SNOMED CT Editorial Advisory Group

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Time:

0900 - 1030 PDT

1700 - 1830 UTC 


Zoom Meeting Details

Hi there, 

Jim Case is inviting you to a scheduled SNOMED International Zoom meeting. 

Topic: EAG Conference call
Time: Jun 3, 2024 09:00 Pacific Time (US and Canada)

Join from PC, Mac, Linux, iOS or Android: 
https://snomed.zoom.us/j/84094042590?pwd=2Z3a3ZjUAKxMEGZJlOdkl2YZcFUwhH.1
    Password: 348039

    International numbers available: https://snomed.zoom.us/u/kcIXuMl5Is



Attendees

Chair:

AG Members:

John Snyder 

Invitees:

Victor Medina 

Nicola Ingram 

Monica Harry 

Observers



Apologies:

John Snyder 

Meeting Files:

View file
nameDraft Briefing note_ Remodeling of 48537004 _Bypass graft (procedure)_ hierarchy.pdf
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View file
nameIHTSDO-1258_Remodeling of 1263452006 _Anesthesia and_or sedation procedure (procedure)_ hierarchy.pdf
height250
View file
nameBriefing note_ Informative note about results of testing of changes to MRCM rules for an Approach (attribute).pdf
height250
View file
nameProposal_ Definitions Bypass _ Shunt procedures.docx.pdf
height250

Inline in agenda below

Meeting minutes:

The call recording is located here.


Objectives

  • Obtain consensus on agenda items

Discussion items

The current concepts 1263452006 |Anesthesia and/or sedation procedure (procedure)| and 410011004 |Administration of anesthesia AND/OR sedation (procedure)| are disjunctive groupers.  The attached document provides details on proposed changes to this hierarchy that improves the modeling and specificity of anesthetic and sedation procedures.  The proposed changes have been reviewed and accepted by the Anesthesia CRG.  Key elements include:

  • Inclusion of a HAS INTENT relationship to specify the nature of the anesthesia or sedation (e.g. local, regional, general)
  • Inactivation of "anesthesia for X" type concepts
  • Remodeling concepts to adhere to templates

Discussion:

Decision:

There is an inconsistency in our review of nontraumatic vs. spontaneous injury. In some cases SNOMED makes a distinction between them:
1296953008 |Nontraumatic rupture of extensor tendon of left hand (disorder)|
321371000119100 |Spontaneous rupture of extensor tendon of left hand (disorder)|
whereas in other cases we treat them as synonymous:
Image Removed
In determining the meaning of nontraumatic vs. spontaneous, we have found that nontraumatic means injury not caused by an external force and could occur with or without premonitory signs or symptoms, whereas "spontaneous" injuries usually refer to acute injuries without premonitory signs or symptoms.
The primary question is whether in general clinical practice this distinction has value, and if so, 1) should SNOMED explicitly separate out concepts where spontaneous injury is expressed as a synonym for nontraumatic and 2) should SNOMED create nontraumatic injury concepts as parents to spontaneous injuries where a nontraumatic parent does not currently exist?

A discussion page has been set up to solicit comments from the EAG (Re: Nontraumatic vs. Spontaneous injury)

The discussion brought out a number of meaningful points.

  • These terms are most often used interchangeably to mean an injury that does not occur as a result of external force
  • While a differentiating definition can be developed based on premonitory signs or symptoms, that distinction is often ignored by clinicians
  • It is unclear what the additional benefit is of making the distinction from a clinical perspective

If it is thought that these should be distinct, then much more specific definitions need to be developed and published.

If it is not thought that the distinction is clinically meaningful, then what should SNOMED select as the FSN and PT and should all existing differentiated concepts be merged?  Should a nontraumatic and spontaneous description be a consistent feature of these concepts?

Discussion:

Decision:

ItemDescriptionOwner

Notes

Action
1Call to order and role call

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

  •  Recording of meeting approved by participants.



2

Conflicts of interest and agenda review

Jim Case

None recorded


3TRAG discussion on "withdrawn" reason for inactivation

Jim Case 

TRAG discussion page located at:

Potential for adding a "withdrawn" reason for inactivated content

Additional discussion page: Proposal to increase the level of metadata available for authors to log decisions made during content authoring

Discussion:

Need a clearer definition of what is meant by "active" content.  Does it require an effective time to be active?  One use case is translation or mapping to unreleased content.  Would the notion of "never activated" be an acceptable alternative?  Should this content ever be referenced in release files?  While the daily build is a useful tool for previewing new content, it should not be used as a basis for "early" translation or mapping.  The content should be used "at your own risk".

Decision:

General consensus  is that prerelease content should not be used in production and thus the need for a "withdrawn" identifier is not needed.  Need to be more explicit that prerelease content is subject to change or deletion.


4Proposed policy for Assessment Instruments in SNOMED CT International release

Jim Case 

Find attached a proposed policy related to Assessment instruments.  Comments from the EAG members are solicted.

View file
namePrinciples for managing Assessment Scales in SNOMED CT 20240430 v0.1.docx.pdf
height250

Discussion:

While the underlying principles are OK, it does not address the lack of ability to perform analytics on individual components of an assessment instrument.  The key issue is the permission to use copyrighted material.

Explanation of the reasons for adding the three types was provided.  Usage data on the score observables was requested

Decision:

No issues with document as proposed.



5Briefing Note regarding the inactivation of therapeutic role groupers in the Medicinal Product hierarchy. 

Nicola Ingram 

Informational only:  Based on the discussion during the EAG meeting in London, the following Briefing note is distributed.

View file
name20240501 BN Informational note inactivation medicinal product role groupers V1.pdf
height250

Discussion:

Concern about potential misunderstanding of the use of the term "role groupers".  Suggest clearer phrasing to represent the fact that the inactivation are grouping concepts as opposed to the removal of role groups (or relationship groups) from the model.

There is an ongoing issue with substances that are really products acting as groupers of other substances without a link to a product, which is correct.  Another approach is needed.

Decision:

No objections  to proposal


6Updated Briefing note for transplantation procedures

Nicola Ingram 

An updated Briefing note for transplantation procedures of both solid organs and tissues is provided.

View file
name20240501 BN Solid Organ and Tissue Transplant Procedures.pdf
height250

Discussion:

Questions to be sent to Nicola Ingram and Jim Case for discussion and clarification at a future EAG call

Decision:


7Reterming of "Percutaneous transluminal angioplasty " concepts

Monica Harry 

A proposed re-terming of angioplasty concepts due to inconsistencies that have lead to the creation of duplicate concepts.

https://docs.google.com/presentation/d/1_Zv9sasfB-elzwNiZgUC-nrdmgx-Sew74pchOxqsyVM/edit?usp=sharinghttps://docs.google.com/presentation/d/1_Zv9sasfB-elzwNiZgUC-nrdmgx-Sew74pchOxqsyVM/edit?usp=sharing

Discussion:

Jira
serverIHTSDO JIRA
serverIdb202d822-d767-33be-b234-fec5accd5d8c
keyGC-287
Need consistent FSNs to represent variations. 

Widget Connector
urlhttps://docs.google.com/presentation/d/1_Zv9sasfB-elzwNiZgUC-nrdmgx-Sew74pchOxqsyVM/edit?usp=sharing


There is sufficient evidence that many of the similar terms are in fact duplicates.  Suggest that the action could be "compression" as it is the plaque that affected rather than a repair of the vessel. Because not all angioplasties are percutaneous, can we say that the existing angioplasty concepts represent a percutaneous transluminal angioplasty?  Likewise, since not all PTAs are done using fluoroscopic guidance, can we make the assumption that the existing concepts all use fluoroscopic guidance?   

The concepts that were created back in 2002, all represented fluoroscopic guidance as ultrasound was not an option.  We need a clear definition for existing concepts to determine whether we can inactivate concepts as duplicates.  We can only model the content to the level that they are represented by the FSN.  

The generic term "angioplasty" is almost universally understood to be a PTA in the general literature.  Question the need for a generic grouper as it can lead to misuse.  This raises the issue around groupers that may be useful for analytics but should not be used in clinical records due to their inherent vagueness.  (outstanding issue)


Decision:


8Change Surgical approach to Procedure approach

Victor Medina 

Jim Case 

At the March 2024 EAG call, the group asked for an impact analysis of the change from Surgical approach to a more general Procedure approach.  The results of that analysis are were presented in the attached document.

Discussion:

Why were there no classification changes when sufficiently defining a large number of currently primitive concepts?  

The group would like to see the results on this for the at the April 2024 meeting.  At the April face-to-face meeting a list of non-surgical procedures .  Not sure that the benefits of this generalization are sufficient.  There may be additional impacts when this attribute is applied to existing sufficiently defined concepts.

There is always an implicit approach in procedures. There are questions about reproducibility.  Are some approaches solely surgical?

Decision:

that might benefit from this change was requested and is attached (download to view as spreadsheet).  

View file
nameProcedures for adding Procedure approach.xlsx
height250

Discussion:


Decision:

2024-04-16: Request to distribute Distribute list of non-surgical procedures affected by this change

2024-06-03:

  •  Victor Medina to distribute a list of non-surgical procedures affected by the proposed change
69Bypass graft revision proposal

Victor Medina 

Jim Case 

As part of the QI project, substantial changes to the representation of bypass grafts and shunts have been proposed.  A briefing note (attached) and a detailed document for the proposed changes (referenced in the briefing note) are provided.

Discussion:

2024-03-11 How are bypass concepts without definition of proximal and distal targets going to be modeled?  A: Need review. How are proximal and distal defined?  A: It is based on either anatomic position or flow of contents. Definitions for proximal and distal anastomosis will be provided.

Concern about creating intermediate primitives as this complicates the assignment of parents.  Also need to make sure the definitions are clear.  Where do "-stomy" concepts fit into this proposed model. 

2024-04-16:

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.:

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:Added document with proposed definitions for bypass, shunt, bypass graft, shunt with graft, anastomosis, etc.


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.  

2024-06-03:

  •  Victor Medina to revise definitions based on input from the EAG
107Remodeling of 1263452006 |Anesthesia and/or sedation procedure (procedure)| hierarchy

Victor Medina 

Jim Case 

8

USING DEVICE vs. DIRECT DEVICE use in procedures

(Information only)

Jim Case 

Victor Medina 

During QI review of procedures, inconsistencies were revealed in the use of USING DEVICE and DIRECT DEVICE in procedures.  The current definitions for these attributes from the editorial guide: 

Direct device

Direct device (attribute) represents the device on which the method directly acts.

Using device

Using device (attribute) refers to the instrument or equipment utilized to execute an action. It is used when the device is actually used to carry out the action, that is the focus of the procedure. If the device is simply the means to access the site of the procedure, then Using access device is the appropriate attribute.

Examples of inconsistencies:
175254001 |Repair of pulmonary artery using prosthesis (procedure)| = Using device -> Prosthesis device.
771713005 |Open repair of inguinal hernia using sutures (procedure)| = Using device -> Surgical suture, device.
719263004 |Repair of parastomal hernia using mesh patch (procedure)| = Direct device -> Hernia surgical mesh.
719290008 |Repair of umbilical hernia using surgical mesh (procedure)| = Direct device -> Hernia surgical mesh.
238190005 |Repair of incisional hernia using synthetic patch (procedure)| = Using device -> Prosthetic patch.

We would like to come up with more specific editorial guidelines related to what is meant by "the device on which the method directly acts".  In general, parameters could include things such as "materially changed by the procedure", "remains in the body following the procedure", etc.  The use of the word "using" in FSNs can bias a content author to use the attribute USING DEVICE when the more appropriate DIRECT DEVICE should be used.  A broader application of DIRECT DEVICE in procedure modeling could have large impacts on the number of concept affected, but would resolve the current inconsistencies.

An example of where this is an issue is described in the attached document related to the modeling of hernia repair.

USING DEVICE and USING ACCESS DEVICE are also inconsistently used and sometimes incorrectly.  In a review of procedure subhierarchies (e.g. arthroplasty), USING ACCESS DEVICE was modeled in the surgical action RG, when in many cases the device does not act as an access to the surgical area, but plays another role, (e.g. illumination).  An evaluation of the current benefits of USING ACCESS DEVICE over USING DEVICE  is underway.  

While it is not part of this topic, we expect the same issues to be present related to USING SUBSTANCE and DIRECT SUBSTANCE

Discussion:

Decision:

9Nontraumatic vs spontaneous injuryJim Case 

Following discussion at the last EAG meeting and the document provided by Monique van Berkum (attached), new proposed definitions and examples for:

USING DEVICE

DIRECT DEVICE 

USING ACCESS DEVICE

will be presented to the EAG for discussion at a future meeting

View file
nameDevice_Attribute_Feedback_SEAG_MvB_20240513.pdf
height250

Discussion:


Decision:


  •  Jim Case to provide new definitions for review
11AOBEAG



1210AOBEAG

It is planned to increase the use of the Discussion section of the EAG Confluence site to allow for a more straightforward consolidation of comments solicited from the EAG regarding topics under consideration as well as publishing the outcome of the discussion and the planned implementation of decisions made, if applicable.  This will require some modifications to the discussion section to allow for the assignment of statuses to discussion pages, which will be requested from the SI technical team.

11Next meeting

Jim Case 

May 27July 22, 2024 - pending availability of members