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

• 2025-03-18 - SNOMED on FHIR Meeting (TS & TB)

• 2025-03-12 - SNOMED on FHIR Meeting (TS & TB)

• 2025-03-04 - SNOMED on FHIR Meeting (TS & TB)

Other Meetings

10

@Peter Williams

@Rob Hausam

Recent Events:

SNOMED International April 6 - 10 2025 Oslo. SNOMED on FHIR afternoon of Sunday 6.

Future Events:

HL7 May 10 - 16 Madrid + Connectathon (Potential for Terminology Track if sufficient interest - PJ sees need to test Concept Map in R5 and R6)

Vitalis Thursday 22 May.  Workshop with Grahame Grieve - Terminology Track + Federation.  See here

Dev Days 3 - 6 June 2025 Amsterdam

IHE 23 - 27 June https://connectathon.ihe-europe.net/node - 

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 

HL7 Cross group projects : CDA & FHIR Translation Meetings (weekly): @Jay Lyle Going well, there is an implementation guide and the group is doing connectathons. May in Dallas and Minneapolis.  See https://confluence.hl7.org/display/CGP/C-CDA+to+FHIR+and+from+US+Core+Mapping

Hospitals on FHIR, Connectathon, FHIR User Day

Round Table Introductions & Updates

All

Austria - EHR Coding mandated.  Attempting to map ICD-10 to SNOMED CT and also translation

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

@Reuben Daniels NB National Extensions of SNOMED need to transition to be self hosted rather than Tx.fhir.org end of 2024.

CSIRO @michael lawley now representing the NRC.  Terminology Registry - Ontoserver registered as authoritative.  Increasing interest from affiliates.   Interest in LLM for mapping and matching/ranking in VS.   2025 particular focus on VCL (similar to ECL, for FHIR) especially for R6.  2025-04-06 Interest in LOINC.  API usage outside of FHIR ecosystem eg OpenEHR

Austria / Germany - Annotating clinical narratives.  GemTex - 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.  2024-10-20 @stefan.schulz Focus on translation and indexing (interfacing terminology), analysis of clinical narratives AIDVA - Guide for Annotating Clinical Narratives (SCT + FHIR)

B2i @Márk Czotter SnowOwl Terminology Server supporting multiple versions of FHIR at same time.

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. 2025-04-06 E-Prescriptions moving to FHIR.  Considering moving Drug Database to SNOMED.

Canada  - @Linda Bird working with Medicines.  Ontoserver installation. Interest in Parameterized ValueSets (See https://build.fhir.org/ig/FHIR/fhir-tools-ig/parameterized-valuesets.html also https://build.fhir.org/ig/FHIR/fhir-tools-ig/parameterized-valuesets.html ).  Also interest in access the MRCM.   Mapping from Observable Entities to ValueSets, taking dependencies as what was previously entered.

Estonia  - Medication schema nearly complete.  2024-10-20 Ministry of Social Affairs, switching from CDI3 to FHIR.  Issues with document signing on a per Resource basis (possibly enough to prove use of secure gateway), plus issues with data access & permissions.

Europe - Laboratory Guide published 2024-10-20 (@Daniel Karlsson ) Ballot to make Lab work a global standard, some issues representing panels.  IG for European Patient Summary. Group working on VS for Lab.  HL7 Europe projects. "My Health EU" supporting cross border and lab result sharing for 2025 using HL7 Europe IG.   "Extended EHR" - logical models to support prioritised areas eg lab, patient summary and IGs based on same.  2025-04-06 Legislation passed that (in 4 years time) will mandate communication in a standardized manner (FHIR + SNOMED most likely)

France -  @François Macary 

Hong Kong  - 

HL7 May Ballot for comment

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) 2024-10-20 National Terminology Server (Ontoserver) Patient friendly synonyms and explanations. 

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).  @Peter Jordan Affiliate Engagement Group.  Notes that 30% of (personal) primary health record codes did not pass validation.  Recommends LinkedIn FHIR group, see https://www.linkedin.com/in/darrendevitt/ Notes that Tx.fhir.org never supported ECL hence need for National TS to come into play.   See also HealthPoint use of SNOMED CT presentation.

CCA @Linda Bird 2024-10-20 NZHTS National TS (Ontoserver) using CanShare language reference set for patient friendly terms.

Norway - 

Sweden - Swedish national FHIR profile 2024-10-20 HL7 Sweden discussing TS for building Swedish IGs.   Existing TS is MVP so procurement underway with growing requirements.  Alerting work collaborating with Norway eg question of what is alert worthy. 2025-04-06 Swedish eHealth (not the NRC).  Working with HL7 Sweden to set up national terminology server.  Implementing FHIR for national services.

Switzerland - 

SNOMED International - internal work to reduce configuration using archive hierarchy with cached metadata.  Request for MLDS badges. 2025 Work scheduled to bring Snowstorm into line with IG Tooling requirements. See also implementation demos, growing in number, here:  https://ihtsdo.github.io/sct-implementation-demonstrator/#/

Spain  - (SS update) RESQ+ Harmonizing data acquisition forms for stroke, looking to standardize form across several languages.  Difficult to work with clinicians directly in SCT, more success using SCT in FHIR context

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.  2024-10-20 @Stuart Abbott Improved dose syntax.  2025-04-06 progress made particularly on pathology.

Daedelus support services for multiple countries using Ontoserver.  Running "Learnathons" with InterOpen. 

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

Regenstrief @Robert McClure Gravity - Social determinants of care.  Interest in how the MRCM is being applied.

Parameterized ValueSets

@Linda Bird 

@michael lawley 

Parameterized ValueSets (See https://build.fhir.org/ig/FHIR/fhir-tools-ig/parameterized-valuesets.html also https://build.fhir.org/ig/FHIR/fhir-tools-ig/parameterized-valuesets.html )

This extension allows one or more parameters to be passed into a valueset definition such that the underlying code system can be interrogated using the value of parameter to filter the full list down to some subset.

Tx Ecosystem

@Daniel Karlsson 

ML Owner of extension gets to say what the authoratative source for that extension is.

https://tx.fhir.org/tx-reg/

Registration (after proving conformance) is done via a json file - pull request to a GitHub repository

Snowstorm FHIR API Workplan 

@Peter Williams 

@Kai Kewley 

The following Snowstorm FHIR API work is planned for May/June

• Upgrade to HAPI 8.0

• Fix caching of Terminology Capability Statement

• Enhance API to pass tests needed to be used as authoritative source for HL7 IG Tooling

• Documentation & Postman coverage (check we're pointing to the correct repo)

• Exposing LOINC id when working in LOINC Ontology Extension 

• Implicit Concept Map - support for default maps between CodeSystems where an Alternate Identifier file exists

• Support for ECL 2.2 feature that adds support for alternate identifiers

• R5 (not had any requests here, does any user have specific feature requests?).   Consider options for adding eg Map advice in R4 as a compromise or in any event. 

@Kai Kewley would like to see this work completed in Snowstorm-X first, so it can be released and tested prior to being included in Snowstorm.

https://github.com/IHTSDO/snowstorm-x

Concept Maps

All

LOINC Ontology 

@Peter Williams 

http://loincsnomed.org version 1.0 released 2025-03-21

See Surfacing Alternate Identifier Values in FHIR

URI will use the LOINC module http://snomed.info/module/11010000107

RMcL makes distinction between the identifier and the code

See Zulip discussion https://chat.fhir.org/#narrow/channel/179202-terminology/topic/Alternate.20Codes

ECL 2.2 specifies support for Alternate Identifiers see 6.1 Simple Expression Constraints eg LOINC#54486-6 (which would be expanded inline before any further processing is done). DK wondered if this could be used more widely, eg for lookups

ML Suggests that alternate codes in a different CodeSystem  should not be surfaced as an alternate code via a CodeableConcept 

Shrimp exposes "Identifier" as a Coding type, so specifies both that it's the LOINC URI and the code

See also https://chat.fhir.org/#narrow/channel/179166-implementers/topic/Conditional.20additional.20bindings

RMcL Particular interest in the Document Ontology 

European Projects

@Marie-Alexandra Lambot 

Xia (eXpanding Innovation Alliance) European Project - 11 February, starting with review of existing teaching material (to level of BSc) - SNOMED, LOINC & FHIR.  Working in English.   Looking for review, identification of gaps.

2025-04-06 See https://be.linkedin.com/company/csct-be Looking at educating both implementers and Healthcare Professionals.  Looking to take existing materials and transform into micro-courses. https://www.linkedin.com/company/xia-eu-project

MAL To join for an interview of your needs https://forms.office.com/Pages/ResponsePage.aspx?id=gExd0B7a10yDpg0glLIEGC7IDn-Y609HruE58vzlKb9UNUE2MzBZT1oxTlc5NEFBVks0VTBHREZQQy4u

This quick survey of needs that can be shared with users: https://forms.office.com/Pages/ResponsePage.aspx?id=zVoFSJuyw0aY70P78H6TDibonnaXyVZPpjGQQFEwQpxUMkRaUTAwWkpYTEE5RFQxSjhBSFhMSkQ0SC4u

Many thanks for those who will take the time to answer it and you're welcome to join our CSCT pages and the XiA page on LinkedIn to follow the evolution of the project

SS AIDAVA - project in 3rd year, free text annotation. Simple Ontology Co-creation workshop December 2 2025.

Magic Codes Zulip Discussion

@Peter Williams 

@Daniel Karlsson 

@Rob Hausam 

Magic Codes and Observable Entities as Questions and Clinical Findings as Answers

https://chat.fhir.org/#narrow/channel/179166-implementers/topic/SNOMED.20Magic.20Codes.20.28RESTful.20API.20Observation.20Queries.29

Support for Clinicians in using Information Models

@Kusal Wijayaweera 

Suggested resources:

Introduction - Clinical Reference Groups

https://confluence.ihtsdotools.org/display/CP

SNOMED CT Clinical Implementation Guide for Allergy, Hypersensitivity and Intolerance

FHIR Observation Observation VS for Vital Signs

@Rob Hausam 

HL7 Orders and Observations Workgroup looking at Observation profiles for Vital Signs and Value Sets for what is considered to be a vital sign and need to consider SNOMED CT (possibly also NPU) for analogous value sets, started with LOINC.  DK We have looked at this - suggests using the superset of this material and allowing users to work with a cut down set.  Concerns that this might need to be context specific.  SA, UK has also looked at this. 

SH Could take forever to agree a set of vital signs, better to specify archetypes of data required.

Post Coordination

@Feikje Hielkema (Unlicensed) 

Information models as expression of post coordination → classifying to determine equivalence with pre-coordinated content.

Would like to associate a FHIR Resource with a SNOMED Template 

@Linda Bird noted (from previous work done) that the solution involves first defining the template and then working out the transformation to comply with the concept model.   DK notes that this equivalence with the SCT model does not always correspond.  SS notes problem with representing (specifically in modeling/classifying) negation in SCT.

FHR Lack of documentation that explains 'this is how to approach the problem' 

Question on de-labelling allergies

@Kusal Wijayaweera 

PWI Suggested Verification Status = Refuted here: https://build.fhir.org/allergyintolerance.html (DK See previous work done mapping to SCT Free SNOMED CT set for FHIR eg 723511001 | Refuted (qualifier value) | / 410594000 |Definitely NOT present (qualifier value)|)

See also SNOMED CT Clinical Implementation Guide for Allergy, Hypersensitivity and Intolerance

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

HL7 and OpenEHR

@Maryam Razavi 

@Alejandro Lopez Osornio 

https://www.pulseit.news/australian-digital-health/hl7-and-openehr-considering-closer-ties-and-standards-alignment/

https://www.youtube.com/watch?v=qbq-kuWyTcg

Use of Codeable Concept to transmit multiple codes

@Kath Priest 

@Daniel Karlsson 

EU requirements for transmitting closest SNOMED International codes along with relevant local code systems is a great use case for the new ECL Top and Bottom operators.   Having this requirement come from the Member Forum would assist in ensuring that the implementation of this feature into Snowstorm is prioritised.

@Daniel Karlsson 

Note that Top and Bottom operators simplify access, which can be replicated in earlier implementations of ECL with a more complex query:  6.12 Top and Bottom

ALO See also Interoperability Demo (last tab) at https://ihtsdo.github.io/iid-ips/ which offers the closest concept in the IPS Set, along with the ECL used to obtain it.

Translation in Code System Supplements

@Daniel Karlsson 

Translation in Code System Supplements.   See Zulip discussion 

https://chat.fhir.org/#narrow/stream/179202-terminology/topic/CodeSystem.20supplement.20use.20cases

See also https://build.fhir.org/ig/FHIR/ig-guidance/languages.html#creating-a-language-pack

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:  “…alt

hough 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 

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 

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 

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

2025-04-06 - 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 

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 

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.