2022 Early Visibility Release Notifications

MRCM Changes for July 2022 Release

Details for forthcoming changes can be seen here

MRCM Cardinality Changes for July 2022 Release

All historical content issues where two or more finding sites were included in a single role group have been resolved in the International release as part of the QI project.

There are two MRCM rules for finding site to accommodate the historical content. One MRCM is applicable to all content, it allows more than one finding site in a role group. The other MRCM is only applicable for 'All new precoordinated SNOMED CT content'.

The existing MRCM rules will be updated to only allow at most one finding site in a role group from the July 2022 release.

This early visibility notice is intended to provide additional time for content updates in national extensions. 

MRCM Change for September 2022 Release

Extend the range 370135005 |Pathological process (attribute)| to include < < 1495041000004108 |Proliferation of neoplasm (qualifier value)|

Inactivation of 272426002|Specific site descriptor (qualifier value)| and Subtypes

Approximately 101 concepts.

272426002|Specific site descriptor (qualifier value)| and subtypes contain a set of concepts that are mainly represented in the body structure hierarchy.  Concepts such as 264010009|Gastric (qualifier value)| represent the adjectival form of the body structure. Some of these concepts duplicate descriptions for new concepts that are required for the drug maintenance project.

272426002|Specific site descriptor (qualifier value)| and subtypes will be inactivated with inactivation reason ‘non conformance to editorial policy’ and association target ‘alternative’ with a target concept that is a subtype of 123037004|Body structure (body structure)| where appropriate.

For further information please see briefing note here.

Measurement Findings - December 2022 Release
Numerous changes to the measurement findings content are planned for several releases. The first set of changes will involve the reference range content:

1) Concepts which include 'high,' 'elevated,' 'raised,' 'low,' 'decreased,' normal,' etc. in the FSN will have their FSN updated to 'above reference range,' 'below reference range,' or 'within reference range.' 
2) Concepts which include 'abnormal' in the FSN will have their FSN updated to include 'outside reference range.' The modeling of these concepts will include 394844007 |Outside reference range (qualifier value)| as the value for Has interpretation (attribute).
3) Concepts representing a finding about a therapeutic range will be updated to include 'above therapeutic range,' 'below therapeutic range,' or 'within reference range' in the FSN. The Has interpretation (attribute) value of these concepts is  281303003 |Above therapeutic range (qualifier value)|, 281306006 |Below therapeutic range (qualifier value)| or 281304009 |Within therapeutic range (qualifier value)| accordingly. 
4) Concepts which include "borderline" in the FSN are being inactivated as ambiguous.

See the briefing note "20221103 BN Reference range measurement findings.pdf" (https://confluence.ihtsdotools.org/x/5OB4C) for more information.

These changes are planned for the December 2022 release. 

Additional changes to measurement findings concepts will occur over several releases. Upcoming changes for each future release will be posted here as the work progresses.

Planned Changes to Findings/Disorders of Gravid Uterus

The scope of changes to findings/disorders (over 100 concepts) modelled by the gravid uterus.

These concepts can be identified by the ECL << 404684003 |Clinical finding (finding)| : * = (9258009 |Gravid uterus structure (body structure)| or 362253003 |Entire gravid uterus (body structure)|)

These concepts will be remodeled by using finding site of |Uterine structure| and occurrence in |Maternal pregnancy period (qualifier value)| or more specific |Maternal antepartum period|. The updated model pattern will address the missing subsumptions of conditions modeled by parts of the uterus during pregnancy.  

Update Hierarchy 17322007 |Disease caused by parasite (disorder)|

370135005 |Pathological process (attribute)| with value 442614005 |Parasitic process (qualifier value) will be added where it is missing to descendants of 17322007 |Disease caused by parasite (disorder)| and any relevant clinical findings concepts.

Update for 363101005 |Drug withdrawal (disorder)| 

Review of the modeling and terming of 363101005 |Drug withdrawal (disorder)| and child concepts to reflect the associated meaning.

See the briefing note submitted to the Member Forum for details. 

Description Update for 191816009 |Drug dependence (disorder)| and Associated Concepts

The terming for concepts including "drug dependence" will be updated to reflect "substance dependence": the word “drug” in the existing terms is ambiguous and does not have a universal definition or a consistent international representation; it can refer to illicit drugs and/or prescription medications. Additionally, dependence can occur with the use of substances such as ethanol, which are not considered an illicit drug or a prescription medication.

Poisoning Caused by Organism

As part of the Quality Initiative project, the modelling for concepts of type poisoning caused by organism, including the following sub-hierarchies, will be reviewed and updated where applicable:

• 275390005 |Toxic effect of plant (disorder)|
• 44400004 |Toxic effect of venom (disorder)|
• 75258004 |Food poisoning (disorder)|
• 26033009 |Toxic effect of mycotoxin (disorder)|
• 1149327007 |Poisoning caused by Clostridium botulinum toxin (disorder)|

Inactivation of "X of person (person)" concepts

Based on a consensus decision by the SNOMED International Editorial Advisory Group, concepts of the form "X of subject (person)" will be inactivated and concepts using these as the value for SUBJECT RELATIONSHIP CONTEXT relationships will be replaced by analogous "X (person)" concepts.  

Inactivation and Replacement of 76981001|Discogram (procedure)| and Subtypes

76981001|Discogram (procedure)| and subtypes will be inactivated and replaced with concepts that explicitly state the use of contrast and injection into the intervertebral disc.  

The replacement concepts will follow the pattern 'Discography with injection of contrast into intervertebral disc'.

Inactivation of Walker Concepts

Concepts 705404007 |Walker/Walking frame (physical object)| and 705406009 |Walker (physical object)| will be inactivated with reason ambiguous, as the term 'walker' is being used to represent both walking frames and wheeled walkers (rollators).

A new concept Wheeled walker (physical object)| will be created with a text definition added to both that concept and also 266731002 |Walking frame (physical object)|.

Concepts that were previously subtypes of 705406009 |Walker (physical object)| will be inactivated with an inactivation replacement value to a new explicit wheeled version of those concepts and where applicable a pre-existing subtype of 266731002 |Walking frame (physical object)| in addition.

Primary and Metastatic Project - QI Description Updates

Work is ongoing as part of this project to address the incorporation into SNOMED CT neoplastic morphologies and disorders of the ICD classification rule that if a malignancy does not specify primary then this can be assumed.

A result of this assumption, primary malignancy disorders have had non-primary descriptions added as synonyms and also vice versa  (primary malignancy synonyms have been added to malignant neoplasm disorders). For the December 2022 release, these descriptions will be inactivated and new disorder concepts created where necessary.

Primary and Metastatic Project - Inactivation of Neoplastic Morphologies Stated as 'Primary' in the FSN

86049000 |Malignant neoplasm, primary (morphologic abnormality)| is to be inactivated and replaced with a new concept 1240414004 |Malignant neoplasm (morphologic abnormality)|. Similarly, neoplastic morphologies with 'primary' in their FSN will be inactivated.
Concepts scheduled for inactivation are:

367651003 |Malignant neoplasm of primary, secondary, or uncertain origin (morphologic abnormality)|

1187469002 |Squamous cell carcinoma of primary, secondary, or uncertain origin (morphologic abnormality)|

86049000 |Malignant neoplasm, primary (morphologic abnormality)| 

450594004 |Primary malignant adenomatous neoplasm (morphologic abnormality)|

252988009 |Malignant squamous tumor, primary (morphologic abnormality)|

400156001 |Malignant blood vessel neoplasm, primary (morphologic abnormality)|

719952009 |Primary sarcoma (morphologic abnormality)|

734095001 |Primary solid type intraosseous squamous cell carcinoma (morphologic abnormality)|

733913003 |Primary intraosseous squamous cell carcinoma derived from keratocystic odontogenic neoplasm (morphologic abnormality)|

278411006 |Primary intra-osseous carcinoma (morphologic abnormality)|

733912008 |Primary intraosseous squamous cell carcinoma derived from odontogenic cyst (morphologic abnormality)|

720346009 |Primary seminoma (morphologic abnormality)|

133850008 |Primary synovial chondromatosis (morphologic abnormality)|

These inactivations will impact around 2,400 concepts in the disorder hierarchy, and approximately 1200 observable entity concepts (2,000 disorders will be impacted following inactivation of 86049000 |Malignant neoplasm, primary (morphologic abnormality)|) and all concepts will be restructured as outlined in the circulated Briefing Notes.

The reason for inactivation is Nonconformance to Editorial Policy, and the replacement inactivation target for 86049000 |Malignant neoplasm, primary (morphologic abnormality)| and 367651003 |Malignant neoplasm of primary, secondary, or uncertain origin (morphologic abnormality)| will be new concept 1240414004 |Malignant neoplasm (morphologic abnormality)|.

There may be some inconsistencies as this large project develops, including certain adenocarcinoma disorders that are modeled with 1186968006 |Malignant adenomatous neoplasm (morphologic abnormality)| in order to ensure that there is no change to the hierarchical subsumption and the assignment of subtypes by the classifier. As the project develops, and in particular the pathology group give their expert input to update the neoplastic morphologies in SNOMED CT, these inconsistencies will be addressed.

Quality Initiative: Inactivation of Disjunctive Concepts in 363346000 |Malignant neoplastic disease (disorder)| Hierarchy

Descendants of 363346000 |Malignant neoplastic disease (disorder)| that include a disjunctive "and/or" in the FSN will be inactivated.

• 15 concepts containing " extranodal AND/OR solid organ site" e.g., Malignant lymphoma of extranodal AND/OR solid organ site (disorder) will be inactivated with a historical association target to the parent concept (or the relevant concept without 'extranodal AND/OR solid organ site'). The origin of these concepts has been traced to ICD-9 grouper codes.
• 14 malignant neoplastic concepts containing 'head, face AND/OR neck' Example: 93533001 |Hodgkin's granuloma of lymph nodes of head, face AND/OR neck (disorder)|  will be inactivated and 3 new replacement concepts created for the 3 sites of head, neck and head and neck. Also, the inactivation of 1 benign concept: 109920008 |Benign neoplasm of peripheral nerve of head, face AND/OR neck (disorder)| and creation of 3 new replacements.
• 15 concepts containing 'lymph nodes of axilla AND/OR upper limb' e.g., 93185008 |Malignant histiocytosis of lymph nodes of axilla AND/OR upper limb (disorder)| will be inactivated and new replacement concepts created for 'lymph nodes of upper limb'. Where these concepts had primitive subtypes for ' lymph nodes of axilla and upper limb' (11 concepts) these concepts will also be inactivated.
• 12 malignant neoplastic concepts containing 'lymph nodes of inguinal region AND/OR lower limb' Example: 93516008 |Hodgkin's disease, nodular sclerosis of lymph nodes of inguinal region AND/OR lower limb (disorder)| will be inactivated and new replacement concepts created for 'lymph nodes of lower limb'. This work includes inactivation of their primitive subtypes for 'lymph nodes of inguinal region and lower limb' (12 concepts). Also, inactivation of 188044004 |Malignant melanoma of scalp and/or neck (disorder)| and 3 new replacements created.

Primary and Metastatic Project - Addition of 415 New Primary Malignancy Disorder Subtypes

"Agnostic” malignancy disorders (i.e. not specified as primary or metastatic) that can not be correctly modeled using the current “agnostic” morphologic abnormalities that are subtypes of 86049000 |Malignant neoplasm, primary (morphologic abnormality)|, precisely because they are subtypes of a primary malignant neoplasm morphology parent will be made subtypes of a non-primary parent following the inactivations flagged above.

The majority of the changes will be by inactivation of 86049000 |Malignant neoplasm, primary (morphologic abnormality)| and replacement with Malignant neoplasm (morphologic abnormality) with 'primary' being defined in disorders and observable entities by 370135005 |Pathological process (attribute)| (704321009|Characterizes (attribute)| for observable entities) and target value 1234914003 |Malignant proliferation of primary neoplasm (qualifier value)|. 

Approximately 415 current agnostic malignancy disorders inferring a primary designation through their hierarchy parent, will have a new primary malignancy concept added as a subtype that will be available for use in implementations as a subtype of 372087000 |Primary malignant neoplasm (disorder)|.

Primary and Metastatic Project - Inactivation of Metastatic Disorder Content

7 concepts termed ‘Malignant tumor involving an organ by separate metastasis from X’ and 20 concepts termed  ‘Metastasis from malignant neoplasm of X’ are to be inactivated.

Metastasis  ‘involving an organ’ and metastasis concepts that are unspecified as to site of the metastatic neoplasm are not clinically useful as in most cases there will already be a record of the site of the primary malignant tumor and the actual site of the metastasis will also be recorded as a separate concept. 

Going forward, metastatic malignant neoplasm ‘to X site’ and ‘from X site’ will not be precoordinated in one concept but recorded separately as 2 concepts. 

Description Updates Haemophilus influenzae types “a” to “f"

Terming for descriptions containing Haemophilus influenzae types “a” to “f” are being updated such that concepts in other hierarchies are consistent with the terming of associated concepts in the Organism hierarchy, which is the source of truth as specified in the general naming guidelines.

Inactivation of Metadata Concepts

The following metadata concepts will be inactivated for the July 2022 Release:

• 741068007 |SNOMED CT to European Directorate for the Quality of Medicines & HealthCare simple map reference set (foundation metadata concept)|
• 735233007 |European Directorate for the Quality of Medicines & HealthCare simple map reference set module (core metadata concept)|
• 762959004 |European Directorate for the Quality of Medicines & HealthCare to SNOMED CT simple map reference set (foundation metadata concept)|
• 733900009 |SNOMED CT to Unified Code for Units of Measure simple map reference set (foundation metadata concept)|
• 741814003 |SNOMED CT to Unified Code for Units of Measure simple map reference set module (core metadata concept)|

Dupuytren Content Changes

The Dupuytren content will be remodeled. The following concepts will be inactivated for the September 2022 Release:

• 410812005 |Dupuytren's disease (disorder)| 
• 203052004 |Dupuytren's disease of palm and finger (disorder)| 
• 203046000 |Dupuytren's disease of palm, nodules with no contracture (disorder)|
• 203047009 |Dupuytren's disease of palm, with contracture (disorder)|
• 203050007 |Dupuytren's disease of finger(s), nodules with no contracture (disorder)|
• 203053009 |Dupuytren's disease of palm and finger(s), nodules with no contracture (disorder)|
• 203051006 |Dupuytren's disease of finger, with contracture (disorder)|
• 203054003 |Dupuytren's disease of palm and finger, with contracture (disorder)|
• 16216861000119107 |Dupuytren's contracture (morphologic abnormality)|"

Remodeling of Descendants of 1202017008 |Surgical procedure using flap (procedure)|

As part of the Quality Initiative project to improve the 1202017008 |Surgical procedure using flap (procedure)| subhierarchy, a new more comprehensive template is under development, and as a result approximately 50 complex flap procedures have subsequently newly been included in the QI project and will be remodeled for the June 2022 release.
This will involve defining some existing complex flap procedures for congenital conditions. Whilst every effort will be made to align with the template and sufficiently define relevant concepts (for example, by creation of new concepts for 1230024004 |Congenital deformity of lower limb (disorder)| and new 1230067007 |Correction of congenital anomaly (procedure)|), it is recognized that the area would benefit from the input of domain experts in the future.

Cancer Synoptic Reporting - Protein Substances

Around 40 new protein concepts will be added to the substance hierarchy which are needed to model the immunohistochemistry neoplasm observables. In addition, around 10-15 existing protein substance concepts will be remodeled to align their terming with the authoritative source for protein nomenclature and to assign parents and other relationships based on the current guidelines for the substance hierarchy.

Guidelines for protein substance concepts will be incorporated into the Editorial Guide following completion of this work.

These substance concepts will be added starting with the May 2022 release and may continue for the June and/or July 2022 releases.

Inactivation of 360215002 |Pharmaceutical excipient (substance)| Hierarchy

The 360215002 |Pharmaceutical excipient (substance)| hierarchy will be inactivated with descendant grouper concepts (e.g. 418403001 |Drug preservative (substance)|, 412307009 |Drug vehicle (substance)|) being inactivated as duplicates of existing or new concepts in the 43747001 |Drug excipient (product)| hierarchy.

Concepts representing discrete substances will remain in the Substance hierarchy. One concept, 438784000 |Adverse reaction caused by pharmaceutical excipient (disorder)|, will be remodeled using the corresponding product concept, with classification results consistent with the pattern for vaccine products.

Change for Groupers in Substance Hierarchy - Analyte

Groupers in the Substance hierarchy that refer to analyte (e.g. 259988005 |Transplantation analyte (substance)|, 312273006 |Microbiology analyte (substance)|) will be inactivated with reason Meaning unknown; no potential replacement concept will be provided.

Dose Form-Related Changes - June 2022 Release

• Dispersion - New basic dose form concept, 1230183009 |Dispersion (basic dose form)| with text definition "A liquid dose form consisting of semi-solid, gaseous, or small (less than 1 micron) liquid particles dispersed in a suitable vehicle.”, has been added. Associated pharmaceutical dose form (PDF) concepts have also been added; the PDFs can be used in creation of clinical drug (CD) concepts in the International Release moving forward but no changes to existing concepts will be made unless specifically requested via CRS.
• Gingival - Existing intended site concept 738943003 |Gingival (intended site)| has been updated to be a subtype of 738982001 |Oromucosal (intended site)|.
• Stick - Has administration method will be updated to 738993004 |Insert (administration method)| for existing concepts 385246006 |Conventional release urethral stick (dose form)|, 385148001 |Conventional release otic stick (dose form)|, and 385162008 |Conventional release nasal stick (dose form)|.

• Periodontal - New basic dose form concept, 1230218002 |Periodontal (intended site)| with text definition "An intended site for administration of a dose form that is the tissue around a tooth.”, has been added for June 2022 release. Associated pharmaceutical dose form (PDF) concepts have also been added; the PDFs can be used in creation of clinical drug (CD) concepts in the International Release moving forward but no changes to existing concepts will be made unless specifically requested via CRS.

• Lozenge - New basic dose form concepts, 1230206006 |Compressed lozenge (basic dose form)| (with text definition = A type of solid dose form prepared by compression intended to dissolve or disintegrate slowly in the mouth while being sucked.) and 1230217007 |Molded lozenge (basic dose form)| (with text definition = A type of solid dose form prepared by molding and intended to dissolve or disintegrate slowly in the mouth while being sucked.) have been added for the June 2022 release as descendants of existing basic dose form 385087003 |Lozenge (basic dose form)| (with text definition = A type of solid dose form intended to dissolve or disintegrate slowly in the mouth while being sucked.). Associated pharmaceutical dose form (PDF) concepts have also been added; the PDFs will not be used for modeling concepts in the International Release but will be available for use in national extensions. No related changes to existing clinical drug concepts is planned.

• Elixir - Existing basic dose form 738997003 |Elixir (basic dose form)| will be made a child of 739006009 |Solution (basic dose form)|; no changes to existing Clinical drug concepts will be made unless specifically requested via CRS.

• Emulsion - Text definition for existing concept 738998008 |Emulsion (basic dose form)| will be updated to "A liquid dose form consisting of a system of non-miscible liquids where droplets of the discrete phase are distributed in the continuous phase (usually oily in aqueous but can also be aqueous in oily)."; no changes to existing Clinical drug concepts will be made unless specifically requested via CRS.

• Gas - New basic dose form concepts 1230326008 |Compressed gas (basic dose form)| with text definition "A gas supplied under pressure which is entirely gaseous at - 50 °C.", 1230327004 |Cryogenic gas (basic dose form)| with text definition ", and 1230328009 |Liquified gas (basic dose form)| with text definition "A gas supplied under pressure, which is partially liquid (gas over liquid) at -50 °C.” will be added. Associated pharmaceutical dose form (PDF) concepts will also be added; the PDFs will not be used for modeling concepts in the International Release but will be available for use in national extensions. No related changes to existing clinical drug concepts is planned.

• Syrup - Existing basic dose form 739009002 |Syrup (basic dose form)| will be made a child of 739006009 |Solution (basic dose form)|; no changes to existing Clinical drug concepts will be made unless specifically requested via CRS.

• Granules - Has dose form transformation will be updated to 764779004 |Disperse or dissolve (transformation)| for 385044001 |Conventional release effervescent oral granules (dose form)|. Existing basic dose form concept 761897002 |Effervescent granules (basic dose form)| will be updated to be a subtype of 385043007 |Granules (basic dose form)|.

• Tablet - Existing basic dose form concept 761877007 |Effervescent tablet (basic dose form)| will be updated to be a subtype of 385055001 |Tablet (basic dose form)|.

• Powder - Existing basic dose form concept 762948008 |Effervescent powder (basic dose form)| will be updated to be a subtype of 739005008 |Powder (basic dose form)|.
• Cement - New basic dose form concept, 1231321009 |Cement (basic dose form)| with text definition "A semi-solid dose form that sets and hardens after application and adheres to other materials to bind or seal them together.”, will be added for June 2022 release. Associated pharmaceutical dose form (PDF) concepts will also be added; the PDFs can be used in creation of clinical drug (CD) concepts in the International Release moving forward but no changes to existing concepts will be made unless specifically requested via CRS.
• Collodion - Text definition for existing basic dose form concept 385115001 |Collodion (basic dose form)| will be updated to "A liquid dose form consisting of active substance(s) in a mixture of pyroxylin or similar in ether and ethanol.”
• System - New basic dose form concept, 1231568003 |System (basic dose form)|| with text definition "A solid dose form consisting of one or more components which together are used to deliver active substance(s) with a prolonged-release mechanism.”, will be added for June 2022 release. Associated pharmaceutical dose form (PDF) concepts will also be added or updated accordingly; the PDFs can be used in creation of clinical drug (CD) concepts in the International Release moving forward but no changes to existing concepts will be made unless specifically requested via CRS.

• Dialysis - New administration method concept, 1231460007 |Dialysis (administration method)| with text definition “A method of administration of a dose form through a dialysis system.” and new intended site concept, 1231459002 |Extracorporeal (intended site)| with text definition “An intended site or administration of a dose form that is initially outside of the body and is subsequently returned to the body.” will be added. Associated pharmaceutical dose form (PDF) concepts will also be added; the PDFs can be used in creation of concepts in the International Release. 

• Vaporize - New dose form transformation concept, 1231537002 |Vaporize (transformation)|| with text definition "A dose form transformation that occurs immediately before administration, often when the dose form is subjected to heat either directly or by addition to hot water to create the vapor.”, will be added for June 2022 release. Associated pharmaceutical dose form (PDF) concepts will also be added or updated accordingly; the PDFs can be used in creation of clinical drug (CD) concepts in the International Release moving forward but no changes to existing concepts will be made unless specifically requested via CRS.
• Pure liquid - New basic dose form concept, 1231710002 |Pure liquid (basic dose form)| with text definition "A liquid dose form consisting of a pure substance in its liquid state.”, will be added for June 2022 release. Associated pharmaceutical dose form (PDF) concepts will also be added; the PDFs will not be used for modeling concepts in the International Release but will be available for use in national extensions. No related changes to existing clinical drug concepts is planned.
• Lacquer - New basic dose form concept, 1230223002 |Lacquer (basic dose form)| with text definition "A liquid dose form where active substance(s) are suspended or dissolved in a volatile liquid which evaporate to leave them in a hard coating.”, has been added. Associated pharmaceutical dose form (PDF) concepts have also been added.

Dose Form-Related Changes - July 2022 Release

• Intraocular - Existing intended site concept 762070008 |Intraocular (intended site)| will be remodeled as a descendant of 738952007 |Ocular (intended site)|. Associated pharmaceutical dose form (PDF) and clinical drug (CD) concepts will be updated accordingly.
• Impregnated material - new basic dose form 1231762000 |Impregnated material (basic dose form)| with text definition "A solid dose form consisting of porous or absorbent material onto or into which active substance(s) are taken up or taken in, for subsequent release after administration.” will be added for the July 2022 release. Associated pharmaceutical dose form (PDF) concepts will also be added; the PDFs can be used in creation of clinical drug (CD) concepts in the International Release moving forward but no changes to existing concepts will be made unless specifically requested via CRS.
• Mouthwash - Has administration method will be updated to 785900008 |Rinse or wash (administration method)| for mouthwash pharmaceutical dose forms.
• Mix - New dose form transformation concept, 764462006 |Mix (transformation)| with text definition "Transformation of a dose form into a different dose form by combining it together with a component item." will be added for the 2022-July release. Associated pharmaceutical dose form (PDF) concepts will be added or updated accordingly. No related changes to existing clinical drug (CD) concepts is planned.
• Intestinal - New intended site concept, 1231834000 |Intestinal (intended site)| with text definition "An intended site for a dose form that is for administration directly to the intestine (duodenum through the colon) using an appropriate device.”, has been added for the 2022-July release. Associated pharmaceutical dose form (PDF) concepts have also been added; the PDFs can be used in creation of clinical drug (CD) concepts in the International Release moving forward but no changes to existing concepts will be made unless specifically requested via CRS.