• Recording of meeting approved by participants.

Conflicts of interest and agenda review

Inactivation of Navigational concept hierarchy

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. - 
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:

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. 

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
• minimal / mild / moderate / severe / very severe
• mild / mild to moderate / moderate / moderate to severe / severe / life threatening / fatal

The current editorial guidance for the use of the SEVERITY attribute has a modeling note attached:

The question is whether 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?  

Discussion:

Decision:

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. 

SNOMED has received a request to add a clinical drug for which the FSN exceeds the limits 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)

Options to address this included:

• Remove the word "international" from the numerator units 
• Abbreviate the denominator unit to "ml"

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 as to this exception to FSN terming.

Discussion:

Decision: