1 Introduction

The SNOMED CT International General/Family Practice Reasons for Encounter and/or Health Issues reference set (hereafter called the GP/FP Subset) was developed between 2010 and 2013 by the GP/FP Subset and ICPC mapping project group. This project ended on December 31, 2013 after field-testing of the products was completed. Initial releases were accompanied by a map from the subset to ICPC-2, but a review in late 2017 about usage of this product and outreach to the user community (Members, vendors and Wonca) indicated that the map product was not used in electronic systems.  Bearing this in mind, and the fact that ICPC-3 was in development (and since released in December 2020 (https://www.icpc-3.info/)) meaning that ICPC-2 was no longer being updated, a decision was taken jointly with Wonca to deprecate the map.  As from the July 2019 version, therefore, the GP/FP release has no longer included active map records for ICPC-2.

2. Background

In December 2009 a harmonization agreement was finalized between SNOMED International and the World organisation of Family Doctors (Wonca) to promote co-operation and collaboration between the two organisations. 

This agreement led to the formation of the International Family Physician/General Practitioner Special Interest Group (IFP/GP SIG) under the auspices of SNOMED International. The IFP/GP SIG was established to propose content for SNOMED CT® related to general/family practice and to provide quality assurance for SNOMED CT content from the general/family practice perspective. SNOMED International's existing Primary Care Special Interest Group was converted to the IFP/GP SIG after the agreement was signed. 

The Refset was released as 2 distinct Refsets as a candidate baseline in April 2014 - Reasons for Encounter and Health Issues. Based on feedback and advice of the project group, the 2 refsets were consequently amalgamated in to a single refset.   

3 Release content

3.1 Changes to the January 2024 release GP/FP subset

As a result of changes present in the January 2024 release, 58 concepts were inactivated. The following table lists the inactive concepts which were removed from the Refset, together with the target replacements. Some target replacements were already in the Refset and some were new to the Refset but not necessarily new to SNOMED CT.  See Column E for details. 

When a concept is inactivated as Ambiguous, more than one concept may be selected as replacement therefore not a 1:1 match between inactivated and replaced. There were 60 new concepts added to the Refset as replacements. 

3.2 Overview of the GP/FP subset

The GP/FP subset contains SNOMED CT concepts relating to two semantic data types commonly used in general/family practice electronic health records:

• Reasons For Encounter (RFEs)
• Health Issues

A 'Reason for encounter' was defined by the project group as:

"An agreed statement of the reason(s) why a person enters the health care system, representing the demand for care by that person. The terms written down and later classified by the provider clarify the reason for encounter and consequently the patient's demand for care without interpreting it in the form of a diagnosis. The reason for encounter should be recognized by the patient as an acceptable description of the demand for care" (WONCA Dictionary of General/Family Practice, 2003). 

A 'Health issue' was defined by the project group as:

"An Issue related to the health of a subject of care, as identified or stated by a specific health care party". This is further defined in the notes as "according to this definition, a health issue can correspond to a health problem, a disease, an illness" (Health Informatics – System of concepts to support continuity of care – Part 1: basic concepts (CEN/ISO FDIS 13940-1)). 

These definitions were used to define the scope of the GP/FP subset. The subset contains SNOMED CT concepts that represent terms commonly used to populate these semantic data types. 
The content of the subset covers the following:

• • Symptoms and signs
  • Disorders and diseases
  • Results
  • Family history
  • Allergies
  • Adverse drug reactions
  • Processes and procedures
  • Social history

Details on the development of the subset are available on request from info@snomed.org

4 General information about the GP/FP refset

Refsets act as the extensibility mechanism in SNOMED CT, allowing developers and users to customize SNOMED CT content to meet specific use cases. 

Content for the general/family practice refset was initially provided by the SNOMED International's General/Family Practice and ICPC-2 mapping project group. It is designed for use in general/family practice clinical settings within electronic health records (EHRs). 

4.1 Purpose of the GP/FP subset

To provide a refset of frequently used SNOMED CT concepts for use in general/family practice EHRs within the following data fields:

• Reason for encounter
• Health issue

4.2 Some example use cases of the GP/FP refset

4.2.1 Data entry – direct entry of SNOMED CT concepts from the GP/FP refset

During an encounter in the general/family practice, a GP/FP sees a patient who has presented with a newly identified health issue. The GP/FP enters the new health issue into the data field for 'health issue', and into a problem list (if appropriate) in the patient's EHR using the GP/FP subset that has been incorporated in the patient's EHR by the EHR software vendor. The GP/FP is presented with a validated list of potential terms from the refset, from which GP/FP selects the SNOMED CT concept that best represents the patient's health issue.

4.2.2 Electronic transfer of care (referrals, admissions, handovers, discharge)

A GP/FP wishes to transfer the care of a patient to a medical specialist for further investigation. The GP/FP's EHR contains the SNOMED CT GP/FP refset, and the GP/FP has entered all the patient's health issues into the EHR using the refset. An HL7 referral message is then constructed; containing SNOMED CT coded concepts from the patient's problem list. The message is sent electronically to the specialist who populates his/her EHR using the data contained in the message. This reduces the time needed to take a patient history and enter this data into the specialist's EHR.

4.2.3 Constraint of terminology use for population and sub-population analysis

A group of GPs are interested in comparing aspects of care across populations of GPs and their patients. The adoption of a refset will, to an extent, constrain the variability of coding of similar issues, conditions and situations that may confound data analysis where very large terminologies such as SNOMED CT are used without constraint.

4.3 Obtaining the GP/FP refset

Access within SNOMED International member countries is provided by the Member National Release Centre in each country, via the relevant Member page. Affiliates of SNOMED International in non-member countries can access the table through their Member Licensing and Distribution Service (MLDS) account. Please contact info@snomed.org for more information if required. 

4.4 Benefits of the refset

SNOMED CT is regarded as the leading global clinical terminology for use in EHRs. The GP/FP refset utilises the power of SNOMED CT by refining the refset to a list of concepts specific to those commonly used in General/Family practice, in this way assuring and enabling a SNOMED CT encoded system for recording aspects of the clinical record. This increases the usefulness of SNOMED CT for GPs/FPs because searches are targeted to the SNOMED CT concepts that GPs/FPs use most often, and, if implemented properly, users should be able to search and select a SNOMED CT concept quickly and easily. 

As stated in Section 4.5, the SNOMED CT GP/FP refset is being maintained and distributed on an annual basis and in line with the July edition of the SNOMED CT International Release. 

4.5 Characteristics of the GP/FP refset

The GP/FP refset contains the following characteristics:

• Only concepts with a status of 'current' (status = 0) have been included, ensuring that the only concepts included are active and able to be used for data entry.
• The Reason for encounter and Health issue subsets have been combined into one subset.

• A series of principles for the development of the GP/FP refset were created during the development phase of the project. These principles are documented in the SNOMED CT GP/FP subset and ICPC mapping project: Phase 2 project report.

• The GP/FP refset is released using Release Format 2 (RF2).

4.6 SNOMED CT target content

The GP/FP subset only contains SNOMED CT content from the following hierarchies:

• • Clinical finding
  • Event
  • Procedure
  • Situation with explicit context.

4.7 Known issues in the GP/FP refset

The GP/FP refset was developed using a 'bottom-up' approach, based on the terms frequently used in general/family practice to describe reasons for encounter and health issues. As a result, it does not contain all the SNOMED CT concepts that could be used to populate the reasons for encounter or health issue data fields in electronic health records. The IFP/GP Clinical Reference Group will add to the content of the subset based on usage in Family/General Practice. 

5 Implementation of the GP/FP refset 

5.1 Implementation overview

• There are a variety of ways in which the GP/FP refset can be implemented, and it would be impossible to outline each possible scenario in these release notes.
• Vendors are encouraged to contact the IFP/GP Clinical Reference Group to discuss specific implementation scenarios at info@snomed.org.
• Background about the creation and maintenance of refsets can be found by contacting info@snomed.org
• The refset should be implemented in SNOMED CT enabled systems in order to access both additional content and also enable the power of SNOMED CT for retrieval and use of the information stored in systems. 

5.2 Use of a secondary search mechanism

The GP/FP refset contains concepts that are commonly used by GPs/FPs on an international basis, offering initially the SNOMED CT concepts they are likely to use frequently. However, rare conditions are managed in general/family practice, and GPs/FPs will often need to access a wider source of SNOMED CT concepts to populate their reasons for encounter or health issues and this should be possible in a SNOMED enabled system.
For this reason, when implementing the GP/FP refset vendors are strongly encouraged to implement a two-stage search mechanism, where users search for concepts in the GP/FP refset in the first instance. Then, if a suitable concept cannot be found in the GP/FP refset, a 'secondary search' is activated, allowing the search to be repeated using a broader set of relevant SNOMED CT concepts.

6 Effective Date and Maintenance

6.1 Effective date

The refset is aligned to the January 2024 SNOMED CT International Release.  The effectiveTime for the content has therefore been set to 20240101 (1 January 2024). 

The ICPC-2 map files have been deprecated as part of the GP/FP release package from the July 2019 publication onwards, as publicised in the General Practitioner/Family Practitioner (GP/FP) Reasons for Encounter/Health Issues SNOMED CT package Release Notes - July 2019.

7 Technical Notes

7.1 RF2 package format

The RF2 package convention dictates that it contains all relevant files, regardless of whether or not there is content to be included in each particular release.  Therefore, the package contains a mixture of files which contain both header rows and content data, and also files that are intentionally left blank (including only a header record).  The reason that these files are not removed from the package is to draw a clear distinction between:

1. ...files that have been deprecated (and therefore removed from the package completely), due to the content no longer being relevant to RF2 in this or future releases, and 
2. ...files that just happen to contain no data in this particular release (and are therefore included in the package but left blank, with only a header record), but are still relevant to RF2, and could therefore potentially contain data in future releases.

This allows users to easily distinguish between files that have purposefully been removed or not, as otherwise if files in option 2 above were left out of the package it could be interpreted as an error, rather than an intentional lack of content in that release.

7.2 RF2 package file naming convention

The file package naming convention has been updated to remove the references to the now inactivated ICPC-2 map records.  The GP/FP packages now follows the following naming convention:

• SnomedCT_GPFP_PRODUCTION_[date/time].zip

7.3 Metadata now incorporated into the Derivative Packages

After consultation in 2023, SNOMED International are in the process of migrating the Metadata components for Derivative product from the International Edition to the Derivative release packages themselves.

These Derivatives are solely single refsets/maps, and so don’t mean anything to end users without the supporting terms and other components from the International content.  The nature of these products is therefore such that we necessarily create Derivative packages that are inherently dependent on the relevant International Edition content.  Previously, therefore, we have always created the metadata components (refset/module concepts, descriptions, relationships, etc) in the International Edition release packages, with the Derivative products being dependent on the relevant International content. 

Whilst this dependency on the International content would continue, the transition would include the metadata components in the Derivative packages themselves, rather than in the International Edition packages – this will involve:

• Inactivation (but not complete removal) of the current components in the International Edition
• Activation of the Metadata components in each of the Derivative release packages

The consensus is that moving the Metadata components into the Derivative packages will bring benefits to both the Derivative maintainers, and also to the end users who will no longer need to pull this particular data down from the dependent International Edition in order to use the Derivative products.   It enables maintainers to move to a more efficient model of hosting the Derivative content in termServer branches, rather than importing Delta files from external tools.

Therefore in this GPFP Refset release, we are including the relevant metadata components in the following files in the Derivative release package:

• sct2_Concept_GPFPSnapshot_INT_20240101.txt
• sct2_Description_GPFPSnapshot-en_INT_20240101.txt
• der2_cRefset_GPFPLanguageSnapshot-en_INT_20240101.txt
• sct2_Relationship_GPFPSnapshot_INT_20240101.txt
• sct2_sRefset_OWLExpressionGPFPSnapshot_INT_20240101.txt

Notice of changes to the GP/FP Release package

In line with the new implementation of Annotations, two new refsets have been added to the International Edition Release package, from December 2023 onwards:

• der2_scsRefset_ComponentAnnotationStringValueSnapshot_INT_20231201.txt
• der2_sscsRefset_MemberAnnotationStringValueSnapshot_INT_20231201.txt

The latest version of the GP/FP release is based upon the January 2024 International Edition, and therefore these Annotations file types will also be included in the GP/FP release package from the January 2024 GP/FP release onwards, until further notice:

• der2_scsRefset_GPFPComponentAnnotationStringValueFull_INT_20240101.txt
• der2_scsRefset_GPFPComponentAnnotationStringValueSnapshot_INT_20240101.txt
• der2_sscsRefset_GPPFMemberAnnotationStringValueFull_INT_20240101.txt
• der2_sscsRefset_GPFPMemberAnnotationStringValueSnapshot_INT_20240101.txt

These refset files are empty for the January 2024 GP/FP release, whilst content is being authored for future editing cycles. 

In addition to this, we have standardised the naming convention of the OWL Axiom files, in order to align them to the International standards:

• Old:     sct2_sRefset_GPFPOWLExpressionSnapshot_INT.txt
• New:   sct2_sRefset_OWLExpressionGPFPSnapshot_INT.txt