Clinical Terminology Alan Rector School of Computer Science

Clinical Terminology Alan Rector School of Computer Science

Clinical Terminology Alan Rector School of Computer Science / Northwest Institute of Bio-Health Informatics [email protected] Dr Jeremy Rogers Senior Clinical Fellow in Health Informatics Northwest Institute of Bio-Health Informatics www.co-ode.org www.clinical-escience.org www.opengalen.org Terminology Whats it for? Where did it come from? Where might it go? London Bills of Mortality every Thursday from 1603 until the 1830s Aggregated Statistics 1665 Manchester Mercury January 1st 1754 List of diseases & casualties this year Aged 1456

Executed 18 Consumption 3915 Found Dead 34 Convulsion 5977 Frighted 2 Dropsy 794 19276 burials Fevers 2292 Kill'd by falls and other accidents 55 15444 christenings Teeth 961 Deaths by centile Broken Limbs 5 Smallpox 774 Bit by mad dogs 3 Bruised 5

Burnt 9 Drowned 86 Excessive Drinking 15 Kill'd themselves 36 Murdered 3 Overlaid 40 Poisoned 1 Scalded 5 Smothered 1 Stabbed 1 Starved 7 Suffocated 5 Origins of modern terminologies 100 years of epidemiology ICD - Farr in 1860s to ICD9 in 1979 International reporting of morbidity/mortality ICPC - 1980s Clinically validated epidemiology in primary care Now expanded for use in Dutch GP software Origins of modern terminologies Organising Care Librarianship MeSH - NLM from around 1900 - Index Medicus & Medline

EMTree - from Elsevier in 1950s - EMBase Remumeration ICD9-CM (Clinical Modification) 1980 10 x larger than ICD; aimed at US insurance reimbursement CPT, Pathology indexing SNOMED 1970s to 1990 (SNOMED International) First faceted or combinatorial system Topology, morphology, aetiology, function Specialty Systems Mostly similar hierarchical systems ACRNEMA/SDM - Radiology NANDA, ICNP - Nursing Origins of modern terminologies Documenting/Reporting Care Early computer systems OXMIS Aimed at saving space on early computers READ competitor 1-5 Mbyte / 10,000 patients

Derived from empirical data Read (1987 - 1995) Hierarchical modelled on ICD9 Detailed signs and symptoms for primary care Purchased by UK government in 1990 Flat list of codes Defunct circa 1999 ICPC Epidemiologically tested, Dutch LOINC For laboratory data Single use Medical Entities Dictionary (MED) Jim Cimino, Hospital support, Columbia, USA DICOM (sdm) For images MEDDRA Adverse Reactions Unified Medical

Language System US National Library of Medicine De facto common registry for vocabularies Metathesaurus 1.8 million concepts categorised by semantic net types Semantic Net 135 Types 54 Links Specialist Lexicon Unified Medical Language System Concept Unique Identifiers (CUIs) Lexical Unique Identifiers (LUIs) String Unique Identifers (SUIs) Code SUI LUI CUI CUI LUI LUI Code

SUI Code SUI Code SUI Code but The Coding of Chocolate An international conversion guide SNOMED-CT ? C-F0811 C-F0816 C-F0817 C-F0819 C-F081A C-F081B C-F081C C-F0058 Term Bounty bar Crme egg Kit Kat

Mars Bar Milky Way Smarties Twix Snicker CTV3 UbOVv UbOW2 UbOW3 UbOW4 UbOW5 UbOW6 UbOW7 Ub1pT Origins of modern terminologies Beyond recording Electronic patient records (EPRs) Weeds Problem Oriented Medical Record Direct entry by health care professionals Decision support Ted Shortliffe (MYCIN), Clem McDonald (Computer based reminders), Perry Miller (Critiquing), Musen (Protg) Re-use Patient centred information Origins of modern terminologies

1990s: a Paradigm Shift Human-Human and Human-Machine to Machine-Machine From paper to software From single use to multiple re-use From coding clerks to direct entry by clinicians From pre-defined reporting to decision support From Books to Software Software Machine MachineProcessing Processing requires requires Machine MachineReadable ReadableInformation Information Need Needshared, shared,multi-use, multi-use, multi-purpose multi-purpose computable computable Clinical Clinicalterminology terminology

Compositional logic-based Termiologies Origins of modern terminologies The PEN&PAD/GALEN Vision Clinical Terminology Data Entry Clinical Record Decision Support Best Practice HealthCard Mr Ivor Bigun Dun Roamin Anytown Any country 4431 3654 90273 NEW Clinica l

Terminology Data Entry Electronic Health Records Decision Support & Aggregated Data Best Practice Fundamental problems: Enumeration doesnt scale The scaling problem: The combinatorial explosion Predicted It keeps happening! Simple brute force solutions do not scale up! Conditions x sites x modifiers x activity x context Huge number of terms to author

Software CHAOS Actual Combination of things to be done & time to do each thing Effort per term Terms and forms needed Increases exponentially t acc What we migh Effort per term or form Must decrease to compensate To give the effectiveness we want e What w e lik would Or might accept Things to build ept

The exploding bicycle 1972 ICD-9 (E826) 8 READ-2 (T30..) 81 READ-3 87 1999 ICD-10 topClass 1999 ICD10: 587 codes I Certain infectious and parasitic diseases II Neoplasms III Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism IV Endocrine, nutritional and metabolic diseases V Mental and behavioural disorders VI Diseases of the nervous system VII Diseases of the eye and adnexa VIII Diseases of the ear and mastoid process IX Diseases of the circulatory systems X Diseases of the respiratory system XI Diseases of the digestive system XII Diseases of the skin and subcutaneous tissue XIII Diseases of the musculoskeletal system and connective tissue XIV Diseases of the genitourinary system XV Pregnancy, childbirth and the puerperium XVI Certain conditions originating in theperinatal period XVII Congenital malformations, deformations and chromosomal abnormalities XVIII Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified XIX Injury, poisoning and certain other consequences of external causes XX External causes of morbidity and mortality V01-V99 Transport accidents

V01-V09 Pedestrian injured in transport accident V10-V19 Pedal cyclist injured in transport accident V10 Pedal cyclist injured in collision with pedestrian or animal V10.0 Pedal cyclist injured in collision with pedestrian or animal, driver,nontraffic accident V10.00 Pedal cyclist injured in collision with pedestrian or animal, driver,nontraffic accident, while engaged in sports activity V10.01 Pedal cyclist injured in collision with pedestrian or animal, driver,nontraffic accident, while engaged in leisure activity V10.02 Pedal cyclist injured in collision with pedestrian or animal, driver,nontraffic accident, while working for an income V10.03 Pedal cyclist injured in collision with pedestrian or animal, driver,nontraffic accident, while engaged in other types of work V10.04 Pedal cyclist injured in collision with pedestrian or animal, driver,nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V12.4 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, traffic accident V10.08 Pedal cyclist injured in collision with pedestrian or animal, driver,nontraffic accident, while engaged in other specified activities V12.40 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, traffic accident, while engaged in sports activity V10.09 Pedal cyclist injured in collision with pedestrian or animal, driver,nontraffic accident, during unspecified activity V12.41 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, traffic accident, while engaged in leisure activity V10.1 Pedal cyclist injured in collision with pedestrian or animal, passenger,nontraffic accident V12.42 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, traffic accident, while working for an income V10.10 Pedal cyclist injured in collision with pedestrian or animal, passenger,nontraffic accident, while engaged in sports activity V10.11 Pedal cyclist injured in collision with pedestrian or animal, passenger,nontraffic accident, while engaged in leisure activity V12.43 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, traffic accident, while engaged in other types of work V14.4 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, traffic accident V10.12 Pedal cyclist injured in collision with pedestrian or animal, passenger,nontraffic accident, while working for an income V12.44 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, traffic accident, while resting, sleeping, eating or engaging in other vitalV14.40 activities Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, traffic accident, while engaged in sports activity V10.13 Pedal cyclist injured in collision with pedestrian or animal, passenger,nontraffic accident, while engaged in other types of work V12.48 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, traffic accident, while engaged in other specified activities V10.14 Pedal cyclist injured in collision with pedestrian or animal, passenger,nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V14.41 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, traffic accident, while engaged in leisure activity V10.18 Pedal cyclist injured in collision with pedestrian or animal, passenger,nontraffic accident, while engaged in other specified activities V12.49 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, traffic accident, during unspecified activity V14.42 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, traffic accident, while working for an income

V10.19 Pedal cyclist injured in collision with pedestrian or animal, passenger,nontraffic accident, during unspecified activity V12.5 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, traffic accident V14.43 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, traffic accident, while engaged in other types of work V10.2 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist,nontraffic accident V12.50 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, traffic accident, while engaged in sports activity V10.20 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist,nontraffic accident, while engaged in sports activity V14.44 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, traffic accident, while resting, sleeping, eating or engaging in other vital activities V12.51 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, traffic accident, while engaged in leisure activity V10.21 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist,nontraffic accident, while engaged in leisure activity V14.48 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, traffic accident, while engaged in other specified activities V10.22 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist,nontraffic accident, while working for an income V12.52 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, traffic accident, while working for an income V14.49 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, traffic accident, during unspecified activity V10.23 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist,nontraffic accident, while engaged in other types of work V12.53 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, traffic accident, while engaged in other types of work V14.5 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, traffic accident V10.24 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist,nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V12.54 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, traffic accident, while resting, sleeping, eating or engaging in other V14.50 vital activities V10.28 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist,nontraffic accident, while engaged in other specified activities Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, traffic accident, while engaged in sports activity V10.29 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist,nontraffic accident, during unspecified activity V12.58 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, traffic accident, while engaged in other specified activities V14.51 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, traffic accident, while engaged in leisure activity V10.3 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting V12.59 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, traffic accident, during unspecified activity V14.52 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, traffic accident, while working for an income V10.30 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting, while engaged in sports activity V12.9 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident V10.31 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting, while engaged in leisure activity V14.53 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, traffic accident, while engaged in other types of work

V12.90 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident, while engaged in sports activity V10.32 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting, while working for an income V14.54 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, traffic accident, while resting, sleeping, eating or engaging in other vital activities V10.33 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting, while engaged in other types of work V12.91 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident, while engaged in leisure activity V14.58 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, traffic accident, while engaged in other specified activities V10.34 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting, while resting, sleeping, eating or engaging in other vital activities V12.92 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident, while working for an income V14.59 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, traffic accident, during unspecified activity V10.38 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting, while engaged in other specified activities V12.93 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident, while engaged in other types of work V10.39 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting, during unspecified activity V14.9 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, traffic accident V10.4 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident V12.94 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident, while resting, sleeping, eating or engaging othercyclist vital activities V14.90inPedal injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, traffic accident, while engaged in sports activity V10.40 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident, while engaged in sports activity V12.98 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident, while engaged in other specified activities V14.91 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, traffic accident, while engaged in leisure activity V10.41 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident, while engaged in leisure activity V12.99 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident, during unspecified activity V10.42 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident, while working for an income V14.92 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, traffic accident, while working for an income V10.43 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident, while engaged in other types of work V14.93 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, traffic accident, while engaged in other types of work V10.44 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident, while resting, sleeping, eating or engaging in other vital activities V13 Pedal cyclist injured in collision with car, pick-up truck or van V14.94 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, traffic accident, while resting, sleeping, eating or engaging in other vital activities

V10.48 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident, while engaged in other specified activities V13.0 Pedal cyclist injured in collision with car, pick-up truck or van, driver,nontraffic accident V14.98 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, traffic accident, while engaged in other specified activities V10.49 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident, during unspecified activity V13.00 Pedal cyclist injured in collision with car, pick-up truck or van, driver,nontraffic accident, while engaged in sports activity V10.5 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident V14.99 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, traffic accident, during unspecified activity V31.22 V31.22Occupant Occupantof ofthree-wheeled three-wheeledmotor motorvehicle vehicleinjured injured in collision with pedal cycle, person on outside of vehicle, in collision with pedal cycle, person on outside of vehicle, nontraffic nontrafficaccident, accident,while whileworking workingfor

forincome income W65.40 W65.40Drowning Drowningand andsubmersion submersionwhile whilein inbath-tub, bath-tub, street streetand andhighway, highway,while whileengaged engagedin insports sportsactivity activity X35.44 X35.44Victim Victimof ofvolcanic volcaniceruption, eruption,street streetand andhighway, highway, while resting, sleeping, eating

or engaging in other while resting, sleeping, eating or engaging in othervital vital activities activities V10.50 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident, while engaged in sports activity V13.01 Pedal cyclist injured in collision with car, pick-up truck or van, driver,nontraffic accident, while engaged in leisure activity V15 Pedal cyclist injured in collision with railway train or railway vehicle V10.51 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident, while engaged in leisure activity V13.02 Pedal cyclist injured in collision with car, pick-up truck or van, driver,nontraffic accident, while working for an income V15.0 Pedal cyclist injured in collision with railway train or railway vehicle, driver,nontraffic accident V10.52 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident, while working for an income V13.03 Pedal cyclist injured in collision with car, pick-up truck or van, driver,nontraffic accident, while engaged in other types of work V10.53 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident, while engaged in other types of work V15.00 Pedal cyclist injured in collision with railway train or railway vehicle, driver,nontraffic accident, while engaged in sports activity V13.04 Pedal cyclist injured in collision with car, pick-up truck or van, driver,nontraffic accident, while resting, sleeping, eating or engaging in other vital activitiesV15.01 Pedal cyclist injured in collision with railway train or railway vehicle, driver,nontraffic accident, while engaged in leisure activity V10.54 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident, while resting, sleeping, eating or engaging in other vital activities V10.58 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident, while engaged in other specified activities V13.08 Pedal cyclist injured in collision with car, pick-up truck or van, driver,nontraffic accident, while engaged in other specified activities V15.02 Pedal cyclist injured in collision with railway train or railway vehicle, driver,nontraffic accident, while working for an income V10.59 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident, during unspecified activity V13.09 Pedal cyclist injured in collision with car, pick-up truck or van, driver,nontraffic accident, during unspecified activity V15.03 Pedal cyclist injured in collision with railway train or railway vehicle, driver,nontraffic accident, while engaged in other types of work V10.9 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident V13.1 Pedal cyclist injured in collision with car, pick-up truck or van, passenger,nontraffic accident V10.90 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident, while engaged in sports activity V15.04 Pedal cyclist injured in collision with railway train or railway vehicle, driver,nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V10.91 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident, while engaged in leisure activity

V13.10 Pedal cyclist injured in collision with car, pick-up truck or van, passenger,nontraffic accident, while engaged in sports activity V15.08 Pedal cyclist injured in collision with railway train or railway vehicle, driver,nontraffic accident, while engaged in other specified activities V10.92 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident, while working for an income V13.11 Pedal cyclist injured in collision with car, pick-up truck or van, passenger,nontraffic accident, while engaged in leisure activity V15.09 Pedal cyclist injured in collision with railway train or railway vehicle, driver,nontraffic accident, during unspecified activity V10.93 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident, while engaged in other types of work V13.12 Pedal cyclist injured in collision with car, pick-up truck or van, passenger,nontraffic accident, while working for an income V10.94 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident, while resting, sleeping, eating or engaging in other vital activities V15.1 Pedal cyclist injured in collision with railway train or railway vehicle, passenger,nontraffic accident V13.13 Pedal cyclist injured in collision with car, pick-up truck or van, passenger,nontraffic accident, while engaged in other types of work V10.98 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident, while engaged in other specified activities V15.10 Pedal cyclist injured in collision with railway train or railway vehicle, passenger,nontraffic accident, while engaged in sports activity V10.99 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident, during unspecified activity V13.14 Pedal cyclist injured in collision with car, pick-up truck or van, passenger,nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V15.11 Pedal cyclist injured in collision with railway train or railway vehicle, passenger,nontraffic accident, while engaged in leisure activity V11 Pedal cyclist injured in collision with other pedal cycle V13.18 Pedal cyclist injured in collision with car, pick-up truck or van, passenger,nontraffic accident, while engaged in other specified activities V15.12 Pedal cyclist injured in collision with railway train or railway vehicle, passenger,nontraffic accident, while working for an income V11.0 Pedal cyclist injured in collision with other pedal cycle, driver,nontraffic accident V13.19 Pedal cyclist injured in collision with car, pick-up truck or van, passenger,nontraffic accident, during unspecified activity V11.00 Pedal cyclist injured in collision with other pedal cycle, driver,nontraffic accident, while engaged in sports activity V15.13 Pedal cyclist injured in collision with railway train or railway vehicle, passenger,nontraffic accident, while engaged in other types of work V11.01 Pedal cyclist injured in collision with other pedal cycle, driver,nontraffic accident, while engaged in leisure activity V13.2 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist,nontraffic accident V15.14 Pedal cyclist injured in collision with railway train or railway vehicle, passenger,nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V11.02 Pedal cyclist injured in collision with other pedal cycle, driver,nontraffic accident, while working for an income V13.20 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist,nontraffic accident, while engaged in sports activity V15.18 Pedal cyclist injured in collision with railway train or railway vehicle, passenger,nontraffic accident, while engaged in other specified activities V11.03 Pedal cyclist injured in collision with other pedal cycle, driver,nontraffic accident, while engaged in other types of work V13.21 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist,nontraffic accident, while engaged in leisure activity V11.04 Pedal cyclist injured in collision with other pedal cycle, driver,nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V15.19 Pedal cyclist injured in collision with railway train or railway vehicle, passenger,nontraffic accident, during unspecified activity

V13.22 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist,nontraffic accident, while working for an income V11.08 Pedal cyclist injured in collision with other pedal cycle, driver,nontraffic accident, while engaged in other specified activities V11.09 Pedal cyclist injured in collision with other pedal cycle, driver,nontraffic accident, during unspecified activity V13.23 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist,nontraffic accident, while engaged in other types of workV15.2 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist,nontraffic accident V11.1 Pedal cyclist injured in collision with other pedal cycle, passenger,nontraffic accident V13.24 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist,nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V15.20 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist,nontraffic accident, while engaged in sports activity V11.10 Pedal cyclist injured in collision with other pedal cycle, passenger,nontraffic accident, while engaged in sports activity V13.28 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist,nontraffic accident, while engaged in other specified activities V11.11 Pedal cyclist injured in collision with other pedal cycle, passenger,nontraffic accident, while engaged in leisure activity V15.21 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist,nontraffic accident, while engaged in leisure activity V11.12 Pedal cyclist injured in collision with other pedal cycle, passenger,nontraffic accident, while working for an income V13.29 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist,nontraffic accident, during unspecified activity V15.22 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist,nontraffic accident, while working for an income V11.13 Pedal cyclist injured in collision with other pedal cycle, passenger,nontraffic accident, while engaged in other types of work V13.3 Pedal cyclist injured in collision with car, pick-up truck or van, while boarding or alighting V15.23 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist,nontraffic accident, while engaged in other types of work V11.14 Pedal cyclist injured in collision with other pedal cycle, passenger,nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V13.30 Pedal cyclist injured in collision with car, pick-up truck or van, while boarding or alighting, while engaged in sports activity V11.18 Pedal cyclist injured in collision with other pedal cycle, passenger,nontraffic accident, while engaged in other specified activities V15.24 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist,nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V13.31 Pedal cyclist injured in collision with car, pick-up truck or van, while boarding or alighting, while engaged in leisure activity V11.19 Pedal cyclist injured in collision with other pedal cycle, passenger,nontraffic accident, during unspecified activity V15.28 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist,nontraffic accident, while engaged in other specified activities V11.2 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist,nontraffic accident V13.32 Pedal cyclist injured in collision with car, pick-up truck or van, while boarding or alighting, while working for an income V15.29 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist,nontraffic accident, during unspecified activity V11.20 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist,nontraffic accident, while engaged in sports activity

V13.33 Pedal cyclist injured in collision with car, pick-up truck or van, while boarding or alighting, while engaged in other types of work V15.3 Pedal cyclist injured in collision with railway train or railway vehicle, while boarding or alighting V11.21 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist,nontraffic accident, while engaged in leisure activity V13.34 Pedal cyclist injured in collision with car, pick-up truck or van, while boarding or alighting, while resting, sleeping, eating or engaging in other vital activities V11.22 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist,nontraffic accident, while working for an income V15.30 Pedal cyclist injured in collision with railway train or railway vehicle, while boarding or alighting, while engaged in sports activity V11.23 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist,nontraffic accident, while engaged in other types of work V13.38 Pedal cyclist injured in collision with car, pick-up truck or van, while boarding or alighting, while engaged in other specified activities V15.31 Pedal cyclist injured in collision with railway train or railway vehicle, while boarding or alighting, while engaged in leisure activity V11.24 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist,nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V13.39 Pedal cyclist injured in collision with car, pick-up truck or van, while boarding or alighting, during unspecified activity V15.32 Pedal cyclist injured in collision with railway train or railway vehicle, while boarding or alighting, while working for an income, while working for an income V11.28 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist,nontraffic accident, while engaged in other specified activities V13.4 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident V11.29 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist,nontraffic accident, during unspecified activity V15.33 Pedal cyclist injured in collision with railway train or railway vehicle, while boarding or alighting, while engaged in other types of work V13.40 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident, while engaged in sports activity V11.3 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting V15.34 Pedal cyclist injured in collision with railway train or railway vehicle, while boarding or alighting, while resting, sleeping, eating or engaging in other vital activities V11.30 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, while engaged in sports activity V13.41 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident, while engaged in leisure activity V15.38 Pedal cyclist injured in collision with railway train or railway vehicle, while boarding or alighting, while engaged in other specified activities V11.31 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, while engaged in leisure activity V13.42 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident, while working for an income V15.39 Pedal cyclist injured in collision with railway train or railway vehicle, while boarding or alighting, during unspecified activity V11.32 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, while working for an income V13.43 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident, while engaged in other types of work V11.33 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, while engaged in other types of work V15.4 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident V11.34 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, while resting, sleeping, eating or engaging in other vital activities V13.44 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident, while resting, sleeping, eating or engaging in other vital activities V15.40 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident, while engaged in sports activity V11.38 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, while engaged in other specified activities

V13.48 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident, while engaged in other specified activities V15.41 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident, while engaged in leisure activity V11.39 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, during unspecified activity V13.49 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident, during unspecified activity V11.4 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident V15.42 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident, while working for an income V13.5 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident V11.40 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, while engaged in sports activity V15.43 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident, while engaged in other types of work V11.41 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, while engaged in leisure activity V13.50 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident, while engaged in sports activity V15.44 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident, while resting, sleeping, eating or engaging in other vital activities V11.42 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, while working for an income V13.51 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident, while engaged in leisure activity V15.48 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident, while engaged in other specified activities

V11.43 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, while engaged in other types of work V13.52 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident, while working for an income V11.44 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, while resting, sleeping, eating or engaging in other vital activities V15.49 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident, during unspecified activity V11.48 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, while engaged in other specified activities V13.53 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident, while engaged in other types of work V15.5 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident V11.49 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, during unspecified activity V13.54 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident, while resting, sleeping, eating or engaging in other vital activities V15.50 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident, while engaged in sports activity V11.5 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident V13.58 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident, while engaged in other specified activities

V11.50 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, while engaged in sports activity V15.51 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident, while engaged in leisure activity V13.59 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident, during unspecified activity V11.51 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, while engaged in leisure activity V15.52 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident, while working for an income V11.52 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, while working for an income V13.9 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, traffic accident V15.53 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident, while engaged in other types of work V11.53 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, while engaged in other types of work V13.90 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, traffic accident, while engaged in sports activity V15.54 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident, while resting, sleeping, eating or engaging in other vital activities V11.54 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, while resting, sleeping, eating or engaging in other vital activities V13.91 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, traffic accident, while engaged in leisure activity V11.58 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, while engaged in other specified activities V15.58 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident, while engaged in other specified activities V11.59 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, during unspecified activity V13.92 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, traffic accident, while working for an income V15.59 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident, during unspecified activity V11.9 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident V13.93 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, traffic accident, while engaged in other types of work V15.9 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, traffic accident V11.90 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, while engaged in sports activity V13.94 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, traffic accident, while resting, sleeping, eating or engaging in other vitalPedal activities V11.91 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, while engaged in leisure activity V15.90 cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, traffic accident, while engaged in sports activity V13.98 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, traffic accident, while engaged in other specified activities V11.92 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, while working for an income V15.91 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, traffic accident, while engaged in leisure activity V11.93 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, while engaged in other types of work V13.99 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, traffic accident, during unspecified activity

V15.92 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, traffic accident, while working for an income V11.94 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, while resting, sleeping, eating or engaging in other vital activities V14 Pedal cyclist injured in collision with heavy transport vehicle or bus V15.93 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, traffic accident, while engaged in other types of work V11.98 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, while engaged in other specified activities V14.0 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver,nontraffic accident V11.99 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, during unspecified activity V15.94 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, traffic accident, while resting, sleeping, eating or engaging in other vital activities V12 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle V14.00 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver,nontraffic accident, while engaged in sports activity V15.98 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, traffic accident, while engaged in other specified activities V12.0 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver,nontraffic accident V14.01 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver,nontraffic accident, while engaged in leisure activity V15.99 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, traffic accident, during unspecified activity V12.00 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver,nontraffic accident, while engaged in sports activity V14.02 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver,nontraffic accident, while working for an income V12.01 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver,nontraffic accident, while engaged in leisure activity V16 Pedal cyclist injured in collision with othernonmotor vehicle V14.03 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver,nontraffic accident, while engaged in other types of work V12.02 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver,nontraffic accident, while working for an income V16.0 Pedal cyclist injured in collision with othernonmotor vehicle, driver, nontraffic accident V12.03 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver,nontraffic accident, while engaged in other types of work V14.04 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver,nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V16.00 Pedal cyclist injured in collision with othernonmotor vehicle, driver, nontraffic accident, while engaged in sports activity V12.04 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver,nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V14.08 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver,nontraffic accident, while engaged in other specified activities V16.01 Pedal cyclist injured in collision with othernonmotor vehicle, driver, nontraffic accident, while engaged in leisure activity V12.08 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver,nontraffic accident, while engaged in other specified activities V14.09 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver,nontraffic accident, during unspecified activity V12.09 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver,nontraffic accident, during unspecified activity V16.02 Pedal cyclist injured in collision with othernonmotor vehicle, driver, nontraffic accident, while work V12.1 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger,nontraffic accident

V14.1 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger,nontraffic accident V12.10 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger,nontraffic accident, while engaged in sports activity V14.10 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger,nontraffic accident, while engaged in sports activity V12.11 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger,nontraffic accident, while engaged in leisure activity V14.11 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger,nontraffic accident, while engaged in leisure activity V12.12 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger,nontraffic accident, while working for an income V14.12 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger,nontraffic accident, while working for an income V12.13 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger,nontraffic accident, while engaged in other types of work V12.14 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger,nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V14.13 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger,nontraffic accident, while engaged in other types of work V12.18 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger,nontraffic accident, while engaged in other specified activities V14.14 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger,nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V12.19 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger,nontraffic accident, during unspecified activity V14.18 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger,nontraffic, while engaged in other specified activities accident V12.2 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, nontraffic accident V12.20 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist,nontraffic accident, while engaged in sports activity V14.19 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger,nontraffic, during unspecified activity accident V12.21 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist,nontraffic accident, while engaged in leisure activity V14.2 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist,nontraffic accident V12.22 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist,nontraffic accident, while working for an income V14.20 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist,nontraffic accident, while engaged in sports activity V12.23 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist,nontraffic accident, while engaged in other types of work V14.21 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist,nontraffic accident, while engaged in leisure activity V12.24 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist,nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V12.28 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist,nontraffic accident, while engaged in other specified activities V14.22 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist,nontraffic accident, while working for an income V12.29 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist,nontraffic accident, during unspecified activity V14.23 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist,nontraffic accident, while engaged in other types of work V12.3 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting V14.24 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist,nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V12.30 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting, while engaged in sports activity

V14.28 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist,nontraffic accident, while engaged in other specified activities V12.31 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting, while engaged in leisure activity V14.29 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist,nontraffic accident, during unspecified activity V12.32 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting, while working for an income V14.3 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting V12.33 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting, while engaged in other types of work V14.30 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting, while engaged in sports activity V12.34 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting, while resting, sleeping, eating or engaging in other vital activities V14.31 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting, while engaged in leisure activity V12.38 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting, while engaged in other specified activities V14.32 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting, while working for an income V12.39 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting, during unspecified activity V14.33 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting, while engaged in other types of work V14.34 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting, while resting, sleeping, eating or engaging in other vital activities V14.38 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting, while engaged in other specified activities V14.39 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting, during unspecified activity Clinical Data Capture Choose terms from a coding scheme enter search: cystitis Cholecystitis, Cystitis, Iatrogenic NOS cystitis NOS Acute Chronic

Chemical cystitis cholecystitis cystitis Subacute Acute Postoperative cholecystitis cystitis, cystitis NOS Follicular Bacterial Drug induced cystitis Cholecystitis cystitis Idiopathic Bacterial Radiation cystitis cystitis cystitis etc next page Too Big ...picking lists too long Too Small

...not enough clinical detail Defusing the exploding bicycle: 500 codes in pieces 10 things to hit Pedestrian / cycle / motorbike / car / HGV / train / unpowered vehicle / a tree / other 5 roles for the injured Driving / passenger / cyclist / getting in / other 5 activities when injured resting / at work / sporting / at leisure / other 2 contexts In traffic / not in traffic V12.24 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, nontraffic accident, while resting, sleeping, eating or engaging in other vital activities Conceptual Lego it could be... Goodbye to picking lists Structured Data Entry File Edit Help

Cycling Accident What you hit Your Role Activity Location Intelligent Forms and more forms And generate it in language Logic as the clips for Conceptual Lego gene hand protein extremity polysacharide body cell

expression chronic Lung acute infection inflammation abnormal normal bacterium deletion ischaemic polymorphism mucus virus Logic as the clips for Conceptual Lego SNPolymorphism of CFTRGene causing Defect in MembraneTransport of Chloride Ion causing Increase in Viscosity of Mucus in CysticFibrosis Hand which is anatomically normal

Species Genes Protein Function Gene in humans Disease Protein coded by gene in humans Build complex representations from modularised primitives Function of Protein coded by gene in humans Disease caused by abnormality in Function of Protein coded by gene in humans Problem: System may be perfect but Users still fallible User Problems Inter-rater variability

ART & ARCHITECTURE THESAURUS (AAT) Domain: art, architecture, decorative arts, material culture Content: 125,000 terms Structure: 7 facets, 33 polyhierarchies Associated concepts (beauty, freedom, socialism) Physical attributes (red, round, waterlogged) Style/Period (French, impressionist, surrealist) Agents: (printmaker, architect, jockey) Activities: (analysing, running, painting) Materials (iron, clay, emulsifier) Objects: (gun, house, painting, statue, arm) Synonyms Links to associated terms Access: lexical string match; hierarchical view User Problems Inter-rater variability X Headcloth Cloth X X X X Scarf

X Model Person Woman X X X Adults X X X X X X X X X X

X X Background X Blue X X X X X X X X Chemise X Dress Tunics X Clothes

Suitcase X X X Standing Brown X X X X X X Luggage X Attache case X X Brass Instrument French Horn Horn

Tuba X X X X User Problems Inter-rater variability New codes added per Dr per year READ CODE Practice A Sore Throat Symptom 0.6 Visual Acuity 0.4 ECG General 2.2 Ovary/Broad Ligament Op 7.8 Specific Viral Infections 1.4 Alcohol Consumption 0 H/O Resp Disease 0 Full Blood Count 0

Practice B 117 644 300 809 556 106 26 838 Repeatability Inter-rater reliability Only ICPC has taken seriously Originally less than 2000 well tested rubrics with proven inter-rater reliability across five languages As it has been put into wider use, has grown and is less tested Includes the delivery software Confounding, but we cant ignore it Where next? The genome / omics explosion Open Biolological Ontologies (OBO) Gene Ontology, Gene expression ontology (MGED), Pathway ontology (BioPAX), 400+ bio databases and growing National Cancer Institute Thesaurus CDISC/BRID - Clinical Trials HL7 genomics model

Coming to an EHR near you! Enter the O word the M word and the S word Ontologies - claimed by philsophers, computer scientists, Logically, computationally solid skeletons Metadata Applications that know what they need and resources that can say what they are about Service Oriented Architectures Loosely coupled computing based on discovery The GRID and the Semantic Web / GRID and E-Science / E-Health and digital libraries and and RDF, RDFS, OWL, SWRL, WSDL, Web Services, W3C Healthcare and Life Sciences Special Interest Group ISO 11179 Dublin Core SKOS Metadata and ontologies with everything Google & web mining Text Processing Open Directory & Wikipedia - Folksonomies & social computing Its a big open world out there!

Key issue 1: Creating an open community Terminologies have succeeded for three reasons Coercion - use them or dont get paid ICD-CM, CPT, MEDDRA, Read 2 They belonged to the community and were useful or key to software LOINC, HL7v2, Gene Ontology, Read 1 They gave access to a key resource MeSH, BNF, Logic + Web liberates users Open Just-in-time Terminology If you can test the consequences then you can give users the freedom to develop New compositions New additions to established lists Hide the complexity Close to user forms GALENs Intermediate Representation Training time down from 3 months to 3 days! The logic is the assembly language Move the development to the community Look at OpenDirectory, Wikipedia, FLKR, etc. Social computing

Requires more and better tools Requires a different style of curation Worldwide Resources GALENs Pre-Web version Local author uses resources & templates to formulate definition templates Local Author needs new terms for application Server validates & organises Local author checks Local Ontology updates problems Central Gurus integrate & fix

problems Central Ontology Key issue II: Applications centric development If it is built for everything it will be fit for nothing! Must have a way to see if it works If it is built for just one thing it will not be fit even for that Change is the only constant Cannot predict which abstractions needed in advance Even very large ontologies tend to be missing 50% or more of terms in practice Compose them when you need them and share Is there a optimal 90-10 point? You can only tell against a specific application Applications centric Development Meta-authoring / es t a pl s m

te view Common Terminology/ Ontology authoring environments Intermediate Representations clinicians / Applications builders Empowered Authors te vie mpl w s a te s/ clinical applications Meta-authoring Key issue III: Binding to the EHR HL7 v3 + SNOMED = Chaos Unless we can formalise the mutual constraints The documentation is beyond human capacity To write or to understand Templates/Archetypes + SNOMED = Missed opportunities Unless we avoid trivialising terminology

or chaos if we attempt to use the terminology Requires new tools Formalisms probably adequate Key issue IV: Decision support Meaningful decision support is still rare Terminology is not the only problem But it is a barrier Ontology should be the scaffolding But requires the terminology to be computable SNOMED still too idiosyncratic to use easily Inter-rater reliability crucial Can we afford GIGO for patient management? Semantics of combined EHR+Terminology must be well defined Key issue V: Avoiding Pregacy Prebuilt legacy Errors built in from the beginning .01% of SNOMED coded data to be held in 10 years time has been collected Fixes now will be less expensive than fixes later Rigorous schemas rigorously adhered to Conformance and Regression testing Cannot depend on people to do it right

Must be formally verifiable Its software - Lets have some basic software engineering! Key issue VI: Empirical data Need empirical data on Whats worth doing - whats esssential Language used by doctors Terms used What works Reliability of terms used - errors made Effect on Decision Support and other applications What scales What are the consequences of design decisions Effort required to develop software Usability of development tools Effort required by users Usability of interfaces and clinical systems Where is the science base for our work? Key issue VII: Human FactorsHelping with a humanly impossible task Language technology will help But will always have limitations Tailored forms will help

But we must beet the combinatorial explosion but the key issues are organisational, social & clinical and needs empirical data Requires serious investment and Commitment Summary: Lessons & Directions Understand scaling and the combinatorial explosion All lists are too big and too small Too many niches to cope with one by one Focus on applications Answer Whats it for? Bind terminology to EHR and Decision support An open world changing rapidly Especially basic biology Avoid Pregacy Gather empirical data Human factors are critical

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