1. IHTSDO Editorial Advisory Group James T. Case Head of Terminology

2. Agenda ▪Welcome & ApologiesChair ▪Conflicts of InterestChair ▪Review of Terms of ReferenceChair ▪Pre-coordination of lateralityGroup ▪Review of prioritization for content tracker itemsGroup ▪Content model needsGroup ▪Application of ECE guidance retrospectively. Maintenance of ambiguous descriptionsBGO ▪Unilateral – retire or retain?Group ▪Limited status concepts – keep or retireGroup ▪SNOMED CT as interface or reference terminology?Group ▪Conference call scheduleGroup ▪Any Other BusinessGroup ▪Date of next meetingGroup

3. ▪Purpose of the AG ▪“…provide IHTSDO with advice and guidance on issues related to… editorial policy…” ▪Scope ▪Editorial advice not resolved by the SNOMED CT Editorial Panel ▪Providing a “second opinion” on proposed editorial guidance ▪Review and advise on content tracker proposals ▪Review and update SNOMED CT Editorial Guide ▪Perform out-of-cycle editorial investigation and review for complex issues ▪Out of Scope ▪Content development prioritization ▪Derivative development prioritization ▪Tooling Terms of Reference

4. ▪Membership ▪Four members staggered terms ▪Certified Consultant Terminologists (or similar) ▪Two year terms – two consecutive terms max ▪SNOMED CT Editorial Panel – ex officio ▪Meetings ▪Two face-to-face meeting per year ▪Fortnightly meetings between (if agenda items available) ▪Minutes stored on AG confluence site ▪Time commitment ▪Up to three hours per week Terms of Reference - continued

5. Pre-coordination of Laterality

6. ▪Documented as “Temporarily not allowed” since 2011 ▪Existing pre-coordination artifact: artf223747 “Concepts with pre-coordinated laterality may be regarded as excessive pre-coordination. With rare exceptions, it should be possible to make the recording of laterality part of the electronic health record, with record architecture elements to record, store, transmit, retrieve and analyze. Post-coordination is further supported with the Revision of the anatomy hierarchy, which has developed (draft) refset indicating those anatomical codes for which lateralization is sensible. This makes pre-coordination even less necessary in the findings/disorders and procedures.” History of laterality

7. ▪Many existing EHR systems do not have the ability to store laterality as a model element. ▪Many large EHR systems do not have the capability of managing post-coordinated expressions ▪The proposed refset of anatomical structures that can be lateralized is not readily available ▪There is a substantial amount of lateralized content existing in SNOMED CT, users see precedence for adding it. ▪A large number of “bilateral” content requests have been received that cannot be adequately modeled. Laterality challenges

8. ▪Should the restriction on the addition of lateralized content to the International release be reconsidered? ▪If so, which option to add laterality-based content should be adopted? ▪Options - Abstracted from art6188 - Bilateral clinical findings and disorder concepts ▪Option 1 – Nested role groups ▪Option 2 – Pre-coordinate laterality with anatomic structure ▪Option 3 – Use additional finding site with “left/right side of body” Laterality discussion

9. Option 1: Nested role group 10930601000119107 Closed fracture of metatarsal bone of right foot 116676008 Associated morphology 363698007 Finding site ≡ 64572001 Disease 20946005 Fracture, closed 301000 Fifth metatarsal structure 272741003 Laterality 24028007 Right

10. ▪Pros ▪Eliminates the need for explosion of lateralized anatomic structures ▪Introduction of nesting addresses many other modeling issues ▪Cons ▪Requires nesting – not currently supported by tooling or release file structure ▪Requires changes to MRCM to restrict anatomy to only those structures that are actually “lateralizable” Pros and cons: Option 1

11. Option 2: Lateralized anatomic structure 10930601000119107 Closed fracture of metatarsal bone of right foot 116676008 Associated morphology 363698007 Finding site ≡ 64572001 Disease 20946005 Fracture, closed New concept Structure of metatarsal bone of right foot

12. ▪Pros ▪Simplifies modeling to a single un-nested role group ▪Ensures that ONLY “lateralizable” anatomic structures are available for use ▪Allows for retirement of multiple abstract anatomical concepts related to “bi-laterality” ▪Cons ▪Requires creation of a large number of lateralized anatomic structures Pros and cons: Option 2

13. Option 3: Additional finding site 10930601000119107 Closed fracture of metatarsal bone of right foot 116676008 Associated morphology 363698007 Finding site ≡ 64572001 Disease 20946005 Fracture, closed 363698007 Finding site 85421007 Structure of right half of body 301000 Fifth metatarsal structure

14. ▪Pros ▪Flattens the laterality model (no nesting needed) ▪Close to “user-form” ▪Does not require any changes to the concept model ▪Does not require the creation of new anatomic structure concepts ▪Is “consistent” with the post-coordination expression syntax ▪Has precedence in current content (i.e. refinement of finding site on fully defined concepts) ▪Cons ▪Can only be used when all associated role groups are related to the same side of the body (99.99%?) Pros and cons: Option 3

15. ▪Should the restriction on the addition of lateralized content to the International release be reconsidered? ▪If so, which option to add laterality-based content should be adopted? ▪Changes to the editorial guide ▪Scope of revision project Laterality discussion

16. Prioritization of tracker items

17. ▪Open tracker items ▪Content tracker – 748 open items ▪302 rated “High” or “Highest” ▪Pre-coordination tracker – 200 open items ▪Most rated “Low” ▪Review of size – content tracker only ▪142 rated “large” ▪196 rated “medium” ▪356 rated “small”, “single concept” or “less than 10 concepts” ▪54 not assigned size ▪Currently under review ▪Lifecycle phase ▪None – 5 items ▪Inception – 578 items ▪Elaboration – 108 items ▪Construction – 42 items ▪Transition – 15 items Current status

18. ▪82 items opened in the last year ▪3 items closed in the last year ▪New items being added faster than they can be resolved ▪High volume of day-to-day work prevents addressing time-consuming editorial issues ▪Bottlenecks ▪Review of documentation from Consultant Terminologists a bottleneck ▪What role can the Editorial AG play to remove this bottleneck? ▪Key point is moving from Elaboration to Construction phase –Then it goes to the content AG for prioritization ▪Resources not available to do the construction Content tracker discussion items

19. Content model changes

20. ▪Domain and range revisions ▪Clinical course – Add additional disease phases ▪E.g. “In remission”, “latent” ▪Specimen substance – physical object ▪Allows for public and environmental health monitoring ▪Potential new attributes ▪During ▪E.g. “Disorder X DURING procedure Y ▪Has prodcut role ▪Needed to support the specific roles that are being removed as IS-A relationships from the product hierarchy Content model changes recently requested

21. Implementing the Event- Condition-Episode guidance Bruce Goldberg

22. ▪Update on X with Y, X due to Y ▪Clarification on “due to” vs. “co-occurrent” vs. “co-occurrent and due to” ▪Has “Associated with” been “banished” from use? ▪Retrospective application of the guidance ▪Scope of concepts that can be “remodeled” ▪Is guidance clear enough for editors to apply consistently? ▪Clarification of potentially ambiguous descriptions ECE discussion topics

23. Unilateral concepts artf6236 : Unilateral

24. ▪Most “Unilateral” concepts moved from Clinical Findings to the Situation with Explicit Context hierarchy in 2009 ▪Current concept model cannot explicitly state “one side but not the other”. ▪Unilateral is ambiguous as to which side is affected ▪Without negation, in the open world Unilateral is silent about the status of “the other side”. ▪May be present and not affected by the procedure or finding ▪May or may not be present ▪Content most likely originated from a classification that is agnostic about laterality (e.g. ICD-9-CM) ▪Question: Are these clinically useful or a patient safety issue? Unilateral discussion topics

25. Limited status concepts

26. ▪Currently modeled with a WAS A relationship ▪When the WAS A target needs to be retired, how do you fix the relationship to the limited status concept? Issues with limited status concepts

27. SNOMED CT – Interface or reference terminology? Open discussion

28. Conference call scheduling Any other business Date of next meeting