 | Measurement findings QI proposal | Paul Amos | In a previous discussion at EAG, a decision was taken to review the concepts that represented a "positive" or "negative" finding with the intention to replace those with concepts that declared "detected" and "not detected" as this more properly represents the presence or absence of a substance in a fluid/tissue. This arose because detection of a substance is limited by the capability of the laboratory test conducted. Additionally, the words "positive" and "negative'" can be misrepresented to mean that a diagnosis has been confirmed or refuted by the results of the test. Members of the EAG also requested that where a concept's FSN was ambiguous it should be replaced with more specific concepts that represent the different types of measurements. Implementation of this decision has become complicated for a number of reasons:
Example: 406115008 |Syphilis test finding (finding)| requires 3 nontreponemal test findings and 5 treponemal test findings, each with detected and not detected = 16 concepts, 6 of which would be primitive due to the LOINC agreement terms and conditions. We are aware that there may be some push back in changing from "positive" and "negative" to "detected" and "not detected" - please could we confirm that the EAG supports the use of "detected" and "not detected"? Is the change in proposed FSN and PT terming a sufficient change (e.g. 390879000 |Treponema pallidum enzyme-linked immunosorbent assay negative (finding)| changes to "Treponema pallidum detected by enzyme-linked immunosorbent assay") that inactivation and replacement are necessary (impacts thousands of concepts)? Should the terms "positive" and "negative" be retained as additional descriptions for search and retrieval purposes? Discussion: This is related to the definition of existing findings concepts. Now concepts would only be created to replace erroneous or ambiguous findings concepts. Is there a need for creation of findings for all ordinal observations? Historically, yes. In general, changing the FSN and PT is not a substantial change requiring inactivation and replacement. The findings concepts do not have to represent all of the detail of the laboratory test that was performed to detect an analyte. They can be added as needed if sufficient justification provided. Decision: Changing the FSN to "Detected" and "Not detected" does not require inactivation and replacement. Adding Positive and Negative as synonyms is appropriate. | |
| 6 | Left heart failure/Right heart failure representation | Postponed until the April Business meeting The Netherlands have pointed out the inconsistency with the following two concepts: 85232009 |Left heart failure (disorder)| - has synonym, Left ventricular failure. 367363000 |Right ventricular failure (disorder)| - has synonym, Right heart failure Their cardiology experts advise left/right heart failure can be caused by ventricular or valve disease. They have suggested the following structure with three new concepts: Left heart failure (disorder) -Left ventricular failure (disorder) Right heart failure (disorder) -367363000 |Right ventricular failure (disorder)| A position paper posted earlier this year proposing new definitions are consistent with the Netherlands cardiologist view. UNIVERSAL DEFINITION OF HF Symptoms and or signs (Table 6) caused by a structural and/or functional cardiac abnormality (as determined by EF <50%, abnormal cardiac chamber enlargement, E/E′ >15, moderate/severe ventricular hypertrophy or moderate/severe valvular obstructive or regurgitant lesion) A briefing note has been prepared to address potential changes (see PDF in meeting files). We have received comments from the CMAG. The US Comments expose the complexity of the issue:(Changes to the Universal Definition and Classification of Heart Failure - Impact on SNOMED CT) Discussion: Decision: | ||
| 7 | "Long-COVID" representation in SNOMED CT | Jim Case | An inquiry was recently made on SI's question and answer page related to SNOMED CT representation of "Long COVID". This term was first coined on social media and has since become a hot topic in both the patient and clinical communities. There are a few published articles that try to define this clinical condition and many have divided the condition into two separate types: "Post acute COVID-19" which represents a continuation of clinical signs attributable to infection with SARS-CoV-2 for longer than 3-4 weeks (depending on which definition you choose) with or without the presence of either live virus or detection by PCR; and "Chronic post-COVID syndrome", where clinical signs similar to chronic fatigue syndrome persist for more than 12 weeks following acute infection. WHO’s case definition is as follows: “Post COVID-19 condition occurs in individuals with a history of probable or confirmed SARS CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms and that last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms include fatigue, shortness of breath, cognitive dysfunction but also others and generally have an impact on everyday functioning. Symptoms may be new onset following initial recovery from an acute COVID-19 episode or persist from the initial illness. Symptoms may also fluctuate or relapse over time.” This definition may change as new evidence emerges and our understanding continues to evolve. SNOMED CT currently has four concepts related to COVID conditions:
The UK has similar concepts:
The WHO definition of long COVID does not include the post-acute phase of the disease. The general community of patients experiencing this condition do not make the distinction between Post-acute and Chronic and lump it all into "Long-COVID". We have been requested to create an overarching terms that includes both the post-acute and Chronic conditions due to the fact that it was observed that many clinicians do not make the distinction between the post acute and chronic phases and that this results in misclassification of some patients, with a potential patient safety issue. Given that there is no well established, authoritative terminology that addresses this issue, what should SNOMED's policy be to address the needs of the clinical community? For an interesting read on the social, clinical, and political aspects of this, see: https://www.sciencedirect.com/science/article/pii/S0277953621009515 Discussion: The challenge is that it is difficult to determine whether there is active infection in the post-acute COVID-19 condition. There is no agreed definition of any of these. There are a number of projects ongoing to try and define these conditions. Decision: Consensus is that it is premature to try and create a concept that represents the Long-COVID condition, based on the lack of definitive research to determine what the condition is. | |
| 7 | X (person) vs. X of subject (person) | Jim Case | A question from a member country on when to use "X (person)" vs. "X of subject (person)" has exposed issues with determination of equivalence in information models that either split the relationship from the condition vs. using a precoordinated Situation concept to represent the SUBJECT RELATIONSHIP CONTEXT. Discussion: "X of person" was introduced to support the SUBJECT_RELATIONSHIP_CONTEXT of Situations. Monique van Berkumwill look for some history on why they were added. Suggested that the ECE might have some history on these. Question is whether we need to separate out the relationship values from "persons" as a class? The main distinction made in the reference paper is that between an "Entity" and the "Role" played by an Entity. However, this distinction is not made within the person hierarchy, with << 444148008 |Person in family of subject (person)| primarily representing roles that Person entities play being in the same Person hierarchy. Since the 444148008 |Person in family of subject (person)| is primarily used as values for the SUBJECT RELATIONSHIP CONTEXT attribute, we can question why it is in the Person entity hierarchy. A question raised by the reference provided is whether a well established role (e.g. father) can also exist as an entity? Can a father exist as a standalone entity without the establishment of a relationship to another entity? Decision: Background will be investigated. The person hierarchy needs some review and rationalization. Background document posted above. Will review for next meeting. Make sure page is open for viewing by the EAG. |
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| 8 | AOB | EAG | SNOMED International's Events team is very pleased to announce that registration for the in-person component of the forthcoming April 2022 Business Meetings is now open (pre-registration for attending virtually is not required). Please see our website for full details, including our COVID-19 health and safety approach and the registration and accommodation booking links. We would also like to make sure that you are aware that the SNOMED CT Expo 2022 Call for Abstracts has just launched, for the conference in Lisbon this September. You can find all the information on Confluence here. | |
| 9 | Next meeting | EAG | April Business meeting April 5 2022 | |
2 Comments
Jeremy Rogers
For the record: have listened to the recording and fully support the meeting's decision on Agenda Item 4 (Malignant/Primary/Metastatic cancer) not to rename any FSNs, to remodel in place as necessary the existing content according to what is already said on the tin - ie align modelling to the letter of the existing FSN - and to create explicit new Primary/Metastatic etc codes with unambiguous new FSNs where needed.
Nicola Ingram
Thank you Jeremy Rogers for your clear response (agreement with aligning modelling to the letter of the existing FSN - and to create explicit new Primary/Metastatic etc codes with unambiguous new FSNs where needed) and your support for our decision. Thank you also for supplying the UK usage statistics which helped inform this decision.
The Briefing Note for the CMAG and Member Forum is ready and should be uploaded shortly.