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

• 2023-02-21 - SNOMED on FHIR Meeting (TS & TB)

• 2023-02-07 - SNOMED on FHIR Meeting (TS & TB)

Other Meetings

5

@Peter Williams

@Rob Hausam

Recent events:

Upcoming events:

HL7 FHIR Connectathon AU 22 - 23 March Tracks : Provider Connect Australia, e-Requesting and SMART Launch (Open source questionnaire rendering framework). https://github.com/aehrc/smart-forms

SNOMED International Business Meetings 1 - 5 April Schedule & Registration now available for SNOMED International April 2023 Business Meetings  FHIR Meeting confirmed for 9 - 12am on Sunday 2 April.

HL7 New Orleans May  6 - 7 Connectathon 8 - 12 Working Groups

FHIR Dev Days June 6 -9 Amsterdam https://www.devdays.com/  (call for abstracts now closed, registration opens February).

NHS Scotland Connectathon June 12 - 13 (Further Details TBC)

MedInfo 8 - 12 July Sydney Australia see here session on a wide number of standards.

HL7 September (Atlanta Phoenix TBC?) 9 - 10 followed by working groups.

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 

Jamaica update

Working with OpenEHR and FHIR 

CDS Hooks

10

@Kai Kewley 

HL7 CDS Hooks appears to have 2 specification releases.   Is version 1 the main release in use.  

https://cds-hooks.org/   (Clinical Decision Support workgroup own this - Bryn Rhodes)

CQL may have more traction.

2023-03-07: Demonstrator developed https://github.com/IHTSDO/snomed-fhir-cds-service

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.

Contacting HL7 Working Groups (Use co-chairs as points of contact)

2023-02-07 Looking for diagrams showing relationships between resources, in particular workflows.

RH suggests: ClinFHIR: http://clinfhir.com/ Graph Builder 2 tool: http://gb2.clinfhir.com/

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)

2023-03-07: Corrections to the Allergy Guide made, proof reading in progress, Target publication before business meeting in April 2023.

R5 changes suggested around specifying language using BCP-47 

10

@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 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. http://hl7.org/fhir/5.0.0-draft-final/conceptmap.html 

MRCM in FHIR

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

@Kai Kewley 

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 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

(note SNOMED is the only CodeSystem that uses implicit concept maps, wording around that is changing, see https://jira.hl7.org/browse/FHIR-39266 )

Support for other CodeSystems in Snowstorm.

@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.

2023-02-07 Just waiting for test plan completion before merge can be progressed.

2023-02-21 This work now merged from Snowstorm-X into the "develop" branch of Snowstorm Prime.

Upcoming R5 changes

@Rob Hausam

2022-8-23 RH R5 Deadline now September 4  

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

2023-02-21  PJ Reconcilliation to be completed by next week.

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

• Post Coordination & Transformation

• Relevant changes in R5 eg Concept Map (correlation changes)

2022-11-29

Example markdown page that could be copied and modified:  https://github.com/IHTSDO/snomed-ig/blob/master/input/pagecontent/sct_specific_behaviours.md

Work to be presented for 13 December (payment will be made in Glory^tm)

Peter & Kai - ECL in FHIR  (Update:   Used https://hackmd.io/  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

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 : https://build.fhir.org/ig/HL7/US-Core/terminology.html & http://build.fhir.org/ig/HL7/fhir-ips/  ( also http://build.fhir.org/ig/HL7/fhir-ips/terminology.html )

Looked at http://build.fhir.org/snomedct-usage.html and the animal breeds http://build.fhir.org/valueset-animal-breeds.html which is extensionally defined with a complete set of animal breeds, most of which were inactivated in the International Edition in 20210731 and reactivated in the Veterinary Extension.

2023-02-07 MAL work for Allergy Implementation Guide (which the SNOMED IG will link to) see SNOMED CT Clinical Implementation Guide for Allergy, Hypersensitivity and Intolerance

2023-02-21 DK Work done for languages - https://build.fhir.org/ig/danka74/snomed-ig/branches/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)).

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 http://snomed.info/sct/*   (ie not specifying the version) or http://snomed.info/sct/*/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:  https://browser.ihtsdotools.org/fhir/CodeSystem/$validate-code?coding=http://snomed.info/sct|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.

Long Term Home for Terminology Information

@Rob Hausam (primarily Vocab WG)

Long Term Home for Terminology Information that can be maintained independently of FHIR versions.

See https://chat.fhir.org/#narrow/stream/179202-terminology/topic/Why.20does.20the.20spec.20contain.20a.20SNOMED.20CodeSystem.20resource.3F

7 Sept Relates to problematic page https://www.hl7.org/fhir/r4/codesystem-snomedct.html   PWI discuss internally - done.

Update 21 September 2021 - General agreement that that page can be removed.  Is out of date and not serving useful purpose.

Update 25 Jan 2022 - HL7 intend to make The THO https://terminology.hl7.org/ a home for all terminologies and valuesets.

Next Time: Move to archived discussion, make note in IG

2023-03-07: RH Vocab WG has a new name: Terminology infrastructure WG

IPS / GPS progress

@Suzy Roy

@Alejandro Lopez Osornio

IPS Terminology Subontology - beta went out 2 weeks ago, now in feedback until June 30.  Publication for the end of the year.  ML expressed issues around not being conformant to RF2 spec but is missing module dependency file.   ModuleId is present but invented Concept.    ALO/SR suggested ML give that as feedback.     

GPS expected towards the end of September. Currently working with contributing organisations, which will then go to internal authoring.   ALO GPS may turn out to be less useful and focus could be on IPS in future.

2022-10-18  See https://gps.snomed.org/   also available in MLDS, published 2021-09-30, based on INT 20210731   PWI will follow up for 2022's copy.   SR IPS targeting Nov 30 2022.   Sub-ontology steering committee (internal) meeting next week.

2022-11-1: RB ML have received a new beta version and are testing. ML: The effective time in MDRS may be pointing to July instead of November. No MRCM content, it is required fur the type of the concrete domain attributes.

2023-03-07: IPS has a new management process. Feedback received will be managed by the most appropriate SDO. 

Snowstorm post-coordination updates

@Kai Kewley 

2023-03-07 Post-coordination is added to the FHIR API and more (include $lookup, $validateCode, $subsumes, etc.). Will be published together with the Post-coordination guide. 

Any Other Business

Next meeting - 2023-03-21

SNOMED Family of Languages

@Peter Jordan (Unlicensed)

@michael lawley