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Nebraska Lexicon Release Documentation Introduction Purpose This document summarizes the RF2 release set and supporting documents which publishes the Nebraska Lexicon© extension namespace including content for the cancer synoptic reporting content mapping of College of American Pathologists (CAP) and the associated RF2 mapping files and supportive documentation. The Nebraska Lexicon© module is dependent upon the US extension and so terminology developers wishing to classify this content should load the US extension 20160330 and SNOMED CT Internal Release 20160130. Scope Nebraska Lexicon © namespace content includes problem list terminology developed and deployed by UNMC as well as SNOMED CT and LOINC content developed in conjunction with the Observables project sponsored by the IHTSDO and synoptic reporting terminology data developed in collaboration with the College of American Pathologists (CAP) and the Royal College of Pathologists (MRCP). Audience This material is intended for SNOMED CT system managers and system analysts who may wish to expand their SNOMED CT terminology for problem list, or have interest in employing SNOMED CT-LOINC structured reporting of cancer synoptic data compliant with CAP check sheets. Content development activity Nebraska Lexicon extension set 1000004 (sct2_XXX_Snapshot_INT_20160725) Table: Inventory of content by domain Version SNOMED CT content domain 1.0 Clinical finding Body structure Substance Observable entity Procedure Qualifiers Situation Relationships (stated) Descriptions Concepts 1496 61 8 197 1002 27 200 13958 12286 Derived products SNOMED CT – HGNC Equivalence map (der2_sRefset_SNOMED\NebbraskaLexicon-HGNCEquivalenceMapSnapshot_INT_20160725) The SNOMED CT concept model for Body structures was extended for this publication in order to define named genes (nucleotide sequences) of clinical importance, nucleotide sequence variants and associated proteins. These extensions were necessary for full definition of Observable entities for molecular pathology and cytogenetics. Genes are defined in this model as named nucleotide sequences which are part of chromosome structures. Reference data for the gene definition resides in the publication of the HUGO Gene Nomenclature Committee (HGNC) (http://www.genenames.org/). The simple map reference set enclosed with this release includes the reference component gene locus concept identifier such as 100670521000004106|BRAF gene locus(cell structure)| linked to the HGNC record Identifier and a REST services call which will retrieve the supplemental data regarding the nucleotide sequence identification (‘HGNC:1097^http://rest.genenames.org/fetch/symbol/BRAF’). Figure: Concept model for 100670521000004106|BRAF gene locus(cell structure)| Figure: REST services reference data from Human Gene Nomenclature reference BRAF gene locus SNOMED CT – LOINC Equivalence map (der2_sRefset_SNOMED\NebbraskaLexicon-LOINCEquivalenceMapSnapshot_INT_20160725) This work represents a portion of the deployment of the expanded Observable entity concept model developed by the IHTSDO and the Regenstrief Institute. Use of this model in service of cancer synoptic reporting identifies pre-existing Observable content in LOINC which are summarized in this simple map for extension concepts. This RF2 refset is a mapping between the extension concept identifier assigned by Nebraska to content modelled for this project and LOINC concept codes where pre-existing content was identified in LOINC V2.54. Annotated Synoptic Checksheets from College of American Pathologists© CAP 2016 With permission of the College of American Pathologists (CAP), we enclose the CAP synoptic documents in PDF format supplemented with hyperlinks in context to the Observable entity and valueset for all checksheet data items. In most cases these are one-to-one matches with checksheet data items. In a minority of cases, the information model implied by the checksheet structure was expanded or modified in order to properly define the nature of the observation. An example of this can be found in the colorectal cancer anatomic pathology checksheet on page 6. Since the checklist valueset for Microscopic tumor extension required four types of observations, the last three items in the list (organ adherence, direct invasion and penetration of visceral peritoneum) have unique observable entities defined for a total of four observables for this checklist. The comprehensive set of observable entities, valuesets and concept model definition are included immediately following the CAP checklist document. To use the annotated checksheets, simply open the document in an Adobe browser. Scrolling down the CAP checksheet to individual data sections, a ‘hand’ widget will appear when hovering over the checklist. Clicking on this portion of the document will take the reader to the SNOMED CT observable entity and the associated valueset in tabular form. Clicking a second time on the valueset table will return the reader to the CAP document at the point of departure. Publication date 6/5/2016 6/13/2016 6/13/2016 6/14/2016 File name CAP_colorectal_cancer_anatomic_pathology_20160613 Content Annotated colorectal checksheet with observables and valuesets CAP_colorectal_cancer_biomarkers_20160613 Annotated colorectal biomarker checksheet CAP_invasive_breast_cancer_anatomic_pathology_20160613 Annotated breast cancer checksheet CAP_breast_cancer_biomarkers_20160614 Annotated breast cancer biomarkers checksheet Technical notes Publication history Publication date 7/21/2016 Content 1)Nebraska lexicon post-coordinated problem list content 2)CAP checksheets includes histopathology and biomarkers for colon and breast carcinoma 3) HGNC simple map refset for gene locus definition 4) LOINC simple map refset for extension observables concepts Version 1.0