Clinical Terminology Dr Jeremy Rogers MD MRCGP Senior

Clinical Terminology Dr Jeremy Rogers MD MRCGP Senior Clinical Fellow in Health Informatics Northwest Institute of Bio-Health Informatics

Why Terminology History The Future UMLS & SNOMED CT

Why Terminology? Measuring vs Describing

Measure the world ► Quantitative ► Numerical data: ► 2 mm, 2. 4 V, between 4 and 5 feet ► Unambiguous tokens ► Main problem is accuracy at initial capture ► Numerical analysis (e. g. statistics) well understood ► Examples: ► How big is this breast lump? ► What is the average of patients with cancer ? ► How much time elapsed between original GP referral and first appointment at the hospital ?

Describe the World ► Qualitative ► Descriptive data ► Cold, colder, blueish, not pink, drunk ► Ambiguous tokens ► What’s wrong with being drunk ? ► Ask a glass of water. ► Accuracy poorly defined ► Automated analysis or aggregation is a new science ► Examples ► Which patient is more psychotic ? ► What is the typical microscopic appearance of these tumours ? ► How bad are the side effects of chemotherapy ?

Clinical Terminologies Who uses them? Input Middle Output Clinical Professions Information intermediaries Policy makers & commissioners Coders & coding trainers Intellectual property owners Academics & Research Providers System Developers Private Sector Clinicians ?

Clinical Terminologies What are they used for? ► Research & policy ► Link to other datasets ► Epidemiology ► Workload management ► Trends analysis ► Resource management ► Reimbursement/costing ► Clinical Audit ► Performance management ► Activity analysis ► Outcome analysis ► Identify operator/skills ► Intervention recording ► Changing care patterns ► Forecasting & budgeting The medical record ? The medicolegal record ? Decision support ?

History of Clinical Terminology 1: Epidemiology

London Bills of Mortality every Thursday from 1603 until the 1830 s

Aggregated Statistics 1665

Manchester Mercury January 1 st 1754 List of diseases & casualties this year 19276 burials 15444 christenings Deaths by centile Enumerated Aged 1456 Executed 18 Consumption 3915 Found Dead 34 Convulsion 5977 Frighted 2 Dropsy 794 Kill'd by falls and other accidents 55 Fevers 2292 Kill'd themselves 36 Smallpox 774 Murdered 3 Teeth 961 Overlaid 40 Bit by mad dogs 3 Poisoned 1 Broken Limbs 5 Scalded 5 Bruised 5 Smothered 1 Burnt 9 Stabbed 1 Drowned 86 Starved 7 Excessive Drinking 15 Suffocated 5 No Classification Alien terms

Origins of modern terminologies 100 years of epidemiology ► ICD - Farr in 1860 s to ICD 9 in 1979 ► International reporting of morbidity/mortality ► ICPC - 1980 s ► Clinically validated epidemiology in primary care ► Now expanded for use in Dutch GP software -9 C ICP CM ICD 1970 -9 - ICD -8 1960 ICD 1950 -7 1940 ICD e Tre-6 EM ICD -5 1930 ICD -4 1920 ICD -3 -2 1910 ICD SH MCED-1 I ICD 1900 1980 1990 2000

ICD-9 -CM International Classification Of Disease Subacute Thyroiditis Congenital Hypothyroidism Thyroid Cyst Subacute granulomatous thyroiditis Radiation thyroiditis Thyroid Cancer Enumerated Monoaxial Incomplete Dustbins

History of Clinical Terminology 1: Epidemiology 2. Organising care

Origins of modern terminologies Organising Care ► Librarianship ► Me. SH - NLM from around 1900 - Index Medicus & Medline ► EMTree - from Elsevier in 1950 s - EMBase ► Remumeration ► ICD 9 -CM (Clinical Modification) 1980 ► 10 x larger than ICD; aimed at US insurance reimbursement ► Pathology indexing ► SNOMED 1970 s to 1990 (SNOMED International) ►First faceted or combinatorial system ►Topology, morphology, aetiology, function ► Specialty Systems ► Mostly similar hierarchical systems -8 ICDOP SN 1950 -7 1940 ICD e Tre-6 EM ICD -5 1930 ICD -4 1920 ICD -3 -2 1910 ICD SH MCED-1 I ICD 1900 1960 t -In ED OM SN C ICP CM -9 -D-2 ICDMED-9 O SN IC ►ACRNEMA/SDM - Radiology ►NANDA, ICNP… - Nursing 1970 1980 1990 2000

History of Clinical Terminology 1: Epidemiology 2. Organising care 3. Documenting care

Origins of modern terminologies Documenting Care ► Early computer systems ► OXMIS ► Aimed at saving space on early computers ► READ competitor ► 1 -5 Mbyte / 10, 000 patients ► Defunct circa 1999 ► Flat list of codes ► Read (1987 - 1995) ► ICPC ► Hierarchical modelled on ICD 9 ►Detailed signs and symptoms for primary care ►Purchased by UK government in 1990 ►Single use ► Medical Entities Dictionary (MED) -7 1950 1960 1970 1980 -CT ED-CM OM-10 SNICD D-1 -03 ICTV C AD RE C ICP CMT -9 --C-2 EDED-9 ICMDM O O DRT SNSN ICDE OM 8 SN D-I-nt EICD OP OM SN SN 1940 ICD -5 1930 ICD -4 1920 ICD -3 -2 1910 ICD SH MCED-1 I ICD 1900 e Tre-6 EM ICD ► Jim Cimino 1990 2000

History of Clinical Terminology 1: Epidemiology 2. Organising care 3. Documenting Care 4. Artificial Intelligence

Origins of modern terminologies 1990 s: a Paradigm Shift ► From terminologies for people to terminologies for machines ► From paper to software ► From single use to multiple re-use for patient centred systems ► From entry by coding clerks to direct entry by health care professionals ► From pre-defined reporting for statistics to reliable indexing for decision support

Origins of modern terminologies Artificial Intelligence ►Electronic patient records (EPRs) ► Weed’s Problem Oriented Medical Record ► Direct entry by health care professionals ►Decision support ► Ted Shortliffe (MYCIN), Clem Mc. Donald (Computer based reminders), Perry Miller (Critiquing), Musen (Protégé) ►Re-use ► Patient centred information

AI: The bottom Line Machine Processing requires Machine Readable Information Need shared, multi-use, multi-purpose computable Clinical terminology

Origins of modern terminologies A New Vision Clinical Terminology Data Entry Clinical Record Decision Support Best Practice Health. Card Mr Ivor Bigun Dun Roamin Anytown Any country 4431 3654 90273 NEW Clinical Terminology Data Entry Electronic Health Records Decision Support & Aggregated Data Best Practice

Problems: Enumeration doesn’t scale

Combinatorial explosion ►‘The Persian chessboard’ ► 264 1019 ► 1019 grains of rice 100 billion tonnes of rice ► 1019 nanoseconds 10, 000 years ►Example: Burns ► 100 sites x 3 depths 404 codes ► 5 subsites/site x chemical or thermal 7272 ►x 3 extents x 3 durations 116, 352 ►Read II grew from 20, 000 to 250, 000 terms in ~100 staff-years ► still too small to be useful ►but too big to use

1970 s ICD 9: 8 Codes

The exploding bicycle ► 1972 ICD-9 (E 826) 8 ► READ-2 (T 30. . ) 81 ► READ-3 87 ► 1999 ICD-10 ……

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Class 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 V 01 -V 99 Transport accidents V 01 -V 09 Pedestrian injured in transport accident V 10 -V 19 Pedal cyclist injured in transport accident V 10 Pedal cyclist injured in collision with pedestrian or animal V 10. 0 Pedal cyclist injured in collision with pedestrian or animal, driver, nontraffic accident V 10. 00 Pedal cyclist injured in collision with pedestrian or animal, driver, nontraffic accident, while engaged in sports activity V 10. 01 Pedal cyclist injured in collision with pedestrian or animal, driver, nontraffic accident, while engaged in leisure activity V 10. 02 Pedal cyclist injured in collision with pedestrian or animal, driver, nontraffic accident, while working for an income V 10. 03 Pedal cyclist injured in collision with pedestrian or animal, driver, nontraffic accident, while engaged in other types of work V 12. 4 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, traffic accident V 10. 04 Pedal cyclist injured in collision with pedestrian or animal, driver, nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V 10. 08 Pedal cyclist injured in collision with pedestrian or animal, driver, nontraffic accident, while engaged in other specified activities V 12. 40 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, traffic accident, while engaged in sports activity V 10. 09 Pedal cyclist injured in collision with pedestrian or animal, driver, nontraffic accident, during unspecified activity V 12. 41 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, traffic accident, while engaged in leisure activity V 10. 1 Pedal cyclist injured in collision with pedestrian or animal, passenger, nontraffic accident V 12. 42 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, traffic accident, while working for an income V 10. 10 Pedal cyclist injured in collision with pedestrian or animal, passenger, nontraffic accident, while engaged in sports activity V 10. 11 Pedal cyclist injured in collision with pedestrian or animal, passenger, nontraffic accident, while engaged in leisure activity V 12. 43 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, traffic accident, while engaged in other types of work. Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, traffic accident V 14. 4 V 10. 12 Pedal cyclist injured in collision with pedestrian or animal, passenger, nontraffic accident, while working for an income V 12. 44 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, traffic accident, while resting, sleeping, eating or engaging in other vital activities V 14. 40 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, traffic accident, while engaged in sports activity V 10. 13 Pedal cyclist injured in collision with pedestrian or animal, passenger, nontraffic accident, while engaged in other types of work V 12. 48 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, traffic accident, while engaged in other specified activities V 14. 41 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, traffic accident, while engaged in leisure activity V 10. 14 Pedal cyclist injured in collision with pedestrian or animal, passenger, nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V 12. 49 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, traffic accident, during unspecified activity V 10. 18 Pedal cyclist injured in collision with pedestrian or animal, passenger, nontraffic accident, while engaged in other specified activities V 14. 42 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, traffic accident, while working for an income V 10. 19 Pedal cyclist injured in collision with pedestrian or animal, passenger, nontraffic accident, during unspecified activity V 12. 5 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, traffic accident V 14. 43 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, traffic accident, while engaged in other types of work V 10. 2 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, nontraffic accident V 12. 50 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, traffic accident, while engaged in sports activity V 14. 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 V 10. 20 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, nontraffic accident, while engaged in sports activity V 12. 51 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, traffic accident, while engaged in leisure activity V 14. 48 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, traffic accident, while engaged in other specified activities V 10. 21 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, nontraffic accident, while engaged in leisure activity V 12. 52 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, traffic accident, while working for an income V 10. 22 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, nontraffic accident, while working for an income V 14. 49 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, traffic accident, during unspecified activity V 10. 23 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, nontraffic accident, while engaged in other types of work V 12. 53 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, traffic accident, while engaged in other types of work V 14. 5 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, traffic accident V 10. 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 V 12. 54 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, traffic accident, while resting, sleeping, eating or engaging in other vital activities V 14. 50 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, traffic accident, while engaged in sports activity V 10. 28 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, nontraffic accident, while engaged in other specified activities V 12. 58 Pedal cyclist injured in collision with twoor three-wheeled motor vehicle, passenger, traffic accident, while engaged in other specified activities V 10. 29 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, nontraffic accident, during unspecified activity V 14. 51 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, traffic accident, while engaged in leisure activity V 10. 3 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting V 12. 59 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, traffic accident, during unspecified activity V 14. 52 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, traffic accident, while working for an income V 10. 30 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting, while engaged in sports activity V 12. 9 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident V 14. 53 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, traffic accident, while engaged in other types of work V 10. 31 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting, while engaged in leisure activity V 12. 90 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident, while engaged in sports activity V 14. 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 V 10. 32 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting, while working for an income V 12. 91 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident, while engaged in leisure activity V 10. 33 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting, while engaged in other types of work V 14. 58 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, traffic accident, while engaged in other specified activities 1999 ICD 10: 587 codes V 10. 34 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting, while resting, sleeping, eating or engaging in other vital activities V 12. 92 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident, while working for an income V 14. 59 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, traffic accident, during unspecified activity V 10. 38 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting, while engaged in other specified activities V 12. 93 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident, while engaged in other types V 14. 9 of work Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, traffic accident V 10. 39 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting, during unspecified activity V 12. 94 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident, while resting, sleeping, eating or engaging in other activities V 14. 90 Pedalvital cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, traffic accident, while engaged in sports activity V 10. 4 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident V 12. 98 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident, while engaged in other specified activities V 10. 40 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident, while engaged in sports activity V 14. 91 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, traffic accident, while engaged in leisure activity V 10. 41 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident, while engaged in leisure activity V 12. 99 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident, during unspecified activity V 14. 92 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, traffic accident, while working for an income V 10. 42 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident, while working for an income V 14. 93 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, traffic accident, while engaged in other types of work V 10. 43 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident, while engaged in other types of work V 13 Pedal cyclist injured in collision with car, pick-up truck or van V 10. 44 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident, while resting, sleeping, eating or engaging in other vital activities V 14. 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 V 10. 48 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident, while engaged in other specified activities V 13. 0 Pedal cyclist injured in collision with car, pick-up truck or van, driver, nontraffic accident V 14. 98 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, traffic accident, while engaged in other specified activities V 10. 49 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident, during unspecified activity V 13. 00 Pedal cyclist injured in collision with car, pick-up truck or van, driver, nontraffic accident, while engaged in sports activity V 14. 99 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, traffic accident, during unspecified activity V 10. 5 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident V 13. 01 Pedal cyclist injured in collision with car, pick-up truck or van, driver, nontraffic accident, while engaged in leisure activity V 15 Pedal cyclist injured in collision with railway train or railway vehicle V 10. 50 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident, while engaged in sports activity V 13. 02 Pedal cyclist injured in collision with car, pick-up truck or van, driver, nontraffic accident, while working for an income V 10. 51 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident, while engaged in leisure activity V 15. 0 Pedal cyclist injured in collision with railway train or railway vehicle, driver, nontraffic accident V 10. 52 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident, while working for an income V 13. 03 Pedal cyclist injured in collision with car, pick-up truck or van, driver, nontraffic accident, while engaged in other types of work V 15. 00 Pedal cyclist injured in collision with railway train or railway vehicle, driver, nontraffic accident, while engaged in sports activity V 10. 53 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident, while engaged in other types of work V 13. 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 activities V 15. 01 Pedal cyclist injured in collision with railway train or railway vehicle, driver, nontraffic accident, while engaged in leisure activity V 10. 54 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident, while resting, sleeping, eating or engaging in other vital activities V 13. 08 Pedal cyclist injured in collision with car, pick-up truck or van, driver, nontraffic accident, while engaged in other specified activities V 15. 02 Pedal cyclist injured in collision with railway train or railway vehicle, driver, nontraffic accident, while working for an income V 10. 58 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident, while engaged in other specified activities V 13. 09 Pedal cyclist injured in collision with car, pick-up truck or van, driver, nontraffic accident, during unspecified activity V 10. 59 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident, during unspecified activity V 15. 03 Pedal cyclist injured in collision with railway train or railway vehicle, driver, nontraffic accident, while engaged in other types of work V 10. 9 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident V 13. 1 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, nontraffic accident V 15. 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 V 10. 90 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident, while engaged in sports activity V 13. 10 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, nontraffic accident, while engaged in sports activity V 15. 08 Pedal cyclist injured in collision with railway train or railway vehicle, driver, nontraffic accident, while engaged in other specified activities V 10. 91 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident, while engaged in leisure activity V 13. 11 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, nontraffic accident, while engaged in leisure activity V 10. 92 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident, while working for an income V 15. 09 Pedal cyclist injured in collision with railway train or railway vehicle, driver, nontraffic accident, during unspecified activity V 10. 93 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident, while engaged in other types of work V 13. 12 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, nontraffic accident, while working for an income V 15. 1 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, nontraffic accident V 10. 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 V 13. 13 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, nontraffic accident, while engaged in other types of work V 15. 10 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, nontraffic accident, while engaged in sports activity V 10. 98 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident, while engaged in other specified activities V 13. 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 V 15. 11 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, nontraffic accident, while engaged in leisure activity V 10. 99 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident, during unspecified activity V 13. 18 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, nontraffic accident, while engaged in other specified activities V 11 Pedal cyclist injured in collision with other pedal cycle V 15. 12 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, nontraffic accident, while working for an income • V 31. 22 Occupant of three-wheeled motor vehicle injured in collision with pedal cycle, person on outside of vehicle, nontraffic accident, while working for income V 11. 0 Pedal cyclist injured in collision with other pedal cycle, driver, nontraffic accident V 13. 19 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, nontraffic accident, during unspecified activity V 15. 13 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, nontraffic accident, while engaged in other types of work V 11. 00 Pedal cyclist injured in collision with other pedal cycle, driver, nontraffic accident, while engaged in sports activity V 13. 2 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, nontraffic accident V 15. 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 V 11. 01 Pedal cyclist injured in collision with other pedal cycle, driver, nontraffic accident, while engaged in leisure activity V 13. 20 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, nontraffic accident, while engaged in sports activity V 15. 18 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, nontraffic accident, while engaged in other specified activities V 11. 02 Pedal cyclist injured in collision with other pedal cycle, driver, nontraffic accident, while working for an income V 13. 21 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, nontraffic accident, while engaged in leisure activity V 11. 03 Pedal cyclist injured in collision with other pedal cycle, driver, nontraffic accident, while engaged in other types of work V 15. 19 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, nontraffic accident, during unspecified activity V 11. 04 Pedal cyclist injured in collision with other pedal cycle, driver, nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V 13. 22 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, nontraffic accident, while working for an income V 11. 08 Pedal cyclist injured in collision with other pedal cycle, driver, nontraffic accident, while engaged in other specified activities V 13. 23 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, nontraffic accident, while engaged in other types of work V 15. 2 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, nontraffic accident V 11. 09 Pedal cyclist injured in collision with other pedal cycle, driver, nontraffic accident, during unspecified activity V 13. 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 V 11. 1 Pedal cyclist injured in collision with other pedal cycle, passenger, nontraffic accident V 15. 20 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, nontraffic accident, while engaged in sports activity V 11. 10 Pedal cyclist injured in collision with other pedal cycle, passenger, nontraffic accident, while engaged in sports activity V 13. 28 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, nontraffic accident, while engaged in other specified activities V 15. 21 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, nontraffic accident, while engaged in leisure activity V 11. 11 Pedal cyclist injured in collision with other pedal cycle, passenger, nontraffic accident, while engaged in leisure activity V 13. 29 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, nontraffic accident, during unspecified activity V 15. 22 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, nontraffic accident, while working for an income V 11. 12 Pedal cyclist injured in collision with other pedal cycle, passenger, nontraffic accident, while working for an income V 13. 3 Pedal cyclist injured in collision with car, pick-up truck or van, while boarding or alighting V 15. 23 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, nontraffic accident, while engaged in other types of work V 11. 13 Pedal cyclist injured in collision with other pedal cycle, passenger, nontraffic accident, while engaged in other types of work V 13. 30 Pedal cyclist injured in collision with car, pick-up truck or van, while boarding or alighting, while engaged in sports activity V 11. 14 Pedal cyclist injured in collision with other pedal cycle, passenger, nontraffic accident, while resting, sleeping, eating or engaging in other vital activities V 15. 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 V 11. 18 Pedal cyclist injured in collision with other pedal cycle, passenger, nontraffic accident, while engaged in other specified activities V 13. 31 Pedal cyclist injured in collision with car, pick-up truck or van, while boarding or alighting, while engaged in leisure activity V 15. 28 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, nontraffic accident, while engaged in other specified activities V 11. 19 Pedal cyclist injured in collision with other pedal cycle, passenger, nontraffic accident, during unspecified activity V 13. 32 Pedal cyclist injured in collision with car, pick-up truck or van, while boarding or alighting, while working for an income V 15. 29 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, nontraffic accident, during unspecified activity V 11. 2 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, nontraffic accident V 13. 33 Pedal cyclist injured in collision with car, pick-up truck or van, while boarding or alighting, while engaged in other types of work V 15. 3 Pedal cyclist injured in collision with railway train or railway vehicle, while boarding or alighting V 11. 20 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, nontraffic accident, while engaged in sports activity V 13. 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. V 15. 30 Pedal cyclist injured in collision with railway train or railway vehicle, while boarding or alighting, while engaged in sports activity V 11. 21 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, nontraffic accident, while engaged in leisure activity V 11. 22 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, nontraffic accident, while working for an income V 13. 38 Pedal cyclist injured in collision with car, pick-up truck or van, while boarding or alighting, while engaged in other specified activities V 15. 31 Pedal cyclist injured in collision with railway train or railway vehicle, while boarding or alighting, while engaged in leisure activity V 11. 23 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, nontraffic accident, while engaged in other types of work V 13. 39 Pedal cyclist injured in collision with car, pick-up truck or van, while boarding or alighting, during unspecified activity V 15. 32 Pedal cyclist injured in collision with railway train or railway vehicle, while boarding or alighting, while working for an income V 11. 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 V 13. 4 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident V 11. 28 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, nontraffic accident, while engaged in other specified activities V 15. 33 Pedal cyclist injured in collision with railway train or railway vehicle, while boarding or alighting, while engaged in other types of work V 11. 29 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, nontraffic accident, during unspecified activity V 13. 40 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident, while engaged in sports activity V 15. 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 V 11. 3 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting V 13. 41 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident, while engaged in leisure activity V 15. 38 Pedal cyclist injured in collision with railway train or railway vehicle, while boarding or alighting, while engaged in other specified activities V 11. 30 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, while engaged in sports activity V 13. 42 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident, while working for an income V 15. 39 Pedal cyclist injured in collision with railway train or railway vehicle, while boarding or alighting, during unspecified activity V 11. 31 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, while engaged in leisure activity V 13. 43 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident, while engaged in other types of work V 11. 32 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, while working for an income V 15. 4 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident V 11. 33 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, while engaged in other types of work V 13. 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 V 15. 40 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident, while engaged in sports activity V 11. 34 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, while resting, sleeping, eating or engaging in other vital activities V 13. 48 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident, while engaged in other specified activities V 15. 41 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident, while engaged in leisure activity V 11. 38 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, while engaged in other specified activities V 13. 49 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident, during unspecified activity V 15. 42 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident, while working for an income V 11. 39 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, during unspecified activity V 13. 5 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident V 11. 4 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident V 15. 43 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident, while engaged in other types of work V 11. 40 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, while engaged in sports activity V 13. 50 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident, while engaged in sports activity V 15. 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 V 11. 41 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, while engaged in leisure activity V 13. 51 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident, while engaged in leisure activity V 15. 48 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident, while engaged in other specified activities V 11. 42 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, while working for an income V 13. 52 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident, while working for an income V 11. 43 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, while engaged in other types of work V 15. 49 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident, during unspecified activity V 11. 44 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, while resting, sleeping, eating or engaging in other vital activities V 13. 53 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident, while engaged in other types of work V 15. 5 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident V 11. 48 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, while engaged in other specified activities V 13. 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 V 15. 50 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident, while engaged in sports activity V 11. 49 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, during unspecified activity V 13. 58 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident, while engaged in other specified activities V 15. 51 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident, while engaged in leisure activity V 11. 5 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident V 13. 59 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident, during unspecified activity V 11. 50 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, while engaged in sports activity V 15. 52 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident, while working for an income V 11. 51 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, while engaged in leisure activity V 13. 9 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, traffic accident V 15. 53 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident, while engaged in other types of work V 11. 52 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, while working for an income V 13. 90 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, traffic accident, while engaged in sports activity V 15. 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 V 11. 53 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, while engaged in other types of work V 13. 91 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, traffic accident, while engaged in leisure activity V 15. 58 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident, while engaged in other specified activities V 11. 54 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, while resting, sleeping, eating or engaging in other vital activities V 13. 92 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, traffic accident, while working for an income V 11. 58 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, while engaged in other specified activities V 15. 59 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident, during unspecified activity V 11. 59 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, during unspecified activity V 13. 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 V 15. 9 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, traffic accident V 11. 9 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident V 13. 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 V 15. 90 vital activities Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, traffic accident, while engaged in sports activity V 11. 90 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, while engaged in sports activity V 13. 98 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, traffic accident, while engaged in other specified activities V 11. 91 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, while engaged in leisure activity V 15. 91 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, traffic accident, while engaged in leisure activity V 11. 92 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, while working for an income V 13. 99 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, traffic accident, during unspecified activity V 15. 92 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, traffic accident, while working for an income V 11. 93 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, while engaged in other types of work V 14 Pedal cyclist injured in collision with heavy transport vehicle or bus V 15. 93 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, traffic accident, while engaged in other types of work V 11. 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 V 14. 0 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, nontraffic accident V 15. 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 V 11. 98 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, while engaged in other specified activities V 14. 00 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, nontraffic accident, while engaged in sports activity V 11. 99 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, during unspecified activity V 15. 98 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, traffic accident, while engaged in other specified activities • W 65. 40 Drowning and submersion while in bath-tub, street and highway, while engaged in sports activity • X 35. 44 Victim of volcanic eruption, street and highway, while resting, sleeping, eating or engaging in other vital activities V 12 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle V 14. 01 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, nontraffic accident, while engaged in leisure activity V 15. 99 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, traffic accident, during unspecified activity V 12. 0 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, nontraffic accident V 14. 02 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, nontraffic accident, while working for an income V 16 Pedal cyclist injured in collision with othernonmotor vehicle V 12. 00 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, nontraffic accident, while engaged in sports activity V 14. 03 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, nontraffic accident, while engaged in other types of work V 16. 0 Pedal cyclist injured in collision with othernonmotor vehicle, driver, nontraffic accident V 12. 01 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, nontraffic accident, while engaged in leisure activity V 14. 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 V 12. 02 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, nontraffic accident, while working for an income V 16. 00 Pedal cyclist injured in collision with othernonmotor vehicle, driver, nontraffic accident, while engaged in sports activity V 12. 03 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, nontraffic accident, while engaged in other types of work V 14. 08 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, nontraffic accident, while engaged in other specified activities V 16. 01 Pedal cyclist injured in collision with othernonmotor vehicle, driver, nontraffic accident, while engaged in leisure activity V 12. 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 V 14. 09 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, nontraffic accident, during unspecified activity V 16. 02 Pedal cyclist injured in collision with othernonmotor vehicle, driver, nontraffic accident, while work V 12. 08 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, nontraffic accident, while engaged in other specified activities V 14. 1 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, nontraffic accident V 12. 09 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, nontraffic accident, during unspecified activity V 12. 1 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, nontraffic accident V 14. 10 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, nontraffic accident, while engaged in sports activity V 12. 10 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, nontraffic accident, while engaged in sports activity V 14. 11 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, nontraffic accident, while engaged in leisure activity V 12. 11 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, nontraffic accident, while engaged in leisure activity V 14. 12 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, nontraffic accident, while working for an income V 12. 12 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, nontraffic accident, while working for an income V 14. 13 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, nontraffic accident, while engaged in other types of work V 12. 13 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, nontraffic accident, while engaged in other types of work V 12. 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 V 14. 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 V 12. 18 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, nontraffic accident, while engaged in other specified activities V 14. 18 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, nontraffic, while engaged in other specified activities accident V 12. 19 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, nontraffic accident, during unspecified activity V 14. 19 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, nontraffic, during unspecified activity accident V 12. 2 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, nontraffic accident V 14. 2 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, nontraffic accident V 12. 20 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, nontraffic accident, while engaged in sports activity V 12. 21 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, nontraffic accident, while engaged in leisure activity V 14. 20 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, nontraffic accident, while engaged in sports activity V 12. 22 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, nontraffic accident, while working for an income V 14. 21 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, nontraffic accident, while engaged in leisure activity V 12. 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 nontraffic accident, while working for an income V 12. 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. V 14. 22 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, V 12. 28 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, nontraffic accident, while engaged in other specified activities V 14. 23 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, nontraffic accident, while engaged in other types of work V 12. 29 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, nontraffic accident, during unspecified activity V 14. 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 V 12. 3 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting V 12. 30 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting, while engaged in sports activity V 12. 31 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting, while engaged in leisure activity V 14. 28 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, nontraffic accident, while engaged in other specified activities V 14. 29 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, nontraffic accident, during unspecified activity V 14. 3 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting V 12. 32 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting, while working for an income V 14. 30 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting, while engaged in sports activity V 12. 33 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting, while engaged in other types of work V 14. 31 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting, while engaged in leisure activity V 12. 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 V 14. 32 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting, while working for an income V 12. 38 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting, while engaged in other specified activities V 14. 33 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting, while engaged in other types of work V 12. 39 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting, during unspecified activity V 14. 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 V 14. 38 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting, while engaged in other specified activities V 14. 39 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting, during unspecified activity

Problems: Enumeration doesn’t scale Computers can’t read

Computers can’t read ►On paper for use on paper ► Enumerated - top down, all possibilities listed ► Serial - Single use - Single View ►Hierarchical Thesauri ► Traditional terminological techniques from librarianship ► ‘Broader than’ / ‘Narrower than’ (ISO 1087) ► No logical or computable foundation

Computers can’t read ►Built by people for interpretation by people ►Information implicit in the rubrics ► “Hypertension excluding pregancy” ► No explicit information except the hierarchy ►Minimal support for software ►No opportunity to use software to help ►Language and concepts confused ► Synonyms ► Preferred terms ► Homonyms ► Only simple look up and spelling correction

Problems: Enumeration doesn’t scale Computers can’t read Humans can’t organise

Humans can’t organise Slow & expensive… ► 20 Years from ICD 9 to ICD 10 ►~100 person-years from Read 1 to Read 3 ►Mega francs/guilders/crowns/marks on European coding schemes ►Thousands of unpaid hours of committee time ► Impossible / meaningless decisions take longest ►You can search forever for something that is not there ► Multiple uses compete ►Must choose one use ►Most successful were clear about their purpose - ICD, ICPC, Me. SH

Humans can’t organise …and unreliable ► Mixed Organisation ► ‘Heart diseases’ in 13 of 19 chapters of ICD ►Tumours, infections, congenital abnormalities, toxic, … ► ‘Steroids’ in five chapters of standard drug classifications ►Anti-inflammatories, anthi-asthmatics, … ► Unreliable for indexing or Abstractions ►How to say something about ‘all heart diseases’? ► Fixed organisation ► Single hierarchy - Single use ►Where to put ‘gout’ - arthritis or metabolic disease? ►Back and forth in each edition of ICD ►No re-use

Problems: Enumeration doesn’t scale Computers can’t read Humans can’t organise Tower of Babel

Codes, codes everywhere. . . SNOMED-3 CDAM ECRI-UMDNS READ-2 NGAP SNOP Me. SH ICPC HCFA ICD-9 OPCS-4 READ-2 ICD-9 -CM ICD-O NCSP ICPM OXMIS ICD-9 -CM CPT-4 ICD-O NDC NCSP NANDA ICPM ICNP OXMIS ACR-NEMA IUPAC-NPU LOINC DICOM-SDM MCTGE

Help, I’m drowning the list goes on AIDSLINE AVLINE TRIFACTS BRMS 96 MED 80 BIOETHICS NIOSH COSTAR MED 66 CANCERLIT NPIRS CPM AIDSDRUGS CATLINE NEDRES CRISP AIDSTRIALS DENTALPROJ MED 85 COSTART Chem. ID MEDLINE MED 75 DMD CHEMLINE POPLINE HSTAT DSM III & IV GENE-TOX SERLINE HDA DOR HISTLINE DOCUSER MED 90 HHC SDLINE Dxplain Health. STAR INS TOXLINE AI/RHEUM ACR 92 LCH TOXLINE 65 Iliad AIR 93 MCM TOXLIT Gen. Bank BRMP 96 MIM PDQ OMS NIC Neuronames PSY ULT WHOART

. . . and on. . . CCHI (Canada) CCAM (France) MBS-E (Australia) READ 3. 1 (UK) ICD-10 -PCS (USA) WCC 5 (Netherlands) NCSP (Swedish Version) NCSP (Finnish Version) ICPM-DE (Germany) SNOMED-RT (USA) OPCS-5 (UK) SKS (Denmark) ICIDH (WHO)

So many to choose from What’s in use? HOSPITALS PRIMARY ICD-10 ICPC ICD-10/OPCS-4 READ ICD-10 NONE ICD-10 de Lusignan S, Minmagh C, Kennedy J, Zeimet M, Bommezijn H, Bryant J. (2001) Survey to identify the clinical coding and classification systems currently in use across Europe Medinfo. 2001; 10(Pt 1): 86 -9

Barriers to interoperability Cimino’s Desiderata (1) ► Concept orientation ► Separate language (terms) and concepts (codes) ► Concept permanence ► Never re-use a code (‘retire’ it) ► Nonsemantic concept identifiers ► Separate the code from the path ► Polyhierarchy ► Allow one concept to be classified in multiple ways ►Gout can be both a metabolic disease and an arthritis

Barriers to interoperability Cimino’s Desiderata (2) ► Formal Definitions ► i. e ‘Be compositional’ ► Reject ‘Not elsewhere classified’ ► concept permanence and NEC ► Multiple granularities ► Organ, tissue, cellular, molecular ► Grades, types, classes of diseases ► Special clinical criteria ► Multiple consistent views ► Allow different organisations ►e. g. functional, anatomical, pathological

Barriers to interoperability Cimino’s Desiderata (3) ► Represent context ► Family history, risk, source of information ► Evolve gracefully ► Allow controlled changes ► Recognise redundancy (equivalence) ► ‘Carcinoma’ + ‘Lung’ ? =? ‘Carcinoma of the lung’

Problems: Enumeration doesn’t scale Computers can’t read Humans can’t organise Tower of Babel The Users

Clinical Data Capture 1970 Choose terms from a coding scheme enter search: cystitis Cholecystitis, Cystitis, Iatrogenic NOS cystitis NOS Acute Chronic Chemical cystitis cholecystitis Subacute Acute Postoperative cholecystitis, cystitis NOS Follicular Bacterial Drug induced cystitis Cholecystitis Idiopathic Bacterial Radiation cystitis etc next page Too Big. . . picking lists too long Too Small. . . not enough clinical detail

To err is human Codes in use ►Incoherence ► Cross-mapping of NOS or NEC ► Puerperal Depression ►Inconsistency ► Perinatal mortality ► Translation effort ► Constipation ►Idiosyncracy ► Elks and Spacecraft ► Swedish and Finnish NCSP ►Incompleteness ► Endoscopic Surgery ► Plastic Surgery ►Ingenuity ► ‘TATT’

Problems: TOWER OF BABEL SCALE ORGANISATION USABILITY

Problem: TOWER OF BABEL Solution: UMLS

Unified Medical Language System ►US National Library of Medicine ►Defacto 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 STTY CUI LUI Code SUI Code

UMLS Semantic Net Governmental or Regulatory Activity (abridged) Finding Intellectual Product Organism Attribute Social Behaviour Daily or Recreational activity Machine Actiivty Educational Activity Occupational Activity Individual Behaviour Research Activity Health care Activity Group Language Therapeutic Procedure Activity Conceptual Entity Occupation Or Discipline Organism Function Group Attribute Entity Cell Function Phenomenon Or Process Organisation Organism Substance Physical. Object Genetic Function Event Idea or Concept Manufactured Object Mental Process Diagnostic Procedure Human-caused Phenomenon Or Process Biologic Function Natural Phenomenon Or Process Physiologic Function Disease or Syndrome Pathologic Function Anatomical Structure Environment Effect of Humans Injury or Poisoning Experimental Model of Disease Cell or Molecular Dysfunction Laboratory Procedure Molecular Function Organ or Tissue Function Mental or Behavioural Dysfunction Neoplastic Process

Semantic Net: 54 Links Has_location Adjacent_to Surrounded_by Traversed_by managed_by indicated_by treated_by Spatially Related. To Conceptually Related. To measured_by complicated_by analyzed_by diagnosed_by disrupted_by affected_by has_degree has_manifestation Assessed_for_effect_by Functionally Related. To has_method interacted_with prevented_by has_result produced_by used-by has_evaluation has_property has_conceptual_part caused_by has_issue has_derivative performed_by carried_out_by has_measurement exhibited_by brought_about_by has_developmental_form Physically Related. To has_occurrence Temporally Related. To Contained_in Connected_to Constitutes Has_branch Interconnected_by practiced_by co-occurs_with follows Has_ingredient Has_tributary has_process Has_part

UMLS Pros and Cons ►An invaluable resource, but. . . ► No better than the vocabularies which are mapped ►Limited detail for patient care ►Unreliable for indexing or abstraction of knowledge ►Best for relating everything to Me. SH for indexing literature ► Still limited by combinatorial explosion ►Still can’t cope with fractal knowledge ►Not extensible - no help in building or extending terminologiese ►No help in reorganising existing terminologies to re-use for new purposes ►Top down ► Information still implicit ►Minimal help with software ► No help with data capture, user interfaces http: //www. cs. man. ac. uk/mig/education/dummies-guide-to-umls. ppt

Problem: SCALE & ORGANISATION Solution: FORMAL ONTOLOGIES

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 V 12. 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

Requirement: Conceptual Lego toe mild toe moderate finger severe Lung chronic inflammation infection acute bacterial exertional angina ischaemic cough phlegm viral

Conceptual Lego Goodbye to picking lists… Structured Data Entry File Edit Help Cycling Accident What you hit Your Role Activity Location

Conceptual Lego Hello to new challenges ► How DO you classify things? ► ‘driver of locomotive’ and ‘driver of train’ ► ‘passenger in caboose of train’ ? ► When are two things the same ? ► ‘Driver of Bicycle’ vs ‘Cyclist’ ► Are there any illegal combinations? ► ‘fractured eyebrow causing donkey’ ► Are any combinations redundant? ► ‘finger which is part of hand’ ► ‘finger’

DLs for Beginners Primitives Descriptions Definitions Reasoning Validating Thing Feature Structure electric Car Thing red + feature: electric Engine Motor * ALWAYS part. Of: Car * ALWAYS feature: electric Structure + feature: electric + involves: Car red + part. Of: Car Motor + involves: Engine + feature: electric

DL based ontologies: Strengths… ►More complete than humans can achieve ►Faster than human ►Reproducible results ►Scalable (in theory) ►Explainable (? ) ►Support complex, precise and detailed modelling

DL based ontologies: …and Weaknesses ► Require complex, precise and detailed modelling ► Which puts off suppliers and customers alike ► Humans ► Not good at high levels of complexity, precision or detail ► Legacy issues ► Illogical manual systems ► Scale ► Machine can cope with scale ► But can users comprehend it ? ► GIGO

New requirement: package so users operate within limits of logic Terminology Server

Ontologies A unifying foundation? Coding & Classification Decision support Clinical Applications Me. SH ACRNEMA UMLS SNOMED Axes ONTOLOGY ` Medical Records MEGATERM ICPC Data entry READ OPCS ICD-9 ICD-10

Caveats: Language is slippery ► Human cognition makes it look easy ► Logic fails to capture it ►Classification is easy until you try to do it ►Trying since Aristotle in the West and Ancient Chinese in the East ► Words/Concepts mean what a community decides they mean ► Does a chimpanzee have four hands? ► Is a prion alive? ► Is surgery on the ovary a kind of ‘Endocrine surgery’? ► Easier to agree on the concrete than the abstract ► Easy to agree on useful abstractions and generalisations ►Harder to agree on how to name them

Scaling of SNOMED 350, 000 366, 000 (Sep 2005) 344, 000 (Jan 2003) 300, 000 SNOMED CT 250, 000 SNOMED RT (Beta) 200, 000 Concepts SNOMED International (V 3. 5) (V 3. 4) 150, 000 (V 3. 0) (V 3. 3) (V 3. 1)(V 3. 2) 100, 000 50, 000 SNOMED II (1979) Pathology II (1980) (V 3. 4)(V 3. 5) (V 3. 0) (V 3. 1)(V 3. 2)(V 3. 3) 1980 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 UMLS: 975, 000 different medical concepts

Problem: System may be perfect But Users still fallible

The Coding of Chocolate An international conversion guide SNOMED-CT ? C-F 0811 C-F 0816 C-F 0817 C-F 0819 C-F 081 A C-F 081 B C-F 081 C C-F 0058 Term Bounty bar Crème egg Kit Kat Mars Bar Milky Way Smarties Twix Snicker CTV 3 Ub. OVv Ub. OW 2 Ub. OW 3 Ub. OW 4 Ub. OW 5 Ub. OW 6 Ub. OW 7 Ub 1 p. T

User Problems Interrater 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 Interrater variability Headcloth Cloth Scarf Model Person Woman Adults Standing Background Brown Blue Chemise Dress Tunics Clothes Suitcase Luggage Attache case Brass Instrument French Horn Tuba X X X X X X X X X X X X X

User Problems Interrater 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

Problem: System may be perfect But users still fallible… …and the task is harder

A Typical Record Reviewed. Primip FT No ANC probs F/D at 08: 45 Needed synto for contractions about 7 cm Decent progress since. Epidural in-situ No urges to push really according to patient Contractions 4: 10 but poor duration & strength (on 60 u/s /synto) PA: Ceph 0/5 VE: Head at +1 Caput +1 No ? ? ? OA position Cx F/D NO DESCENT Tried pushing – poor maternal effort despite instruction Although epidural working well, doesn’t stop longstanding spasmodic hip pain. Very problematic FHR CTG No descent with attempts at pushing – poor effort. Plan… a) Push synto b) Need really try to push & work on technique c) reassess at interval 15 mins & D/W consultant

Clinical Terminology Summary ► Evolving use case ► Epidemiology ► Organising care ► Documenting Care ► Artificial Intelligence ►Technological Barriers ►Enumeration doesn’t scale ►Computers can’t read ►Humans can’t organise ►Tower of Babel ►Evolving Technology ►Enumeration – ICD ►Interlingua – UMLS ►Formal Ontology – SNOMED CT ► Unsolved Problems ► Quality Assurance ► Efficient data capture ► Interrater variability ► Cost Model