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Approvals 

1. Content Issue Summary 

Based on a request from members, it was suggested that "At risk (finding) concepts were inappropriately located and should be Situation with explicit context concepts.  The potential move of the <<281694009 |Finding of at risk (finding)| hierarchy to the Situation with explicit context hierarchy was discussed at the EAG meeting in April 2022.  At that meeting, there was consensus that leveraging the FINDING CONTEXT relationship would allow for sufficient definition of many of the existing 336 concepts in the existing Clinical findings hierarchy.  External consultation resulted in concerns from the Nursing CRG that moving these concepts would have a severe adverse effect on existing implementations as these were frequently used concepts that were considered to be properly located in the findings hierarchy. Alternatives to moving these concepts were developed.

2. Analysis of Issue 

An analysis of the current concepts related to risk found that the majority of "At risk" concepts were locate in a primitive clinical finding hierarchy, while a few concepts were located in the Situation with explicit context, modeled with a FINDING CONTEXT = At risk (context).  It was proposed to the SNOMED Editorial Advisory Group that all "At risk" concepts be moved to the Situation hierarchy.

Rationale:

1. "At risk" is an ambiguous term that could mean either "at low(er) or decreased risk" or "at high(er) or increased risk", although it commonly is used to represent "at increased risk"

2. Nearly all of the current "At risk (finding)" concepts are primitive and thus difficult to maintain and of limited analytical use

3. There are a limited number of "At risk (situation)" concepts that are all sufficiently defined using the FINDING CONTEXT = "At risk context (qualifier value)

At risk findings = 254 (5 sufficiently defined, but through multiple primitive parents)

At risk situation = 5

Given the rationale above, it was proposed to inactivate and replace the current finding concepts with new Situation concepts using the terming pattern "At increased risk of X (situation)" based on the change of meaning to be more explicit and the movement to the Situation hierarchy.

Questions posed to the EAG:

• Should these concepts be simply moved and remodeled (retaining SCTID)?

• Should these concepts be inactivated and replaced (preferred but potential large impact on users)?

• If inactivated, which inactivation reason would be used given that the existing terms are ambiguous, but are most frequently used to represent only "increased risk".  It is not necessarily of benefit to add both increased and decreased risk concepts where the latter would not be of much clinical use except in a few cases.

At risk is a disposition.  We have developed predispositions as findings for allergy.  This is a prototype of representation of risk and may be used to remodel the existing content.

There was initial consensus that this would be a good first step and would help to inform later needs for risk. Terms will be inactivated and replaced based on change of meaning.

3. Additional issues identified  

The consensus was that "At risk" was nearly universally interpreted as "At increased risk" and inactivation and replacement of concepts as opposed to re-terming would cause an excessive amount of churn that was not warranted given the current use of the existing terms.  An additional issue identified was that many of the at risk finding concepts do not have findings or disorders to use as ASSOCIATED FINDING values.  These would need to be created and may have limited value outside of the notion of risk.

Response from the Nursing Clinical Reference Group indicated that moving these concepts was unacceptable given the way they had been used in nursing  practice for some time and would cause an unnecessary burden to implementations.  They requested that these concepts remain in the findings hierarchy and an alternative approach to improving the content be developed.

4. Solution 

A new model has been created and reviewed by both the Nursing CRG and EAG that uses the HAS REALIZATION attribute to represent the disposition nature of risk.  A new Observable entity representing "Risk level (observable entity)" would be created to allow for representation of the level of risk for each finding.  For risk concepts that did not have an existing value for the HAS REALIZATION relationship, new finding or event concepts would be created to allow for sufficient definition of the risk concept.

The affected concepts are listed here: https://docs.google.com/spreadsheets/d/1eKx27z48mWSfhMaxYVKatMs5PgY3W9Mi/edit#gid=15600151

The template for modeling these concepts is located here: At [qualifier] risk of [finding/event] (finding) - Ready for review

5. Construction 

6. Transition phase 

7. Glossary of Terms