Comparing various Concept Dictionary options in Bahmni

This page lists down the various options for Concept Dictionary data setup and their pros/cons and provides some parameters to help make a decision.
Please note: SNOMED TS means “Terminology Server”. Do not confuse this with SNOMED CT Terms. A TS is a server that holds a set of SNOMED CT terms/dictionary and provides APIs to search/browse/update/remove clinical terms. Read more about Snowstorm TS server here: Terminology Services - SNOMED Implementation Support - SNOMED Confluence
Bahmni has been integrated with SNOMED TS server, as a distribution option. Read more about this architecture and see demos here.
Bahmni is also shipped by default with custom dictionary (bahmni-standard) or with CIEL (bahmni-lite). Read more about the differences / pros / cons in this page.
If you have a comment about a point below, please highlight it and select the comment option (you need to be logged into Bahmni wiki for this). This is called “inline comments” in Confluence. This way, we will know exactly what part of the page you wish to comment on.
Related discussions on Bahmni/OpenMRS Talk threads: Current status of SNOMED CT integration with Bahmni and Co-existence with CIEL and SNOMED-CT as a source?

	Parameter	[A] Custom Dictionary	[B] CIEL Dictionary	[C] SNOMED TS backed dictionary (with Bahmni custom dictionary as Base)	[D] SNOMED TS backed dictionary (with CIEL dictionary as Base)

	Parameter	[A] Custom Dictionary	[B] CIEL Dictionary	[C] SNOMED TS backed dictionary (with Bahmni custom dictionary as Base)	[D] SNOMED TS backed dictionary (with CIEL dictionary as Base)
1	Brief Overview	In this option you are choosing to run Bahmni with a custom concept dictionary that contains clinical terms decided by you (and your clinical terminology team).	In this option you are choosing to load Bahmni with publicly available and opensource CIEL dictionary comprising of 50K+ terms with SNOMED, ICD10, LOINC, RxNorm reference mappings, already done. The Bahmni Concept Dictionary will be loaded with CIEL data and you will use CIEL Terms to record data on the Bahmni UI. For more details see: CIEL: Bridging Terminology for the Global Community	In this option you are choosing to load Bahmni with few pre-configured Bahmni custom concepts and also connecting it to a FHIR Terminology Server loaded with SNOMED CT, which will act as a real-time terminology server. You are going to use SNOMED CT terms on Bahmni UI to record clinical data. Whenever a SNOMED term is chosen on the UI, that term is pulled into Bahmni, and stored into the Concept Dictionary. So, over time, Bahmni concept dictionary starts reflecting a list of your facility commonly used clinical terms. For more details see this wiki page. SNOMED CT has over 300K clinical terms.	Similar to prev column, but Bahmni concept dictionary is pre-loaded with CIEL data as the base dictionary. For most operations you will still be using SNOMED CT terms on the Bahmni UI for recording data (because Bahmni will be referencing a FHIR TS server for real time lookups of terms).
2	How do I browse this dictionary online?	Browse the concept dictionary on our demo server here: demo.mybahmni.org (superman/Admin123)	Browse on OCL here. Browse on Bahmni Lite demo server here (OpenMRS Admin->Dictionary).	Browse on Snowstorm (choose International Edition or your preferred edition) browser here. Browser on Demo Server (OpenMRS Admin → Dictionary) here.	(Same as prev column)
3	Which option is used most frequently in the real world with Bahmni?	Majority of the real world deployments of Bahmni (until v0.93) before Bahmni Lite have used a Custom Dictionary.	Since Bahmni Lite v1.0 release in June2023, new adopters have started evaluating / adopting CIEL dictionary. CIEL is being used with OpenMRS already in many real world settings.	SNOMED CT is used widely in many EHRs across the world. With Bahmni, since this is a recent development, we don’t yet have any known real-world deployment of Bahmni-SNOMED TS directly.	(Same as prev column)
4	Which configuration of Bahmni comes out-of-the-box with this option?	default-config (currently default for Bahmni-Standard for Hospitals)	clinic-config (with Bahmni Lite)	snomed-default-config (with Bahmni Lite & SNOMED configuration)	snomed-clinic-config (with Bahmni Lite and SNOMED Configuration). Has some known issues, see this link.
5	How do I report a term that should be present in standard dictionary but it somehow isn’t?	You can add it yourself.	Drop an email to Dr. Andrew Kanter from CIEL	Inform SNOMED international, or check if your country has already added it in the country specific extensions.	(Same as prev column)
6	Can I use OCL (Open Concept Lab) to manage terms?	Yes	Yes. Bahmni ships the CIEL zip file that is released via OCL.	No, the SNOMED-TS (terminology server) acts as the TS here. In this configuration OCL is not involved.	(Same as prev column)
7	While recording Diagnosis in Bahmni what terms will I see on the UI?	Your custom terms	CIEL terms or any custom terms added by you to the Concept Dictionary.	SNOMED terms under Clinical Findings (404684003). Can be configured via global.properties.	(Same as prev column)
8	For recording Chief Complaints in Bahmni what terms will I see?	Your custom terms	CIEL terms or any custom terms added by you to the Concept Dictionary.	Search results are constrained using a SNOMED “ECL query”, specified in the form designer for Chief Complaints in the H&E form. Currently configured same as all Clinical Findings. See documentation.	(Same as prev column)
9	For recording Drugs in Bahmni what terms will I see?	Your custom terms as loaded in Drug Concepts. You can also use initialiser module to load drugs.	CIEL terms or any custom terms added by you to the Drug Concepts. You can use initialiser module to load drugs via csv. See example.	Custom terms added in Drug Concepts (but should have SNOMED CT reference mappings for CDSS features to work) You can use initializer module to load drugs via csv. See example.	(Same as prev column)
10	What terms can I use in the Form Designer for Questions/Answers?	Your custom terms can be used.	Any CIEL dictionary or custom added term can be used.	Any custom term directly added into Concept Dictionary can be used. SNOMED TS terms can be used as Answers (by specifying a ValueSet url or ECL urls). See documentation.	(Same as prev column)
11	Can I use my own custom terms along with this option?	Yes.	Yes, but recommend checking with Dr. Andrew Kanter, who maintains CIEL dictionary if the term can be added to standard CIEL distribution.	For questions/answers in Forms, one can directly add them into Concept Dictionary. Many countries publish a national Edition of SNOMED CT with customised content. Consider evaluating those for suitability before adding custom terms. Adding your own terms to existing concepts or creating new concepts is possible by creating a SNOMED CT extension. See SNOMED CT artifacts.	(Same as prev column)
12	How are conflicts in Concept Names handled (when a custom concept is also present)?	You cannot add two concepts with the same FSN.	You cannot add two concepts with the same FSN.	You cannot add two concepts with the same FSN. While copying a concept from SNOMED TS into Bahmni, the following concept resolution logic is applied: GitHub - Bahmni/openmrs-module-snomed If the FSN already exists in Bahmni, then during copying from SNOMED TS, the synonyms are added to existing concept (but FSN is untouched).	(Same as prev column)
13	Will I be able to record data in SNOMED CT?	If you define reference mappings for a term in SNOMED CT, you should be able to create reports in SNOMED CT (but not see anything in SNOMED CT on screen).	CIEL dictionary has defined SNOMED reference maps for most terms, and you should be able to create an SQL report based on that data. On screen, you would still see CIEL terms.	Yes, on screen you are directly seeing SNOMED CT data. Ability to create out-of-box reports quickly are available. See this documentation.	(Same as prev column)
14	Will I be able to use Bahmni’s custom CDS integration over FHIR? (More details on Clinical Decision Support - CDS feature see this documentation and video)	Yes, if you define SNOMED CT reference maps, then you should be able to use the CDS features in Bahmni (SAME-AS mapping is needed). Note: Drugs will need SNOMED SAME-AS mappings. Note: This will only work if a FHIR TS is included with SNOMED CT loaded. This is because the CDSS service uses the TS to traverse the SNOMED CT hierarchies to execute the rules. The dose rules also lookup the substances and strengths within the drugs from the TS.	Yes, since CIEL has already defined SNOMED reference maps for many terms (SAME-AS mapping is needed). Note: Drugs will need SNOMED SAME-AS mappings. Note: This will only work if a FHIR TS is included with SNOMED CT loaded. This is because the CDSS service uses the TS to traverse the SNOMED CT hierarchies to execute the rules. The dose rules also lookup the substances and strengths within the drugs from the TS.	Yes. Note: Drugs will need SNOMED SAME-AS mappings.	(Same as prev column)
15	Will be be able to use Hierarchical reporting to aggregate specific diseases into a parent group easily?	No, since Hierarchical reporting needs SNOMED Terminology Server configuration.	No, since Hierarchical reporting needs SNOMED Terminology Server configuration.	Yes. Ability to create out-of-box reports quickly are available. See this documentation.	(Same as prev column)
16	Will I be able to use Bahmni ICD10 reporting feature?	No, since ICD-10 reporting needs SNOMED Terminology Code column as input (which as mentioned above, requires SNOMED TS Server configured). But if the concepts already have an ICD-10 mapping (which CIEL has done), then one can write an SQL based report for this.	No, since ICD-10 reporting needs SNOMED Terminology Code column as input (which as mentioned above, requires SNOMED TS Server configured). But if the concepts already have an ICD-10 mapping (which CIEL has done), then one can write an SQL based report for this.	Yes	(Same as prev column)
17	Can I use this option in an offline / on-premise installation of Bahmni?	Yes	Yes	Yes - with Snowstorm LITE (available with Bahmni pre-packaged in docker compose). The release file for the International Edition of SNOMED CT is around 500mb. You could download it or take it to a remote side on a USB stick and install it into Snowstorm Lite that way. There is a new release every month but upgrading every six months / once a year is common practice. It takes less than 5 minutes to load.	(Same as prev column)
18	Is there any performance impact?	No,as data is locally stored in Bahmni.	No, as data is locally stored in Bahmni.	If the system is referencing Snowstorm on a server which is geographically far, then real-time look-ups will have latency. Using snowstorm LITE locally is recommended in such a case. No performance impact noticed in our testing.	(Same as prev column)
19	Migrate to another terminology set?	Will require migration effort if shifting to CIEL or SNOMED CT.	Will require significant migration effort if shifting to SNOMED CT.	Shifting to a different terminology system will require significant migration effort.	(Same as prev column)
20	Is there a docker-compose option available that packages this set out-of-the-box for me to try?	Yes. bahmni-standard.	Yes. bahmni-lite	Yes. See snomed-bahmni-docker repository (with snomed-default-config configuration)	Yes. See snomed-bahmni-docker repository (with snomed-clinic-config configuration)
21	If I use OpenELIS (Lab), or Odoo, or DCM4chee, will this option work?	Yes.	No. Not yet tested. Only OpenMRS and Crater tested to work.	Yes. See JIRA-3453. Works for both, SNOWSTORM and SNOWSTORM-LITE.	No. Not tested. Will likely need some development & testing.
22	Can i use the Patient FHIR Export feature?	Yes	Yes	Yes	(Same as prev column)
23	What competency is expected of the clinicians who will be recording this data?	They can use the same terms they currently use on Paper / hospital.	Will need to be familiar with CIEL terms (50k).	Will need to be familiar with SNOMED terms and ontology (300K terms).	(Same as prev column)
24	Is this option FREE or PAID or OpenSource?	Free and Opensource	Free and Opensource. See this page.	Use of SNOMED CT dictionary is licensed to countries / facilities. It is not free. For NGO/Non-Profit use, one can easily apply and usually get a free license. See this page. In cases where a country has licensed SNOMED CT, like India, every facility can use it for free after applying for it. (e.g link for India) All SNOMED software systems like snowstorm-lite, CDSS, snolytical, etc are opensource. There are free sets also available that can be used like the IPS (International Patient Summary), etc. See this page.	(Same as prev column)
25	How often does this option get updated with new terms?	You decide.	CIEL is updated monthly with more frequent updates in the cases of emergencies like COVID-19. See this page.	See Releases page on SNOMED.	(Same as prev column)
26	Are other languages supported besides English?	Since this is your custom dictionary, you will need to enter & manage the translations.	Yes, other languages are also included in CIEL. Link?	In current integration, we have only added support for ENGLISH, even though SNOMED CT supports others locales. Supporting other languages will require some development efforts. Other languages are also included in SNOMED TS, typically in country extensions. SNOMED CT is a multinational, multilingual terminology. It has a built-in framework to manage different languages and dialects. The international browser has many national extensions loaded: SNOMED International Browser These are available to download on request. See also: SNOMED CT Translation Tooling	(Same as prev column)
27	What advantages will I get with this option?	You get full control with the terms you see on the screen, but you need to manage all the master data and reference maps yourself, which is tedious, and usually requires strong clinical terminology expertise.	CIEL team (and Dr. Andrew Kanter) have done the hard work of using the most commonly required clinical terms, and their reference maps to SNOMED, ICD, LOINC, etc. You can still add custom terms, questions – but recommended not to do so. The team behind CIEL is small, so responsiveness to questions will likely be very fast (and so could adoption of new terms).	Massive list of terms (with ontology/hierarchy based connections) Great for facilities who understand SNOMED and want to use SNOMED based interface terms.	(Same as prev column)
28	What possible disadvantages I should consider with this option?	Tedious / error prone to use, or introduce terms later in the process. Requires strong terminology expertise.	The CIEL dictionary is centrally managed and only “one version” exists. There aren’t any country/region specific versions of CIEL dictionary currently. Therefore, if some term or usage is not globally accepted, it may not make it into the CIEL dictionary. But technically nothing stops CIEL from having country specific extensions in the future (which can also be managed in OCL).	Since the list of terms on screen for a search term can be large (e.g Search for Asthma gives 300+ terms). This can result in clinicians recording data in different levels of granularity, or make recording of data slow for some users due to indecision. Additional services (e.g Snowstorm LITE) need to be installed/managed over time.	(Same as prev column) Duplicates between CEIL and SNOMED CT might need to be monitored.
29	Any Other Information?	-	-	-	-