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10:00 UTC on Wednesday 30 August 2023 - 1Hr 


  • FHIR Terminology Services and Resources discussion
  • FHIR Terminology Binding discussion

Discussion items





Notes & Actions

1Welcome and introductions2

Recording, notes & attendance.

Check questions in Zulip and SNOMED International #snomed-hl7-fhir

2Previous Meetings2
3Other Meetings10

Recent events:MedInfo 8 - 12 July Sydney Australia see here session on a wide number of standards.  See 

Upcoming events:

HL7 September (Phoenix, AZ) 9 - 10 Connectathon, followed by 5 days working groups.

FHIR North (Canada) Oct 17 - 18  https://





SNOMED International Atlanta, GA  22 - 27 October.   FHIR Meeting on Sunday 22 Oct.

HL7 Australia 20 - 21 November Melbourne FHIR Connectathon

HL7 Netherlands November 9 - 10

   RH & PJ presenting session on IPS (Sunday).  HL7 & SNOMED International being represented. Panel involving JIC.

  - IPS Sessions:  Peter Jordan  workshop based on use case from all involved SDOs, and Sunday devoted to IPS. Rory Davidson was there, presented the IPS terminology ad a SNOMED intro, ECL. A good image of the SDOs working together. Conversations about the scope on the IPS free set.

  - There were presentations about OpenEHR, attended some meetings, but they are not part of JIC yet. Suzy Roy SNOMED is looking for use cases of concurrent use of SNOMED, HL7, and OpenEHR

GDHP Connectathon last night. 30+ participants. Multiple presentations, Graeme, Google. Conversations about valuesets and use of No Information record. News from the content team: concepts for "No information" have been created in SNOMED and will be available publicly soon. 2023-08-02: Plan updates to the group about the creation of these values in SNOMED

Upcoming events:

HL7 September (Atlanta Phoenix) 9 - 10 Connectathon, followed by 5 days working groups.

HL7 New Zealand and Australia: 28th of November, in Hamilton NZ. Joint FHIR connectathon centered around the IPS use case. Backed by HealthNZ.

Other Regular Meetings:

HL7 Group TSMG (meeting Wed PM ET every other week) - Terminology Service Management Group (HTA Thursday AM is now a subgroup of the TSMG).   2022-05-17 RH Joint session with Vocab at last business meeting.  2022-06-14 Group has approved minimum capabilities for terminology servers.  Now looking at bigger/better HL7 Terminology Server has approved minimum capabilities for terminology servers.  Now looking at bigger/better HL7 Terminology Server 

4Observables Model

Discussion on grouping.  AP advertised 'exclusion refsets'  which identify groupers, including descendant count and textual matches. 

5IG Tooling Compatibility20

Requirements for making a Terminology Server compatible with IG Tooling

See Zulip discussion here:



  • Michael Lawley is implementing the requirements in Ontoserver
  • Graeme is preparing the Terminology Server registry, probably a JSON document, that would make available different terminology servers, listing the capabilities, including which code systems on each server
6Observables model

Question on the Observables Model (- was discussed in both the MAG and the EAG.   Yongsheng Gao currently looking at proposals and next discussion will be at all staff meeting in June.

7Post R5 Concept Map - support for SNOMED Map features.

Concept maps and SNOMED Maps  - how to materialize as both R4 and R5.

Metadata needed:  target CodeSystem URI,  source and target ValueSets.

Do we assume that a simple map is an equivalence.

For complex maps, how are the additional fields represented?   Eg in property, dependsOn and product (these are typed).   See Complex and Extended Map from SNOMED CT Reference Sets  

CC Kai Kewley 

Update 2023-06-13 Now working in confluence Concept Map in R5

2023-07-11 Work being done (ML) around clarity and specification for the parameters used in implicit Concept Maps.

2023-07-25 Michael Lawley and Dion had a discussion on metadata and put together a proposal of a JSON based metadata, presumably to be presented to the MAG

8Allergy IG Demonstrator20

To be shared at the next Allergies CRG (late May)

2023-07-25 Alejandro Lopez Osornio a new version available, resolving Marie-Alexandra Lambot feedback

The guide is published in: SNOMED CT Implementation Guide for Allergy, Hypersensitivity and Intolerance (Alejandro Lopez Osornio to review sync with WIP version, link from the guide to the demo tool)

9Expand Alliance20

XPA - Expand Alliance European Project.  Interoperability in Europe, targeting providing 6 x 40 hours of medical interoperability training to 40 students to fill gaps in existing offerings.  HL7 Europe (consisting of all HL7 European country affiliates) also participating.   

2023-05-30 Submission made (SNOMED International is a co-partner).  Response expected by the end of the Summer.

10Testing Frameworks20

Testing Frameworks.  Background: IG Tooling using servers other than    servers may need to implement additional parameters that are outside of the core specification.   GG has put together a test suite to confirm alignment to meet IG Tooling needs.   Command line flag to the validator to run these checks.

Issues encountered - some expected responses include nesting (Ontoserver's response does not do this).  Syntax for regexs may be non-standard flavour.   Examples show only translation display elements - "use" is not populated.   Tx Server limited to 1000 codes in expansion so test suite is expecting to see errors for large CodeSystem whereas Ontoserver would not expect to return an error.

Now related to #4 IG Tooling compatibility.

11Jamaica update

New SNOMED member. Working with OpenEHR and FHIR. Onboarding is ongoing. No detailed use cases are recorded yet.
12Agenda for April Business Meeting
  • National Implementation - how best to manage ValueSets (Rutt Lindström )
    • should be a one-off exercise
    • static substrate, or generate documentation around changes.
  • Allergy Guide - crossing SNOMED and FHIR (See Jane Millar for template)
  • Demo of Post Coordination
  • Snowstorm support for additional codesystems
  • Marie-Alexandra Lambot resource visualisation work
13Visualisation of FHIR resources10
14New page for eHealth Standards Belgium10

PJ suggests looking into: Based on the NZ medication interoperability experience. Challenges of sharing codes.

15European Terminology Services Collaboration10Rutt Lindström 

There is a European Commission working group under MyHealth@EU that is considering requirements for future terminology services for EU cross border eHealth services (ePrescription, eDispensation, Patient Summary, etc).
A temporary side activity of this group is to discuss national terminology server and terminology management systems implementations. Most people involved in the group are also involved in the national terminology services projects, and sharing those plans and experiences are helpful for finding the middle ground and needs for common EU services. 

Rutt Lindström is the co-lead of that group. If you're interested in learning more, or you're just bored with your life and feel like chatting with someone about these topics, please get in touch.

16HL7 Europe Laboratory Implementation Guide15

See for context.

Language issues inside Codings - a way of putting a language tag inside a Coding?  DK: In cross border situation, question is where the translation should happen (eg keep the original pre-translated terms present along with the translation).

ML: Normally the display text in the coding is in the language of the Resource itself.  There is a generic extension for anything String typed that would allow its language to be specified.  See

17Language behaviour compliance in Snowstorm10

BCP-47 requires a dash every 8 digits so SCTIDs need to be broken up to be compliant.

Also the "x-sctlang" is required. 

Also discussed GG's request to Kai Kewley in the behaviour around language headers and how they interact with the displayLanguage in the HTTP GET request.

18Allergy Guide work 5

Allergy Guide binding question on representing symptoms - discuss on next Tuesday call.

MAL - has finished current version of guide.  Some layout work to do and small additions possible prior to publishing. 

19Resource consistency10Looking to engage with various HL7 Work groups to flag up inconsistency of various elements between resources.   There is hopefully an opportunity to address this as we start talking about FHIR 6.0
20CDS Hooks10

HL7 CDS Hooks appears to have 2 specification releases.   Is version 1 the main release in use.   (Clinical Decision Support workgroup own this - Bryn Rhodes)

CQL may have more traction.

2023-03-07: Demonstrator developed

21Clinical Impression Questions30_

RH: R5 will be entirely trial use.   Nothing will be made normative in there.  PJ: R6 (2026?) will attempt to move as many resources as possible to be normative.  RH This resource does not have clear consensus around what it is to be used for.  RH assumes "Subjective, Objective, Assessment and Plan (SOAP)" - expected to be a single physician performing 

  1. ClinicalIImpression.Performer has 0..1 cardinality.   What happens if a team is involved?  Options:  cardinality could be changed,  team leader could be recorded, single practitioner object could be used to represent a team.
  2. ClinicalImpression.problem what does "relevant" mean in this element?  RH Took this to mean relevant to this particular encounter.  ML Would be up to the clinician to decide what is relevant to a particular encounter.  MAL: How do we indicate a grouping of potential diagnoses to be a differential set?
  3. ClinicalImpression.investigation is this only history and examination.  This 0..* element was removed between R4 and R5.  RH Thought that it wasn't sufficiently distinct from the other fields.  RH Recommends that MAL have a discussion with the Patient Care Working Group to explore why these decisions were made.
  4. Apparently inconsistency between resources which sometimes use two separate start / end dates and sometimes use a period object.  RH Agrees that working towards consistency is desirable.
  5.  ImmunizationRecommendation.   Why was the request resource pulled out specifically when a generic request object could be used? RH Public Health WorkGroup made this decision, notes that immunization is distinct from medication because a condition is not necessarily.   PJ suggests that these questions be raised in Zulip ( ) and in specific workgroup discussions.

Contacting HL7 Working Groups (Use co-chairs as points of contact)

2023-02-07 Looking for diagrams showing relationships between resources, in particular workflows.

RH suggests: ClinFHIR: Graph Builder 2 tool:

22Allergy Guide Examples

Patients with multiple symptoms - is not obvious how to do this in FHIR.  The condition resource does not lend itself to symptoms.   There are examples of using the Observation Resource, but seems "sketchy"  

Both Condition and Observation Resource have ways of recording who is making the observation (see "performer").   

PJ - This should be attached to an Encounter.  See  which has a 0..* Reason which takes a  

RH "Presenting Complaint in the patient's own words"  DK before there is an Encounter, there is a Service Request (in R4 has reasonCode and reasonReference, but in R5 there is just a reason which is a CodeableReference)

2023-03-07: Corrections to the Allergy Guide made, proof reading in progress, Target publication before business meeting in April 2023.

23R5 changes suggested around specifying language using BCP-47 10

See Tuesday meeting item #6

Changes for R5  and check on use of dialect in x form in ECL Specification Appendix C:  Appendix C - Dialect Aliases

Note that where a language reference set pulls from more than one language, the BCP-47  tag could potentially missing out the <lang> element and start directly with "x-".  Options for referring to multiple languages: could be done either with a * (see ) or with a comma separated list to indicate a priority order (although this isn't supported by the FHIR parameter (unless the server went out of it's way to allow for this), or use the accept-language header).  Use case is in the displayLanguage input parameter to a ValueSet $expand operation

2022-08-31 ML CSIRO attempting to get R5 compliant Ontoserver ready in time for HL7 Connectathon.

2022-10-04 With this page moving to it is no longer subject to the ballot process.  Instead a "TSMG" ticket should be created.  Daniel Karlsson and Rob Hausam will progress this. 

Also tracking R5 changes to concept map - see   Peter G. Williams to check SI intention for R5 compliance.

2022-10-18 DK EHealth Working Group on Semantics - discussion on cross border infrastructure based on CDA.  Suggestion that it could move to FHIR for new specifications/developments eg Lab Reports.

2022-11-02 RH Rob will check the status and how we can help it move

2023-02-07 RH R5 Ballot is complete.   Deadline to complete resolutions is Feb 24th.   Expectation to publish late April / early May.

2023-03-07: RH R5 going through QA currently. Some last-minute changes in ConceptMap: RH change in relationship types, new ValueSet to remove ambiguity. Directions of maps (very) explicit. No-map situation simplification. Element name changes. Choice datatypes in more places. ML property, dependsOn and product clarification. E.g. property is used in implicit ConceptMaps based on SNOMED complex maps. 

2023-07-11 ML Added UP ticket - (Unified Terminology Governance Project)



Machine Readable Concept Model (applies to both pre and post coordinated content)

MRCM is needed for writing good ECL and also for writing 'good' Post coordinated expressions.

Going forward:  suggestion that PJ and RH expose both the MRCM and the capabilities of ECL 2.0 with the wider HL7 and FHIR Communities.  See slides on ECL 2.0 here.  ML more generally this is a refinement axis which is represented as two things - the attribute and the range of values that that attribute can take.

2022-11-1 ECL 2.0 can retrieve MRCM refsets content, the question is how to return them as FHIR resources (structure map?)

Using implicit concept maps may be an option to add operations such as get acceptable attributes or get range

(note SNOMED is the only CodeSystem that uses implicit concept maps, wording around that is changing, see )

25Support for other CodeSystems in Snowstorm.

Confirmation that SI will be adding some support for other CodeSystems based on leveraging the existing HAPI library support for such things.  Will be limited to the FHIR API (not the "native" Snowstorm API, except perhaps augmenting our return for ICD-10 maps to include the term associated with the code).  This Will allow us to host the UK Extension due to the requirements of their extensive maps.   

Targeting August release of Snowstorm.  Plan is to contribute code back where enhancement is required.

2022-08-23 See (in use by India)

2022-10-18 PWI Pull request for this work to be merged into MAIN Snowstorm, priority of this under discussion.

2023-02-07 Just waiting for test plan completion before merge can be progressed.

2023-02-21 This work now merged from Snowstorm-X into the "develop" branch of Snowstorm Prime.

26Upcoming R5 changes

2022-8-23 RH R5 Deadline now September 4  

  •  Rob Hausam please create relevant tracker to take forward the additions marked green in this page:  Changes for R5  2022-10-04 See above re DK + RH taking this forward.
  •  Peter G. Williams merge this agenda item with similar one above.

2022-11-1 RB: Publication is expected after February 2023.

2023-02-21  PJ Reconcilliation to be completed by next week.

27Topics for Terminology Binding Stream

Collecting topics for TB stream here, with a view to having a call when there's sufficient material

FamilyMemberHistory - how is "no family history of X" best represented?

FreshDesk ticket question on Allergy substance cross field validation.  DK: Mappings to other information models, is that helpful?

Oct 5 2021 Request for input from nutrition CRG.

8 Feb 2022 MAL Patient Care group proposing the use of an extension (specified by Daniel) to represent Allergy Type to add non-allergic hypersensitivity.  MAL wondered about allowing a Codeable Concept there rather than a Code to allow for greater expressivity.   Resource not planning on being Norminative in R5.

2022-11-1 DK: Immunizations may be a good candidate for future discussion MAL: can present advances. DK: Also, Specimen SNOMED vs Specimen resource.

28Publishing SNOMED codes in IGs and licencing conditions.

Licensing issues for IGs referring to SNOMED codes. Is this written down anywhere with some sort of rigour?

Consider the licence statement that is presented when accessing the browser. Should something similar be mandated for inclusion in any document published? What if a patient's medical record were to be published?

Update 12 Jan - "One Page Policy" to be discussed internally.   HL7 agreement indicates other parties would require affiliate licence unless they restricted their usage to the Global Patient Set.

26 Jan Question from PJ about inclusion of COVID Vaccine concepts in the GPS (advised that it is only released yearly)  FYI Rory Davidson See also MF discussion here.  SuzyR will follow up.  See also early preview page.

06 April: SR covid vaccines have been/will be incorporated into July release. They will be in GPS when ready. 

8 Feb 2022 This was discussed at a CSRM meeting - Peter G. Williamsfollow up with Suzy Roy  DK Also do we specify boilerplate copyright statement?  This should also be specified in our IG (or referenced).

2022-04-19 Beta release of the IPS sub-ontology (which will include relationships but not axioms)  see due for Tues 3 May.    ML concerned that having the codes in a different CodeSystem breaks interoperability - further discussion required on this point internally Kai Kewley Alejandro Lopez Osornio Suzy Roy

2022-11-1 RB: For the IPS Guide the copyright messages were reviewed, and approved by Suzy:

Possible valid copyright statements used in IPS Implementation Guide, select and adapt the appropriate one depending on the content:

  1. The SNOMED International IPS Terminology is distributed by International Health Terminology Standards Development Organisation, trading as SNOMED International, and is subject the terms of the Creative Commons Attribution 4.0 International Public License. For more information, see SNOMED IPS Terminology
  2. The HL7 International IPS implementation guides incorporate SNOMED CT®, used by permission of the International Health Terminology Standards Development Organisation, trading as SNOMED International. SNOMED CT was originally created by the College of American Pathologists. SNOMED CT is a registered trademark of the International Health Terminology Standards Development Organisation, all rights reserved. Implementers of SNOMED CT should review usage terms or directly contact SNOMED International:
  3. This value set includes content from SNOMED CT, which is copyright © 2002+ International Health Terminology Standards Development Organisation (IHTSDO), and distributed by agreement between IHTSDO and HL7. Implementer use of SNOMED CT is not covered by this agreement
29Language Reference Sets in FHIR

Mechanisms for working with Languages

Designation extension

24 August DK Added pull request to Snowstorm  here

Implementation by ML using existing fields and specifying LangRefset in displayLanguage parameter with "preferredForLanguage" code and wildcard  Eg$expand?displayLanguage=*-x-sctlang-20581000-087109&_format=json&url=

Oct 5 Release of Ontoserver 6.5.0 which includes support for language reference sets as above.

Next Steps: How to promote - could we present at a Vocab call?   (1530 ET Thursdays - may clash with SI Languages call)

8 Feb 2022 DK added Designation Extension into the SNOMED on FHIR IG see

30SNOMED FHIR Implementation Guide

Implementation Guide for using SNOMED CT with FHIR.

IG Documentation:

Also look at the sample IG see build


2022-11-1: No news, check in the next call.

2022-11-15  Suggestion to set page per meeting list to work through.  Setting up one or two HTML style pages that could then be copied and modified and then use meetings to tackle more difficult content and review.  Finding best publishing location, cross referenced between

Pairings - Kai, Peter, Marie, Daniel, Rob

Top Topics

  • What are the various Resources in terms of how they relate to SNOMED CT (Link to Follow the yellow brick code presentation).  
  • ECL in FHIR (intensional ValueSets being less brittle)
  • Languages
  • Terminology Binding (General Approaches)
  • IPS (GPS)
  • FAQs eg how to recover historical assertions using Map
  • Post Coordination & Transformation
  • Relevant changes in R5 eg Concept Map (correlation changes)


Example markdown page that could be copied and modified:

Work to be presented for 13 December (payment will be made in Glorytm)

Peter & Kai - ECL in FHIR  (Update:   Used  for collaborative markdown editing. )

Daniel & Marie - Allergy & Intolerance : (Update: Menu item added for extensions, confirmed examples are useful and appropriate for the Allergy Guide. )

Rob - IPS

  •  Peter G. Williams contact Ole Vage & Feijke re Translation Group and contributing to IG relating to use of languages in FHIR.

2022-12-13 ECL Page reviewed - MarkDown not displaying the same as it did the IDE, revisit.

Looking for some more structure that could be applied to the apparently unordered list of ValueSets (which is machine generated).  Any documentation on how to do that would be appreciated.   Other IG's we could compare to are : &  ( also )

Looked at and the animal breeds which is extensionally defined with a complete set of animal breeds, most of which were inactivated in the International Edition in 20210731 and reactivated in the Veterinary Extension.

  •  Peter G. Williams raise tickets for the usefulness of the usage page and also for the animal breeds that if they referenced the Veterinary Extension then the concepts would be active there, and a an ECL or ISA definition could be used in the ValueSet

2023-02-07 MAL work for Allergy Implementation Guide (which the SNOMED IG will link to) see SNOMED CT Implementation Guide for Allergy, Hypersensitivity and Intolerance

2023-02-21 DK Work done for languages -  Discussion about overloading of parameter for both display language and search language.   Checking behaviour around fall-back on displayed terms (eg context specific → national language → English).   For example, display parameter being a comma separated list (which has a defined order, unlike repeating the same parameter multiple times (also not allowed in the spec)).


Expanding ValueSets across multiple Editions.

Discussion on * version wildcard. (relates to a Zulip discussion on expanding a ValueSet against multiple editions to give a superset?)  DK How could we specify the latest version of multiple modules.   Answer*   (ie not specifying the version) or*/version/*  to include concepts from previous versions.

For use in the module / version URI.   Existing workaround is to use multiple include elements for each version.

7 Sept ML Sticking point - what do we do with incompatible properties eg active/inactive between two different versions - the most recent?

Use case: primarily being able to validate codes that might exist in different editions.   Secondarily, being able to validate code received in a historical record ie where codes were valid at time of data entry.

25 Jan 2022: Snowstorm will already look across all Editions loaded when a codesystem version is not specified, eg:$validate-code?coding=|443971000124108 only exists in the US Edition.  (See also the History proposals for ECL)

2022-05-17 ML Ontoserver supports ValueSets that draw from more than one version, so you could use that to compute the difference between one version and another.

2022-11-1: DK: Snowstorm does not yet support multiple include elements in different versions for the SNOMED code system. ML: The semantic is not yet clear, how to decide in which versions you check properties, parents, etc. Run separately for all inclusions and join the results. May need to understand better the use cases.

32Long Term Home for Terminology Information

Rob Hausam (primarily Vocab WG)

Long Term Home for Terminology Information that can be maintained independently of FHIR versions.


7 Sept Relates to problematic page   PWI discuss internally - done.

Update 21 September 2021 - General agreement that that page can be removed.  Is out of date and not serving useful purpose.

Update 25 Jan 2022 - HL7 intend to make The THO a home for all terminologies and valuesets.

Next Time: Move to archived discussion, make note in IG

2023-03-07: RH Vocab WG has a new name: Terminology infrastructure WG

33IPS / GPS progress

IPS Terminology Subontology - beta went out 2 weeks ago, now in feedback until June 30.  Publication for the end of the year.  ML expressed issues around not being conformant to RF2 spec but is missing module dependency file.   ModuleId is present but invented Concept.    ALO/SR suggested ML give that as feedback.     

GPS expected towards the end of September. Currently working with contributing organisations, which will then go to internal authoring.   ALO GPS may turn out to be less useful and focus could be on IPS in future.

2022-10-18  See   also available in MLDS, published 2021-09-30, based on INT 20210731   PWI will follow up for 2022's copy.   SR IPS targeting Nov 30 2022.   Sub-ontology steering committee (internal) meeting next week.

2022-11-1: RB ML have received a new beta version and are testing. ML: The effective time in MDRS may be pointing to July instead of November. No MRCM content, it is required fur the type of the concrete domain attributes.

2023-03-07: IPS has a new management process. Feedback received will be managed by the most appropriate SDO. 

34Snowstorm post-coordination updates

2023-03-07 Post-coordination is added to the FHIR API and more (include $lookup, $validateCode, $subsumes, etc.). Will be published together with the Post-coordination guide. 

2023-06-13 Post coordination support now available in Snowstorm-X  see

35Any Other Business

  • Next meeting 

Potential Items for Discussion

OwnerNotes & Actions

Concluded Discussion

See also FHIR Terminology Services Discussions

OwnerNotes & Actions

Meeting Files