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Mapping SIG Meeting Minutes
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Mapping SIG Joint Meetings with Implementation SIG
and Event, Condition and Episode Model Project Group
27 October 2014
Minutes of Meetings
Location: Amsterdam, Netherlands
QUARTER 3, Maurits Room, Allergy/adverse sensitivity implementation guide discussion
REVIEW OF DISCUSSION HISTORY AND USE CASES
JRC gave a review of the history of the allergy and intolerance situation.
Primary use cases:
Netherlands – components confusion; EpSOS interactions
Cerner – guidance of mapping legacy data
UK – NHS use cases
US – CCDA model, FHIM, VA
Adverse reaction record is second use case. Clinician makes diagnosis of adverse reaction,
recorded as diagnosis in system. There were discrepancies in several implementations.
Sensitivity test record: This is the actual test that needs to either support or deny an allergic
event.
The allergy list often includes things that are not just allergies; it must be an immunological
event. Clinical relevance needs to be represented in the record.
REVIEW AND DISCUSSION OF SCOPE AND REQUIREMENTS FOR DRAFT IMPLEMENTATION GUIDE

Glossary review

Use cases for inclusion and elaboration

Stakeholder identification and discussion of workgroups
A proposed piece of work is the “Implementation Guide for SNOMED CT in Documentation of
Adverse Sensitivity Data in the Electronic Medical Record”.
Are the proposed use cases exhaustively representing everyone’s situation?
What portions of SNOMED should I be using and where in the record?
Bruce Goldberg:
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Recap of the interim allergy (SDP) model applied to the current data, as well as a description of
the aspirational model; explains to all parties how each of the allergy-related classes is
represented (and interrelated)
Rob Hausam:
Recap of the HL7 patient care designs for allergy representation; explains how SNOMED CT
content will fit into one of the candidate information model designs
QUARTER 4, Maurits Room, Joint meeting with both Implementation SIG and Event,
Condition, & Episode Model Project Group
The Mapping and Implementation SIGs have been working on an implementation guide for
allergy-type data in the EHR. How should allergy information be represented in the EHR? We
want to help the vendors implement the data interoperably. We want to align our model with
the aspirational model with the IHTSDO.
Focus is three use cases:
1. Diagnosis of allergic event that occurred as part of an encounter
2. Drug allergy list
3. Reporting and structuring of allergy testing
HL7, Nictiz, NHS, VA, HL7 models have been reviewed. Variability was found. We want to
propose a convergent information model for these three use cases.
BG gave a recap of the situation. Allergy content was three different areas. Allergies are
hypersensitivities. The difference in allergies and pseudoallergies may not be apparent to
general clinicians. Dispositions do not have causative agents, so a new role is agent realization.
Text definitions were created for hypersensitivity reaction, disposition, condition; as well as
allergic reaction, disposition, condition, and allergic sensitization.
Stefan Schultz – “if the answers are already there”
There are no IHTSDO resources for the implementation allergy guide right now. Does
everyone agree an implementation guide is needed and work working towards?
Eric Rose (US) – It’s a qualified agreement on creating an implementation guide. No one
disagrees that it’s important for allergy information to flow, but the interoperability is
questionable. There’s a lot of pressure in the US in getting the information flowing in high-value
use cases. No one will use structured data on criticality when prescribing, for example – the
crippling need may not be present. Some of the pieces of metadata may not be necessary.
Physicians document this information in different levels of granularity.
EdC: We need a 2- or 3-dimensional set of use cases.
particular detail that’s needed.
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There should be a ranking for the
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JRC: The scope needs to be broadened to include intolerance. Hypersensitivity is the root node
for the propensity types. Suggest taking this up one level to “Propensity to adverse reactions”.
Our subtypes should include intolerances.
EdC: Hierarchies may not be the solution to this problem. There are technical artifacts to treat
that problem as a set without being defined using one data mechanism. Restricting data into a
value set may be an alternative solution.
KWF: Suggests we broaden the scope. From a clinical standpoint, it’s good to group things
together [such as what shouldn’t be prescribed]. It’s good to be able to group these
concepts/conditions together.
Alejandro/Uruguay: We should include intolerance in the same model.
JRC: Some vendors may not choose to include pseudoallergies.
Decision 1
agreed upon.
Our focus and terminology is agreed. Scope of measure of propensity can be
Will we pursue formal interaction with HL7? How can we do that? If we agree on value sets,
will HL7 agree on these value sets? Bear in mind competition out there. Is an
Implementation Guide that represents only SNOMED be good?
RobH: Rob is involved with HL7 but this isn’t a formal agreement.
Matt Cordell (Australia):
There’s a resistance to record the differentiation in
allergy/pseudoallergy/reaction. The specific agent is recorded when “something happened”.
The drug terminology is in an extension of SNOMED CT.
BGold: The problem with having general classes of any kind of reactions to any medications is
that they’re frequently inaccurate. Unnecessary avoidance of medications is the result.
Patients that say they have allergies that has been proved with testing is relatively low.
Jeremy U.K.: Is it worth making clear the inaccuracies of the terminology moved? We’re trying
to use the specification. In the UK, sharing the information on allergies was initially added in
the EHR because it doesn’t hurt to avoid something that may cause a negative reaction.
RobH: Regenstrief and LOINC have worked well. TermInfo plays a role and is likely to figure out
how to “do” allergies and wants to work with patient care to sort out the boundaries. This is
not with SNOMED only. RxNorm is heavily used in the US.
Decision 2
The group is not keen on creating a transbody standard with HL7.
Is it worth our time? Convergence with observables with LOINC is hardly known currently.
There’s not a lot of information about allergy testing; there’s more information in LOINC.
U.K. wants to avoid trigger avoidance.
JRC says we can eliminate (or rank low) the third use case and still have a useful and valuable
document.
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Chapter 5 section on previous IHTSDO work, will EC&E take responsibility for creating a
draft?
Decision 3
EdC: Yes, we should do this.
Do we want to only acknowledge the difficulties or develop interoperation tools such as crossrealm drug [inaudible]?
JRC: One possible deliverable would be a refset of top 500 drugs mapped to 2 or 3 of our
member realms.
EdC: The first sentence should say, “This guide is for implementing SNOMED CT.”
Domain integrity is important: Is strawberry a substance or an organism or what hierarchy?
The drug realm of allergies is more complex than foods, stings, etc.
Jay Kola: I could see why you would want to use SNOMED to say, “Here’s what this would look
like”. Drug dictionaries are mapped to SNOMED in many countries. It’s not clear if this is what
we should be spending our energy on as a SIG.
JRC: Are there resources available for allowing the SIG to establish a crosswalk with drugs using
the US’s UMLS?
KWF: ATC [Anatomical Therapeutic, Chemical Classification System] WHO classification of drugs
are commonly used in Europe and Latin America. This is one way to do a crosswalk.
RobH: RxNorm is far too specific than what you really want to record. We really want to use
drug classes. SNOMED can do general and specific.
Matt C: There are three ways to model allergy to amoxicillin: Amoxicillin, Amoxicillin product,
specific product that contains amoxicillin.
Decision 4
be.
JRC: We need more analysis here and need to know what the resources would
Scope for Propensity type versus Adverse Reaction
This will include Intolerances.
JRC: Is a starter set of common allergy tests useful?
Jay Kola: No. Get rid of these unless someone says it’s needed.
JRC: Several value sets will be created for Propensity type. There will be refsets. We don’t
know how many or how large they will be. Does anyone want to comment on subsets of SNOMED
CT?
NO RESPONSE.
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Other comments from the group?
KWF: Allergy is not the only use case that requires a common bridge from different countries.
Can we leverage some of the work from other SIGs on this front? Ask about problems, resources?
Provide insight on whether we should attempt to do this or not?
JosB: How do we cope with pre-coordinated and post-coordinated terms? How do we combine
allergy indications in terms from different countries in the E.U.? How do we handle when a drug
is on the market in the Netherlands but comes from U.K.? There must be a transparent solution
offered by the IHTSDO for this. There are enough results in the IHTSDO to say, “this is how we
do it”. I’m not a clinician but the IHTSDO has these resources. It’s very difficult to start
communication on issues like this with counties when you also have to translate things. Postcoordinated concepts mean a lot but they might be too difficult to use. There are problems in
reality when the solutions are highly post-coordinated terms. Translation in the European Union
is also an issue. Maybe we could have a refset in precoordinated terms.
JRC: A significant part of the document is how to interoperate between a pre-coordinated and
post-coordinated approach.
Jay Kola: What are people doing now when they have to interoperate with other countries when
they have different drug dictionaries. What is epSOS project using as a coding system to transfer
and/or exchange allergies such as drug allergies. This is a useful business use case for the SIG to
look at. How do you do normalization back into SNOMED from different realm dictionaries?
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