That looks useful, but is it finished? The heading 5.1 has the text “Use of SNOMED CT and/or LOINC in” …
Hi,
It has the status ”Release Documents” in the SNOMED International’s official document repository https://www.snomed.org/doc , so I think that it is finished. However, I think that they had some problems with converting some of the documents from Word into Confluence, so the problem with the heading might relate to that?
Regards
Mikael
Mikael,
It might be worthwhile if Snomed International checks that, in case something more important is missing. I say that symathetically, I’ve had to address numerous such errors we had in our format changeover a couple of years ago, and there have been a couple that were important. I['m still finding the occasional one …
- thomas
I have now submitted an error report.
/Mikael
Please never underestimate the Germans...
In Latin America is all the contrary, more countries are becoming SNOMED members and adopting SNOMED at the govt level.
Pablo, I wish you sincerely all the best.
IMHO, the question is not really to enroll but to deliver… and considering the tremendous amount of money that was invested in HL7 and Snomed (both to elaborate and try to implement) and the actual societal return, there is such a discrepancy that the hypothesis that, due to missing the “information society” turn, health systems are entering terrible crisis times is to be considered seriously.
In current “information society”, you have two options when considering “health information systems”:
- You dedicate yourself to “medical information systems” instead, and can freely build for (inter-connected) silos,
- You consider “health” in its genuine meaning and you have to realize that it is a complex domain fully opened to all other societal issues… hence should ban components that are endemic to medicine.
Maybe (and I really mean it for Latin America), it should be high time to leapfrog, not to join the “dollars wasting club” 
Philippe
Interesting times indeed 
hi Philippe
No one who’s actually tried to use Snomed CT could think that in it’s current form it’s the answer to everything.
But anyone who’s tried to work on real terminologies must also be aware of just how much work is involved in these things.
So there’s very much a glass half full/empty thing here. I understand not being thrilled with Snomed CT as a choice, but as the french government, for instance, actually confronted how much more it will cost to do something else?
There’s more than one kind of club to have that wastes money…
I’ve had a quick look at Meriterm… like all good rdf, it’s not easily penetrable. But it looks like the authors are not informed about Cimino’s desiderata… which brings us back to the wasting money thing…
Grahame
Grahame,
What you state is plainly valid, and the “it exists” argument is not to be considered lightly.
However, as an engineer and a developer, I always try to measure the payload of a component when I consider using it. Where does it fit in the “pair of wings” to “dead horse” range?
IMHO, HL7 and Snomed are not on the right side and adopting such components is like drilling in concrete: it never becomes easier.
When it is about considering costs, I can argue that something that is “not well born” will cost considerably more than necessary during its entire life span. Any such technique is hard to build, hard to integrate and hard to maintain. As a guy that built and operate a self made 54000 atomic terms ontology, I can tell you that addressing this issue in the proper way can save considerable amount of money and (this is the most important part of it) free considerable energy that can be invested in reinventing health instead of plaguing practitioners with new burdens.
My aim with this “troll” was just to tell that this kind of questioning exists and also that some “fools” are currently joining to create what they think could be “well born components”.
I have the feeling that it is high time we “leapfrog” in being able to “organize the journey” from the patient’s “bio-psycho-social bubble” instead of getting dedicated to “siloed care center boxes”… and that HL7 and Snomed will keep their users in the wrong reference frame.
Time will tell… but interesting times ahead!
Philippe
Hi Phillipe and Graham,
This may help your discussion:
https://www.snomedinaction.org
Unfortunately, it only gives a high level view of where SNOMED CT is used, for example, if you look at the map, it mentions, “Leeds Teaching Hospitals decided to embrace SNOMED CT in their Emergency Department”. However, I wonder, why the many other departments in that hospital are not using SNOMED CT too? I would really like to know where the true successful implementations of SNOMED CT are? Where I mean an implementation, I don’t mean for example a just a mapping from one terminology to another, like mapping READ codes to SNOMED CT, but also using the post coordination functionality of SNOMED, and making full use of the hierarchical structure of SNOMED CT.
I am get the impression that SNOMED CT is hard to implement, and therefore wondered if we are at some kind of tipping point, like where HL7v3 was a few years ago, and some bright spark came along, and now we have FHIR that is gaining great traction in the health community due to the ease at which it can be implemented.
(attachments)
I think you have just created the new technological utility scale!
I am get the impression that SNOMED CT is hard to implement, and therefore
wondered if we are at some kind of tipping point, like where HL7v3 was a
few years ago, and some bright spark came along, and now we have FHIR that
is gaining great traction in the health community due to the ease at which
it can be implemented.
this is very true, and I wish that someone would stick their neck out and
do this at scale with
a community behind them. Many of the parameters for how it could be done
are obvious around
free and crowd-support etc. But the big problem is that there is no
capacity for it to happen as a
palace revolution; it must be a full civil war first.
Grahame
Hi John,
The tipping point will only get reached when a sufficient amount of
Snomed users will state that it is uselessly hard to implement... and
when someone will invent a smart way to simplify it... not there yet
But I really insist on the two orthogonal issues at stake:
1) a component should ease your job and not kill your project (detect
"dead horses" early),
2) a component should not keep you stuck in the wrong (ancient)
reference frame.
No need to say that FHIR is easier to put at work than the plain RIM,
but it still keeps its community in a system where "boxes that saw the
patient passing by can exchange information" when we should (due to both
the chronic turn and the information society era) be dedicated to
organize multidisciplinary teamwork around patients.
Best,
Philippe
Hi,
IMO having s national terminology server like we have in Uruguay, is a first step of delivering. jus imagine standardizing every diagnosis, every procedure and every drug around the country? I can only see benefits for clinical environments and public health, they will have data to actually see what’s happening in a complex system. also this is part of a state strategy for health accessibility.
BTW, we don’t have tons of money, so even if some tactical areas fail, is the investment of learning. But we are learning from institutions that already did this and using their experience, this not an isolated journey reinventing the wheel.
There are 3 questions to make when your are starting: 1. Is there any use of SNOMED in my ehealth strategy? 2. Is there an alternative? 3. What’s the cost of SNOMED vs. the alternative?
I’m an engineer and just recently I was understood the real value of SNOMED sheet using it for data querying. Without getting your hand dirty a little bit is difficult to know for sure what are the pros and cons. Obviously this is not a panacea and needs a lot of work to implement and maintain. ROI is long term as in everything in ehealth (like implementing openEHR!)
best,
Pablo
The killer move would be to do something I advocated for years unsuccessfully: separate SNOMED technology from content and allow them to be independently licensable and used. Here, technology means representation (RF2 for example), open source programming libraries for working with ref-sets, specs and implems for e..g the constraint language, URIs and so on.
It should be possible for a country (the one I am most familiar with w.r.t. to terminology today is Brazil) to create an empty ‘SNOMED container’ of its own, and put its existing terminologies in there - typically procedure lists, drug codes, lab codes, devices & prosthesis codes, packages (chargeable coarse-grained packages like childbirth that you get on a health plan) and so on. There are usually < 20k or even 10k such codes for most countries (UK and US would an exception), not counting lab analyte codes (but even there, 2000 or so codes would take care of most results). But the common situation is that nearly every country has its own version of these things, and they are far smaller than SNOMED. Now, SNOMED’s version of things is usually better for some of that content, but in some cases, it is missing concepts.
The ability to easily create an empty SNOMED repo, fill it with national vocabularies, have it automatically generate non-clashing (i.e. with other countries, or the core) concept codes and mappings, and then serve it from a standard CTS2 (or other decent standard) terminology service would have revolutionised things in my view. This pathway has not been obviously available however, and has been a real blockage. The error was not understanding that the starting point for most countries isn’t the international core, it’s their own vocabularies.
The second killer feature would have been to make creating and managing ref-sets for data/form fields much easier, based on a subsetting language that can be applied to the core, and tools that implement that. Ways are needed to make the local / legacy vocabularies that have been imported, to look like a regular ref-set.
The third killer feature would have been to make translation tools work on the basis of legacy vocabulary and new ref-sets, not on the basis of the huge (but mostly unused) international core.
I think IHTSDO’s / SNOMED International’s emphasis has historically been on curating the core content, and making/buying tools to do that (the IHTSDO workbench, a tool that comes with its own PhD course), rather than promulgating SNOMED technology and tooling to enable the mess of real world content in each country to be rehoused in a standard way, and incrementally joined up by mapping or other means to the core. I think the latter would have been more helpful.
There is additionally an elephant in the room: IHTSDO (now SNOMED International) has been tied to a single terminology - SNOMED CT, but it would have been better to have had a terminology standards org that was independent of any particular terminology, and worked to create a truly terminology-independent technology ecosystem, along with technical means of connecting terminologies to each other, without particularly favouring any one of them. It’s just a fact that the world has LOINC, ICDx, ICPC, ICF and hundreds of other terminologies that are not going anywhere. What would be useful would be to:
-
classify them according to meta-model type - e.g. multi-hierarchy (Snomed); single hierarchy (ICDx, ICPC, … ); multi-axial (LOINC); units (UCUM, …), etc
-
build / integrate technology for each major category - I would guess < 10
-
help the owning orgs slowly migrate their terminologies to the appropriate representation and tools
-
embark on an exercise to graft in appropriate upper level ontology/ies, i.e. BFO2, RO, and related ontologies (this is where the <10 comes from by the way)
-
specify standards for URIs, querying, ref-sets that work across all terminologies, not just SNOMED CT
A further program would look at integrating units (but not by the current method of importing to SNOMED, which is a complete error because of the different meta-models), drugs and substances (same story), lab result normal and other range data, and so on. None of this can be done without properly studying and developing the underlying ontologies, which are generally small, but subtle.
I’ll stop there for now. I suspect I have kicked the hornet’s nest, but since Grahame kicked it first, and I can run faster than him, I feel oddly safe. Probably an illusion.
- thomas
Thomas,
Since, in that domain (terminologies, classification, ontologies…), it is not that easy to understand someone else’s explanation without a sketching tool available, do you think I betray your thoughts if I sum it up as “Snomed should not be licensed as a “one size fits all” package but should be mainly usable as a set of tools and services in support of localized adaptations by national organizations”?
It is certainly a good thing to be discussed in order to have Meriterm fill the gap.
Besides, as you probably remember, the main reason I don’t like Snomed is because it is structured like a coding system and not a “narration ontology”.
As an example, I would say that a narration ontology should contain atomic concepts, like “fracture”, “location”, “right ankle”, but should let “fracture of the right ankle” be built as a description structure (say a small tree that express that the fracture is located at the right ankle). Snomed inherited the incorporation of meta-concepts from its history as a coding system (the kind of component that is to be used in systems where information are stored in simple value-pair slots that don’t allow for elaborated description structures), as would be the vocabulary of a massively agglutinating language… Since our languages are not massively agglutinating ones (we built sentences), each group has to invest a very long time selecting the subset that fits their “local language” (for example the subset for GPs).
I have always seen Snomed as a system that could be fit to “fill slots in forms” but not as a proper vocabulary to tell a patient’s health story… in my own terms, it means that it is not the proper component for modern applications.
Philippe
Wasn't it Voltaire who said that the best is the enemy of the good?
just imagine standardizing every diagnosis
That typically leads to either bad statistics or disimproved care.
Karsten
" but in some cases, it is missing concepts"
Shouldn’t we contribute?
Is the same as openEHR, there are missing archetypes and we need the community, users, clinical modelers and engineers to contribute.
LOINC also misses concepts, and when I asked them how can I contribute, they sent me the process and some templates for requesting a new concept to be added, pretty simple, formal and open!
IMO we can’t expect perfection, is a bad strategy and a move towards isolation. I think pragmatism is better and go with “this is the best we can expect for”. We are the ones that should push towards the ideal, but as a guide not as a goal (getting a little philosophical here…).
The same idea applies to tooling, anyone can create tools to manage the terminology better. In our own backyard we have tools that need improvement, but we accept them because there is no better alternative.