SNOMED CT January 2020 International Edition - SNOMED International Release notes
Release Date | 20200131 |
Release Status | PRODUCTION RELEASE |
Document Version | 1.0 |
Introduction
Background
SNOMED CT terminology provides a common language that enables a consistent way of indexing, storing, retrieving, and aggregating clinical data across specialties and sites of care.
SNOMED International maintains the SNOMED CT technical design, the content architecture, the SNOMED CT content (includes the concepts table, the descriptions table, the relationships table, a history table, and ICD mappings), and related technical documentation.
Purpose
This document provides a summarized description of the content changes included in the January 2020 release of SNOMED Clinical Terms® (SCT) International Release.
It also includes technical notes detailing the known issues which have been identified and agreed to be released. These are content or technical issues where the root cause is understood, and the fix has been discussed and agreed, but has yet to be implemented.
The SNOMED International Release Notes are available alongside the January 2020 International Edition release.
Scope
This document is written for the purpose described above and is not intended to provide details of the technical specifications for SNOMED CT or encompass every change made during the release.
Audience
The audience includes National Release Centers, WHO-FIC release centers, vendors of electronic health records, terminology developers and managers who wish to have an understanding of changes that have been incorporated into the January 2020 International Edition release.
Content Development Activity
Summary
Continuous quality improvement and enhancement of existing content is an ongoing process by SNOMED International for every release. The January 2020 International Release has seen a continuation of the work driven by contributions from: Kaiser Permanente Convergent Medical Terminology (CMT), Global Medical Device Nomenclature Agency (GMDNA), Orphanet and other domain specific collaborations as well as requests received via the Content Request System (CRS).
Additionally quality improvement activities are in progress for new and enhanced content through project driven initiatives which are also summarized below. Also included as work items for every release are various updates to SNOMED CT derived maps such as ICD-10 and ICD-O and details are also included in these release notes. Information about editorial decisions may be found in the SNOMED CT Editorial Guide, mapping guidance for ICD-10 can be found at this link https://confluence.ihtsdotools.org/display/DOCICD10
New content added for 2019 novel coronavirus
A set of new concepts have been added for the January 2020 release:
840539006|Disease caused by 2019 novel coronavirus (disorder)|
840534001|2019 novel coronavirus vaccination (procedure)|
840544004|Suspected disease caused by 2019 novel coronavirus (situation)|
840536004|Antigen of 2019 novel coronavirus (substance)|
840535000|Antibody to 2019 novel coronavirus (substance)|
840533007|2019 novel coronavirus (organism)|
840546002|Exposure to 2019 novel coronavirus (event)|
These concepts all have an additional synonym of 'Wuhan coronavirus' to aid searchability.
Update: WAS_A
Inactivation reason of LIMITED/WAS_A is not allowed for any new content inactivations after the July 2018 release. The WAS_A association refset has not been updated thereafter.
At the Editorial Advisory Group meeting in April 2019, agreement was reached to discontinue the maintenance of WAS_A relationships when inactivating concepts that have a historical association to an inactive concept. When changes are made to a historical relationship for a concept that was previously inactivated using WAS_A, effort will be made to assign a new historical relationship that facilitates traceability of the concept (e.g. DUPLICATE or AMBIGUOUS) as opposed to NON-CONFORMANCE TO EDITORIAL POLICY.
Existing WAS_A relationships will be inactivated in a future release once a plan for batch reassignment of historical relationships has been developed. Until then, SNOMED International will not continue to use or maintain WAS_A relationships.
Content Quality Improvement
SCT Statistics | |
|---|---|
Domain | #New concepts |
SNOMED CT Concept (SNOMED RT+CTV3) | 3044 |
Body structure (body structure) | 467 |
Clinical finding (finding) | 1446 |
Event (event) | 16 |
Environment or geographical location (environment / location) | 1 |
Observable entity (observable entity) | 136 |
Organism (organism) | 185 |
Pharmaceutical / biologic product (product) | 276 |
Physical object (physical object) | 39 |
Procedure (procedure) | 105 |
Qualifier value (qualifier value)86 | 88 |
Record artifact (record artifact) | 11 |
Social context (social concept)| | 1 |
Situation with explicit context (situation) | 31 |
Specimen (specimen) | 3 |
Substance (substance) | 223 |
Staging and scales (staging scale) | 4 |
SNOMED CT Model Component (metadata) | 12 |
SCT Improvement Statistics | |
|---|---|
Existing Concepts | #Changes |
Inactivated concepts | 1329 |
Reactivated concepts | 16 |
Relationship changes | 33985 |
Primitive changed to sufficiently defined | 1518 |
Sufficiently defined changed to primitive | 64 |
Description changes | 5462 |
Inactivated descriptions (synonyms only) | 1608 |
New descriptions (synonyms only) for existing concepts | 2695 |
Reactivated descriptions (synonyms only) | 47 |
Body structure
New body structure concepts: 467
The new anatomy concept model implements the enhanced Description Logic features, e.g. reflexive and transitive properties, additional axioms for consistent logical modeling. The inferred IS_A relationships from the OWL anatomy ontology have been reviewed and the changes have been implemented in production. Potential impact to other hierarchies for example clinical finding, procedure, observable entity, situation with explicit context, were also reviewed as part of the project. Revision of hierarchical relationships for all body systems has been completed. The changes in the 2020 January release include:
Changes to hierarchical relationships in body structures:
• Nervous system: 1,303
• Respiratory system: 402
• Hematological system: 157
• Immune system: 132
• Lymphoreticular system: 144
• Integumentary system: 513
• Special senses organ system: 413
• Endocrine system: 88
Review of potential impact and most issues addressed in other hierarchies for example disorder, procedure, by body system:
• Nervous system: 5,714
• Respiratory system: 2,264
• Hematological system: 844
• Immune system: 772
• Lymphoreticular system: 696
• Integumentary system: 5,970
• Special senses organ system: 5,080
• Endocrine system: 1,123
Quality Improvement in the Body Structure Hierarchy
Nervous system:
Hierarchical relationships and concepts that are descendants of 25087005 |Structure of nervous system (body structure)| have been reviewed and improved. The appraisal included rationalization of the peripheral nerves and cranial nerves to ensure that a branch of a specified nerve is not subordinate to the nerve from which it originates, but has an IS_A relationship to the regional nerve structure that covers the entire anatomical boundaries of every branch of that nerve. Any relationships that did not fulfil this rule have been corrected.
It has been identified that the use of the term ‘cerebrum’ is ambiguous within clinical terminology historically: sometimes referring to the brain as a whole, and on other occasions referring to the more limited meaning of the cerebral hemispheres. In order to clarify the semantics of ‘cerebrum’, the concept 83678007 |Structure of cerebrum (body structure)| location and definition has been elucidated using the following statement: ‘The cerebrum is the regional structure of the brain, which is the adult equivalent of the forebrain or prosencephalon. It is constituted by the structural derivatives of the telencephalon and diencephalon including the cerebral hemispheres, epithalamus, thalamus, hypothalamus, lateral ventricles and third ventricle. This definition is harmonious with the Federation of Association of Anatomist Second Edition (2019) Part V Terminologia Anatomica'.
Revision of concepts for abdomen and pelvis regions:
The relationships of the walls, cavities and contents of the abdomen and pelvis have undergone intensive review and re-work for more information please see https://docs.google.com/document/d/1gxkcEYf89eJl0RJG8-S2w4zOdpF8R2sn5SHx7InWxZI/edit?usp=sharing
The notion of ‘abdomen’ in clinical practice can vary between different specialties and circumstances; for example, ‘abdomen’ in natural language can be used to refer to, but not limited to, the following concepts:
Abdominopelvic cavity
Abdominopelvic cavity excluding the true pelvic cavity (Abdomen proper cavity)
Abdominopelvic cavity and/or content (Intra-abdominopelvic structure)
Intra-abdominopelvic structure excluding intra-pelvic structure of true pelvis
Intra-abdominopelvic structure and/or anterior abdominal wall
Intra-abdominopelvic structure and/or anterior abdominal wall, excluding intra-pelvic structure of true pelvis (Abdomen proper)
Abdominal segment of trunk
Abdominal cross-sectional segment of trunk
SNOMED International considers the most commonly used clinical variant referred to as ‘abdomen’ to be 818983003 |Structure of abdominopelvic cavity and/or content of abdominopelvic cavity and/or anterior abdominal wall (body structure)|, which in SNOMED CT is now the only concept using ‘Abdomen’ as a synonym. New concepts have been added to satisfy the requirements of imaging including:
Structure of abdominal cross-sectional segment of trunk (body structure)
Structure of pelvic cross-sectional segment of trunk (body structure)
Structure of abdominopelvic cross-sectional segment of trunk (body structure)
Structure of thoracic cross-sectional segment of trunk (body structure)
The different anatomical entities in this area have all been allocated a definition in order to bring clarity to this domain. A considerable number of definitions of disorders and procedures have been reviewed and rationalized according to these clearer principles. Further work on modeling updates for disorders and procedures, such as CT and MRI related to the abdomen has been planned for the next release.
Review of Respiratory System
The hierarchical relationships for subtypes of 20139000 Structure of respiratory system (body structure) have been reviewed and improved, specifically:
55214000 Bronchiole structure (body structure) was removed as a child of 955009 Bronchial structure (body structure) as this was causing inappropriate classification of many concepts, the parents are now 72674008 Bronchopulmonary segment structure (body structure) and 119198002 Tracheobronchial tree part (body structure).
Several ‘pharyngeal space concepts’ were deemed to be ambiguous and also there was some redundancy. These were modeled as pharyngeal structures however in reality they are not internal pharyngeal structures, although they are sometimes loosely described as such. Concepts using this terminology have been inactivated and relevant concepts are now organized under a new concept 789210002 Structure of peripharyngeal space (body structure).
New areas of content for Anatomy
New concepts added for Hair follicle of specific body regions.
New concepts added for spinal nerve proper at different levels.
Reference set updates
Updated and validated release file for the lateralizable body structure reference set.
Updated and validated release files for the SEP refsets.
Clinical finding
New concepts added for clinical finding hierarchy: 1446
Update for Known Content Issue July 2019 Release
Approximately 149 text definitions were missing either a US or GB spelling variation - this has been rectified in the January 2020 release with implementation of new validation to identify any future issues.
A small set of disorder concepts were identified with descendants that had a semantic tag of clinical finding along with a further small set of concepts that had a semantic tag of disorder but were not descendants of 64572001|Disease (disorder)|. These issues have been rectified in the January 2020 release with implementation of new validation to identify any future issues.
New content additions include
Wound = 40 concepts
Abrasion = 8 concepts
Abscess = 13 concepts
Benign neoplasm = 38 concepts
Burn = 44 concepts
Chemical burn = 36 concepts
Closed fracture = 15 concepts
Edema = 14 concepts
Epidermal burn = 20 concepts
Female genital mutilation type = 7 concepts
Fracture = 10 concepts
Full thickness burn = 14 concepts
Hematoma = 13 concepts
Infected wound = 23 concepts
Injury = 33 concepts
Laceration = 21 concepts
Open fracture = 35 concepts
Open wound = 108 concepts
Partial thickness burn = 33
Repetitive motion disorder = 19 concepts
Subungual hematoma = 16 concepts
Superficial foreign body = 14 concepts
Quality Initiative
The Quality Initiative (QI) project is the implementation of the Quality Strategy. After a successful pilot project for the July 2018 release the next stage has been implemented for subsequent releases including January 2020.
Quality improvement tasks were deployed to improve internal structural consistency and ensure compliance with editorial policy related to the stated modeling of content. Additionally, correction or addition of defining relationships was carried out to accurately reflect current clinical knowledge and ensure the semantic reliability of descriptions associated with a concept.
Total count of changes for the QI project:
Stated: A total of 9608 concepts had changes made to the Stated relationships in the model.
Inferred: A total of 16726 concepts affected by inferred changes.
Quality Improvement in the Clinical Finding Hierarchy
Inactivation of 33359002 |Degeneration (morphologic abnormality)|
In order to distinguish the degenerative process from the structure, 33359002 |Degeneration (morphologic abnormality)| has been inactivated as a DUPLICATE, SAME AS 107669003 |Degenerative abnormality (morphologic abnormality)|. All morphologies in the disorder hierarchy have been replaced accordingly.
Inactivation of 23583003 |Inflammation (morphologic abnormality)
In order to distinguish inflammatory process from structure, 23583003 |Inflammation (morphologic abnormality)| has been Inactivated as DUPLICATE, SAME AS 409774005 |Inflammatory morphology (morphologic abnormality)|. All concepts in the Inflammatory disorder hierarchy have been remodeled accordingly.
Revision of 129156001|Traumatic dislocation of joint (disorder)|
Traumatic dislocation concepts are being remodeled according to the new representation using DUE TO "Traumatic event". This work has been partially completed for the Jan 2020 release, resulting in the remaining subhierarchies moving from under "Traumatic dislocation of joint" to "Dislocation of joint". These remaining subhierarchies will be remodeled for the July 2020 release.
Revision of 298180004 |Finding of range of joint movement (finding)
The concepts under the subhierarchy 298180004 |Finding of range of joint movement (finding)|have been remodeled to represent the finding site of <<785818007 |Structure of joint region (body structure)| instead of <<39352004 |Joint structure (body structure)|. Range of movement of a joint region can be impacted by both bone and soft tissues, therefore the use of 39352004 |Joint structure (body structure)| was too restrictive and caused issues in other areas of the terminology.
Revision of Fracture Concepts
Added new morphologic abnormality concepts in the following areas:
Neer classification of fracture of proximal humerus part fracture types (8 new concepts).
Seinsheimer classification of subtrochanteric femur fracture types I through V (5 new concepts).
This work led to changing relationships and definition status to "fully defined" for 6 fracture disorder concepts. Four qualifier value "Neer" fracture concepts were inactivated and referred to the new morphologic abnormality concepts.
QI Project focus for January 2020 release (work has begun or been completed) | |
|---|---|
128482007|Acute inflammatory disease (disorder)| | 5294002|Developmental disorder (disorder)| |
85828009|Autoimmune disease (disorder)| | 298180004|Finding of range of joint movement (finding)| |
87628006|Bacterial infectious disease (disorder)| | 128139000|Inflammatory disorder (disorder)| |
20376005|Benign neoplastic disease (disorder)| | 400006008|Hamartoma (disorder)| |
131148009|Bleeding (finding)| | 400178008|Lymphangioma (disorder)| |
276654001|Congenital malformation (disorder)| | 399981008|Neoplasm and/or hamartoma (disorder)| |
417893002|Deformity (finding)| | 118616009|Neoplastic disease of uncertain behavior (disorder)| |
362975008|Degenerative disorder (disorder)| | 233776003|Tracheobronchial disorder (disorder)| |
Content Tracker Project Updates
Work continues on the following Content Project:
IHTSDO- 393 Diabetes Complications: Diabetic complications have now been updated and modeled according to the updated Editorial Guidance and use of "DUE TO".
Diabetic complications can be found in the hierarchy 74627003 |Complication due to diabetes mellitus (disorder)| which is a subtype of 116223007 |Complication (disorder)|. These concepts no longer reside as a subtype of 73211009 |Diabetes mellitus (disorder)|.
The ECL query which will give a list of all diabetic complications modeled with a "DUE TO" is as follows:*: 42752001 |Due to (attribute)| = <<73211009 |Diabetes mellitus (disorder)|
Work will begin with domain experts during the release cycle for July 2020 to update the clinical content in this area.
Other Areas of Quality Improvement in the Clinical Finding Hierarchy
Remodel concepts - 254666005 |Keratosis (disorder)| 782957005 |Ichthyosis (disorder)| 396228006 |Hyperkeratosis (disorder)|
These concepts were all defined with "hyperkeratosis" and "skin". There was duplication across the concepts with synonyms and modeling. After consultation with clinical experts the following was agreed in summary:
Hyperkeratosis and Keratosis are the same.
Ichthyosis has an underlying morphology of "keratosis" but with a different distribution pattern.
Changes for 'On Examination' and 'Complaining of' concepts
The 'on examination' and 'complaining of' content is being returned to the UK as part of planned work for the July 2020 release. Where no suitable replacement concept exists new content without the 'examination' or 'complaining of' component of the meaning is being created.
For example: Eye does not move left (finding) has been added in preparation for the inactivation of 'On examination - eye does not move left (finding)'.
For the January 2020 release 180 new concepts were added.
Inactivation - "Finding of form of X (finding)"
Inactivation of 30 concepts using the format "Finding of form of ..."
Remodel 70153002 |Hemorrhoids (disorder)|
Improvements made in the modeling of subtypes of 70153002 |Hemorrhoids (disorder)|.
Changes to Case Sensitivity
Over 31,000 descriptions have been reviewed and approximately 5,402 descriptions across 2806 concepts have had their case significance settings corrected as appropriate. The changes are across all SNOMED CT hierarchies but in particular disorder concepts (1774), procedure (978) and qualifier values (736). The Editorial Guidance on case significance related to descriptions containing numeric values and special characters has been updated for the January 2020 release.
Notice: Planned changes for the 'Co-occurrent and due to' pattern: During the implementation of the new Description Logic features, a conflict was uncovered between the modeling of 'Co-occurrent and due to' and General Concept Inclusions (GCIs). This has resulted in the need to reconsider the modeling of "Co-occurrent and due to' and update the Editorial Guide for this area. There are a number of concepts that are based upon the existing guidance for 'Co-occurrent and due to'. The plan is to update the Editorial Guide and all concepts that are currently modeled as 'Co-occurrent and due to' over future releases. |
|---|
Convergent Medical Terminologies (CMT)
New CMT concepts: 775
The majority of these newly authored concepts are in scope for mapping to ICD-10 and from the following domains:
CMT Injuries - 106
CMT Mixed Domains - 584
CMT Musculoskeletal - 22
CMT Ophthalmology - 20
CMT Orthopedics - 43
Procedure
New concepts for procedure hierarchy: 105
Areas of Quality Improvement for the Procedure Hierarchy
Implantation and Insertion procedures
Work commenced on content tracker IHTSDO-175. There are ongoing structural changes for the Procedure concepts related to the content tracker: It was agreed that not all Insertion and Implantation procedures are surgical. As a result, further work in the hierarchy under 129284003 |Surgical action (qualifier value)| has been undertaken for the January 2020 release and this includes:
Reactivation of 129338005 |Surgical implantation - action (qualifier value)|
Addition of a new concept 788288006 |Surgical reimplantation - action (qualifier value)|
Remodel of 'Reimplantation procedures' replaced METHOD = 129337000 |Reimplantation - action (qualifier value)| with new 788288006 |Surgical reimplantation - action (qualifier value)|
Work on this project will continue for future releases after January 2020.
Evaluation Procedures
Inactivated four duplicate concepts.
Inactivated six ambiguous concepts.
Inactivated one erroneous concept.
Created one new concept to replace an ambiguous concept.
Inactivated descriptions of sixteen concepts.
Removed incorrect parent for two concepts.
Added descriptions to fourteen concepts.
Changes to Existing Concepts in the Procedure Hierarchy
The following concepts and/or areas in the procedure hierarchy were remodeled:
Osteopathic manipulation techniques
Emergency coronary artery bypass graft
Tylectomy
Neck excision
Procedure on brain ventricular shunt
Change of diaper
Removal of leeches
Dermabrasion of facial scars
Triennial health exam
Detoxification therapy (regime/therapy)
Hormone therapy replacement
Transplantation of dura
Cervical biopsy
Excisional biopsy of cerebral meninges, percutaneous, needle
Suture of plexus
Oral fluorescence imaging
Administration of heavy metal antagonist
Collaboration/Harmonization Projects
Orphanet
Working in collaboration with Orphanet (http://www.orpha.net/consor/cgi-bin/index.php), creation of new concepts for the original set of prioritized rare diseases has been completed.
The mapping and validation process has begun for an alpha release after the January 2020 International release of SNOMED CT.
All of the concepts added for the Orphanet project have been mapped to ICD-10.
Global Medical Device Nomenclature Agency (GMDNA)
21 new device concepts were added to the physical object hierarchy for GMDN.
4 device concepts were inactivated.
For the GMDN mapping equivalence tables:
21 New concepts have been added to inscope and mapped.
161 concepts have been modified and removed from the mapping tool as out of scope.
92 concepts ave been deemed obsolete and removed from the mapping tool and flagged as out of scope.
334 concepts were identified as no longer in scope for the map and have been removed. These concepts were identified as part of the Quality Improvement of the mapping equivalence tables and the monthly submissions from GMDN.
ICD-O-3.2 Update
For the January 2020 release, and based on the recent release of ICD-O-3.2 the priority has being adding new content for updated morphologies; this refers to additions to the 400177003 |Neoplasm and/or hamartoma (morphologic abnormality)| sub-hierarchy. Approximately 63 changes in the sub-hierarchy are related to the ICD-O-3.2 update analysis, including the direct addition of 25 new morphology concepts that were identified from analysis of the ICD-O-3.2 preview as missing from SNOMED CT.
Impacted concepts in the disorder hierarchy have been revised to align with any new ICD-O-3.2 morphology changes, and in many cases the addition of a relationship to the new morphology concept has resulted in the neoplasm disorder concept being defined fully. This work has included the creation of a small number of new neoplasm disorder concepts to match the new morphologies.
Descriptions with [obs] have been inactivated as outdated because they are artefacts of descriptions from the ICD-O-3 print version for their history tracking. There are two concepts and one synonym with [obs] that remain and will be addressed for the July 2020 release.
Event
New concepts added: 16
Qualifier Value
New concepts added: 88
Situation with explicit context
New concepts added: 31
This includes 17 new concepts for 'History of X'.
Observable Entity
New concepts added: 136
This includes 8 new concepts for insulin dose observables.
Organism
New organism concepts added: 185
Added new descriptions for 10 organism concepts.
Inactivated 9 organism concepts as duplicates.
Changed descriptions of two organism concepts.
Pharmaceutical / biologic product
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