Jim Case

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Jim Case

Jim Case 

SNOMED has received a request to add a clinical drug for which the FSN exceeds the limit of characters allowed (255). 

Product containing precisely dexamethasone 1 milligram/1 milliliter and neomycin (as neomycin sulfate) 3500 international unit/1 milliliter and polymyxin B sulfate 6000 international unit/1 milliliter conventional release suspension for eye drops (clinical drug)

Number of characters = 262

Options to address this include:

• Remove the word "international" from the numerator units and just use "unit"
• Abbreviate the denominator unit to "mL" instead of milliliter

It is anticipated that this is the first of a number of issues related to drug name length.  Whatever decision is made will need to be applied consistently for all future drug names.  Editorial policy will be developed to inform authors regarding this exception to FSN terming.

Discussion:

Comments from Monique van Berkum are attached.

Comment from Feikje Hielkema-Raadsveld  - Abbreviations in FSNs for drugs: There are not just international units but also arbitrary units and, I think, units that are neither; so removing ‘international’ makes me uncomfortable. I would sooner use the abbreviated unit. Having said that, the Netherlands has nothing at stake here because we do not use the drug hierarchy.

Internal discussions raised the issue of misinterpreting the abbreviation "IU", as well as the different ways it is represented in other languages (e.g. "UI")

No concern about the misinterpretation of IU with IV as this represents a product and not a procedure.  Concern expressed about when to use IU vs "International unit".  Only for those that exceed the length or for all concepts that have international unit in the FSN? 

Decision:

Recommendation: For all drug concepts in the International release that use the term "International units", replace with the abbreviation "IU" ( without expansion).  This would be  note as an exception in the editorial guidance. 

Jim Case 

At the 2023-02-27 EAG conference call, the EAG approved the inactivation of the Navigational concept hierarchy. The EAG members requested a Briefing Note for the Community of Practice outlining the rationale and steps for inactivation.  The briefing note is attached for review.

Update 4/4/2023:

In discussions with the UK, it was discovered that the current use of Navigational concepts are the result of maps from Read version 2 to SNOMED provided to primary care vendors.  The erroneous nature of the maps may be a result of the movement of concepts from their original location in the taxonomy to the Navigational concept hierarchy at variable times in the past.  

The UK will provide SNOMED International with a list of mappings to navigational concepts and their current use cases.  SNOMED will provide replacement concepts for these prior to inactivation of the navigational concept.  Briefing note will be revised to reflect this new information.

Update 2023-05-08:

The following concepts have been identified as high usage concepts by the UK:

CONCEPTID    FSN
394617004    Result (navigational concept)
160237006    History/symptoms (navigational concept)
309157004    Normal laboratory finding (navigational concept)
267368005    Endocrine, nutritional, metabolic and immunity disorders (navigational concept)
243800003    Test categorized by action status (navigational concept)
250541005    Biochemical finding (navigational concept)
309230008    Borderline laboratory finding (navigational concept)
309158009    Laboratory finding abnormal (navigational concept)
118246004    Laboratory test finding (navigational concept)
282465005    Physiological functions and activities (navigational concept)
165347009    Laboratory test result borderline (navigational concept)
309159001    Normal hematology finding (navigational concept)
250207003    Hematology finding (navigational concept)
370121008    Disorder of blood / lymphatics / immune system (navigational concept)
309194008    Hematology finding abnormal (navigational concept)
276437003    Skin, hair and nail finding (navigational concept)
243798005    Procedure categorized by action status (navigational concept)

An updated Briefing note listing these concepts and the proposed replacements is attached to this agenda. This draft has been sent to the UK for their input as they are the member primarily affected by this change.

Discussion:

If the UK is OK with the proposal, then EAG is supportive of the inactivations.

Decision:  

Await input from UK and move forward with inactivations as described in the BN.

• Jim Case to update the BN and distribute to EAG, CMAG and Clinical Leads

A query was posed as to the difference between 129433002 |Inspection - action (qualifier value)| and 281615006 |Exploration - action (qualifier value)|, both subtypes of 302199004 |Examination - action (qualifier value)|. The internal consensus was that these are clinically different with the former limited to visual evaluation and the latter implying an active examination.  Various medical dictionary definitions concur with this view:

e.g. Exploration - "An active examination, usually involving endoscopy or a surgical procedure, to ascertain conditions present as an aid in diagnosis. - 
Medical Dictionary for the Health Professions and Nursing © Farlex 2012"

Inspection - "The visual examination of the body using the eyes and a lighted instrument if needed. The sense of smell may also be used. - Gale Encyclopedia of Medicine. Copyright 2008 The Gale Group, Inc. All rights reserved."

This would imply that surgical procedures would more frequently use exploration as the METHOD than inspection; however, this does not appear to be the case

<<387713003 |Surgical procedure|:260686004 |Method| = 129433002 |Inspection - action| = 306

<<387713003 |Surgical procedure|:260686004 |Method| = 281615006 |Exploration - action| = 150

For non-surgical procedures the difference is more extreme

(<<71388002 |Procedure| MINUS <<387713003 |Surgical procedure|):260686004 |Method| = 129433002 |Inspection - action| = 710

(<<71388002 |Procedure| MINUS <<387713003 |Surgical procedure|):260686004 |Method| = 281615006 |Exploration - action| = 220

Many of the non-surgical procedures modeled using inspection are some form of endoscopy.  Given the definitions above and the consensus of the internal content development team, should SI undertake a project replacing Inspection with Exploration for surgical and endoscopic procedures?  It is anticipated that much of this can be done automatically.

Discussion (2023-04-04):

Need to review the definition associated with Inspection procedure and Exploration procedure. General consensus is that we do not change the modeling unless there is a clear distinction that can be applied other than what is expressed in the FSN. 

Explorations can be performed without visualization, but Inspections do require visualization.  The current definitions on both need clarification as they imply a supertype/subtype relationship:

122458006 |Exploration procedure (procedure)| -  An observation of the body or a body part done by inspection and/or palpation.

32750006 |Inspection (procedure)| - An exploration using the sense of sight, done with the eyes.

Endoscopy/laparoscopy etc. all use a scope of some sort to visualize the body structures, so should use Inspection as the action. Almost all concepts that use Exploration - action have the word Exploration in the FSN. 

An associated question, based on the current definition in SNOMED of Exploratory procedure, should Palpation -action be a subtype of Exploration - action?  

Update 2023-04-30:

Exploration concepts were derived from the UK OPCS procedure terminology.  The terminology uses "exploration" almost exclusively, with only one procedure using the term "inspection" (K53.1 Inspection of valve of heart). All of their terms have existed in OPCS since at least 1990. 

The AHIMA coding guide states "Inspection is defined as visually and/or manually exploring a body part. Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers."  This suggests that AHIMA treats "inspection and "exploration" as synonymous; however, a classification expert from the UK states "I think an exploration in OPCS represents a procedure where there is some sort of entry of an organ/structure to have a look around whether that be with or without incision...I don’t think we can say that the terms ‘inspection’ and ‘exploration’ are synonymous in OPCS-4 and to do so would have the potential for up-coding."

They also state that there are no definitions in OPCS that would help in distinguishing between inspection and exploration.  It is possible that in this scenario, the UK has chosen to use the term "exploration" in favor of the term "inspection" as they state that the one inspection term they have is an anomaly. 

Update 2023-05-17:

The WHO International Classification on Healthcare Interventions (ICHI) provides a definition for Inspection: "Exploring a body part by visual, olfactory, acoustic or tactile means.".  It also includes a number of related actions as subtypes:

• Auscultation 
• Endoscopy 
• Examination, not otherwise specified
• Exploration
• Exploratory laparotomy
• Fluoroscopy
• Laparoscopy
• Palpation

As we have not been able to find a consistent definition for the difference between Inspection and Exploration, would it be acceptable to adhere to the WHO definition and relationships, i.e. make Exploration - action and Palpation - action subtypes of inspection.  It is unknown at this time what the overall impact on the procedure taxonomy would be, so testing would be required.

Discussion:

Comment from Feikje Hielkema-Raadsveld  - Inspection vs exploration: Making exploration a subtype of inspection would I think indeed solve our original problem: we could model all staging laparoscopies and staging laparotomies with exploration and they would be subsumed by the international concepts, whatever method those were using. So I would not mind this solution. Reading the definitions provided by WHO and AHIMA, OPCS does seem rather alone in making a distinction… Perhaps there should also be a guideline that recommends being wary of using ‘exploration’ in modelling new content?

We do not have a solution due to the various ways that the terms are used.  It was suggested that "Inspection" would be an overarching term, but there are concerns that the relationships described by the WHO are confusing as it equates inspection and examination as well as exploration. SNOMED Needs to come up with a definition for inspection (requires visualization?).  There is still not a good understanding of what is encompasses by an exploration and whether there is any supertype/subtype relationship between exploration and inspection.  

The primary challenge is the definition of what is meant by "exploration". The consensus of the group is that inspection and exploration are not synonymous and may not have a taxonomic relationship. The other consensus is that "Inspection" refers to visualization.  

Decision:

Need a review of the existing terms that use "exploration" to see whether there are redundancies (e.g. "exploration" vs. "surgical exploration" vs "incision and exploration") 

Inspection should be defined in SNOMED CT as a visualization.  Evaluate the impact of changing "Inspection" to "Visual inspection".

Jim Case to provide group with OPCS terms and usage.

• Jim Case to provide a list of current OPCS terms and usage levels for those concepts that use the term "Exploration"

The attribute 246112005 |Severity (attribute)| is an approved defining attribute for Clinical findings in the MRCM; however editorial guidance has been rather ill-defined in relation to the use of this attribute due to the subjectivity of assigning a severity to a clinical finding (i.e. "Severity is defined relative to the expected degree of intensity or hazard of the Clinical finding that is being qualified.")

Modeling

Generally, 246112005 |Severity (attribute)| is not used to model concepts precoordinated in the International Release, but there are some exceptions. 

A valid exception requires an internationally accepted definition that can be consistently applied and used reliably for international comparison.  Even though a reference may be internationally sourced, its use may not always be uniformly applied by multiple countries. Classifications of severity that represent variation in clinical presentations and enact limitations with age ranges, sex, or pregnancy status, do not apply universally to all patients of all ages, prove problematic, and may not be generally useful. 

The requestor is responsible for obtaining permission for use in SNOMED CT if required by the international body.  

Issue

The issue to be discussed originated at the April 2023 business meeting where it was noticed that some diseases (e.g. Severe asthma) were primitive concepts and thus it is not possible to identify the duplications and subsumptions in postcoordinated expressions that use the severity attribute. 

As an alternative to precoordination in the international release, this attribute can be used as a qualifier in postcoordination.  However, beware that postcoordination of severity results in the same irreproducibility issues as pre-coordination. 

• Jim Case to take the discussion back to internal team

Jim Case 

Victor Medina 

In January, the EAG discussed the definition of "Surgical procedure" and revision of the current MRCM attribute was discussed (2023-01-23 SNOMED Editorial Advisory Group Conference Call).  In light of the fact that we are not able to come up with a standard definition for surgical procedure, we should eliminate the specific action methods under 129284003 |Surgical action (qualifier value)| to the more general 129264002 |Action (qualifier value)| concepts.  As we review the current 129264002 |Action (qualifier value)| hierarchy, we are finding that there are a number of actions that can be applied to either a surgical or non-surgical procedure.  

What we have found is that the definition of a surgical procedure depends primarily on who performs the procedure.  This is problematic as the same procedure may be performed by multiple categories of healthcare professionals. The current definition was broadened from the initial definition in 2021 and now represents an overarching meaning that overlaps with many types of procedures that would not normally be considered surgical (e.g. freezing of warts, reduction of nursemaid elbow). 

Retaining this distinction of surgical and non-surgical procedure will result in the need to create a number of specific surgical actions with unknown benefit in the classification of procedure concepts.  Elimination of the need to specify Surgical procedure as a specific subtype of procedure would obviate the need for the creation of these specific "surgical" actions. 

If it is determined that there is no need to specify a procedure as a surgical procedure, is it reasonable to replace the existing "Surgical approach" attribute with a  more generic "Procedure approach"?

Discussion:

Comment from Feikje Hielkema-Raadsveld - Surgical action: This is a tricky question. I completely agree that it is unclear which actions are surgical and which are not. The current distinction has caused us many headaches and confusion in trying to model repairs: sometimes they are explicitly surgical, sometimes implicitly, and sometimes not surgical.
But the Netherlands uses and creates many concepts that refer to an operation or surgery: operation for glaucoma, mastoid operation, surgical repair of this that and the other; and many ‘surgical treatments’ too. That seems a usecase that occurs very frequently. How would we model those, if we retire the method surgical action? Is there an alternative definition, e.g. ‘an operation is a procedure that involves an incision’?

Decision:

Meetings will continue on the fourth Monday of the month and may be cancelled if necessary.