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 recorded

3

Bypass graft and shunt modeling proposal update

@Victor Medina 

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:

2024-03-11 SNOMED Editorial Advisory Group Conference callPreview

2024-04-16 SNOMED Editorial Advisory Group Face to Face MeetingPreview

2024-06-03 SNOMED Editorial Advisory Group Conference CallPreview

2024-08-19 SNOMED Editorial Advisory Group Conference CallPreview

2024-10-21 SNOMED Editorial Advisory Group Face-to-Face MeetingPreview

2025-04-07 SNOMED Editorial Advisory Group MeetingPreview

2025-07-29 SNOMED Editorial Advisory Group Conference CallPreview

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 and agreements 10/22/2025:

A revised set of options, including the original proposal was provided.

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

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 when the latter is explicitly stated or implied in the descriptions..

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.

Update 27/01/2026:

Take-down procedures can be remodeled using the same model as per 47585001 |Surgical closure of anastomosis (procedure)| and will be subsumed by this grouper.

Changes and remodeling agreed in the October 2025 in-person call are available for review by the EAG members in the TS browser choosing Project: QICONST and TASK: QICONST-16. (https://authoring.ihtsdotools.org/browser/?perspective=full&conceptId1=427552002&edition=MAIN/QICONST&release=QICONST-16&languages=en

Note: The task is intended to show the changes to the model of procedure concepts under the 48537004 |Bypass graft (procedure)| hierarchy. It is not an exhaustive review and it reflects exclusively the changes made to a subhierarchy, showing the model and susbsumption within that subhierarchy. The reviewer would find lost supertypes caused by the old model kept for those supertypes as they are out of the scope of the task. Also, there may be found some Inherited RGs caused by the same issue. The changes made are aligned to the agreements from the in person EAG session in October. Mainly, the addition of the Proximal and Distal anastomosis RGs and the use of a Bypass RG. Substances or devices used to perform the procedure are modeled within the Bypass RG as target concepts for the 424226004 |Using device (attribute)| or the 424361007 |Using substance (attribute)|.

Jan 27, 2026

The changes recommended from the last meeting have been partially made and are available in the TS browser. The EAG was asked to review the changes and make comments.

JSN: Specific questions on some remodeled concepts. Bypass of stomach did not have a distal anastomosis. This concept was not yet remodeled as they were outside the scope of the sample list. VME will review.

Decision:

Waiting for comments from the EAG

4

Endoscopy procedures

@Victor Medina 

Update and agreements 22/10/2026:

• 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.

• Removal of the the Incision RG from the model.

• 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.

Update 27/01/2026:

Agreed changes to the 423827005 |Endoscopy (procedure)| are finished and available for review by the EAG members in the TS Browser choosing Project: SURGAPP and TASK: None (https://authoring.ihtsdotools.org/browser/?perspective=full&conceptId1=427552002&edition=MAIN/SURGAPP&release=None&languages=en

Discussion:

This is an exhaustive remodeling of the endoscopy content. The remaining issues are related to the devices hierarchy related to endoscopes. Intracavitary endoscopes have yet to be revised.

JCA will ensure that the group has access to the TS browser for these projects.

Decision:

EAG will review the changes when access to the TS browser is available.

5

Proposal to add gene names to SNOMED CT

@Jim Case

Open

Following evaluation of the review comments posted on the SNOMED EAG Forum, the document was further revised. Summary of changes include:

• Clarified scope: proposal does not replicate HGNC, provide a comprehensive gene catalogue, or support direct recording of gene names as test results

• Gene additions limited to those required to define existing content (Disorders, Clinical findings, Observable entities)

• Added section documenting the suggested alternative of linking directly to HGNC and explaining why it was not adopted

• Distinguished alignment with HGNC from technical dependency, addressing governance and maintenance concerns

• Clarified gene–disorder modeling:

  • Finding site used when the gene is the locus of abnormality

  • HAS ASSOCIATED GENE used for non-site, etiological or biological associations

• Distinguished foundational chromosomal anatomy content already implemented (chromosomes, arms, centromeres) from proposed additions (bands and genes)

• Confirmed chromosome bands will be added incrementally, driven by clinical and gene-location needs

• Acknowledged existing use of band ranges in disorder concepts; formal representation of ranges noted as out of scope for first phase and under investigation

• Strengthened impact assessment:

  • Includes new gene and band concepts and any remodeled Disorders, Clinical findings, or Observable entities

  • Evaluation of classification, analytics, and data-entry impact positioned as part of standard SNOMED CT QA and release processes

  • Noted that the absence of gene concepts has already constrained modeling quality

• Overall: technical direction unchanged; scope, safeguards, governance rationale, and modeling rules are now explicit.

Discussion:

The group discussed refining the modeling of genetic findings, focusing on how to represent gene abnormalities and associations. Jim explained that gene mutations should be modeled with the gene name as the finding site for the affected gene, while disorders would be modeled using the proposed HAS ASSOCIATED GENE relationship to name the gene. Jeremy raised questions about modeling multiple genes contributing to a single condition, which Jim addressed by suggesting that such cases should be represented as individual findings rather than multiple associated genes. The team agreed that the revised proposal adequately addressed previous comments and could proceed to early visibility notifications, with chromosomal structures already implemented and gene representation remaining as the final step. John suggested having a generic "has-associated gene" concept at the NRC level for classification purposes and requested clearer editorial guidance for measurement findings.

Additionally, The group discussed the disposition of existing gene names in the substance hierarchy. These concepts will be inactivated and replaced by concepts in the body structure (i.e. cell structure) hierarchy in accordance with the gen name proposal.

Decision:

Briefing note was endorsed by the group. An early visibility notice will be crafted and added to the early visbility page

6

Proposal to add attributes to support modeling of deficiency and excess concepts.

@Jim Case

New deficiency BN revision has been added to the agenda for discussion. The scope of the proposal has been increased to include the addition of a symmetric “has excess of” attribute as well as addressing the issues raised during the initial review of the first proposal.

Following evaluation of the review comments posted on the Breifing Note Forum, the document was further revised. Summary of changes include:

• Expanded scope to address modeling issues identified during review, beyond approval of Deficiency of (attribute) alone

• Added a symmetric Has excess of (attribute) to avoid asymmetry in modeling abnormal physiological states

• Renamed Deficiency of (attribute) to Has deficiency of (attribute) to align with editorial guidance (no change in meaning)

• Explicitly separated deficiency and excess disorders from measurement-based clinical findings

• Clarified that INTERPRETS / HAS INTERPRETATION is inappropriate for modeling pathological physiological states

• Added an explicit response to governance concerns regarding attribute proliferation

• Defined criteria under which new attributes are justified and committed to non-expansion

• Clarified scope boundaries (no impact on measurement findings, structural deficiencies, or functional impairments)

Discussion:

Discussion was around how the propposed two new attributes (has deficiency of and has excess of) to improve the modeling of deficiency concepts, would be restricted to the propser domain. This will be handled by the domain and range properties of the attribute as defined within the MRCM. Jim emphasized that these attributes would be used only for disorders and there is no proposal to convert existing qualifier values to attributes, noting that the proposal had been refined based on previous feedback and would require further review.

The group discussed the proposal for naming patterns for findings and disorders, with Jim explaining that all measurement findings would be represented as above, below, or within reference range, while deficiency disorders would not be subtypes of the clinical findings and do not require a quantitative property. There was some disucssion regarding the distinction between quantitative and functional deficiencies, with Jim noting that while both types could be represented, there was currently no clinical use case to justify making that distinction. The discussion concluded with John asking about the restriction of attributes to pathological and physiological state disorders, which Jim clarified would be addressed through editorial guidance and MRCM restrictions.

Decision:

Briefing note was endorsed by the group. Early visibility note to be drafted when work begins.

7

AOB

EAG

Container modeling revisions:

Want to model additives to containers. Original proposal discussed at the October 2025 meeting. Use of pharmaceutical products or substances as the value was tested.

Discussion:

The team discussed modeling container types with additives, focusing on whether to use a medicinal product hierarchy or a simpler substance-based approach. Feikje presented examples and explained that while the medicinal product approach would create more fully defined concepts, it would add unnecessary complexity for their use cases. The group agreed to proceed with the original proposal using substances as additives, as it better balanced simplicity with functionality. Jim outlined the next steps, including posting the proposal on the briefing notes page for community review.

Decision:

The Briefing note will be posted to the Briefing Note Forum, the Member forum, CMAG, and Clinical Leads groups.

8

Next meeting

@Jim Case 

TBD