Jim Case

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

Jim Case

None recorded

Jim Case 

The EAG welcomes Dr. Jeremy Rogers back to the EAG after a hiatus and expresses their gratitude to Dr. Jeff Pierson for his service on the EAG for the last 6 years.

Jim Case 

Status of EAG discussed topics since April 2024:  Completed, In progress

• Modeling of "No known X" - Revision of Context values has not progressed.  Consensus on approach not yet reached
• Transplantation vs. grafting and Terming of Transplantation concepts - work has been completed for both solid organs and tissues
• Mechanical complication of device - Inactivation of concepts complete
• Replacement of "Surgical approach" with "Procedure approach - MRCM change and batch changes to concepts underway
• MRCM change and revision of Physical object hierarchy - Being discussed at this meeting
• Inactivation of 370115009 |Special concept (special concept)| - Pending inactivation of Navigational hierarchy
• Creation of new top level hierarchy for Generic products -  proposal in development
• Bypass graft revision proposal - document under review by the EAG, will be discussed at October meeting
• Remodeling of 1263452006 |Anesthesia and/or sedation procedure (procedure)| hierarchy - On hold pending input from the Anesthesia CRG
• USING DEVICE vs. DIRECT DEVICE use in procedures - Editorial guidance to be updated with examples
• Nontraumatic vs spontaneous injury - In process
• Proposed policy for Assessment Instruments in SNOMED CT International release - Published
• Reterming of "Percutaneous transluminal angioplasty " concepts and cleanup of hierarchy - complete, ready for review by EAG
• Naming pattern for components of clinical syndromes - proposal rejected
• Representation of Exacerbations - additional discussion needed

Nicola Ingram 

Jim Case 

At the September EAG call, it was suggested by the group that normal body structures be used instead of the transplanted body structures and that the direct substance relationship be removed unless it was necessary to sufficiently define the concept.  These changes have been made and are currently ready for review by the EAG in the TS browser (project QININ and tasks QININ-270, QININ-271).  It was also noticed that the top level concept 77465005 |Transplantation (procedure)| had lost a substantial number of subtypes following the remodeling efforts.  The EAG asked for more details on this loss of subtypes.  A worksheet detailing these changes for 89 affected concepts is attached.  (Please download before trying to review the content)

Discussion:

Feikje Hielkema-Raadsveld Daniel Karlsson 

At the November 2023 EAG call, a proposal to update the Physical object MRCM to allow for the modeling of containers was presented.  The EAG requested additional information as well as examples of the proposed modeling.  Feikje Hielkema-Raadsveld and Daniel Karlsson were provided with access to the SNOMED authoring platform to test their proposed model.  Questions that arose from this testing include:

• Should we group the attributes? We immediately ran into a problem grouping them. The MS discourages grouping attributes with the same type, but to create different role groups for each additive is very counter-intuitive. Are there other branches in SNOMED where this issue emerged, and what solution was adopted there?
• We propose a modification to our initial proposal: intended content should be specimen, not substance, to accommodate for instance container for 24 hour urine specimen
• Should we distinguish between blood collection tube and blood transfer tube? Why (not)? Our example project is working on the assumption that we drop that distinction.
• Should we distinguish between blood tube and blood container? If so, is the relevant distinction the shape or something else?
• We can model coagulation factors but not (yet) clot activators. We have left those concepts primitive, but we could model them by adding a disposition. Preferably one that can be grouped with coagulation factors. Is that worth doing? Those clot activators do pop up in every blood container branch.
• Do we want to want an attribute to dinstinguish between evacuated and non-evacuated containers, or do we keep those concepts primitive?

Discussion:

Comment from Matt Cordell 

Container modelling – “intended content should be specimen”, substance seems more accurate. If becomes a “specimen” in the container.
Consider the various blood collections – they all get whole blood put in them. but the tubes (with additives) produce different specimens, plasma, serum, whole blood, pack cells, buffy coat etc.
(Maybe there is a different attribute for input content, and contained substance?)

General comments:

Discussion on the use of substance vs. specimen.  The purpose of the model is to create models for pre-manufactured specimen specific containers.

The reason for the project is to address the need from some members to create a hierarchy of specimen containers to support European data projects and to allow for subsumption testing.  An issue that it would resolve is to allow specification of a container based on its characteristics in a FHIR model.  There are currently about 100 concepts that would be affected by this model.  This would allow for a cleanup of the container hierarchy as well.  Many of the concepts will require renaming or replacement.

What is the difference between a collection tube and a transfer tube?  May need to go back to GMDN to get definitions.  Their definitions may not be consistent with SNOMED.

Need more information on clot activators.  How to represent.  

Evacuated or non-evacuated containers.  Jim Case  stated this is an intrinsic characteristic of the container and should  be represented.

Concern expressed about the complexity of the model and its relationship to other attributes  that are already defined for devices.  Specific editorial guidance will be necessary to allow for proper and consistent use of a physical object concept model that needs to represent such a wide variety of objects.

Decision:

Further discussion will be held at the October face-to-face meeting in Korea.

Jim Case 

Current and prior editorial policy for modeling of Events (<<272379006 |Event (event)|) stated that while the allowed attributes for events closely aligned with the Clinical finding concept model, editorial policy for using these attributes to model events were still under development.  However, one restriction has been applied and that is: "The Event hierarchy should not precoordinate periods of life/occurrence within the event concept."  It has been brought to our attention that there are a number of event concepts that do reference periods of life in which the event occurred.  Examples:

• 418189009 |Child abuse (event)|
• 242571000 |Accident due to neglect of child (event)|
• 12399091000119108 |Adult abuse (event)|
• 70055007 |Unexpected sudden death of adult (event)|
• 160957000 |Sudden infant death (event)|

A few of these have been modeled using the OCCURRENCE attribute in spite of the editorial guidance.  A member request has asked that we look at this policy as modeling of other concepts is being affected due to this restriction on modeling of events.  

Q: As  the OCCURRENCE attribute is currently an allowed attribute for EVENTS, should there be any restrictions on the use of these attributes.  If they should not be used, should the MRCM be modified to remove them from the allowed attributes set?

Discussion:

Comment from Matt Cordell 

• Age-related events modeling - I’m OK with keeping occurrence for these. I think simply having “Abuse” or “Death” (for the examples loses much of the meaning). I know there’s implications the “periods of life/occurrence” range brings, but perhaps we need to accept this is the language people use.

Decision:

Victor Medina 

Jim Case 

As requested from the EAG, a list of definitions has been developed that will guide content authors in the correct modeling of concepts related to bypass, bypass graft, shunt, etc.:

The relevant Briefing note is attached above.

Proposal for definition of concepts under 48537004 |Bypass graft (procedure)|.
Proposal for Definitions.

• CONSTRUCTION OF BYPASS. Surgical creation of a passage to carry contents
  around a part of a structure in its normal route and back to a structure in its
  normal route.
• CONSTRUCTION OF BYPASS USING GRAFT. Surgical creation of a passage, using a
  biological or synthetic material, to carry contents around a part of a structure in its
  normal route and back to a structure in its normal route.
• CONSTRUCTION OF SHUNT. Surgical creation of a passage allowing contents to
  move from one structure to another, not following its normal route.
• CONSTRUCTION OF SHUNT USING GRAFT (SYN: INTERPOSITION SHUNT). Surgical
  creation of a passage using a biological or synthetic material, allowing contents to
  move from one structure to another, not following its normal route.
• INTERPOSITION GRAFT. A surgical repair, using a biological or synthetic graft, of a
  structural defect that does not allow tension-free anastomosis.
• ANASTOMOSIS. Surgical procedure to create a cross-connection between
  channels, tubes, fibers, or other parts of a network.

Discussion:

Decision:

2024-03-11 Comments will be added to the document by the EAG members. 

2024-04-16: Proposed definitions will be revised based on input and resubmitted to the EAG for review.  

2024-08-19: Postponed

2024-09-23: Postponed to later meeting

2024-10-21: 

• Victor Medina to revise definitions based on input from the EAG

Jim Case 

TBD