Peter G. Williams

Rob Hausam

Recording, notes & attendance.

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

Discussion on moving to once every month or 4 weeks.  RH Would like to see focus on IG, MAL would like shorter meetings, rather than less frequent. PWI Would like to collect items in between times to have focused topic list for meetings.   Conclusion:  Take meetings down to 60 minutes but stick with current schedule.

Peter G. Williams

Rob Hausam

Peter G. Williams

Rob Hausam

Recent events:

Hospitals on FHIR October 27 - MAL did presentation. "Great presentations."

2nd X-eHealth Innovation Day (October 26th, 2022) link: https://www.x-ehealth.eu/2nd-xehealth-innovation-day/    

FHIR North - October 26 & 27.    Discussions on IPA and IPS.

KK: Israel national event - talking about using FHIR as a standard.

Upcoming events:

HL7 Australia Connectathon - Dec 1 & 2.   Will be R4   Questionnaires being a main agenda item.

NZ Connectathon Mon 5 Dec Health Terminology Server (Ontoserver) Connectathon run by CSIRO followed by joint standards workshop - "Escape from burning Platforms with SNOMED on FHIR" with PJ and AK.  Part of Digital Health Week (Rotorua)    Followed by standards workshop - SNOMED on FHIR.   Wide ranging topics (eg Terminology Binding), TBC.

SNOMED International Event w/b Dec 14 : Implementation Webinar - Terminology Binding in Questionnaires (FHIR resource).

Rob Hausam 

Daniel Karlsson 

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 https://developer.mozilla.org/en-US/docs/Web/HTTP/Headers/Accept-Language#syntax ) 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

• Peter G. Williams This extra detail should be filled into FHIR-languages to avoid overloading/over complicating the HL7 page.

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 terminology.hl7.org it is no longer subject to the ballot process.  Instead a "TSMG" ticket should be created.  Daniel Karlsson and Rob Hausam will progress this. 

• Rob Hausam 

Also tracking R5 changes to concept map - see http://build.fhir.org/valueset-concept-map-relationship.html.   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 RB Rob will check the status and how we can help it move

How and where in the immunization resource would you represent the information that the vaccine is given because the subject was exposed to a risk like exposure to monkeypox? Would you use Immunization.reasonCode element? And if so, would you populate it with SNOMED CT event concepts like 1290711000000105 |Exposure to monkeypox virus (event)| or would you use 409516001 |Post-exposure prophylaxis (procedure)| to convey the notion that the vaccine is given because of pre-exposition and use the Immunization.reasonReference element to further specify this? Now the second option brings me to ask if an exposure event concept can be used as a Problem in a problem resource. I'd say no when I look at the resource but an event can be the reason for admission and in the case of suspected exposure to a risk, you won't get any other diagnosis then that at the end of the consultation so how would you record this? How do you record and where a patient coming because he/she was exposed to a risk, that has currently no complaints or signs, and that gets a vaccine as prophylaxis against this risk transforming into a disease?

The interest of 409516001 |Post-exposure prophylaxis (procedure)| is that you also have 1137457009 |Pre-exposure prophylaxis (procedure)| which is applicable to all other vaccines given to prevent a risk one has never been exposed to. The exact nature of the risk prevented is actually known through the name of the vaccine concept itself and it might be redundant to try to precoordinate more the immunization reason, especially is one links a full report in Immunization.reasonReference.

2022-10-04 DK/PGW Four places where this information could be recorded - vaccineCode (mandatory), reasonCode, basedOn (linked to an ImmunizationRecommendation where the target disease is specified).  Also protocol applied specifies the target disease.

Investigating the reason code element, the suggested ValueSet offers 281657000 |Travel vaccinations| which is now inactive with PossEquivTo 14747002 |Elective immunisation for international travel|.  Also suggest that they add 409516001 |Post-exposure prophylaxis, 1137457009 |Pre-exposure prophylaxis| or the parent of both: 710170000 |Administration of prophylactic treatment|

• Peter G. Williams raise ticket to have this updated in R5.  Done see https://jira.hl7.org/browse/FHIR-39442

2022-10-18 MAL Proposing changes to profile to augment ValueSet values eg Pre/Post exposure prophylaxis.   Can archive now.

Kai Kewley 

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.

• Peter G. Williams make a note of this in the IG

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

• Alejandro Lopez Osornio and Kai Kewley will draft a demo

Kai Kewley

Peter Jordan

Rob Hausam

https://jira.hl7.org/browse/FHIR-29821 "Updated cardinality of designation.use"

Expected to be part of R5.

Could we offer Use of BCP-47 + designation.use for review by the HL7 Vocab Group Rob Hausam? Targeting 9 - 13 meetings.

2022-10-04 Designation.Use extension still required for specific use cases eg consumer definitions.

2022-11-1 Archive

Kai Kewley

2022-02-22:  Presentation: https://docs.google.com/presentation/d/1Kz-8N6UQsGZ8C1xsC8TZT6LEbeyr6elrgMt2FI-whjU

• Supplements might not be able to hold new concepts: https://www.hl7.org/fhir/codesystem.html#supplements bullet no 4.
• (Ontoserver seems to do this: https://ontoserver.csiro.au/docs/6/postcoordination.html#Expression_Libraries )

Proposal might include using side-effects which some might be sensitive to.

Runtime maintenance is required. Is it possible to reuse the existing API in order to standardize the approach?

A Code System Supplement may be used to hold a set of postcoordinated expressions as FHIR concepts

• This approach used by Ontoserver so that they are "known" to the Terminology Server so that $expand can be used without considering all possible PCEs.  Not that some clients may not be able to process PCEs so the CS Supplement allows these to be kept separate.  Michael Lawley will raise ticket to "Add parameter to ValueSet $expand to specify Code System Supplements to be included" (would need to be compatible with code system that the ValueSet is being expanded against)
• "No requirement for a designation"

CodeSystem/$validate-code operation could be used to validate the expression

• Yes (doesn't need previous knowledge of the PCE, similarly for $lookup

Could calling CodeSystem/$lookup automatically create expression concepts in the supplement, to be returned in ECL queries for analytics? Or use PATCH?

• Probably not, see use of Supplement above.   Yes use of PATCH seems reasonable (PUT a whole new version more common, but PATCH might allow for finer grained updates ie not having to re-submit the entire cohort of expressions).   ML: Custom operation might be useful here to add to the codeSystem and update the ConceptMap in one go.

ConceptMap/$translate could translate an expression to a single identifier to support more limited clinical record systems.  Could this work in real time, automatically creating entries as required?

• ML: Use a local CodeSystem for the expression identifiers and a concept map to link them together.

• Peter G. WilliamsAdd to PCE page in IG

2022-05-17 KK Were tickets raised around clarifying questions?   2022-05-31 ML Taking an action to raise a ticket for expand so that you can specify one or more CodeSystem Supplements to be used in that expansion. "Expressions already exist as concepts in the given CodeSystem implicitly, Therefore they can be used in a CodeSystem Supplement.   The rules for CodeSystem Supplements state that they can only be used with Concepts that already exist in the CodeSystem"  "An expression is not adding a concept to a CodeSystem, it is just expressing something that is already there"

See https://jira.hl7.org/browse/FHIR-37529

2022-06-28 KK would like an agenda item added to next meeting (1 month time) to discuss a couple of strawmen proposals.

2022-07-26 KK walking through the postcoordination workflow (link above).

CodeSystem supplement for expression library, ConceptMap to map between expressions and fixed-length generated identifiers. ConceptMaps need explicit ValueSets for source (expressions) and target (generated ids).

What should be the system of the generated identifiers, should these identifiers be SCTID(-like)? ML: Would use UUIDs rather than SCTIDs.

A POST on $expand would allow composing a value set with the dependent SNOMED CT edition and the post-coordination supplement and the be filtered with any relevant ECL (for example).

RH: we're not creating new concepts (new meaning) but rather a new identifier from something that is already SNOMED defined meaning.

Having the generated id as a property on the concepts in the supplement would allow:

• the alternate id would be returned for any $expand operation including the supplement, possibly filtered by ECL
• an expand on a ValueSet composed of the supplement and supplemented CodeSystem filtered by the alternate id property would return the expression.

Alternatively, an additional CodeSystem for the generated ids could be created where the expression could be provided as properties.

2022-08-23 We'll pick this up when Linda Bird is next available for a Wednesday 10:00UTC call.

2022-09-06 KL worked through SNOMED CT Postcoordination Workflow (Discussion)

ML Would a refset of PCEs represent a Code System Supplement?

PGW - Archive Above Discussion.

2022-11-1 KK Will separate the draft documentation between the part that explains the post coordinated expression storage in the code system supplement from the assignment of an alternative identifier, in order to work on the 2 problems separately.

KK: How to assign an alternate ID to the expression using a concept map, how to reference the "value set" of all expressions in the supplement.

Discussion: With R5 a map may not be necessary? (not confirmed, extension?), however the guide will target R4. The extension "code-system-alternate" is available in R4, it might not be valid in supplement, maturity level 1. DK: Concept map may be a cleaner solution.

ML RB: It is not necessary to have a value set to create a concept map from Expressions to Identifiers.

RB: Will try to find out more on the extension.

Rob Hausam

Discussion about proposed federation.  ML Doesn't work so well with SNOMED CT because there's not a single authoritative source due to country extensions (and multiple versions being released).  Use case for this is mainly in creation of IGs.  Agreement that what a conformant server should be able to state in Capability Statement is helpful.   ML Touchstone test script artefacts need investment.  See https://touchstone.aegis.net/touchstone/

See also https://inferno.healthit.gov/

16 Nov Update RH: Updates in for next ballot (not January now).

8 Feb RH: Next ballot confirmed May (deadline March 6, since extended 2 - 3 months)

8 March RH Community being polled on preferred approach to next release from three options: 1. R5 Release with additional Normative content (ie in 2023) 2. Hold R5 3. New content, but not new normative content (looking most popular option).   See https://onfhir.hl7.org/2022/02/28/soliciting-feedback-concerning-the-roadmap-for-fhir-r5/

22 March 2022 RH Expecting September Ballot (hoping for sooner, prior to the working group meeting? - RH)

2022-05-17 RH Ballot expected later. Content freeze Aug 21

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

Peter Jordan

Daniel Karlsson

Jeremy Rogers

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.

Michael Lawley

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?

• Peter G. Williams find clarity here - email discussion started with Suzy Royand Jane Millar

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.

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 https://r4.ontoserver.csiro.au/fhir/ValueSet/$expand?displayLanguage=*-x-sctlang-20581000-087109&_format=json&url=http://snomed.info/sct/20611000087101?fhir_vs=ecl/160303001&includeDesignations=true

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

• Peter G. Williamsdocument examples using live Snowstorm instance

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 http://build.fhir.org/ig/IHTSDO/snomed-ig/StructureDefinition-designation-use-context.html

Peter G. Williams

Implementation Guide for using SNOMED CT with FHIR.

IG Documentation: http://build.fhir.org/ig/FHIR/ig-guidance/index.html

Also look at the sample IG https://github.com/fhir/sample-ig see build http://build.fhir.org/ig/FHIR/sample-ig/

• Rob Hausam to speak to Lloyd about extending the base template as per http://build.fhir.org/ig/FHIR/ig-guidance/template.html Update 24 March: Documentation on this is "TODO"
• Peter G. Williams FHIR core content to be copied over to Snowstorm instance.

TODOS 

• Check build issues http://build.fhir.org/ig/IHTSDO/snomed-ig/qa.html    Update 2022-06-20 Tooling currently giving a null pointer, see https://build.fhir.org/ig/IHTSDO/snomed-ig/failure/build.log  asked question in Zulip  See https://chat.fhir.org/#narrow/stream/179252-IG-creation/topic/Null.20pointer.20in.20ValueSetRenderer   
• Note page to manually execute build through HL7 Tooling: https://fhir.github.io/auto-ig-builder/builds.html
• Rerun locally with latest tooling (also sushi)
• Run with local snowstorm provided as Tx
• See Mark Kramer presentation   https://www.youtube.com/watch?v=OmcSuAMf20s  Also https://fshschool.org/ 
• CONTENT! 
• Merge in DUC branch (Designation Use Context) with a view to implementing in a branch of Snowstorm and making available via connectathon.ihtsdotools.org
• Clean up other branches
• Check templates are up to date - should now be self updating, see https://github.com/FHIR/sample-ig (fsh may ask to update this structure).   Sushi sending out information about new format (PJ says leading whitespace is now significant).
• ReadMe should provide links for Publisher tooling
• Add discussion on Refset / IN (see above)
• Provide link to it in http://build.fhir.org/snomedct.html and discuss further socializing.
• TerminologyCapabilities caching is overly aggressive.
• Added 2022-08-23 Discuss ownership, hosting and copyright (joint copyright with HL7).  Source will be hosted in GitHub, pull requests will be welcome with this group acting as gatekeepers (reviewers) for that?   Suzy Roy would the wording of our original collaboration be helpful here?

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 https://terminology.hl7.org/SNOMEDCT.html

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)

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 http://snomed.info/sct/*   (ie not specifying the version) or http://snomed.info/sct/*/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:  https://browser.ihtsdotools.org/fhir/CodeSystem/$validate-code?coding=http://snomed.info/sct|443971000124108 only exists in the US Edition.  (See also the History proposals for ECL)

• Peter G. Williamsdocument Snowstorm multi-edition validation in IG

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.

Rob Hausam (primarily Vocab WG)

Suzy Roy

Alejandro Lopez Osornio

Quick Questions:  

Next time:  Need some way of identifying which language reference sets are "patient friendly" aka "consumer"  (eg make those specific reference sets have an additional parent that indicates their use CS "Explanatory Terms".   Alternative solutions: annotations/metadata )    2022-05-17 MAL Daniel presented at translation User Group - looking for definition of "what is a patient friendly / consumer.  See here. ) 2022-08-23 PWI If we go forward with annotations, would a flag for "consumer" be one of those values?  Alternatively (or additionally) do we want a common ancestor for these refsets.  To add to agenda for the Joint AG session on the Wednesday PM September Business Meetings.

2022-09-20 What was the outcome of the IPS Subontology feedback?

Next meeting - should have clarity about what the IPS is going to look like.  See also https://community-browser.ihtsdotools.org/

Peter Jordan

Michael Lawley

Impact of proposed changes (eg text searching in ECL) on FHIR. Questions around which language reference sets to use when there are multiple, especially partial/overriding context (referred to MAG for discussion)

8 Sept The FHIR specification does not specify a particular version of ECL, so we assume the latest.  Any enhancements added to ECL will be immediately relevant and available in FHIR.   Note that these latest additions while targeting descriptions are a concept filter, so display options (language etc) will affect the output of those concepts.   How about the filter parameter though, especially since ECL wo (ld allow multiple filters in multiple/different languages.

• Michael Lawley Suggested ticket: Parent and Child properties to (optionally?) support the Coding type.

Daniel Karlsson

Peter G. Williams

API for FHIR Resource to SNOMED Expression

• Daniel Karlsson Thought there might be some documentation from CIMI on this. Also notes from DMarkwell about constructor bindings.
• Peter G. Williams Pull these notes into confluence - can we mention it in the IG?

Peter G. Williams

Problems when dependencies do not align. Multiple code system resources represent multiple editions / versions.

ML: See code parameter to code system search. Should return code systems (ie versions) where that code is defined. International concepts would appear in every edition known to the server.

eg /CodeSystem?system=htp://snomed.info/sct&code=12345678&_elements=version

• Peter G. Williams Ticket implementing this lookup. Note that this could be implemented more generally for lookups of http://snomed.info/id/<SCTID> where the SCTID exists in an extension. Done - see STORM-262.

Peter G. Williams

CodeSystem "class vs instance" in url parameter between CodeSystem and ValueSet operations.

CodeSystem is understood.

In Valueset, url is the ValueSet url for example url = http://snomed.info/sct?fhir_vs= allows for the version URI to be used as stated in https://build.fhir.org/snomedct.html The base URL is either http://snomed.info/sct , or the URI for the edition version, in the format specified by SNOMED International in the SNOMED CT URI Specification.

The ValueSet version valueSetVersion is just some string identifier eg a timestamp or 0.1.0

Rob Hausam

What properties are returned?

Discussion: Both Ontoserver and Snowstorm are returning EffectiveTime which is not listed here (unlike other SNOMED specifics): https://build.fhir.org/snomedct.html

• Peter Jordan to raise a Jira ticket to ask for this to be returned - completed https://jira.hl7.org/browse/FHIR-26555

Point of interest: Grahame's server returns a copyright property.

Update 7 April - Question about whether this is required / desirable?

Michael Lawley

Terminology Capabilities: Default SNOMED Edition for a Server. Suggestion to invite Graham for a wider discussion. Resource is still at maturity 0.

11 August The resource is based on instances of code systems. Difficult to make statements about code systems generally, or specific SNOMED editions, etc. Will start a Zulip discussion on this. Michael Lawley Then potentially invite Grahame for a future discussion?

25 August It has been agreed that this resource will now have maturity level 1

See https://chat.fhir.org/#narrow/stream/179202-terminology/topic/tx.2Efhir.2Eorg.20New.20parameters.20for.20.24expand.20.26.20.24validate-code

8 Sept 20 Is there a Jira ticket ?   Rob says Grahame implemented this.

12 Jan:  RH update made to GG Server.   Documentation (assuming required) still outstanding.

Michael Lawley

Use case for fall back lookup when server does not know the answer to any particular question eg a façade server which has knowledge of all services it could potentially delegate to.

Aug 25: New capabilities in HAPI to allow delegation to an external terminology server.