Time:
1030 - 1400 PST
1330 - 1700 EDT
1730-2100 UTC
Zoom Meeting Details
Topic: SNOMED Editorial Advisory Group
Time: Oct 23, 2023 10:30 Pacific Time (US and Canada)
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The call recording is located here.
Objectives
- Obtain consensus on agenda items
Discussion items
Item | Description | Owner | Notes | Action |
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1 | Call to order and role call | This meeting is being recorded to ensure that important discussion points are not missed in the minutes. The recording will be available to the SNOMED International community. Joining the meeting by accepting the Zoom prompt declares that you have no objection to your comments being recorded |
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2 | Conflicts of interest and agenda review | |||
Modeling of "No known X" | Inconsistent representation of "No known...(situation)" with proposed remodeling. See attached document. | |||
3 | Abbreviations in FSN for drugs | SNOMED has received a request to add a clinical drug for which the FSN exceeds the limit 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) Number of characters = 262 Options to address this include:
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 regarding this exception to FSN terming. Discussion: Comments from Monique van Berkum are attached. Comment from Feikje Hielkema-Raadsveld - Abbreviations in FSNs for drugs: There are not just international units but also arbitrary units and, I think, units that are neither; so removing ‘international’ makes me uncomfortable. I would sooner use the abbreviated unit. Having said that, the Netherlands has nothing at stake here because we do not use the drug hierarchy. Internal discussions raised the issue of misinterpreting the abbreviation "IU", as well as the different ways it is represented in other languages (e.g. "UI") No concern about the misinterpretation of IU with IV as this represents a product and not a procedure. Concern expressed about when to use IU vs "International unit". Only for those that exceed the length or for all concepts that have international unit in the FSN? Decision: Recommendation: For all drug concepts in the International release that use the term "International units", replace with the abbreviation "IU" ( without expansion). This would be note as an exception in the editorial guidance. Update (June 2023): There was some discussion about this decision with the drug extension user group and other SME in the pharmacy domain and they expressed concern that the use of "IU" would cause issues for a number of reasons:
Based on this input proposed editorial guidance was developed: "For arbitrary units representing biological activity, the unit of measure will be represented as "units", regardless of whether there is an approved WHO specification (i.e. international unit). For those substances where the definition of the biological activity is proprietary, medicinal products will only be modeled to the level of MPF." | ||
5 | Inspection vs. exploration actions | Jim Case | 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. - 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:
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. |
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6 | Severity as a defining attribute | Jim Case | The attribute 246112005 |Severity (attribute)| is an approved defining attribute for Clinical findings in the MRCM; however editorial guidance has been rather ill-defined in relation to the use of this attribute due to the subjectivity of assigning a severity to a clinical finding (i.e. "Severity is defined relative to the expected degree of intensity or hazard of the Clinical finding that is being qualified.") Modeling Generally, 246112005 |Severity (attribute)| is not used to model concepts precoordinated in the International Release, but there are some exceptions. A valid exception requires an internationally accepted definition that can be consistently applied and used reliably for international comparison. Even though a reference may be internationally sourced, its use may not always be uniformly applied by multiple countries. Classifications of severity that represent variation in clinical presentations and enact limitations with age ranges, sex, or pregnancy status, do not apply universally to all patients of all ages, prove problematic, and may not be generally useful. The requestor is responsible for obtaining permission for use in SNOMED CT if required by the international body. Issue The issue to be discussed originated at the April 2023 business meeting where it was noticed that some diseases (e.g. Severe asthma) were primitive concepts and thus it is not possible to identify the duplications and subsumptions in postcoordinated expressions that use the severity attribute. As an alternative to precoordination in the international release, this attribute can be used as a qualifier in postcoordination. However, beware that postcoordination of severity results in the same irreproducibility issues as pre-coordination. 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 The current editorial guidance for the use of the SEVERITY attribute has a modeling note attached: The question is, given its common use in clinical practice, should 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, with the caveat that interpretation of the intended meaning is subjective? I.e. the notion of severity exists and is commonly used, but may not be interpreted the same by everyone. Discussion: Comment from Feikje Hielkema-Raadsveld - The notion of severity is highly subjective. But it seems strange to ban it from modelling, yet allow it in the FSN. And a whole lot of other things (disease vs. finding, heh) are just as subjective. I think I would be in favour of relaxing the modelling restrictions on severity, but we would need strong guidance on when it is okay to use it, and when it should be avoided. For instance, 722401001 |Severe fever with thrombocytopenia syndrome virus| - should one apply a severity there? To the fever, or the whole? Or is it a particular disease that could have its own severity? I am what the others’ reactions will be. Historically there are many reasons why it was originally removed, however, many disorders that are by nature "severe" that would not classify under them because the FSN does not contain the word "Severe". This would require a review of many terms that would be expected to classify under a supertype. There are defined uses for severity. In cases where these definitions exist, an authoritative text definition must be included. However, this does not guarantee that all of the appropriate subtypes would properly classify unless the subtypes are specifically defined with a severity relationship. Suggested there be a review of terms that currently have a severity relationship to determine whether such an authoritative definition exists. The current use of Severity relationship in SNOMED is limited to two concepts and they are problematic. Decision: |
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8 | AOB | EAG | ||
9 | Next meeting | EAG | Meetings will continue on the fourth Monday of the month and may be cancelled if necessary. | |