Dear all,
Many thanks for your feedback and raising this clinically important concern. The challenge you’ve identified the gaps between what clinicians document and what our hierarchies support is what drove our extended discussion at the Member Forum, EAG, MAG and TUG groups.
I should be transparent about where my thinking has evolved on the recommended solution. The initial internal recommendation from our Editorial Panel, reflecting the MAG and TUG feedback, favored Option 2c (a hybrid approach where body structures undergo formal inactivation while procedures and findings receive FSN updates). This reflected genuine international support and multiple NRCs clearly stated they need digit-of-hand concepts instead of the current exclusive meaning of finger that creates translation and modeling gaps they struggle with.
However, as Jim and I discussed the practical implementation details after the EAG, a more important concern surfaced: the actual disruption cost of Option 2 may outweigh the modeling purity it gains. Let me explain why Option 1 now appears to be the safer path forward, even though it’s less aligned with what international groups initially requested.
Option 2c requires updating Fully Specified Names across procedure and finding hierarchies—somewhere between 1,000 and 1,400 concepts depending on scope. These FSN changes would reinterpret finger to mean digit-of-hand (inclusive), aligning SNOMED with most international practice. But this semantic shift creates substantial ripple effects. Systems relying on the finger’s historic exclusive meaning could break unexpectedly. National Release Centres that have already translated finger according to the current exclusive definition must now retranslate. Users in clinical systems encounter name changes without sufficient guidance on what changed or why. For English-language users, this represents significant semantic disruption in specialties where the exclusive distinction is still clinically embedded. Even for non-English speakers, while an inclusive definition aligns better with their language, those who’ve completed translations based on the exclusive meaning face substantial rework.
Here’s the fundamental issue: Option 2 does effectively solve the international translation problem by making finger inclusive as it is exactly what MAG and TUG clearly need. But the feedback also revealed something equally important: English-speaking clinicians depend on the exclusive finger interpretation for established workflows and clinical documentation. These are competing preferences and genuine parallel needs. Most international clinical need is an inclusive grouper (digit of hand) for universal applicability. English-language clinicians need the thumb-specific distinction that finger currently provides. Option 2 cannot serve both. If we reinterpret fingers as inclusive, we eliminate the exclusive meaning entirely. We cannot simultaneously serve both needs from a single concept. English-language users requiring exclusive finger meaning would lose that capability. If exclusive-finger concepts are later recreated under a different name that would be unnatural to native English speakers. Option 2 does address international requirements, but only at a cost to existing English-language practice. We haven’t resolved the conflict but chosen one side over the other. Editorial guidance can’t bridge this gap: clinicians trained on the exclusive finger meaning will encounter standards explaining “finger now includes the thumb,”. For clinicians with embedded workflows and decision support built on the exclusive interpretation, the change remains disruptive regardless of how well we document it.
Option 1 offers a different trade-off. We retain the existing 1,400+ finger concepts untouched, no name changes, no backward-compatibility breaks, no retroactive reinterpretation of historical data. This is a major benefit for existing systems, clinical workflows, and stable historical data interpretations. Simultaneously, we add over 1,300 new digit-of-hand concepts that provide comprehensive coverage of all five digits. Yes, this increases terminology size, a potential drawback. But this growth is additive, not destructive. We’re not disrupting what works, we’re adding capability where it’s needed. This approach directly addresses the modeling gaps for concepts such as ‘arthrotomy with drainage of digit of hand’ and ‘bursa of digit of hand’ become codeable, eliminating the need to force thumb into finger hierarchies.
The option 1 is actually a safer option because it respects the reality that SNOMED has decades of installed clinical systems, research datasets, and workflows built around current finger concepts. Clinicians don’t need those concepts reinterpreted. It fills the gaps without retroactive disruption. For countries where “finger” is culturally inclusive, they can map to the new ‘digit of hand’ concepts and hierarchies. Their language stays natural, and they get the grouper concept they need. For clinicians who require the exclusive meaning, it remains available. Both use cases work. Of course, this does not address the unnatural translation of the exclusive meaning of “finger” in SNOMED CT for the countries where “finger” is culturally inclusive. Translation work is still required, but it shifts from destructive rework to constructive addition. You’re creating new translations for ‘digit of hand’ concepts, not retranslating 1,400 existing finger concepts. For example, in Dutch, your clinical practice already treats fingers as inclusive, the new digit of hand hierarchy maps directly to your existing terminology and language remains natural. However, it does not address the translation of exclusive finger as “finger excluding thumb”. If these finger concepts are not needed, they could be excluded from translation. Of course, the decision needs to be made on the basis of the national clinical requirements and regulations.
The shift to recommending Option 1 isn’t abandonment of the international feedback. It’s a careful read of what they actually need versus what we initially assumed would satisfy it. They need digit-of-hand concepts and translation support. They need us to reinterpret ‘finger’. Option 1 delivers the first without imposing the second, and that turns out to be safer and more sustainable.
Please let us know your thoughts on the shift to Option 1.