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Date: 2027-02-27


0600 - 0730 PDT

1400 - 1530 UTC

Zoom Meeting Details

Topic: SNOMED Editorial Advisory Group Conference Call
Time: Feb 27, 2023 06:00 Pacific Time (US and Canada)

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Meeting minutes:

The call recording is located here.


  • Obtain consensus on agenda items

Discussion items

1Call to order and role call

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  • Recording of meeting approved by participants.

Conflicts of interest and agenda review

None noted.


Expansion of range for HAS INTERPRETATION

At risk concepts as example.

Scenarios where qualifier values are not sufficient; e.g. at risk findings, coma score subscore results

From GC-1248 - Getting issue details... STATUS

In developing the model for defining risk findings, we have run up against an issue with describing the specific risk factor as the range of HAS INTERPRETATION is limited to 

<<  [260245000 |Finding value (qualifier value)||]  OR
 <<  [263714004 |Colors (qualifier value)||]  OR
 <<  [308916002 |Environment or geographical location (environment / location)||]

There are two approaches to modeling specific risk factors.

  • Use the DUE TO relationship to describe the risk factor
  • Use the INTERPRETS = <<80943009 |Risk factor (observable entity)|. HAS INTERPRETATION = <Clinical finding OR <Event OR <417662000 |History of clinical finding in subject (situation)| OR <416940007 |Past history of procedure (situation)|

Example 1:

1184692002 |At increased risk due to lack of fire extinguisher in residence (finding)|

Clinical finding:

   DUE TO Inadequate fire extinguishing equipment in residence (finding)   

   {INTERPRETS =  Risk level,     HAS INTERPRETATION =  Increased}

Example 2:

1184692002 |At increased risk due to lack of fire extinguisher in residence (finding)|

Clinical finding:

   {INTERPRETS =  Risk level,     HAS INTERPRETATION =  Increased}

   {INTERPRETS =  Risk factor,    HAS INTERPRETATION = Inadequate fire extinguishing equipment in residence (finding)}

Currently, there is no way to assign values to the Observable 80943009 |Risk factor (observable entity)| due to the limitations of the range of HAS INTERPRETATION.  Existing use of the 80943009 |Risk factor (observable entity)| has been restricted to a few concepts that also use DUE TO as the relationship to the factor with no HAS INTERPRETATION VALUE (e.g. 1162398002 |Adverse health risk due to mold in residence (finding)|)

There is a similar issue with assigning the values associated with assessment instrument Observables

There is a huge risk in extending the range of HAS INTERPRETATION, but using this pattern is a better representation of the definition than the implied relationship using the DUE modeling pattern.


Additional issues.

Should "Decreased risk" and "Low risk" be siblings or parent-child?  In the current project (not yet promoted to MAIN), 75540009 |High (qualifier value)| has been made a subtype of 35105006 |Increased (qualifier value)|; however, the interpretation of the meaning of "high" is absolute (compared to a standard), whereas "Increased" is a relative term, i.e. compared with a prior measurement or with a "relative" norm). 

Example: High risk

There is currently only one concept stating decreased risk (1144845004 |Risk of suicide decreased (finding)|).  All "Low risk" concepts currently classify directly under 281694009 |Finding of at risk (finding)|


This is a general issue in the use of ordinal and nominal observables.  The use of DUE TO is suboptimal.  

Concern about defining findings using the INTERPRETS/HAS INTERPRETATION where adjectives are used as the value.  This is a question/answer boundary issue.  The top level concept of finding of at risk is too vague to be useful. There is some ambiguity as to whether low, moderate and high mean absolute or relative to the population.  There is a concern about the meaning of qualifiers other than high risk (i.e. low, moderate, etc.).  What is the context?  Does "increased" risk mean "high" risk?  Does "low" mean lower than the general population or some other cohort? Need to reevaluate the qualifier value hierarchy to ensure consistency in the representation of the relative values.

Some of the risk "due to" are not needed and may be inactivated.

The full model currently being used for "At risk" concepts is defined in the template located at: At [qualifier] risk of [finding/event] (finding) - Ready for review

There was consensus that the Example 2 model was preferable to model 1 (using DUE TO), but there are questions about the meaning of INTERPRETS/HAS INTERPRETATION in the context of risk factors.   The definition of INTERPRETS is "This attribute refers to the entity being evaluated or interpreted, when an evaluation, interpretation, or judgment is intrinsic to the meaning of a concept."  Thus, in the case of 80943009 |Risk factor (observable entity)|, the entity being evaluated is the specific risk factor related to the HAS REALIZATION value (i.e. the disorder or finding being realized).  The definition of HAS INTRPRETATION is "This attribute refers to and designates the judgment aspect being evaluated or interpreted...". In the case of 714664001 |At increased risk of ulcer of foot due to diabetes mellitus (finding)|:

Foot ulcer is the realization

The entity being evaluated (INTERPRETS) is 80943009 |Risk factor (observable entity)| with Diabetes mellitus (judgement) as the value of HAS INTERPRETATION

Need additional examples of where the need for expansion of the HAS INTERPRETATION  would be needed. Jim Campbell will provide a paper describing additional examples and uses for expanding the range.


A document provided by Monique van Berkum  (Attached above) provides options for resolving the modeling of At risk issue for this topic as well as providing alternative options for consistency in modeling more complex concepts of the pattern: At <risk level> for <Y> due to <Z>.

Proposals include:

  • Inactivation of Gravity submitted content of the form "Adverse health risk due to <X>" or "At risk due to <X>" and replacement with findings describing <X>.  This would potentially eliminate the need to expand the range of HAS INTERPRETATION to support risk concepts, although additional testing would be needed in other areas of the terminology (such as survey instruments)
  • Creating precoordinated concepts, where needed to represent <Y> due to <Z> in order to be consistent in the use of HAS REALIZATION only vs. either HAS REALIZATION  or both HAS REALIZATION and DUE TO.

This document also underscores some additional issues with functioning concepts that use the INTERPRETS/HAS INTERPRETATION pattern of modeling, especially in the area of negation (or does not).  This is similar to the issue seen in the Situation hierarchy with inverted taxonomies.  While out of scope for this immediate issue, it is something that SNOMED needs to address..

High vs. increased and Low vs. decreased

Similar issue as to the measurement findings where we reassigned values to a reference range.  Initial testing of moving "High (qualifier)" under "Increased (qualifier value)" had no negative impact on taxonomy.  The use of non-specific qualifiers may cause a problem with other areas where "high" is not related to risk. The issue with "decreased" in the area of suicide is that it is unknown where it means "Low" or reduced relative to a prior evaluation.

Increased risk for the most part refers to an increase relative to a "norm" for a population. "High" is absolute related to an individual? Under what circumstances would "High" be used synonymously with "Increased"?  This is dependent on the at risk condition.  Consider using other qualifier values that include "risk"?  Requires additional evaluation. Suggested that we do not accept new "decreased" concepts due to the ambiguity and consider using "decreasing" in the future.  consider inactivating "decreased risk of suicide" as ambiguous. Create "Low risk of suicide".

Expansion of HAS INTERPRETATION continued to the April meeting.

  • James R. Campbell to write up a more general description of the issue with additional examples.

Mechanical Complication of deviceJim Case 

Should "Mechanical complication of device" be a disorder or a finding?

Current situation:

111746009 |Mechanical complication of device (disorder)| has 215 subtypes, all of which refer to a failure of a device without specifying a deleterious effect on the patient. 

       e.g. 285961000119107 |Mechanical breakdown of prosthetic heart valve (disorder)|

We also have disorder concepts that refer to a patient condition due to mechanical failure of a device 

       e.g. 5053004 |Cardiac insufficiency due to prosthesis (disorder)|

Without specifying the resultant condition associated with device mechanical issues, is it appropriate that these are represented as patient disorders, or should they be findings that may be related to disorders in the patient?

A briefing note using "Leakage of device as an example is located here.


Without an associated condition in the patient it is unclear whether there is an adverse impact on the patient.  In general, if the device is implanted, it can be assumed that there is a negative impact. These should be retained as disorders.  Each of the subtypes would need to be evaluated as to the potential impact on the patient.

Potential for inactivation of navigational conceptsJim Case 

It was suggested at a recent Modeling Advisory Group meeting that SNOMED should consider inactivating the 363743006 |Navigational concept (navigational concept)| hierarchy.  A list of 635 primitive concepts that are unable to be defined due to their highly contextual use.  The concern is that because they are more or less "orphan" concepts, and provide no analytical advantage, they would be discouraged from use in medical records.  However, because many of these descriptions are those that are commonly used in clinical records, with organizationally specific meaning, they are being entered into EHRs.

UK has high usage of a few of these:

CONCEPTID             FSN                                                                                                                         USAGE 2011-2022

394617004              Result (navigational concept)                                                                                 48,227,610

160237006              History/symptoms (navigational concept)                                                             10,146,392

309157004              Normal laboratory finding (navigational concept)                                                 581,209

267368005              Endocrine, nutritional, metabolic and immunity disorders                                   160,475

243800003              Test categorized by action status (navigational concept)                                      108,176

250541005              Biochemical finding (navigational concept)                                                           100,632

It is unclear how these are used in clinical records although from the above list it appears they may be used as document headers .  An inquiry to the UK resulted in an interesting observation that some of these highly used concepts are primarily found in only one of two major primary care systems, and some that were not used much a decade ago are beginning to increase in usage. It was proposed to SNOMED that aside from the highly used concepts above, the remainder of the navigational concepts could be inactivated without much impact on users.  However, we would need to consider carefully before inactivating the above concepts without suitable replacements due to their high, albeit incorrect, usage.

Question: Should these be replaced with Record artifact concepts or something else?


The NL and AU have not approved the use of navigational concepts.  IMO does not recommend use of these. The more general question is whether to inactivate navigational concepts as a whole.  The consensus was that that these should be inactivated. Because there are concepts of high use in the UK, they will be contacted and informed of the impending inactivation.  Potential replacement concepts for the high use concepts include:

394617004  Result (navigational concept)    → 423100009 |Results section (record artifact)|

160237006  History/symptoms (navigational concept) → 371529009 |History and physical report (record artifact)|

309157004  Normal laboratory finding (navigational concept) → None (laboratory is a vague concept)

267368005  Endocrine, nutritional, metabolic and immunity disorders → None (arbitrary grouping)

243800003  Test categorized by action status (navigational concept)  → None (meaning unclear)

250541005  Biochemical finding (navigational concept) → None (context dependent)


Message sent to the UKTC, no response as of yet.  Briefing note will be written once input from the UK is received.

Section of Chief Terminologist report to Content Committee June, 2010

Questions have been raised regarding editorial policy for Navigational Concepts. There are two main
1) What are the criteria for making a concept navigational?
2) Should navigational concepts be used for recording clinical data?

The current User Guide (2010)has the following information:
Navigational concept
These concept codes are to be used only as nodes in a Navigation Subset. They are not suitable for
data recording or aggregation.
The subclasses of Navigational concept have the following characteristics:
• They have no IS A subtypes.
• They have no IS A supertypes other than Navigational concept.
• They may be associated with other concept codes by the use of Navigation Links.

JTC Note: From the current SNOMED Editorial Guide: "...Navigational concepts were created to group other concepts without explicit regard for defining attributes (since there were none). Their purpose was to provide top level groupers for subsets and reference sets used in implementations.  Because the Reference Set mechanism is now available, there is no longer a need for navigational concepts in the International Release; however, they can be added at the national or lower level."

The Content Managers Advisory Group comments indicate that these terms are not or rarely used (probably erroneously) aside from the few concepts in the UK listed above.


Many of these concepts provide some use, but because they cannot be defined they should not be within the SNOMED taxonomy.  For replacement values for high usage, we will determine whether a replacement is needed. Consensus that these concepts be inactivated and a briefing note created for the CoP.

  • Jim Case to contact UKTC to inform them of the impending inactivation
  • Jim Case to write briefing note explaining the rationale for inactivation of the Navigational concept hierarchy.

Intermediate primitive parent and definition status of subtype

Review of Glossary definition for "Sufficiently defined concept".  See sufficiently defined concept

Additional information on Necessary and sufficient conditions: D.2 Necessary and Sufficient - Examples

Can a concept be sufficiently defined if part of the meaning of the FSN is captured only in the wording of a stated intermediate primitive parent, not in defining attribute-value relationships? For example: Joint laxity (finding) is primitive since it has no defining relationship(s) that capture the "laxity" aspect of the FSN meaning - but can its subtypes (e.g. Elbow joint laxity (finding), Hand joint laxity (finding) etc.) be considered to have a sufficient definition based on the stated parent Joint laxity + their finding site relationship specifying which joint is involved? Currently they are all primitive, but some subtypes of Laxity of ligament are defined on the basis of their intermediate primitive parent and their finding site.

Clear, explicit editorial guidance is needed on this question. The statement here "A concept is sufficiently defined if its defining characteristics are adequate to define it relative to its immediate supertypes" is somewhat ambiguous, since it's not clear whether "defining characteristics" here refers to defining attribute-value relationships specifically or to the logical definition as a whole.

  • the phrase "relative to its immediate supertypes" would seem to argue against making a concept defined based in part on information in the FSN of an intermediate primitive parent (since a parent concept, as an immediate supertype itself, obviously cannot contribute to define its own subtype relative to itself. However, that implication may be an artifact of imprecise wording rather than representing actual editorial policy.
    If information represented in the FSN of a stated intermediate primitive parent can be considered to fill a gap in meaning left by the defining attribute relationships, I think that policy should be clearly stated (and ideally illustrated with an example) either here or under Intermediate Primitive Concept Modeling. (Whichever section the guidance is placed in, it might also be helpful to add a "See ____" link to that guidance in the other section as a kind of cross-indexing).
  • The SNOMED Glossary states: ""A sufficiently defined concept has at least one sufficient definition that distinguishes it from any concepts or expressions that are neither equivalent to, nor subtypes of, the defined concept". Is "definition status" of a concept part of the definition of a concept? Currently it acts in that way.  This occurs when two or more concepts have the same defining relationships, but only one is marked as sufficient defined.  Those that are not marked as sufficiently defined classify as subtypes.
    • In some cases the SNOMED concept model is inadequate to "fully" define the meaning of an FSN, yet can provide a sufficient definition to make it unique within the terminology.  In these cases the primitive subtypes with the same relationship have the necessary relationships, but not sufficient definitions.
  • The Glossary also states "Prior to July 2018, SNOMED CT could only support one sufficient definition for each concept could not represent the 8801005 | Secondary diabetes mellitus (disorder)| example above. A further limitation, that also prevented formal representation of that example was the stated relationship file was only able to represent necessary conditions.". 
    • Proposed clarification: "Prior to July 2018, SNOMED CT could only support one sufficient definition for each concept, and the stated relationships comprising that definition could represent only necessary conditions. A concept such as 8801005 | Secondary diabetes mellitus (disorder)| , which can be caused either by a substance or by another disorder, could not be sufficiently defined within these constraints, since neither | Causative agent| | Substance| nor| Due to| = 64572001 | Disease| is necessarily true. Assigning the concept two sufficient definitions can, however, allow the full meaning of 8801005 | Secondary diabetes mellitus (disorder)| to be formally represented. (See sufficient definition)."
  • Lastly, there is a statement: "Following these changes a concept will only be marked as sufficiently defined if it is sufficiently defined by relationships. However, the OWL axioms may provide a sufficient definition that cannot be fully represented as relationships."
    • This has come about with the ability to model concepts with multiple sufficient axioms using GCIs. Proposed clarification: "Following these changes a concept will only be given a definition status of Defined if it is sufficiently defined by the stated relationships in a single axiom. However, multiple OWL axioms may provide a sufficient definition representing different sufficient but not necessary relationships. These concepts will retain the default status Primitive but function as sufficiently defined concepts that will subsume subtypes."


Concepts with identical definitions aside from the Definition status may be classified as supertype/subtypes, due to the limitations of the concept model to allow for more robust definitions. This is being left with the EAG for additional comments to be reviewed at the April meeting. There is a question about whether the browser can be modified to show an icon that can identify a concept as having GCIs.  A question will be forwarded to the tech team.

  • Jim Case to send a note to the MAG inquiring about the value of a new definition status that identifies a concept with GCIs

11Next meetingEAG

Next meeting April 4. SNOMED business meeting


  1. Aside from the document header types used by UK there's avigational Concepts are a real grab bag of things... an equally mix of value...

    • Some are low value - are what I really think of as True Navigational e.g. 310233006|Type attribute G - L (navigational concept)| or 273476008|Assessment scales Ge-Iz (navigational concept)|
    • Some are groupers, not much different to what exists in the heirarchy proper. e.g.
      • 373323003|Procedure by abdominal approach (navigational concept)| is arguably more useful than 309038006|Operations by approach (procedure)
      • Similarly with 309300003|Negative laboratory finding (navigational concept)| vs 442225006|Negative measurement finding (finding)|"Keep both" or "Keep none"
    • Many are valid concepts (e.g. organisms or diseases) but not specific (which I guess might be why they're shunned)
      • Communicable disease (navigational concept)
        Compare to
        • Sexually transmitted infectious disease (disorder)
        • Communicable disease management (procedure)
        • Risk of exposure to communicable disease (situation)
      • Intestinal trematode (navigational concept)
      • Arbovirus (navigational concept)Compared to:
        • Antibody to Arbovirus (substance)
        • Arbovirus infection (disorder)
        • Arbovirus nucleic acid assay (procedure)

    This last lot are the most interesting, as I think they ARE useful. And more than simply navigational.
    I think I tried to do some work (several years ago) with an |arbovirus (organism)| but hit some obstacles. Perhaps now with GCIs this is more feasable.

  2. Re: Intermediate primitive parent and definition status of subtype

    I thought it was inevitable that some defined concepts had primitive parents, and that was what differentiated them?
    734143007|Structure of left thumb (body structure)| and 89644007|Left ear structure (body structure)|
    (Maybe I'm not understanding the issue properly at the moment)

    The definition was the set of stated relationships (of which there could only be one).
    But now is the Axiom (of which there could be multiple).

    I think this is related.. I recently discovered that a concept can't(shouldn't) be considered defined if it only has stated IS A relationships
    I'm sure that this was once allowed, where a concept has >1 IS A (maybe I imagined it?) - primarily in the primitive heirarchies (substances/organisms) etc.
    This would mean something like 445721008|Carbapenem resistant Acinetobacter (organism)| could be marked as sufficiently defined?