- Created by Peter G. Williams, last modified by Daniel Karlsson on 2018-Dec-04
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Relevant Valuesets
Required value sets that are possibly in scope:
http://build.fhir.org/valueset-detectedissue-severity.html
http://build.fhir.org/valueset-allergy-clinical-status.html
http://build.fhir.org/valueset-allergy-verification-status.html
http://build.fhir.org/valueset-allergy-intolerance-type.html
http://build.fhir.org/valueset-allergy-intolerance-category.html
http://build.fhir.org/valueset-allergy-intolerance-criticality.html
http://build.fhir.org/valueset-reaction-event-severity.html
http://build.fhir.org/valueset-adverse-event-severity.html
http://build.fhir.org/valueset-adverse-event-outcome.html
http://build.fhir.org/valueset-condition-ver-status.html
http://build.fhir.org/valueset-condition-clinical.html
Update 28 September 2018 from Grahame Grieve
Additional candidates as discussed from the patient care space:
+ http://build.fhir.org/valueset-detectedissue-severity.html
+ http://build.fhir.org/valueset-request-priority.html
possible candidates out of other spaces:
genomics
http://build.fhir.org/valueset-sequence-type.html
http://build.fhir.org/valueset-orientation-type.html
http://build.fhir.org/valueset-strand-type.html
http://build.fhir.org/valueset-quality-type.html
http://build.fhir.org/valueset-repository-type.html
care planning
http://build.fhir.org/valueset-action-cardinality-behavior.html
http://build.fhir.org/valueset-action-precheck-behavior.html
http://build.fhir.org/valueset-action-required-behavior.html
http://build.fhir.org/valueset-action-selection-behavior.html
http://build.fhir.org/valueset-action-grouping-behavior.html
http://build.fhir.org/valueset-action-relationship-type.html
http://build.fhir.org/valueset-action-condition-kind.html
This confluence page concerns a list of valuesets that we understand to be new to the FHIR specification (ie did not already exist as older HL7 valuesets); each of these valuesets is defined in FHIR as a FHIR-internal code system. The same code symbol (e.g. 'active') may appear in more than one different such valueset/codesystem but has a clearly different meaning in each which is expressed in each value's narrative text definition. Some of these code systems include an explicitly hierarchical taxonomic arrangement of the values they contain (e.g. Condition.ClinicalStatus, where relapsed is a subtype of active)
The VA and SOLOR are interested in being able to substitute SNOMED CT coded valuesets in place of the FHIR Internal codesystems, and so required a mapping.
It is, however, not yet clear whether the main benefit of having a SNOMED code is purely technical - it reduces the number of different codesystems required to enumerate all possible resource element bindings - or whether the link to SNOMED is also required to preserve, add to or otherwise clarify the semantics of each member of the valueset.
Note: There is another 'free' SNOMED CT codelist also in development for the International Patient Summary Specification, which is CDA R2 and FHIR incarnations. This free set would be used globally. Its a larger and more clinically focussed set.
Design Choices for mapping these valuesets:
EITHER: Individual FHIR values are meaningless (or ambiguous) if encountered when detached from their original host resource (e.g. 'active' could be either a condition.clinicalstatus, or an allergy.clinicalstatus)
There is therefore no requirement for the SNOMED mapped code to add further semantics over and above being numerical codes for the words that are the FHIR symbols. Offering maps to e.g. members of <<106234000|General adjectival modifier| would be fine; if FHIR declares a disjoint and covering codesystem to comprise symbols {a,b,c} and these are mapped to {A,B,C} in SNOMED CT, then there is no requirement for A, B or C to exist in SNOMED as e.g. siblings of one another, or even all in the same branch of SNOMED's taxonomy, or for SNOMED to duplicate any original taxonomic arrangement of {a,b,c}. That information will remain encoded ONLY within the relevant FHIR code system as the reference. It may even be argued that it would be a mistake for SNOMED to attempt to precisely mirror the FHIR code system semantics.
OR: Individual FHIR value symbols are explicitly tied to a particular code system : although 'active' exists as a symbol in two different FHIR internal code systems, it has a different explicit narrative text meaning in both.
Therefore, the SNOMED mapping should attempt to preserve those distinctions and definitions. Most of these values therefore should NOT be mapped to any descendent of 362981000|Qualifier value| but rather to postcoordinated expressions (or new precoordinated codes) more precisely capturing the full semantics of each value's narrative text definition. For example, AllergyIntolerance.Category={food} should be mapped to 414285001|Food allergy (disorder)| and not to 255620007|Foods (substance)|; Condition.ClinicalStatus={recurrent} should be mapped to 58184002|Recurrent disease (disorder)| and not to e.g. 255227004|Recurrent (qualifier value)|
DetectedIssue.Severity - 3 concepts, mapped 2 Oct 2018, DONE
Possible home in << 272141005 |Severities (qualifier value)|
HL7 Value | Suggested SNOMED Term | Discussion |
---|---|---|
High | 24484000 |Severe (severity modifier) (qualifier value)| | These values are inherited from V3. "High" does exist but in a different hierarchy - 75540009 |High (qualifier value)| Severe does have a synonym of "High Grade" Should we flag up this apparent inconsistency? All these values are children of 272141005 |Severities (qualifier value)| Conclusion: Mapping suggested here is sufficient (sufficient for what - use case required). 20 Nov |
Moderate | 6736007 |Moderate (severity modifier) (qualifier value)| | |
Low | 255604002 |Mild (qualifier value)| |
AllergyIntolerance.ClinicalStatus - 3 values (superficially similar to Condition.ClinicalStatus but without relapse and recurrent)
Possible home in << ? 20 Nov
HL7 Value | Suggested SNOMED Term | Discussion |
---|---|---|
Active | JR suggests new sub-hierarchy for SCT containing disease activity to align with 370996005 |Patient condition resolved (finding)| LB suggested use of << 394731006 |Problem statuses (qualifier value)| would need to add "Resolved". YG Notes that these are not in use and their use is not dictated by the MRCM. DK suggested use of << 36692007 |Known (qualifier value)| again "Resolved" would be required. | |
Inactive | ||
Resolved |
AllergyIntolerance.VerificationStatus
<< 106230009 |Qualifier for certainty of diagnosis (qualifier value)| doesn't have refuted
Better << 410514004 |Finding context value (qualifier value)|
HL7 Value | Suggested SNOMED Term | Discussion |
---|---|---|
Unconfirmed | 410590009 |Known possible (qualifier value)| | These 3 are children of 410514004 |Finding context value (qualifier value)| |
Confirmed | 410605003 |Confirmed present (qualifier value)| | |
Refuted | Move 723511001 | Refuted (qualifier value) | to a subtype of 410594000 |Definitely NOT present (qualifier value)| | Also considered 2667000 |Absent (qualifier value)| ? Doesn't really put over that a test was done and the absence of the allergy was proven. "Definitely not present" doesn't capture the implied history of "we used to think this was the case". New concept required? Dictionary defn of refuted is "to prove wrong" so possibly history is not implied, but convention is that there was some previous possible condition. But "Not Present" is clearer - is there scope for FHIR changing the value? |
Entered in Error | 723510000 |Entered in error (qualifier value)| | Child of 106232001 |Adjectival modifier (qualifier value)| |
AllergyIntolerance.Type DONE
Conclusion: Mapping suggested here is sufficient. 20 Nov
HL7 Value | Suggested SNOMED Term | Discussion |
---|---|---|
Allergy | 609328004 |Allergic disposition (finding)| | Descendant of 420134006 |Propensity to adverse reaction (finding)| via 609433001 |Hypersensitivity disposition (finding)| Allergic reaction is covered elsewhere in FHIR. Consider: 781474001 |Allergic disorder (disorder)| ? |
Intolerance | 782197009 |Intolerance to substance (finding)| | Child of 420134006 |Propensity to adverse reaction (finding)| and it subsumes intolerance to both foods and drugs separately. |
AllergyIntolerance.Category
HL7 Value | Suggested SNOMED Term | Discussion |
---|---|---|
food | 418471000|Propensity to adverse reactions to food (disorder)| | |
medication | 419511003|Propensity to adverse reactions to drug (disorder)| | |
environment | 420134006 |Propensity to adverse reaction (finding)| | If this is a NEC (Not elsewhere classified) sort of value, then would we use the more general 420134006 |Propensity to adverse reaction (finding)| here? DK: ECL Expression helpful ie parent minus already used children? FHIR says: "Any substances that are encountered in the environment, including any substance not already classified as food, medication, or biologic." |
biologic | Not Found | Could we ask Bruce Goldberg if he thinks additional concepts in SNOMED are warranted here? |
AllergyIntolerance.Criticality 2 concepts, mapped 18 Oct 2018
HL7 Value | Suggested SNOMED Term | Discussion |
---|---|---|
low risk | 723505004|Low risk (qualifier value)| | But very questionable whether (a) passing either of this pair 'adjectival modifier' codes is any more useful than passing the words 'low' and 'high; and (b) the wisdom and clinical safety of passing a coded clinical statement stating 'high risk' that does not also explicitly include 'of what?'. Would it be better/safer to pass as new clinical finding codes along the lines of 'high risk of adverse reaction' ? Actually, the exact meaning of the original valueset is in fact not to grade the likelihood of an adverse event but rather of whether, should an adverse event occur,it is likely to be clinically significant one. A high probability of only trivial reactions would be graded 'low risk'. So passing only 'low risk' may be especially clinically rather ambiguous. YG: If the qualifier values are used in a concept model rule, we need to be careful. JC: All qualifier values need to be interpreted in the context provided by the information model OR the context provided by the concept model. |
high risk | 723509005|High risk (qualifier value)| |
AdverseEvent.Severity - 3 concepts, mapped 2 Oct 2018
AllergyIntolerance.Reaction.Severity - 3 concepts, mapped 2 Oct 2018
HL7 Value | Suggested SNOMED Term | Discussion |
---|---|---|
Severe | 24484000 |Severe (severity modifier) (qualifier value)| | |
Moderate | 6736007 |Moderate (severity modifier) (qualifier value)| | |
Mild | 255604002 |Mild (qualifier value)| |
AdverseEvent.Outcome
HL7 Value | Suggested SNOMED Term | Discussion |
---|---|---|
resolved | 413322009|Problem resolved (finding)| | |
recovering | Not Found | |
ongoing | Not Found | 303350001|Ongoing episode (qualifier value)| exists, but to be consistent with semantic category of maps proposed for other valueset members, need a finding. |
resolvedWithSequelae | Not Found | 413322009|Problem resolved (finding)| is only part of the way there. Also 370996005|Patient condition resolved (finding)| |
fatal | 419099009|Dead (finding)| | 399166001|Fatal (qualifier value)| is a severity.. |
unknown | Not Found |
Condition.VerificationStatus
HL7 Value | Suggested SNOMED Term | Discussion |
---|---|---|
Unconfirmed | 410590009 |Known possible (qualifier value)| | |
Provisional | 410592001|Probably present (qualifier value)| | |
Differential | 410590009|Known possible (qualifier value)| OR 415684004|Suspected (qualifier value)| | 'known possible' is not quite the same as differential... |
Confirmed | 410605003 |Confirmed present (qualifier value)| | |
Refuted | 410594000 |Definitely NOT present (qualifier value)| | |
Entered In Error | 723510000 |Entered in error (qualifier value)| |
Condition.ClinicalStatus
Discussion 13 Nov 18- consider enhancing << 394731006 |Problem statuses (qualifier value)| currently containing active & inactive. This valueset does seem like its use would go beyond just that of FHIR and may have broader usage.
Condition.ClinicalStatus relates to the SNOMED CT Clinical findings model in a non-trivial way, hence the red color coding. E.g. parts of the value set is related to the clinical course SNOMED CT relationship type.
HL7 Value | Suggested SNOMED Term | Discussion |
---|---|---|
Active | Not Found | 55561003|Active (qualifier value)| would be undesirable to use. Its just a code for the word as an adjective : having a SNOMED code would add zero value over the original string, and only marginally more than the more obviously ludicrous but entirely possible SNOMED CT encoding as the expression: 422097006|Upper case Roman letter A (qualifier value)| PWI 6 Nov: I think it's worth doing two things routinely here, firstly including what the parent is (in this case 106234000 |General adjectival modifier (qualifier value)|) and secondly seeing where that concept is aleady used in SNOMED. In this case, no International concept uses this qualifier value. |
..Recurrence | Not Found | 263853000|Recurrent episode (qualifier value)| is in right neck of woods, as a member of SNOMED's Episodicities valueset, but other members of the HL7 valueset cross over into other aspects of disease phase rather than episodicity, so if a guiding map design principle were to be that all members of the valueset should at least be from the same SCT semantic category, then we'd need Findings for all of the values. Also 255227004|Recurrent (qualifier value)| as a member of SNOMED's Courses valueset. |
..Relapse | Not Found | 303359000|Relapse episode (qualifier value)| |
Inactive | Not Found | 73425007|Inactive (qualifier value)| would be undesirable to use as its just a code for the word and so having a SNOMED code adds zero value over the original string. Parent here is, again, 106234000 |General adjectival modifier (qualifier value)| |
..Remission | Not Found | 277022003|Remission phase (qualifier value)| |
..Resolved | Not Found | 723506003|Resolved (qualifier value)| would be undesirable to use as its just a code for the word : having a SNOMED code adds zero value over the original string |
Outstanding questions
Which descriptions will the free set include - None, FSN, PT (in what languages?)
What if SNOMED Concepts split into more expressive versions ie HL7 code would then map to multiple SNOMED CT codes.
Discussed Potential Additional ValueSets
https://www.hl7.org/fhir/observation-definitions.html#Observation.interpretation (39 Values) Possible home to be found in << 260245000 |Findings values (qualifier value)|
RH Suggested that this value set has already been harmonised between existing standards and that SNOMED CT was not used in general.
HL7 Value | Suggested SNOMED Term | Discussion |
---|---|---|
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