IHTSDO-161 - Getting issue details... STATUS

SNOMED CT Content Improvement Project Combined Inception and Elaboration phases
Project ID: artf231911 IHTSDO-161 Topic: Radiography versus X-Ray
Date	19 September 2016
Version		1.0 Approved

Version 1.0 artf231911 IHTSDO-161 Radiography vs X-ray CTP Project Combined Inception-Elaboration Phase.pdf

Amendment History

Version	Date	Editor	Comments
0.01	20160531	Maria Braithwaite	First draft for submission
0.02	20160802	Maria Braithwaite	Second draft to incorporate review feedback
1.0	20160919	Maria Braithwaite	Approved version with minor changes

Review Timetable

Review date	Responsible owner	Comments

SNOMED CT® was originally created by the College of American Pathologists.

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Table of Contents

1 Glossary............................................................................................................................................... 5

1.1 Domain Terms................................................................................................................................... 5

2 Introduction.......................................................................................................................................... 6

2.1 Purpose............................................................................................................................................ 6

2.2 Audience and stakeholder domain................................................................................................... 6

2.2.1 Input from stakeholders............................................................................................................... 6

2.2.2 Degree of consensus on the statement of problem..................................................................... 6

3 Statement of the problem or need................................................................................................... 7

3.1 Summary of problem or need, as reported....................................................................................... 7

3.2 Summary of requested solution........................................................................................................ 7

3.3 Statement of problem as understood............................................................................................... 7

3.3.1 Radiographic Procedures Example 1......................................................................................... 8

3.3.2 Radiographic Procedures Example 2......................................................................................... 8

3.3.3 Radiographic Procedures Example 3......................................................................................... 9

3.4 Detailed analysis of reported problem, including background.......................................................... 9

3.4.1 Ambiguous Grouper Concept................................................................................................... 10

3.4.2 Duplicate Synonyms................................................................................................................. 11

3.4.3 Inconsistent Use of Imaging Action.......................................................................................... 11

3.4.4 Inconsistent Naming of Procedures.......................................................................................... 13

3.4.5 Where does ‘Diagnostic’ fit in?.................................................................................................. 14

3.4.6 Plain Film................................................................................................................................. 15

3.4.7 Impact on the Clinical Finding Hierarchy................................................................................. 15

3.5 Subsidiary and interrelated problems............................................................................................. 16

3.5.1 Impact On Hierarchies Other Than Procedure......................................................................... 16

3.5.2 Undesirable Inferred Relationships........................................................................................... 16

3.5.3 Intermediate Primitive Concepts.............................................................................................. 16

3.5.4 Potential duplication................................................................................................................ 16

3.5.5 Miscellaneous Modelling Issues............................................................................................... 17

4 Risks / Benefits................................................................................................................................. 18

4.1.1 Risks of not addressing the problem.......................................................................................... 18

4.1.2 Risks of addressing the problem................................................................................................ 19

5 Requirements: criteria for success and completion................................................................. 21

5.1 Criteria for success/completion...................................................................................................... 21

5.2 Strategic and/or specific operational use cases............................................................................ 21

6 Solution Development..................................................................................................................... 22

6.1 Initial Design.................................................................................................................................... 22

6.1.1 Modelling of Imaging Action.................................................................................................... 22

6.1.2 Description Recommendation.................................................................................................. 26

6.1.3 Text Definition.......................................................................................................................... 27

6.1.4 Significant design or implementation decisions / compromises............................................... 28

6.1.5 Evaluation of Design................................................................................................................ 28

6.2 Iteration One................................................................................................................................ 28

6.2.1 Outline of Revised Design........................................................................................................ 28

6.2.2 Significant Design or Implementation Changes....................................................................... 29

6.2.3 Evaluation of Revised Design................................................................................................... 30

7 Recommendation............................................................................................................................ 32

7.1.1 Initial Detailed Design Specification........................................................................................ 32

7.1.2 Iteration Plan – Updated Detailed Design Specification.......................................................... 32

8 Quality program criteria................................................................................................................... 35

8.1 Quality metrics................................................................................................................................ 35

8.1.1 Quality metric 1........................................................................................................................ 35

8.1.2 Quality metric 2........................................................................................................................ 35

9 Project Resource Estimates.......................................................................................................... 36

9.1 Scope of construction phase......................................................................................................... 36

9.2 Projection of remaining overall project resource requirements...................................................... 36

9.2.1 Expected project resource requirement category..................................................................... 36

9.2.2 Expected project impact and benefit....................................................................................... 36

9.2.3 Indicative resource estimates for construction, transition and maintenance:............................ 36

10 Appendices..................................................................................................................................... 38

10.1 Appendix A................................................................................................................................... 38

10.2 Appendix B................................................................................................................................... 38

10.3 Appendix C................................................................................................................................... 44

10.4 Appendix D................................................................................................................................... 44

1 Glossary

1.1 Domain Terms

Radiography

“Radiography is a broad term that covers several types of studies that require the visualization of the internal parts of the body using x-ray techniques…radiography means a technique for generating and recording an x-ray pattern for the purpose of providing the user with a static image(s) after termination of the exposure…”

http://www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/ucm175028.htm

“Conventional radiography involves the use of x-rays; the term “plain x-rays” is sometimes used to distinguish x-rays used alone from x-rays combined with other techniques (eg, CT). For conventional radiography, an x-ray beam is generated and passed through a patient to a piece of film or a radiation detector, producing an image”

http://www.merckmanuals.com/professional/special-subjects/principles-of-radiologic-imaging/conventional-radiography.

X-ray

“X-ray technology is the oldest and most commonly used form of medical imaging. X-rays use ionizing radiation to produce images of a person’s internal structure by sending X-ray beams through the body, which are absorbed in different amounts depending on the density of the material. In addition, included as “x-ray type” devices are also mammography, interventional radiology, computed radiography, digital radiography and computed tomography (CT).”

Source: http://www.medicalimaging.org/about-mita/medical-imaging-primer/

Plain X-ray

“…The term “plain x-rays” is sometimes used to distinguish x-rays used alone from x-rays combined with other techniques (eg, CT)…”

Source: http://www.msdmanuals.com/en-gb/professional/special-subjects/principles-of-radiologic-imaging/conventional-radiography

2 Introduction

2.1 Purpose

The purpose and scope of this content project is to:

Review the inconsistent naming of ‘X-ray’ and ‘Radiographic imaging’ and ‘Plain X-ray’ concepts that are subtypes of 363680008|Radiographic imaging procedure (procedure) in the procedure hierarchy.
Propose a naming convention in order to improve the representation of these concepts in descriptions and facilitate the drafting of guidance for the Editorial Guide.
Review the inconsistent modelling of ‘X-ray’ and ‘Radiographic imaging’ and ‘Plain X-ray’ concepts that are subtypes of 363680008|Radiographic imaging procedure (procedure) in the procedure hierarchy.
Propose a consistent modelling approach for these concepts in order to improve representation and subsumption and remove duplication.

2.2 Audience and stakeholder domain

The audience for this document includes all standards terminology leaders, implementers and users of SNOMED CT.

A further significant audience is the community of SNOMED CT terminologists that may be requested to implement the recommended specification this includes the IHTSDO Content Team.

2.2.1 Input from stakeholders

Review of some aspects of the proposed solution was sought from a group of expert clinicians in interventional and diagnostic imaging with the assistance of a National Release Centre. Review and input was also sought from within the Consultant Terminologist community.

A review of RadLex (http://www.rsna.org) and DICOM (http://dicom.nema.org) was undertaken to gain a broader perspective of how the area of imaging that is addressed in this document is managed in other terminologies. DICOM has recently signed a collaboration agreement with IHTSDO and so a uniform approach may be of benefit.

It is noted that there are approximately 160 requests in the IHTSDO request portal (SIRS) for new concepts that will fall into the scope of this content project. These new requests are from a variety of National Release Centres and users of SIRS demonstrating that users require content in this area.

2.2.2 Degree of consensus on the statement of problem

This content project is required to address a known content issue that has been acknowledged in the Editorial Guidance, the document states:

“There is a need to differentiate a grouper for all imaging procedures that utilize X-rays, from plain X-rays. The goal for this guidance is plain X-rays of a site. Given the apparent lack of consensus, the solution probably will involve a text definition and a naming convention specific to SNOMED CT, with advice to implementers.” https://confluence.ihtsdotools.org/display/public/EditorialGuide/7.8.1+X-ray+imaging

3 Statement of the problem or need

3.1 Summary of problem or need, as reported

There is inconsistency with naming ‘Radiology of X’ and ‘X-ray of X’ and ‘Plain X-ray of X’ and the modelling of these concepts. Some concepts use the description ‘Radiographic imaging,’ others use ‘X-ray’ or ‘Plain X-ray’ and in some concepts all of these terms are applied synonymously. In many cases the value for the method attribute does not align with the descriptions.

The SNOMED CT Editorial Guide indicates:

7.8.1 X-ray imaging

Two possible approaches have been discussed, and final resolution has not yet been reached.

Option 1:

Descriptions:

FSN: Radiography of X (procedure) PT: Radiography of X

Option 2: Descriptions:

FSN: X-ray of X (procedure) PT: X-ray of X

https://confluence.ihtsdotools.org/display/public/EditorialGuide/7.8.1+X-ray+imaging

3.2 Summary of requested solution

The solution as suggested in the Editorial Guide is to “differentiate a grouper for all imaging procedures that utilize X-rays, from plain X-rays. Given the apparent lack of consensus, the solution probably will involve a text definition and a naming convention specific to SNOMED CT, with advice to implementers.”

https://confluence.ihtsdotools.org/display/public/EditorialGuide/7.8.1+X-ray+imaging

3.3 Statement of problem as understood

In the international edition of SNOMED CT there is inconsistency with naming and modelling of concepts that reference Radiographic imaging, X-ray and Plain X-ray. This is a known issue, the SNOMED CT Editorial Guide states:

“6.2.5.7 Radiographic procedures

| Radiographic imaging procedure | [363680008 | Radiographic imaging procedure |] was created as the top of a hierarchy of imaging procedures utilizing x-rays. | Diagnostic radiologic examination | [38743002] had a synonym of “X-ray”, but this code has been retired because it may have been interpreted more narrowly, in particular because of the possibly narrower interpretation of radiologic versus radiographic, and the possibly narrower interpretation of diagnostic. Nevertheless, the phrase "diagnostic radiography is allowed in many of the FSNs of subtypes of | radiographic imaging procedure |.”

https://confluence.ihtsdotools.org/display/public/EditorialGuide/6.2.5+Specific+procedure+types

The following are examples taken from the January 2016 international release of SNOMED CT:

3.3.1 Radiographic Procedures Example 1

The above example 363680008|Radiographic imaging procedure (procedure) has the Synonym ‘X-ray’ and uses the value 278110001|Radiographic imaging - action (qualifier value) for the Method attribute.

As a result of this the concept has subtypes which include 77477000|Computerized axial tomography (procedure) and 44491008|Fluoroscopy (procedure).

These descendant concepts are logical due to the method applied however the synonym appears to indicate X-ray in its broadest term i.e. an X-ray technique.

3.3.2 Radiographic Procedures Example 2

In this example 168537006|Plain radiography (procedure) has the Synonym ‘X-ray’ and is modelled with an imaging action of 312254007|Plain X-ray imaging - action (qualifier value).

This concept has both Plain X-ray and X-ray as synonyms. One term is broader than the other and it is likely that the interchangeable use of these terms is confusing to both content editors and end users.

3.3.3 Radiographic Procedures Example 3

In this final example 426945003|X-ray of bone (procedure) has both X-ray and Plain X-ray used synonymously in the descriptions. This concept does NOT currently inherit all of the descendant concepts that it should. For example:

241089007|Ilium X-ray (procedure) is NOT currently a descendant of 426945003|X-ray of bone (procedure) it is a sibling. This is because the concept is modelled with a method of 278110001|Radiographic imaging - action (qualifier value). Taking into account the descriptions, the concept was most likely intended to denote a plain X-ray procedure and therefore should be modelled with a method of 312254007|Plain X-ray imaging - action (qualifier value).

Similar examples to these above can be found throughout the hierarchy 363680008|Radiographic imaging procedure (procedure).

3.4 Detailed analysis of reported problem, including background

There may be local preferences that dictate which particular wording a clinician prefers to use. However within SNOMED CT, the fully specified name must “uniquely describe a concept and clarify its meaning…” https://confluence.ihtsdotools.org/display/public/EditorialGuide/7.1.1+Fully+Specified+Name

In the international edition of SNOMED CT, 278110001|Radiographic imaging - action (qualifier value) acts as a grouper for other concepts in the qualifier value hierarchy as demonstrated below:

278110001|Radiographic imaging - action (qualifier value) was most probably originally intended to be used to model concepts that use x-ray imaging of some form and to subsume more granular imaging modality procedures that utilise special equipment such as a computed tomography scanner.

In reality 278110001|Radiographic imaging - action (qualifier value) has been used to model concepts that reference X-ray and the terms ‘X-ray’, ‘radiograph’, ‘radiographic imaging’ and ‘plain X-ray’ are being used synonymously across SNOMED CT as they might be in clinical practice.

The result is inconsistency that can be seen in the hierarchy 363680008|Radiographic imaging procedure (procedure). The key issues to be addressed are outlined in the sections below.

3.4.1 Ambiguous Grouper Concept

363680008|Radiographic imaging procedure (procedure) has 2801 descendant concepts at the time of the January 2016 release. In its broadest interpretation a radiographic imaging procedure “covers several types of studies that require the visualization of the internal parts of the body using x-ray techniques” http://www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/ucm175028.htm

Arguably inclusion of the synonym ‘X-ray’ is a contravention of editorial policy because it is a narrower term that that of the FSN (see Editorial Guide Section 7.4.3 Narrower Synonyms).

https://confluence.ihtsdotools.org/display/public/EditorialGuide/7.4.3+Narrower+synonyms

However it is acknowledged that these terms may be used widely as synonyms in clinical practice. The interchangeable nature of the terms ‘X-ray’ and ‘radiographic imaging procedure’ throughout SNOMED CT was raised with the expert group. The group expressed the opinion that these descriptions are routinely used synonymously in clinical practice in order to denote the same imaging procedure.

3.4.2 Duplicate Synonyms

The concept 168537006|Plain radiography (procedure) has a synonymous description ‘X-ray’ as does its parent concept 363680008|Radiographic imaging procedure (procedure).

‘Roentgenography’ appears on both parent (363680008|Radiographic imaging procedure (procedure)) and child (168537006|Plain radiography (procedure)). The application of the same synonym to both concepts is confusing to users and in contravention of the Editorial Guidance that stipulates

“7.4.2 Synonyms

A synonym is a term with the same meaning as another term…Addition of the same term as a synonym to more than one concept will not usually be acceptable, but of course some terms have more than one meaning…When a term can take more than one meaning, the term may be attached to multiple concepts without violating this rule. Where multiple concepts have an identical term as a synonym, a review will be undertaken to ascertain if the concepts involved are duplicates.

Where the concepts are duplicates, one concept will be retired with a SAME_AS relationship to the concept it duplicated.

Where a term with a single meaning is associated with more than one concept (which are not duplicates), the term should be retained on only one of the concepts and retired on the other(s).

In some cases a general term may be acceptable as a synonym for two or more specific concepts, depending on the context of use to derive proper specificity (e.g. "fundus" in the context of obstetrics vs ophthalmology). It is expected that these occasions will be unusual, and should be highlighted as exceptions, to assist with proper usage. Editorial guidance for broader synonyms should be taken into account.”

https://confluence.ihtsdotools.org/display/public/EditorialGuide/7.4.2+Synonyms

3.4.3 Inconsistent Use of Imaging Action

278110001|Radiographic imaging - action (qualifier value) is a grouper concept and it is assumed it was originally intended to be a supertype for more granular imaging techniques that also utilise X-ray such as computed tomography and mammography. Where the fully specified name describes a particular imaging modality for example ‘Plain X-ray’, the granular subtype of imaging modality should be applied as the method to existing content.

In many instances 278110001|Radiographic imaging - action (qualifier value) has been used as the method for a concept that either only uses X-ray in the descriptions or uses a mix of both X-ray and radiographic imaging in the descriptions. The inappropriate use of 278110001|Radiographic imaging - action (qualifier value) has resulted in suboptimal inferred relationships across the hierarchy.

The following concepts are examples of this from the January 2016 release:

3.4.3.1 Radiography of chest wall (procedure)

Method 278110001|Radiographic imaging - action (qualifier value) and has the synonym ‘X-ray of chest wall. However, this concept is not a descendant of 399208008|Plain chest X-ray (procedure) as end users may expect. Where this concept appears in the clinical record, it is open to interpretation whether the clinician has recorded a procedure that uses X-ray of some type or whether this is a plain X-ray procedure that uses a single imaging modality of X-ray without specialist equipment or contrast media.

3.4.3.2 Soft tissue X-ray chest (procedure)

Uses the method 278110001|Radiographic imaging - action (qualifier value) and as a result the concept is not a descendant of 399208008|Plain chest X-ray (procedure).

3.4.3.3 Whole body X-ray of stillborn infant (procedure)

Uses the term ‘X-ray’ and is modelled with the method 278110001|Radiographic imaging - action (qualifier value).

3.4.4 Inconsistent Naming of Procedures

Across the hierarchy 363680008|Radiographic imaging procedure (procedure) the terms Radiograph, Radiographic Imaging, X-ray, Plain X-ray and Roentgenography are being used synonymously.

An example from the January 2016 release

This concept uses ‘X-ray’ and ‘Radiographic imaging’ synonymously however it is modelled with a method of 312254007|Plain X-ray imaging - action (qualifier value). X-ray is one type of radiographic imaging and so this synonym is more granular than the FSN. There is an approved naming convention for the addition of new content to the diagnostic imaging domain see Editorial Guide 7.8 Naming Conventions for Clinical Imaging Procedures.

The guidance document notes “There are a number of inconsistencies in existing content, but it is not required that these naming conventions necessarily be applied wholesale to that content. It is definitely intended for new content. Changes to existing content to conform to these guidelines will be considered based on value to users.”

https://confluence.ihtsdotools.org/display/public/EditorialGuide/7.8+Naming+conventions+for+clinical+imaging+procedures

3.4.5 Where does ‘Diagnostic’ fit in?

There are a number of concepts in the hierarchy 363680008|Radiographic imaging procedure (procedure) that explicitly use the word ‘Diagnostic’.

For example

32328007|Diagnostic radiography during operative procedure (procedure)

33450004|Diagnostic radiography with special study (procedure)

36004004|Diagnostic tomography (procedure)

There is inconsistency in the application of ‘has intent’ and diagnostic’ and the way this type of content is modelled. For example 27483000|Diagnostic radiography with contrast media (procedure) is marked as fully defined but does not use the 363703001|Has intent (attribute) in its modelling. 60654006|Diagnostic radiography of abdomen (procedure) is marked as fully defined and has the same issue.

Clinical imaging procedures may be divided into ‘diagnostic’ and ‘interventional imaging.’ Diagnostic imaging is used for the purposes of obtaining information for example 305053005|Computed tomography of aorta (procedure)|. Interventional imaging is often used for the purpose of treating a specific condition for example 431749009|Aspiration using computed tomography guidance (procedure)| or obtaining further information such as 277591006|Computed tomography guided biopsy (procedure)|.

For interventional imaging where the explicit procedure intent is guidance, this usually modelled using 363703001|Has intent (attribute) and 429892002|Guidance intent (qualifier value). This attribute and value pair are assigned as part of a relationship group and results in the concept being a descendant of 258174001|Imaging guidance procedure (procedure).

258174001|Imaging guidance procedure (procedure) is a descendant of 362961001|Procedure by intent (procedure).

There are many examples in the hierarchy 363680008|Radiographic imaging procedure (procedure) where ‘diagnostic’ is included in a fully specified name but diagnostic intent is not included in the relationship groups of the concept and this requires further evaluation. There is an existing content project Artf6232 to address the issues around the use of 363703001|Has intent (attribute) and although this is noted as an issue in this content project it is beyond the scope of the problems to be addressed as part of this content project.

3.4.6 Plain Film

The terms ‘Plain film’ and ‘Plain X-ray’ are being used synonymously in the hierarchy 363680008|Radiographic imaging procedure (procedure). The method 312254007|Plain X-ray imaging - action (qualifier value) also stipulates ‘plain.’ There does not appear to be a clinical difference between Plain X-ray and Plain film. This issue was referred to the clinical expert group for opinion who confirmed this assumption. The group also expressed the view that the inclusion of ‘plain’ is superfluous and does not align with clinical parlance. However the group also acknowledged that it is important for the terminology to make some distinction between plain X-ray and its broader interpretations.

Examples from the January 2016 release:

370142005|Plain film of head (procedure)

303938002|Plain film of neck (procedure)

The above concepts are examples of current content that is modelled with a method of 312254007|Plain X-ray imaging - action (qualifier value) however these concepts do not use the term ‘X-ray’ in any description.

This is an issue for search, retrieval of data and audit. It is also possible that this degree of inconsistency in naming will result in the addition of duplicate concepts.

3.4.7 Impact on the Clinical Finding Hierarchy

The issues with modelling in the procedure hierarchy as outlined above have had a considerable impact in the clinical finding hierarchy. In the screenshot below it is demonstrated that the concept 168541005|Plain X-ray result normal (finding) does not subsume a large number of ‘Plain X-ray of X normal (finding)’ concepts.

It is not possible to correct this issue in the Clinical finding hierarchy until the original issue in the procedure hierarchy is rectified.

3.5 Subsidiary and interrelated problems

3.5.1 Impact On Hierarchies Other Than Procedure

The issues found in the procedure hierarchy are perpetuated in the Clinical finding hierarchy as described in the section above. There are also associated problems identified in other hierarchies.

708175003|Diagnostic imaging service (qualifier value) has a descendant concept 310125001|Radiology service (qualifier value).

It is not clear if 310125001|Radiology service (qualifier value) actually means X-ray service or radiographic imaging service. If it means the latter then 310128004|Computerized tomography service (qualifier value) as an example should be a child and not a sibling concept. Also of note 708174004|Interventional radiology service (qualifier value) is a descendant of 708175003|Diagnostic imaging service (qualifier value). Interventional radiology and Diagnostic Imaging are two separate branches in the domain of clinical imaging.

The situation hierarchy has a large number of concepts that refer to unilateral imaging, for example 702005|Unilateral imaging of renal artery (situation). Unilateral content falls into scope for an existing content project artf6236, this content should be reviewed for validity.

3.5.2 Undesirable Inferred Relationships

Where possible all existing content that is a descendant of 363679005|Imaging (procedure) should be reviewed and remodelled to the closest primitive parent with the addition of relationship groups as required. This will ensure that undesirable inferred relationships are removed and optimise subsumption of existing and future content. This matter is being considered and addressed as a separate IHTSDO content project.

3.5.3 Intermediate Primitive Concepts

A number of primitive concepts (some of which are intermediate primitive concepts) have been identified during this review. It would be highly advantageous to review these concepts with the aim of making the concepts fully defined. This would allow the classifier to assign logical inferred relationships.

Examples of these concepts are:

241685002|X-ray photon absorptiometry (procedure)

22760005|Xeroradiography (procedure)

429700005|Radiopharmaceutical imaging (procedure)

442567001|Radiographic imaging of lymphatic system using contrast (procedure)

3.5.4 Potential duplication

As a result of the issues outlined with modelling approach and descriptions, once changes are made and the classifier run equivalency between concepts will be uncovered. Removal of equivalency will contribute to the overall quality of SNOMED CT.

3.5.5 Miscellaneous Modelling Issues

A number of other issues with content in the hierarchy 363679005|Imaging (procedure) have been identified during this review. Whilst these issues are outside the scope for this project, addressing them as part of an overall clean up of the hierarchy will improve the quality.

A few examples of this are:

439101006|X-ray tomography (procedure) is an intermediate primitive which could be fully defined. Is this a dual imaging modality?

Inactivate 303936003|Specific plain X-ray investigations (procedure)

Review 168731009|Standard chest X-ray (procedure) this appears to duplicate the parent concept

Inactivate 55402005|Hospital admission, for laboratory work-up, radiography, etc. (procedure)

4 Risks / Benefits

Achieving a workable solution to this content project is desirable because the concept 363680008|Radiographic imaging procedure (procedure) has 2801 descendants of which 168537006|Plain radiography (procedure) has 175 descendant concepts. 278110001|Radiographic imaging - action (qualifier value) appears more than 1600 times in either the stated or inferred relationships of existing content. It is also demonstrated that the procedure concepts impact content in the Clinical finding hierarchy. Current content contains a mixture of synonyms that are broader or narrower than the fully specified name of the concept and this is accompanied by inconsistent modelling. There are currently around 160 requests in SIRS that reference the words ‘X-ray,’ ‘radiography’ and ‘plain x-ray’ and clear guidance is required if the existing problems are not to be perpetuated.

End users will benefit from resolution of this content project with a solution that ensures that current content aligns with editorial policy and future content development will do the same. Application of a consistent approach will also ensure that duplicate concepts are identified and inactivated.

For those involved in translation, the implementation of a consistent approach to descriptions is likely to reduce anomalies in translated content and may assist with an algorithmic approach to translation.

By addressing this content and the existing new requests, overall quality and consistency of content will be improved. Content in this area is likely to be under increased scrutiny with the New Global Licensing Agreement for SNOMED CT Code Inclusion in the DICOM Standard.

Achieving a workable solution for this content project will also be of benefit to the IHTSDO content team, as the disposition of new requests will be consistent and more efficient. The value of the effort involved with the undertaking of this content project is considerable when considering its likely impact.

4.1.1 Risks of not addressing the problem

The project risk is calculated by utilizing the Project Risk Profile assessment tool as detailed on Page 11 of “A Guide to Stakeholder Engagement” https://confluence.ihtsdotools.org/pages/viewpage.action?spaceKey=CONSULTANTTERMINOLOGISTGROUP&title=Stakeholder++Engagement++Resources

Criteria	Analysis	Score
Number of concepts affected	July 2016 release data: Total number of ‘in scope’ descriptions requiring review– 456 Total number of concepts that use 278110001\|Radiographic imaging - action (qualifier value)\| as the imaging method – 784 Total number of concepts that use 312254007\|Plain X-ray imaging - action (qualifier value)\| as the imaging method - 176	2
Number of users affected	This content is widely used across National Release Centres and other users	2
Changes to vendor software required	The solution is intended to reduce inconsistency in concept descriptions and modelling. There is no requirement for changes to software.	0
Change to concept model	None proposed.	0
Change to content development software or processes	None required.	0
Average score		1

The risk level is assessed as a score of 1, which is medium risk.

If this problem is not addressed end users, vendors, NRC and the IHTSDO content team will remain unclear about editorial policy and this will lead to inconsistent inclusion of content and concept modelling.

In addition to the risks quantified above, not addressing the problem means that X-ray, plain X-ray and radiography concepts will be scattered inconsistently across hierarchies with inconsistency of descendent concepts. User queries for these concepts will consequently be more difficult to formulate, as there will be continue to be inconsistency in the way new content is modelled. In order to capture all instances of ‘radiography’, ‘X-ray’ and ‘plain X-ray’, extraction criteria will need to include different method action attributes.

Clear guidance will assist the content team to add and model new content in a consistent manner that prevents future recurrence of this problem. It is highly desirable to fully define new content in order to harness the benefits of using a classifier, optimise subsumption and eliminate equivalency.

4.1.2 Risks of addressing the problem

There is a large amount of content involved in this content project. Concepts across both the procedure and Clinical finding hierarchies will be impacted. However it is noted that changes to the Clinical finding hierarchy will be mostly the result of changes in inferred relationships from the resolution of existing problems with inheritance. Some review of descriptions may be required to align the clinical finding hierarchy content with the changes made to the procedure hierarchy.

Whilst improvement to the quality and consistency of the content is of benefit to all users, the implementation of proposed changes will result in amendments to released descriptions, modifications to existing hierarchies and inactivation of some released content. This may impact implementations of SNOMED CT.

However the potential negative impact of these factors may be mitigated by

Clinical review of the proposed solution to ensure it is robust reflects clinical practice and does not make assumptions that are not clinically valid.
Provision of detailed release notes when the changes are implemented
Ensuring that all inactivated concepts maintain a historical relationship to an active released concept that the end user can implement in place of the existing concept.
Updating editorial guidance to detail all changes that are made and how content of this nature will be added to SNOMED CT in the future.

5 Requirements: criteria for success and completion

5.1 Criteria for success/completion

All concepts that are in scope for this project will

Be clearly and consistently represented in SNOMED CT
Have descriptions that align to an agreed format
Have stated IS_A relationships, attributes and values that have been assigned in a consistent manner to ensure that classification results in logical inferred relationships.

5.2 Strategic and/or specific operational use cases

This content development project aligns with one of the core principles as outlined in the IHTSDO Strategic Direction 2015-2020 - Quality focused content development with adherence to strict editorial rules.

6 Solution Development

6.1 Initial Design

6.1.1 Modelling of Imaging Action

6.1.1.1 Option One

278110001|Radiographic imaging - action (qualifier value) groups all of the different radiographic procedures that are based on X-ray. The first option is to take the approach that 278110001|Radiographic imaging - action (qualifier value) be used sparingly because it will subsume all concepts that are modelled using a descendant imaging action such as 312251004|Computed tomography imaging - action (qualifier value). The proposal would therefore be to retain a small number of concepts as groupers with a text definition and clear editorial guidance for use and then re-model all granular descendant concepts (procedure with a finding site) to be a type of Plain X-ray.

6.1.1.2 Option Two

The second option is to consider 278110001|Radiographic imaging - action (qualifier value) the same as 312254007|Plain X-ray imaging - action (qualifier value). This would result in wide-scale inactivation of content. All existing content that uses the terms ‘radiograph,’ ‘X-ray’ and plain ‘X-ray’ would be remodelled with a method of 312254007|Plain X-ray imaging - action (qualifier value). This would have a large-scale impact across the imaging procedure hierarchy and require wider assessment and consultation. As demonstrated throughout this document, it is also the approach that is least aligned with clinical practice as there is a place for both ‘radiographic imaging’ procedures and ‘plain X-ray’ procedures as separate entities within SNOMED CT.

6.1.1.3 Modelling Recommendation

The initial recommendation is that ‘Option One’ be initiated, 278110001|Radiographic imaging - action (qualifier value) will group all of the different radiographic procedures that are based on X-ray. The following concepts should utilise the action 278110001|Radiographic imaging - action (qualifier value) and act as grouper concepts:

363680008|Radiographic imaging procedure (procedure)

108273007|Radiographic imaging procedure by site (procedure)

418542003|Radiologic guidance procedure (procedure)

27483000|Diagnostic radiography with contrast media (procedure)

The current descendants of these concepts are mostly localised with a body structure, which suggests that the original intent was ‘plain X-ray’ imaging of a particular structure and not a higher-level grouper.

It is therefore recommended that with the exception of the four grouper concepts listed above 312254007|Plain X-ray imaging - action (qualifier value) should be used as the method to model imaging procedures that currently contain the words ‘radiographic imaging,’ ‘radiography’, ‘X-ray’ or ‘plain X-ray’.

This proposal would rectify existing inconsistencies in the current modelling of content that is resulting in unwanted inferences. For example in the January 2016 release 277666002|X-ray guided biopsy (procedure) is a sibling of 277673007|Plain X-ray guidance (procedure). It would be expected that the 277666002|X-ray guided biopsy (procedure) be a child of 277673007|Plain X-ray guidance (procedure).

By remodelling the concept 277666002|X-ray guided biopsy (procedure) to have an method of 312254007|Plain X-ray imaging - action (qualifier value), subsumption is improved

It is however acknowledged that there are areas of the content where this change would have considerable impact.

The concept 268425006|Pelvis X-ray (procedure) is modelled with the method 278110001|Radiographic imaging - action (qualifier value) and so has descendants that include 169071000|Computed tomography of pelvis (procedure).

If 268425006|Pelvis X-ray (procedure) is remodelled to the imaging action of 312254007|Plain X-ray imaging - action (qualifier value) this will result in equivalency between 268425006|Pelvis X-ray (procedure) and 713021002|Plain radiography of pelvis (procedure).

The current grouper concept 268425006|Pelvis X-ray (procedure) will be remodelled or inactivated which will result in changes to the inferred relationships for descendant concepts.

This factor is replicated throughout the hierarchy with another similar example:

424398008|Radiographic imaging of bone (procedure)

426945003|X-ray of bone (procedure)

In order to test the impact of the proposed change, one small area of content was remodelled

1225002|Radiography of humerus (procedure) which has the descendant concept 713026007|Plain x-ray of humerus (procedure)

There is equivalency between 1225002|Radiography of humerus (procedure) and

713026007|Plain x-ray of humerus (procedure) after the changes are implemented, 713026007|Plain x-ray of humerus (procedure) is to be retired with a SAME_AS relationship to 1225002|Radiography of humerus (procedure).

After implementing the proposed change the hierarchy looks like this.

The concept 1225002|Radiography of humerus (procedure) has been remodelled with a method of 312254007|Plain X-ray imaging - action (qualifier value) and a FSN of X-ray of humerus (procedure)

Stated view

Inferred view

It is arguable that both concepts could be maintained, both modelled with different imaging modality and also following an agreed description convention. However this option is likely to persist the existing problems of duplication and confusion across the hierarchy. The addition of high-level grouper concepts cannot be entirely prohibited and could be added on request if there is a specific use case to be supported.

713026007|Plain x-ray of humerus (procedure) is a new addition to the January 2016 release, this is despite the presence of the existing concept 1225002|Radiography of humerus (procedure) which has a synonym of X-ray of humerus. This supports the assertion that there is confusion for both editors and users of SNOMED CT with the current content in this area.

The recommended action would resolve the issue with duplication and ambiguous interchangeable use of descriptions and so improve overall quality in this area of SNOMED CT.

6.1.1.4 Associated Modelling Recommendation

Also of note is the presence of a number of concepts that do not make reference to a specific imaging modality in their fully specified name and have their own naming convention of ‘gram’ or ‘graphy’.

For example 168854009|Cystogram (procedure) is modelled with an action of radiographic imaging and subsumes more granular concepts

It would be advantageous to review this type of concept to ensure that the concepts have an unambiguous fully specified name and are fully defined where possible. The expert group were consulted about the above example and advised that this procedure should have its descriptions refined with a specific imaging modality 278110001|Radiographic imaging - action (qualifier value)| as the presence of a concept that does not incorporate a specific imaging modality into its descriptions is ambiguous to end users who may be unsure which concept they should choose.

6.1.2 Description Recommendation

As demonstrated, across SNOMED CT there is variation in the naming convention that has been implemented into the FSN. It is recommended that X-ray of X (procedure) be implemented for concepts that use the terms ‘radiographic imaging,’ ‘radiography,’ ‘X-ray’ and ‘plain X-ray’ with the following exceptions:

363680008|Radiographic imaging procedure (procedure)

108273007|Radiographic imaging procedure by site (procedure)

418542003|Radiologic guidance procedure (procedure)

27483000|Diagnostic radiography with contrast media (procedure)

Note: a small number of further concepts may not align with the proposed naming convention for example 241209000|Sinogram (procedure) however the FSN should incorporate an imaging modality and these concepts can be treated on a case by case basis as exceptions.

It is recommended the descriptions follow this pattern:

FSN: X-ray of X (procedure)

Preferred term: X-ray of X

Acceptable synonyms:

Plain X-ray of X

Plain film of X

Plain radiography of X

However it is not compulsory to add these variations to a new concept they can be added upon request. Note: the expert group indicated that ‘plain’ is not commonly used within the clinical environment however this may vary from country to country.

Radiograph of X is a broader synonym and therefore should not be accepted as a new synonym for concepts that have the FSN X-ray of X. However instances of released concepts where this description already exists should remain active to prevent the need for large-scale retirements assuming that the synonym only appears on that single concept. Maintaining the broader synonyms will facilitate searching. This information should be incorporated into the editorial guide.

RadLex http://www.radlex.org/RID/RID10351 uses the naming convention of ‘Radiography.’ However the method of image capture (screen film or digital) is listed as a separate entity and this differs from the convention in SNOMED CT. Also of significance RadLex uses a post-coordinated approach where the imaging site and imaging modality are coded separately.

DICOM http://www.dicomlibrary.com/dicom/modality/ also uses the name “Radiographic imaging” for its imaging procedures and this encompasses conventional film/screen image capture. The question of whether there is a requirement to distinguish between digital and conventional film capture in SNOMED CT was raised with the expert group who advised that the imaging procedure itself is not altered by the method of storage for the image. The group did not advocate the inclusion of new content for digital or conventional image capture.

Duplicate synonyms across separate concepts are not acceptable except in very rare cases as described in the editorial guidance. Instances of duplication will require inactivation of descriptions. So for example 168537006|Plain radiography (procedure) has a synonymous description ‘X-ray’ as does its parent concept 363680008|Radiographic imaging procedure (procedure) and ‘Roentgenography’ appears on both parent (363680008|Radiographic imaging procedure (procedure)) and child (168537006|Plain radiography (procedure). Application of the existing editorial guidance for broader and narrower synonyms will assist in determining which concept should retain the duplicate synonym and which should be inactivated.

6.1.3 Text Definition

It is recommended that a text definition be applied to the concepts 278110001|Radiographic imaging - action (qualifier value) and 312254007|Plain X-ray imaging - action (qualifier value) and also to the concepts 363680008|Radiographic imaging procedure (procedure) and 168537006|Plain radiography (procedure) to prevent future inconsistency in the manner these concepts are used.

6.1.4 Significant design or implementation decisions / compromises

Addressing any inconsistency in released concepts may require changes to way the concept is modelled or changes to descriptions. This is likely to result in changes to inferred relationships after classification. As noted above, in order to resolve this content issue it is recommended that changes be made to the descriptions and modelling of existing content rather than the large scale inactivation and replacement of content. It is likely that the proposed changes will uncover equivalency between released concepts and this will need to be managed using inactivation and historical relationships. The impact of the proposed changes on end users is difficult to assess however the benefits of improvement in the quality of existing content without large scale inactivations is intended to mitigate any associated implementation burden.

6.1.5 Evaluation of Design

6.1.5.1 Exceptions and Problems

Generally where a concept has a mixture of descriptions and is also inconsistent in the way in which its attribute and value pairs have been assigned, it would be considered to be ambiguous. This would lead to concept inactivation. The recommendations of this content project do not include large-scale inactivation of existing inconsistent content. However this will result in changes to released FSN that cannot be considered to be minor as defined in the Editorial Guidance https://confluence.ihtsdotools.org/display/public/EditorialGuide/7.3.1+Minor+changes+in+the+Fully+Specified+Name

6.2 Iteration One

6.2.1 Outline of Revised Design

After initial review of this inception/elaboration document, ‘Option Three’ has been added.

It is noted that in the clinical environment ‘plain X-ray’ may be used to refer to X-ray examinations that

1) Do not need special equipment (like the CT scanner)

2) Do not involve the use of radiologic contrast.

Therefore it is justifiable to consider the need to retain the distinction between radiographic imaging as a grouper for several different imaging procedures and its more granular descendant of Plain X-ray.

Option three

Retain 278110001|Radiographic imaging - action (qualifier value)| and 312254007|Plain X-ray imaging - action (qualifier value)|.
Interpret ‘X-ray’ as synonymous with 278110001|Radiographic imaging - action (qualifier value)|.
Note that 312254007|Plain X-ray imaging - action (qualifier value)| has a more specific clinical meaning than its supertype.
312254007|Plain X-ray imaging - action (qualifier value)| will remain a subtype of 278110001|Radiographic imaging - action (qualifier value)|.
A text definition should be added to both of these concepts.

This option would align most closely with the existing content and would therefore prove least disruptive to the known large-scale implementations of imaging content in member countries that include Canada and the UK.

6.2.2 Significant Design or Implementation Changes

278110001|Radiographic imaging - action (qualifier value) will continue to group all of the different radiographic procedures that are based on X-ray. 312254007|Plain X-ray imaging - action (qualifier value)| will be used as the method for any procedure that uses a single imaging modality of plain X-ray without use of special equipment.

Where an active concept utilises the words ‘X-ray of X’ in its descriptions, it could be considered ambiguous because this term clinically may mean ‘any radiographic imaging procedure that uses X-ray’ or it may mean specifically a plain X-ray.

However implementation of this interpretation would result in the large scale inactivation of content that uses the term ‘X-ray of X.’ As an alternative it is recommended that a review of all content that uses the terms ‘Radiographic imaging of X’, ‘X-ray of X’ and ‘Plain X-ray of X’ and ‘Radiography of X” in their descriptions be undertaken. Where a concept is a grouper and utilises the term ‘Radiographic imaging’ in the fully specified name along with the imaging action 278110001|Radiographic imaging - action (qualifier value)| this concept can be retained with a change to the FSN to become “Radiography of X’. Detailed information about the management of the descriptions in these concepts can be found in Section 7.1.2.

Where two concepts exist for example 1225002|Radiography of humerus (procedure)| and 713026007|Plain x-ray of humerus (procedure)| both concepts will be retained with the proviso that both concepts are modelled with the correct imaging method and there is no duplication of synonyms across both concepts.

In cases such as 268425006|Pelvis X-ray (procedure)| this concept is a high level grouper but has a subtype of 713021002|Plain radiography of pelvis (procedure)|, these concepts will be renamed.

I. 268425006|Pelvis X-ray (procedure)| will be amended to Radiography of pelvis (procedure)

II. 713021002|Plain radiography of pelvis (procedure) will be amended to Plain X-ray of pelvis (procedure)

The actions as set out in point 6 are to be replicated across existing in scope content, this will rectify existing inconsistencies with active concepts.

It is noted that there are exceptions that cannot be modelled in this way for example 168821007|Barium swallow (procedure)| which is a descendant of 34885003|Radiography of esophagus (procedure)|. These exceptions can be reviewed on a case-by-case basis to identify if any improvements are required to either the descriptions or relationship groups. This work is already being undertaken as part of the IHTSDO quality improvement schedule.

6.2.3 Evaluation of Revised Design

6.2.3.1 Exceptions and Problems

There are a number of imaging procedures that cannot be named to align with a pattern of “Radiography of X’ or Plain ‘X-ray of X’. Examples of types of procedures include Cineradiography of pharynx, Angiocardiography by cineradiography, Xeroradiography. However whilst these types of procedure cannot conform to a specified naming convention for procedures, it is possible to ensure that their imaging action model is accurate and this is recommended.

6.2.3.2 Design Strengths

The recommended solution follows the conventional and existing approach to concept modelling, and applying this approach consistently to all in scope content will ensure that any existing inconsistencies that can be resolved are resolved. Rigor in the logic applied will improve the outputs of queries for end users.

This new proposal will reduce the number of inactivations required across content whilst improving consistency and removing any areas of duplication or ambiguity.

6.2.3.3 Design Weaknesses

There will be a requirement to ‘interpret’ existing content in order to align descriptions with the method of imaging action. This will mean that the fully specified name of some concepts will need to be inactivated and replaced with a new description. This does not align with the editorial guidance that relates to minor “allowable changes’ for the fully specified name.

There is the risk that the problems that already exist with the interpretation of radiographic imaging, X-ray and plain X-ray will be perpetuated in future new content.

6.2.3.4 Design Risks

Description of risk	Importance	Mitigation plan
Misinterpretation of existing content	Major	All in scope active concepts will be reviewed to align descriptions with imaging action. These changes will be peer reviewed.
Uncertainty across users and implementers about which concept to choose	Major	Use of text definitions Consistent pattern to align existing content Publication of editorial guidance
Change to existing content will impact clinical usage where a procedure has been recorded with the intention of it being a plain X-ray and then it changes to a radiographic imaging procedure – grouper concepts should not be used for reporting.	Major	Radiographic imaging is a grouper, guidance should include advice to avoid use in clinical data entry, as it is not possible to identify the specific image utilised. Guidance to include information that future data entry should use specific imaging modality and not grouper concepts. New concepts should align with the new guidance with clarification sent to requesters to ensure that the correct imaging modality is assigned at the time of authoring.
Risk of perpetuation of existing inconsistencies when adding new content new content	Major	Use of text definitions Efforts to align the existing content to the proposed conformant pattern. Publication of editorial guidance Adherence to editorial guidance and quality assurance review of new content.

7 Recommendation

7.1.1 Initial Detailed Design Specification

Review the inconsistent naming of ‘Radiographic imaging,'‘X-ray’ and ‘Radiographic imaging’ and ‘Plain X-ray’ concepts in the procedure hierarchy.

Propose a naming convention in order to improve the representation of these concepts in descriptions.

The descriptions will follow this pattern:

FSN: X-ray of X (procedure)

Preferred term: X-ray of X

Acceptable synonyms will include Plain X-ray of X, Plain film of X, Plain radiography of X however it is not compulsory to add these variations to a new concept they can be added upon request.

Radiograph of X is a broader synonym and therefore should not be accepted as a new synonym. However instances of released concepts where this description already exists should remain active to prevent the need for large-scale retirements of descriptions with the associated implementation burden this inevitably brings. This information should be incorporated into the editorial guide.

Duplicate synonyms on separate concepts are not acceptable unless the circumstances are exceptional and therefore instances of this will result in inactivation of descriptions.

Review the inconsistent modelling of ‘X-ray’ and ‘Radiographic imaging’ and ‘Plain X-ray’ concepts in the procedure hierarchy. It is recommended that the following concepts should utilise the action 278110001|Radiographic imaging - action (qualifier value) and act as grouper concepts:

363680008|Radiographic imaging procedure (procedure)

108273007|Radiographic imaging procedure by site (procedure)

418542003|Radiologic guidance procedure (procedure)

27483000|Diagnostic radiography with contrast media (procedure)

Propose a consistent modelling approach in order to improve the representation and subsumption of these concepts and remove duplication. It is recommended that with the exception of the four grouper concepts listed above 312254007|Plain X-ray imaging - action (qualifier value) should be used as the imaging action for X-ray imaging procedures..

Draft editorial guidance will be a brief summary of these recommendations.

7.1.2 Iteration Plan – Updated Detailed Design Specification

Review the inconsistent naming of ‘X-ray’ and ‘Radiographic imaging’ and ‘Plain X-ray’ and “Radiography” concepts in the procedure hierarchy.

Find all concepts with the fully specified name ‘X-ray of X (procedure), Plain X-ray of X (procedure) and ‘Radiographic imaging of X (procedure)’ and ‘Radiography of X (procedure).

Appendix A - lists all concepts that include ‘Plain X-ray’ in the FSN (total 21 concepts)

Appendix B – lists all concepts that include ‘X-ray’ minus the word ‘plain’ in the FSN (total 244 concepts)

Appendix C – lists all concepts that include ‘Radiographic imaging’ in the FSN (total 18 concepts)

Appendix D – lists all concepts that include ‘Radiography’ in the FSN (total 173 concepts).

Identify the meaning of each concept based on its position in the hierarchy and the imaging action assigned in the relationship groups. Synonyms may assist with this however these are not to be used in isolation.

Remodel inconsistent concepts to ensure that the description matches the assigned imaging modality. The bulk of the problem lies in the confusion between ‘X-ray’ and ‘Radiography’. In order to rectify this it is recommended that ‘X-ray of X’ should no longer be allowed as a fully specified name. Either ‘Radiography of X’ or ‘Plain X-ray of X’ should be used, depending on the intended meaning as reflected in the modelling.

For example:

‘X-ray of rib (procedure)’ should be renamed ‘Plain X-ray of rib (procedure)’ because method is Plain X-ray imaging; whereas ‘Radiography of ribs (procedure)’ can remain unchanged.

Similarly, ‘X-ray of cervical spine (procedure)’ should be renamed ‘Plain X-ray of cervical spine (procedure)’ to distinguish it from ‘Radiography of cervical spine (procedure)’ which will be unchanged.

a) Where a concept has ‘Plain X-ray’ in the fully specified name, then the imaging action assigned should be 312254007|Plain X-ray imaging - action (qualifier value)|.

b) Where the concept has ‘Radiographic imaging’ in the fully specified name, the imaging action should be 278110001|Radiographic imaging - action (qualifier value)|. The fully specified name should be changed to ‘Radiography of X.’

c) Where a concept has 'X-ray’ in its fully specified name, the FSN must align with its intended meaning. For example 268425006|Pelvis X-ray (procedure)| should have its FSN changed to Radiography of pelvis (procedure) to align with the concept modelling and its position as a grouper. This may be a contentious change and retirement of the example concept as ambiguous with a replacement concept Radiography of pelvis (procedure) is likely to be a safer alternative.

d) Notable exceptions: for example 168537006|Plain radiography (procedure)| is a plain X-ray procedure but uses radiography in its FSN and acts as a grouper for many plain X-ray procedures. This concept should have its FSN changed to Plain X-ray (procedure).

The term ‘X-ray’ may only be used as a synonym for concepts that use 278110001|Radiographic imaging - action (qualifier value)|, for all other instances where this term has been applied, the description should be inactivated on the basis of a broader synonym being applied to the concept (see editorial guidance https://confluence.ihtsdotools.org/display/EditorialGuide/7.4.4+Broader+synonyms)

Add a text definition to the concepts 278110001|Radiographic imaging - action (qualifier value) and 312254007|Plain X-ray imaging - action (qualifier value) and also to the concepts 363680008|Radiographic imaging procedure (procedure) and 168537006|Plain radiography (procedure) to prevent future inconsistency in the manner these concepts are used.

Propose a brief summary of the above information to be incorporated into the editorial guidance.

8 Quality program criteria

8.1 Quality metrics

8.1.1 Quality metric 1

Component

Characteristic and Description

Metric

Target

Result

Logic definitions of descendants of 363680008|Radiographic imaging procedure (procedure)

Char:

sufficiently defined

Existing concepts to be reviewed, the method action changed as detailed in recommendation (see Section 7.1.2)

95%

Descr:

Concept logic definitions should be “defined” not “primitive”

8.1.2 Quality metric 2

Component

Characteristic and Description

Metric

Target

Result

Fully specified names in descendants of 363680008|Radiographic imaging procedure (procedure)

Char:

Adherence to terming guidelines

Review all existing concepts and make change to descriptions as required (see section 7.1.2)

95%

Descr:

The fully specified name should adhere to terming guidelines listed in the editorial guide

9 Project Resource Estimates

Estimated project size medium.

Changes to the procedure hierarchy will also impact on the clinical finding hierarchy however these changes are inferred changes and will be implemented by the classifier.

The changes can be implemented over two releases using an algorithmic approach to description changes and also to the method value. This would require assistance from the technical team.

9.1 Scope of construction phase

The proposed solution is detailed in Section 6 of this document with recommendations detailed in Section 7. The scope of the initial phase of this content project will be to review all existing content in order to align the relationship groups and descriptions as set out in Section 7 where possible. The in scope descriptions for review as part of this project are detailed in Appendices A, B, C and D and totals 456 concepts. This would represent the first phase of implementation to be undertaken in one release cycle.

The second phase will be to review all existing requests for new content currently in SIRS and would be undertaken in the subsequent release after completion of phase one to ensure that the released changes are implemented and allow time for stakeholder feedback.

To prevent recurrence of the problem the editorial guide must be aligned with the recommendations of Section 7 to ensure that modellers and requestors are supported by documentation.

9.2 Projection of remaining overall project resource requirements

9.2.1 Expected project resource requirement category

This content project in isolation does not require project management and can be implemented by the content team. However, implementation of this content project would be resource intensive and requires input from the technical team in order to make large-scale changes to both descriptions and relationships to prevent the need for multiple manual editing changes. Quality review of the changes will be required and this will be a labour intensive activity.

9.2.2 Expected project impact and benefit

It is acknowledged that changes to this area of content do not appear to be a high priority with end users, perhaps because issues with coding in this area of imaging have a lower financial impact. However the problems as outlined in this project are not confined to one area of SNOMED CT, the procedure hierarchy impacts on the clinical finding and situation hierarchy. The implementation of this project will benefit end users by improving the quality of existing and future content.

9.2.3 Indicative resource estimates for construction, transition and maintenance:

Approximately 456 existing concepts to be reviewed and changes made where necessary. Likely resource requirements for this are as follows:

456 existing concepts to be reviewed and changes made to align with new policy at a rate of 20 concepts per day would mean that one terminologist could implement the required changes in 9 working weeks. As outlined above, this estimate could be substantially reduced if the data changes are implemented directly by the technical team and then reviewed by a content editor prior to release.

Existing SIRS requests (approximately 160 requests) are to be reviewed and added to SNOMED CT.

Maintenance is not required assuming that going forward new content follows the recommended approach for term construction and modelling.

10 Appendices

10.1 Appendix A

All concepts that have ‘Plain X-ray’ included in the FSN

426296008	Plain x-ray of joint (procedure)
713023004	Plain x-ray of upper limb (procedure)
713024005	Plain x-ray of wrist (procedure)
713025006	Plain x-ray of elbow (procedure)
713026007	Plain x-ray of humerus (procedure)
713027003	Plain x-ray of hand (procedure)
713028008	Plain x-ray of scapula (procedure)
713565002	Plain X-ray of abdomen with contrast (procedure)
713701007	Plain X-ray of ventriculoperitoneal shunt (procedure)
168565008	Plain X-ray base of skull (procedure)
168566009	Plain X-ray facial sinuses (procedure)
168619004	Plain X-ray head of humerus (procedure)
168620005	Plain X-ray shaft of humerus (procedure)
168637003	Plain X-ray radius (procedure)
168663008	Plain X-ray head of femur (procedure)
168665001	Plain X-ray shaft of femur (procedure)
168702005	Plain X-ray abdomen (procedure)
277673007	Plain X-ray guidance (procedure)
303936003	Specific plain X-ray investigations (procedure)
303937007	Plain X-ray techniques (procedure)
428907005	Plain X-ray guided wire localization of breast lesion (procedure)

10.2 Appendix B

All concepts that have ‘X-ray’ minus the word ‘plain’ in the FSN

1597004	Skeletal X-ray of ankle and foot (procedure)
5433008	Skeletal X-ray of lower limb (procedure)
22791004	X-ray of lumbosacral spine (procedure)
24200008	Calculus analysis, quantitative, X-ray diffraction (procedure)
38336006	Soft tissue X-ray of chest wall (procedure)
39714003	Skeletal X-ray of wrist and hand (procedure)
40064005	Soft tissue X-ray of face, head AND neck (procedure)
40348008	Skeletal X-ray of pelvis and hip (procedure)
48966008	Skeletal X-ray of shoulder and upper limb (procedure)
49856005	Soft tissue X-ray of lower limb (procedure)
55965002	X-ray of skull (procedure)
60668004	Soft tissue X-ray of abdominal wall (procedure)
70780000	Skeletal X-ray of elbow and forearm (procedure)
72872009	Skeletal X-ray of upper limb (procedure)
81380004	Electron microscopy study, scanning, with X-ray analysis, examination and report (procedure)
83641009	X-ray of epididymis and vas deferens (procedure)
168558000	Ethmoid sinuses X-ray (procedure)
168559008	Frontal sinuses X-ray (procedure)
168560003	Maxillary sinuses X-ray (procedure)
168564007	Mastoid processes X-ray (procedure)
168573004	Atlantoaxial X-ray (procedure)
168594001	Clavicle X-ray (procedure)
168599006	Sternoclavicular joint X-ray (procedure)
168600009	Thoracic inlet X-ray (procedure)
168609005	Symphysis pubis X-ray (procedure)
168623007	X-ray shaft of radius/ulna (procedure)
168632009	Stress X-ray shoulder joint (procedure)
168633004	Acromioclavicular joint X-ray (procedure)
168654006	Stress X-ray thumb (procedure)
168664002	Femoral neck X-ray (procedure)
168669007	Patella X-ray (procedure)
168681006	Stress X-ray knee (procedure)
168682004	Stress X-ray ankle joint (procedure)
168713008	Soft tissue X-ray face (procedure)
168716000	Ear soft tissue X-ray (procedure)
168717009	Soft tissue X-ray nose (procedure)
168719007	Neck soft tissue X-ray (procedure)
168722009	X-ray cervical lymph nodes (procedure)
168723004	Soft tissue X-ray thyroid (procedure)
168725006	Soft tissue X-ray mouth (procedure)
168729000	Soft tissue X-ray tongue (procedure)
168731009	Standard chest X-ray (procedure)
168736004	Soft tissue X-ray chest (procedure)
168743005	Soft tissue X-ray pleura (procedure)
168744004	Soft tissue X-ray heart (procedure)
168745003	Soft tissue X-ray thoracic aorta (procedure)
168746002	Soft tissue X-ray diaphragm (procedure)
168759005	Abdominal obstetric X-ray (procedure)
168760000	Obstetric X-ray - fetus (procedure)
168763003	Upper abdomen soft tissue X-ray (procedure)
168764009	Cardioesophageal X-ray (procedure)
168766006	Liver soft tissue X-ray (procedure)
168767002	Spleen soft tissue X-ray (procedure)
168770003	Soft tissue X-ray kidney (procedure)
168772006	X-ray male external genitalia (procedure)
168773001	X-ray female external genitalia (procedure)
168775008	Soft tissue X-ray limbs (procedure)
168779002	Soft tissue X-ray lymph nodes (procedure)
168780004	Soft tissue X-ray veins (procedure)
168781000	Soft tissue X-ray arteries (procedure)
169116004	X-ray of pathological specimen (procedure)
169279005	X-ray fluorescence spectrometry (procedure)
169291001	X-ray beam therapy (procedure)
169293003	Superficial X-ray therapy 10-60 kV (procedure)
169295005	Deep X-ray therapy 150-400 kV (procedure)
169297002	Short distance X-ray therapy (procedure)
169298007	Intracavitary X-ray therapy (procedure)
169299004	Combined X-ray therapy (procedure)
171229005	Screening chest X-ray (procedure)
183830008	Refer for X-ray (procedure)
228662001	Betatron X-ray therapy (procedure)
228663006	Microtron X-ray therapy (procedure)
228664000	Van der Graaff X-ray therapy (procedure)
228707002	Radiotherapy planning using a simulator X-ray film (procedure)
241034009	Skull vault X-ray (procedure)
241035005	Internal auditory meatus X-ray (procedure)
241036006	External auditory meatus X-ray (procedure)
241037002	X-ray of eye for foreign body (procedure)
241038007	Sphenoid sinuses X-ray (procedure)
241040002	Cephalometry X-ray (procedure)
241042005	Mandible X-ray posteroanterior (procedure)
241044006	Mandible X-ray oblique lateral (procedure)
241045007	Styloid process X-ray (procedure)
241046008	Dental X-ray bitewing (procedure)
241047004	Dental X-ray periapical (procedure)
241048009	Dental X-ray occlusal (procedure)
241049001	Maxillary occlusal X-ray (procedure)
241050001	Mandibular occlusal X-ray (procedure)
241051002	Tangential X-ray of incisor and canine (procedure)
241059000	Obstetric X-ray - placenta (procedure)
241062002	Gallbladder straight X-ray (procedure)
241063007	Bicipital groove X-ray (procedure)
241066004	Ulna groove X-ray (procedure)
241069006	Ulna X-ray (procedure)
241071006	Scaphoid X-ray (procedure)
241072004	Carpal tunnel X-ray (procedure)
241073009	Metacarpal X-ray (procedure)
241074003	Thumb X-ray (procedure)
241075002	Femur X-ray (procedure)
241076001	Tibia and/or fibula X-ray (procedure)
241077005	Tibia X-ray (procedure)
241078000	Fibula X-ray (procedure)
241079008	Metatarsal X-ray (procedure)
241080006	Tarsus X-ray (procedure)
241081005	Hindfoot X-ray (procedure)
241082003	Hallux X-ray (procedure)
241083008	Foot X-ray orthopedic/biomechanical examination (procedure)
241085001	Subtalar joint X-ray (procedure)
241088004	Ischium X-ray (procedure)
241089007	Ilium X-ray (procedure)
241090003	Perineum X-ray (procedure)
241091004	X-ray pelvimetry (procedure)
241092006	Cervicothoracic junction X-ray (procedure)
241093001	Thoracolumbar spine X-ray (procedure)
241094007	Scoliosis survey X-ray (procedure)
241109006	Pelvic soft tissue X-ray (procedure)
241110001	Genitalia soft tissue X-ray (procedure)
241111002	Bronchus soft tissue X-ray (procedure)
241112009	Lung soft tissue X-ray (procedure)
241113004	X-ray of soft tissue of trachea (procedure)
241114005	Head soft tissue X-ray (procedure)
241115006	Lip soft tissue X-ray (procedure)
241116007	Parotid gland X-ray (procedure)
241117003	Submandibular gland X-ray (procedure)
241118008	Foot soft tissue X-ray (procedure)
241119000	X-ray of extracted tooth (procedure)
241146005	Tracheoesophageal fistula X-ray study (procedure)
241685002	X-ray photon absorptiometry (procedure)
241686001	Dual energy X-ray photon absorptiometry (procedure)
268425006	Pelvis X-ray (procedure)
268427003	X-ray shaft of tibia/fibula (procedure)
268428008	Erect abdominal X-ray (procedure)
268430005	Gallbladder soft tissue X-ray (procedure)
268431009	Lower abdomen soft tissue X-ray (procedure)
268432002	X-ray of non-obstetric pelvic organs (procedure)
271311001	Carpal bones X-ray (procedure)
271312008	Soft tissue X-ray of lung/bronchus (procedure)
276015003	Forefoot X-ray (procedure)
276478001	Odontoid peg X-ray (procedure)
277458000	Single energy X-ray photon absorptiometry (procedure)
277666002	X-ray guided biopsy (procedure)
281616007	Trunk soft tissue X-ray (procedure)
281617003	Soft tissue X-ray of abdomen (procedure)
281619000	Vascular soft tissue X-ray (procedure)
281671008	Biliary tract X-ray (procedure)
302402006	Radius and/or ulna X-ray (procedure)
302797005	Whole body X-ray of stillborn infant (procedure)
302798000	Gallbladder X-ray (procedure)
303931008	Lung X-ray (procedure)
303932001	Thoracic cage X-ray (procedure)
303935004	Specific spinal X-ray (procedure)
310810003	Soft tissue X-ray floor of mouth (procedure)
314604005	Palliative course of deep X-ray therapy (procedure)
314605006	Preoperative course of deep X-ray therapy (procedure)
314606007	Postoperative course of deep X-ray therapy (procedure)
390983001	Referral for dual energy X-ray photon absorptiometry scan (procedure)
399128004	X-ray crystallography (procedure)
408493004	Referral for dual energy X-ray photon absorptiometry scan of hip and spine (procedure)
408494005	Referral for dual energy X-ray photon absorptiometry scan of forearm (procedure)
408495006	Referral for dual energy X-ray photon absorptiometry scan of heel (procedure)
416733000	Supine abdominal X-ray (procedure)
418181007	X-ray for colonic transit study (procedure)
418426008	X-ray of fingers (procedure)
418515004	X-ray of little finger (procedure)
418802004	X-ray of index finger (procedure)
419080000	X-ray of ring finger (procedure)
419380005	X-ray of middle finger (procedure)
419942003	X-ray of lumbar spine and sacroiliac joints (procedure)
420068003	X-ray of ear (procedure)
420233006	X-ray of chest and abdomen (procedure)
425583002	Portable X-ray (procedure)
425703002	X-ray of both ankles (procedure)
426311001	X-ray of right foot (procedure)
426420006	X-ray of left ankle (procedure)
426581005	X-ray of both feet (procedure)
426721006	X-ray of right ankle (procedure)
426860004	X-ray of both knees (procedure)
426908009	X-ray of left foot (procedure)
426945003	X-ray of bone (procedure)
427019001	X-ray of left knee (procedure)
427407003	X-ray of right knee (procedure)
428313006	Dual energy X-ray photon absorptiometry scan of mandible (procedure)
428377003	Dual energy X-ray photon absorptiometry scan of lumbar spine (procedure)
428569003	Dual energy X-ray photon absorptiometry scan of forearm (procedure)
428603007	X-ray of hand and wrist for bone age (procedure)
428665002	X-ray of carpometacarpal joint under stress (procedure)
429148001	X-ray of zygoma (procedure)
429373009	Dual energy X-ray photon absorptiometry scan of heel (procedure)
429529009	Dual energy X-ray photon absorptiometry scan of hip (procedure)
429646003	X-ray skeletal survey for multiple myeloma (procedure)
431251007	X-ray of pelvis using mobile image intensifier (procedure)
431557005	X-ray of cervical spine using mobile image intensifier (procedure)
431677006	X-ray of upper limb using mobile image intensifier (procedure)
431871005	X-ray of lumbar spine using mobile image intensifier (procedure)
431892005	X-ray of lumbar spine and pelvis (procedure)
432078003	X-ray of sacrum using mobile image intensifier (procedure)
432769002	X-ray of thorax using mobile image intensifier (procedure)
432770001	X-ray of thoracic spine using mobile image intensifier (procedure)
432778008	X-ray of abdomen using mobile image intensifier (procedure)
432848006	X-ray of hip using mobile image intensifier (procedure)
432906003	X-ray of lower limb using mobile image intensifier (procedure)
433155002	X-ray cystometrogram (procedure)
439100007	X-ray of skull using mobile image intensifier (procedure)
439101006	X-ray tomography (procedure)
439477003	Dual energy X-ray photon absorptiometry scan of femoral neck (procedure)
440496005	Dual energy X-ray photon absorptiometry scan of whole body (procedure)
440607000	X-ray of teeth in oblique lateral view (procedure)
440695003	X-ray of midfoot (procedure)
441284005	Multidirectional X-ray tomography (procedure)
444634007	X-ray of thoracic and lumbar spine (procedure)
445515006	X-ray of cerebrospinal fluid shunt (procedure)
445844000	X-ray of cochlear implant (procedure)
446181006	Forensic X-ray (procedure)
446458002	X-ray of bone of shoulder and upper arm (procedure)
446463003	Full mouth x-ray of teeth (procedure)
446473001	X-ray of radius and ulna (procedure)
446621008	X-ray of bone of knee (procedure)
446629005	X-ray of bone of shoulder (procedure)
446639004	X-ray of bone of ankle (procedure)
446640002	X-ray of urinary bladder (procedure)
446748000	X-ray of ureter (procedure)
446749008	X-ray of bone of hand (procedure)
446785008	X-ray of bone of hip (procedure)
446811003	X-ray of bone of foot (procedure)
446888002	X-ray of vas deferens using contrast (procedure)
447248009	X-ray of bone of elbow (procedure)
448336005	Radiofrequency biopsy of breast using X-ray guidance (procedure)
449616006	X-ray of lower limb for bone length measurement (procedure)
449617002	X-ray of lower leg for bone length measurement (procedure)
703940002	X-ray of elbow for bone age (procedure)
708656007	Dual energy X-ray absorptiometry scan of wrist (procedure)
708690003	Dual energy X-ray photon absorptiometry scan of spine (procedure)
708734000	X-ray of prostate and seminal vesicles (procedure)
711104001	X-ray of cervical and thoracic spine (procedure)
711220000	X-ray of limb (procedure)
711225005	Injection using X-ray guidance (procedure)
711226006	Biopsy of bone using X-ray guidance (procedure)
711307001	Colonoscopy using X-ray guidance (procedure)
711420002	X-ray consultation (procedure)
711422005	Intravenous pyelogram using X-ray guidance (procedure)
711488007	X-ray of shunt (procedure)
711555002	X-ray of rib (procedure)
712970008	X-ray of cervical spine (procedure)
713564003	Localization of iodine 125 radioactive seed to breast lesion using X-ray guidance (procedure)

10.3 Appendix C

All concepts that include ‘Radiographic imaging’ in the FSN

169103004	Postmortem radiographic imaging (procedure)
169106007	Postmortem radiographic imaging of brain (procedure)
169109000	Postmortem radiographic imaging of heart (procedure)
169111009	Postmortem radiographic imaging of skeleton (procedure)
169107003	Postmortem radiographic imaging of skull (procedure)
169110005	Postmortem radiographic imaging of soft tissue (procedure)
169108008	Postmortem radiographic imaging of teeth (procedure)
169112002	Postmortem radiographic imaging of whole body (procedure)
418198007	Radiographic imaging nephrostomy (procedure)
427961005	Radiographic imaging of acetabulum (procedure)
424398008	Radiographic imaging of bone (procedure)
443248008	Radiographic imaging of both hands and wrists, anteroposterior, lateral and ballcatch views (procedure)
443451004	Radiographic imaging of both knees, lateral, sunrise and anteroposterior standing views (procedure)
424475001	Radiographic imaging of lower leg (procedure)
442567001	Radiographic imaging of lymphatic system using contrast (procedure)
415231009	Radiographic imaging of soft tissue (procedure)
363680008	Radiographic imaging procedure (procedure)
108273007	Radiographic imaging procedure by site (procedure)

10.4 Appendix D

All concepts that include ‘Radiography’ in the FSN

413247008	Submucosal injection of contrast media for radiography (procedure)
241032008	Stereographic radiography (procedure)
169061002	Serial radiography of lungs (procedure)
80501006	Radiography of zygomaticomaxillary complex (procedure)
60027007	Radiography of wrist (procedure)
47187002	Radiography of uvula (procedure)
90711000	Radiography of uterus (procedure)
113103008	Radiography of urinary system (procedure)
24267008	Radiography of upper limb soft tissue (procedure)
74170002	Radiography of upper limb (procedure)
79777008	Radiography of tonsils and adenoids (procedure)
79190008	Radiography of thyroid region (procedure)
45554006	Radiography of thoracic spine (procedure)
204327002	Radiography of thigh (procedure)
22891007	Radiography of teeth (procedure)
22289008	Radiography of symphysis menti (procedure)
31931003	Radiography of supraorbital area (procedure)
23394003	Radiography of sternum (procedure)
79760008	Radiography of spine (procedure)
76573005	Radiography of soft tissue of upper arm (procedure)
23846005	Radiography of soft tissue of thigh (procedure)
113107009	Radiography of soft tissue of shoulder (procedure)
38366004	Radiography of soft tissue of knee (procedure)
61147008	Radiography of soft tissue of hip (procedure)
72911009	Radiography of soft tissue of hand (procedure)
43947005	Radiography of soft tissue of forearm (procedure)
18912009	Radiography of soft tissue of elbow (procedure)
73771004	Radiography of soft tissue of ankle (procedure)
29592009	Radiography of shoulder (procedure)
367414003	Radiography of salivary gland (procedure)
8449009	Radiography of sacrococcygeal spine (procedure)
37603004	Radiography of root canal (procedure)
21970003	Radiography of ribs (procedure)
37541000	Radiography of retroperitoneum (procedure)
83932002	Radiography of prostate (procedure)
49140003	Radiography of penis (procedure)
58259007	Radiography of pelvic soft tissue (procedure)
88914000	Radiography of pelvic bones (procedure)
37307009	Radiography of nasopharynx (procedure)
82499005	Radiography of nasolacrimal duct (procedure)
84492002	Radiography of nasal sinuses (procedure)
52514008	Radiography of maxilla (procedure)
19589009	Radiography of mandible (procedure)
17745004	Radiography of male genital organs (procedure)
31911002	Radiography of kidney-ureter-bladder (procedure)
21339000	Radiography of intestine (procedure)
1225002	Radiography of humerus (procedure)
408740001	Radiography of hip (procedure)
69143005	Radiography of heart (procedure)
48450000	Radiography of head (procedure)
49345004	Radiography of hand (procedure)
264318007	Radiography of gravid uterus (procedure)
75679007	Radiography of gastrointestinal tract (procedure)
74809003	Radiography of forearm (procedure)
52221007	Radiography of foot (procedure)
29433003	Radiography of female genital organs (procedure)
29357002	Radiography of face, head AND/OR neck (procedure)
34885003	Radiography of esophagus (procedure)
76913009	Radiography of elbow (procedure)
5131003	Radiography of chest wall (procedure)
66769009	Radiography of cervical spine (procedure)
19490002	Radiography of ankle (procedure)
3799005	Radiography of adenoids (procedure)
91186003	Radiography for bone length studies (procedure)
88504002	Radiography for bone age studies (procedure)
713021002	Plain radiography of pelvis (procedure)
168537006	Plain radiography (procedure)
287601004	Pericardial contrast radiography (procedure)
168818005	Pelvic contrast radiography (procedure)
168900006	Omphalomesenteric duct contrast radiography (procedure)
241033003	Movement radiography (procedure)
439514002	Intraoperative radiography of hip (procedure)
43058004	Injection of contrast media for radiography by direct puncture (procedure)
11850007	Injection of contrast media for radiography by catheter, supraselective (procedure)
56539001	Injection of contrast media for radiography by catheter, selective (procedure)
21503005	Injection of contrast media for radiography by catheter, retrograde (procedure)
23799006	Injection of contrast media for radiography by catheter, non-selective (procedure)
14273008	Injection of contrast media for radiography by catheter (procedure)
58981006	Injection of contrast media for radiography (procedure)
71599004	Gas contrast radiography of pelvis (procedure)
169014003	Fluoroscopy and radiography (procedure)
169025007	Fluoroscopy and radiography - urinary (procedure)
169016001	Fluoroscopy and radiography - skull (procedure)
169018000	Fluoroscopy and radiography - skeleton (procedure)
169020002	Fluoroscopy and radiography - mediastinum (procedure)
169021003	Fluoroscopy and radiography - lungs (procedure)
169019008	Fluoroscopy and radiography - heart (procedure)
169026008	Fluoroscopy and radiography - female genital (procedure)
169023000	Fluoroscopy and radiography - digestive (procedure)
169022005	Fluoroscopy and radiography - chest wall (procedure)
169017005	Fluoroscopy and radiography - cervical column (procedure)
169015002	Fluoroscopy and radiography - brain (procedure)
48564003	Fluoroscopic monitoring and radiography for cardiac pacemaker insertion (procedure)
33450004	Diagnostic radiography with special study (procedure)
50025001	Diagnostic radiography with oral contrast (procedure)
30788002	Diagnostic radiography with measurements (procedure)
91649003	Diagnostic radiography with gas-air, negative contrast (procedure)
8503002	Diagnostic radiography with contrast media, bilateral (procedure)
65590007	Diagnostic radiography with contrast media by injection, positive contrast, post-operative (procedure)
65066001	Diagnostic radiography with contrast media by injection, positive contrast, operative (procedure)
46291008	Diagnostic radiography with contrast media by injection, positive contrast, bilateral (procedure)
37348007	Diagnostic radiography with contrast media by injection, positive contrast (procedure)
82006003	Diagnostic radiography with contrast media by injection, positive and negative contrast, bilateral (procedure)
359866008	Diagnostic radiography with contrast media by injection, positive and negative contrast (procedure)
82899002	Diagnostic radiography with contrast media by injection, negative contrast (procedure)
59800002	Diagnostic radiography with contrast media by injection, bilateral (procedure)
363075003	Diagnostic radiography with contrast media by injection (procedure)
27483000	Diagnostic radiography with contrast media (procedure)
88745008	Diagnostic radiography of uterus for fetal age, fetal position and/or placental localization (procedure)
37385004	Diagnostic radiography of upper gastrointestinal tract with serial films (procedure)
5846007	Diagnostic radiography of toes (procedure)
55357008	Diagnostic radiography of tibia, combined anteroposterior and lateral (procedure)
35443000	Diagnostic radiography of thoracolumbar spine, supine and erect for scoliosis (procedure)
40372003	Diagnostic radiography of temporomandibular joint (procedure)
91583001	Diagnostic radiography of spine, survey study (procedure)
61368000	Diagnostic radiography of spine with flexion and extension studies (procedure)
90223007	Diagnostic radiography of soft tissues (procedure)
42075002	Diagnostic radiography of skull (procedure)
49626003	Diagnostic radiography of scapula (procedure)
57235004	Diagnostic radiography of sacrum (procedure)
6238009	Diagnostic radiography of sacroiliac joints (procedure)
10181005	Diagnostic radiography of sacrococcygeal joint (procedure)
47987001	Diagnostic radiography of sacral spine, combined anteroposterior and lateral (procedure)
77532004	Diagnostic radiography of ribs, bilateral (procedure)
41785006	Diagnostic radiography of pharynx (procedure)
18529002	Diagnostic radiography of pelvis, stereo views (procedure)
75675001	Diagnostic radiography of orbits (procedure)
43255009	Diagnostic radiography of optic foramina (procedure)
87411003	Diagnostic radiography of nasal bones (procedure)
44691001	Diagnostic radiography of mastoids (procedure)
26537001	Diagnostic radiography of lumbar spine, combined anteroposterior and lateral (procedure)
90805008	Diagnostic radiography of lumbar spine (procedure)
58011003	Diagnostic radiography of larynx (procedure)
12513003	Diagnostic radiography of hip, bilateral (procedure)
40502003	Diagnostic radiography of fistula or sinus tract, positive contrast (procedure)
60619004	Diagnostic radiography of finger (procedure)
79082005	Diagnostic radiography of fibula, combined anteroposterior and lateral (procedure)
68306006	Diagnostic radiography of facial bones (procedure)
24856003	Diagnostic radiography of coccyx (procedure)
49459005	Diagnostic radiography of chest, stereo (procedure)
67632007	Diagnostic radiography of chest, posteroanterior (procedure)
67071009	Diagnostic radiography of chest, oblique, standard (procedure)
22446007	Diagnostic radiography of chest, minifilm (procedure)
113094008	Diagnostic radiography of chest, lateral (procedure)
42869005	Diagnostic radiography of chest, combined posteroanterior and lateral (procedure)
69064006	Diagnostic radiography of cervical esophagus (procedure)
37815002	Diagnostic radiography of calcaneus (procedure)
373365009	Diagnostic radiography of bony orbits (procedure)
78670005	Diagnostic radiography of all fingers (procedure)
6127002	Diagnostic radiography of abdomen, oblique standard (procedure)
62295005	Diagnostic radiography of abdomen, decubitus and erect (procedure)
60654006	Diagnostic radiography of abdomen (procedure)
66596009	Diagnostic radiography for foreign body detection and localization (procedure)
32328007	Diagnostic radiography during operative procedure (procedure)
359869001	Diagnostic radiography double contrast (procedure)
315028004	Contrast radiography via drain (procedure)
168800007	Contrast radiography orbit (procedure)
274405001	Contrast radiography of trachea (procedure)
271313003	Contrast radiography of respiratory organs (procedure)
168817000	Contrast radiography of peritoneal cavity (procedure)
268435000	Contrast radiography of paranasal sinuses (procedure)
168803009	Contrast radiography of oropharynx (procedure)
86354001	Contrast radiography of nasopharynx (procedure)
54042002	Contrast radiography of nasolacrimal ducts (procedure)
274404002	Contrast radiography of larynx (procedure)
168894006	Contrast radiography of glands (procedure)
285754008	Contrast radiography of esophagus (procedure)
168816009	Contrast radiography of abdominal cavity (procedure)
268436004	Contrast radiography larynx/trachea (procedure)
168783002	Contrast radiography excluding cardiovascular system (procedure)
168899001	Contrast radiography - ducts (procedure)
287994002	Choledochotomy and radiography (procedure)
271315005	Biliary contrast radiography (procedure)

SNOMED CT Content Improvement Project Combined Inception and Elaboration phases
Project ID: artf231911 IHTSDO-161 Topic: Radiography versus X-Ray
Date	2^nd August 2016
Version		0.2 Draft

Amendment History

Version	Date	Editor	Comments
0.01	20160531	Maria Braithwaite	First draft for submission
0.02	20160802	Maria Braithwaite	Second draft to incorporate review feedback

Review Timetable

Kin Wah Fung14 Sep 2016 Version 0.2 of Inception /elaboration for IHTSDO-161 Review feedback page: JIRA IHTSDO-161 (artf231911) Radiography vs X ray Documentation Review

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Table of Contents
1 Glossary
1.1 Domain Terms
2 Introduction
2.1 Purpose
2.2 Audience and stakeholder domain
2.2.1 Input from stakeholders
2.2.2 Degree of consensus on the statement of problem
3 Statement of the problem or need
3.1 Summary of problem or need, as reported
3.2 Summary of requested solution
3.3 Statement of problem as understood
3.3.1 Radiographic Procedures Example 1
3.3.2 Radiographic Procedures Example 2
3.3.3 Radiographic Procedures Example 3
3.4 Detailed analysis of reported problem, including background
3.4.1 Ambiguous Grouper Concept
3.4.2 Duplicate Synonyms
3.4.3 Inconsistent Use of Imaging Action
3.4.4 Inconsistent Naming of Procedures
3.4.5 Where does 'Diagnostic' fit in?
3.4.6 Plain Film
3.4.7 Impact on the Clinical Finding Hierarchy
3.5 Subsidiary and interrelated problems
3.5.1 Impact On Hierarchies Other Than Procedure
3.5.2 Undesirable Inferred Relationships
3.5.3 Intermediate Primitive Concepts
3.5.4 Potential duplication
3.5.5 Miscellaneous Modelling Issues
4 Risks / Benefits
4.1.1 Risks of not addressing the problem
4.1.2 Risks of addressing the problem
5 Requirements: criteria for success and completion
5.1 Criteria for success/completion
5.2 Strategic and/or specific operational use cases
6 Solution Development
6.1 Initial Design
6.1.1 Modelling of Imaging Action
6.1.2 Description Recommendation
6.1.3 Text Definition
6.1.4 Significant design or implementation decisions / compromises
6.1.5 Evaluation of Design
6.2 Iteration One
6.2.1 Outline of Revised Design
6.2.2 Significant Design or Implementation Changes
6.2.3 Evaluation of Revised Design
7 Recommendation
7.1.1 Initial Detailed Design Specification
7.1.2 Iteration Plan – Updated Detailed Design Specification
8 Quality program criteria
8.1 Quality metrics
8.1.1 Quality metric 1
8.1.2 Quality metric 2
9 Project Resource Estimates
9.1 Scope of construction phase
9.2 Projection of remaining overall project resource requirements
9.2.1 Expected project resource requirement category
9.2.2 Expected project impact and benefit
9.2.3 Indicative resource estimates for construction, transition and maintenance:
10 Appendices
10.1 Appendix A
10.2 Appendix B
10.3 Appendix C
10.4 Appendix D

Glossary

Domain Terms

Radiography	"Radiography is a broad term that covers several types of studies that require the visualization of the internal parts of the body using x-ray techniques…radiography means a technique for generating and recording an x-ray pattern for the purpose of providing the user with a static image(s) after termination of the exposure…" http://www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/ucm175028.htm "Conventional radiography involves the use of x-rays; the term "plain x-rays" is sometimes used to distinguish x-rays used alone from x-rays combined with other techniques (eg, CT). For conventional radiography, an x-ray beam is generated and passed through a patient to a piece of film or a radiation detector, producing an image" http://www.merckmanuals.com/professional/special-subjects/principles-of-radiologic-imaging/conventional-radiography.
X-ray	"X-ray technology is the oldest and most commonly used form of medical imaging. X-rays use ionizing radiation to produce images of a person's internal structure by sending X-ray beams through the body, which are absorbed in different amounts depending on the density of the material. In addition, included as "x-ray type" devices are also mammography, interventional radiology, computed radiography, digital radiography and computed tomography (CT)." Source: http://www.medicalimaging.org/about-mita/medical-imaging-primer/
Plain X-ray	"…The term "plain x-rays" is sometimes used to distinguish x-rays used alone from x-rays combined with other techniques (eg, CT)…" Source: http://www.msdmanuals.com/en-gb/professional/special-subjects/principles-of-radiologic-imaging/conventional-radiography

Introduction

Purpose

The purpose and scope of this content project is to:

Review the inconsistent naming of 'X-ray' and 'Radiographic imaging' and 'Plain X-ray' concepts that are subtypes of 363680008|Radiographic imaging procedure (procedure) in the procedure hierarchy.
Propose a naming convention in order to improve the representation of these concepts in descriptions and facilitate the drafting of guidance for the Editorial Guide.
Review the inconsistent modelling of 'X-ray' and 'Radiographic imaging' and 'Plain X-ray' concepts that are subtypes of 363680008|Radiographic imaging procedure (procedure) in the procedure hierarchy.
Propose a consistent modelling approach for these concepts in order to improve representation and subsumption and remove duplication.

Audience and stakeholder domain

The audience for this document includes all standards terminology leaders, implementers and users of SNOMED CT.
A further significant audience is the community of SNOMED CT terminologists that may be requested to implement the recommended specification this includes the IHTSDO Content Team.

Input from stakeholders

Review of some aspects of the proposed solution was sought from a group of expert clinicians in interventional and diagnostic imaging with the assistance of a National Release Centre. Review and input was also sought from within the Consultant Terminologist community.
A review of RadLex (http://www.rsna.org) and DICOM (http://dicom.nema.org) was undertaken to gain a broader perspective of how the area of imaging that is addressed in this document is managed in other terminologies. DICOM has recently signed a collaboration agreement with IHTSDO and so a uniform approach may be of benefit.
It is noted that there are approximately 160 requests in the IHTSDO request portal (SIRS) for new concepts that will fall into the scope of this content project. These new requests are from a variety of National Release Centres and users of SIRS demonstrating that users require content in this area.

Degree of consensus on the statement of problem

This content project is required to address a known content issue that has been acknowledged in the Editorial Guidance, the document states:
"There is a need to differentiate a grouper for all imaging procedures that utilize X-rays, from plain X-rays. The goal for this guidance is plain X-rays of a site. Given the apparent lack of consensus, the solution probably will involve a text definition and a naming convention specific to SNOMED CT, with advice to implementers." https://confluence.ihtsdotools.org/display/public/EditorialGuide/7.8.1+X-ray+imaging

Statement of the problem or need

Summary of problem or need, as reported

There is inconsistency with naming 'Radiology of X' and 'X-ray of X' and 'Plain X-ray of X' and the modelling of these concepts. Some concepts use the description 'Radiographic imaging,' others use 'X-ray' or 'Plain X-ray' and in some concepts all of these terms are applied synonymously. In many cases the value for the method attribute does not align with the descriptions.
The SNOMED CT Editorial Guide indicates:
7.8.1 X-ray imaging
Two possible approaches have been discussed, and final resolution has not yet been reached.
Option 1:
Descriptions:
FSN: Radiography of X (procedure) PT: Radiography of X
Option 2: Descriptions:
FSN: X-ray of X (procedure) PT: X-ray of X
https://confluence.ihtsdotools.org/display/public/EditorialGuide/7.8.1+X-ray+imaging

Summary of requested solution

The solution as suggested in the Editorial Guide is to "differentiate a grouper for all imaging procedures that utilize X-rays, from plain X-rays. Given the apparent lack of consensus, the solution probably will involve a text definition and a naming convention specific to SNOMED CT, with advice to implementers."
https://confluence.ihtsdotools.org/display/public/EditorialGuide/7.8.1+X-ray+imaging

Statement of problem as understood

In the international edition of SNOMED CT there is inconsistency with naming and modelling of concepts that reference Radiographic imaging, X-ray and Plain X-ray. This is a known issue, the SNOMED CT Editorial Guide states:
"6.2.5.7 Radiographic procedures
| Radiographic imaging procedure | [363680008 | Radiographic imaging procedure |] was created as the top of a hierarchy of imaging procedures utilizing x-rays. | Diagnostic radiologic examination | [38743002] had a synonym of "X-ray", but this code has been retired because it may have been interpreted more narrowly, in particular because of the possibly narrower interpretation of radiologic versus radiographic, and the possibly narrower interpretation of diagnostic. Nevertheless, the phrase "diagnostic radiography is allowed in many of the FSNs of subtypes of | radiographic imaging procedure |."
https://confluence.ihtsdotools.org/display/public/EditorialGuide/6.2.5+Specific+procedure+types

The following are examples taken from the January 2016 international release of SNOMED CT:

Radiographic Procedures Example 1

The above example 363680008|Radiographic imaging procedure (procedure) has the Synonym 'X-ray' and uses the value 278110001|Radiographic imaging - action (qualifier value) for the Method attribute.
As a result of this the concept has subtypes which include 77477000|Computerized axial tomography (procedure) and 44491008|Fluoroscopy (procedure).
These descendant concepts are logical due to the method applied however the use of the synonym 'X-ray' is questionable for this concept. In this case the synonym appears to indicate X-ray in its broadest term i.e. an X-ray technique.
The presence of this mix of descriptions is likely to be confusing to both content editors and end users.

Radiographic Procedures Example 2

In this example 168537006|Plain radiography (procedure) has the Synonym 'X-ray' and is modelled with an imaging action of 312254007|Plain X-ray imaging - action (qualifier value).
This concept has both Plain X-ray and X-ray as synonyms. Is there a clinical difference between plain X-ray, plain film and X-ray? This question was raised with the expert clinical group who indicated that these terms can be considered synonymous but with a preference for the use of the term X-ray, the use of the term 'plain' was thought to be superfluous.
It is likely that the interchangeable use of these terms is confusing to both content editors and end users.

Radiographic Procedures Example 3

In this final example 426945003|X-ray of bone (procedure) has both X-ray and Plain X-ray used synonymously in the descriptions. This concept does NOT currently inherit all of the descendant concepts that it should. For example:

241089007|Ilium X-ray (procedure) is NOT currently a descendant of 426945003|X-ray of bone (procedure) it is a sibling. This is because the concept is modelled with a method of 278110001|Radiographic imaging - action (qualifier value). Taking into account the descriptions, the concept should be modelled with a method of 312254007|Plain X-ray imaging - action (qualifier value).
Similar examples to these above can be found throughout the hierarchy 363680008|Radiographic imaging procedure (procedure).

Detailed analysis of reported problem, including background

There may be local preferences that dictate which particular wording a clinician prefers to use. However within SNOMED CT, the fully specified name must "uniquely describe a concept and clarify its meaning…" https://confluence.ihtsdotools.org/display/public/EditorialGuide/7.1.1+Fully+Specified+Name
In the international edition of SNOMED CT, 278110001|Radiographic imaging - action (qualifier value) acts as a grouper for other concepts in the qualifier value hierarchy as demonstrated below:

278110001|Radiographic imaging - action (qualifier value) was most probably originally intended to be used to model concepts that use x-ray imaging of some form and will subsume more granular imaging modality procedures such as computed tomographythat utilise special equipment such as a computed tomography scanner..

In reality 278110001|Radiographic imaging - action (qualifier value) has been used to model concepts that reference X-ray and the terms 'X-ray', 'radiograph', and 'radiographic imaging' and 'plain X-ray' are being used synonymously across SNOMED CT as they might be in clinical practice.
The result is inconsistency that can be seen in the hierarchy 363680008|Radiographic imaging procedure (procedure). The key issues to be addressed are outlined in the sections below.

Ambiguous Grouper Concept

363680008|Radiographic imaging procedure (procedure) has 2801 descendant concepts at the time of the January 2016 release. In its broadest interpretation a radiographic imaging procedure "covers several types of studies that require the visualization of the internal parts of the body using x-ray techniques" http://www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/ucm175028.htm
ArguablyTherefore inclusion of the synonym 'X-ray' is a contravention of editorial policy because it is a narrower term that that of the FSN (see Editorial Guide Section 7.4.3 Narrower Synonyms).
https://confluence.ihtsdotools.org/display/public/EditorialGuide/7.4.3+Narrower+synonyms
However it is acknowledged that these terms may be used widely as synonyms in clinical practice. TThe interchangeable nature of the terms 'X-ray' and 'radiographic imaging procedure' throughout SNOMED CT was raised with the expert group. The group expressed the opinion that these descriptions are routinely used synonymously in clinical practice and express the same procedure.

Duplicate Synonyms

The concept 168537006|Plain radiography (procedure) has a synonymous description 'X-ray' as does its parent concept 363680008|Radiographic imaging procedure (procedure).
'Roentgenography' appears on both parent (363680008|Radiographic imaging procedure (procedure)) and child (168537006|Plain radiography (procedure)). The application of the same synonym to both concepts is confusing to users and in contravention of the Editorial Guidance that stipulates
"7.4.2 Synonyms
A synonym is a term with the same meaning as another term…Addition of the same term as a synonym to more than one concept will not usually be acceptable, but of course some terms have more than one meaning…When a term can take more than one meaning, the term may be attached to multiple concepts without violating this rule. Where multiple concepts have an identical term as a synonym, a review will be undertaken to ascertain if the concepts involved are duplicates.
Where the concepts are duplicates, one concept will be retired with a SAME_AS relationship to the concept it duplicated.
Where a term with a single meaning is associated with more than one concept (which are not duplicates), the term should be retained on only one of the concepts and retired on the other(s).
In some cases a general term may be acceptable as a synonym for two or more specific concepts, depending on the context of use to derive proper specificity (e.g. "fundus" in the context of obstetrics vs ophthalmology). It is expected that these occasions will be unusual, and should be highlighted as exceptions, to assist with proper usage. Editorial guidance for broader synonyms should be taken into account."
https://confluence.ihtsdotools.org/display/public/EditorialGuide/7.4.2+Synonyms

Inconsistent Use of Imaging Action

278110001|Radiographic imaging - action (qualifier value) is a grouper concept and it is assumed it was originally intended to be a supertype for more granular imaging techniques that also utilise X-ray such as computed tomography and mammography. Where the fully specified name describes a particular imaging modality for example 'X-ray or Plain X-ray', the granular subtype of imaging modality should be applied as the method to existing content.

In many instances 278110001|Radiographic imaging - action (qualifier value) has been used as the method for a concept that either only uses X-ray in the descriptions or uses a mix of both X-ray and radiographic imaging in the descriptions. The use of 278110001|Radiographic imaging - action (qualifier value) has resulted in suboptimal inferred relationships across the hierarchy.
The following concepts are examples of this from the January 2016 release:

Radiography of chest wall (procedure)

Method 278110001|Radiographic imaging - action (qualifier value) and hasbut has the synonym 'X-ray of chest wall. However, tAs a result this concept is not a descendant of 399208008|Plain chest X-ray (procedure) as end users may expect. Where this concept appears in the clinical record, it is open to interpretation whether the clinician has recorded a procedure that uses X-ray of some type or whether this is a plain X-ray procedure that uses a single imaging modality of X-ray without specialist equipment or contrast media..

Soft tissue X-ray chest (procedure)

Method 278110001|Radiographic imaging - action (qualifier value) with the result that the concept is not a descendant of 399208008|Plain chest X-ray (procedure).

Whole body X-ray of stillborn infant (procedure)

Uses the term 'X-ray' andbut is modelled with the method 278110001|Radiographic imaging - action (qualifier value).

Inconsistent Naming of Procedures

Across the hierarchy 363680008|Radiographic imaging procedure (procedure) the terms Radiograph, Radiographic Imaging, X-ray, Plain X-ray and Roentgenography are currently used synonymously.
An example from the January 2016 release

This concept uses 'X-ray' and 'Radiographic imaging' synonymously however it is modelled with a method of 312254007|Plain X-ray imaging - action (qualifier value). X-ray is one type of radiographic imaging and so this synonym is more granular than the FSN. There is an approved naming convention for the addition of new content to the diagnostic imaging domain see 7.8 Naming conventions for clinical imaging procedures.
Also of note is the presence of a number of concepts that do not make reference to a specific imaging modality and have their own naming convention of 'gram' or 'graphy'.
For example 168854009|Cystogram (procedure) is modelled with an action of radiographic imaging and subsumes more granular concepts

It is not clear if this concept is intended to be a 'plainn X-ray' imaging procedure or a higher-level grouper concept that should subsume concepts with a more specific imaging modality such as 711227002|Computed tomography cystography (procedure).
Perhaps at the time 168854009|Cystogram (procedure) was created, there was only one possible way to carry out the procedure (by plain X-ray) and the advent of more sophisticated imaging modalities has resulted in this concept becoming a grouperng ambiguous. The inclusion of a specific imaging modality into the FSN of each new concept will future proof content that is likely to be impacted by the evolving nature of medicine for example .711227002|Computed tomography cystography (procedure).
The guidance document notes "There are a number of inconsistencies in existing content, but it is not required that these naming conventions necessarily be applied wholesale to that content. It is definitely intended for new content. Changes to existing content to conform to these guidelines will be considered based on value to users."
https://confluence.ihtsdotools.org/display/public/EditorialGuide/7.8+Naming+conventions+for+clinical+imaging+procedures

Where does 'Diagnostic' fit in?

There are a number of concepts in the hierarchy 363680008|Radiographic imaging procedure (procedure) that explicitly use the word 'Diagnostic'.
For example
32328007|Diagnostic radiography during operative procedure (procedure)
33450004|Diagnostic radiography with special study (procedure)
36004004|Diagnostic tomography (procedure)
There is inconsistency in the application of 'has intent' and diagnostic' and the way this type of content is modelled. For example The concept 27483000|Diagnostic radiography with contrast media (procedure) is marked as fully defined but does not use the 363703001|Has intent (attribute) in its modelling. 60654006|Diagnostic radiography of abdomen (procedure) is marked as fully defined and has the same issue.
Imaging procedures may be divided into 'diagnostic' and 'interventional imaging.' Diagnostic imaging is used for the purposes of obtaining information for example 305053005|Computed tomography of aorta (procedure)|. Interventional imaging is often used for the purpose of treating a specific condition for example 431749009|Aspiration using computed tomography guidance (procedure)| or obtaining further information such as 277591006|Computed tomography guided biopsy (procedure)|.
For interventional imaging In the domain of diagnostic imaging, where the explicit procedure intent is guidance, this usually modelled using 363703001|Has intent (attribute) and 429892002|Guidance intent (qualifier value). This attribute and value pair are assigned as part of a relationship group and results in the concept being a descendant of 258174001|Imaging guidance procedure (procedure).
An example of this is the grouper concept 258174001|Imaging guidance procedure (procedure) . The concept is a descendant of 362961001|Procedure by intent (procedure).

There are many examples in the hierarchy 363680008|Radiographic imaging procedure (procedure) where 'diagnostic' is included in a fully specified name but diagnostic intent is not included in the relationship groups of the concept and this requires further evaluation. t.
There is an existing content project Artf6232 to address the issues around the use of 363703001|Has intent (attribute) and although this is noted as an issue in this content project it is beyond the scope of the issues to be addressed as part of this for this content project.

Plain Film

The terms 'Plain film' and 'Plain X-ray' are seen being used synonymously in the hierarchy 363680008|Radiographic imaging procedure (procedure). The method 312254007|Plain X-ray imaging - action (qualifier value) also stipulates 'plain.' There does not appear to be a clinical difference between Plain X-ray and Plain film. This issue was referred to the clinical expert group for opinion who confirmed this assumption. The group also expressed the view that the inclusion of 'plain' is superfluous and does not align with clinical parlance however was acknowledged that it is important for the terminology to make some distinction between plain X-ray and its broader interpretations.
Examples from the January 2016 release:
370142005|Plain film of head (procedure)
303938002|Plain film of neck (procedure)
The above concepts are examples of current content that is modelled with a method of 312254007|Plain X-ray imaging - action (qualifier value) however these concepts do not use the term 'X-ray' in any description.
This is an issue for search, retrieval of data and audit. It is also possible that this degree of inconsistency in naming will result in the addition of duplicate concepts.

Impact on the Clinical Finding Hierarchy

The issues with modelling in the procedure hierarchy as outlined above have had a considerable impact in the clinical finding hierarchy. In the screenshot below it is demonstrated that the concept 168541005|Plain X-ray result normal (finding) does not subsume a large number of 'Plain X-ray of X normal (finding)' concepts.
It is not possible to correct this issue in the Clinical finding hierarchy until the original issue in the procedure hierarchy is rectified.

Subsidiary and interrelated problems

Impact On Hierarchies Other Than Procedure

The issues found in the procedure hierarchy are perpetuated in the Clinical finding hierarchy as described in the section above. There are also associated problems identified in other hierarchies.

708175003|Diagnostic imaging service (qualifier value) has a descendant concept 310125001|Radiology service (qualifier value).

It is not clear if 310125001|Radiology service (qualifier value) actually means X-ray service or radiographic imaging service. If it means the latter then 310128004|Computerized tomography service (qualifier value) as an example should be a child and not a sibling concept. Also of note 708174004|Interventional radiology service (qualifier value) is a descendant of 708175003|Diagnostic imaging service (qualifier value). Interventional radiology and Diagnostic Imaging are two separate branches in the domain of clinical imaging.

The situation hierarchy has a large number of concepts that refer to unilateral imaging, for example 702005|Unilateral imaging of renal artery (situation). Unilateral content falls into scope for an existing content project artf6236, this content should be reviewed for validity.

Undesirable Inferred Relationships

Where possible all existing content that is a descendant of 363679005|Imaging (procedure) should be reviewed and remodeled to the closest primitive parent. This will ensure that all undesirable inferred relationships are removed and optimise subsumption of existing and future content. This matter is being considered and addressed as a separate IHTSDO content project.

Intermediate Primitive Concepts

A number of primitive concepts (some of which are intermediate primitive concepts) have been identified during this review. It would be highly advantageous to review these concepts with the aim of making the concepts fully defined. This would allow the classifier to assign logical inferred relationships.
Examples of these concepts are:
241685002|X-ray photon absorptiometry (procedure)
22760005|Xeroradiography (procedure)
429700005|Radiopharmaceutical imaging (procedure)
442567001|Radiographic imaging of lymphatic system using contrast (procedure)

Potential duplication

As a result of the issues outlined with modelling approach and descriptions, once changes are made and the classifier run equivalency between concepts will be uncovered. Removal of equivalency will contribute to the overall quality of SNOMED CT.

Miscellaneous Modelling Issues

A number of other issues with content in the hierarchy 363679005|Imaging (procedure) have been identified during this review. Whilst these issues are outside the scope for this project, addressing them as part of an overall clean up of the hierarchy will improve the quality.
A few examples of this are:
439101006|X-ray tomography (procedure) is an intermediate primitive which could be fully defined. Is this a dual imaging modality?
Inactivate 303936003|Specific plain X-ray investigations (procedure)
Review 168731009|Standard chest X-ray (procedure) this appears to duplicate the parent concept
Inactivate 55402005|Hospital admission, for laboratory work-up, radiography, etc. (procedure)

Risks / Benefits

Achieving a workable solution to this content project is desirable because the concept 363680008|Radiographic imaging procedure (procedure) has 2801 descendants of which 168537006|Plain radiography (procedure) has 175 descendant concepts. 278110001|Radiographic imaging - action (qualifier value) appears more than 1600 times in either the stated or inferred relationships of existing content. It is also demonstrated that the procedure concepts impact content in the Clinical finding hierarchy. Current content contains a mixture of synonyms that are broader or narrower than the fully specified name of the concept and this is accompanied by inconsistent modelling. There are currently around 160 requests in SIRS that reference the words 'x-ray,' 'radiography' and 'plain x-ray' and clear guidance is required if the existing problems are not to be perpetuated.
End users will benefit from resolution of this content project with a solution that ensures that current content aligns with editorial policy and future content development will do the same. Application of a consistent approach will also ensure that duplicate concepts are identified and inactivated.
For those involved in translation, the implementation of a consistent approach to descriptions is likely to reduce anomalies in translated content and may assist with an algorithmic approach to translation.
By addressing this content and the existing new requests, overall quality and consistency of content will be improved. Content in this area is likely to be under increased scrutiny with the New Global Licensing Agreement for SNOMED CT Code Inclusion in the DICOM Standard.
Achieving a workable solution for this content project will also be of benefit to the IHTSDO content team, as the disposition of new requests will be consistent and more efficient. The value of the effort involved with the undertaking of this content project is considerable when considering its likely impact.

Risks of not addressing the problem

The project risk is calculated by utilizing the Project Risk Profile assessment tool as detailed on Page 11 of "A Guide to Stakeholder Engagement" https://confluence.ihtsdotools.org/pages/viewpage.action?spaceKey=CONSULTANTTERMINOLOGISTGROUP&title=Stakeholder++Engagement++Resources

Criteria	Analysis	Score
Number of concepts affected	July 2016 release data: Total number of 'in scope' descriptions requiring review– 456 Total number of concepts that use 278110001	Radiographic imaging - action (qualifier value)	as the imaging method – 784 Total number of concepts that use 312254007	Plain X-ray imaging - action (qualifier value)	as the imaging method - 176	2
Number of users affected	This content is widely used across National Release Centres and other users	2
Changes to vendor software required	The solution is intended to reduce inconsistency in concept descriptions and modelling. There is no requirement for changes to software.	0
Change to concept model	None proposed.	0
Change to content development software or processes	None required.	0
Average score		1

The risk level is assessed as a score of 1, which is medium risk.
If this problem is not addressed end users, vendors, NRC and the IHTSDO content team will remain unclear about editorial policy and this will lead to inconsistent inclusion of content and concept modelling.
In addition to the risks quantified above, not addressing the problem means that X-ray, plain X-ray and radiography concepts will be scattered inconsistently across hierarchies with inconsistency of descendent concepts. User queries for these concepts will consequently be more difficult to formulate, as there will be continue to be inconsistency in the way new content is modelled. In order to capture all instances of 'radiography', 'X-ray' and 'plain X-ray', extraction criteria will need to include different method action attributes. Clear guidance will assist the content team to add and model new content in a consistent manner that prevents future recurrence of this problem. It is highly desirable to fully define new content in order to harness the benefits of using a classifier, optimise subsumption and eliminate equivalency.

Risks of addressing the problem

There is a large amount of content involved in this content project. Concepts across both the procedure and Clinical finding hierarchies will be impacted. However it is noted that changes to the Clinical finding hierarchy will be mostly the result of changes in inferred relationships from the resolution of existing problems with inheritance. Some review of descriptions may be required to align the clinical finding hierarchy content with the changes made to the procedure hierarchy.
Whilst improvement to the quality and consistency of the content is of benefit to all users, the implementation of proposed changes will result in amendments to released descriptions, modifications to existing hierarchies and inactivation of some released content. This may impact implementations of SNOMED CT.
However the potential negative impact of these factors may be mitigated by

Clinical review of the proposed solution to ensure it is robust reflects clinical practice and does not make assumptions that are not clinically valid.
Provision of detailed release notes when the changes are implemented
Ensuring that all inactivated concepts maintain a historical relationship to an active released concept that the end user can implement in place of the existing concept.
Updating editorial guidance to detail all changes that are made and how content of this nature will be added to SNOMED CT in the future.

Requirements: criteria for success and completion

Criteria for success/completion

All concepts that are in scope for this project will

Be clearly and consistently represented in SNOMED CT
Have descriptions that align to an agreed format
Have stated IS_A relationships, attributes and values that have been assigned in a consistent manner to ensure that classification results in logical inferred relationships.

Strategic and/or specific operational use cases

This content development project aligns with one of the core principles as outlined in the IHTSDO Strategic Direction 2015-2020 - Quality focused content development with adherence to strict editorial rules.

Solution Development

Initial Design

Modelling of Imaging Action

Option One

278110001|Radiographic imaging - action (qualifier value) groups all of the different radiographic procedures that are based on X-ray. Option one would be to take the approach that 278110001|Radiographic imaging - action (qualifier value) As a result of this the action should be used sparingly because it will subsume all concepts that are modelled using a descendant imaging action such as 312251004|Computed tomography imaging - action (qualifier value). Retain a small number of the concepts as a groupers with a text definition and clear editorial guidance for its use and re-model all granular descendant concepts (procedure with a finding site) to be a type of Plain X-ray.

Option Two

Options two would be to consider 278110001|Radiographic imaging - action (qualifier value) the same as means exactly the same as 312254007|Plain X-ray imaging - action (qualifier value). This would result in wide-scale inactivation of content. and is therefore a duplicate and should be inactivated. All existing content that uses the terms 'radiograph,' 'X-ray' and plain 'X-ray' wouldill be remodelled with a method of 312254007|Plain X-ray imaging - action (qualifier value). This would have a large-scale impact across the imaging procedure hierarchy and require wide impact assessment and consultation. As demonstrated throughout this document, it is also the approach that is least aligned with clinical practice as there is a place for both 'radiographic imaging' procedures and 'plain X-ray' procedures as separate entities within SNOMED CT.

Modelling Recommendation

The initial recommendation is It is recommended that 'Option One' be initiated, 278110001|Radiographic imaging - action (qualifier value) will group all of the different radiographic procedures that are based on X-ray. The following concepts should utilise the action 278110001|Radiographic imaging - action (qualifier value) and act as grouper concepts:
363680008|Radiographic imaging procedure (procedure)
108273007|Radiographic imaging procedure by site (procedure)
418542003|Radiologic guidance procedure (procedure)
27483000|Diagnostic radiography with contrast media (procedure)
The current descendants of these concepts are mostly localised with a body structure, which suggests that the original intent was 'plain X-ray' imaging of a particular structure and not a higher-level grouper.
It is therefore recommended that with the exception of the four grouper concepts listed above 312254007|Plain X-ray imaging - action (qualifier value) should be used as the method to model imaging procedures that currently contain the word 'radiography', 'X-ray' or 'plain X-ray'.
for all of the concepts listed in Appendix A (779 concepts in total).
This proposal would rectify existing inconsistencies in the current modelling of content that is resulting in unwanted inferences. For example in the January 2016 release 277666002|X-ray guided biopsy (procedure) is a sibling of 277673007|Plain X-ray guidance (procedure). It would be expected that the 277666002|X-ray guided biopsy (procedure) be a child of 277673007|Plain X-ray guidance (procedure).

By remodelling the concept 277666002|X-ray guided biopsy (procedure) to have an method of 312254007|Plain X-ray imaging - action (qualifier value), subsumption is improved

It is however acknowledged that there are areas of the content where this change would have considerable impact.

The concept 268425006|Pelvis X-ray (procedure) is modelled with the method 278110001|Radiographic imaging - action (qualifier value) and so has descendants that include 169071000|Computed tomography of pelvis (procedure).
If 268425006|Pelvis X-ray (procedure) is remodelled to the imaging action of 312254007|Plain X-ray imaging - action (qualifier value) this will result in equivalency between 268425006|Pelvis X-ray (procedure) and 713021002|Plain radiography of pelvis (procedure).
The current grouper concept 268425006|Pelvis X-ray (procedure) will be remodelled or inactivated which will result in changes to the inferred relationships for descendant concepts.
This factor is replicated throughout the hierarchy with another similar example:
424398008|Radiographic imaging of bone (procedure)
426945003|X-ray of bone (procedure)
In order to test the impact of the proposed change, one small area of content was remodelled
1225002|Radiography of humerus (procedure) which has the descendant concept 713026007|Plain x-ray of humerus (procedure)

There is equivalency between 1225002|Radiography of humerus (procedure) and
713026007|Plain x-ray of humerus (procedure) after the changes are implemented, 713026007|Plain x-ray of humerus (procedure) is to be retired with a SAME_AS relationship to 1225002|Radiography of humerus (procedure).
After implementing the proposed change the hierarchy looks like this.

The concept 1225002|Radiography of humerus (procedure) has been remodelled with a method of 312254007|Plain X-ray imaging - action (qualifier value) and a FSN of X-ray of humerus (procedure)

Stated view

Inferred view

It is arguable that both concepts could be maintained, both modelled with different imaging modality and also following an agreed description convention. However this option is likely to persist the existing problems of duplication and confusion across the hierarchy. The addition of high-level grouper concepts cannot be entirely prohibited and could be added on request if there is a specific use case to be supported.
713026007|Plain x-ray of humerus (procedure) is a new addition to the January 2016 release, this is despite the presence of the existing concept 1225002|Radiography of humerus (procedure) which has a synonym of X-ray of humerus. This supports the assertion that there is confusion for both editors and users of SNOMED CT with the current content in this area.
The recommended action would resolve the issue with duplication and ambiguous interchangeable use of descriptions and so improve overall quality in this area of SNOMED CT.

Associated Modelling Recommendation

Also of note is the presence of a number of concepts that do not make reference to a specific imaging modality in their fully specified name and have their own naming convention of 'gram' or 'graphy'.
For example 168854009|Cystogram (procedure) is modelled with an action of radiographic imaging and subsumes more granular concepts

However it is not clear if this concept is intended to be an X-ray imaging procedure or a higher-level grouper concept. It would be advantageous to review this type of concept to ensure that the concepts have an unambiguous fully specified name and are can fully defined where possible.be modelled with an imaging modality and be fully defined. The question was raised with the expert group were consulted about the above example and who advised that this procedure should have its descriptionsbe refined with to a specific imaging modality y, in this case278110001|Radiographic imaging - action (qualifier value)| X-ray , as the presence of a concept that does not incorporate a specific imaging modality into its descriptions is ambiguous to end users who may be are unsure which concept they should choose.procedure to record.

Description Recommendation

As demonstrated, across SNOMED CT there is variation in the naming convention that has been implemented into the FSN. It is recommended that X-ray of X (procedure) be implemented for concepts that use the terms 'radiography' 'X-ray' and 'plain X-ray' with the following exceptionsthe concepts in listed in Appendix B (262 concepts) have their existing FSN inactivated and replaced with a standard description X-ray of X (procedure):
Exceptions:
363680008|Radiographic imaging procedure (procedure)
108273007|Radiographic imaging procedure by site (procedure)
418542003|Radiologic guidance procedure (procedure)
27483000|Diagnostic radiography with contrast media (procedure)
Note: a small number of further concepts may not align with the proposed naming convention for example 241209000|Sinogram (procedure) however the FSN should incorporate an imaging modality and these concepts can be treated on a case by case basis as exceptions.
It is recommended the descriptions follow this pattern:
FSN: X-ray of X (procedure)
Preferred term: X-ray of X
Acceptable synonyms:
Plain X-ray of X
Plain film of X
Plain radiography of X
However it is not compulsory to add these variations to a new concept they can be added upon request. Note: the expert group indicated that 'plain' is not commonly used within the clinical environment however this may vary from country to country.
Radiograph of X is a broader synonym and therefore should not be accepted as a new synonym for concepts that have the FSN X-ray of X. However instances of released concepts where this description already exists should remain active to prevent the need for large-scale retirements assuming that the synonym only appears on that single concept. Maintaining the broader synonyms will facilitate searching. This information should be incorporated into the editorial guide.
RadLex http://www.radlex.org/RID/RID10351 uses the naming convention of 'Radiography.' However the method of image capture (screen film or digital) is listed as a separate entity and this differs from the convention in SNOMED CT. Also of significance RadLex uses a post-coordinated approach where the imaging site and imaging modality are coded separately.
DICOM http://www.dicomlibrary.com/dicom/modality/ also uses the name "Radiographic imaging" for its imaging procedures and this encompasses conventional film/screen image capture. The question of whether there is a requirement to distinguish between digital and conventional film capture in SNOMED CT was raised with the expert group who advised that the imaging procedure itself is not altered by the method of storage for the image. The group did not advocate the inclusion of new content for digital or conventional image capture.
Duplicate synonyms across separate concepts are not acceptable except in very rare cases as described in the editorial guidance. Instances of duplication will require inactivation of descriptions. So for example 168537006|Plain radiography (procedure) has a synonymous description 'X-ray' as does its parent concept 363680008|Radiographic imaging procedure (procedure) and 'Roentgenography' appears on both parent (363680008|Radiographic imaging procedure (procedure)) and child (168537006|Plain radiography (procedure). Application of the existing editorial guidance for broader and narrower synonyms will assist in determining which concept should retain the duplicate synonym and which should be inactivated.

Text Definition

It is recommended that a text definition be applied to the concepts 278110001|Radiographic imaging - action (qualifier value) and 312254007|Plain X-ray imaging - action (qualifier value) and also to the concepts 363680008|Radiographic imaging procedure (procedure) and 168537006|Plain radiography (procedure) to prevent future inconsistency in the manner these concepts are used.

Significant design or implementation decisions / compromises

Addressing any inconsistency in released concepts may require changes to way the concept is modelled or changes to descriptions. This is likely to result in changes to inferred relationships after classification. As noted above, in order to resolve this content issue it is recommended that changes be made to the descriptions and modelling of existing content rather than the large scale inactivation and replacement of content. It is likely that the proposed changes will uncover equivalency between released concepts and this will need to be managed using inactivation and historical relationships. The impact of the proposed changes on end users is difficult to assess however the benefits of improvement in the quality of existing content without large scale inactivations is intended to mitigate any associated implementation burden.

Evaluation of Design

Exceptions and Problems

Generally where a concept has a mixture of descriptions and is also inconsistent in the way in which its attribute and value pairs have been assigned, it would be considered to be ambiguous. This would lead to concept inactivation. The recommendations of this content project do not include large-scale inactivation of existing inconsistent content. However this will result in changes to released FSN that cannot be considered to be minor as defined in the Editorial Guidance https://confluence.ihtsdotools.org/display/public/EditorialGuide/7.3.1+Minor+changes+in+the+Fully+Specified+Name

Iteration One

Outline of Revised Design

After initial review of this inception/elaboration document, 'Option Three' has been added.
It is noted that in the clinical environment 'plain X-ray' may be used to refer to X-ray examinations that

1. Do not need special equipment (like the CT scanner)
2. Do not involve the use of radiologic contrast.

Therefore it is justifiable to consider the need to retain the distinction between radiographic imaging as a grouper for several different imaging procedures and its more granular descendant of Plain X-ray.
Option three

Retain 278110001|Radiographic imaging - action (qualifier value)| and 312254007|Plain X-ray imaging - action (qualifier value)|.
Interpret 'X-ray' as synonymous with 278110001|Radiographic imaging - action (qualifier value)|.
Note that 312254007|Plain X-ray imaging - action (qualifier value)| has a more specific clinical meaning than its supertype.
312254007|Plain X-ray imaging - action (qualifier value)| will remain a subtype of 278110001|Radiographic imaging - action (qualifier value)|.
A text definition should be added to both of these concepts.

This option would align most closely with the existing content and would therefore prove least disruptive to the known large-scale implementations of imaging content in member countries that include Canada and the UK.

Significant Design or Implementation Changes

278110001|Radiographic imaging - action (qualifier value) will continue to group all of the different radiographic procedures that are based on X-ray. 312254007|Plain X-ray imaging - action (qualifier value)| will be used as the method for any procedure that uses a single imaging modality of plain X-ray without use of special equipment.

Where an active concept utilises the words 'X-ray of X' in its descriptions, it could be considered ambiguous because this term clinically may mean 'any radiographic imaging procedure that uses X-ray' or it may mean specifically a plain X-ray.

However implementation of this interpretation would result in the large scale inactivation of content that uses the term 'X-ray of X.' As an alternative it is recommended that a review of all content that uses the terms 'Radiographic imaging of X', 'X-ray of X' and 'Plain X-ray of X' and 'Radiography of X" in their descriptions be undertaken. Where a concept is a grouper concept and utilises the term 'Radiographic imaging' in the fully specified name along with the imaging action 278110001|Radiographic imaging - action (qualifier value)| this concept can be retained. Detailed information about the management of the descriptions in these concepts can be found in Section 7.1.2.

Where two concepts exist for example 1225002|Radiography of humerus (procedure)| and 713026007|Plain x-ray of humerus (procedure)| both concepts will be retained with the proviso that both concepts are modelled with the correct imaging method and there is no duplication of synonyms across both concepts.

In cases such as 268425006|Pelvis X-ray (procedure)| this concept is a high level grouper but has a subtype of 713021002|Plain radiography of pelvis (procedure)|, these concepts will be renamed.
268425006|Pelvis X-ray (procedure)| will be amended to Radiographic imaging of pelvis (procedure)
713021002|Plain radiography of pelvis (procedure) will be amended to Plain X-ray of pelvis (procedure)

The actions as set out in point 6 are to be replicated across existing in scope content, this will rectify existing inconsistencies with active concepts.

It is noted that there are exceptions that cannot be modelled in this way for example 168821007|Barium swallow (procedure)| which is a descendant of 34885003|Radiography of esophagus (procedure)|. These exceptions can be reviewed on a case-by-case basis to identify if any improvements are required to either the descriptions or relationship groups. This work is already being undertaken as part of the IHTSDO quality improvement schedule.

Evaluation of Revised Design

Exceptions and Problems

There are a number of imaging procedures that cannot be named to align with a pattern of "Radiographic imaging of X' or Plain 'X-ray of X'. Examples of types of procedures include Cineradiography of pharynx, Angiocardiography by cineradiography, Xeroradiography. However whilst these types of procedure cannot conform to a specified naming convention for procedures, it is possible to ensure that their imaging action model is accurate and this is recommended.

Design Strengths

The recommended solution follows the conventional and existing approach to concept modeling, and applying this approach consistently to all in scope content will ensure that any existing inconsistencies that can be resolved are resolved. Rigor in the logic applied will improve the outputs of queries for end users.
This new proposal will reduce the number of inactivations required across content whilst improving consistency and removing any areas of duplication or ambiguity.

Design Weaknesses

There will be a requirement to 'interpret' existing content in order to align descriptions with the method of imaging action. This will mean that the fully specified name of some concepts will need to be inactivated and replaced with a new description. This does not align with the editorial guidance that relates to minor "allowable changes' for the fully specified name.
There is the risk that the problems that already exist with the interpretation of radiographic imaging, X-ray and plain X-ray will be perpetuated in future new content.

Design Risks

Description of risk	Importance	Mitigation plan
Misinterpretation of existing content	Major	All in scope active concepts will be reviewed to align descriptions with imaging action. These changes will be peer reviewed.
Uncertainty across users and implementers about which concept to choose	Major	Use of text definitions Consistent pattern to align existing content Publication of editorial guidance
Change to existing content will impact clinical usage where a procedure has been recorded with the intention of it being a plain X-ray and then it changes to a radiographic imaging procedure – grouper concepts should not be used for reporting.	Major	Radiographic imaging is a grouper, guidance should include advice to avoid use in clinical data entry, as it is not possible to identify the specific image utilised. Guidance to include information that future data entry should use specific imaging modality and not grouper concepts. New concepts should align with the new guidance with clarification sent to requesters to ensure that the correct imaging modality is assigned at the time of authoring.
Risk of perpetuation of existing inconsistencies when adding new content new content	Major	Use of text definitions Efforts to align the existing content to the proposed conformant pattern. Publication of editorial guidance Adherence to editorial guidance and quality assurance review of new content.

Recommendation

Initial Detailed Design Specification

Review the inconsistent naming of 'X-ray' and 'Radiographic imaging' and 'Plain X-ray' concepts in the procedure hierarchy.

Propose a naming convention in order to improve the representation of these concepts in descriptions.

The descriptions will follow this pattern:
FSN: X-ray of X (procedure)
Preferred term: X-ray of X
Acceptable synonyms will include Plain X-ray of X, Plain film of X, Plain radiography of X however it is not compulsory to add these variations to a new concept they can be added upon request.
Radiograph of X is a broader synonym and therefore should not be accepted as a new synonym. However instances of released concepts where this description already exists should remain active to prevent the need for large-scale retirements of descriptions with the associated implementation burden this inevitably brings. This information should be incorporated into the editorial guide.
Duplicate synonyms on separate concepts are not acceptable unless the circumstances are exceptional and therefore instances of this will result in inactivation of descriptions.

Review the inconsistent modelling of 'X-ray' and 'Radiographic imaging' and 'Plain X-ray' concepts in the procedure hierarchy. It is recommended that the following concepts should utilise the action 278110001|Radiographic imaging - action (qualifier value) and act as grouper concepts:

363680008|Radiographic imaging procedure (procedure)
108273007|Radiographic imaging procedure by site (procedure)
418542003|Radiologic guidance procedure (procedure)
27483000|Diagnostic radiography with contrast media (procedure)

Propose a consistent modelling approach in order to improve the representation and subsumption of these concepts and remove duplication. It is recommended that with the exception of the four grouper concepts listed above 312254007|Plain X-ray imaging - action (qualifier value) should be used as the imaging action for X-ray imaging procedures. method for the concepts listed in Appendix A.

Draft editorial guidance will be a brief summary of these recommendations.

Iteration Plan – Updated Detailed Design Specification

Review the inconsistent naming of 'X-ray' and 'Radiographic imaging' and 'Plain X-ray' and "Radiography" concepts in the procedure hierarchy.

Find all concepts with the fully specified name 'X-ray of X (procedure), Plain X-ray of X (procedure) and 'Radiographic imaging of X (procedure)' and 'Radiography of X (procedure).
Appendix A - lists all concepts that include 'Plain X-ray' in the FSN (total 21 concepts)
Appendix B – lists all concepts that include 'X-ray' minus the word 'plain' in the FSN (total 244 concepts)
Appendix C – lists all concepts that include 'Radiographic imaging' in the FSN (total 18 concepts)
Appendix D – lists all concepts that include 'Radiography' in the FSN (total 173 requests).

Identify the meaning of each concept based on its position in the hierarchy and the imaging action assigned in the relationship groups. Synonyms may assist with this however are not to be used in isolation.

Remodel inconsistent concepts to ensure that the description matches the assigned imaging modality
Where a concept has 'Plain X-ray' in the fully specified name, then the imaging action assigned should be 312254007|Plain X-ray imaging - action (qualifier value)|.
Where the concept has 'Radiographic imaging' in the fully specified name, the imaging action should be 278110001|Radiographic imaging - action (qualifier value)|.
Where a concept has 'X-ray' in its FSN, the FSN must align with its intended meaning. For example 268425006|Pelvis X-ray (procedure)| should have its FSN changed to Radiographic imaging of pelvis (procedure) to align with the concept modelling and its position as a grouper. This may be a contentious change and retirement of the example concept as ambiguous with a replacement concept Radiographic imaging of pelvis (procedure) is likely to be a safer alternative.
Notable exceptions: for example 168537006|Plain radiography (procedure)| is a plain X-ray procedure but uses radiography in its FSN and acts as a grouper for many plain X-ray procedures. This concept should have its FSN changed to Plain X-ray (procedure).

The term 'X-ray' may only be used as a synonym for concepts that use 278110001|Radiographic imaging - action (qualifier value)|, for all other instances where this term has been applied, the description should be inactivated on the basis of a broader synonym being applied to the concept (see editorial guidance https://confluence.ihtsdotools.org/display/EditorialGuide/7.4.4+Broader+synonyms)

Add a text definition to the concepts 278110001|Radiographic imaging - action (qualifier value) and 312254007|Plain X-ray imaging - action (qualifier value) and also to the concepts 363680008|Radiographic imaging procedure (procedure) and 168537006|Plain radiography (procedure) to prevent future inconsistency in the manner these concepts are used.

Propose a brief summary of the above information to be incorporated into the editorial guidance.

Quality program criteria

Quality metrics

Quality metric 1

Component	Characteristic and Description		Metric	Target	Result
Logic definitions of descendants of 363680008	Radiographic imaging procedure (procedure)	Char:	sufficiently defined	Existing concepts to be reviewed,listed in Appendix A to be reviewed and the method action changed as detailed in recommendation (see Section 7.1.26)	95%
	Descr:	Concept logic definitions should be "defined" not "primitive"

Quality metric 2

Component	Characteristic and Description		Metric	Target	Result
Fully specified names in descendants of 363680008	Radiographic imaging procedure (procedure)	Char:	Adherence to terming guidelines	Review all existing concepts as listed in Appendix B and make change to descriptions as required (see section 7.1.2)	95%
	Descr:	The fully specified name should adhere to terming guidelines listed in the editorial guide

Project Resource Estimates

Estimated project size medium.
Changes to the procedure hierarchy will also impact on the clinical finding hierarchy however these changes are inferred changes and will be implemented by the classifier.
The changes can be implemented over two releases using an algorithmic approach to description changes and also to the method value. This would require assistance from the technical team.

Scope of construction phase

The proposed solution is detailed in Section 6 of this document with recommendations detailed in Section 7. The scope of the initial phase of this content project will be to review all existing content as identified in Appendix A and Appendix B in order to align the relationship groups and descriptions as set out in Section 7 where possible. The in scope descriptions for review as part of this project are detailed in Appendices A, B, C and D and totals 456 concepts. This would represent the first phase of implementation to be undertaken in one release cycle.
The second phase will be to review all existing requests for new content currently in SIRS and would be undertaken in the subsequent release after completion of phase one to ensure that the released changes are implemented and allow time for stakeholder feedback.
To prevent recurrence of the problem the editorial guide must be aligned with the recommendations of Section 7 to ensure that modellers and requesters are supported by documentation.

Projection of remaining overall project resource requirements

Expected project resource requirement category

This content project in isolation does not require project management and can be implemented by the content team. However, implementation of this content project would be resource intensive and requires input from the technical team in order to make large-scale changes to both descriptions and relationships to prevent the need for multiple manual editing changes. Quality review of the changes will be required and this will be a labour intensive activity.

Expected project impact and benefit

It is acknowledged that changes to this area of content do not appear to be a high priority with end users, perhaps because issues with coding in this area of imaging have a lower financial impact. However the problems as outlined in this project are not confined to one area of SNOMED CT, the procedure hierarchy impacts on the clinical finding and situation hierarchy. The implementation of this project will benefit end users by improving the quality of existing and future content.

Indicative resource estimates for construction, transition and maintenance:

Approximately 456 existing concepts to be reviewed and changes made where necessary. Likely resource requirements for this are as follows:
456 existing concepts to be reviewed and changes made to align with new policy at a rate of 20 concepts per day would mean that one terminologist could implement the required changes in 9 working weeks. As outlined above, this estimate could be substantially reduced if the data changes are implemented directly by the technical team and then reviewed by a content editor prior to release.
Existing SIRS requests (approximately 160 requests) are to be reviewed and added to SNOMED CT.
Maintenance is not required assuming that going forward new content follows the recommended approach for term construction and modelling.

Appendices

Appendix A

All concepts that have 'Plain X-ray' included in the FSN

426296008	Plain x-ray of joint (procedure)
713023004	Plain x-ray of upper limb (procedure)
713024005	Plain x-ray of wrist (procedure)
713025006	Plain x-ray of elbow (procedure)
713026007	Plain x-ray of humerus (procedure)
713027003	Plain x-ray of hand (procedure)
713028008	Plain x-ray of scapula (procedure)
713565002	Plain X-ray of abdomen with contrast (procedure)
713701007	Plain X-ray of ventriculoperitoneal shunt (procedure)
168565008	Plain X-ray base of skull (procedure)
168566009	Plain X-ray facial sinuses (procedure)
168619004	Plain X-ray head of humerus (procedure)
168620005	Plain X-ray shaft of humerus (procedure)
168637003	Plain X-ray radius (procedure)
168663008	Plain X-ray head of femur (procedure)
168665001	Plain X-ray shaft of femur (procedure)
168702005	Plain X-ray abdomen (procedure)
277673007	Plain X-ray guidance (procedure)
303936003	Specific plain X-ray investigations (procedure)
303937007	Plain X-ray techniques (procedure)
428907005	Plain X-ray guided wire localization of breast lesion (procedure)

Appendix B

All concepts that have 'X-ray' minus the word 'plain' in the FSN

1597004	Skeletal X-ray of ankle and foot (procedure)
5433008	Skeletal X-ray of lower limb (procedure)
22791004	X-ray of lumbosacral spine (procedure)
24200008	Calculus analysis, quantitative, X-ray diffraction (procedure)
38336006	Soft tissue X-ray of chest wall (procedure)
39714003	Skeletal X-ray of wrist and hand (procedure)
40064005	Soft tissue X-ray of face, head AND neck (procedure)
40348008	Skeletal X-ray of pelvis and hip (procedure)
48966008	Skeletal X-ray of shoulder and upper limb (procedure)
49856005	Soft tissue X-ray of lower limb (procedure)
55965002	X-ray of skull (procedure)
60668004	Soft tissue X-ray of abdominal wall (procedure)
70780000	Skeletal X-ray of elbow and forearm (procedure)
72872009	Skeletal X-ray of upper limb (procedure)
81380004	Electron microscopy study, scanning, with X-ray analysis, examination and report (procedure)
83641009	X-ray of epididymis and vas deferens (procedure)
168558000	Ethmoid sinuses X-ray (procedure)
168559008	Frontal sinuses X-ray (procedure)
168560003	Maxillary sinuses X-ray (procedure)
168564007	Mastoid processes X-ray (procedure)
168573004	Atlantoaxial X-ray (procedure)
168594001	Clavicle X-ray (procedure)
168599006	Sternoclavicular joint X-ray (procedure)
168600009	Thoracic inlet X-ray (procedure)
168609005	Symphysis pubis X-ray (procedure)
168623007	X-ray shaft of radius/ulna (procedure)
168632009	Stress X-ray shoulder joint (procedure)
168633004	Acromioclavicular joint X-ray (procedure)
168654006	Stress X-ray thumb (procedure)
168664002	Femoral neck X-ray (procedure)
168669007	Patella X-ray (procedure)
168681006	Stress X-ray knee (procedure)
168682004	Stress X-ray ankle joint (procedure)
168713008	Soft tissue X-ray face (procedure)
168716000	Ear soft tissue X-ray (procedure)
168717009	Soft tissue X-ray nose (procedure)
168719007	Neck soft tissue X-ray (procedure)
168722009	X-ray cervical lymph nodes (procedure)
168723004	Soft tissue X-ray thyroid (procedure)
168725006	Soft tissue X-ray mouth (procedure)
168729000	Soft tissue X-ray tongue (procedure)
168731009	Standard chest X-ray (procedure)
168736004	Soft tissue X-ray chest (procedure)
168743005	Soft tissue X-ray pleura (procedure)
168744004	Soft tissue X-ray heart (procedure)
168745003	Soft tissue X-ray thoracic aorta (procedure)
168746002	Soft tissue X-ray diaphragm (procedure)
168759005	Abdominal obstetric X-ray (procedure)
168760000	Obstetric X-ray - fetus (procedure)
168763003	Upper abdomen soft tissue X-ray (procedure)
168764009	Cardioesophageal X-ray (procedure)
168766006	Liver soft tissue X-ray (procedure)
168767002	Spleen soft tissue X-ray (procedure)
168770003	Soft tissue X-ray kidney (procedure)
168772006	X-ray male external genitalia (procedure)
168773001	X-ray female external genitalia (procedure)
168775008	Soft tissue X-ray limbs (procedure)
168779002	Soft tissue X-ray lymph nodes (procedure)
168780004	Soft tissue X-ray veins (procedure)
168781000	Soft tissue X-ray arteries (procedure)
169116004	X-ray of pathological specimen (procedure)
169279005	X-ray fluorescence spectrometry (procedure)
169291001	X-ray beam therapy (procedure)
169293003	Superficial X-ray therapy 10-60 kV (procedure)
169295005	Deep X-ray therapy 150-400 kV (procedure)
169297002	Short distance X-ray therapy (procedure)
169298007	Intracavitary X-ray therapy (procedure)
169299004	Combined X-ray therapy (procedure)
171229005	Screening chest X-ray (procedure)
183830008	Refer for X-ray (procedure)
228662001	Betatron X-ray therapy (procedure)
228663006	Microtron X-ray therapy (procedure)
228664000	Van der Graaff X-ray therapy (procedure)
228707002	Radiotherapy planning using a simulator X-ray film (procedure)
241034009	Skull vault X-ray (procedure)
241035005	Internal auditory meatus X-ray (procedure)
241036006	External auditory meatus X-ray (procedure)
241037002	X-ray of eye for foreign body (procedure)
241038007	Sphenoid sinuses X-ray (procedure)
241040002	Cephalometry X-ray (procedure)
241042005	Mandible X-ray posteroanterior (procedure)
241044006	Mandible X-ray oblique lateral (procedure)
241045007	Styloid process X-ray (procedure)
241046008	Dental X-ray bitewing (procedure)
241047004	Dental X-ray periapical (procedure)
241048009	Dental X-ray occlusal (procedure)
241049001	Maxillary occlusal X-ray (procedure)
241050001	Mandibular occlusal X-ray (procedure)
241051002	Tangential X-ray of incisor and canine (procedure)
241059000	Obstetric X-ray - placenta (procedure)
241062002	Gallbladder straight X-ray (procedure)
241063007	Bicipital groove X-ray (procedure)
241066004	Ulna groove X-ray (procedure)
241069006	Ulna X-ray (procedure)
241071006	Scaphoid X-ray (procedure)
241072004	Carpal tunnel X-ray (procedure)
241073009	Metacarpal X-ray (procedure)
241074003	Thumb X-ray (procedure)
241075002	Femur X-ray (procedure)
241076001	Tibia and/or fibula X-ray (procedure)
241077005	Tibia X-ray (procedure)
241078000	Fibula X-ray (procedure)
241079008	Metatarsal X-ray (procedure)
241080006	Tarsus X-ray (procedure)
241081005	Hindfoot X-ray (procedure)
241082003	Hallux X-ray (procedure)
241083008	Foot X-ray orthopedic/biomechanical examination (procedure)
241085001	Subtalar joint X-ray (procedure)
241088004	Ischium X-ray (procedure)
241089007	Ilium X-ray (procedure)
241090003	Perineum X-ray (procedure)
241091004	X-ray pelvimetry (procedure)
241092006	Cervicothoracic junction X-ray (procedure)
241093001	Thoracolumbar spine X-ray (procedure)
241094007	Scoliosis survey X-ray (procedure)
241109006	Pelvic soft tissue X-ray (procedure)
241110001	Genitalia soft tissue X-ray (procedure)
241111002	Bronchus soft tissue X-ray (procedure)
241112009	Lung soft tissue X-ray (procedure)
241113004	X-ray of soft tissue of trachea (procedure)
241114005	Head soft tissue X-ray (procedure)
241115006	Lip soft tissue X-ray (procedure)
241116007	Parotid gland X-ray (procedure)
241117003	Submandibular gland X-ray (procedure)
241118008	Foot soft tissue X-ray (procedure)
241119000	X-ray of extracted tooth (procedure)
241146005	Tracheoesophageal fistula X-ray study (procedure)
241685002	X-ray photon absorptiometry (procedure)
241686001	Dual energy X-ray photon absorptiometry (procedure)
268425006	Pelvis X-ray (procedure)
268427003	X-ray shaft of tibia/fibula (procedure)
268428008	Erect abdominal X-ray (procedure)
268430005	Gallbladder soft tissue X-ray (procedure)
268431009	Lower abdomen soft tissue X-ray (procedure)
268432002	X-ray of non-obstetric pelvic organs (procedure)
271311001	Carpal bones X-ray (procedure)
271312008	Soft tissue X-ray of lung/bronchus (procedure)
276015003	Forefoot X-ray (procedure)
276478001	Odontoid peg X-ray (procedure)
277458000	Single energy X-ray photon absorptiometry (procedure)
277666002	X-ray guided biopsy (procedure)
281616007	Trunk soft tissue X-ray (procedure)
281617003	Soft tissue X-ray of abdomen (procedure)
281619000	Vascular soft tissue X-ray (procedure)
281671008	Biliary tract X-ray (procedure)
302402006	Radius and/or ulna X-ray (procedure)
302797005	Whole body X-ray of stillborn infant (procedure)
302798000	Gallbladder X-ray (procedure)
303931008	Lung X-ray (procedure)
303932001	Thoracic cage X-ray (procedure)
303935004	Specific spinal X-ray (procedure)
310810003	Soft tissue X-ray floor of mouth (procedure)
314604005	Palliative course of deep X-ray therapy (procedure)
314605006	Preoperative course of deep X-ray therapy (procedure)
314606007	Postoperative course of deep X-ray therapy (procedure)
390983001	Referral for dual energy X-ray photon absorptiometry scan (procedure)
399128004	X-ray crystallography (procedure)
408493004	Referral for dual energy X-ray photon absorptiometry scan of hip and spine (procedure)
408494005	Referral for dual energy X-ray photon absorptiometry scan of forearm (procedure)
408495006	Referral for dual energy X-ray photon absorptiometry scan of heel (procedure)
416733000	Supine abdominal X-ray (procedure)
418181007	X-ray for colonic transit study (procedure)
418426008	X-ray of fingers (procedure)
418515004	X-ray of little finger (procedure)
418802004	X-ray of index finger (procedure)
419080000	X-ray of ring finger (procedure)
419380005	X-ray of middle finger (procedure)
419942003	X-ray of lumbar spine and sacroiliac joints (procedure)
420068003	X-ray of ear (procedure)
420233006	X-ray of chest and abdomen (procedure)
425583002	Portable X-ray (procedure)
425703002	X-ray of both ankles (procedure)
426311001	X-ray of right foot (procedure)
426420006	X-ray of left ankle (procedure)
426581005	X-ray of both feet (procedure)
426721006	X-ray of right ankle (procedure)
426860004	X-ray of both knees (procedure)
426908009	X-ray of left foot (procedure)
426945003	X-ray of bone (procedure)
427019001	X-ray of left knee (procedure)
427407003	X-ray of right knee (procedure)
428313006	Dual energy X-ray photon absorptiometry scan of mandible (procedure)
428377003	Dual energy X-ray photon absorptiometry scan of lumbar spine (procedure)
428569003	Dual energy X-ray photon absorptiometry scan of forearm (procedure)
428603007	X-ray of hand and wrist for bone age (procedure)
428665002	X-ray of carpometacarpal joint under stress (procedure)
429148001	X-ray of zygoma (procedure)
429373009	Dual energy X-ray photon absorptiometry scan of heel (procedure)
429529009	Dual energy X-ray photon absorptiometry scan of hip (procedure)
429646003	X-ray skeletal survey for multiple myeloma (procedure)
431251007	X-ray of pelvis using mobile image intensifier (procedure)
431557005	X-ray of cervical spine using mobile image intensifier (procedure)
431677006	X-ray of upper limb using mobile image intensifier (procedure)
431871005	X-ray of lumbar spine using mobile image intensifier (procedure)
431892005	X-ray of lumbar spine and pelvis (procedure)
432078003	X-ray of sacrum using mobile image intensifier (procedure)
432769002	X-ray of thorax using mobile image intensifier (procedure)
432770001	X-ray of thoracic spine using mobile image intensifier (procedure)
432778008	X-ray of abdomen using mobile image intensifier (procedure)
432848006	X-ray of hip using mobile image intensifier (procedure)
432906003	X-ray of lower limb using mobile image intensifier (procedure)
433155002	X-ray cystometrogram (procedure)
439100007	X-ray of skull using mobile image intensifier (procedure)
439101006	X-ray tomography (procedure)
439477003	Dual energy X-ray photon absorptiometry scan of femoral neck (procedure)
440496005	Dual energy X-ray photon absorptiometry scan of whole body (procedure)
440607000	X-ray of teeth in oblique lateral view (procedure)
440695003	X-ray of midfoot (procedure)
441284005	Multidirectional X-ray tomography (procedure)
444634007	X-ray of thoracic and lumbar spine (procedure)
445515006	X-ray of cerebrospinal fluid shunt (procedure)
445844000	X-ray of cochlear implant (procedure)
446181006	Forensic X-ray (procedure)
446458002	X-ray of bone of shoulder and upper arm (procedure)
446463003	Full mouth x-ray of teeth (procedure)
446473001	X-ray of radius and ulna (procedure)
446621008	X-ray of bone of knee (procedure)
446629005	X-ray of bone of shoulder (procedure)
446639004	X-ray of bone of ankle (procedure)
446640002	X-ray of urinary bladder (procedure)
446748000	X-ray of ureter (procedure)
446749008	X-ray of bone of hand (procedure)
446785008	X-ray of bone of hip (procedure)
446811003	X-ray of bone of foot (procedure)
446888002	X-ray of vas deferens using contrast (procedure)
447248009	X-ray of bone of elbow (procedure)
448336005	Radiofrequency biopsy of breast using X-ray guidance (procedure)
449616006	X-ray of lower limb for bone length measurement (procedure)
449617002	X-ray of lower leg for bone length measurement (procedure)
703940002	X-ray of elbow for bone age (procedure)
708656007	Dual energy X-ray absorptiometry scan of wrist (procedure)
708690003	Dual energy X-ray photon absorptiometry scan of spine (procedure)
708734000	X-ray of prostate and seminal vesicles (procedure)
711104001	X-ray of cervical and thoracic spine (procedure)
711220000	X-ray of limb (procedure)
711225005	Injection using X-ray guidance (procedure)
711226006	Biopsy of bone using X-ray guidance (procedure)
711307001	Colonoscopy using X-ray guidance (procedure)
711420002	X-ray consultation (procedure)
711422005	Intravenous pyelogram using X-ray guidance (procedure)
711488007	X-ray of shunt (procedure)
711555002	X-ray of rib (procedure)
712970008	X-ray of cervical spine (procedure)
713564003	Localization of iodine 125 radioactive seed to breast lesion using X-ray guidance (procedure)

Appendix C

All concepts that include 'Radiographic imaging' in the FSN

169103004	Postmortem radiographic imaging (procedure)
169106007	Postmortem radiographic imaging of brain (procedure)
169109000	Postmortem radiographic imaging of heart (procedure)
169111009	Postmortem radiographic imaging of skeleton (procedure)
169107003	Postmortem radiographic imaging of skull (procedure)
169110005	Postmortem radiographic imaging of soft tissue (procedure)
169108008	Postmortem radiographic imaging of teeth (procedure)
169112002	Postmortem radiographic imaging of whole body (procedure)
418198007	Radiographic imaging nephrostomy (procedure)
427961005	Radiographic imaging of acetabulum (procedure)
424398008	Radiographic imaging of bone (procedure)
443248008	Radiographic imaging of both hands and wrists, anteroposterior, lateral and ballcatch views (procedure)
443451004	Radiographic imaging of both knees, lateral, sunrise and anteroposterior standing views (procedure)
424475001	Radiographic imaging of lower leg (procedure)
442567001	Radiographic imaging of lymphatic system using contrast (procedure)
415231009	Radiographic imaging of soft tissue (procedure)
363680008	Radiographic imaging procedure (procedure)
108273007	Radiographic imaging procedure by site (procedure)

Appendix D

All concepts that include 'Radiography' in the FSN

413247008	Submucosal injection of contrast media for radiography (procedure)
241032008	Stereographic radiography (procedure)
169061002	Serial radiography of lungs (procedure)
80501006	Radiography of zygomaticomaxillary complex (procedure)
60027007	Radiography of wrist (procedure)
47187002	Radiography of uvula (procedure)
90711000	Radiography of uterus (procedure)
113103008	Radiography of urinary system (procedure)
24267008	Radiography of upper limb soft tissue (procedure)
74170002	Radiography of upper limb (procedure)
79777008	Radiography of tonsils and adenoids (procedure)
79190008	Radiography of thyroid region (procedure)
45554006	Radiography of thoracic spine (procedure)
204327002	Radiography of thigh (procedure)
22891007	Radiography of teeth (procedure)
22289008	Radiography of symphysis menti (procedure)
31931003	Radiography of supraorbital area (procedure)
23394003	Radiography of sternum (procedure)
79760008	Radiography of spine (procedure)
76573005	Radiography of soft tissue of upper arm (procedure)
23846005	Radiography of soft tissue of thigh (procedure)
113107009	Radiography of soft tissue of shoulder (procedure)
38366004	Radiography of soft tissue of knee (procedure)
61147008	Radiography of soft tissue of hip (procedure)
72911009	Radiography of soft tissue of hand (procedure)
43947005	Radiography of soft tissue of forearm (procedure)
18912009	Radiography of soft tissue of elbow (procedure)
73771004	Radiography of soft tissue of ankle (procedure)
29592009	Radiography of shoulder (procedure)
367414003	Radiography of salivary gland (procedure)
8449009	Radiography of sacrococcygeal spine (procedure)
37603004	Radiography of root canal (procedure)
21970003	Radiography of ribs (procedure)
37541000	Radiography of retroperitoneum (procedure)
83932002	Radiography of prostate (procedure)
49140003	Radiography of penis (procedure)
58259007	Radiography of pelvic soft tissue (procedure)
88914000	Radiography of pelvic bones (procedure)
37307009	Radiography of nasopharynx (procedure)
82499005	Radiography of nasolacrimal duct (procedure)
84492002	Radiography of nasal sinuses (procedure)
52514008	Radiography of maxilla (procedure)
19589009	Radiography of mandible (procedure)
17745004	Radiography of male genital organs (procedure)
31911002	Radiography of kidney-ureter-bladder (procedure)
21339000	Radiography of intestine (procedure)
1225002	Radiography of humerus (procedure)
408740001	Radiography of hip (procedure)
69143005	Radiography of heart (procedure)
48450000	Radiography of head (procedure)
49345004	Radiography of hand (procedure)
264318007	Radiography of gravid uterus (procedure)
75679007	Radiography of gastrointestinal tract (procedure)
74809003	Radiography of forearm (procedure)
52221007	Radiography of foot (procedure)
29433003	Radiography of female genital organs (procedure)
29357002	Radiography of face, head AND/OR neck (procedure)
34885003	Radiography of esophagus (procedure)
76913009	Radiography of elbow (procedure)
5131003	Radiography of chest wall (procedure)
66769009	Radiography of cervical spine (procedure)
19490002	Radiography of ankle (procedure)
3799005	Radiography of adenoids (procedure)
91186003	Radiography for bone length studies (procedure)
88504002	Radiography for bone age studies (procedure)
713021002	Plain radiography of pelvis (procedure)
168537006	Plain radiography (procedure)
287601004	Pericardial contrast radiography (procedure)
168818005	Pelvic contrast radiography (procedure)
168900006	Omphalomesenteric duct contrast radiography (procedure)
241033003	Movement radiography (procedure)
439514002	Intraoperative radiography of hip (procedure)
43058004	Injection of contrast media for radiography by direct puncture (procedure)
11850007	Injection of contrast media for radiography by catheter, supraselective (procedure)
56539001	Injection of contrast media for radiography by catheter, selective (procedure)
21503005	Injection of contrast media for radiography by catheter, retrograde (procedure)
23799006	Injection of contrast media for radiography by catheter, non-selective (procedure)
14273008	Injection of contrast media for radiography by catheter (procedure)
58981006	Injection of contrast media for radiography (procedure)
71599004	Gas contrast radiography of pelvis (procedure)
169014003	Fluoroscopy and radiography (procedure)
169025007	Fluoroscopy and radiography - urinary (procedure)
169016001	Fluoroscopy and radiography - skull (procedure)
169018000	Fluoroscopy and radiography - skeleton (procedure)
169020002	Fluoroscopy and radiography - mediastinum (procedure)
169021003	Fluoroscopy and radiography - lungs (procedure)
169019008	Fluoroscopy and radiography - heart (procedure)
169026008	Fluoroscopy and radiography - female genital (procedure)
169023000	Fluoroscopy and radiography - digestive (procedure)
169022005	Fluoroscopy and radiography - chest wall (procedure)
169017005	Fluoroscopy and radiography - cervical column (procedure)
169015002	Fluoroscopy and radiography - brain (procedure)
48564003	Fluoroscopic monitoring and radiography for cardiac pacemaker insertion (procedure)
33450004	Diagnostic radiography with special study (procedure)
50025001	Diagnostic radiography with oral contrast (procedure)
30788002	Diagnostic radiography with measurements (procedure)
91649003	Diagnostic radiography with gas-air, negative contrast (procedure)
8503002	Diagnostic radiography with contrast media, bilateral (procedure)
65590007	Diagnostic radiography with contrast media by injection, positive contrast, post-operative (procedure)
65066001	Diagnostic radiography with contrast media by injection, positive contrast, operative (procedure)
46291008	Diagnostic radiography with contrast media by injection, positive contrast, bilateral (procedure)
37348007	Diagnostic radiography with contrast media by injection, positive contrast (procedure)
82006003	Diagnostic radiography with contrast media by injection, positive and negative contrast, bilateral (procedure)
359866008	Diagnostic radiography with contrast media by injection, positive and negative contrast (procedure)
82899002	Diagnostic radiography with contrast media by injection, negative contrast (procedure)
59800002	Diagnostic radiography with contrast media by injection, bilateral (procedure)
363075003	Diagnostic radiography with contrast media by injection (procedure)
27483000	Diagnostic radiography with contrast media (procedure)
88745008	Diagnostic radiography of uterus for fetal age, fetal position and/or placental localization (procedure)
37385004	Diagnostic radiography of upper gastrointestinal tract with serial films (procedure)
5846007	Diagnostic radiography of toes (procedure)
55357008	Diagnostic radiography of tibia, combined anteroposterior and lateral (procedure)
35443000	Diagnostic radiography of thoracolumbar spine, supine and erect for scoliosis (procedure)
40372003	Diagnostic radiography of temporomandibular joint (procedure)
91583001	Diagnostic radiography of spine, survey study (procedure)
61368000	Diagnostic radiography of spine with flexion and extension studies (procedure)
90223007	Diagnostic radiography of soft tissues (procedure)
42075002	Diagnostic radiography of skull (procedure)
49626003	Diagnostic radiography of scapula (procedure)
57235004	Diagnostic radiography of sacrum (procedure)
6238009	Diagnostic radiography of sacroiliac joints (procedure)
10181005	Diagnostic radiography of sacrococcygeal joint (procedure)
47987001	Diagnostic radiography of sacral spine, combined anteroposterior and lateral (procedure)
77532004	Diagnostic radiography of ribs, bilateral (procedure)
41785006	Diagnostic radiography of pharynx (procedure)
18529002	Diagnostic radiography of pelvis, stereo views (procedure)
75675001	Diagnostic radiography of orbits (procedure)
43255009	Diagnostic radiography of optic foramina (procedure)
87411003	Diagnostic radiography of nasal bones (procedure)
44691001	Diagnostic radiography of mastoids (procedure)
26537001	Diagnostic radiography of lumbar spine, combined anteroposterior and lateral (procedure)
90805008	Diagnostic radiography of lumbar spine (procedure)
58011003	Diagnostic radiography of larynx (procedure)
12513003	Diagnostic radiography of hip, bilateral (procedure)
40502003	Diagnostic radiography of fistula or sinus tract, positive contrast (procedure)
60619004	Diagnostic radiography of finger (procedure)
79082005	Diagnostic radiography of fibula, combined anteroposterior and lateral (procedure)
68306006	Diagnostic radiography of facial bones (procedure)
24856003	Diagnostic radiography of coccyx (procedure)
49459005	Diagnostic radiography of chest, stereo (procedure)
67632007	Diagnostic radiography of chest, posteroanterior (procedure)
67071009	Diagnostic radiography of chest, oblique, standard (procedure)
22446007	Diagnostic radiography of chest, minifilm (procedure)
113094008	Diagnostic radiography of chest, lateral (procedure)
42869005	Diagnostic radiography of chest, combined posteroanterior and lateral (procedure)
69064006	Diagnostic radiography of cervical esophagus (procedure)
37815002	Diagnostic radiography of calcaneus (procedure)
373365009	Diagnostic radiography of bony orbits (procedure)
78670005	Diagnostic radiography of all fingers (procedure)
6127002	Diagnostic radiography of abdomen, oblique standard (procedure)
62295005	Diagnostic radiography of abdomen, decubitus and erect (procedure)
60654006	Diagnostic radiography of abdomen (procedure)
66596009	Diagnostic radiography for foreign body detection and localization (procedure)
32328007	Diagnostic radiography during operative procedure (procedure)
359869001	Diagnostic radiography double contrast (procedure)
315028004	Contrast radiography via drain (procedure)
168800007	Contrast radiography orbit (procedure)
274405001	Contrast radiography of trachea (procedure)
271313003	Contrast radiography of respiratory organs (procedure)
168817000	Contrast radiography of peritoneal cavity (procedure)
268435000	Contrast radiography of paranasal sinuses (procedure)
168803009	Contrast radiography of oropharynx (procedure)
86354001	Contrast radiography of nasopharynx (procedure)
54042002	Contrast radiography of nasolacrimal ducts (procedure)
274404002	Contrast radiography of larynx (procedure)
168894006	Contrast radiography of glands (procedure)
285754008	Contrast radiography of esophagus (procedure)
168816009	Contrast radiography of abdominal cavity (procedure)
268436004	Contrast radiography larynx/trachea (procedure)
168783002	Contrast radiography excluding cardiovascular system (procedure)
168899001	Contrast radiography - ducts (procedure)
287994002	Choledochotomy and radiography (procedure)
271315005	Biliary contrast radiography (procedure)

IHTSDO-161 (artf231911) Radiography vs X-ray

1 Glossary

1.1 Domain Terms

2 Introduction

2.1 Purpose

2.2 Audience and stakeholder domain

2.2.1 Input from stakeholders

2.2.2 Degree of consensus on the statement of problem

3 Statement of the problem or need

3.1 Summary of problem or need, as reported

3.2 Summary of requested solution

3.3 Statement of problem as understood

3.3.1 Radiographic Procedures Example 1

3.3.2 Radiographic Procedures Example 2

3.3.3 Radiographic Procedures Example 3

3.4 Detailed analysis of reported problem, including background

3.4.1 Ambiguous Grouper Concept

3.4.2 Duplicate Synonyms

3.4.3 Inconsistent Use of Imaging Action

3.4.3.1 Radiography of chest wall (procedure)

3.4.3.2 Soft tissue X-ray chest (procedure)

3.4.3.3 Whole body X-ray of stillborn infant (procedure)

3.4.4 Inconsistent Naming of Procedures

3.4.5 Where does ‘Diagnostic’ fit in?

3.4.6 Plain Film

3.4.7 Impact on the Clinical Finding Hierarchy

3.5 Subsidiary and interrelated problems

3.5.1 Impact On Hierarchies Other Than Procedure

3.5.2 Undesirable Inferred Relationships

3.5.3 Intermediate Primitive Concepts

3.5.4 Potential duplication

3.5.5 Miscellaneous Modelling Issues

4 Risks / Benefits

4.1.1 Risks of not addressing the problem

4.1.2 Risks of addressing the problem

5 Requirements: criteria for success and completion

5.1 Criteria for success/completion

5.2 Strategic and/or specific operational use cases

6 Solution Development

6.1 Initial Design

6.1.1 Modelling of Imaging Action

6.1.1.1 Option One

6.1.1.2 Option Two

6.1.1.3 Modelling Recommendation

6.1.1.4 Associated Modelling Recommendation

6.1.2 Description Recommendation

6.1.3 Text Definition

6.1.4 Significant design or implementation decisions / compromises

6.1.5 Evaluation of Design

6.1.5.1 Exceptions and Problems

6.2 Iteration One

6.2.1 Outline of Revised Design

6.2.2 Significant Design or Implementation Changes

6.2.3 Evaluation of Revised Design

6.2.3.1 Exceptions and Problems

6.2.3.2 Design Strengths

6.2.3.3 Design Weaknesses

6.2.3.4 Design Risks

7 Recommendation

7.1.1 Initial Detailed Design Specification

7.1.2 Iteration Plan – Updated Detailed Design Specification

8 Quality program criteria

8.1 Quality metrics

8.1.1 Quality metric 1

8.1.2 Quality metric 2

9 Project Resource Estimates

9.1 Scope of construction phase

9.2 Projection of remaining overall project resource requirements

9.2.1 Expected project resource requirement category

9.2.2 Expected project impact and benefit

9.2.3 Indicative resource estimates for construction, transition and maintenance:

10 Appendices

10.1 Appendix A

10.2 Appendix B

10.3 Appendix C

10.4 Appendix D

Glossary

Domain Terms

Introduction

Purpose