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1700 - 1830 UTC 

Zoom Meeting Details

Topic: SNOMED EAG Conference Call
Time: Jan 29, 2024 09:00 Pacific Time (US and Canada)

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  • Obtain consensus on agenda items

Discussion items



1Call 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

  • Recording of meeting approved by participants.

Conflicts of interest and agenda review

None recorded

3Replacement of "Surgical approach" with "Procedure approach

In May 2023 the EAG discussed the potential for eliminating the distinction of "Surgical procedure" due to the challenges in developing an internationally acceptable definition for what constitutes a surgical procedure.  An ancillary topic that was not discussed in detail was the generalization of the "Surgical approach" attribute and replacement with the unapproved attribute "Procedure approach".  A briefing note describing the issues is attached.

Discussion held in October was not recorded.  Revisiting this.


In addition to review of concepts using the term "approach" include FSNs that use the term "trans" and "per...".  A history of Procedure approach vs. surgical approach was review.  We do not have a distinction between the values of Procedural approaches used for surgical procedures vs. general procedural approaches.  Need an impact impact analysis including where a procedure might have both a procedure approach and a surgical procedure.  It is difficult to determine what procedures are surgical and how to make the approach differentiation.

Probably safe to do, but need testing for impact.  Another option might be to just reactivate Procedure approach as a supertype?  That still leaves the problem of determining what is a surgical approach.  

Need to consider the scope of procedural approach and limit it to procedures that have a procedure site (i.e. on or in a body).  

The editorial guide definition of surgical procedure does not align with the current modeling of the concept.


EAG members asked to review and add comments based on the briefing note.

Consensus to move forward with testing. Following testing, present the impact on the taxonomy to the EAG.

4Adverse reaction usage

Disorders or conditions caused by a drug or medicinal product are variably modeled as subtypes of either 281647001 |Adverse reaction (disorder)| or a variety of other Disorder concepts. This inconsistency has led to many disorders that should be subtypes of 281647001 |Adverse reaction (disorder)| to not classify as subtypes.  Based on definitions of adverse reactions from multiple sources, it is proposed that all disorder concepts with a CAUSED BY relationship value from the Pharmaceutical/biological product hierarchy be modeled as a subtype of Adverse reaction.  In some cases this parent assignment will be in addition to other proximal primitive parents assigned in the concept model.


Glossary of International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use, for Adverse Drug Reaction (ADR):

--In the pre-approval clinical experience with a new medicinal product or its new usages, particularly as the therapeutic dose(s) may not be established: All noxious and unintended responses to a medicinal product related to any dose should be considered adverse drug reactions.

The phrase "responses to a medicinal products" means that a causal relationship between a medicinal product and an adverse event is at least a reasonable possibility, i.e., the relationship cannot be ruled out.

--Regarding marketed medicinal products, a well-accepted definition of an adverse drug reaction in the post-marketing setting is found in WHO Technical Report 498 [1972] and reads as follows: A response to a drug which is noxious and unintended and which occurs at doses normally used in man for prophylaxis, diagnosis, or therapy of disease or for modification of physiological function. 
The old term "side effect" has been used in various ways in the past, usually to describe negative (unfavourable) effects, but also positive (favourable) effects. It is  recommended that this term no longer be used and particularly should not be regarded as synonymous with adverse event or adverse reaction.

Pg 9 of 205: Adverse drug reactions, as established by regional regulations, guidance, and practices, concern noxious and unintended responses to a medicinal product. The phrase “responses to a medicinal product” means that a causal relationship between a medicinal product and an adverse event is at least a reasonable possibility. A reaction, in contrast to an event, is characterized by the fact that a causal relationship between the drug and the occurrence is suspected. For regulatory reporting purposes, if an event is spontaneously reported, even if the relationship is unknown or unstated, it meets the definition of an adverse drug reaction.

Downloaded from Referenced by MedDRA. 

US Regulatory Definition (21 CFR 201.57(c)(7)): •“An undesirable effect, reasonably associated with use of a drug… − that may occur as part of the pharmacological action of the drug or may be unpredictable in its occurrence” •“Does not include all adverse events observed… −only those adverse events for which there is some basis to believe there is a causal relationship between the drug and the occurrence of the adverse event” •Causal relationship need not have been definitively established (see also §201.57(c)(6)(i))


When proposal such as this come forward, provide an ECL to give the scope of the proposal.

Concern that changes to the Adverse reaction template may have a negative impact on adverse reactions that are defined by substance.  The initial proposal was to remodel existing concepts that have Disease as the parent with Adverse reaction.  The scope of the proposal is limited to those concepts in the international release.


Agreed that disorders as listed above be remodeled as proposed.

<< 64572001 |Disease (disorder)| : << 246075003 |Causative agent (attribute)| = << 373873005 |Pharmaceutical / biologic product (product)|

Minus  Vaccine induced fibrosarcoma as the vaccine is not necessarily the cause.

5Inactivation of 370115009 |Special concept (special concept)|

Expansion of the prior briefing note to inactivate the Navigational concept hierarchy to include its parent 370115009 |Special concept (special concept)|, as it only has one subtype.  See link to briefing note above.


There was consensus that retaining this top level concept only causes confusion and is better inactivated than maintain for some future use case. 


Prepare a general briefing note for consultation with the CoP for input as to potential use cases.

  • SI to develop a detailed proposal for communication with the community of practice, i.e. impact on implementations.
6Creation of new top level hierarchy for Generic products

Issue with positioning non-pharmaceutical products (e.g. nicotine, environmental products) as there is not generic Product top level hierarchy. The proposal is to create this new top-level concept, and make the current 373873005 |Pharmaceutical / biologic product (product)| a subtype.  This would also allow the movement of many of the current substance concepts under 312412007 |Substance categorized functionally (substance)|, most of which are not pharmaceutical, to be reclassified as products.


SI has received requests to add non-pharmaceutical products, but there are not a place within the current hierarchy to locate them. 

Concern that some products being moved might have an impact on decision support.  Need to ensure that only products would be moved, not substances. 

There is a lot of overlap between substances and products, but there needs to be more work in cleaning up the substance hierarchy to ensure that it is clear what the differentiation is between substances and products.  In general, the creation with such a top level generic product hierarchy is a good idea, but needs additional analysis. 

Need very clear definitions for products and substances to ensure correct categorization. This may have an impact on modeling other concepts.


Develop a more detailed proposal and the impact that it has on both modeling and decision support.  Scope and definitions need to be developed and included in the proposal. Need detailed editorial guidance as to when to use substance or product in modeling content.  E.g. Allergy and allergic reaction

  • Jim Case to develop a detailed proposal for creation of a new top level concept. 
7Modeling of "No known X"

Inconsistent representation of "No known...(situation)" with proposed remodeling.  See attached document.

Different resolution depending on whether the Situation is a "Finding with explicit context" (allowed range = <<  410514004 |Finding context value (qualifier value)|) or a "Procedure with explicit context" (allowed range - <<  288532009 |Context values for actions (qualifier value)|)?

Proposed definition for "No known" after consultation with EAG members.  Differs from "unknown" in that it implies a reasonable effort to acquire the information, or a lack of evidence to support the issue at hand as opposed to a general lack of information for any reason.  Agreed in the last meeting in Atlanta that it should be a sibling of "Unknown".

Latest proposed Definition:

Subsequent to a reasonable attempt to acquire information, there is no evidence or information that proves the presence of a particular finding, therefore assuming its absence without objective proof.

11/27/2023 Discussion:

The is an issue with the application of "No known".  There are many instances where there is no knowledge, but there is a lack of objective knowledge. The question is how much investigation needs to be done to make the statement.  A detailed discussion document on the use of different finding contexts has been provided by Monique van Berkum and is attached to the minutes.  While there may be a clear distinction between "No known" and "Unknown", it is difficult to determine to what concepts these should be applied.  

There is a flavor of bias towards the condition not being there with "no known", whereas "unknown" has no bias in either direction.   How much uncertainty do we want to include in pre-coordinated content?  Suggestion that we should not add new content in this area until we can more precisely represent the underlying meaning of these terms.  Family history is one example where it is never possible to know definitively that a condition has not been in family members.

11/27/2023 Decision:

Topic table for now.  EAG members encouraged to review Monique's document and add comments in preparation for a later meeting. Review the attached document:

Context_No known_MvB_Short_20231127.docx


These concepts in general should be modeled as situations.  The confusion arises when there is a conflation of two aspects of Context: Absence and Certainty as values for Finding context:
Definition of FINDING CONTEXT: “This attribute represents a situation in which a Clinical finding or Event is known or unknown. If known, whether it is present, absent, or uncertain (possible). It also represents that the finding is not actual, but anticipated or possible in the future.” Splitting to two attributes seems inappropriate.  Consider expansion of current valueset to support this use case.


8MRCM change and revision of Physical object hierarchy
  • A request from multiple member countries to enhance the MRCM in the Physical object hierarchy to support the definition of specimen containers.
  • A request to add a new attribute to the Specimen hierarchy MRCM to support the container in which a specimen is "contained".
  • Briefing note attached 

11/27/2023 Discussion:

Requirements were developed with lab specialists to meet their needs.  There needs to be some more specific use cases to make the effort worth it other than just making the hierarchy more manageable.

Additives are substances that would be incorporated into the specimen, whereas the separator attribute represents something that is not incorporated into the specimen. Also suggested that separators should not also be physical objects, but should be substances.  

What is the impact of adding these to other hierarchies that might use these needs to be considered.  

There is some use for the HAS INTENDED SPECIMEN even knowing it is not "always and necessarily true".

How should "spray-dried coating" be modeled in this scenario?  Is it an additive or just a substance coating on the container?  How manufacturers represent the difference between coatings and additives needs to be considered.

Need definitions for each of the attributes that make it clear to modelers what substances are allowed.  

Will the level of effort needed to make these SD be worth the results.

11/27/2023 Decision:

Referred back to Daniel Karlsson and Feikje Hielkema-Raadsveld for revision based on comments from the EAG


Feikje Hielkema-Raadsveld and Daniel Karlsson have reviewed the comments from Monique van Berkum (see attached document) and while not disagreeing that the current state of containers would benefit little due to the small number of affected concepts, with new requests for container types coming in as part of European health projects that for allow better maintenance of a growing area of the terminology.  It is felt that the discussion of whether creating a concept model for containers is more in scope for this discussion than perhaps the model itself.  Examples of new container types that would benefit from a concept model would be helpful.


Postponed to next meeting due to time constraint.


10Next meeting

Mar 11, 2024 (due to travel and holidays)