[Troll] Terminology bindings ... again

Mikael Nyström mikael.nystrom at liu.se
Wed Mar 14 19:10:34 EDT 2018

Hi Tom,

I don’t see that your “first killer move” by separating SNOMED CT technology from content would make that much sense. The specification and technology you are describing in quite many sentences in your e-mail seems to be quite much like the EN 14463 Classification Markup Language (ClaML) specification and the ecosystem around that specification. However, that specification and the associated tools are not that well known or well used, so why would it be a “first killer move” to separate SNOMED CT technology from content? If it was a killer move someone had already created EN 14463 Association and competed out SNOMED CT and SNOMED International …

Instead it seems to be the collaboration and pooling of resources to create, extend and improve the common content in SNOMED CT that is possible to share among different countries that is the driving force for countries to join SNOMED International. The members would like to move away of the situation where each country spend large resources to create similar terminology products covering the same kind of clinical findings, anatomy, substances and much more. Instead they would like to focus on the things that are truly specific for each country. However, spending large resources to create similar things in each country doesn’t seem to be a problem in your argumentation, Tom?

Your “second killer feature” seems to be the existing SNOMED CT Expression Constraint Language - Specification and Guide (http://snomed.org/ecl) and the supporting tooling, or do you mean something else?

In your “third killer feature” I don’t really understand what you mean by that the translation tools should work on “the basis of legacy vocabulary”. But your second claim seems to be that it should be possible to use the tools to only translate parts of SNOMED CT and that is a function in all SNOMED CT translation tools I have heard of.

I don’t think that anyone would say that IHTSDO Workbench was a success, but more as a result of a few quite wrecked IT-projects made under various external less than optimal circumstances. To judge an organization’s will from the functions of the final IHTSDO Workbench, which you seem to do, is therefore quite unfair. (The IHTSDO Workbench was replaced with better adapted software quite quickly, so I think nowadays quite few people in the SNOMED International community remember the IHTSDO Workbench .)


From: openEHR-technical [mailto:openehr-technical-bounces at lists.openehr.org] On Behalf Of Thomas Beale
Sent: den 13 mars 2018 15:21
To: openehr-technical at lists.openehr.org; For openEHR clinical discussions <openehr-clinical at lists.openehr.org>
Subject: Re: [Troll] Terminology bindings ... again

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
On 13/03/2018 12:12, Grahame Grieve wrote:

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.



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Thomas Beale
Principal, Ars Semantica<http://www.arssemantica.com>
Consultant, ABD Team, Intermountain Healthcare<https://intermountainhealthcare.org/>
Management Board, Specifications Program Lead, openEHR Foundation<http://www.openehr.org>
Chartered IT Professional Fellow, BCS, British Computer Society<http://www.bcs.org/category/6044>
Health IT blog<http://wolandscat.net/> | Culture blog<http://wolandsothercat.net/>
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