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

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.


Le 13/03/2018 à 15:21, Thomas Beale a écrit :
> 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.
>> Grahame
>> _______________________________________________
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> -- 
> Thomas Beale
> Principal, Ars Semantica <>
> Consultant, ABD Team, Intermountain Healthcare
> <>
> Management Board, Specifications Program Lead, openEHR Foundation
> <>
> Chartered IT Professional Fellow, BCS, British Computer Society
> <>
> Health IT blog <> | Culture blog
> <>
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