1

Call to order and role call

@Jim Case

This meeting is being recorded to ensure that important discussion points are not missed in the minutes.  The recording will be available to the SNOMED International community.  Joining the meeting by accepting the Zoom prompt declares that you have no objection to your comments being recorded

2

Conflicts of interest and agenda review

@Jim Case

None reported

3

Introduction to Forums

@Jim Case

SNOMED International has migrated most of its tools to new platforms. One new tool is SNOMED Forums (https://forums.snomed.org/ ). The Editorial advisory Group has its own forum to allow asynchronous discussions to occur. Topics discussed at regular EAG calls and meetings may be added to the EAG forum to allow for an extended discussion on those topics that could not be resolved at a single call or meeting.

Forums are open to everyone, so comments should be added with public view in mind.

4

Advisory group membership changes

@Jim Case

Following this meeting, we are losing two members of the EAG who have done much to contribute to improvements in the editorial policies of SNOMED International: Dr. Jim Campbell and Dr. Monique Van Berkum. We thank them for their dedication and service to the group and look forward to their contintued participation in SNOMED activities.

We welcome two new members to the group:

Mattias Ridell, Swedish National Board of Health and Welfare

Jaya Pravinkumar Sonavane, Centre for Development of Advanced Computing, India

5

Update: “No known” qualifier value

@Jim Case

An issue was identified in inconsistent modeling of concepts with “No known” in the FSN.

Topic was raised in October 2023, and consensus was reached the “No known” should be a sibling of 261665006 |Unknown (qualifier value)| in the 410514004 |Finding context value (qualifier value)| hierarchy, but required an explicit text definition to ensure proper and consistent usage. Over a number of meetings and calls, alternative definitions were considered, but rejected by the EAG members.

Agreement was reached on the following:

• No known concepts should all be modeled as Situations with explicit context

• “No known” is a sibling concept to “Unknown”

Previous discussion can be found on the EAG minutes from the following meetings:

https://conf.spaces.snomed.org/wiki/spaces/editorialag/pages/133988672

https://conf.spaces.snomed.org/wiki/spaces/editorialag/pages/133988674

https://conf.spaces.snomed.org/wiki/spaces/editorialag/pages/133988676

A new proposed definition is provided for consideration: “No evidence of the specified finding has been identified. It reflects the absence of observed or reported findings, not a guarantee of true absence."

If the definition is accepted by the group, the new context value will be added to SNOMED CT and affected soncepts remodeled with the new context value. No known findings will be moved to the Situation hierarchy.

Initial testing showed no adverse impacts on the 413350009 |Finding with explicit context (situation)| subtypes; however it expsoed an issue where the “No known” context value was applied to Procedures with explicit context. These concept have a current Context value of 410537005 |Action status unknown (qualifier value)|. Affected concept include (examples):

787482006 |No known immunizations (situation)|

787480003 |No known procedures (situation)|

Is the existing Procedure context sufficient or is a procedure context value analogous to the No known for Findings with explicit context needed?

Should 224089000 |No known relatives (finding)| be moved to the Situation hierarchy?

Discussion:

Consensus was reached on the context value. Remodeling “No known” clinical situations will be undertaken.

Decision:

Accepted new definition of “No known” and placement of the concept as a sibling of “Unknown”. Remodeled “Finding with explicit context” with “No known” will be promoted.

Reach out to the FHIR folks to determine the meaning of “no known procedures” and “No known immunizations”. Also, the meaning of “No know relatives” and any concerns about moving that to the Situation hierarchy.

6

Update: Cellulitis

@Jim Case

First discussed at https://conf.spaces.snomed.org/wiki/spaces/editorialag/pages/133988726 .

Discussion point was whether 128045006 |Cellulitis (disorder)| and 402929007 |Bacterial cellulitis (disorder)| were synonymous in common clinical usage. There are a number of concepts in SNOMED CT that do not specify the agent (e.g. 19240003 |Cellulitis of digit (disorder)|. There were also a small number of concepts referring to cellulitis that were not of skin and/or subcutanteous tissue. These were in conflict with the current definition.

EAG members below indicate a preference for maintaining the distinction between cellulitis of unspecified cause (whether bacterial or not) as there are many instances in which the offending organism is not identified.  This would be consistent with the open world view that the absence of a statement in an ontology does not imply that the statement is false in the real world (i.e. not bacterial).  This would leave the subhierarchy of 402929007 |Bacterial cellulitis (disorder)| as only subsuming concepts where the specific bacteria or bacterial class is specified in the FSN .

Decision:

To address the issues concerning the anatomical location and causative agent of cellulitis, a new definition was added to the top level term 128045006 |Cellulitis (disorder)|. “Diffuse, non-necrotizing inflammatory process of connective tissue most often involving the skin and subcutaneous tissues, but may also occur in deeper structures such as fascia, muscle, mucosa, or organ connective tissue. Most frequently caused by bacterial infection, but may also arise from other microorganisms, sterile inflammation, physical or chemical injury, vascular or lymphatic dysfunction, or autoimmune activity.”

7

Endoscopy

@Victor Medina

A review of the 423827005 |Endoscopy (procedure)| hierarchy is ongoing. Changes will reflect the agreements made within the Editorial Advisory Group:

• Consistent modeling of 423827005 |Endoscopy (procedure)| with the 260686004 |Method (attribute)| = 129433002 |Inspection - action (qualifier value)| AND 424226004 |Using device (attribute)| = 37270008 |Endoscope, device (physical object)|

• Consistent modeling of 363687006 |Endoscopic procedure (procedure)| using a second RG when a concurrent procedure is performed beyond the Endoscopic Inspection of a Body Structure.

• Consistent use of the 425391005 |Using access device (attribute)| exclusively for
  Endoluminal endoscopies where the endoscope is the device granting access to perform a secondary action.
  a. The 425391005 |Using access device (attribute)| will be retired from Intracavitary
  endoscopies, where the endoscope is not the direct device granting access to
  perform a secondary action.

• Changes to the 387713003 |Surgical procedure (procedure)| GCI axiom aimed to ensure the subsumption of the Intracavitary endoscopies under Surgical procedure

  • The GCI axiom will be modeled with the 424226004 |Using device (attribute)| =
    << 312032003 |Body cavity endoscope (physical object)|.

  • The Incision RG will be retired from the Intracavitary endoscopies model.

• Consistent use of the different types of 37270008 |Endoscope, device (physical object)| through the hierarchy. Specific endoscopes will be used following the FSN terming or when the procedure requires a specialized endoscope.

• The 116688005 |Procedure approach (attribute)| will be used accordingly to the FSN
  terming, following the next general principle:

  • Avoid adding the Procedure approach attribute when the procedure is performed
    through the usual natural orifice, as this information is already implied in the
    description. However, include the attribute when the approach deviates from the
    norm, has specific clinical significance or is stated in the FSN.

• Normalization of Proximal Primitive Parents.
  Release planned for Q4 2025

Discussion:

Discussion around the use of device type (i.e. intracavity vs. intraluminal endoscopes) as a way to classify the procedures as surgical or non-surgical led to a further discussion on the usefulness of the distinction between surgical and non-surgical procedures. As we have not yet come upon a consensus definition, this was tabled.

Decision:

Agreed to remove the Incision RG from the model.

Agreed to use device relationships (as intracavitary vs. intraluminal scopes) to classify procedures as surgical or non-surgical, moving away from using actions for classification. Additional review of endoscope subtype will be performed.

8

Container modeling

@Feikje Hielkema (Unlicensed) 

@Daniel Karlsson 

Continued discussion on the feasibility of a model to represent container types.

Discussion:

Previous discussions:

https://conf.spaces.snomed.org/wiki/spaces/editorialag/pages/133988720

A revised briefing note for the model representation of container types has been provided and is attached for discussion.

The previous discussion resulted in questions around the value of this proposal in light of the small number of affected concepts. Recent evaluation identified that there are at least 70 new concepts that need to be added. Discussions in the EU indicated that for the laboratory it is not relevant whether a container is evacuated; that information is only relevant for the organisation or person that takes the sample. Therefore, many of the concepts currently in the international edition are too detailed for the EU use case.

The list of container types proposed by the EU project has been reviewed by the SHIELD group and they have provided comments:

• The distinction between collection and transfer tubes is not necessary

• The importance of evacuated vs. non-evacuated needs further investigation

• Recommend the use of substances for the range of INTENDED CONTENT relationship rather than specimen.

Update 10/22/2025:

Presentation attached.

Discussion:

The group discussed how to model additives in medical containers, considering whether to use the medicinal product hierarchy or substance hierarchy. They debated whether additives should be modeled as separate products or as attributes of containers, with Jeremy suggesting they table the discussion and conduct experiments to determine the best approach. The need to sometimes represent concentrations may require the use of a product, or an additional attribute representing the quantity could be use, or the concept needing it could remain primitive.

Decision:

9

Bypass graft and shunt modeling proposal update

@Victor Medina 

The remodeling work proposed at the face-to-face meeting related to bypass grafts is ready for review in the authoring platform.  It can be found here:

https://authoring.ihtsdotools.org/#/tasks/task/QICONST/QICONST-11/edit

The EAG had been asked to review the proposed changes in context and provide feedback.

Previous decisions by the EAG (2024-10-21):

• The proposed definitions for bypass and shunt be updated based on input from the EAG 

• Proximal and distal anastomosis actions would be used for bypass graft METHODS (under review)

• Moving 129376004 |Construction - action (qualifier value)| from under Repair - action to a subtype of 129284003 |Surgical action (qualifier value)|

• Moving 360021005 |Bypass - action (qualifier value)| and 424208002 |Shunt - action (qualifier value)| from under 257741005 |Anastomosis - action (qualifier value)| to become a subtype of 129376004 |Construction - action (qualifier value)|.

Specific questions:

• Is the direction of flow in bypass and shunt relevant?

  • If not, the proposed model would be Using Bypass/Shunt actions in the first RG, and the generic 257741005 |Anastomosis - action (qualifier value)| to model the proximal and distal anastomosis.

• How do you model shunt to/shunt from?

• What is the alternative to using Procedure site - indirect for the destination site for shunts not using an anastomosis?  Two RGs?

Discussion:

Previous discussions:

https://conf.spaces.snomed.org/wiki/spaces/editorialag/pages/133988678

https://conf.spaces.snomed.org/wiki/spaces/editorialag/pages/133988680

https://conf.spaces.snomed.org/wiki/spaces/editorialag/pages/133988686

https://conf.spaces.snomed.org/wiki/spaces/editorialag/pages/133988718

https://conf.spaces.snomed.org/wiki/spaces/editorialag/pages/133988722

https://conf.spaces.snomed.org/wiki/spaces/editorialag/pages/133988726

https://conf.spaces.snomed.org/wiki/spaces/editorialag/pages/133988728

Summary of previous discussions:

The surgical actions Should bypass - action and shunt - action be a subtype of anastomosis? Previously agreed that these would be moved under construction.  The question is how to model the remaining semantics of the procedure.  The current model for shunt only represents the result of the procedure, not the actions that are being performed. 

While previous discussions approved the proposed use of new subtypes of 257741005 |Anastomosis - action (qualifier value)| to represent the proximal and distal connections, a number of EAG members expressed a revised view of anastomoses as the result of the construction procedure and represented a resulting morphology rather than an action in and of itself. There is still the perceived need that direction of flow is important; however, if a model that implies the direction of flow can be designed, that would simplify the model.

There were also concerns about using Procedure site - indirect as a proxy for the direction of flow in a shunt. However, in scenarios where there is not a device or an anastomosis in a shunt procedure, how would we address the flow direction?  

The language of bypass and shunt are often conflated.  In many cases the flow is implied, especially in shunts.  

In general the use of action seemed to be the root of the problem and using morphologies would address the issue.  A more general action and focus on the morphology and body structure would be more appropriate.  WRT direction of flow, it can mostly be implied, but there are cases where it is needed. However, using morphologies would add the same complexity to the model as using Proximal and Distal anastomosis actions in different RGs.

There was concern that there bypass and shunt models differed.  Concern about the misuse of Procedure site - indirect in the shunt model. 

Additional comments from MVB:

Open

It was suggested that evaluation of the use of more general 129376004 |Construction - action (qualifier value)| with the direct morphology of <<41796003 |Anastomosis (morphologic abnormality)| (with new morphologies of proximal and distal anastomosis) be undertaken.

Update 10/22/2025:

A revised set of options, inclusing the original proposal is provided.

One area that had not been considered was the impact of this modeling proposal on takedown procedures

Decision:

Agreed:

• Both shunt and bypass represent anastomoses

• for both Bypass and Shunt, three RGs are needed. The upstream and downstreams organs involved and the organ or structure being by passed or shunted.

• While modeling with anastomosis - action or anastomosis (morphology) result the same amount of work, the upstream impact of changing from action to morphology is not warranted at this time.

• SI will look at the impact of the accepted modeling pattern on takedown procedures.

10

Replacement procedures

@Victor Medina 

An analysis document "Review of the replacement procedure hierarchy" is attached for discussion.  The issues related to the use of a single concept "Replacement - action" to model replacement procedures are discussed as an alternative modeling constructs proposed. Consistent use of the Procedure site attributes for Replacement procedures is also discussed. 

The content team reviewed the consistency of the use of the Procedure site attributes for Replacement procedures, specially those regarding the appropriate procedure site for prosthetic implantations.

A document with a proposal is available for review and discussion here.

Discussion:

General consensus that inactivating “replacement - action” by separate “removal” and “introduction” actions on the appropriate body structure was preferred, due to the erroneous classification using the single action “replacement”.

Decision:

• Agreed to split replacement actions into removal and introduction

• Use the procedure site indirect to refer to the space occupied by the removed structure.

• Update the editorial guide for procedure site to clarify its use.

• Provide visibility of the results to the EAG for review using the TS browser.

11

Proposal to add gene names to SNOMED CT

@Jim Case

Based on earlier requests from some members to develop a proposal to add gene names to SNOMED CT a draft was submitted to the SNOMED Member Forum for comment. Based on the comments the proposal was revised and is being provided to the EAG for further comment prior to being distributed to the SNOMED CoP.

Open

Discussion:

Details of the proposal were presented. The scope of the proposal was discussed.

Decision:

The EAG was asked to provide comments by the end of November, 2025

12

AOB

EAG

13

Next meeting

@Jim Case 

TBD