Jim Case

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Jim Case

None stated.

Jim Case

Alejandro Lopez Osornio

A question submitted via Freshdesk asked the proper way to represent "Combined procedures".  These often represent two or more atomic procedures performed during the same encounter or surgery. 

E.G. 16180003 |Laryngotomy with removal of tumor (procedure)|

       78165004 |Take-down of arteriovenous shunt with creation of new shunt (procedure)|

Many procedures of this type involve endoscopy of some type.  

SNOMED no longer allows for combined disorders where there is no common causal relationship between the two, except in rare instances where two concepts are generally temporally associated with a potential underlying cause (e.g. diarrhea and vomiting).  For procedures, SNOMED has good coverage of the atomic procedures involved in such combined procedures . However, there are potentially many hundreds of these types of concepts that could be added based on the current modeling of these as a Procedure with two relationship groups representing the two different atomic procedures.  As Alejandro Lopez Osornio has pointed out in the Freshdesk response, these can also be represented simply as a post-coordinated expression using the "+". e.g. 61561005 |Incision of larynx (procedure)| + 370612006 |Excision of neoplasm (procedure)|.

Due to the relatively unbounded set of combined procedures that can be modeled, what should be the editorial policy related to future requests for combined procedures?  The requester expressed a desire to not have to record two separate procedures as they are temporally linked.

Discussion:

Philip Brown

Jim Case

A question from a member country on when to use "X (person)" vs. "X of subject (person)" has exposed issues with determination of equivalence in information models that either split the relationship from the condition vs. using a precoordinated Situation concept to represent the SUBJECT RELATIONSHIP CONTEXT.

Discussion:

"X of person" was introduced to support the SUBJECT_RELATIONSHIP_CONTEXT of Situations.  Monique van Berkumwill look for some history on why they were added. Suggested that the ECE might have some history on these.  Question is whether we need to separate out the relationship values from "persons" as a class?

Background - https://confluence.ihtsdotools.org/download/attachments/17039782/Subject%20relationship%20context%20values_EDC_20060127.doc?api=v2

The main distinction made in the reference paper is that between an "Entity" and the "Role" played by an Entity.  However, this distinction is not made within the person hierarchy, with << 444148008 |Person in family of subject (person)| primarily representing roles that Person entities play being in the same Person hierarchy. Since the 444148008 |Person in family of subject (person)| is primarily used as values for the SUBJECT RELATIONSHIP CONTEXT attribute, we can question why it is in the Person entity hierarchy.

A question raised by the reference provided is whether a well established role (e.g. father) can also exist as an entity?  Can a father exist as a standalone entity without the establishment of a relationship to another entity?

Decision:

Background will be investigated.  The person hierarchy needs some review and rationalization.

Background document posted above.  Will review for next meeting. Make sure page is open for viewing by the EAG.  

• Monique van Berkumto investigate history of "X of person" concepts.

Freshdesk ticket from member country:

"Our expert group have questioned the concepts 57797005 |Induced termination of pregnancy (disorder)| and all the child concepts as to why these are in the ‘disorder’ hierarchy as they are actually procedures? I actually agree, it seems a bit strange? There are synonyms as ‘termination of pregnancy’ which insinuates a procedure and that are the same as 386639001 |Termination of pregnancy (procedure)| which sits in the procedure hierarchy."

This hierarchy includes 196 concepts, which fall into the following categories

• Induced termination of pregnancy during a particular gestation period (e.g. 6251000119101 |Induced termination of pregnancy in first trimester (disorder)|
• Induced termination of pregnancy with a "complication" that occurs DURING or AFTER the procedure.  (e.g.  609514009 |Induced termination of pregnancy complicated by vaginal damage (disorder)|)
• Induced termination of pregnancy performed "legally" or "illegally" (e.g. 49632008 |Illegally induced abortion (disorder)|)

Most of these have been in SNOMED since the 20020231 release. 

Questions:

• Should some of these concepts that refer solely to the procedure be moved to the procedure hierarchy?
• Should history concepts be created for each procedure (many already exist; e.g. 713649008 |History of induced termination of pregnancy (situation)|)?
• Should the complication related concepts be retermed with a focus on the resulting disorder DUE TO the procedure (e.g. Vaginal damage due to induced termination of pregnancy))?

Discussion:

These have been of long-standing concern about the proper location.  Most look like they should be procedures.  

The notion of legal and illegal abortion is still something that is of concern, but should it be as part of the international terminology as this is a jurisdictional issue. Some expressed that this determination does not belong in the International release.  There are many aspects of induced termination that affect the risk of the procedure.  This cannot be captured within a single procedure.  The issue is the risk associated with the procedure that affects the outcome.  The method used, etc. is all of importance.  Best represented by a clinical statement model.  

Many of these originated with ICD-9 and have been carried through to ICD-10 including legal or illegal. 

The distinction of medical vs. surgical needs to be made where needed. Would this require the use of GCIs to represent the distinction?

The notion of legality should be represented with an alternative representation. It is important that we represent the environment in which the procedure is performed as well as the skill of the provider and the devices/medications used. Look at existing content for concepts related to the state of the patient as well as the procedures.

Need to look at the hierarchy above Induced termination of pregnancy as well for potential procedures. <<363681007 |Pregnancy with abortive outcome (disorder)|

Decision:

Will ask Jeremy Rogersfor frequency of use to determine value.  Will check on the impact of reterming on the complication concepts?

Most agree that these look like procedures then we will do an evaluation of what needs to be moved.  

The notion of "legal" or "illegal" is important for medical care, but not pre-coordinated with the procedure. Extensions may add this notion back if they find it necessary.

Need terming guidance to make the naming of these concepts consistent (continued use of "abortion"?)  

Next call tentatively on Nov 24.  Time to be determined