Date

10 January 2017

Location

GoToMeeting

Attendees and Observers

See agenda page. KCA joined during the ECE discussion.

Topics

Welcome, call to order, attendance, conflicts of interest, minutes

JCA welcomed everyone. No changes to the agenda. Attendance (see agenda). No Conflicts declared. Minutes approved. 

Guidelines surrounding use of numbers or roman numerals

GRE said he had been looking at examples and he was most comfortable with the last proposal, doing it as in the literature, because there was no consistency. He said they should go with the diversity, no way to standardize. On whether to represent the alternative number as a synonym, GRE said search engines would not expect to do the transformation, so if users might do it both ways, then the team would have to record both ways. If they are usually represented one way, there was no reason to write the synonym.

BGO said if there is no preference in common usage, then just choose one. JCA suggested using arabic if there is no preference in the literature. The AG members agreed.

As noted on the agenda, "Recommendation: use the most common use in the literature for the FSN. The alternative representation will be included as a synonym if also represented in the literature. If no preference, use the arabic representation."

Clinical genomics

Presentation by Ian Green (IGR). See powerpoint presentation linked to agenda. 

Discussion (27:30): 

PAM said from UK perspective this is quite important and there were strong political imperatives involved, so fast action was needed so that people would not come up with their own, independent solutions. Not mentioned was how tests - LOINC - would interact, which was key due to the IHTSDO/LOINC agreement.

JCA said he realized there were some possible problems with the LOINC agreement but SNOMED International and LOINC would be meeting with soon to discuss the agreement. He said another big topic not mentioned was how to reference external terminologies as values for SNOMED, and whether that was possible or even feasible in the existing environment. GRE suggested looking at linkage tables, which would have to be referenced but he was not sure whether they would be defining or not. He said the strategy and the role SNOMED would play was key. It was a nice start to define what SNOMED CT's role and then could try to align with that.

JCA said it would be a continuing topic on the AG's agenda as the organization tried to take the strategy and realize it as tactical objectives. He expected other groups like modeling to be involved as well. 

PAM said he was due to become involved in the topic next month. NHS Digital would have discussions with SNOMED International in early February. IGR said NHS Digital was focused on rare diseases at the moment, so incredibly interested in Orphanet. 

Drug Model

38:00-45:20 TMO gave a presentation on the drug concept model and products as attributes (see Powerpoint on the agenda page). 

JCA asked a question about reviews of the document with the proposed model and linkage of terms to other standards like IDMP. Do we want to document the separate classes we have with those represented in IDMP? TMO agreed and said she and the drug group would do that. JCA said he just wanted to note the relation between SNOMED and other standards.

JCA also noted that the group was focusing on manufactured form, not administrable form as the focus for this particular model.

47:00-49:00 TMO went on with her presentation on extension of causative agent to include product concepts (same powerpoint).

JCA noted that once product level concepts were cleaned up, they could provide clearer editorial guidance on use of products for values of relationships. TMO agreed. She said this was a subproduct of the drug work. JCA said it involved the work of cleaning up the foundational hierarchies and it would be easier to address these hierarchies once foundational hierarchies cleaned up. 

GRE: do you have a set of examples of the type of products you would like to reference? Sometimes we have been using substance when we should have been using product b/c it was manufactured. in case of disorders may get more complicated. Could get in the same position as laterality. Someone has allergy to asperin products and somoen else allergy to asperin substance, so some examples would help so if you could post them after this? TMO: absolutely.

• TMO to post some examples of causative agents for AG review.

JCA: one of the actions is if we want to ask Tech Services to possibly extend the range of the causative agent relationship to include products prior to the cleanup of the hierarchy. He asked TMO if that was premature. TMO said she thought it was. JCA said the action should be deferred until the cleanup of the product hierarchy. The AG agreed. He noted that BGO would be impacted by ECE work. BGO said it was okay - there was a lot of work to do in the area. 

• Adjust prior action regarding Technical Services extending the range of the causative agent relationship to include products to delay such action until after the cleanup of the hierarchy.

ECE Update (Event, Condition and Episode)

55:00 BGO gave a presentation (see powerpoint on agenda page or recording).

1:05 discussion: JCA said there are there substantial number of late effect concepts - are they sequelae of disorder? BGO said no, many of those were under the complication hierarchy, events classified as sequelae of disorder would be classified as complications too. Many would need to be remodeled to be classified under sequelae, so a lot of clean up work would be needed to fully implement these models. JCA asked if that might be done through a batch process? BGO replied to an extent, but there were specific issues too that would require attention. 

GRE said he was generally content with the model, but existing content is scattered around. What is the plan for that content, and the scope? So it's not only the model, it's the plan in applying the model.

BGO replied that it started out focusing on modeling perioperative complications, so starting out with that hierarchy would be the first step. He invited GRE to work with him on it. GRE agreed. JCA said he was also planning on working on it. we can use some of the tooling Peter Williams has developed and see if batch processing is an option to put it into more consistent modeling. BGO said he would be interested in working on that. JCA said they were close to being happy with the model, then it could be put into a batch queue. 

1:11:16 BGO then gave a presentation on the allergy model.

1:24 discussion: JCA asked how if fit with the proposal years ago for the condition class. BGO replied that it fit very well with that. This made it more consistent, he said. There was a discussion of high-level primitive concepts in relation to the model.

Ed Cheetham (ECH) offered some comments on the model. He said it systematized what had been sloppy.

At this point, KCA joined the meeting.

GRE said all models have problems, he said, but what is the appropriate representation of reality? Over the years there had been some good ideas, but when they were modeled it turned out that reality was much more complex. We may feel that we need some small changes to improve it, but we will not have universal application, but we can improve some specific cases. He felt that pathological process was necessary, and simplifying the model to only the really necessary attributes would help. He would accept allergy concepts to be fully defined. He had not seen examples where they needed to role group things.

GRE noted that BGO's understanding of the model is much more detailed and complex than the average user and that could be a problem. GRE agreed that they could not make work arounds for years and years. But he felt they needed to get back to what is possible to consistently model. 

KCA said he felt similarly to GRE. We need to evolve the models slowly over time, he said, and focus on adding new value bit by bit rather than adding a lot of complexity all at once. He said he could not comment on the allergies model because he had missed the presentation, but the observables model was similar. 

BGO said he thought the model he presented was simpler than the current model. But they needed to make decisions due to the allergy to substances being dependent on those decisions. 

PAM said any solution chosen, the Community of Practice could use a user's guide because a significant number of GPs wouldn't know what to record. What impact would this have on systems checking on allergies and offering decision support? BGO replied to the second part.

JCA noted that the results were exactly the same, it was just a difference of making one of the concepts primitive. What is benefit of making allergic sensitization primitive? BGO: disposition occurs after the sensitization and sensitization is caused by the substance. Other one after the sensitization, causative agent due to some unspecified process. JCA said he agreed with GRE and KCA about not making something more complicated if there is no clear benefit. BGO said he still felt his proposal actually simplified things. But he felt that that needed to be discussed more in ECE.

JCA asked what the AG would need to make a recommendation. GRE replied maybe slides or short document (GRE) get back to requirements and what are things we have agreed and particularly so many batch sand changes and work arounds, get back to what problem is and what want to achieve, whether still feasible or if there are simpler solutions. GRE said maybe he needed to go through the slides and maybe have a one-on-one call with BGO, but he was not comfortable recommending a change unless they were certain it was a better way, even though the current state was problematic. 

KCA said the solution would have to be simplifying, he would defer.

JCA asked BGO if he had a paper on this. BGO said he could add to the paper this latest proposal.

PAM wondered if this might be tested in a system to see how people would actually use it. Would the tinkering with the model affect the way it's used? It might have no impact, in which case simplest is probably best. But we should test it out. BGO asked how it might be done. JCA said he did not think there was a mechanism to do that in advance. KCA said real experience would be interesting. Most of the systems are just using the strings and the codes, so changing this model would probably have 0 impact from the clinically-facing perspective. there could be some smaller systems if they are trying to implement the models. So he did not think it would have much of a positive or negative impact at this point. He cautioned to make sure the changes were something they wanted to live with for a long time. But impact would be zero right now, so we need to think about business case, including industry's perspective on the value of SNOMED. JCA said there were also complaints about SNOMED's lack of internal consistency, and areas like this are mess, so cleaning up the mess would be an advantage from a reputational perspective. 

• JCA said they could not come up with a recommendation at the moment but he asked BGO to but these suggested modifications in the discussion paper around allergies and then share the link to that with the group, then move apace at trying to get a recommendation from the ECE. 

Moving on, BGO said there had not been much progress since Wellington on the final approval on the editorial updates but provided a short update.

End of recording #1.