Welcome and introductions

2

@Peter Williams

@Rob Hausam

Recording, notes & attendance.

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

Previous Meetings

2

@Peter Williams

@Rob Hausam

• 2023-09-05 - SNOMED on FHIR Meeting (TS & TB)

• 2023-08-30 - SNOMED on FHIR Meeting (TS & TB)

Other Meetings

10

@Peter Williams

@Rob Hausam

Recent events:

HL7 September (Phoenix, AZ) 9 - 10 Connectathon - DXPQ particular involvement, followed by 5 days working groups.

Future Events:

FHIR North (Canada) Oct 17 - 18  https://fhirnorth.mohawkcollege.ca/

SNOMED International Atlanta, GA  22 - 27 October.   FHIR Meeting on Sunday 22 Oct.

HL7 Australia 20 - 21 November Melbourne FHIR Connectathon

HL7 Netherlands November 9 - 10

HL7 New Zealand and Australia: 28th of November, in Hamilton NZ. Joint FHIR connectathon centered around the IPS use case. Backed by HealthNZ.

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 

General discussion on work being done in EU

@Marie-Alexandra Lambot @Daniel Karlsson (Unlicensed) 

See https://build.fhir.org/ig/hl7-eu/laboratory/branches/master/index.html

https://github.com/hl7-eu/laboratory

https://confluence.hl7.org/display/HEU/Laboratory+Report+Implementation+Guide%2C+Edition+1

https://build.fhir.org/ig/hl7-eu/xpandh-hdr/

ML: https://csct.be/projects.html

https://nuva.mesvaccins.net/

Expressions and MIME types

@Rob Hausam 

A question on "fhircracker" about if ECL could be a registered MIME type (application/ecl ?)

https://jira.hl7.org/browse/FHIR-27828

https://www.iana.org/form/media-types (MIME Type registration form)

There is an extension datatype with an expression language element (http://hl7.org/fhir/metadatatypes.html#Expression) that could in some hypothetical use case represent an ECL

@michael lawley the extension is not necessary to represent valueset compositions, there is already a proper way to do it

@Peter Williams we need a clear use case

@michael lawley maybe an expressions authoring tool? exchanging plain expressions?

@michael lawley registering may help to protect the name

@Alejandro Lopez Osornio is the ECL name going to change? probably not but there were discussions in the languages group, ECL name does not reflect its current capabilities, and the "SNOMED Query Language" was never developed and its functions are now part of ECL

@Rob Hausam What does SNOMED prefer? register the MIME type? leave that to HL7?

An agenda item is proposed to be added in the next SPLG (languages) group meeting (@Kai Kewley )

2023-09-19 Update: Still working out the use case on this one.   Precedent set with SQL listed here:  https://www.iana.org/assignments/media-types/media-types.xhtml.  

IG Tooling Compatibility

20

Requirements for making a Terminology Server compatible with IG Tooling

See Zulip discussion here:  https://chat.fhir.org/#narrow/stream/179202-terminology/topic/Terminology.20server.20requirements.20for.20IG.20builds.2E.2E.2E

2023-07-25

• @michael lawley is implementing the requirements in Ontoserver

• Graeme is preparing the Terminology Server registry, probably a JSON document, that would make available different terminology servers, listing the capabilities, including which code systems on each server

2023-08-22

• @michael lawley the scope has expanded, advancing on the implementation. The registry will document which terminology server meet requirements, it is a centralized resource, maintained by HL7. There is document that describes this. An implementation guide developer would use this information to choose a compatible terminology server as the backend of the IG valuesets. There is a test suite that servers can apply to demonstrate compatibility, Graeme will be the curator of the list, the submission process for a new server is under development.

Observables model

@michael lawley 

Question on the Observables Model (- was discussed in both the MAG and the EAG.   @Yongsheng Gao currently looking at proposals and next discussion will be at all staff meeting in June.

There was an inconsistent role grouping pattern in the observables, and the question was trying to find the reason for this. This is being evaluated.

@Peter Williams There is a decision to move to the grouped pattern

@Andrew Perry (Unlicensed) looking for opportunities to contribute to the observables and LOINC modeling decisions

2023-09-19 Update:  Direction of travel here suggests moving to have all attributes in a single role group, but preparatory hierarchy movements will be required first - Evaluation Procedures moving to Observables.  Discussion expected at October MAG meeting, followed by a briefing note if no major objections raised.   AP UK have concerns about problems caused with existing counterparts between the two subhierarchies.  UK did respond to RFC last week.

Post R5 Concept Map - support for SNOMED Map features.

@michael lawley 

Concept maps and SNOMED Maps  - how to materialize as both R4 and R5.

Metadata needed:  target CodeSystem URI,  source and target ValueSets.

Do we assume that a simple map is an equivalence.

For complex maps, how are the additional fields represented?   Eg in property, dependsOn and product (these are typed).   See 5.2.3.3 Complex and Extended Map from SNOMED CT Reference Sets  

CC @Kai Kewley 

Update 2023-06-13 Now working in confluence Concept Map in R5

2023-07-11 Work being done (ML) around clarity and specification for the parameters used in implicit Concept Maps.

2023-07-25 @michael lawley and Dion had a discussion on metadata and put together a proposal of a JSON based metadata, presumably to be presented to the MAG

Allergy IG Demonstrator

20

@Alejandro Lopez Osornio @Marie-Alexandra Lambot 

https://ihtsdo.github.io/sct-implementation-demonstrator/

To be shared at the next Allergies CRG (late May)

2023-07-25 @Alejandro Lopez Osornio a new version available, resolving @Marie-Alexandra Lambot feedback

The guide is published in: SNOMED CT Clinical Implementation Guide for Allergy, Hypersensitivity and Intolerance (@Alejandro Lopez Osornio to review sync with WIP version, link from the guide to the demo tool)

A new version of the guide was published integrating all feedback and links to the demonstrators.

Expand Alliance

20

@Marie-Alexandra Lambot 

XPA - Expand Alliance European Project.  Interoperability in Europe, targeting providing 6 x 40 hours of medical interoperability training to 40 students to fill gaps in existing offerings.  HL7 Europe (consisting of all HL7 European country affiliates) also participating.   

2023-05-30 Submission made (SNOMED International is a co-partner).  Response expected by the end of the Summer.

Testing Frameworks

20

@michael lawley 

Testing Frameworks.  Background: IG Tooling using servers other than tx.fhir.org    servers may need to implement additional parameters that are outside of the core specification.   GG has put together a test suite to confirm alignment to meet IG Tooling needs.   Command line flag to the validator to run these checks.

Issues encountered - some expected responses include nesting (Ontoserver's response does not do this).  Syntax for regexs may be non-standard flavour.   Examples show only translation display elements - "use" is not populated.   Tx Server limited to 1000 codes in expansion so test suite is expecting to see errors for large CodeSystem whereas Ontoserver would not expect to return an error.

Now related to #4 IG Tooling compatibility.

Jamaica update

New SNOMED member. Working with OpenEHR and FHIR. Onboarding is ongoing. No detailed use cases are recorded yet.

Agenda for April Business Meeting

@Peter Williams 

• National Implementation - how best to manage ValueSets (@Rutt Lindström )

  • should be a one-off exercise

  • static substrate, or generate documentation around changes.

• Allergy Guide - crossing SNOMED and FHIR (See @Jane Millar for template)

• Demo of Post Coordination

• Snowstorm support for additional codesystems

• @Marie-Alexandra Lambot resource visualisation work

Visualisation of FHIR resources

10

@Marie-Alexandra Lambot 

MAL working on visualisation of FHIR resources - entity relationship diagram.

Open

2023-03-21 AP Shared:

• https://www.nhsbsa.nhs.uk/pharmacies-gp-practices-and-appliance-contractors/dictionary-medicines-and-devices-dmd 

• https://digital.nhs.uk/developer/api-catalogue/digital-medicine-fhir

• https://digital.nhs.uk/developer/api-catalogue/gp-connect-patient-facing-prescriptions-fhir

2023-07-25:  interesting tools:

• http://clinfhir.com/

• https://ps-ca-renderer.apibox.ca/

New page for eHealth Standards Belgium

10

@Marie-Alexandra Lambot 

https://www.ehealth.fgov.be/standards/fhir/

PJ suggests looking into: http://hl7.org/fhir/R5/clinicalusedefinition.html Based on the NZ medication interoperability experience. Challenges of sharing codes.

European Terminology Services Collaboration

10

@Rutt Lindström 

There is a European Commission working group under MyHealth@EU that is considering requirements for future terminology services for EU cross border eHealth services (ePrescription, eDispensation, Patient Summary, etc).
A temporary side activity of this group is to discuss national terminology server and terminology management systems implementations. Most people involved in the group are also involved in the national terminology services projects, and sharing those plans and experiences are helpful for finding the middle ground and needs for common EU services. 

@Rutt Lindström is the co-lead of that group. If you're interested in learning more, or you're just bored with your life and feel like chatting with someone about these topics, please get in touch.

HL7 Europe Laboratory Implementation Guide

15

@Daniel Karlsson (Unlicensed) 

See https://github.com/hl7-eu/laboratory for context.

Language issues inside Codings - a way of putting a language tag inside a Coding?  DK: In cross border situation, question is where the translation should happen (eg keep the original pre-translated terms present along with the translation).

ML: Normally the display text in the coding is in the language of the Resource itself.  There is a generic extension for anything String typed that would allow its language to be specified.  See https://hl7.org/fhir/extensions/StructureDefinition-translation.html

Language behaviour compliance in Snowstorm

10

@michael lawley 

@Kai Kewley 

BCP-47 requires a dash every 8 digits so SCTIDs need to be broken up to be compliant.

Also the "x-sctlang" is required. 

Also discussed GG's request to @Kai Kewley in the behaviour around language headers and how they interact with the displayLanguage in the HTTP GET request.

Allergy Guide work 

5

@Daniel Karlsson (Unlicensed) 

Allergy Guide binding question on representing symptoms - discuss on next Tuesday call.

MAL - has finished current version of guide.  Some layout work to do and small additions possible prior to publishing. 

Resource consistency

10

@Marie-Alexandra Lambot 

Looking to engage with various HL7 Work groups to flag up inconsistency of various elements between resources.   There is hopefully an opportunity to address this as we start talking about FHIR 6.0

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 

2023-07-11 ML Added UP ticket - https://jira.hl7.org/browse/UP-436 (Unified Terminology Governance Project)

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 .  DK Also do we specify boilerplate copyright statement?  This should also be specified in our IG (or referenced).