Welcome and introductions

2

@Peter Williams

@Rob Hausam

Recording, notes & attendance.

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

Previous Meetings

0

@Peter Williams

@Rob Hausam

• 2022-12-21 - SNOMED on FHIR Meeting (TS & TB)

• 2022-12-13 - SNOMED on FHIR Meeting (TS & TB)

Other Meetings

5

@Peter Williams

@Rob Hausam

Recent events:

SNOMED International Event w/b Dec 14 : Implementation Webinar - Terminology Binding in Questionnaires (FHIR resource).  Link for Implementation webinar registration: https://snomed.zoom.us/webinar/register/WN_oj_OP_q-SoGoMZgQHEnmeA

Upcoming events:

FHIR Dev Days June 6 -9 Amsterdam https://www.devdays.com/

SNOMED International Business Meetings 1 - 5 April (Probably do a FHIR Meeting on Sunday 2 April)

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 

CDS Systems (Clinical Decision Support)

10

@Kai Kewley 

OpenMRS Project.   Are there any open source CDS systems out there?

Clinical Impression Questions

30

@Marie-Alexandra Lambot 

_https://docs.google.com/document/d/1KwhQDbQ6lcOl8JukuCp-lXWGJE2aYxqJ/edit

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 

1. ClinicalIImpression.Performer has 0..1 cardinality.   What happens if a team is involved?  Options:  cardinality could be changed,  team leader could be recorded, single practitioner object could be used to represent a team.

2. ClinicalImpression.problem what does "relevant" mean in this element?  RH Took this to mean relevant to this particular encounter.  ML Would be up to the clinician to decide what is relevant to a particular encounter.  MAL: How do we indicate a grouping of potential diagnoses to be a differential set?

3. ClinicalImpression.investigation is this only history and examination.  This 0..* element was removed between R4 and R5.  RH Thought that it wasn't sufficiently distinct from the other fields.  RH Recommends that MAL have a discussion with the Patient Care Working Group to explore why these decisions were made.

4. Apparently inconsistency between resources which sometimes use two separate start / end dates and sometimes use a period object.  RH Agrees that working towards consistency is desirable.

5.  ImmunizationRecommendation.   Why was the request resource pulled out specifically when a generic request object could be used? RH Public Health WorkGroup made this decision, notes that immunization is distinct from medication because a condition is not necessarily.   PJ suggests that these questions be raised in Zulip ( https://chat.fhir.org/ ) and in specific workgroup discussions.

Discharge Reports

15

@Marie-Alexandra Lambot 

Modular Discharge Reports - MAL looking at the Encounter resource.

DK work being done in Europe, see x-eHealth https://www.x-ehealth.eu/  (ending end Nov) specifications for sharing health data across Europe.   FHIR IGs for this are still being written - can we have a contact point there, DK to supply to MAL. 

Clinicians on FHIR

@Marie-Alexandra Lambot 

Training and Resources for Clinicians

MAL planning on making something available Q1 2023 @Jon Zammit involved.

Allergy Guide Examples

@Daniel Karlsson (Unlicensed) 

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)

FHIR & CTS2

20

@Daniel Karlsson (Unlicensed) 

FHIR & CTS2 : Discussion in EU on cross border information sharing (has been running on CTS2 for some time) moving to FHIR.  Would require a FHIR service to be made available.   IG publishing would be based on a FHIR Server.  

See https://websites.fraunhofer.de/CTS2-LE/index.php/Hauptseite has FHIR R4 support according to that website.

R5 changes suggested around specifying language using BCP-47 

15

@Rob Hausam 

@Daniel Karlsson (Unlicensed) 

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 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.

2022-10-04 With this page moving to terminology.hl7.org it is no longer subject to the ballot process.  Instead a "TSMG" ticket should be created.  @Daniel Karlsson (Unlicensed) and @Rob Hausam will progress this. 

Also tracking R5 changes to concept map - see http://build.fhir.org/valueset-concept-map-relationship.html.   @Peter 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 RB Rob will check the status and how we can help it move

SNOMED URI Specification

@Peter Williams 

Discussion around URIs for module composition.

Also URI for SNOMED languages eg Post Coordinated Expressions.   Discussed and agreed but not yet officially published.

2022-10-18 With the departure of Linda Bird, the chairing of the SNOMED Languages Working Group will be taken up by the rest of the Implementation Support Team.

MRCM in FHIR

Machine Readable Concept Model (applies to both pre and post coordinated content)

30

@Kai Kewley 

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

Support for other CodeSystems in Snowstorm.

10

@Kai Kewley

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.

Cardinality on Designation.use

@Peter Jordan (Unlicensed)

@Rob Hausam

https://jira.hl7.org/browse/FHIR-29821 "Updated cardinality of designation.use"

Expected to be part of R5.

Could we offer Use of BCP-47 + designation.use for review by the HL7 Vocab Group @Rob Hausam? Targeting 9 - 13 meetings.

2022-10-04 Designation.Use extension still required for specific use cases eg consumer definitions.

2022-11-1 Archive

Post-coordination Expressions on FHIR

@Kai Kewley

2022-02-22:  Presentation: https://docs.google.com/presentation/d/1Kz-8N6UQsGZ8C1xsC8TZT6LEbeyr6elrgMt2FI-whjU

• Supplements might not be able to hold new concepts: https://www.hl7.org/fhir/codesystem.html#supplements bullet no 4.

• (Ontoserver seems to do this: https://ontoserver.csiro.au/docs/6/postcoordination.html#Expression_Libraries )

Proposal might include using side-effects which some might be sensitive to.

Runtime maintenance is required. Is it possible to reuse the existing API in order to standardize the approach?

A Code System Supplement may be used to hold a set of postcoordinated expressions as FHIR concepts

• This approach used by Ontoserver so that they are "known" to the Terminology Server so that $expand can be used without considering all possible PCEs.  Not that some clients may not be able to process PCEs so the CS Supplement allows these to be kept separate.  @michael lawley will raise ticket to "Add parameter to ValueSet $expand to specify Code System Supplements to be included" (would need to be compatible with code system that the ValueSet is being expanded against)

• "No requirement for a designation"

CodeSystem/$validate-code operation could be used to validate the expression

• Yes (doesn't need previous knowledge of the PCE, similarly for $lookup

Could calling CodeSystem/$lookup automatically create expression concepts in the supplement, to be returned in ECL queries for analytics? Or use PATCH?

• Probably not, see use of Supplement above.   Yes use of PATCH seems reasonable (PUT a whole new version more common, but PATCH might allow for finer grained updates ie not having to re-submit the entire cohort of expressions).   ML: Custom operation might be useful here to add to the codeSystem and update the ConceptMap in one go.

ConceptMap/$translate could translate an expression to a single identifier to support more limited clinical record systems.  Could this work in real time, automatically creating entries as required?

• ML: Use a local CodeSystem for the expression identifiers and a concept map to link them together.

2022-05-17 KK Were tickets raised around clarifying questions?   2022-05-31 ML Taking an action to raise a ticket for expand so that you can specify one or more CodeSystem Supplements to be used in that expansion. "Expressions already exist as concepts in the given CodeSystem implicitly, Therefore they can be used in a CodeSystem Supplement.   The rules for CodeSystem Supplements state that they can only be used with Concepts that already exist in the CodeSystem"  "An expression is not adding a concept to a CodeSystem, it is just expressing something that is already there"

See https://jira.hl7.org/browse/FHIR-37529

2022-06-28 KK would like an agenda item added to next meeting (1 month time) to discuss a couple of strawmen proposals.

2022-07-26 KK walking through the postcoordination workflow (link above).

CodeSystem supplement for expression library, ConceptMap to map between expressions and fixed-length generated identifiers. ConceptMaps need explicit ValueSets for source (expressions) and target (generated ids).

What should be the system of the generated identifiers, should these identifiers be SCTID(-like)? ML: Would use UUIDs rather than SCTIDs.

A POST on $expand would allow composing a value set with the dependent SNOMED CT edition and the post-coordination supplement and the be filtered with any relevant ECL (for example).

RH: we're not creating new concepts (new meaning) but rather a new identifier from something that is already SNOMED defined meaning.

Having the generated id as a property on the concepts in the supplement would allow:

• the alternate id would be returned for any $expand operation including the supplement, possibly filtered by ECL

• an expand on a ValueSet composed of the supplement and supplemented CodeSystem filtered by the alternate id property would return the expression.

Alternatively, an additional CodeSystem for the generated ids could be created where the expression could be provided as properties.

2022-08-23 We'll pick this up when @Former user (Deleted) is next available for a Wednesday 10:00UTC call.

2022-09-06 KL worked through SNOMED CT Postcoordination Workflow (Discussion)

ML Would a refset of PCEs represent a Code System Supplement?

PGW - Archive Above Discussion.

2022-11-1 KK Will separate the draft documentation between the part that explains the post coordinated expression storage in the code system supplement from the assignment of an alternative identifier, in order to work on the 2 problems separately.

KK: How to assign an alternate ID to the expression using a concept map, how to reference the "value set" of all expressions in the supplement.

Discussion: With R5 a map may not be necessary? (not confirmed, extension?), however the guide will target R4. The extension "code-system-alternate" is available in R4, it might not be valid in supplement, maturity level 1. DK: Concept map may be a cleaner solution.

ML RB: It is not necessary to have a value set to create a concept map from Expressions to Identifiers.

RB: Will try to find out more on the extension.

Upcoming R5 changes

@Rob Hausam

Discussion about proposed federation.  ML Doesn't work so well with SNOMED CT because there's not a single authoritative source due to country extensions (and multiple versions being released).  Use case for this is mainly in creation of IGs.  Agreement that what a conformant server should be able to state in Capability Statement is helpful.   ML Touchstone test script artefacts need investment.  See https://touchstone.aegis.net/touchstone/

See also https://inferno.healthit.gov/

16 Nov Update RH: Updates in for next ballot (not January now).

8 Feb RH: Next ballot confirmed May (deadline March 6, since extended 2 - 3 months)

8 March RH Community being polled on preferred approach to next release from three options: 1. R5 Release with additional Normative content (ie in 2023) 2. Hold R5 3. New content, but not new normative content (looking most popular option).   See https://onfhir.hl7.org/2022/02/28/soliciting-feedback-concerning-the-roadmap-for-fhir-r5/

22 March 2022 RH Expecting September Ballot (hoping for sooner, prior to the working group meeting? - RH)

2022-05-17 RH Ballot expected later. Content freeze Aug 21

2022-8-23 RH R5 Deadline now September 4  

2022-11-1 RB: Publication is expected after February 2023

New change proposals for $validate-code

@Peter Jordan (Unlicensed)

G Grieve have created new HL7 Jira tickets: https://chat.fhir.org/#narrow/stream/179202-terminology/topic/Change.20Proposals.20for.20.24validate-code.20post.20Connectathon

Grahame Grieve: https://jira.hl7.org/browse/FHIR-33941: $validate-code should return system | version | code when display is returned

Grahame Grieve: https://jira.hl7.org/browse/FHIR-33943: $validate-code should return an operation outcome with the full details of issues found, including paths

Grahame Grieve: https://jira.hl7.org/browse/FHIR-33944: $validate-code and $expand should have a parameter for related value sets and code systems

Grahame Grieve: https://jira.hl7.org/browse/FHIR-33946: $validate-code and $expand need a session parameter (as optimisation where ValueSet may need to be uploaded for a series of calls)

Grahame Grieve: https://jira.hl7.org/browse/FHIR-33947: Clarify the use of fragment  (this is a discovered issue from the same session, relating to the first of the tasks above)

ML - general principle that services should echo back the details they've been sent to process.

PJ - CodeableConcept (with multiple codings) will require multiple responses.  ML - call multiple times with single codes as a workaround.

2022-05-03 PJ Agreement to add "Operation Outcome" as a way of returning more detail.

2022-10-18 FHIR-33944 is still showing as being in Triage?

2022-11-1  The first 2 issues have been "Applied", the other 3 are "Triaged" (not in the ballot for R5)

Topics for Terminology Binding Stream

@Daniel Karlsson (Unlicensed)

@Jeremy Rogers (Unlicensed)

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.

@michael lawley

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 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:

1. The SNOMED International IPS Terminology is distributed by International Health Terminology Standards Development Organisation, trading as SNOMED International, and is subject the terms of the Creative Commons Attribution 4.0 International Public License. For more information, see SNOMED IPS Terminology

2. The HL7 International IPS implementation guides incorporate SNOMED CT®, used by permission of the International Health Terminology Standards Development Organisation, trading as SNOMED International. SNOMED CT was originally created by the College of American Pathologists. SNOMED CT is a registered trademark of the International Health Terminology Standards Development Organisation, all rights reserved. Implementers of SNOMED CT should review usage terms or directly contact SNOMED International: info@snomed.org

3. This value set includes content from SNOMED CT, which is copyright © 2002+ International Health Terminology Standards Development Organisation (IHTSDO), and distributed by agreement between IHTSDO and HL7. Implementer use of SNOMED CT is not covered by this agreement

Language Reference Sets in FHIR

All

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 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

@Peter Williams

Implementation Guide for using SNOMED CT with FHIR.

IG Documentation: http://build.fhir.org/ig/FHIR/ig-guidance/index.html

Also look at the sample IG https://github.com/fhir/sample-ig see build http://build.fhir.org/ig/FHIR/sample-ig/

TODOS 

• Check build issues http://build.fhir.org/ig/IHTSDO/snomed-ig/qa.html    Update 2022-06-20 Tooling currently giving a null pointer, see https://build.fhir.org/ig/IHTSDO/snomed-ig/failure/build.log  asked question in Zulip  See https://chat.fhir.org/#narrow/stream/179252-IG-creation/topic/Null.20pointer.20in.20ValueSetRenderer   

• Note page to manually execute build through HL7 Tooling: https://fhir.github.io/auto-ig-builder/builds.html

• Rerun locally with latest tooling (also sushi)

• Run with local snowstorm provided as Tx

• See Mark Kramer presentation   https://www.youtube.com/watch?v=OmcSuAMf20s  Also https://fshschool.org/ 

• CONTENT! 

• Merge in DUC branch (Designation Use Context) with a view to implementing in a branch of Snowstorm and making available via connectathon.ihtsdotools.org

• Clean up other branches

• Check templates are up to date - should now be self updating, see https://github.com/FHIR/sample-ig (fsh may ask to update this structure).   Sushi sending out information about new format (PJ says leading whitespace is now significant).

• ReadMe should provide links for Publisher tooling

• Add discussion on Refset / IN (see above)

• Provide link to it in http://build.fhir.org/snomedct.html and discuss further socializing.

• TerminologyCapabilities caching is overly aggressive.

• Added 2022-08-23 Discuss ownership, hosting and copyright (joint copyright with HL7).  Source will be hosted in GitHub, pull requests will be welcome with this group acting as gatekeepers (reviewers) for that?   @Suzy Roy would the wording of our original collaboration be helpful here?

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

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