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

• 2024-06-25 - SNOMED on FHIR Meeting (TS & TB)

• 2024-06-05 - SNOMED on FHIR Meeting (TS & TB)

Other Meetings

10

@Peter Williams

@Rob Hausam

Recent Events:

Future Events:

SI Business Meetings and Expo  19 - 25 October 2024 Seoul, Republic of Korea

HL7 September 24 - 27 Atlanta

CDA & FHIR Translation Meetings: @Jay Lyle Going well, there is an implementation guide and the group is doing connecthatons. May in Dallas and Minneapolis.

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 

Terminology Binding in the Condition FHIR resource

@Katrien Scheerlinck (Unlicensed) 

There is currently a discussion going on in Belgium regarding the desirable terminology binding in the Condition FHIR resource. We are working together with a group of clinicians/domain experts who almost all indicate that there are a whole series of finding concepts in SNOMED CT, which are required in the use case of diagnosis registration in the patient.  As well, the information website (https://build.fhir.org/condition.html) on this FHIR resource indicates that, in case of persistent symptoms or in case there is no official diagnosis yet, only symptom identification as a preliminary diagnosis, concepts from the finding hierarchy may be used:  “…although in some cases a persistent symptom, e.g. fever, headache may be captured as a condition before a definitive diagnosis can be discerned by a clinician.”

What would be your opinion on this? Hoping this helps to give a direction to the discussion including good, substantiated arguments.

ML See https://build.fhir.org/ig/hl7au/au-fhir-core/StructureDefinition-au-core-condition.html

LB Has anyone looked at the alignment of the verification status and explicit context concepts?

PWI This group looked at this as part of the proposed "Free Set" in 2019 - see FHIR SNOMED CT Free Set - Questions for HL7 (Amber mappings).   Consider the likes of << 41769001 |Disease suspected (situation)| and << 373573001 |Clinical finding present (situation)|

ML Existing issues: “probably not present” is a child of “Known absent” where the term “probably not” indicates that it is NOT a child of “Known absent”

Resources for Allergy Intolerance / Adverse Events

@Kusal Wijayaweera (Unlicensed) 

Question on Allergy Intolerance resources.  Group responded with:

SNOMED CT Clinical Implementation Guide for Allergy, Hypersensitivity and Intolerance

https://build.fhir.org/ig/HL7/fhir-ips/ValueSet-allergy-intolerance-snomed-ct-ips-free-set.html

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

March 1, 2024 Allergy CRG meeting agenda

Previous discussions listed in : https://snomed.atlassian.net/wiki/display/FHIR/Discussions

Allergy Intolerance vs Adverse Events

TODO: Archive

How to handle ad-hoc post coordination in medical records

@Kusal Wijayaweera (Unlicensed) 

Question about EHRs containing unconnected concepts - like post coordination but not using SNOMED Compositional Grammar.   Like 12345005, 5678004 (which is syntactically invalid according to SCG) or 185324002 |Failed encounter| + 281399006 |Did not attend (finding)| (UK) + 275694009 |Patient defaulted from follow-up (finding)| (this would actually be valid syntax as these are considered to be parents, but would need to come from same hierarchy).  See also 410543007 |Did not attend (qualifier value)|

ML Well expressed post coordinated expressions are allowed in FHIR, but the challenge is what might this mean to some client system.  AP Suppliers are particularly resistant to receiving even the simplest post-coordination and would prefer to have atomic concepts split out to make use of the information model (might even get stored as free text if supplied but unexpected).

PWI Specific example allows for general rules to be determined eg Failed Encounter is redundant due to more specific concept in list, or that we could particularly flag up concepts which come from separate hierarchies as needing intervention.

IPS ValueSet Question raised

15

@Alejandro Lopez Osornio 

https://jira.hl7.org/browse/FHIR-44904.  "Resolve SNOMED Version challenge with value set"

Canada specify version details for each filter in a valueset specification, which then trips validation when the version being expanded against does not match.

DK: If you use extension content then you need to specify the version to know where the concept exists.  Although the lookup will work across multiple versions.   ML:  Note that compose/include/filter descendent of that specifies the core edition, and so it would not include Canadian concepts.   Also, a version - if included - should include the effective time.

Discussion about sending both the local code plus the IPS / International Code using a Codeable Concept (in that case the version element of each code would indicate which one is International.  Or a test could be made for subsumption) which could be determined using (ML supplied) ECL:

See also https://ihtsdo.github.io/iid-ips/ and be aware of new ECL top and bottom operators which could be used to simplify this.

MRCM in FHIR

@Linda Bird (Unlicensed) 

Exposing the MRCM in FHIR

KK Exposing it directly would be difficult because we can return lists of concepts, but we cannot return a string eg ECL

ML Thought it could be exposed via the CodeSystem as another property - metadata about each domain's range.

LB Use case is driving an expression or ECL editor (KK Remember content type).   KK choice between (simple) server statement vs (more work) implicit expansions.

General Discussion

2024-07-03 - SNOMED on FHIR Meeting (TS & TB)

All

Misc Discussion

Internal discussion on languages in general and specifically latin words.  MAL suggested looking at https://iate.europa.eu/home which includes latin.  See Latin Terms - Discussion

Snowstorm-lite revisited (see 2024-01-09 - SNOMED on FHIR Meeting (TS & TB) )

URIs and Identifying Modules - "Edition identifier" - this is the full URI, not just that module. "Most dependant module" - yes but fails in the International Edition.  "Identifying Module". "Root module" - Not always the top/bottom of the hierarchy.

Discussion on adding / removing modules to / from packages.   Check on license conditions allowing for automatic promotion to ensure interoperability.

Discussion on expansion related to 5.2.1.7 Query Specification Reference Set.  ML Could we try to expand the referenced component id, ie look in this refset if no refset members are initially encountered?  MLO Canada is already doing this and they have pre-expanded simple reference sets.  KK Snowstorm does not use this reference set.   LB An extended version of this refset has been drafted which allows the substrate to be specified.  

New Slimline Agenda 

5

@Peter Williams 

See discussion pages for links to archived discussion:  Discussions

Post Coordination

@Kai Kewley 

Moved in from "Potential Topics": 

API for FHIR Resource to SNOMED Expression

See also discussion on URIs for PCEs. 2024-03-05 - SNOMED on FHIR Meeting (TS & TB)

Additional information from ComplexMap $translate

@Daniel Karlsson (Unlicensed) 

ICD-10 Complex Map in ConceptMap$translate (see agenda item 18 2024-03-05 - SNOMED on FHIR Meeting (TS & TB) )

DK Suggests using match.product for each additional item with a URI for each column in refset as per 2.6 URIs for Properties

KK The R4 Products are flat and various ICD-10 rules are grouped.  Example here:  https://snowstorm.ihtsdotools.org/fhir/ConceptMap/$translate?code=421671002&system=http://snomed.info/sct&targetsystem=http://hl7.org/fhir/sid/icd-10

FHIR Resource cross field validation

10

@Marie-Alexandra Lambot

Question:  Can we do cross field validation of FHIR resources, to restrict valueset available for one element dependent on the value entered in some other field.

DK Do this using "Invariants".  See https://build.fhir.org/conformance-rules.html  and https://build.fhir.org/profiling.html#slicing (complex approach!)

ALO FHIR Questionnaires have more support for cross field rules.

LB - would specify this in the Implementation Guide with the specific rules.

@stefan.schulz (Unlicensed) 

ValueSets eg for procedures which recommend SNOMED CT codes that have been retired.

ML: ValueSets described via enumeration will need to be kept updated.  The party that specified the ValueSet is primarily responsible for maintenance.

RC: License requirements do imply that SNOMED CT versions should be kept up to date in systems. 

FHIR in the new SNOMED Implementation course

@Marie-Alexandra Lambot

@Kath Priest  

The new implementation course could focus on SNOMED + FHIR, and transformations between information models, using maybe the Allergy demonstrator as an example. Maybe adding consideration on adding LOINC concepts, like the allergy test using LOINC (Observation in FHIR).

Suggestions: add onset to reactions (date), and use problems already recorded for reactions manifestations, and vice-versa.

Helpful Introduction Videos:

Introduction to SNOMED with FHIR YouTube recordings of Dev Days Presentations:

https://www.youtube.com/watch?v=40Lvv2t8OxU

https://www.youtube.com/watch?v=x6UqJtcJwmQ

https://www.youtube.com/watch?v=8cXRAtNoSvc

Round Table Updates

20

All

See previous updates 2023-07-05 - SNOMED on FHIR Meeting (TS & TB)

Australia  - Sparked FHIR Accelerator Programme - https://confluence.csiro.au/x/39Fqa

• AU CDI – including binding to ValueSets

• AU Core

• eRequesting

• Ontoserver now registered for use with HL7 IG Tooling allowing ECL-based ValueSets in IGs

Austria / Germany - Annotating clinical narratives.  GemText - annotated corpus (annotation using SNOMED CT) relations mapped to SNOMED patterns.   Looking for more support for mapping FHIR ValueSets to SNOMED concepts - particularly when involving negation, would like to collaborate on common solution.

Belgium  - National architecture level work being done, to consolidate regional structures.  Datasets for Allergies and Vaccinations,  Care Plan.  Now working on Medication Resources well in progress, Obs and Conditions followed by Procedures.

Canada  - 

Estonia  - Medication schema nearly complete

Europe - Laboratory Guide published.   Implementation Guide for prescription and dispensation.  Ongoing work for more constrained Lab for cross boarder sharing.    Czech Republic following this course.

France - 

Hong Kong  - 

India  - 

Netherlands  -  Looking for dissemination of patient friendly descriptions + longer explanations.   Using FHIR Supplement.  May look at converting more code systems to FHIR eg IDMP (see @Rutt Lindström)

New Zealand -  Cancer control agency building FHIR / SNOMED platform for sharing cancer data (multiple domains) with query based FHIR Valuesets.  Interested in hearing about: standardizing language reference sets, access to MRCM (see item 20 "MRCM in FHIR" demo being progressed), Concept Maps - logic for dependsOn (see Concept Map in R5) & how to select ValueSets based on context,  Syndication (see https://github.com/IHTSDO/termserver-syndication  but this is not FHIR. FHIR uses more of an NPM approach), Query Specification (Query based reference sets their expansion).

Norway - 

Sweden - Swedish national FHIR profile / Swedish core work restarted, initially on Administration side but also alerting.  IG for Provider directory

Switzerland - 

Snomed International - internal work to reduce configuration using archive hierarchy with cached metadata.  Request for MLDS badges.

Spain  - 

United Kingdom - UK Core based on R4, developing IGs and Profiles.  Medicines, GP Connect Profile, National Terminology Service used for mappings and ECL expansions (looking to use for primary publication point).   Pathology team developed IGs, challenge moving from legacy arrangements.  OpenEHR being revisited.   Interested in SNOMED Extended maps in FHIR (see Concept Map in R5 ) and making it more automatically executable.

United States - US CDI draft of v5.  Cancer on FHIR - connectathon at HIMMS

April 2024 Business Meeting General Discussion Topics 

@Ronald Cornet (Unlicensed) 

@michael lawley 

FHIR for Terminology vs FHIR for Patient Records - eg for cohort identification.  See https://www.hl7.org/fhir/search.html#modifierin can try out on https://hapi.fhir.org/ Also CSIRO Pathling server for analytics 

Navigational ValueSets - how can you express hierarchy and/or grouping in a ValueSet expansion?  Nested code can be used to show hierarchy (navigational concept could be represented as blank).  Question is more about how you initially input that structure such that it would take effect.  Note that valueset composition (valueset containing valuesets) is not sufficient because it does not infer any structure, only membership.   Note that in this context navigational groupers are not considered to be concepts - they don't have a CodeSystem identifier.   SH: users would prefer to search than to navigate their way through a hierarchy to the item they want.  "Picklists" can be considered distinct from ValueSets (adding priority and other properties).  ML Usage in questionnaires.   "The way to do this is in the expansion"  DK Solution also available using Concept map translate given  'source' context, what likely values would be selected in a subsequent field. RH See also ValueSet Concept Order Extension. PWI "Tagging" may be preferred as it allows for multiple dimensions to be represented at the same time ML and also avoids codes appearing multiple times if they belong to more than one group. SH Would like to see standard for wider sharing of resources like reusable UI elements, and avoid overloading FHIR (separation of concerns).  SS Much harder to add semantics to existing data, than it is to enforce the semantics at the point of data capture.

TODO Elicit use cases from @Rutt Lindström 

Condition vs Observation - care plan based on symptom.

Other CodeSystems which reference SNOMED CT

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/

2023-09-19 ML CSCT now has official "Not for Profit" status as an entity.

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.

2023-10-03 ML Ontoserver still a work in progress in this area.

2023-10-22 ML Ontoserver progressing to be trialed during NZ Connectathon in this context.

• Test suite is here: https://github.com/FHIR/fhir-test-cases.git

• They are executed via the valiadtion-cli, something like:
  java -jar org.hl7.fhir.validation.cli-6.1.3-SNAPSHOT.jar -txTests -tx https://r4.ontoserver.csiro.au/fhir

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.

2023-10-03 SI responding to briefing note feedback (including encouragement from UK to engage as a matter of priority).  Discussion expected in both MAG and EAG at October Business Meetings. Two Schools of Thought:  LOINC style single observable hierarchy (order / result) vs. procedure + observable pairs for expressing ordering and results.

2023-10-22 AP <copy from 15:43>

Post R5 Concept Map - support for SNOMED Map features.

@michael lawley 

@Daniel Karlsson (Unlicensed) 

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  

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 (clarified 2023-10-03)

2024-02-14 DK Enquired on status here.  KK has coded some support in R4 but uses comma delimited messaging.   ML Using extension to allow properties in R4 (fully available in R5).  See extension:  http://hl7.org/fhir/5.0/StructureDefinition/extension-ConceptMap.group.element.target.property

See example 1 and example 2 shows multiple groups matching.

Demos showing machine processing of ICD-10 rules:

https://github.com/IHTSDO/snomed-to-icd-10-mapper

https://ihtsdo.github.io/iid-icd-maps/

Discussion on whether or not the Terminology Server should have responsibility for applying the values to the rules to fully identify the correct target of the $translate operation. DK would like to see choice for client to calculate the rules.

Expand Alliance

20

@Marie-Alexandra Lambot 

XpanDH - 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.

2023-10-03 ML News update on course proposals expected for November.  See https://cordis.europa.eu/project/id/101095594

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.

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)

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

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 )

SNOMED FHIR Implementation Guide