• Recording of meeting approved by participants.

Conflicts of interest and agenda review

Release of SNOMED Code usage statistics.

Discussion:

UK Primary Care data had been collected 2019-2021 and will be released publicly representing use of SNOMED CT concepts.  A description of the types of data that will be released was presented.  Precision rounded up to the closest 10 for number of uses.

Can be used to guide SNOMED in terms of inactivations and replacements.  Provides analytical support for use of SNOMED CT concepts and relationships amongst them.

A request from Argentina to inactivate concepts related to the legality or illegality of "Induced termination of pregnancy" or "abortion" (disorders).  Briefing note attached.

In general, the advisory group felt that the representation of legality or illegality were not in the purview of SNOMED CT due to the differences in each country.  This is especially important in cross border interoperability.  SNOMED proposed that this be extended to all concepts mentioning "illegal" or "legal".  

These originated in ICD-9 but the notion of "illegal" has not carried over into ICD-10 and is represented as a synonym associated with "abortion" in the ICD-11 foundation.

This would not prevent NRCs from adding such content to their extensions.

Decision:

Concepts related to "illegal" and "legal" abortion will be inactivated and pointed to a prent term agnostic to legality.

• SNOMED CT content team to inactivate "Induced termination of pregnancy" concetps that specify "legal" or "illegal".

We have received a request for a concept "Patient race not recorded" as a subtype of 312863000|Patient data not recorded (finding)| along with a request to create a new Observable entity and finding value to allow for modeling of concepts related to clinical documentation not being recorded.  

I.E.

INTERPRETS = Demographic detail (observable entity) as well as subtypes specifying the type of demographic information.

HAS INTERPRETATION = Not documented (qualifier value)

This type of concept appears to be a "reason" for missing data as opposed to a NULL value.  FHIR incorporates these "flavors of NULL" in many of their value sets.

Are these really findings?

There is a use case for recording the reason that data are missing.  Suggested that these be qualifiers as opposed to findings. These should be agnostic as to what data are missing but support the reason why the data are missing.  

Decision:

These have been identified as useful concepts that would be added as qualifier values to represent flavors of null.  Need to reference the FHIR value set for a "starter" set of concepts to consider.

The current definition of the Occurrence attribute is:

"This attribute refers to the specific period of life during which a condition first presents. However, conditions may persist beyond the period of life when they first present."

In many cases, the presentation of a condition occurs after the period of life in which it is observed.  This is especially true when there is a continuum of time periods; where it can be determined that a disorder actually began prior to the time in which it is observed.  New additions to the 282032007 |Periods of life (qualifier value)| hierarchy to support maternal pregnancy and fetal development phases warrants a revision of the definition of this attribute.

A proposed new definition for the Occurrence attribute is:

"This attribute refers to the specific period of life determined to be the period of onset of a condition.  This may be prior to the actual initial observation and conditions may persist beyond the period of life when they first present."

This issue arose during a remodeling of Birth trauma, where it can be determined that the trauma occurred prior to or during delivery of the child, but is not necessarily noticed until after complete delivery.

Proposed to change the last words of the definition from "when they first present" to something representing when the condition actually started (is realized). 

4/12/2022: revised wording:

OCCURRENCE: The specific period of life determined, possible retrospectively, to be the period of onset of a condition, as opposed to the period when the condition first presents or is diagnosed.  The condition may persist beyond the period when it was first determined to have occurred. 

Decision:

Definition will be reworked and sent to the EAG for review.

Based on a request from a member country, we seek advice on the potential move of << 281694009 |Finding of at risk (finding)| from the Clinical Findings hierarchy to the Situation hierarchy.

Rationale:

1. "At risk" is an ambiguous term that could mean either "at low(er) or decreased risk" or "at high(er) or increased risk", although it commonly is used to represent "at increased risk"
2. Nearly all of the current "At risk (finding)" concepts are primitive and thus difficult to maintain and of limited analytical use
3. There are a limited number of "At risk (situation)" concepts that are all sufficiently defined using the FINDING CONTEXT = "At risk context (qualifier value)

At risk findings = 254 (5 sufficiently defined, but through multiple primitive parents)

At risk situation = 5

Given the rationale above, it is proposed to inactivate and replace the current finding concepts with new Situation concepts using the terming pattern "At increased risk of X (situation)" based on the change of meaning to be more explicit and the movement to the Situation hierarchy.

Questions:

• Should these concepts be simply moved and remodeled (retaining SCTID)?
• Should these concepts be inactivated and replaced (preferred but potential large impact on users)?
• If inactivated, which inactivation reason would be used given that the existing terms are ambiguous, but are most frequently used to represent only "increased risk".  It is not necessarily of benefit to add both increased and decreased risk concepts where the latter would not be of much clinical use except in a few cases.

Many of the at risk finding concepts do not have findings or disorders to use as ASSOCIATED FINDING values.

At risk is a disposition.  We have developed predispositions as findings for allergy.  This is a prototype of representation of risk.  What are the requirements for representation of risk.  Is further analysis for the use cases needed? 

There may be a difference between statements of risk that are determined ad hoc and those that are determined through the use of formal assessments.

Do we represent risk as a set of observables?  Propose that a set of modeling exercises to determine the best approach.  

Moving them would clarify the meaning and make them more explicit.  It would also allow for a "cleaning out" of risks of questionable value.  

This would only be the first step in looking at ways to represent risk moving forward.

Decision:

Consensus that this would be a good first step and would help to inform later needs for risk. Terms will be inactivated and replaced based on change of meaning.

Measurement Findings:

Proposed changes to FSNs

Update on Positive/Negative findings

• Proposed changes to FSNs: Please read the attached Briefing before the meeting and if possible return your comments for discussion at the meeting.

So far, with limited input, there has been positive response to the proposal.  One area where there is an issue is where existing concepts that refer to "increased" are referencing a relative increase as opposed to an above or below reference range. 

Another concern...ambiguity based on the source of the component being measured.  E.g. increased albumin. There are a number of "agnostic" groupers (with regards to specimen) that would need to be addressed as to whether they are ambiguous or not. Should these be resolved at the same time as the remodeling and reterming or handled as a separate phase of the project.  

Consensus that the notion of "relative to last time (or time period)" should not be represented in the international release. There were some in favor of inactivating those that use "increased" or "decreased" as inherently ambiguous.    "Normal" in terms of substances/drug is also ambiguous based on the use case.  Given the many examples of how the terms can be interpreted leads the group to determine that these all need to be inactivated and replaced with more explicit.  The issue is that there is a problem with determining what the inactivation reason would be. Suggested to inactivate the entire hierarchy without replacement and create a new hierarchy with more explicit concepts.

Decision:

None