SNOMED CT Editorial Advisory Group

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Inactivation ReasonAssociationDefinition

Classification Concept 

REPLACED_BY

EQUIVALENT_TO

The inactivation reason “Classification Concept” explicitly states that the inactivated concept originates from the “closed world” classification paradigm and as such is inappropriate content for use within the clinical record. The inactivated concept (A) may be linked to one or more active concepts (B and/or C…) using historical associations as determined by the type of classification concept and associated guidance given below.

Please note that this inactivation reason replaces "Limited Component" and historical association "WAS_A".

Guidance
  • Identification of "Closed World content"
    The donor 'terminologies' to SNOMED CT were often themselves an early evolution of classifications of mortality and morbidity used for statistical analysis and reporting. To support the closed world view it was necessary to include options that catered for disorders that were known but not currently included within the classification. These concepts can usually be identified by the inclusion of “other specified”,  “not otherwise specified”, or “not elsewhere classified”, etc. While many of these concepts have already been inactivated, a few remain, and others such as "...without.." and concepts that are complex combinations of clinical phenomena still exist and will over time be removed.
  • Editorial guidance for specific flavors of classification concepts
    As each flavor of classification concept is identified, editorial guidance will be provided giving the reasons for inactivation and advice on how to assign an appropriated "REPLACED_BY" historical association.
    Each type of classification concept will then be identified within the authoring tool by a drop-down list e.g.:
    • The concept contains "Not Otherwise Specified"
    • The concept contains "Not Elsewhere Classified"
    • The concept contains "Without"
    • The concept contains an "and" or "with" representing a clinical statement composition (conjunction)
Not Otherwise Specified
  • Concepts that contain the ending "Not Otherwise Specified" are used within the closed world environment to enable the recording of conditions that exist but are not currently specifically identified within the current version of the classification in use. In the open world view adopted by SNOMED CT, this concept could represent any disorder represented by the concept without the addition of the "Not Otherwise Specified".
  • The recommended REPLACED_BY concept for "xxx not otherwise specified" is "xxx" as this represents our current open-world understanding of the meaning of the inactivated concept:
    • "xxx" may already exist as a current supertype or be found elsewhere within SNOMED CT
    • If "xxx" does not exist, it should be created as a new concept
The concept contains an "and" or "with" representing a clinical statement composition
  • This is where the “AND” (or “WITH”) represents clinical statement composition - a record of when independent clinical phenomena are co-occurrent in a particular patient. Many, but not all are derived from classifications, and for the purposes of patient care, it is recommended that each disorder is recorded individually. 
  • Represent each of the individual elements of the conjunction by separate clinical concepts using an association type of “EQUIVALENT_TO”. This signifies to the implementer and end-user that the single concept MUST be represented within the clinical notes by ALL of the EQUIVALENT_TO targets.
  • Annotation
    Authors may wish to add additional notes for specific inactivations.

Examples

Concept with "Not otherwise specified"

Classification concept:

Resolution

The concept contains an "and" or "with" representing a clinical statement composition (true conjunction)

Classification concept:

Resolution


Managing Incoming Historical Associations

The intention is that this functionality will be seamlessly integrated into the tooling so as to present to the user the appropriate updated historically association to be allocated.

Whenever an already stated “REPLACED_BY” target itself also becomes inactive - whether at the same release or later, identifying the replacement for the original concept, should follow the combinatorial logic stated below.

Combinatorial Logic - REPLACED_BY

(A) REPLACED_BY (B) and (B) SAME_AS (C) implies (A) REPLACED_BY (C)

(A) REPLACED_BY (B) and (B) REPLACED_BY (C) implies (A) REPLACED_BY (C)

(AIntEd) REPLACED_BY (BIntEd) and (BIntEd) MOVED_TO (CNRC) implies (AIntEd) MOVED_TO (CNRC)

(A) REPLACED_BY (B) and (B) POSSIBLY_EQUIVALENT_TO (C, D) implies (A) POSSIBLY_EQUIVALENT_TO (C, D)

(A) REPLACED_BY (B) and (B) WAS_A (C AND D) implies (A) WAS_A (C AND D)

Note: Once MOVED_TO the NRC we (SNOMED International) have no knowledge of what has happened to CIntEd

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