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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:
► 2mm, 2.4V, 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 age 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
Providers
System
Developers
Academics &
Research
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 1830s
Aggregated
Statistics 1665
Manchester Mercury
January 1st 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 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
1900
1910
1920
1930
1940
1950
1960
1970
1980
1990
2000
ICD-9-CM
International Classification Of Disease
Subacute
Thyroiditis
Congenital
Hypothyroidism
Thyroid Cyst
Subacute
granulomatous
thyroiditis
D24 Disorders Of Thyroid Gland
D240 Simple And Unspecified Goiter
D240.0 Goiter, Specified As Simple
D240.9 Goiter, Unspecified
D241 Nontoxic Nodular Goiter
D241.0 Nontoxic Uninodular Goiter
D241.1 Nontoxic Multinodular Goiter
D241.9 Unspecified Nontoxic Nodular Goiter
D242 Thyrotoxicosis With Or Without Goiter
D242.0 Toxic Diffuse Goiter
D242.1 Toxic Uninodular Goiter
D242.2 Toxic Multinodular Goiter
D242.3 Toxic Nodular Goiter, Unspecified Type
D242.4 Thyrotoxicosis From Ectopic Thyroid Nodule
D242.8 Thyrotoxicosis Of Other Specified Origin
D242.9 Thyrotoxicosis Without Mention Of Cause
D243 Congenital Hypothyroidism
Radiation thyroiditis
Thyroid Cancer
Enumerated
Monoaxial
D244 Acquired Hypothyroidism
D244.0 Postsurgical Hypothyroidism
D244.1 Other Postablative Hypothyroidism
D244.2 Iodine Hypothyroidism
D244.3 Other Iatrogenic Hypothyroidism
D244.8 Other Specified Acquired Hypothyroidism
D244.9 Unspecified Acquired Hypothyroidism
D245 Thyroiditis
D245.0 Acute Thyroiditis
D245.1 Subacute Thyroiditis
D245.2 Chronic Lymphocytic Thyroiditis
D245.3 Chronic Fibrous Thyroiditis
D245.4 Iatrogenic Thyroiditis
D245.8 Other And Unspecified Chronic Thyroiditis
D245.9 Thyroiditis, Unspecified
D246 Other Disorders Of Thyroid
D246.0 Disorders Of Thyrocalcitonin Secretion
D246.1 Dyshormonogenic Goiter
D246.2 Cyst Of Thyroid
D246.3 Hemorrhage And Infarction Of Thyroid
D246.8 Other Specified Disorders Of Thyroid
D246.9 Unspecified Disorder Of Thyroid
Incomplete
Dustbins
History of Clinical Terminology
1: Epidemiology
2. Organising care
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
► 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
1900
1910
1920
1930
1940
1950
1960
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
ICD9
►Detailed signs and
symptoms for primary care
►Purchased by UK
government in 1990
►Single use
► Medical Entities
Dictionary (MED)
► Jim Cimino
1900
1910
1920
1930
1940
1950
1960
1970
1980
1990
2000
History of Clinical Terminology
1: Epidemiology
2. Organising care
3. Documenting Care
4. Artificial Intelligence
Origins of modern terminologies
1990s: 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 McDonald (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
HealthCard
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
1970s ICD9: 8 Codes
The exploding bicycle
►1972 ICD-9 (E826) 8
►READ-2 (T30..) 81
►READ-3 87
►1999 ICD-10 ……
topClass
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 the perinatal 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
V12.4 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, traffic accident
V10.04 Pedal cyclist injured in collision with pedestrian or animal, driver, nontraffic accident, while resting, sleeping, eating or engaging in other vital activities
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 vital activities
V14.40 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
V14.41 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, traffic accident, while engaged in leisure activity
V10.14 Pedal cyclist injured in collision with pedestrian or animal, passenger, nontraffic accident, while resting, sleeping, eating or engaging in other vital activities
V12.49 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, traffic accident, during unspecified activity
V10.18 Pedal cyclist injured in collision with pedestrian or animal, passenger, nontraffic accident, while engaged in other specified activities
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
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
V10.20 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, nontraffic accident, while engaged in sports activity
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
V12.52 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, traffic accident, while working for an income
V10.22 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, nontraffic 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 vital activities
V14.50 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, traffic accident, while engaged in sports activity
V10.28 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, nontraffic accident, while engaged in other specified activities
V12.58
Pedal
cyclist
injured
in
collision
with
twoor
three-wheeled
motor
vehicle,
passenger,
traffic
accident,
while
engaged
in
other
specified
activities
V10.29 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, nontraffic accident, during unspecified activity
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
V14.53 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, traffic accident, while engaged in other types of work
V10.31 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting, while engaged in leisure activity
V12.90 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident, while engaged in sports activity
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
V10.32 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting, while working for an income
V12.91 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident, while engaged in leisure activity
V10.33 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting, while engaged in other types of work
V14.58 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, traffic accident, while engaged in other specified activities
1999 ICD10: 587 codes
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
V14.9 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, traffic accident
V10.39 Pedal cyclist injured in collision with pedestrian or animal, while boarding or alighting, during unspecified activity
V12.94 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, traffic accident, while resting, sleeping, eating or engagingV14.90
in otherPedal
vital activities
V10.4 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident
cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, 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
V10.40 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident, while engaged in sports 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
V14.92 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, traffic accident, while working for an income
V10.42 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident, while working for an income
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
V10.43 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident, while engaged in other types of work
V13 Pedal cyclist injured in collision with car, pick-up truck or van
V10.44 Pedal cyclist injured in collision with pedestrian or animal, driver, traffic accident, while resting, sleeping, eating or engaging in other vital activities
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
V14.99 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, traffic accident, during unspecified activity
V10.5 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident
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
V10.50 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident, while engaged in sports activity
V13.02 Pedal cyclist injured in collision with car, pick-up truck or van, driver, nontraffic accident, while working for an income
V10.51 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident, while engaged in leisure activity
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
V15.00 Pedal cyclist injured in collision with railway train or railway vehicle, driver, nontraffic accident, while engaged in sports activity
V10.53 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident, while engaged in other types of work
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 activities V15.01 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
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
V10.58 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic accident, while engaged in other specified activities
V13.09 Pedal cyclist injured in collision with car, pick-up truck or van, driver, nontraffic accident, during unspecified activity
V10.59 Pedal cyclist injured in collision with pedestrian or animal, passenger, traffic 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
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
V10.90 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident, while engaged in sports 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
V10.91 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident, while engaged in leisure activity
V13.11 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, nontraffic accident, while engaged in leisure activity
V10.92 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident, while working for an income
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
V15.1 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, nontraffic accident
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
V13.13 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, nontraffic accident, while engaged in other types of work
V15.10 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, nontraffic accident, while engaged in sports activity
V10.98 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident, while engaged in other specified activities
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 activitiesV15.11 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, nontraffic accident, while engaged in leisure activity
V10.99 Pedal cyclist injured in collision with pedestrian or animal, unspecified pedal cyclist, traffic accident, during unspecified activity
V13.18 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, nontraffic accident, while engaged in other specified activities
V11 Pedal cyclist injured in collision with other pedal cycle
V15.12 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, nontraffic accident, while working for an income
•V31.22 Occupant of three-wheeled motor vehicle injured in collision
with pedal cycle, person on outside of vehicle, nontraffic accident, while
working for 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
V15.13 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, nontraffic accident, while engaged in other types of work
V11.00 Pedal cyclist injured in collision with other pedal cycle, driver, nontraffic accident, while engaged in sports 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
V11.01 Pedal cyclist injured in collision with other pedal cycle, driver, nontraffic accident, while engaged in leisure activity
V13.20 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, nontraffic accident, while engaged in sports activity
V11.02 Pedal cyclist injured in collision with other pedal cycle, driver, nontraffic accident, while working for an income
V15.18 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, nontraffic accident, while engaged in other specified activities
V13.21 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, nontraffic accident, while engaged in leisure activity
V11.03 Pedal cyclist injured in collision with other pedal cycle, driver, nontraffic accident, while engaged in other types of work
V15.19 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, nontraffic accident, during unspecified 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
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
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 work V15.2 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, nontraffic accident
V11.09 Pedal cyclist injured in collision with other pedal cycle, driver, nontraffic accident, during unspecified activity
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 otherV15.20
vital activities
V11.1 Pedal cyclist injured in collision with other pedal cycle, passenger, nontraffic accident
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
V15.21 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, nontraffic accident, while engaged in leisure activity
V11.11 Pedal cyclist injured in collision with other pedal cycle, passenger, nontraffic accident, while engaged in leisure activity
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
V11.12 Pedal cyclist injured in collision with other pedal cycle, passenger, nontraffic accident, while working for an income
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
V11.13 Pedal cyclist injured in collision with other pedal cycle, passenger, nontraffic accident, while engaged in other types of work
V13.30
Pedal
cyclist
injured
in
collision
with
car,
pick-up
truck
or
van,
while
boarding
or
alighting,
while
engaged
in
sports
activity
V11.14 Pedal cyclist injured in collision with other pedal cycle, passenger, nontraffic accident, while resting, sleeping, eating or engaging in other vital 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
V11.18 Pedal cyclist injured in collision with other pedal cycle, passenger, nontraffic accident, while engaged in other specified activities
V13.31 Pedal cyclist injured in collision with car, pick-up truck or van, while boarding or alighting, while engaged in leisure 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
V11.19 Pedal cyclist injured in collision with other pedal cycle, passenger, nontraffic accident, during unspecified activity
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
V11.2 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, nontraffic accident
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
V11.20 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, nontraffic accident, while engaged in sports activity
V15.3 Pedal cyclist injured in collision with railway train or railway vehicle, while boarding or alighting
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 V15.30 Pedal cyclist injured in collision with railway train or railway vehicle, while boarding or alighting, while engaged in sports activity
V11.21 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, nontraffic accident, while engaged in leisure activity
V11.22 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, nontraffic accident, while working for an income
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
V11.23 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, nontraffic accident, while engaged in other types of work
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
V11.24 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, nontraffic accident, while resting, sleeping, eating or engaging in other vital activities
V13.4 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident
V11.28 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, nontraffic accident, while engaged in other specified activities
V15.33 Pedal cyclist injured in collision with railway train or railway vehicle, while boarding or alighting, while engaged in other types of work
V11.29 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, nontraffic accident, during unspecified activity
V13.40 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident, while engaged in sports activity
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
V11.3 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting
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
V11.30 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, while engaged in sports 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
V11.31 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, while engaged in leisure activity
V13.43 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident, while engaged in other types of work
V11.32 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, while working for an income
V15.4 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident
V11.33 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, while engaged in other types of work
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
V11.34 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, while resting, sleeping, eating or engaging in other vital activities
V13.48 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
V11.38 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, while engaged in other specified activities
V13.49 Pedal cyclist injured in collision with car, pick-up truck or van, driver, traffic accident, during unspecified activity
V15.42 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident, while working for an income
V11.39 Pedal cyclist injured in collision with other pedal cycle, while boarding or alighting, during unspecified activity
V13.5 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident
V11.4 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident
V15.43 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident, while engaged in other types of work
V11.40 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, while engaged in sports 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
V11.41 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, while engaged in leisure activity
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
V11.42 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, while working for an income
V13.52 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident, while working for an income
V11.43 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, while engaged in other types of work
V15.49 Pedal cyclist injured in collision with railway train or railway vehicle, driver, traffic accident, during unspecified activity
V11.44 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, while resting, sleeping, eating or engaging in other vital 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
V11.48 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, while engaged in other specified activities
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
V11.49 Pedal cyclist injured in collision with other pedal cycle, driver, traffic accident, during unspecified activity
V13.58 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident, while engaged in other specified activities
V15.51 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident, while engaged in leisure activity
V11.5 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident
V13.59 Pedal cyclist injured in collision with car, pick-up truck or van, passenger, traffic accident, during unspecified activity
V11.50 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, while engaged in sports activity
V15.52 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident, while working for an income
V11.51 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, while engaged in leisure activity
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
V11.52 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, while working for an income
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
V11.53 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, while engaged in other types of work
V13.91
Pedal
cyclist
injured
in
collision
with
car,
pick-up
truck
or
van,
unspecified
pedal
cyclist,
traffic
accident,
while
engaged
in
leisure
activity
V15.58 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident, while engaged in other specified 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
V13.92 Pedal cyclist injured in collision with car, pick-up truck or van, unspecified pedal cyclist, traffic accident, while working for an income
V11.58 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, while engaged in other specified activities
V15.59 Pedal cyclist injured in collision with railway train or railway vehicle, passenger, traffic accident, during unspecified activity
V11.59 Pedal cyclist injured in collision with other pedal cycle, passenger, traffic accident, during unspecified activity
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
V11.9 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident
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 vital
activities
V15.90
Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, traffic accident, while engaged in sports activity
V11.90 Pedal cyclist injured in collision with other pedal cycle, 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
V11.91 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, while engaged in leisure activity
V15.91 Pedal cyclist injured in collision with railway train or railway vehicle, unspecified pedal cyclist, traffic accident, while engaged in leisure activity
V11.92 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, while working for an income
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
V11.93 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, while engaged in other types of work
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
V11.94 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, while resting, sleeping, eating or engaging in other vital activities
V14.0 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, nontraffic accident
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
V11.98 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, while engaged in other specified activities
V14.00 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, nontraffic accident, while engaged in sports activity
V11.99 Pedal cyclist injured in collision with other pedal cycle, unspecified pedal cyclist, traffic accident, during unspecified 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
•W65.40 Drowning and submersion while in bath-tub, street and highway,
while engaged in sports activity
•X35.44 Victim of volcanic eruption, street and highway, while resting,
sleeping, eating or engaging in other vital activities
V12 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle
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
V12.0 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, nontraffic accident
V14.02 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, nontraffic accident, while working for an income
V16 Pedal cyclist injured in collision with other nonmotor vehicle
V12.00 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, nontraffic accident, while engaged in sports activity
V14.03 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, nontraffic accident, while engaged in other types of work
V12.01 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, nontraffic accident, while engaged in leisure activity
V16.0 Pedal cyclist injured in collision with other nonmotor vehicle, driver, nontraffic accident
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
V12.02 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, nontraffic accident, while working for an income
V16.00 Pedal cyclist injured in collision with other nonmotor vehicle, driver, nontraffic accident, while engaged in sports activity
V12.03 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, nontraffic accident, while engaged in other types of work
V14.08 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 other nonmotor vehicle, driver, nontraffic accident, while engaged in leisure 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
V14.09 Pedal cyclist injured in collision with heavy transport vehicle or bus, driver, nontraffic accident, during unspecified activity
V16.02 Pedal cyclist injured in collision with other nonmotor vehicle, driver, nontraffic accident, while working for an income
V12.08 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, nontraffic accident, while engaged in other specified activities
V14.1 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, nontraffic accident
V12.09 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, driver, nontraffic accident, during unspecified activity
V16.03 Pedal cyclist injured in collision with other nonmotor veh
V12.1 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, nontraffic accident
V14.10 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, nontraffic accident, while engaged in sports activity
V12.10 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, nontraffic accident, while engaged in sports activity
V14.11 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, nontraffic accident, while engaged in leisure activity
V12.11 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, nontraffic accident, while engaged in leisure activity
V14.12 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, nontraffic accident, while working for an income
V12.12 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, nontraffic accident, while working for an income
V14.13
Pedal
cyclist
injured
in
collision
with
heavy
transport
vehicle
or
bus,
passenger,
nontraffic
accident,
while
engaged
in
other
types
of
work
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
V14.14 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, nontraffic accident, while resting, sleeping, eating or engaging in other vital activities
V12.18 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, nontraffic accident, while engaged in other specified activities
V14.18 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, nontraffic, while engaged in other specified activities accident
V12.19 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, passenger, nontraffic accident, during unspecified activity
V14.19 Pedal cyclist injured in collision with heavy transport vehicle or bus, passenger, nontraffic, during unspecified activity accident
V12.2 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, nontraffic accident
V14.2 Pedal cyclist injured in collision with heavy transport vehicle or bus, 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
V12.21 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, nontraffic accident, while engaged in leisure activity
V14.20 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, nontraffic accident, while engaged in sports activity
V12.22 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, nontraffic accident, while working for an income
V14.21 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, nontraffic accident, while engaged in leisure 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
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 V14.22 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, nontraffic accident, while working for an income
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
V14.23 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, nontraffic accident, while engaged in other types of work
V12.29 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, nontraffic accident, during unspecified activity
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
V12.3 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting
V12.30 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting, while engaged in sports activity
V12.31 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting, while engaged in leisure 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
V14.29 Pedal cyclist injured in collision with heavy transport vehicle or bus, unspecified pedal cyclist, nontraffic accident, during unspecified activity
V14.3 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting
V12.32 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting, while working for an income
V14.30 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting, while engaged in sports activity
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
V14.31 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting, while engaged in leisure 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
V14.32 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting, while working for an income
V12.38 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting, while engaged in other specified activities
V14.33 Pedal cyclist injured in collision with heavy transport vehicle or bus, while boarding or alighting, while engaged in other types of work
V12.39 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, while boarding or alighting, during unspecified activity
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
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 ICD9 to ICD10
►~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,
MeSH
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
SNOMED-3
CDAM
ECRI-UMDNS
READ-2
NGAP
SNOP
MeSH
MeSH
ICPC
HCFA
ICD-9
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
BRMS96
MED80
BIOETHICS
NIOSH
COSTAR
MED66
CANCERLIT
NPIRS
CPM
AIDSDRUGS CATLINE
NEDRES
CRISP
AIDSTRIALS DENTALPROJ
MED85
COSTART
ChemID
MEDLINE
MED75
DMD
CHEMLINE
POPLINE
HSTAT
DSM III & IV
GENE-TOX
SERLINE
HDA
DOR
HISTLINE
DOCUSER
MED90
HHC
SDLINE
Dxplain
HealthSTAR
INS
TOXLINE
AI/RHEUM
ACR92
LCH
TOXLINE65
Iliad
AIR93
MCM
TOXLIT
GenBank
BRMP96
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)
WCC5 (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
ICD-10
ICD-10/OPCS-4
READ
ICD-10
NONE
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 1970Choose 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
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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
STTY
CUI
Code
SUI
Code
LUI
LUI
SUI
Code
SUI
Code
UMLS Semantic Net
Governmental or
Regulatory Activity
(abridged)
Finding
Intellectual
Product
Educational
Activity
Social
Behaviour
Behaviour
Daily or
Recreational
activity
Machine
Actiivty
Occupational
Activity
Individual
Behaviour
Research
Activity
Health care
Activity
Organism
Attribute
Group
Language
Therapeutic
Procedure
Activity
Conceptual Entity
Occupation
Or Discipline
Organism
Function
Group
Attribute
Entity
Cell
Function
Phenomenon
Or Process
Organisation
Organism
Substance
PhysicalObject
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
Injury or
Poisoning
Experimental
Model of
Disease
Molecular
Function
Organ or
Tissue
Function
Mental or
Behavioural
Dysfunction
Pathologic
Function
Neoplastic
Process
Anatomical Structure
Environment
Effect of Humans
Laboratory
Procedure
Cell or
Molecular
Dysfunction
Semantic Net: 54 Links
Has_location
Adjacent_to
Surrounded_by
Traversed_by
managed_by
indicated_by
treated_by
Spatially
RelatedTo
Conceptually
RelatedTo
disrupted_by
affected_by
complicated_by
has_manifestation
measured_by
analyzed_by
interacted_with
Assessed_for_effect_by
prevented_by
has_result
diagnosed_by
has_degree
has_evaluation
has_property
Functionally
RelatedTo
has_method
used-by
caused_by
has_conceptual_part
performed_by
has_issue
has_derivative
produced_by
carried_out_by
has_measurement
exhibited_by
brought_about_by
practiced_by
has_developmental_form
Physically
RelatedTo
has_occurrence
has_process
co-occurs_with
Temporally
RelatedTo
Contained_in
Connected_to
Constitutes
Has_branch
Interconnected_by
follows
Has_ingredient
Has_tributary
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 MeSH 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
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
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 partOf: Car
* ALWAYS feature: electric
Structure
+ feature: electric
+ involves: Car
red
+ partOf: 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
MeSH
ACRNEMA
UMLS
SNOMED
Axes
ONTOLOGY
Medical
Records
`
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 3.4)
(V 3.5)
150,000
(V 3.0)
(V 3.1) (V 3.2)
(V 3.3)
100,000
50,000
SNOMED II (1979)
(V 3.4) (V 3.5)
(V 3.0) (V 3.1) (V 3.2) (V 3.3)
Pathology II (1980)
1980
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
UMLS: 975,000 different medical concepts
2003 2004
2005
Problem:
System may be perfect
But
Users still fallible
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
Crème egg
Kit Kat
Mars Bar
Milky Way
Smarties
Twix
Snicker
CTV3
UbOVv
UbOW2
UbOW3
UbOW4
UbOW5
UbOW6
UbOW7
Ub1pT
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
Horn
Tuba
X
X
X
X
X
X
X
X
X
X
X
X
X X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X X
X
X X
X
X
X
X
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 7cm
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
Would not be happy to have to exert traction with
Forceps when no effort & no descent
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