1.

Procedure

Update Hierarchy 363680008|Radiographic imaging Procedure (procedure)|and Descendants

A Briefing Note documenting the proposed changes for the hierarchy 363680008|Radiographic imaging procedure (procedure)| and descendants was shared with the Editorial Advisory Group, Clinical Leads Group, Member Forum, Content Managers Advisory Group, and other key stakeholders in July 2023.

Feedback was received from a wide range of stakeholders. In response to this feedback, the proposed changes to the hierarchy have been modified. These modifications will address issues raised in the feedback.

This Informational Briefing Note summarizes the changes that will be implemented.

Implementation of the content changes will commence in Q4 2023. The updates will be implemented in sub-hierarchies and promoted over a number of international monthly releases until complete.

Ongoing in phases across 2024 International Releases

2.

Content Improvement

Updates to the Inactivation Reason and Historical Association for 'On Examination' and 'Complaining of' Inactive Content

Many of the 'on examination' and 'complaining of' concepts were previously inactivated with the inactivation reason of |Moved elsewhere| with a historical association value |Extension Namespace 1000000|.

This content will be updated with an inactivation reason of |Non-conformance to editorial policy| and a historical association of |Alternative| to a suitable international concept. 

Q1 2025 International Release

3.

Clinical Finding/Procedure

Patient/Subject concepts in the Clinical finding and Procedure Hierarchies

Concepts in the Clinical finding and Procedure hierarchies that contain the explicit context of patient or subject will be inactivated and replaced with concepts without this explicit context. For further information please see briefing note.

On hold - to be determined

4.

Clinical Finding

Inactivation of Complication Disorder Concepts (371 concepts)

The inactivation of concepts that reference “complication” without specifying the nature of the complication is planned. 

The primitive “Complication (disorder)” grouper was inactivated in 2022 due to a lack of consistency or definition of what would properly be assigned as a subtype.

The concepts will be inactivated with inactivation reason “Classification derived concept” and replacement by the parent concept. 

For further information please see this briefing note. 

Beginning June 2024 International Release and then subsequent releases until complete

5.

Procedure

Review 1263452006 |Anesthesia and/or sedation procedure (procedure)|

A review of the 1263452006 |Anesthesia and/or sedation procedure (procedure)| hierarchy is in progress, the focus is on:

• Inactivation of Classification derived components.

• Review of the current model and possible addition of 363703001 |Has intent (attribute)| to the model.

• Review of current classification of groupers.

Under review - expected completion by Q3 2025 International Release

6.

Procedure

Review 48537004 |Bypass graft (procedure)| 

A review of the 48537004 |Bypass graft (procedure)| hierarchy is in progress, the focus is on:

• Improving consistency of descriptions.

• Improving definitions for different types of concepts in the hierarchy (bypass vs shunt)

• Correct use of the term “graft” within the descriptions.

• Correct modeling of 260686004 |Method (attribute)| in the hierarchy.

• Review of the need for 360021005 |Bypass - action (qualifier value)| and 424208002 |Shunt - action (qualifier value)|in the model and testing of 245854003 |Proximal anastomosis (qualifier value)| and 245855002 |Distal anastomosis (qualifier value)| as new 260686004 |Method (attribute)| values in the hierarchy.

• Review for a consistent and appropriate usage of 425362007 |Surgical insertion - action (qualifier value)|and 129407005 |Grafting - action (qualifier value) in the model.

• Review for re-classification of 129376004 |Construction - action (qualifier value)| as a direct subtype of 129284003 |Surgical action (qualifier value)|.

• Given the complexity of some concepts in the hierarchy, potential duplicate, erroneous, or outdated concepts will be identified.

Under review - expected completion by Q2 2025 International Release

7.

Procedure

Review Use of 424876005 |Surgical approach (attribute)| 

A review to generalize 424876005 |Surgical approach (attribute)| to allow non-surgical procedures to be modeled with a subtype of <<103379005 |Procedural approach (qualifier value)| is in progress. 

• This issue is under review by the Editorial Advisory Group.

• Currently, 424876005 |Surgical approach (attribute)| is restricted to subtypes of 387713003 |Surgical procedure (procedure)|.  However, the values represented by the 103379005 |Procedural approach (qualifier value)| subhierarchy are applicable to concepts that are not subtypes of Surgical procedure and could potentially be used to define "non-surgical" procedure concepts.

• The impact of MRCM rule for using 116688005 |Procedure approach (attribute)| with domain constraint:  << 71388002 |Procedure (procedure)| and range constraint:  << 103379005 |Procedural approach (qualifier value) is under review. This change would allow Non-surgical procedures to be modeled with a generic Procedure approach attribute.

Expected completion by Q2 2025 International Release

8.

Procedure

Surgical Transplantation Procedures

Procedures in the 77465005 |Transplantation (procedure)| hierarchy remodeled following circulation of the Briefing note are still under review following feedback received and discussion at the Editorial Advisory Group. 

Note this project excludes procedures on the eye (for Ophthalmology CRG to revise), and hematopoietic cell transplants including bone marrow and stem cell procedures that are not surgical transplantations.

The majority of tissue transplant procedure concepts (nerves, muscle, tendon, skin etc), will be inactivated as duplicate to the grafting procedure concept where this exists (and the transplant procedure will be added as a synonym to the grafting procedure), or if an existing concept is not available then a new grafting procedure will be created.

Very high level groupers will be inactivated (eg 120158008 |Thorax transplantation (procedure)|). Approximately 100 concepts will be inactivated as part of this update.

Q1 2025 International Release

9.

Descriptions Update

Forward slash in FSN

A review has commenced of those concepts with a forward slash in their FSN.  Editorial guidance exists disallowing the use of forward slashes in FSNs, and we have commenced a systematic review of those existing terms containing them.

Many areas are excluded for example, medicinal products where strength /1 is the denominator, assessment scales, explicit "and/or", gene names, enzyme and other substance naming, organisms, ratios, per in units (or future consideration), intervertebral structures, content added with an Orphanet map and others. The review is ongoing.

If the meaning is clear i.e. single meaning there is no change but groupers, disjoint ('or)' terming and ambiguous terms will be reviewed and possibly inactivated or have a new replacement FSN without a forward slash. Subject matter experts are being consulted as part of this work.

Q4 2024 International Release

Q1 2025 International Release

10.

Qualifier Value

Update for Existing AJCC (American Joint Committee on Cancer) Allowable Values and New UICC (Union for International Cancer Control) Staging System Content

For << 1222584008 |American Joint Committee on Cancer allowable value (qualifier value)| and its 584 subtypes the following changes will be made:

• Preferred Term (PT) will be inactivated and a new PT added that contains the existing AJCC code with a new parenthetical addition of AJCC: (AJCC).

• The existing text definition that contains the attribution to the AJCC Cancer Staging System, American College of Surgeons will be inactivated and re-created as an annotation.

New concepts for the UICC (Union for International Cancer Control) staging system will be added:

• As a separate hierarchy, approximately 580 new concepts for the Union for International Cancer Control (UICC) TNM staging system will be added. This work is being done under a collaboration agreement between SNOMED International and the UICC.

Q1 2025 International Release

11.

Procedure

Review of 129376004 |Construction - action (qualifier value)|

129376004 |Construction - action (qualifier value)| is a subtype of 257903006 |Repair - action (qualifier value) and sibling of 129377008 |Reconstruction - action (qualifier value)|.

Because some concepts modeled with 129376004 |Construction - action (qualifier value)| as target value concept for 260686004 |Method (attribute)| may not be considered a reparative procedure, a review of the 129376004 |Construction - action (qualifier value) and 410614008 |Construction (procedure)| hierarchies is being undertaken.

Expected outcomes may be the classification of 129376004 |Construction - action (qualifier value)| directly under 129284003 |Surgical action (qualifier value)| and the creation of new actions that better define the differences between reparative and construction procedures.

Content review - publication date to be determined

12.

Disorder

SNOMED CT to Orphanet Map - Attribution of In Scope Content

Work has commenced to annotate new concepts added to SNOMED CT with attribution to 'Inserm Orphanet'. As part of this effort, textual definitions for concepts previously added for this project will be updated to align with the current published version of the Orphanet definition. This will result in published text definitions being inactivated and replaced.

Starting Q4 2024 International Releases until complete.

13.

Clinical Finding

Changes to 365921005 | Weight change finding (finding) Hierarchy

Following multiple requests from members regarding overlaps and ambiguities in this hierarchy, the Nutrition and Dietetics Clinical Reference Group (CRG) conducted a systematic review. The requests highlighted confusion over similar and overlapping concepts, such as:

• 89362005 | Weight loss (finding) |

• 262285001 | Weight decreased (finding) |

• 161832001 | Weight decreasing (finding) |

• 426977000 | Recent weight loss (finding) |

The following changes will be implemented:

1. Inactivation of 426977000 | Recent weight loss (finding) | and 427572007 | Recent weight gain (finding)
   These terms are considered ambiguous due to the subjective nature of the word "recent."

2. Inactivation of 161832001 | Weight decreasing (finding) | and 161831008 | Weight increasing (finding)
   These terms will be inactivated because they do not align with editorial policy. They represent patterns or trends better handled by information models or statistical tools for data interpretation and analysis.

3. Inactivation of 89362005 | Weight loss (finding)
   This term is a duplicate of 262285001 | Weight decreased (finding) |. The term "Weight loss" will, however, remain as a synonym for 262285001.

January 2025 International Release

14.

Clinical Finding

Genomic Community Content

Phenotype concepts that currently exist in the genomics community content area are being gradually promoted to the International edition release.  All content is being reviewed and revised based on the current international editorial guidelines and publication will occur incrementally over several releases.

Starting Q4 2024/Q1 2025 International Release

15.

Descriptions Update

Update for Description Concept Non-Current Indicators

Concept Non Current (CNC) indicators are a type of inactivation indicator that are applied to active descriptions, when the concept they are attached to is made inactive. They are intended to allow implementers to show some visual cue to alert users that a description they have searched for relates to an inactive concept.

A bulk update will be implemented to inactivate CNC indicators where they are no longer required either because:

• The concept has since been re-activated or,

• The description itself has now been inactivated

This will result in a change to approximately 30,000 descriptions for the international edition release for January 2025.

January 2025 International Release

16.

Clinical Finding

Review Model for Descendants of 118240005|Finding by method (finding)|

Descendants of 118240005 |Finding by method (finding)| are currently being reviewed to ensure 418775008 |Finding method (attribute)| is appropriately grouped with other attributes.

January 2025 International Release

1.

Content Improvement

Urinary Bladder

Following feedback from translation, descriptions for concepts that contain the word 'bladder' and the site of 89837001|Urinary bladder structure (body structure)| will be updated to include 'urinary' in the FSN and PT, for example:

126885006|Neoplasm of bladder (disorder)

will be updated to

126885006|Neoplasm of urinary bladder (disorder).

January 2024 International Release

2.

Product

International Unit in Descriptions for Clinical Drugs

'International Unit' as a description is arbitrary and to be understood each product requires reference to a particular bioefficacy specification for that entity. Therefore, 'international' is not meaningful or comparable as a description at Clinical Drug level. International unit will be represented as 'unit' in Clinical Drug descriptions and 20 concepts will have their descriptions changed to 'unit'  Note: abbreviations will not be used. Editorial Guidance has been drafted.

January 2024 International Release

3.

Procedure

Inactivation of  “RAST” and “RAST test” from subtypes of 104380004 |Allergen specific antibody measurement (procedure)|

Based on a proposal by the Allergies and Hypersensitivities CRG, descriptions containing “RAST” and “RAST test” will be inactivated from the concepts in this sub-hierarchy as they are not considered real synonyms.

Immunoassays for immunoglobulin specific to an allergen of interest are widely used in the diagnosis of allergic disease. These tests are often incorrectly referred to collectively as "radioallergosorbent tests" ("RAST") because they were the earliest immunoassays to be used extensively.

There are a few concepts of type "X mix radioallergosorbent test (procedure)", where RAST is in fact part of FSN. These concepts will be inactivated as they are ambiguous because they do not mention what allergens are being tested for. Replacement concepts, where individual allergens are spelled out, will be created where the information is available.

January 2024 International Release

4.

Morphologic Abnormality

Inactivation of Congenital Morphologic Abnormality Concepts

37764001 |Congenital abnormal fusion (morphologic abnormality)| and 67798003 |Congenital premature fusion (morphologic abnormality) will be inactivated and replaced by:

• Abnormal fusion (morphologic abnormality)

• Premature fusion (morphologic abnormality)

These two new concepts do not specify occurrence which is to be modeled separately.  As a result of this change the two new concepts can be used to model fetal disorders.

This change aligns with the Editorial Guide.

February 2024 International Release

5.

Clinical Finding

Inactivation of 106109006|Number of previous induced termination of pregnancy (finding)| and Subtypes

106109006|Number of previous induced termination of pregnancy (finding)| and subtypes will be inactivated and replaced by a new concept in the situation with explicit context hierarchy:

1300163008 |Past pregnancy history of multiple induced termination of pregnancy (situation)|

This concept is already published.

713649008 |Past pregnancy history of induced termination of pregnancy (situation)|

February 2024 International Release

6.

Procedure

Update 77465005 |Transplantation (procedure) and Descendants

Note this project is ongoing. Proposals for the new model will be considered by the Editorial Advisory Group (EAG).

410820007 |Surgical transplantation - action (qualifier value)| and 129407005 |Grafting - action (qualifier value)| will be siblings (not child-parent relationship)  and will be subtypes of 129338005 |Surgical implantation - action (qualifier value)|. 

129347002 |Surgical transfer - action (qualifier value)| will no longer be a subtype of 410820007 |Surgical transplantation - action (qualifier value)|.

115956009 |Release (procedure)| will be inactivated and its subtypes remodeled to proximal primitive parent modeling and attributes added where necessary.

<< 422285003 |Solid organ graft - material (substance)|  and its subtypes will be updated from 'graft' to 'transplant'.  For example, 420291005 |Transplant heart (substance)|

The 77465005 |Transplantation (procedure)subtypes will be remodeled with 410820007 |Surgical transplantation - action (qualifier value) where necessary. Also, certain grafting procedures that were subtypes of transplantation procedure will be remodeled with 129407005 |Grafting - action (qualifier value)|.

February 2024 International Release

7.

Clinical Finding

Morphologic Abnormality

Situation with Explicit Context

Remodel 127575007 |Malignant neuroendocrine neoplasm, epithelial (morphologic abnormality)| and Subtypes

127575007 |Malignant neuroendocrine neoplasm, epithelial (morphologic abnormality)|, its subtypes and related disorder concepts will be revised to align with the 5th edition of the WHO Blue Book chapter on Endocrine and Neuroendocrine Tumours as part of the Histology Quality Improvement Project.

Please see the briefing note for more information about these changes.

February 2024 International Release

8.

Procedure

Update for 73632009 |Laparoscopy (procedure)| and Subtypes 

There will be a bulk update to align 73632009 |Laparoscopy (procedure)| and subtypes with the template here: https://snomed.atlassian.net/wiki/display/SCTEMPLATES/Laparoscopy+%28procedure%29+-+Draft

These changes include the addition of INCISION ROLE GROUP and INSPECTION ROLE GROUP for all Laparoscopic procedures. 

February 2024 International Release

9.

Clinical Finding

Update for Diabetes Insipidus

Based on a report from October 2022 from the Working Group for Renaming Diabetes Insipidus, concepts using the term “Diabetes insipidus” will be renamed and/or replaced with terms that more appropriately represent the pathophysiology of this condition.  The top-level concept replacing "Diabetes insipidus" will be "Arginine vasopressin-related polyuria" and the specific subtypes will be represented by two renamed conditions: 

• Arginine Vasopressin Deficiency (AVP-D)” for central etiologies

• Arginine Vasopressin Resistance (AVP-R)” for nephrogenic etiologies

The legacy descriptions of "Diabetes insipidus", "Central diabetes insipidus" and "Nephrogenic diabetes insipidus" will be retained where appropriate to facilitate retrieval of concepts by their newer names. This affects approximately 18 existing concepts in SNOMED CT.

February 2024 International Release

10.

Procedure

17423001 |Epiphysiodesis (procedure) - Remodel Subtypes Epiphyseal Stapling

Epiphyseal stapling concepts will be moved from being a subtype of 17423001 |Epiphysiodesis (procedure)|. 

Epiphysiodesis is a fusion of the epiphyseal plate resulting in a permanent arrest of growth, whereas Epiphyseal stapling is a fixation of the epiphyseal plate in order to arrest growth and is often reversible once the staples are removed.  

February 2024 International Release

11.

Annotation Reference Set

NOTICE - JUNE 2024 RELEASE - CHANGES TO THE ANNOTATIONS REFSET FORMAT

After discussions with the community, SNOMED International has made changes to the coverage of language in the Annotations refsets in the following way:

• The languageCode field was specified as the two characters of ISO-639-1 code for the language of the annotation text. The change is to include support for specifying dialect when it is applicable by adhering to RFC 5646, which allows the combination of two characters of ISO 639-1 code and two uppercase letters of country code (ISO 3166) separated by a hyphen. 

• The column "languageCode" has therefore been changed to "languageDialectCode".

• The concept 1296895003|Language code (foundation metadata concept)| has been inactivated and replaced by 1304275002 |Language or dialect code (foundation metadata concept)|

• The changes apply to both the Member Annotations String Value Reference Set + Component Annotation String Value reference set

The addition of content for the Annotations refset will commence in future International Edition releases.

June 2024 International Release

12.

Morphologic Abnormality

Inactivation of Congenital Morphologic Abnormality Concepts

61295008 |Congenital abnormal number (morphologic abnormality)|

125226006|Congenital malposition, left (morphologic abnormality)|

125225005|Congenital malposition, right (morphologic abnormality)|

56457002|Congenital atresia (morphologic abnormality)| 

41086002 |Congenital smallness (morphologic abnormality)|

81850003 |Congenital sequestration (morphologic abnormality)|

These concepts will be inactivated and replaced by a concept that does not specify congenital. Concepts that are modeled with these morphologic abnormality concepts will be remodeled using the replacement concept. This change aligns with the Editorial Guide.

March 2024 International Release

13.

Annotation

OWL Axiom Expressions for Annotation Properties

The new annotation properties should be represented in the OWL expression axiom refset as follows:

• The 1295447006 |Annotation attribute (attribute)| is correctly represented as subClassOf

  • 01300ccd-d1d7-417d-a70a-f688e72c4d8c 20231201 1 900000000000012004 733073007 1295447006 SubClassOf(:1295447006 :246061005)

• However, all subconcepts of 1295447006 |Annotation attribute (attribute)| should be represented as "SubAnnotationPropertyOf", instead of "subClassOf" as they currently are.

  • e6cd65fe-cb81-4db4-9ac4-040dc74fce28 20231201 1 900000000000012004 733073007 1295448001 SubClassOf(:1295448001 :1295447006)

  • 3729ce47-a96e-4dc7-9eff-83c34740c414 20231201 1 900000000000012004 733073007 1295449009 SubClassOf(:1295449009 :1295447006)

They should therefore be changed to:

• SubAnnotationPropertyOf(:1295448001 :1295447006)

• SubAnnotationPropertyOf(:1295449009 :1295447006)

However, the authoring tool will then need to be updated to ensure all new subconcepts of 1295447006 |Annotation attribute (attribute)| will be represented as SubAnnotationPropertyOf() in the future.  Numerous other tools will also need to be updated first in order to correctly consume the new format.

There are numerous systems that require updating, and that this will therefore need to be carefully tested and rolled out over the next few months.  As the potential impact was analysed and deemed to be low, the Annotations deployment will still go ahead as planned in the January 2024 International Edition release, whereas these axiom updates will be published in subsequent releases.  Please, therefore, be aware that this issue will persist for the first few International Edition releases of 2024.

Axiom updates published March 2024 International Release

Remaining updates to be published in 2024.

Please see section above '2024 Proposed Content Changes' for further updates on the remaining content/tooling changes required to complete this item.

14.

Body Structure

Inactivation of 9258009|Gravid uterus structure (body structure)|

This concept will be inactivated, content that is modeled with this concept will be remodeled with a site of 35039007|Uterine structure (body structure)| along with occurrence <<307159006|Pregnancy time period (qualifier value)|.  

The domain of 246454002 |Occurrence (attribute)| has been extended in the October 2023 release to include << 71388002 |Procedure (procedure)| to support these content changes. Content areas that will be updated include 386811000|Fetal procedure (procedure)| and 386637004|Obstetric procedure (procedure)|.

April 2024 International Release

15.

Body Structure

Inactivation of Concepts Specified Male/Female in Descriptions

67770001 |Male mammary gland structure (body structure)| and 91532001 |Female mammary gland structure (body structure)| and subtypes plus associated disorder and specimen concepts will be inactivated.  Further information is available here (Confluence log in required).

NOTE: this update will include the inactivation of neoplasm concepts that specify male/female, this includes

<<126927001|Neoplasm of female breast (disorder)|

<<126937006|Neoplasm of male breast (disorder)|

These concepts will be replaced with a concept that does not specify male/female, a new concept will be added where one does not already exist.

April 2024 International Release

16.

Procedure

Update Hierarchy 363680008|Radiographic imaging Procedure (procedure)|and Descendants

A Briefing Note documenting the proposed changes for the hierarchy 363680008|Radiographic imaging procedure (procedure)| and descendants was shared with the Editorial Advisory Group, Clinical Leads Group, Member Forum, Content Managers Advisory Group, and other key stakeholders in July 2023.

Feedback was received from a wide range of stakeholders. In response to this feedback, the proposed changes to the hierarchy have been modified. These modifications will address issues raised in the feedback.

This Informational Briefing Note summarizes the changes that will be implemented.

Implementation of the content changes will commence in Q4 2023. The updates will be implemented in sub-hierarchies and promoted over a number of international monthly releases until complete.

April 2024 release:

• 168537006|Plain radiography (procedure)| and subtypes

• 168500000|Radiology result normal (finding)| and subtypes

• 168501001|Radiology result abnormal (finding)| and subtypes

Remaining changes across 2024 International Releases

17.

Qualifier Value

Change Parent for 410460000|Illumination - action (qualifier value)| and Subtypes

410460000|Illumination - action (qualifier value)| and descendants will be updated to be a subtype of 272394005|Technique (qualifier value)|.  The concepts will not be inactivated.  Descriptions that currently include '- action’ will be inactivated and replaced. 

Concepts that are currently modeled with method 410460000|Illumination - action (qualifier value)| will be remodeled with a method of 360037004|Imaging - action (qualifier value)|.  These changes will complete this Content Tracker.

April 2024 International Release

18.

Procedure

Inactivation of 118661008|Physician service (procedure)| and Descendants

118661008|Physician service (procedure)| and subtypes will be inactivated and replaced with concepts that are a subtype of 224891009|Healthcare services (qualifier value)| where appropriate.

These changes will complete this Content Tracker.

April 2024 International Release

19.

Qualifier Value

Addition of New Technique Qualifier Value Concepts

Around 80 new laboratory technique concepts will be added in the 272394005 |Technique (qualifier value)| subhierarchy.

March and April 2024 International Releases

20.

Procedure

Inactivation of 277132007|Therapeutic procedure (procedure)

The concept 277132007 |Therapeutic procedure (procedure) will be inactivated with the inactivation reason of Outdated and a replacement association target of 71388002 |Procedure (procedure)|. The nearly 2000 descendants will be reviewed as to the appropriateness of either the Has intent (attribute) of Therapeutic intent, or a Method (attribute) of Therapy - action.

For further information please see briefing note.

For 1st May 2024 release:

The immediate subtypes of <277132007 |Therapeutic procedure (procedure)|, excluding <<416608005 |Drug therapy (procedure)|, will be reviewed for appropriate presence or absence of the Has intent (attribute) according to the Editorial Guide for the 1 May release.   

A potential concept model for 416608005 |Drug therapy (procedure)| and for 276239002 |Therapy (regime/therapy)| requires further consultation. 277132007 |Therapeutic procedure (procedure)| will remain active until this work has been undertaken please watch the Content Tracker for future development.

May 2024 International Release

21.

MRCM

Changes to MRCM

There are planned changes to MRCM for the attribute in group cardinality to four attributes:

• "characterizes"

• "precondition"

• "technique"

• "component"

These changes are being made to support the implementation of role group changes to observables and evaluation procedures. 

The domain "administration via specific route (procedure)" will be removed and the attribute "route of administration" will be optional for the domain of procedure.

May 2024 International Release

22.

Clinical Finding

Inactivation of 248536006 |Finding of functional performance and activity (finding)

This concept will be inactivated: