Date 20:00 UTC on Tuesday 16 May 2023 - 60 minutes.
- FHIR Terminology Services and Resources
- FHIR Profiles & Terminology Binding
Passcode (not required when using link above): 32075
Chat: public-snomedintl.slack.com # snomed-hl7-fhir (ask for invite!)
|Notes & Actions
|Welcome and introductions
Recording, notes & attendance.
Check questions in Zulip and SNOMED International #snomed-hl7-fhir
NHS Scotland Connectathon June 12 - 13 (Clayton Hotel, Glasgow Registration)
HL7 September (
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
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.
|Post 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 188.8.131.52 Complex and Extended Map from SNOMED CT Reference Sets
CC Kai Kewley
|Allergy IG Demonstrator
|Alejandro Lopez Osornio Marie-Alexandra Lambot
To be shared at the next Allergies CRG (late May)
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.
Testing Frameworks. Background: IG Tooling using servers other than tx.fhir.org 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.
|Working with OpenEHR and FHIR
|Agenda for April Business Meeting
|Visualisation of FHIR resources
MAL working on visualisation of FHIR resources - entity relationship diagram.
2023-03-21 AP Shared:
|European Terminology Services Collaboration
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).
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.
|Allergy Guide work
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.
|Looking 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
HL7 CDS Hooks appears to have 2 specification releases. Is version 1 the main release in use.
https://cds-hooks.org/ (Clinical Decision Support workgroup own this - Bryn Rhodes)
CQL may have more traction.
2023-03-07: Demonstrator developed https://github.com/IHTSDO/snomed-fhir-cds-service
|Clinical Impression Questions
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
Contacting HL7 Working Groups (Use co-chairs as points of contact)
2023-02-07 Looking for diagrams showing relationships between resources, in particular workflows.
|Allergy 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 http://build.fhir.org/encounter.html which has a 0..* Reason which takes a http://build.fhir.org/valueset-encounter-reason.html
RH "Presenting Complaint in the patient's own words" DK before there is an Encounter, there is a Service Request http://build.fhir.org/servicerequest.html (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.
|R5 changes suggested around specifying language using BCP-47
See Tuesday meeting item #6
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
2022-08-31 ML CSIRO attempting to get R5 compliant Ontoserver ready in time for HL7 Connectathon.
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 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. http://hl7.org/fhir/5.0.0-draft-final/conceptmap.html
MRCM in FHIR
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 https://jira.hl7.org/browse/FHIR-39266 )
|Support 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 https://github.com/IHTSDO/snowstorm/releases/tag/8.0.0-beta (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.
|Upcoming R5 changes
2022-8-23 RH R5 Deadline now September 4
2022-11-1 RB: Publication is expected after February 2023.
2023-02-21 PJ Reconcilliation to be completed by next week.
|Topics 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.
|Publishing 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 https://www.snomed.org/snomed-ct/Other-SNOMED-products/sub-ontology-international-patient-summary 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:
|Language Reference Sets in FHIR
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.
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
|SNOMED FHIR Implementation Guide
IG Documentation: http://build.fhir.org/ig/FHIR/ig-guidance/index.html
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
Example markdown page that could be copied and modified: https://github.com/IHTSDO/snomed-ig/blob/master/input/pagecontent/sct_specific_behaviours.md
Work to be presented for 13 December (payment will be made in Glorytm)
Peter & Kai - ECL in FHIR (Update: Used https://hackmd.io/ 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
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 : https://build.fhir.org/ig/HL7/US-Core/terminology.html & http://build.fhir.org/ig/HL7/fhir-ips/ ( also http://build.fhir.org/ig/HL7/fhir-ips/terminology.html )
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 - https://build.fhir.org/ig/danka74/snomed-ig/branches/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 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)
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.
|Long 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 https://www.hl7.org/fhir/r4/codesystem-snomedct.html 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 https://terminology.hl7.org/ 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
|IPS / 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 https://gps.snomed.org/ 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.
|Snowstorm post-coordination updates
2023-03-07 Post-coordination is added to the FHIR API and more (include $lookup, $validateCode, $subsumes, etc.). Will be published together with the Post-coordination guide.
|Any Other Business
Potential Items for Discussion
|Notes & Actions
|SNOMED Family of Languages
Impact of proposed changes (eg text searching in ECL) on FHIR. Questions around which language reference sets to use when there are multiple, especially partial/overriding context (referred to MAG for discussion)
8 Sept The FHIR specification does not specify a particular version of ECL, so we assume the latest. Any enhancements added to ECL will be immediately relevant and available in FHIR. Note that these latest additions while targeting descriptions are a concept filter, so display options (language etc) will affect the output of those concepts. How about the filter parameter though, especially since ECL wo (ld allow multiple filters in multiple/different languages.
|Specify CodeSystem in FSH
|FSH apparently has no way of specifying the version of a CodeSystem. Daniel checking the ANTLR spec. https://github.com/FHIR/sushi/issues/473
|API for FHIR Resource ↔ Post coordinated expression mapping
|Looking up an SCTID in an unknown module
Problems when dependencies do not align. Multiple code system resources represent multiple editions / versions.
ML: See code parameter to code system search. Should return code systems (ie versions) where that code is defined. International concepts would appear in every edition known to the server.
|See Discussion on Global Patient Set (GPS)
|$lookup operation - properties returned
Using http://ontoserver.csiro.au/vstool/ I noticed that both Ontoserver and SnowStorm return a SNOMED CT $lookup property for effectiveTime, which I don't see listed, as one of the SNOMED CT properties in the FHIR R4 specification at http://hl7.org/fhir/snomedct.html. Should we create a Jira TIcket to add this?
Completed - https://jira.hl7.org/browse/FHIR-26555
|Use of url parameter
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
|ECL in the Valueset Expression Extension
Check whether SNOMED ECL is (or should be) registered as a MIME type (as per RFC 4289/BCP 13), or alternatively added to the expression-language code system and value set, for use in the valueset-expression extension used with the ValueSet resource.
For example, HL7 have registered application/json+fhir
This is useful for a ValueSet extension which allows any language to be used to define the selection criteria for an intensional definition using a MIME type. This group has no current reason to use that extension given the existing core specification support for implicit ValueSet definition and the support within the compose element.
RDF community may have an interest.
Update 2 June RH: Existing small valueset extended in BCP13 (existing known codes could be published as a CodeFragment). Vocab Working Group discussion ongoing.
|Behaviour on Lookup
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
Point of interest: Grahame's server returns a copyright property.
Update 7 April - Question about whether this is required / desirable?
|Notes & Actions
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
|New parameters proposed for streamlining operation of expand and validate 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.
|FHIR Server Federation
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.