The reference application attempts to insert metadata which is in some cases a duplicate of what you already have. So, you will end up with: Update OpenMRS completely damaged my personal concept dictionary or this: Concept Dictionary Changes When Upgrading from 1.11.6 to Refapp 2.8.0
@ssmusoke shared the approach that he is using for UgandaEMR: An Opinionated Approach to OpenMRS Concept Management | Stephen Musoke Senkomago