The Technical Application chapter of the SNOMED CT Implementation Guide for the Nutrition Care Process Terminology (NCPT) Reference Set offers practical guidance for implementing and using the reference set in healthcare systems. It covers topics such as implementation approaches, translation of reference set members, accessing and deploying the NCPT Reference Set, and applying it in clinical workflows.

This chapter provides an overview of the steps needed to integrate the NCPT Reference Set effectively, including working with National Release Centers to align with SNOMED CT standards. By following the guidance, organizations can support standardized nutrition care documentation and improve consistency in nutrition-related data use.

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The translation of reference set members involves creating meaningful and linguistically appropriate descriptions for the concepts referenced by the subset. These descriptions are added within the national extension of SNOMED CT, ensuring that healthcare professionals can understand and use the terminology effectively in their local language and clinical context.

Creating Descriptions for Referenced Concepts

The reference set itself does not contain descriptions but instead includes references to specific SNOMED CT concepts.

Translating reference set members involve:

1. Adding Descriptions for Referenced Concepts:

   • For each concept in the reference set, create one or more descriptions for the concept in the target language.

   • These descriptions ensure that the clinical intent of each concept is clear and usable by healthcare professionals in the target region.

2. Maintaining Semantic Integrity:

   • Ensure that the translated descriptions accurately reflect the original meaning of the concepts while using natural language familiar to the target audience.

3. Integration into the National Extension:

   • The translated descriptions are added to the national extension of SNOMED CT, which incorporates the localized content while maintaining alignment with the International Edition.

The translation process should be conducted in collaboration with the National Release Center (NRC) to:

• Ensure Consistency Across Extensions: Work with the NRC to maintain consistent translations across the national extension, avoiding discrepancies between reference sets and other SNOMED CT components.

• Leverage Expertise: Utilize the NRC’s access to clinical, linguistic, and terminological experts to validate the quality and usability of the translations.

• Support Updates: Coordinate with the NRC to integrate translated descriptions into the national extension and manage updates as SNOMED CT evolves.

• Enhanced Usability: Descriptions in the local language make the reference set more accessible to healthcare professionals.

• Improved Data Quality: Localized descriptions reduce the risk of misinterpretation and improve the accuracy of clinical documentation.

• Alignment with National Standards: Ensures the reference set reflects local healthcare practices and terminologies.

• Sweden, contains diagnostic terms, release November 2024

More information

Overview of Members and contact details:

Translation Guidance and principles:

The NCPT reference set is distributed as an independent derivative package. Using it requires a valid Affiliate License, which can be obtained through national or international channels depending on the user’s location. Understanding the licensing requirements and processes is essential for proper utilization and compliance. For more detailed information on obtaining a license and accessing the NCPT reference set, users should contact their National Release Center or SNOMED International directly.

To access and use the NCPT reference set, users must have a valid Affiliate License for SNOMED CT. SNOMED CT is a globally recognized clinical terminology standard, and its usage is governed by strict licensing agreements to ensure compliance and proper utilization. Licensing ensures that users are authorized to access and implement SNOMED CT in their systems.

Individuals or organizations interested in using SNOMED CT must obtain an Affiliate License through their respective National Release Center (NRC) or via SNOMED International.

More information can be found here:

Countries that are members of SNOMED International have specific licensing arrangements in place for accessing SNOMED CT, including the NCPT reference set.

The following points outline the key aspects of member licensing:

Two examples are offered as to how the refset could streamline digital nutrition care. Because the Nutrition Refset is relatively new, few implementation examples exist. However, these two scenarios offer insight into possible use cases. First, in Brisbane, Australia, a nutrition diagnosis dashboard using NCPT was developed for internal reports to demonstrate nutrition care outcomes. (This was presented in a May 2024 webinar, which is available with a Commission on Dietetic Registration account ) And second, Sweden will be transitioning to a new EHR (2024-2025). Dietitians in Sweden see opportunities to incorporate the refset into the transition advancing report generation and demonstrating quality care [personal correspondence]. With the Swedish EHR transition, dietitians are working with nursing to standardize malnutrition diagnostic criteria and nutrition interventions among other issues. The completed nutrition care refset would support this work in Sweden.

Participation in standards development, recognize others with interest in nutrition such as wound care, treatment of dysphagia () and general nursing practice. Implementation of the refset in these care areas would be expected to grow as interventions are included.

The accompanying the refset release (Lloyd et al , 2024) suggests additional use cases. The availability of a defined terminology can promote:

1. Cross border demonstration of nutrition care outcomes: US and Australian dietitians comparing Hemoglobin A1C changes after nutrition intervention

Introduction

Effective use of the content of the Reference Set requires access to the content in ways that leverage the features of the terminology. A terminology service is a software function that interfaces with and provides access to information from one or more representations of a terminology.

Different technical options are available for implementing terminology services, such as using a relational database, other database options (such as Graph databases ), or predefined services accessible via an API (for example, SNOMED International's Snowstorm).

When deploying the NCPT reference set, it is important to decide on an appropriate approach. The choice will depend on factors such as the organization’s existing infrastructure, the complexity of integration, and the level of flexibility required. Whether opting for a local database solution or a cloud-based service, the decision should ensure efficient retrieval, updates, and management of the terminology content.

Regardless of the technological platform chosen to deploy the Reference Set content, the process always involves importing a SNOMED CT Edition and the reference set in the server or database.

Required Release Packages

To load the NCPT reference set, the RF2 packages required are:

• The latest version of the national release you have access to

  • For national extension packages, the corresponding international edition is also required (the version that the national extension is dependent on)

• The latest version of the NCPT Release Package where the International Edition dependency is not newer than the version you are using.

  • The release notes accompanying the NCPT release package include a chapter titled ‘Versions,’ which details the International Edition dependency of the current release package.

The NCPT (Nutrition Care Process Terminology) Reference Set is aligned with specific releases of the SNOMED CT International Edition. Each version of the NCPT Reference Set is released annually in April and is dependent on the January release of the International Edition.

For users in a specific country or region, access to the descriptions of the reference set members, including translations, requires the use of the National Edition. The national extension may incorporate localized descriptions for the concepts referenced in the reference set, ensuring translations are available for use in the target language. Without the national extension, users will only have access to the descriptions provided in the International Edition.

National Editions follow independent release cycles, which vary by country or member organization. Some National Editions are released monthly, others quarterly, and some biannually. SNOMED CT is designed to accommodate these variations in release schedules, with comprehensive history tracking to manage any discrepancies that arise due to differing update cycles.

Example Scenario

A National Edition is released in September and is based on the July release of the International Edition.

At the same time, the NCPT Reference Set, dependent on the January International Edition, is required by implementations in this Member country.

In this case, certain concepts within the International Edition that are referenced in the NCPT Reference Set may have been inactivated between the January and July releases.

When the September National Edition is implemented alongside the April version of the NCPT Reference Set, this could result in references to inactive concepts.

To address this, SNOMED CT’s design enables easy identification and resolution of any references to inactive concepts when updating to the new National Edition.

This process ensures that the NCPT Reference Set remains consistent and operational across varying release cycles.

You have two options:

1. Use the Reference set as it is, accepting the risk that some of the components may refer to inactive concepts

• Benefit : No need to spend time and resources on processing or updating the reference set before implementation. This approach allows for quicker deployment, reducing the upfront effort required. Additionally, SNOMED CT provides tools and workarounds, such as historical associations, to mitigate the impact of using inactive content.

• Challenge : Risk of coding with concepts that are inactive in the current version of SNOMED CT

1. Conduct a pre-implementation processing step to resolve any references to inactive concepts

• Benefit : The reference set will be fully aligned with the version of SNOMED CT applied in the implementation

• Challenge : Various requirements needs to be in place, including

  • Expertise knowledge on SNOMED CT

  • Services supporting the identification of proposed replacements (see section below)

Inactive concepts within the NCPT Reference Set do not present an obstacle for normal use. SNOMED CT provides tools to identify and manage these inactive concepts through Expression Constraint Language (ECL) queries.

To locate references to inactive concepts within the NCPT Reference Set, you can use the following ECL:

This ECL query identifies all concepts within the NCPT Reference Set that are currently inactive (`active = false`). This is useful when you need to review or manage concepts that are no longer active.

If you prefer to work only with active concepts and exclude any that have been inactivated, you can use the inverse ECL:

This query returns only those concepts within the NCPT Reference Set that are currently active (`active = true`). It ensures that you are working with concepts that are up-to-date and valid according to the latest standards.

Additionally, if you need to combine this selection with a hierarchy selection, such as selecting only those concepts within a specific clinical hierarchy, you can do so while ensuring all results are active.

For example, if you are only interested in active concepts within the "Clinical finding" hierarchy, the ECL would be:

This combined ECL query retrieves all active concepts in the NCPT Reference Set that fall within the "Clinical finding" hierarchy, ensuring that your results are both relevant and current.

When working with the Nutrition Care Process Terminology (NCPT) reference set, it’s essential to have efficient access to the content through various systems, regardless of the technology used.

Clinical applications will access the Reference Set content from the selected terminology repository. The main functional requirements include listing all concepts in the Reference Set, filtering by text search strings, and validating whether a concept is a member of the Reference Set.

This page provides examples of how to interact with the reference set, whether you’re using a FHIR terminology server or a relational database like MySQL.

Accessing the Reference Set from a FHIR Terminology Server

When working with the Nutrition Care Process Terminology (NCPT) reference set, leveraging a FHIR terminology server can simplify access and management.

A FHIR terminology server provides mechanisms to work with the Reference Set as a Value Set. The main operations available are $expand and $validate-code.

FHIR Operations

$expand — Get all members of the reference set

Required:

• A reference set specified by its refsetId, for example:

  1303957004 |Nutrition Care Process Terminology reference set (foundation metadata concept)|

• A list of concept or description IDs

• Option to include additional information about each concept or description

$validate-code — Test if a concept or description is a member of the reference set

Required:

• A reference set specified by its refsetId

• A candidate concept.id

• Returns TRUE if the candidate is a member, FALSE otherwise

These examples use the concept 1303957004 |Nutrition Care Process Terminology reference set (foundation metadata concept)| as the refsetId.

Get all members of the reference set

API Call:

Example:

Alternative using Expression Constraint Language (ECL):

or:

Result:

Returns a JSON representation of the reference set members.

Each concept includes:

• code: the conceptId of the reference set member

• display: the preferred term for the reference set member

Also returns:

• total: the total number of reference set members

Paging Parameters:

• count: limits the number of members returned

• offset: specifies the start position in the results (in multiples of the limit)

Test if a concept is a member of the reference set

API Call:

Example:

Result:

Returns a JSON object with a FHIR Parameters resource, including:

• result: a boolean value (true or false) indicating whether the concept is a member of the reference set

If the Reference Set has been loaded into a relational database using a model that complies with the RF2 specification for tables and column names, the reference set content can be accessed using SQL queries.

SQL Query:

Example:

Result:

Returns the IDs of all the concepts or descriptions that are members of the reference set.

SQL Query:

Example:

Result:

• 0: if the candidate component is not in the reference set

• 1: if the candidate component is a member of the reference set

Some reference sets may include the same component more than once. Any value greater than zero indicates that the component is a member of the reference set.

Implementing the SNOMED CT Nutrition Care Process Terminology (NCPT) Reference Set (Refset) within a clinical system can significantly improve the quality, consistency, and interoperability of nutrition documentation. This page outlines general approaches and considerations for successfully integrating the NCPT Refset into clinical workflows. These approaches will support healthcare professionals, technical implementers, and informatics teams in aligning documentation with the Nutrition Care Process (NCP) model.

Key Approaches for Implementing the NCPT Reference Set

The flowchart below illustrates key considerations and decisions involved in selecting the optimal approach for implementing the NCPT. Detailed descriptions of each approach are provided below.

Mapping

Mapping the NCPT Refset to existing local terminology is a common and practical starting point for implementation. By aligning SNOMED CT concepts within the NCPT Refset to equivalent or related terms used in the clinical system, mapping allows for accurate representation of nutrition-specific concepts without requiring extensive changes to existing systems.

Recommendation

Collaborate with clinical experts to ensure mappings accurately reflect the intended meanings within the nutrition and dietetics domain. SNOMED International offers a free online mapping service, Snap2SNOMED, which can be used to efficiently map local codes to SNOMED CT.

Extracting a Plain List of Refset Members for Specific Contexts

In certain contexts, such as documenting diagnoses, interventions, or outcomes, it may be beneficial to extract a plain list of relevant NCPT Refset members. This approach enables easy access to the specific concepts needed for different stages of the Nutrition Care Process without overloading the system with unrelated terms.

For each concept, extract its unique identifier, terms, and domain (e.g., diagnosis, intervention, monitoring) to create a streamlined list that aligns with your specific implementation needs. The is a useful tool for this task, allowing efficient extraction of relevant SNOMED CT concepts directly from the terminology hierarchy. Use the bindings specified in General Terminology Bindings to determine the relevant SNOMED CT areas and subhierarchies for each data element, ensuring precise alignment with the appropriate SNOMED CT concepts. For this approach, it is important that you utilize the latest version of SNOMED CT and the NCPT reference set.

SNOMED CT is organized hierarchically, allowing for flexible navigation from broad categories (e.g., body systems or clinical findings) down to specific details (e.g., particular conditions or interventions). Implementers can utilize these hierarchies to contextualize NCPT concepts, enhance search functionality, and streamline data entry by directing clinicians to the most appropriate concept level.

Refer to the bindings specified in to identify the relevant SNOMED CT areas and subhierarchies for each data element. These bindings will help ensure accurate alignment with the appropriate SNOMED CT concepts. For this approach, it is important that you utilize the latest version of SNOMED CT and the NCPT reference set, as described in .

Using a terminology server can be a powerful way to manage, update, and integrate SNOMED CT concepts, including the NCPT Refset, within a clinical system. Terminology servers provide real-time access to SNOMED CT and can support dynamic updates as new versions of the terminology become available, enhancing both usability and long-term system maintenance.

Terminology servers offer centralized management of terms and facilitate seamless interoperability, especially when sharing data across systems or institutions.

Engage with a technical team experienced in terminology servers and FHIR terminology services (FHIR TS) to ensure proper configuration, integration, and maintenance. Their expertise will help optimize server performance, enable seamless updates, and support interoperability across clinical applications. For this approach, it is important that you utilize the latest version of SNOMED CT and the NCPT reference set, as described in .

We recommend following these fundamental steps to ensure a successful implementation of the NCPT Refset within SNOMED CT. Begin by engaging key stakeholders and assessing system capabilities, then set clear goals and consider starting with a pilot project. Providing user training on the Refset’s purpose and benefits will further support effective integration into clinical practice.

Engage Relevant Stakeholders

Begin by reaching out to your SNOMED CT National Release Center (NRC) or SNOMED International representative. They can offer valuable resources and guidance on accessing and implementing the NCPT Refset, ensuring alignment with regional and global standards.

Review Existing System Capabilities

Evaluate your current clinical information system’s capabilities, focusing on SNOMED CT compatibility, terminology mapping tools, and integration with a terminology server. Understanding system readiness helps identify any technical adjustments needed for successful implementation.

Set Clear Goals for Implementation

Define specific use cases and desired outcomes for the NCPT Refset, such as improved documentation consistency, enhanced clinical decision support, or interoperability with external systems. Clear goals will help guide the project scope and implementation strategy.

Develop a Pilot Project

Initiate a pilot project in a focused area, such as nutritional diagnosis or intervention. Starting small allows for the testing and refinement of workflows and user interactions, providing valuable insights before scaling to a full implementation.

Training and Education

Conduct training for clinical users, particularly nutrition and dietetics professionals, to ensure they understand the NCPT Refset’s purpose and benefits within SNOMED CT. Providing hands-on experience builds confidence and ensures that staff are well-prepared to use the Refset effectively in their practice.

For additional guidance, technical resources, or support with the NCPT Refset implementation, consider reaching out to:

• National Release Center (NRC): snomed.org/members

• Nutrition and Dietetics Clinical Reference Group (CRG): Participate in discussions or obtain updates related to NCPT within SNOMED CT by joining the Nutrition and Dietetics CRG.

• SNOMED International Implementation Support Team: