•  Recording of meeting approved by participants.

Conflicts of interest and agenda review

Currently, most "417662000 |History of clinical finding in subject (situation)|" concepts (~1000) are modeled with a TEMPORAL CONTEXT of 410513005 |In the past (qualifier value)|.  The exceptions are "Family history of X" concepts.  While this makes sense in the context of procedures, it is not so clear with clinical findings.  In many cases clinical history involves conditions that are both current and in the past (e.g. history of cough for last 10 days).  While we have a few concepts that specifically state "Past history", for the most part History of clinical findings represent conditions that were in the past and do not represent ongoing clinical conditions.  

It is recommended that these concepts be remodeled with a new TEMPORAL CONTEXT, either the existing 410511007 |Current or past (actual) (qualifier value)|, or a new "Current and/or past (qualifier value).  As this change is more general than the current modeling, it should have no impact on the taxonomic structure of the hierarchy.

Discussion:

Decision:

We have examples of clinical findings and disorders that have identical modeling, and in some cases have identical descriptions.  An example brought to our attention is that of "Inflamed joint" vs. "Arthritis".  These are modeled identically and 3723001 |Arthritis (disorder)| has the additional description of "Joint inflammation".  During internal discussions it was commented that there is a need to distinguish between observations made during clinical exam and those that represent a "diagnosis".  Other examples include 281795003 |Inflamed tonsils (finding)| vs. 90176007 |Tonsillitis (disorder)|; 298170003 |Knee joint inflamed (finding)| vs. 371081002 |Arthritis of knee (disorder)|, etc.

Some proposed use cases were nursing findings, and the "need" to differentiate a finding on observation vs. diagnosis.  However, we do not have a comprehensive representation of this pairing of findings and disorders in SNOMED CT.  This impacts where specific descriptions may be applied; for example, we would not put the description "Inflammation of knee joint" on the concept 371081002 |Arthritis of knee (disorder)| (which is currently the case), since it would be more appropriate for 298170003 |Knee joint inflamed (finding)|.  There is considerable inconsistency in the current content, for example there is 298171004 |Ankle joint inflamed (finding)|, but no "Arthritis of ankle". 

Q:  Is there a need to maintain this distinction and, if so, where should it be applied?

Discussion:

Decision:

A recent query from members brought to light the fact that SNOMED CT represents "Clinical finding present" concepts in two ways.  The majority of the concepts (>550) are located in the Clinical finding hierarchy (e.g. 297990009 |Hair present (finding)|), with the majority of those concepts having a definition status of primitive.  A small number (~55) are located in the Finding with explicit context hierarchy and are sufficiently defined, having been moved from the Clinical finding hierarchy, first to the "Context dependent category" (precursor to the Situation hierarchy) in 2004 and then to the Situation with explicit context hierarchy in 2006.  

It may seem clear that the remaining "X present (finding)" concepts would logically belong in the Situation hierarchy; however, large changes in hierarchy have historically caused issues with implementations.  Advice is sought concerning the potential move of these concepts.

1. Clinical findings have an implied context that is dependent on where in the medical record they are used.  The default context is "known present" and "current".
2. Clinical findings with finding context explicitly stated do not have alternative interpretations. 
3. Clinical findings with stated context have historically been moved to the Situation hierarchy: however, this has nearly always caused issues with implementations
4. Movement of context-specified content allows them to be sufficiently defined, whereas they are usually primitive in the Clinical finding hierarchy. 
5. Historically, movement of large numbers of concepts to the Situation hierarchy retained the original concept ID as there was no meaningful change in meaning of the term, just a change in hierarchical location.

Ancillary to this is the use or the TEMPORAL CONTEXT value 410512000 |Current or specified time (qualifier value)|.  The addition of "specified time" is assumed to have been used to state that the referenced condition was known to be present based on a timestamp that is specified in the EHR.  An underlying assumption is made that the recording of the finding is contemporaneous with the the observation and that all modern EHR systems provide a timestamp for each recorded instance.  If the observation is recorded at a future date, then a determination of whether the condition is still present (i.e. 15240007 |Current (qualifier value)|), or has resolved (i.e. 410513005 |In the past (qualifier value)|). This makes questionable the use of any temporal context value that refers to "specified time".  The use of these temporal context values has been extremely limited, although subtypes (e.g. 410589000 |All times past (qualifier value)|) have been used for a relatively small number of concepts (<100).  

Q: Given their limited use an questionable value, should Temporal context values that use "specified time" be inactivated and affected concepts be remodeled with the appropriate parent value?

Discussion:

Decision: