Time:
0100 - 0430 0230 PST
0900-1230 1030 UTC
Zoom Meeting Details
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AG Members:
Invitees:
Observers
Apologies:
Hi there,
Jim Case is inviting you to a scheduled SNOMED International Zoom meeting.
Topic: SNOMED Editorial Advisory Group Conference Call
Time: May 22, 2023 09:00 Pacific Time (US and Canada)
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Meeting ID: 837 1456 8251
Password: 983972
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Attendees
Chair:
AG Members:
Invitees:
Observers
Apologies:
Meeting Files:
| View file | ||||
|---|---|---|---|---|
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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 | |||
| 3 | Abbreviations in FSN for drugs | 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:
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. | ||
| 4 | Inactivation of Navigational concept hierarchy | 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 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. |
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| 5 | Inspection vs. exploration actions | Jim Case | 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. - 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:
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:
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. |
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| 6 | Severity as a defining attribute | Jim Case | 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. The use of the SEVERITY attribute is complicated by the lack of knowledge about the ordinal scale from which the selected severity originated. For example, the source severity value set may have different sets of values such as: • mild / moderate / severe The current editorial guidance for the use of the SEVERITY attribute has a modeling note attached: The question is, given its common use in clinical practice, should the restrictions on the use of SEVERITY in the International release be relaxed, allowing for any concept that explicitly states severity in the FSN have a severity relationship assigned, with the caveat that interpretation of the intended meaning is subjective? I.e. the notion of severity exists and is commonly used, but may not be interpreted the same by everyone. Discussion: Comment from Feikje Hielkema-Raadsveld - The notion of severity is highly subjective. But it seems strange to ban it from modelling, yet allow it in the FSN. And a whole lot of other things (disease vs. finding, heh) are just as subjective. I think I would be in favour of relaxing the modelling restrictions on severity, but we would need strong guidance on when it is okay to use it, and when it should be avoided. For instance, 722401001 |Severe fever with thrombocytopenia syndrome virus| - should one apply a severity there? To the fever, or the whole? Or is it a particular disease that could have its own severity? I am what the others’ reactions will be. Historically there are many reasons why it was originally removed, however, many disorders that are by nature "severe" that would not classify under them because the FSN does not contain the word "Severe". This would require a review of many terms that would be expected to classify under a supertype. There are defined uses for severity. In cases where these definitions exist, an authoritative text definition must be included. However, this does not guarantee that all of the appropriate subtypes would properly classify unless the subtypes are specifically defined with a severity relationship. Suggested there be a review of terms that currently have a severity relationship to determine whether such an authoritative definition exists. The current use of Severity relationship in SNOMED is limited to two concepts and they are problematic. Decision: |
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| 7 | Surgical action | 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. Decision: | ||
| 8 | AOB | EAG | ||
| 9 | Next meeting | EAG | Meetings will continue on the fourth Monday of the month and may be cancelled if necessary. |
Meeting Files:
Meeting minutes:
The call recording is located here.
Objectives
- Obtain consensus on agenda items
Discussion items
| Item | Description | Owner | Notes | Action | 1 | Call to order and role call |
| 2 | Conflicts of interest and agenda review | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4 | Inactivation of Navigational concept hierarchy | 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 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: Decision: |
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| 5 | At risk concept modeling update |
| 6 | Expansion of the range of HAS INTERPRETATION | James R. Campbell | 7 | Mechanical Complication of device | Jim Case | 8 | Intermediate primitive parent and definition status of subtype |
| 9 | Inspection vs. exploration actions | Jim Case | 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. - 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: 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? | 10 | AOB | EAG | 11 | Next meeting | EAG | Next meeting April 4. SNOMED business meeting | |||
