Upcoming events:

HL7 September (Atlanta Phoenix) 9 - 10 Connectathon, followed by 5 days working groups.

Other Regular Meetings:

HL7 Group TSMG (meeting Wed PM ET every other week) - Terminology Service Management Group (HTA Thursday AM is now a subgroup of the TSMG).   2022-05-17 RH Joint session with Vocab at last business meeting.  2022-06-14 Group has approved minimum capabilities for terminology servers.  Now looking at bigger/better HL7 Terminology Server 

Australia - 2022-04-13 CSIRO released next version of Ontoserver that implements some R5 features as pre-adoption, mixed with R4 eg typed values in concept maps.  Also code properties without expansion.  2022-08-31 ML CSIRO taking over responsibility for production (including authoring) of SNOMEDCT-AU.  Further announcements in the pipeline.

2023-04-02 - FHIR Community Process, FHIR Training Courses (mix tech and business)

Belgium - Marie-Alexandra Lambot Anne Nerenhausen  multi-discipline data exchange programme for care-sets, FHIR objects codified in SNOMED CT (firstly allergy intollerance).

2023-04-02 - Working though list of FHIR ValueSets

Canada - 

Estonia - Rutt Lindström Kerli Linna switching to FHIR Nationally, preferring international terminologies.  No National TS yet, currently capturing requirements.   2022-09-25 KL Developing National Terminology Server, piloting 

2023-04-02 - Now using Ontoserver Nationally, moving to message (eg ambulances) using FHIR structures.

Europe - 2023-04-02 (MAL) Hospitals on FHIR

France - François Macary Phast 2022-09-25 FM Profiling FHIR based on R4 Nationally.  Intending to join Snomed International as a member.  FM coordinating translation with LP (Canada).

Hong Kong - Karissa Hung Maggie LauHave own terminology table, mapped to other terminologies including SNOMED CT.  Looking to learn more about using 

2022-07-06 Successffuly imported of multiple code system using HAPI FHIR Server (also pending the beta release of the Snowstorm modifications in this area - next few weeks).

2022-09-25 SP FHIR is being adapted as a standard for exchange in National Digital Health Mission of India called Ayushyaman Bharat Digital Health Mission (ABDM). We have FHIR implementation Guide for ABDM where we have created profiles for FHIR resources as per Indian needs. We are using multiple terminology standards like SNOMED CT, LOINC, and ICD depending on the context. We are also working towards having a nation specific term server who can support multiple terminology standards mentioned above. And we are having hands-on on Snowstorm for that.

2023-05-10 SP Testing recommending on Snowstorm 8.1.0

Netherlands - Pim Volkert Chantal Schitmeijer Feikje Hielkema-Raadsveld Ronald Cornet - using FHIR based terminology server which they supply to various vendors free to use except for usual licence fees - is an instance of Ontoserver, but not intended for use in "Live" system, instead used as offline supplier of terminology.  Attempting to lower barriers to adoption.   (Sander Mertens now working for a startup creating EHR system for GPs).  2022-07-06 Hitting technical issues with termserver (suspected scrambled mounting points).

2023-04-02 - Also hosting Ontoserver

New Zealand - Peter Jordan (HL7)  National Terminology Server for NZ currently under development.  Peter's own implementation "Terminz".   FHIR Release 5 underway eg changes to Concept Map.   PJ Medicines Data Repository.  National Terminology Service Mon 5 Dec Connectathon including "Escape from burning platforms"

2023-04-02 - Also using Ontoserver.  Data Repo - 

Norway - Oskar Hurtig using several Snowstorm servers in combination with SNOMED International's Managed Service.  Oskar's team in start-up phase looking at the introduction of SNOMED on FHIR for Norwegian customers.   Existing environment involves many classification systems (eg HealthTerm) which they're trying to consolidate with FHIR.  Developing own FHIR Resources.  2022-05-11 Currently running assessment of various FHIR servers including HAPI, Microsoft.  Focused on VitalSigns.

2022-03-16: This past month is that we’ve done some internal training on FHIR to prepare our team and (softly) requested our leaders to help us create a national recommendation on the use of SNOMED on FHIR in Norway. The use of FHIR and SNOMEDCT are separate recommendations already. We’ve also identified a use case where we would like to create some VitalSign profiles with terminology bindings to SNOMEDCT and be able to locate test patient data using a SNOMEDCT code search. This is primarily a way to learn terminology bindings and ask better questions to this forum, as well as to some extent understand our terminology server needs.

Sweden - Daniel Karlsson, Anna Rossander No clear decision made yet on using FHIR with SNOMED but there are a number of projects underway eg with HL7 Sweden.  Some competition in this space for Terminologies.

2023-04-02 - National based profile work stalled.  Ontoserver procured.  Update on Europe wide FHIR initiatives.

Swiss Annatina Foppa

Austria / Germany. STEFAN SCHULZ Use SNOMED CT together with FHIR for Natural Language Processing in a research context (projects AIDAVA and GeMTeX). Elaboration of an annotation guideline for clinical narratives using SNOMED CT and FHIR.  [https://docs.google.com/document/d/1BQPL8sNIMorRb9qdvsZL0ckpmx2DILsZF6bewRduvWI/edit]

United Kingdom - Andrew Perry(NHS) Various FHIR profiles in use for moving data between primary and secondary care incorporating SNOMED.   National Terminology Server procured (not publicly available - constrained by copyright eg non UK access).  Programme of implementations which use the National Server underway.  See https://digital.nhs.uk/services/terminology-servers 2022-09-25 AP  GP to GP transfer happening in V3.   NHS Digital being brought into the main body of the NHS.  Medicine Connectathon happening in a couple of weeks. NHSx for interoperability also re-absorbed.

2022-04-13 JR working with MS Excel add in to call FHIR $lookups from cells.  Issues with oauth in that environment.

2023-04-02 - Ontoserver.  Working on UK Core "sprint 6" updating profiles.

United States Jeff PiersonIMO 2022-09-25 RH Strong set of Core profiles (came out of Argonaut). Data exchange still based on CDA. Accelerator Projects.  See https://www.hl7.org/about/fhir-accelerator/

SNOMED International -Alejandro Lopez Osornio Kai Kewley Peter G. Williams

2023-05-10 HL7 Europe IG - ongoing work.  DK focussed on SNOMED ValueSets.  Missing content being requested, also potential changes to concept model.

https://github.com/hl7-eu/laboratory

ci build: https://build.fhir.org/ig/hl7-eu/laboratory/branches/master/index.html

Allergy Guide binding question on representing symptoms - discuss on next Tuesday call.

MAL - has finished current version of guide.  Some layout work to do and small additions possible prior to publishing. 

Discussion on Snowstorm multi-codesystems support.   Should get pulling into develop branch.

Sayali and Gurav (India NRC) gave feedback on the current Snowstorm X code.  India focussed on ConceptMap functionality.

2023-03-15 PWI SI has merged the SnowstormX work into the main branch and this will reach production on 22 March.   India had paused testing on Multi codesystems, will return to it.

2023-01-18 DK Asked about provision for ConceptMap

ML Extension for alternate codes is available

ML Question about ValueSets and Bindings - would we accept a LOINC code if it is an alternate identifier?

Group agreed that it would be simpler to do the conversion from LOINC to SCTID up front, and then validation, ValueSets and ECL should all work only using SCTIDs.  ConceptMap would be implicit using the two CodeSystem URIs and no need to specify an SCTID for a map referenceset.   Although DK reminds us that mixed CodeSystem ValueSets exist.

4.2.4 Identifier File Specification  ML suggests changing the SchemeId to a CodeSystem URI or add another column for it.

Support based on HAPI library support for generic CodeSystem imports (doesn't allow for loading maps or valuesets)

• What happens to force-system-version in VS $expand where there is a mix of CodeSystems.   Presumably it only applies to the matching codeSystem.    If there were a mix of two editions, would both editions attempt to expand against the same forced version?
• VS $validate-code with Post-Coordinated concepts as a way of validating correctness of PCE.    How is PCE represented in a GET request?   ML It's one long URL encoded string.   Terms are not required (does the spec suggest they should be stripped out).   KK No PCE support in Snowstorm until later in the year.

ML Question on motivation for adding support for other code systems to Snowstorm KK Was at the request of members.  Also for a SI use case, we'll have access to the terms associated with published core mappings so we can be more expressive than just returning "Q.74" or whatever the code is.

2022-07-06 Question about specific vs general support.   Specific code written for LOINC and ICD-10 / ICD-10CM to allow import in native format  Existing HAPI support for generic code system format is also available.   CodeSystems which declare "IS A" semantics allow parent child ie $subsumption testing to be done.  DK asked if non-international ICD-10 maps have been loaded - they have not.

2022-08-31 KK Snowstorm-X  fork of the SI master Snowstorm project (beta) allows for loading packages from Simplifhir (pre-downloaded).

Review of SNOMED CT Postcoordination Workflow (Discussion)

ML would like the expression supplement to use a system uri of http://snomed.info/xsct rather than http://snomed.info/sct.

See http://snomed.org/scg

2022-09-25 ML Main focus of languages working group is around risk, particularly in the transformation from close to user form.

See also https://confluence.ihtsdotools.org/display/HRCM20200131/Concept+Model+Domains

FHIR Release Schedule : R5 will be trial use Q1 2023.   New normative content will be added Q1 2026.

Minimum capabilities https://jira.hl7.org/browse/FHIR-24698 (aimed at R5)

2022-05-11 RH Date for R5 ballot still open

OH question about ConceptMap - maturity level?  RH Current updates first need to make it officially into R5 (which is expected to happen at ballot).  ML the changes are being driven by increasing maturity, but of course are then 'new'  RH option for 'parts' of a resource to be called 'trial use'.   Dependent mainly on reports of production level implementations.

JR: Current UK use case is: primary care physicians do not want to record the available code for "Long COVID" because (a) they may not have any proof that the patient ever had COVID, because they had it before testing was available and (b) even in those patients who tested positive for COVID there is no test to prove that their current chronic symptoms are caused by that. So the proposal is to give them a "Suspected Long COVID" code. 

MAL: Belgium use the confirmation code on the resource rather than a possible SNOMED CT code.

But that raises interesting questions about what happens when somebody sends a FHIR resource with code="suspected Long COVID" and verificationStatus= confirmed. Or refuted.

Historically, before the information models got around to adding their own support for contingent diagnoses, there have been codes for a small range of "suspected condition" only within the terminology. There are about 400 in SNOMED today. Of these, almost all are NEVER used in UK Primary Care. The significant exception is "Suspected urinary tract infection" plus a handful of others. Which also raises the question of whether clinicians really want, or should be allowed, to enter contingent diagnoses at all. In the case of the "Suspected Long COVID" code, for example, would it not be better to send what you know to be true e.g. "Post viral fatigue syndrome"?

Peter G. Williamsverification status is an example of an HL7 valueset (with a required binding) where some authorities may wish to use SNOMED CT codes instead.  Belgium have created an extension to allow them to do this.  Is there a way forward with the specification that would leave to a more interoperable outcome FYI Rob HausamPJ suggested that the binding strength be loosened eg to extensible or preferred (would go through the Patient Care Workgroup).   Suggestion that any ticket raised is shared with this group and also that country HL7 Affiliate Chairs are involved (interest from at least 4 countries here).  FMc states issue that existing valueset is unsatisfactory for clinicians because"suspected" is missing.

MAL provided:  410605003 | Confirmed present (qualifier value) | 410592001 | Probably present (qualifier value) | 415684004 | Suspected (qualifier value) | 410593006 | Probably NOT present (qualifier value) | 410594000 | Definitely NOT present (qualifier value) | 261665006 | Unknown (qualifier value) | 723510000 | Entered in error (qualifier value) |

https://build.fhir.org/valueset-condition-ver-status.html

PW: Given that this is a required binding to a codeable concept, could we add in the SNOMED CT code as a coding to the existing HL7 Code.  This would force an equivalence that may not be generally agreed with.

JR: Brings up use case of differential diagnosis although this is supported in the HL7 ValueSet.

MAL: There are SCT ways to qualify a diagnosis, see << 106229004 |Qualifier for type of diagnosis (qualifier value)| could be added as an additional field.  

SS: Differential Diagnosis is often used in Germany as a secondary option from the most likely diagnosis.  MAL suggested DD was used more often when there was a set of more equally likely diagnoses.  JR: UK doctors use the order of the DD list ie most likely first.  RC: This was the point of SNOMED CT was that the logical definition of concepts allowed for the detection of equivalence.

SS: Also to note that some languages like German would express suspected asthma as a single word, which needs to be computable.

JR: The AdverseEventActuality valueset looks to be a broadly similar idea for the AdverseEvent resource, but is also different.

2022-04-13  Suggestions for a way forward here? PW Something to raise with Rob Hausamfor the HL7 Vocab working group (also mention the transversal nature of this VS - MAL).   JR List of options eg profile out the codes that leave us open to contradiction.  Guidance on how to interpret various combinations eg a confirmed diagnosis of a SNOMED code that indicates "suspected".  DK Refers to the previous work done that resulted in orange mappings Free SNOMED CT set for FHIR   MAL: Also discussed on the EAG call at the Business Meeting.   Also inconsistency of these "certainty" fields in various FHIR Resources.   Also query around level of certainty when several potential diagnoses are presented.   ML: Suggestion that several condition objects would be linked in this case.     PW Can I say:  "This group recommends that profiles should be used to remove these "contextual" SCT codes from ValueSets which could contradict other fields (AP 'Semantic Clashes') in the FHIR Resource." ?  DK We may already have implementations that are using something like 722545003 |Suspected rabies (situation)| and has decision support systems that would look for this.   ML "The verification status pertains to the condition, itself, not to any specific condition attribute"  (ALL this part of the spec was thought to be ambiguous.  Does this mean just the condition code or the whole Condition resource ie are we verifying all aspects of the resource?   ML Adding in a SNOMED code as an additional coding in a CodeableConcept has a little wiggle room due to "differences in granularity". TB Provisional (or "Working Diagnosis") is often used when a disorder perhaps takes a long time to fully confirm eg Motor Neuron Disease and in fact a treatment plan may already by underway.  So it's further down the line than "suspected".  JR Suspected may also be used when a condition has cleared up and it is no longer to test/prove that that is what it was.  MAL notes that the Refuted status is valuable in terms of saving time and money.   General agreement to avoid the situation hierarchy (No known allergy) and instead pass the allergy condition with the refuted flag.   (Note: psychological feature for humans to fail to hear negation!).  MAL Suggestion to tag the EAG on this Jim Case also with a view to being clearer about the definitions of these concepts (eg suspected diagnosis) in SCT to either align or clearly differentiate with the FHIR VS.    Discussion about "Family History Of" and complications around roles vs sex  see HL7 Gender Harmony Project.  (see "In the Land of Invented Languages" - ML)

• SNOMED+FHIR education

• What should be in the Implementation Guide? (missing/to be added)

• SNOMED+FHIR in multi-language settings

Copied from 2022-03-22 Agenda:  https://jira.hl7.org/browse/FHIR-29821 "Updated cardinality of designation.use"  Expected to be part of R5.

2022-02-22  Add HL7 Jira ticket about designation use context and designation.additionalUse. For discussion on HL7 Vocab call March 3.

2022-03-08 See also https://jira.hl7.org/browse/FHIR-36231 "Add designation context to designation.additionalUse"

Feedback from this group:   relying on the order of elements in the additionalUse array could be tightened up.   If a new element is being proposed, perhaps we could add some structure/hierarchy so that the relationship between refset and acceptability could be more explicit.

DK Compromise using BCP-47 standard seems hopeful.   designation.additionalUse being added with 1..* but DK/ML/RH thought that this would be confusing (more than one way to do things)

DK Suggests implementing BCP-47 in Snowstorm.

PW Has documenting examples of these on TODO List.

FHR: NL have patient friendly text definitions - how is that going to work?

2022-08-03 

RH: Are there any remaining issues for the R5 deadline Aug 21?

ML: Extensions of the BCP-47 language tag specifications does not require any changes to FHIR specifications.

RH: This use of BCP-47 with SNOMED CT still needs to be documented.

Proposal to make a change proposal to the HL7 Using SNOMED CT with FHIR page, and particularly the section Display Terms for Specific Languages. https://www.hl7.org/fhir/snomedct.html#4.3.1.0.4

In this section we should describe:

• The particular use of BCP-47 extensions for language reference sets.
• How and which dialect aliases should at least be supported when using SNOMED CT with FHIR.

There was an agreement in the group that the BCP-47 extensions should have the form <lang>-x-sctlang-<language reference set id>. Note that according to the BCP-47 specification, any string following the "x-" should be divided into at most 8 character sections divided by hyphens. https://tools.ietf.org/rfc/bcp/bcp47.txt

Further there was an agreement in the group that the list of aliases supported by ECL should be referenced, and that there should be one list consisting of aliases for any international or extension language reference set.

A link to a SNOMED-hosted page with more details about the use of languages in a SNOMED+FHIR context has been created (but not filled with content) and should be linked from the HL7 page above. FHIR-languages

The change proposal should be drafter on this page: Changes for R5 with a deadline for the Aug 9 SNOMED on FHIR call.

Next step is to add content to the FHIR-languages page.

FHIR ValueSet $expand Comparison Tool

Next time:   

Marie-Alexandra Lambot inconsistencies between resources should be raised in a FHIR Jira ticket.

Continue work with new Concept Map Elements for R5, see Concept Map in R5