Time:
0100 1030 - 0230 1400 PST
1330 - 1700 EDT
1730-2100 0900-1030 UTC
Zoom Meeting Details
Topic: SNOMED Editorial Advisory Group
Time: Oct 23, 2023 10:30 Pacific Time (US and Canada)
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https://snomed.zoom.us/j/82233252652?pwd=Q7vaRKFqZGeNNMbM2bu49v1QdSbahI.1
Password: 033907
Attendees
Chair:
AG Members:
Invitees:
Observers
Monica Harry , Jane Millar , Timothy Williams , Jusseyea Eotzsch
Yongsheng Gao , Peter Van Ausdeln, Megan Berry , Julie Boutin , STEFAN SCHULZ , Ole Våge , Maria Braithwaite , Michael Jones , Eza Hafeza ,Stuart Abbott , Daniel Karlsson , Hanne Johansen , Guillermo Reynoso , Graeme Elsby , Michael Lawley , Patrick McCormick , Rob Hausam , Olivier Bodenreider , Amanda Wilson, Chia Bih Yee, Cyndie Lundberg
Apologies:
Meeting Files:
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Objectives
- Obtain consensus on agenda items
Discussion items
Item | Description | Owner | Notes | Action | |||||||||
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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 | Modeling of "No known X" | Inconsistent representation of "No known...(situation)" with proposed remodeling. See attached document. | 3 | Abbreviations in FSN for drugs | Different resolution depending on whether the Situation is a "Finding with explicit context" (allowed range = << 410514004 |Finding context value (qualifier value)|) or a "Procedure with explicit context" (allowed range - << 288532009 |Context values for actions (qualifier value)|)? Discussion: "No known" has a different meaning than "Unknown" so should be a sibling, even though both terms refer to a lack of information. It is not clear what some of the terms mean (e.g. known absent, definitely not present). Other context concepts under 36692007 |Known (qualifier value)|, need to be reviewed for the logical organization and definitions, as used in modeling need to be developed Decision: "No known" Should be added as a sibling Finding context value to "Unknown". Existing context values should be reviewed for usage in modeling and meaning of concepts. Concepts expressing level of confidence (possible, probably, suspected) should not be subtypes of "Known". SI to develop a plan for reorganization of the Finding context values specifically under 36692007 |Known (qualifier value)| and add a concept for "No known" with a consensus definition. | ||||||||
4 | Transplantation vs. grafting and Terming of Transplantation concepts | Briefing note for changes in the taxonomic location of 129407005 |Grafting | 5 | Inspection vs. exploration actions | Jim Case | A query was posed as to the difference between 129433002 |Inspection - action (qualifier value)| and 281615006 410820007 |Exploration Surgical transplantation - 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: 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:
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. |
| 6 | Severity as a defining attribute | Jim Case | is attached. Comments on proposed changes are requested. Ancillary to the change in the Action hierarchy, there are concerns about the current terming of many transplantation concepts, where the precise meaning is unclear. Most of these concepts have the form "Transplantation of....". In the case of solid organs, the intended meaning is clear, i.e. transplantation of a donor organ to a recipient; however, for transplantation of tissue concepts, the intended meaning is unclear. Does it mean "Transplantation from X" or "Transplantation to X", and is the type of tissue implied Examples: 119661004 |Transplantation of tissue of hand (procedure)| 119717000 |Transplantation of tissue of nose (procedure)| Does 69428003 |Transplantation of uterine tissue (procedure)| mean transplantation of donor uterine tissue to the uterus of a recipient? Is this even a real procedure or just a grouper for the single subtype? For the most part, this type of concept represents a grouper for subtypes such as "surgical transfer", "Surgical advancement" and "Surgical recession", which do not involve a donor-recipient relationship. If these serve only as "action" groupers and do not represent real procedures, should they be retained or inactivated? If retained, is the FSN clear? Also the model based on EAG feedback would include Procedure site - direct and Procedure site - Indirect. For further discussion does (a.) the transplanted body structure = the Procedure site - direct (b.) Procedure site - indirect is this the location in which the transplanted organ is placed. However many transplanted body structures including tissues do not currently exist. For transplants involving whole organs and tissues harvested from donors is a Procedure site - direct of < 24486003 |Structure of transplant (body structure)| correct (e.g. 81510007 |Structure of transplanted heart (body structure)? Use of Procedure site - direct and Procedure site - Indirect i.e. no Direct substance (attribute) differs from very similar grafts and flap reconstructions that use Method (attribute), Procedure site - Direct (attribute) and Direct substance (attribute) . An updated briefing note is attached to the agenda. Discussion: Decision: | ||
5 | Mechanical complication of device | First discussed by EAG on 2023-04-04: Summary of the initial discussion: Mechanical complication concepts are classification derived (ICD-9, ICD-10, and ICD-11) and may refer to injury or harm to a patient caused by a failure, breakdown, or malfunction of a device. Coding guidance indicated that (for ICD-11) the disorder caused by the mechanical complication should be coded first and then associated with the device. Thus, the intended meaning of these concepts imply a disorder in the patient due to some issue with the device. The actual terms are index terms in the ICD. Example: PK91.22 Cardiovascular devices associated with injury or harm, mechanical or bioprosthetic valves (ICD-11) This would suggest that these concepts are correctly placed in the taxonomy, and they are currently mapped to ICD disorders (i.e. injury or harm to patient) but are possibly not modeled sufficiently to express the implied meaning. Implantable devices might be considered as a type of body part, thus a disorder of the device would of necessity cause a problem in the patient and should be a disorder. While there may not be a morphological abnormality, there is an abnormality of the device. Is a new attribute needed to represent device abnormality? This discussion is restricted to medical devices and not transplanted tissues and organs. An updated briefing note is attached to the agenda. Discussion: Definition of implantable device is needed to appropriately assign the proper METHOD value in procedures. The proposed definition: A medical device that is either: a) inserted partially or fully into the body via an orifice and/or surgical intervention which is intended to remain in situ postprocedure; or b) intended to replace an epithelial surface of the body or corneal surface of the eye and remain in situ postprocedure General consensus is that this is OK, but the need for the definition was still not clear to everyone. These mechanical complication concepts originated from ICD-9 and may refer to either a malfunction of the device (as described in ICD-9 and ICD-10) or an injury to the patient due to a malfunction of a device (as described in ICD-11). The general discussion leaned towards a lack of clinical value of these grouper concepts. There was no consensus as to what defines a mechanical complication. They may provide value as statistical groupers, but of little value in the context of clinical care. Decision: Consensus to propose to inactivate all specific "mechanical complication" grouper concepts due to unclear meaning. Specific complications associated with devices would be created if requested by membership. Briefing note will be developed and circulated. |
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6 | Evaluation procedures to Observable Entity | A briefing note circulated in August proposed a movement of evaluation procedures, initially focused on laboratory procedures, from the Evaluation procedure hierarchy to the Observable entity hierarchy. This proposal was a result of many years of discussion about the duplicative nature of Evaluation procedures, inconsistency in modeling of clinical findings using the INTERPRETS relationship and a divergence of the representation of these types of concepts from other observation standards such as LOINC and NPU. There was substantial opposition to this proposal from member countries that have long used Evaluation procedures for ordering. A presentation explaining the rationale is attached and will be used to inform the discussion. Discussion: During the presentation Jim Case qualified the scope of the discussion to measurement procedures only as there are a number of evaluation procedures that are not affected by this proposal. Summary presentation of the issues attached Following the presentation of the issues around the two vs. one hierarchy conundrum the EAG (and observers) provided input on the following options:
A merge would require a long-term consultation period as there are many implementations that would be affected. As this is a problem that has been around for over 20 year, it was suggested that maintenance of the status quo will be needed prior to any adoption of option 2 or 3. However, enhancement of the existing evaluation procedures would be a benefit to existing users. The E2O project attempted to create a conversion from evaluation procedures to observables, but it was found that many evaluation procedures were underspecified to the point where it was not possible to determine the correct modeling in observables. It was determined that many evaluation procedures were more appropriate as generic orderable procedures due to the inability of being able to define them. If they were moved, they would be grouper concepts. Overall it was discovered that there were overall quality issues with the evaluation procedures hierarchy. Many attribute values were replaced in the conversion. This has indicated that a substantial amount of work is needed to improve the quality of the existing content. Panels are orderable only and so do they belong in the Observable entity hierarchy? The members of panels are not universal so these could be used as defining. Just because other standards have a one hierarchy approach does not mean that SNOMED must follow that approach. It is not clear that option 3 would resolve the inconsistent classification issue. Option 2 would require changes to editorial policy to allow for additional evaluation procedures. However, discussions with RII would need to be had to ensure that there is no violation of the existing agreement. It was also suggested that evaluation procedures could be "recreated" in the observable procedures hierarchy and then educate people to gradually move over to the observable entity hierarchy. This would result in two hierarchies with considerable overlap. Decision: Maintain the status quo for now and move towards option 2 with an additional plan to replace the values of HAS INTERPRETATION with values from one hierarchy only (observable entity). After completion the MRCM can be constrained to allow only Observable entity to be used. Option 3 is not feasible at this time. | |||||||||||
Replacement of "Surgical approach" with "Procedure approach | In May 2023 the EAG discussed the potential for eliminating the distinction of "Surgical procedure" due to the challenges in developing an internationally acceptable definition for what constitutes a surgical procedure. An ancillary topic that was not discussed in detail was the generalization of the "Surgical approach" attribute and replacement with the unapproved attribute "Procedure approach". A briefing note describing the issues is attached. Discussion: Discussion was not included in the meeting recording. Will revisit at the next EAG call. Decision: Postponed to future meeting | ||||||||||||
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| 8 | AOB | EAG | 9 | Next meeting | EAG | Meetings will continue on the fourth Monday of the month and may be cancelled if necessary. | |||||
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