Jim Case

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Jim Case

Feikje Hielkema-Raadsveld 

Inconsistent representation of "No known...(situation)" with proposed remodeling.  See attached document.

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)|)?

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.

•  Jim Case to develop a definition for "No known (context) (qualifier value)" in conjunction with the EAG
•  Jim Case to propose a reorganization and impact report on the Finding context values.
•  EAG to come up with consensus definitions for finding context values

Nicola Ingram 

Jim Case 

Briefing note for changes in the taxonomic location of 129407005 |Grafting

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. - 
Medical Dictionary for the Health Professions and Nursing © Farlex 2012"

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:

• Auscultation 
• Endoscopy 
• Examination, not otherwise specified
• Exploration
• Exploratory laparotomy
• Fluoroscopy
• Laparoscopy
• Palpation

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.

•  Jim Case to provide a list of current OPCS terms and usage levels for those concepts that use the term "Exploration"

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:

Cathy Richardson 

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. 

Jim Case 

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.

Victor Medina 

Jim Case 

Discussion:

Discussion was not included in the meeting recording.  Will revisit at the next EAG call.

•  Jim Case to take the discussion back to internal team

Meetings will continue on the fourth Monday of the month and may be cancelled if necessary.