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10:00 UTC Wednesday 5 June 2024



  • FHIR Terminology Services and Resources
  • FHIR Profiles & Terminology Binding

Meeting Details


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Zulip Chat:

Discussion items



OwnerNotes & Actions
1Welcome and introductions2

Recording, notes & attendance.

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

2Previous Meetings2
3Other Meetings10

Recent Events:

SI Europe 22 - 23 May (Pre-Meeting on 21 for Hospitals on FHIR) See

HL7 May 18 - 24 2024 Dallas Working Group Meeting and HL7 FHIR Connectathon

Future Events:

** Should we skip the Tuesday call during Dev Days? **

FHIR Dev Days :  June 10-13, 2024 Minneapolis -

CDA & FHIR Translation Meetings: Jay Lyle Going well, there is an implementation guide and the group is doin connecthatons. May in Dallas and Minneapolis.

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 

4Resources for Allergy Intolerance / Adverse Events
5IPS ValueSet Question raised15"Resolve SNOMED Version challenge with value set"

Canada specify version details for each filter in a valueset specification, which then trips validation when the version being expanded against does not match.

DK: If you use extension content then you need to specify the version to know where the concept exists.  Although the lookup will work across multiple versions.   ML:  Note that compose/include/filter descendent of that specifies the core edition, and so it would not include Canadian concepts.   Also, a version - if included - should include the effective time.

Discussion about sending both the local code plus the IPS / International Code using a Codeable Concept (in that case the version element of each code would indicate which one is International.  Or a test could be made for subsumption) which could be determined using (ML supplied) ECL:

!<< (>> my_local_code AND ^ IPS_refset)

See also and be aware of new ECL top and bottom operators which could be used to simplify this.

Linda Bird 

Exposing the MRCM in FHIR

KK Exposing it directly would be difficult because we can return lists of concepts, but we cannot return a string eg ECL

ML Thought it could be exposed via the CodeSystem as another property - metadata about each domain's range.

LB Use case is driving an expression or ECL editor (KK Remember content type).   KK choice between (simple) server statement vs (more work) implicit expansions.


General Discussion

2024-06-05 - SNOMED on FHIR Meeting (TS & TB)


Misc Discussion

Internal discussion on languages in general and specifically latin words.  MAL suggested looking at which includes latin.  See Latin Terms - Discussion

Snowstorm-lite revisited (see 2024-01-09 - SNOMED on FHIR Meeting (TS & TB) )

URIs and Identifying Modules - "Edition identifier" - this is the full URI, not just that module. "Most dependant module" - yes but fails in the International Edition.  "Identifying Module". "Root module" - Not always the top/bottom of the hierarchy.

Discussion on adding / removing modules to / from packages.   Check on license conditions allowing for automatic promotion to ensure interoperability.

Discussion on expansion related to Query Specification Reference SetML Could we try to expand the referenced component id, ie look in this refset if no refset members are initially encountered?  MLO Canada is already doing this and they have pre-expanded simple reference sets.  KK Snowstorm does not use this reference set.   LB An extended version of this refset has been drafted which allows the substrate to be specified.  


New Slimline Agenda 


See discussion pages for links to archived discussion:  Discussions


Post Coordination

Moved in from "Potential Topics": 

API for FHIR Resource to SNOMED Expression

See also discussion on URIs for PCEs. 2024-03-05 - SNOMED on FHIR Meeting (TS & TB)


Additional information from ComplexMap $translate

ICD-10 Complex Map in ConceptMap$translate (see agenda item 18 2024-03-05 - SNOMED on FHIR Meeting (TS & TB) )

DK Suggests using match.product for each additional item with a URI for each column in refset as per 2.6 URIs for Properties

KK The R4 Products are flat and various ICD-10 rules are grouped.  Example here:$translate?code=421671002&system=


FHIR Resource cross field validation


Question:  Can we do cross field validation of FHIR resources, to restrict valueset available for one element dependent on the value entered in some other field.

DK Do this using "Invariants".  See  and (complex approach!)

ALO FHIR Questionnaires have more support for cross field rules.

LB - would specify this in the Implementation Guide with the specific rules.


ValueSets eg for procedures which recommend SNOMED CT codes that have been retired.

ML: ValueSets described via enumeration will need to be kept updated.  The party that specified the ValueSet is primarily responsible for maintenance.

RC: License requirements do imply that SNOMED CT versions should be kept up to date in systems. 


FHIR in the new SNOMED Implementation course

The new implementation course could focus on SNOMED + FHIR, and transformations between information models, using maybe the Allergy demonstrator as an example. Maybe adding consideration on adding LOINC concepts, like the allergy test using LOINC (Observation in FHIR).

Suggestions: add onset to reactions (date), and use problems already recorded for reactions manifestations, and vice-versa.

Helpful Introduction Videos:

Introduction to SNOMED with FHIR YouTube recordings of Dev Days Presentations:

14Round Table Updates20


See previous updates 2023-07-05 - SNOMED on FHIR Meeting (TS & TB)

Australia  - Sparked FHIR Accelerator Programme -

  • AU CDI – including binding to ValueSets
  • AU Core
  • eRequesting
  • Ontoserver now registered for use with HL7 IG Tooling allowing ECL-based ValueSets in IGs

Austria / Germany - Annotating clinical narratives.  GemText - annotated corpus (annotation using SNOMED CT) relations mapped to SNOMED patterns.   Looking for more support for mapping FHIR ValueSets to SNOMED concepts - particularly when involving negation, would like to collaborate on common solution.

Belgium  - National architecture level work being done, to consolidate regional structures.  Datasets for Allergies and Vaccinations,  Care Plan.  Now working on Medication Resources well in progress, Obs and Conditions followed by Procedures.

Canada  - 

Estonia  - Medication schema nearly complete

Europe - Laboratory Guide published.   Implementation Guide for prescription and dispensation.  Ongoing work for more constrained Lab for cross boarder sharing.    Czech Republic following this course.

France - 

Hong Kong  - 

India  - 

Netherlands  -  Looking for dissemination of patient friendly descriptions + longer explanations.   Using FHIR Supplement.  May look at converting more code systems to FHIR eg IDMP (see Rutt Lindström)

New Zealand -  Cancer control agency building FHIR / SNOMED platform for sharing cancer data (multiple domains) with query based FHIR Valuesets.  Interested in hearing about: standardizing language reference sets, access to MRCM (see item 20 "MRCM in FHIR" demo being progressed), Concept Maps - logic for dependsOn (see Concept Map in R5) & how to select ValueSets based on context,  Syndication (see  but this is not FHIR. FHIR uses more of an NPM approach), Query Specification (Query based reference sets their expansion).


Sweden - Swedish national FHIR profile / Swedish core work restarted, initially on Administration side but also alerting.  IG for Provider directory


Snomed International - internal work to reduce configuration using archive hierarchy with cached metadata.  Request for MLDS badges.

Spain  - 

United Kingdom - UK Core based on R4, developing IGs and Profiles.  Medicines, GP Connect Profile, National Terminology Service used for mappings and ECL expansions (looking to use for primary publication point).   Pathology team developed IGs, challenge moving from legacy arrangements.  OpenEHR being revisited.   Interested in SNOMED Extended maps in FHIR (see Concept Map in R5 ) and making it more automatically executable.

United States - US CDI draft of v5.  Cancer on FHIR - connectathon at HIMMS

15April 2024 Business Meeting General Discussion Topics 

FHIR for Terminology vs FHIR for Patient Records - eg for cohort identification.  See can try out on Also CSIRO Pathling server for analytics 

Navigational ValueSets - how can you express hierarchy and/or grouping in a ValueSet expansion?  Nested code can be used to show hierarchy (navigational concept could be represented as blank).  Question is more about how you initially input that structure such that it would take effect.  Note that valueset composition (valueset containing valuesets) is not sufficient because it does not infer any structure, only membership.   Note that in this context navigational groupers are not considered to be concepts - they don't have a CodeSystem identifier.   SH: users would prefer to search than to navigate their way through a hierarchy to the item they want.  "Picklists" can be considered distinct from ValueSets (adding priority and other properties).  ML Usage in questionnaires.   "The way to do this is in the expansion"  DK Solution also available using Concept map translate given  'source' context, what likely values would be selected in a subsequent field. RH See also ValueSet Concept Order Extension. PWI "Tagging" may be preferred as it allows for multiple dimensions to be represented at the same time ML and also avoids codes appearing multiple times if they belong to more than one group. SH Would like to see standard for wider sharing of resources like reusable UI elements, and avoid overloading FHIR (separation of concerns).  SS Much harder to add semantics to existing data, than it is to enforce the semantics at the point of data capture.

TODO Elicit use cases from Rutt Lindström 

Condition vs Observation - care plan based on symptom.

Other CodeSystems which reference SNOMED CT

16General discussion on work being done in EU


2023-09-19 ML CSCT now has official "Not for Profit" status as an entity.

17IG 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


  • Michael Lawley the scope has expanded, advancing on the implementation. The registry will document which terminology server meet requirements, it is a centralized resource, maintained by HL7. There is document that describes this. An implementation guide developer would use this information to choose a compatible terminology server as the backend of the IG valuesets. There is a test suite that servers can apply to demonstrate compatibility, Graeme will be the curator of the list, the submission process for a new server is under development.

2023-10-03 ML Ontoserver still a work in progress in this area.

2023-10-22 ML Ontoserver progressing to be trialed during NZ Connectathon in this context.

18Observables model
Michael Lawley 

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.

There was an inconsistent role grouping pattern in the observables, and the question was trying to find the reason for this. This is being evaluated.

Peter G. Williams There is a decision to move to the grouped pattern

Andrew Perry looking for opportunities to contribute to the observables and LOINC modeling decisions

2023-09-19 Update:  Direction of travel here suggests moving to have all attributes in a single role group, but preparatory hierarchy movements will be required first - Evaluation Procedures moving to Observables.  Discussion expected at October MAG meeting, followed by a briefing note if no major objections raised.   AP UK have concerns about problems caused with existing counterparts between the two subhierarchies.  UK did respond to RFC last week.

2023-10-03 SI responding to briefing note feedback (including encouragement from UK to engage as a matter of priority).  Discussion expected in both MAG and EAG at October Business Meetings. Two Schools of Thought:  LOINC style single observable hierarchy (order / result) vs. procedure + observable pairs for expressing ordering and results.

2023-10-22 AP <copy from 15:43>

19Post 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  

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 (clarified 2023-10-03)

  • Peter G. Williams Add to FHIR Agenda for April meeting and floating topic for MAG also.

2024-02-14 DK Enquired on status here.  KK has coded some support in R4 but uses comma delimited messaging.   ML Using extension to allow properties in R4 (fully available in R5).  See extension:

See example 1 and example 2 shows multiple groups matching.

Demos showing machine processing of ICD-10 rules:

Discussion on whether or not the Terminology Server should have responsibility for applying the values to the rules to fully identify the correct target of the $translate operation. DK would like to see choice for client to calculate the rules.

20Expand Alliance20

XpanDH - 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.

2023-10-03 ML News update on course proposals expected for November.  See

21Language 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.

22R5 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)

23Language 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



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 hereML 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 )

25SNOMED 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 (complete 2023-10-16)

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 )

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)).

2023-10-16 PWI Update:  We had a note to follow up on as these have mostly been inactivated and moved to the Veterinary Extension.   In following up, it was determind that this valueset is no longer present in the FHIR core as of R5.


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.

Michael Chu - let's discuss.

27Any Other Business

2023-10-03 ML working on registration of congenital abnormalities - is there a way to group disorders (eg as part of a syndrome), specifically in the Condition Resource to (See Condition Related Extension in R4 / )   See  also condition-dueto.  JC Syndrome is just a grouper name, it doesn't "cause" the manifestations as such.

2024-03-13 RC Querying on patient data using below / isa - how is that negotiated between a data server and a terminology server (or do they need to be one and the same?)

Potential Items for Discussion

OwnerNotes & 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.

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

This has now been implemented as text filters in ECL.   Archive discussion.

Specify CodeSystem in FSH
FSH apparently has no way of specifying the version of a CodeSystem. Daniel checking the ANTLR spec.
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.

eg /CodeSystem?system=htp://


See Discussion on Global Patient Set (GPS)
FHIR Shorthand


$lookup operation - properties returned

Using  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 Should we create a Jira TIcket to add this?

Completed -

Use of url parameter15

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 = allows for the version URI to be used as stated in The base URL is either , 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 Extension10

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 Lookup10

What properties are returned?

Discussion: Both Ontoserver and Snowstorm are returning EffectiveTime which is not listed here (unlike other SNOMED specifics):

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

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

Concluded Discussion

See also FHIR Terminology Services Discussions

OwnerNotes & Actions
Terminology Capabilities

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
Grahame Grieve


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 Federation10

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.

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