Rector

Terminologies, Ontologies,

& SNOMED

What are they for?

What would Quality Assurance mean?



Alan Rector

School of Computer Science / Northwest Institute of Bio-Health Informatics

rector@cs.man.ac.uk





with special acknowledgement to Jeremy Rogers





www.co-ode.org

www.clinical-escience.org

www.opengalen.org









1

Terminology and ontologies in Healthcare:

What for? What is meant by Quality?

• A Talk in three parts

• Part 1

– A review of a bit of history of clinical terminology and ontologies

– Some fundamental issues

• Part 2

– Focus on Quality Assurance

– Quality for what?

– Dimensions of quality

• Part 3

– Quality issues in SNOMED

– What might be done to address them

• Summary







2

Medical Terminology:

A bit of history

• It all started with public health, vital statistics and

epidemiology…









3

London Bills of Mortality

every Thursday from 1603 until the 1830s









4

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









5

… then took on new tasks .

Organising Care

• Librarianship

– MeSH - NLM from around 1900 - Index Medicus & Medline

– EMTree - from Elsevier in 1950s - EMBase

• Remuneration

– ICD9-CM (Clinical Modification) 1980

• 10 x larger than ICD; aimed at US insurance reimbursement

– CPT, …

• Pathology indexing

– SNOMED 1970s to 1990 (SNOMED International)

• First faceted or combinatorial system

• Topology, morphology, aetiology, function

• Specialty Systems

– Mostly similar hierarchical systems

• ACRNEMA/SDM - Radiology

• NANDA, ICNP… - Nursing









6

… and then with computers

Documenting/Reporting Care

• Early computer systems • OXMIS

– Aimed at saving space on early – READ competitor

computers – Flat list of codes

– 1-5 Mbyte / 10,000 patients – Derived from empirical data

• Read (1987 - 1995) – Defunct circa 1999

– Hierarchical modelled on ICD9 • ICPC

• Detailed signs and symptoms for

primary care

– Epidemiologically tested, Dutch

• Purchased by UK government in 1990

• Single use • LOINC

• Medical Entities Dictionary – For laboratory data

(MED)

– Jim Cimino, Hospital support, • DICOM (sdm)

Columbia, USA – For images



• MEDDRA

– Adverse Reactions









7

Unified Medical Language

System

• US National Library of Medicine

• De facto common registry for vocabularies

• Metathesaurus

– 1.8 million concepts

– categorised by semantic net types

• Semantic Net

– 135 Types

– 54 Links

• Specialist Lexicon & other language tools









8

Unified Medical Language

System

• Concept Unique Identifiers (CUIs)

• Lexical Unique Identifiers (LUIs)

• String Unique Identifiers (SUIs)

Code



SUI Code

LUI

SUI

CUI Code

LUI

SUI

Code

LUI

SUI

Code

9

…but …The Coding of Chocolate

An international conversion guide



SNOMED-CT Term CTV3

C-F0811

Bounty bar UbOVv

? C-F0816

Crème egg UbOW2

C-F0817







C-F0819

Kit Kat UbOW3







C-F081A Mars Bar UbOW4









C-F081B Milky Way UbOW5

C-F081C Smarties UbOW6

C-F0058 Twix UbOW7

Snicker Ub1pT

10

1990s: a Paradigm Shift



• Human-Human and Human-Machine to Machine-Machine

• From paper to software

• From single use to multiple re-use

• From coding clerks to direct entry by clinicians

• From pre-defined reporting to decision support



• Machine mediated human communication vs

Machine to machine communication





From Books to Software

11

Where I come from

Clinical research

Clinical Data Clinical & Best

Terminology Entry Record Decision Support Practice



Healthcare

Mr Ivor Bigun

Dun Roamin

Anytown

Any country

4431 3654 90273









GALEN Clinical research

Data Electronic Best

Ontologies &

Description Entry Health

logics Decision Support & Practice

Records

Knowledge

Presentation



12

Why is it so hard?



Fundamental problems:

Enumeration doesn‟t scale







13

The scaling problem:

The combinatorial explosion



• It keeps happening!

– “Simple” brute force

solutions do not scale up!







• Conditions x sites x modifiers x

activity x context

– Huge number of terms to author

– Software CHAOS









Actual

14

Combination of things to be

done & time to do each thing



• Terms and forms needed

– Increases exponentially







• Effort per term or form

– Must decrease to

compensate



• To give the effectiveness we

want

– Or might accept



Things to

build 15

The exploding bicycle

• 1972 ICD-9 (E826) 8

• READ-2 (T30..) 81

• READ-3 87

• 1999 ICD-10 ……









16

l

t opC ass

er

I C t ai n i nf ect i ous and par asi t i c di seases

eopl

I I N asms

i

I I I D seases of t he bl ood and bl ood- f or mi ng or gans and cer t ai n di sor der s i nvol vi ng t he i mmune mechani s m

I V Endocr i ne, nut r i t i onal and met abol i c di seases

V Ment al and behavi our al di sor der s

I i

V D s eases of t he ner vous s yst em

I i

V I D seases of t he eye and adnexa

I i

V I I D seases of t he ear and mast oi d pr ocess

i

I X D s eases of t he ci r cul at or y syst ems

i

X D seases of t he r espi r at or y syst em

I i

X D s eases of t he di gest i ve syst em

I i

X I D seases of t he ski n and subcut aneous t i ssue

I i

X I I D seases of t he muscul oskel et al s yst em and connect i ve t i ssue

I i

X V D seases of t he geni t our i nar y syst em

V puer

X Pr egnancy, chi l dbi r t h and t he per i um

V er t he

X I C t ai n condi t i ons or i gi nat i ng i n per i nat alper i od

V

X I I Congeni t al m al f or mat i ons, def or m at i ons and chr omosom al abnor mal i t i es

V her

X I I I Sympt oms, si gns and abnor mal cl i ni cal and l abor at or y f i ndi ngs, not el sew e cl assi f i ed

I

X X I nj ur y, poi soni ng and cer t ai n ot her consequences of ext er nal causes









1999 ICD10: 587 codes

X

X Ext er nal causes of mor bi di t y and m or t al i t y

01- 99

V V Tr anspor t acci dent s

01- 09

V V Pedest r i an i nj ur ed i n t r anspor t acci dent

10- 19

V V Pedal cycl i st i nj ur ed i n t r anspor t acci dent

10 i

V Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani m al

10. i nont r i ver ,

acci

V 0 Pedal cycl i st i nj ur ed i n col l i si on w t h pedes t r i an or ani mal , draf f i c dent

10. i nont r i ver ,acci hi

V 00 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , draf f i c dent , w l e engaged i n s por t s act i vi t y

10. i nont r i ver ,acci hi

V 01 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , draf f i c dent , w l e engaged i n l ei sur e act i vi t y

10. i nont r i ver ,acci hi or

V 02 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , draf f i c dent , w l e w ki ng f or an i ncome

10. i nont r i ver ,acci hi

V 03 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , draf f i c dent , w l e engaged i n ot her t ypes of w k or

10. i nont r i ver ,acci hi

V 04 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , draf f i c dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi tPedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

V 4 i es

12. i o- heel ed mot or vehi cl e, dr i ver , t r af f i c acci dent

10. i nont r i ver ,acci hi

V 08 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , draf f i c dent , w l e engaged i n ot her speci f i ed act i vi t i es V 40 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

12. i o- hi

heel ed mot or vehi cl e, dr i ver , t r af f i c acci dent , w l e engaged i n s por t s act i vi t y

10. i nont r i ver ,acci

V 09 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , draf f i c dent , dur i ng unspeci f i ed act i vi t y

V 1 Pedal cycl i st i nj ur ed i n col l i si on w t h pedes t r i an or ani mal , pass enger ,c

10. i nont r af f i acci dent V 41 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

12. i o- hi

heel ed mot or vehi cl e, dr i ver , t r af f i c acci dent , w l e engaged i n l ei sur e act i vi t y

V 10 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , pas sengeri,c

10. i nont r af f acci dent , w l e engaged i n s por t s act i vi t y

hi V 42 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

12. i o- heel ed mot or vehi cl e, dr i ver , t r af f i c acci dent , w l e w ki ng f or an i ncome

hi or

10. i nont r af f acci dent , w l e engaged i n l ei sur e act i vi t y

V 11 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , pas sengeri,c hi V 43 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

12. i o- hi

heel ed mot or vehi cl e, dr i ver , t r af f i c acci dent , w l e engaged i 4 ot her cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, dr i ver , t r af f i c acci dent

V n Pedal t ypes of w k

14. or i

10. i nont r af f acci dent , w l e w ki ng f or an i ncome

V 12 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , pas sengeri,c hi or

12. i o-

V 44 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w hi

heel ed mot or vehi cl e, dr i ver , t r af f i c acci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng Pedal her vist ali nj ur i vi ti ines l i si on w t h heavy t r anspor t vehi cl e or bus, dr i ver , t r af f i c acci dent ,

V 40 i n ot cycl i t act ed

14. col i hi

w l e engaged i n spor t s act i vi t y

10. i nont r af f acci dent , w l e engaged i n ot her t ypes of w k

V 13 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , pas sengeri,c hi or

V 14 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , pas sengeri,c

10. i hi

nont r af f acci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es 12. i o-

V 48 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w hi

heel ed mot or vehi cl e, dr i ver , t r af f i c acci dent , w l e engaged i n ot her speci f i ed act iV t i es Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, dr i ver , t r af f i c acci dent ,

vi 41

14. i hi

w l e engaged i n l ei sur e act i vi t y

10. i nont r af f acci dent , w l e engaged i n ot her speci f i ed act i vi t i es

V 18 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , pas sengeri,c hi V 49 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

12. i o- heel ed mot or vehi cl e, dr i ver , t r af f i c acci dent , dur i ng unspeci f i ed act i vi t y 14. i

V 42 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, dr i ver , t r af f i c acci dent , hi or

w l e w ki ng f or an i ncome

10. i nont r af f acci dent , dur i ng unspeci f i ed act i vi t y

V 19 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , pas sengeri,c

12. i o-

V 5 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w heel ed mot or vehi cl e, passenger , t r af f i c acci dent V 43 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, dr i ver , t r af f i c acci dent ,

14. i hi or

w l e engaged i n ot her t ypes of w k

10. i nont af f acci

st

V 2 Pedal cycl i st i nj ur ed i n col l i si on w t h pedes t r i an or ani mal , unspeci f i ed pedal rcycliic , dent

10.

V 20 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , uns peci f i ed pedal rcycliicacci dent , w l e engaged i n spor t s act i vi t y

i nont af f st , hi 12.

V 50 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

i o- heel ed mot or vehi cl e, passenger , t r af f i c acci dent , w l e engaged i n spor t s act i vi t y V 44 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, dr i ver , t r af f i c acci dent ,

hi 14. i hi

w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

10.

V 21 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , uns peci f i ed pedal rcycliicacci dent , w l e engaged i n l ei sur e act i vi t y

i nont af f st , hi 12.

V 51 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

i o- heel ed mot or vehi cl e, passenger , t r af f i c acci dent , w l e engaged i n l ei sur e act i vi t y V 48 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, dr i ver , t r af f i c acci dent ,

hi 14. i hi

w l e engaged i n ot her s peci f i ed act i vi t i es

10. i nont af f st , hi or

V 22 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , uns peci f i ed pedal rcycliicacci dent , w l e w ki ng f or an i ncome V 52 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

12. i o- hi or

heel ed mot or vehi cl e, passenger , t r af f i c acci dent , w l e w ki ng f or an i ncom e 14. i

V 49 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, dr i ver , t r af f i c acci dent , dur i ng unspeci f i ed act i vi t y

10. i nont af f st , hi

V 23 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , uns peci f i ed pedal rcycliicacci dent , w l e engaged i n ot her t ypes of w k or

12. i o-

V 53 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- wheel ed mot or vehi cl e, passenger , t r af f i c acci dent , w l e engaged i n ot her t ypes 5 Pedalk cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, passenger , t r af f i c acci dent

hi V of w

14. or i

10. i nont af f st , hi

V 24 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , uns peci f i ed pedal rcycliicacci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

10. i nont af f st , hi

V 28 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , uns peci f i ed pedal rcycliicacci dent , w l e engaged i n ot her speci f i ed act i vi t i es V 54 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

12. i o- hi

heel ed mot or vehi cl e, passenger , t r af f i c acci dent , w l e r est i ng, sl eepi ng, eat i ng or 14. 50 Pedal n cycl i st vii tnj ur act ii vi tcol l i si on w t h heavy t r anspor t vehi cl e or bus, passenger , t r af f i c acci dent , w l e engaged i n spor t s act i vi t y

V engagi ng i ot her al ed n i es i hi

10. i nont af f st

acci

V 29 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , uns peci f i ed pedal rcycliic , dent , dur i ng unspeci f i ed act i vi t y V 58 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

12. i o- hi

heel ed mot or vehi cl e, passenger , t r af f i c acci dent , w l e engaged i n ot her speci f i ed act i vi t iPedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, passenger , t r af f i c acci dent , w l e engaged i n l ei s ur e act i vi t y

V 51 es

14. i hi

10. i hi

V 3 Pedal cycl i st i nj ur ed i n col l i si on w t h pedes t r i an or ani mal , w l e boar di ng or al i ght i ng

12. i o-

V 59 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w heel ed mot or vehi cl e, passenger , t r af f i c acci dent , dur i ng unspeci f i ed act i vi t y V 52 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, passenger , t r af f i c acci dent , w l e w ki ng f or an i ncome

14. i hi or

10. i hi hi

V 30 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , w l e boar di ng or al i ght i ng, w l e engaged i n s por t s act i vi t y

10. i

V 31 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , w l e boar di ng or al i ght i ng, w l e engaged i n l ei sur e act i vi t y

hi hi 12.

V 9 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

i o- heel ed mot or vehi cl e, unspeci f i ed pedal cycl i st , t r af f i c acci dent 14. i hi

V 53 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, passenger , t r af f i c acci dent , w l e engaged i n ot her t ypes of w k or

10.

V 32 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , w l e boar di ng or al i ght i ng, w l e w ki ng f or an i ncome

i hi hi or 12.

V 90 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

i o- hi

heel ed mot or vehi cl e, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n spor t s act i vi tcycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, passenger , t r af f i c acci dent , w l e r es t i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

V 54 Pedal y

14. i hi

10. i hi hi

V 33 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , w l e boar di ng or al i ght i ng, w l e engaged i n ot her t ypes of w k or V 91 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

12. i o- hi ei 58 act i t y

heel ed mot or vehi cl e, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n lV s ur e Pedal vicycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, passenger , t r af f i c acci dent , w l e engaged i n ot her speci f i ed act i vi t i es

14. i hi

10. i hi hi

V 34 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , w l e boar di ng or al i ght i ng, w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

12. i o-

V 92 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w heel ed mot or vehi cl e, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e w ki ng f or V i ncome cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, passenger , t r af f i c acci dent , dur i ng unspeci f i ed act i vi t y

hi or an 59 Pedal

14. i

10. i hi hi

V 38 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , w l e boar di ng or al i ght i ng, w l e engaged i n ot her speci f i ed act i vi t i es

10. i

V 39 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , w l e boar di ng or al i ght i ng, dur i ng unspeci f i ed act i vi t y

hi V 93 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

12. i o- heel ed mot or vehi cl e, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged iPedalher t ypes iof uror k i n col l i si on w t h heavy t r anspor t vehi cl e or bus, unspeci f i ed pedal cycl i st , t r af f i c acci dent

hi V 9 n ot cycl i st nj wed

14. i

10. i

V 4 Pedal cycl i st i nj ur ed i n col l i si on w t h pedes t r i an or ani mal , dr i ver , t r af f i c acci dent V 94 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

12. i o- hi

heel ed mot or vehi cl e, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e r est i ng, sl eepi ng, Pedal ng or i engagi ng edn i ot her l vi t al actt ihviheavy t r anspor t vehi cl e or bus, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n spor t s act i vi t y

V 90 eat i cycl st i nj ur i n col i si on w

14. i t i es hi

10. i hi

V 40 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , dr i ver , t r af f i c acci dent , w l e engaged i n spor t s act i vi t y

12. i o-

V 98 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w heel ed mot or vehi cl e, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n ot14. 91speci f i ed actst vii tnj es ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n l ei sur e act i vi t y

hi V her Pedal cycl i i i ur i hi

10. i hi

V 41 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , dr i ver , t r af f i c acci dent , w l e engaged i n l ei s ur e act i vi t y

10.

V 42 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , dr i ver , t r af f i c acci dent , w l e w ki ng f or an i ncome

i hi or 12.

V 99 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

i o- heel ed mot or vehi cl e, unspeci f i ed pedal cycl i st , t r af f i c acci dent , dur i ng uns peci f i ed 14. 92viPedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e w ki ng f or an i ncom e

V act i t y i hi or

10. i hi

V 43 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , dr i ver , t r af f i c acci dent , w l e engaged i n ot her t ypes of w k or V 93 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n ot her t ypes of w k

14. i hi or

10. i hi 13 i vi t cycl

V 44 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , dr i ver , t r af f i c acci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t alVactPedali es i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van

i 14. i hi

V 94 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e r est i ng, s l eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

10. i hi

V 48 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , dr i ver , t r af f i c acci dent , w l e engaged i n ot her speci f i ed act i vi t i es

13. i nont r i f i ,

V 0 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, drafvercacci dent 14. i hi

V 98 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n ot her speci f i ed act i vi t i es

10. i

V 49 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , dr i ver , t r af f i c acci dent , dur i ng uns peci f i ed act i vi t y

10. i

V 5 Pedal cycl i st i nj ur ed i n col l i si on w t h pedes t r i an or ani mal , pass enger , t r af f i c acci dent V 00 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, draf f i cacci dent , w l e engaged i n spor t s act i vi t y

13. i nont r i ver , hi 14. i

V 99 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, unspeci f i ed pedal cycl i st , t r af f i c acci dent , dur i ng unspeci f i ed act i vi t y

10. i hi

V 50 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , pas senger , t r af f i c acci dent , w l e engaged i n s por t s act i vi t y V 01 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, draf f i cacci dent , w l e engaged i n l ei sur e act i vi t y

13. i nont r i ver , hi 15 i ay ay

V Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e

10. i hi

V 51 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , pas senger , t r af f i c acci dent , w l e engaged i n l ei sur e act i vi t y

13. i nont r i ver , hi or

V 02 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, draf f i cacci dent , w l e w ki ng f or an i ncome V 0 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, rdr ifver , dent

15. i ay ay nont af i cacci

10. i hi or

V 52 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , pas senger , t r af f i c acci dent , w l e w ki ng f or an i ncome

10. i

V 53 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , pas senger , t r af f i c acci dent , w l e engaged i n ot her t ypes of w k

hi or 13. i nont r i ver , hi

V 03 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, draf f i cacci dent , w l e engaged i n ot her t ypes of w k or 15. i ay ay nont af i c , hi

V 00 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, rdr i fveracci dent , w l e engaged i n spor t s act i vi t y

V 54 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , pas senger , t r af f i c acci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es V 04 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, draf f i cacci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al 15. 01 vi t i es cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, rdr i fveracci dent , w l e engaged i n l ei sur e act i vi t y

10. i hi 13. i nont r i ver , hi V act i Pedal i ay ay nont af i c , hi

10. i hi

V 58 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , pas senger , t r af f i c acci dent , w l e engaged i n ot her speci f i ed act i vi t i es V 08 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, draf f i cacci dent , w l e engaged i n ot her speci f i ed act i vi t i es

13. i nont r i ver , hi 15. i ay ay nont af i c , hi or

V 02 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, rdr i fveracci dent , w l e w ki ng f or an i ncome

10. i

V 59 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , pas senger , t r af f i c acci dent , dur i ng unspeci f i ed act i vi t y

13. i nont r i ver ,

V 09 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, draf f i cacci dent , dur i ng unspeci f i ed act i vi t y 15.

V 03 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, rdr i fveracci dent , w l e engaged i n ot her t ypes of w k

i ay ay nont af i c , hi or

10. i

V 9 Pedal cycl i st i nj ur ed i n col l i si on w t h pedes t r i an or ani mal , unspeci f i ed pedal cycl i st , t r af f i c acci dent









•V31.22 Occupant of three-wheeled motor vehicle injured in

V 90 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , uns peci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n spor t s act i vi t y

10. i hi 13. i passenger c

V 1 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, nont r af f i , acci dent 15. i ay ay nont af i c , hi

V 04 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, rdr i fveracci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

10. i hi

V 91 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , uns peci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n l ei sur e act i vi t y V 10 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, nont r af f i , acci dent , w l e engaged i n spor t s act i vi t y

13. i passenger c hi 15. i ay ay nont af i c , hi

V 08 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, rdr i fveracci dent , w l e engaged i n ot her speci f i ed act i vi t i es

10. i hi or

V 92 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , uns peci f i ed pedal cycl i st , t r af f i c acci dent , w l e w ki ng f or an i ncome V 11 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, nont r af f i , acci dent , w l e engaged i n l ei sur e act i vi t y

13. i passenger c hi

10. i

V 93 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , uns peci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n ot her t ypes of w k

hi or 15. i ay ay nont af i c ,

V 09 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, rdr i fveracci dent , dur i ng unspeci f i ed act i vi t y

V 94 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , uns peci f i ed pedal cycl i st , t r af f i c acci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, nont r af f i , acci dent , w l e w ki ng f or an i ncome

10. i hi V 12 Pedal

13. i passenger c hi or V 1 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, nont r af f i cacci dent

15. i ay ay pass enger ,

10.

V 98 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , uns peci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n ot her speci f i ed act i vi t i es

i hi 13. i passenger c hi

V 13 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, nont r af f i , acci dent , w l e engaged i n ot her t ypes of w k or 15. i ay ay pas r af f i c, hi

V 10 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, nont senger acci dent , w l e engaged i n spor t s act i vi t y

10. i

V 99 Pedal cycl i st i nj ur ed i n col l i si on w t h pedest r i an or ani mal , uns peci f i ed pedal cycl i st , t r af f i c acci dent , dur i ng unspeci f i ed act i vi t y 13. i passenger c hi

V 14 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, nont r af f i , acci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi15. 11act i vi t icycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, nont senger acci dent , w l e engaged i n l ei sur e act i vi t y

V t al Pedal es i ay ay pas r af f i c, hi









collision with pedal cycle, person on outside of vehicle,

11 i

V Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e

13. i passenger c hi

V 18 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, nont r af f i , acci dent , w l e engaged i n ot her speci f i ed act i vi t i es V 12 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, nont senger acci dent , w l e w ki ng f or an i ncome

15. i ay ay pas r af f i c, hi or

11. i nont ver

V 0 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, drriaf f i, cacci dent

11. i nont i ver ,

V 00 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, drr af f i cacci dent , w l e engaged i n spor t s act i vi t y

hi 13. i passenger c

V 19 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, nont r af f i , acci dent , dur i ng unspeci f i ed act i vi t y 15. i ay ay pas r af f i c, hi

V 13 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, nont senger acci dent , w l e engaged i n ot her t ypes of w k or

11. i nont i ver ,

V 01 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, drr af f i cacci dent , w l e engaged i n l ei sur e act i vi t y

hi 13. i nont af f cst ,

V 2 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, unspeci f i ed pedal r cycli i acci dent 15. i ay ay pas r af f i c, hi

V 14 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, nont senger acci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

11. i nont i ver , hi or

V 02 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, drr af f i cacci dent , w l e w ki ng f or an i ncome

13. i nont af f acci hi

V 20 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, unspeci f i ed pedal rcycli icst , dent , w l e engaged i n spor t s act i vi t y V 18 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, nont senger acci dent , w l e engaged i n ot her speci f i ed act i vi t i es

15. i ay ay pas r af f i c, hi

11. i nont i ver , hi

V 03 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, drr af f i cacci dent , w l e engaged i n ot her t ypes of w k or

V 04 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, drr af f i cacci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

11. i nont i ver , hi V 21 Pedal cycl i st i nj ur ed i n col l i si on

13. i nont af f acci

w t h car , pi ck- up t r uck or van, unspeci f i ed pedal rcycli icst , dent , w l e engaged i n l ei sur e act i vi t y

hi V 19 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, nont senger acci dent , dur i ng unspeci f i ed act i vi t y

15. i ay ay pas r af f i c,

V 08 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, drr af f i cacci dent , w l e engaged i n ot her speci f i ed act i vi t i es

11. i nont i ver , hi 13.

V 22 Pedal cycl i st i nj ur ed i n col l i si on i nont af f acci

w t h car , pi ck- up t r uck or van, unspeci f i ed pedal rcycli icst , dent , w l e w ki ng f or an i ncome

hi or









nontraffic accident, while working for income

11. i nont i ver ,

V 09 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, drr af f i cacci dent , dur i ng unspeci f i ed act i vi t y V 23 Pedal cycl i st i nj ur ed i n col l i si on

13. i nont af f acci hi w 2

w t h car , pi ck- up t r uck or van, unspeci f i ed pedal rcycli icst , dent , w l e engaged i n ot her t ypes of V or k Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, unspeci f i ed pedalr af f i ci st , dent

15. i ay ay nont cycl acci

11. i nont r af f

V 1 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, passenger ,i cacci dent

13.

V 24 Pedal cycl i st i nj ur ed i n col l i si on i nont af f acci hi

w t h car , pi ck- up t r uck or van, unspeci f i ed pedal rcycli icst , dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t ali st i i vi t i es i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, uns peci f i ed pedalr af f i cacci dent , w l e engaged i n spor t s act i vi t y

V 20 Pedal cycl act nj ur ed

15. i ay ay nont cycl i st , hi

11. i nont r af hi

V 10 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, passengerf,i cacci dent , w l e engaged i n spor t s act i vi t y

V 11 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, passengerf,i cacci dent , w l e engaged i n l ei sur e act i vi t y

11. i nont r af hi V 28 Pedal cycl i st i nj ur ed i n col l i si on

13. i nont af f acci

w t h car , pi ck- up t r uck or van, unspeci f i ed pedal rcycli icst , dent , w l e engaged i n ot her speci f i ed act i vi t i es 21 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, uns peci f i ed pedalr af f i cacci dent , w l e engaged i n l ei sur e act i vi t y

hi V 15. i ay ay nont cycl i st , hi

11. i nont r af hi

V 12 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, passengerf,i cacci dent , w l e w ki ng f or an i ncome

or 13.

V 29 Pedal cycl i st i nj ur ed i n col l i si on i nont af f acci

w t h car , pi ck- up t r uck or van, unspeci f i ed pedal rcycli icst , dent , dur i ng unspeci f i ed act i vi t y 15. i ay ay nont cycl i st , hi or

V 22 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, uns peci f i ed pedalr af f i cacci dent , w l e w ki ng f or an i ncome

11. i nont r af hi

V 13 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, passengerf,i cacci dent , w l e engaged i n ot her t ypes of w k or

13. i

V 3 Pedal cycl i st i nj ur ed i n col l i si on w t h car , hi

pi ck- up t r uck or van, w l e boar di ng or al i ght i ng V 23 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, uns peci f i ed pedalr af f i cacci dent , w l e engaged i n ot her t ypes of w k

15. i ay ay nont cycl i st , hi or

11. i nont r af hi

V 14 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, passengerf,i cacci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

V 18 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, passengerf,i cacci dent , w l e engaged i n ot her speci f i ed act i vi t i es

11. i nont r af hi V 30 Pedal cycl i st i nj ur ed i n col l i si on

13. i hi

w t h car , pi ck- up t r uck or van, w l e boar di ng or al i ght i ng, w l e engaged i n spor t s act i vi t y

hi V 24 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, uns peci f i ed pedalr af f i cacci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

15. i ay ay nont cycl i st , hi

V 19 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, passengerf,i cacci dent , dur i ng unspeci f i ed act i vi t y

11. i nont r af V 31 Pedal cycl i st i nj ur ed i n col l i si on

13. i hi

w t h car , pi ck- up t r uck or van, w l e boar di ng or al i ght i ng, w l e engaged i n l ei sur e act i vi t y

hi V 28 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, uns peci f i ed pedalr af f i cacci dent , w l e engaged i n ot her speci f i ed act i vi t i es

15. i ay ay nont cycl i st , hi

11. i nont r af c ,

V 2 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, unspeci f i ed pedal cyclfiistacci dent V 32 Pedal cycl i st i nj ur ed i n col l i si on

13. i hi hi or

w t h car , pi ck- up t r uck or van, w l e boar di ng or al i ght i ng, w l e w ki ng f or an i ncom e 15. i ay ay nont cycl i st ,

V 29 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, uns peci f i ed pedalr af f i cacci dent , dur i ng unspeci f i ed act i vi t y

11. i nont r af c , hi

V 20 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, unspeci f i ed pedal cyclfiistacci dent , w l e engaged i n spor t s act i vi t y

13.

V 33 Pedal cycl i st i nj ur ed i n col l i si on i hi hi or V

w t h car , pi ck- up t r uck or van, w l e boar di ng or al i ght i ng, w l e engaged i n ot her t ypes of w k 15. 3 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, w l e boar di ng or al i ght i ng









•W65.40 Drowning and submersion while in bath-tub, street

11. i nont r af c ,

V 21 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, unspeci f i ed pedal cyclfiistacci dent , w l e engaged i n l ei sur e act i vi t y

hi i ay ay hi

V 22 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, unspeci f i ed pedal cyclfiistacci dent , w l e w ki ng f or an i ncome

11. i nont r af c , hi or V 34 Pedal cycl i st i nj ur ed i n col l i si on

13. i hi hi

w t h car , pi ck- up t r uck or van, w l e boar di ng or al i ght i ng, w l e r est i ng, sl eepi ng, eat i ng or engagi ng iV ot her vi t alcycl i ist ti inj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, w l e boar di ng or al i ght i ng, w l e engaged i n spor t s act i vi t y

n 30 Pedal act vi es

15. i ay ay hi hi

11. i nont r af c , hi

V 23 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, unspeci f i ed pedal cyclfiistacci dent , w l e engaged i n ot her t ypes of w k or V 38 Pedal cycl i st i nj ur ed i n col l i si on

13. i hi hi

w t h car , pi ck- up t r uck or van, w l e boar di ng or al i ght i ng, w l e engaged i n ot her speci f i ed act i vi t i es V 31 Pedal cycl i st i nj ur ed

15. i ay ay hi hi

i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, w l e boar di ng or al i ght i ng, w l e engaged i n l ei sur e act i vi t y

11. i nont r af c , hi

V 24 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, unspeci f i ed pedal cyclfiistacci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

13.

V 39 Pedal cycl i st i nj ur ed i n col l i si on i hi

w t h car , pi ck- up t r uck or van, w l e boar di ng or al i ght i ng, dur i ng unspeci f i ed act i vi t y 15.

V 32 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, w l e boar di ng or al i ght i ng, w l e w ki ng f or an i ncome, w l e w ki ng f or an i ncome

i ay ay hi hi or hi or

11. i nont r af c , hi

V 28 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, unspeci f i ed pedal cyclfiistacci dent , w l e engaged i n ot her speci f i ed act i vi t i es

V 29 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, unspeci f i ed pedal cyclfiistacci dent , dur i ng unspeci f i ed act i vi t y

11. i nont r af c , 13. i

V 4 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, dr i ver , t r af f i c acci dent V 33 Pedal cycl i st i nj ur ed

15. i ay ay hi hi or

i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, w l e boar di ng or al i ght i ng, w l e engaged i n ot her t ypes of w k

V 3 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, w l e boar di ng or al i ght i ng

11. i hi V 40 Pedal cycl i st i nj ur ed i n col l i si on

13. i

w t h car , pi ck- up t r uck or van, dr i ver , t r af f i c acci dent , w l e engaged i n spor t s act i vi t y

hi 15.

V 34 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, w l e boar di ng or al i ght i ng, w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

i ay ay hi hi

11. i hi hi

V 30 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, w l e boar di ng or al i ght i ng, w l e engaged i n spor t s act i vi t y V 41 Pedal cycl i st i nj ur ed i n col l i si on

13. i hi

w t h car , pi ck- up t r uck or van, dr i ver , t r af f i c acci dent , w l e engaged i n l ei sur e act i vi t y









and highway, while engaged in sports activity

15. i ay ay hi hi

V 38 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, w l e boar di ng or al i ght i ng, w l e engaged i n ot her speci f i ed act i vi t i es

11. i hi hi

V 31 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, w l e boar di ng or al i ght i ng, w l e engaged i n l ei sur e act i vi t y

13.

V 42 Pedal cycl i st i nj ur ed i n col l i si on i hi or

w t h car , pi ck- up t r uck or van, dr i ver , t r af f i c acci dent , w l e w ki ng f or an i ncome V 39 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, w l e boar di ng or al i ght i ng, dur i ng unspeci f i ed act i vi t y

15. i ay ay hi

11. i hi hi or

V 32 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, w l e boar di ng or al i ght i ng, w l e w ki ng f or an i ncome

11.

V 33 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, w l e boar di ng or al i ght i ng, w l e engaged i n ot her t ypes of w k

i hi hi or V 43 Pedal cycl i st i nj ur ed i n col l i si on

13. i hi

w t h car , pi ck- up t r uck or van, dr i ver , t r af f i c acci dent , w l e engaged i n ot her t ypes of w k

or V 4 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, dr i ver , t r af f i c acci dent

15. i ay ay

11. i hi hi

V 34 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, w l e boar di ng or al i ght i ng, w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es V 44 Pedal cycl i st i nj ur ed i n col l i si on

13. i hi

w t h car , pi ck- up t r uck or van, dr i ver , t r af f i c acci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot15. 40viPedal act i vii tst es nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, dr i ver , t r af f i c acci dent , w l e engaged i n spor t s act i vi t y

V her t al cycl i i i ay ay hi

11. i hi hi

V 38 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, w l e boar di ng or al i ght i ng, w l e engaged i n ot her speci f i ed act i vi t i es

13.

V 48 Pedal cycl i st i nj ur ed i n col l i si on i hi

w t h car , pi ck- up t r uck or van, dr i ver , t r af f i c acci dent , w l e engaged i n ot her speci f i ed act i vi t i es V 41 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, dr i ver , t r af f i c acci dent , w l e engaged i n l ei sur e act i vi t y

15. i ay ay hi

11. i hi

V 39 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, w l e boar di ng or al i ght i ng, dur i ng unspeci f i ed act i vi t y

V 4 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, dr i ver , t r af f i c acci dent

11. i 13. i

V 49 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, dr i ver , t r af f i c acci dent , dur i ng unspeci f i ed act i vi t y V 42 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, dr i ver , t r af f i c acci dent , w l e w ki ng f or an i ncome

15. i ay ay hi or

11. i

V 40 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, dr i ver , t r af f i c acci dent , w l e engaged i n spor t s act i vi t y

hi 13. i

V 5 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, passenger , t r af f i c acci dent V 43 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, dr i ver , t r af f i c acci dent , w l e engaged i n ot her t ypes of w k

15. i ay ay hi or

11. i hi

V 41 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, dr i ver , t r af f i c acci dent , w l e engaged i n l ei sur e act i vi t y V 50 Pedal cycl i st i nj ur ed i n col l i si on

13. i hi

w t h car , pi ck- up t r uck or van, passenger , t r af f i c acci dent , w l e engaged i n spor t s act i vi t y 15. i ay ay hi

V 44 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, dr i ver , t r af f i c acci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

11. i hi or

V 42 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, dr i ver , t r af f i c acci dent , w l e w ki ng f or an i ncome

13.

V 51 Pedal cycl i st i nj ur ed i n col l i si on i hi

w t h car , pi ck- up t r uck or van, passenger , t r af f i c acci dent , w l e engaged i n l ei sur e act i vi t y V 48 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, dr i ver , t r af f i c acci dent , w l e engaged i n ot her speci f i ed act i vi t i es

15. i ay ay hi

11. i hi

V 43 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, dr i ver , t r af f i c acci dent , w l e engaged i n ot her t ypes of w k or









•X35.44 Victim of volcanic eruption, street and highway,

V 44 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, dr i ver , t r af f i c acci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

11. i hi V 52 Pedal cycl i st i nj ur ed i n col l i si on

13. i hi

w t h car , pi ck- up t r uck or van, passenger , t r af f i c acci dent , w l e w ki ng f or an i ncom e

or V 49 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, dr i ver , t r af f i c acci dent , dur i ng uns peci f i ed act i vi t y

15. i ay ay

11. i hi

V 48 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, dr i ver , t r af f i c acci dent , w l e engaged i n ot her speci f i ed act i vi t i es V 53 Pedal cycl i st i nj ur ed i n col l i si on

13. i hi or V

w t h car , pi ck- up t r uck or van, passenger , t r af f i c acci dent , w l e engaged i n ot her t ypes of w k 15. 5 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, pass enger , t r af f i c acci dent

i ay ay

11. i

V 49 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, dr i ver , t r af f i c acci dent , dur i ng unspeci f i ed act i vi t y V 54 Pedal cycl i st i nj ur ed i n col l i si on

13. i hi n 50 Pedal act vi es

w t h car , pi ck- up t r uck or van, passenger , t r af f i c acci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng iV ot her vi t alcycl i ist ti inj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, pas senger , t r af f i c acci dent , w l e engaged i n spor t s act i vi t y

V 5 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, passenger , t r af f i c acci dent

11. i 15. i ay ay hi

V 50 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, passenger , t r af f i c acci dent , w l e engaged i n spor t s act i vi t y

11. i hi V 58 Pedal cycl i st i nj ur ed i n col l i si on

13. i

w t h car , pi ck- up t r uck or van, passenger , t r af f i c acci dent , w l e engaged i n ot her speci f i ed act i vi t i es V 51 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, pas senger , t r af f i c acci dent , w l e engaged i n l ei sur e act i vi t y

hi 15. i ay ay hi

11.

V 51 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, passenger , t r af f i c acci dent , w l e engaged i n l ei sur e act i vi t y

i hi V 59 Pedal cycl i st i nj ur ed i n col l i si on

13. w t h car , pi ck- up t r uck or van, passenger , t r af f i c acci dent , dur i ng unspeci f i ed act i vi t y

i 15.

V 52 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, pas senger , t r af f i c acci dent , w l e w ki ng f or an i ncome

i ay ay hi or

11. i hi

V 52 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, passenger , t r af f i c acci dent , w l e w ki ng f or an i ncome

or 13. i

V 9 Pedal cycl i st i nj ur ed i n col l i si on w t h car , pi ck- up t r uck or van, unspeci f i ed pedal cycl i st , t r af f i c acci dent 15. i ay ay hi

V 53 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, pas senger , t r af f i c acci dent , w l e engaged i n ot her t ypes of w k or

11. i hi

V 53 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, passenger , t r af f i c acci dent , w l e engaged i n ot her t ypes of w k or









while resting, sleeping, eating or engaging in other vital

13.

V 90 Pedal cycl i st i nj ur ed i n col l i si on i hi

w t h car , pi ck- up t r uck or van, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n spor t s act i vi15. 54 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, pas senger , t r af f i c acci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

Vt y i ay ay hi

11. i hi

V 54 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, passenger , t r af f i c acci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

V 58 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, passenger , t r af f i c acci dent , w l e engaged i n ot her speci f i ed act i vi t i es

11. i hi V 91 Pedal cycl i st i nj ur ed i n col l i si on

13. i hi

w t h car , pi ck- up t r uck or van, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n l ei s ur e act iV t y Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, pas senger , t r af f i c acci dent , w l e engaged i n ot her speci f i ed act i vi t i es

vi 58

15. i ay ay hi

11. i

V 59 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, passenger , t r af f i c acci dent , dur i ng unspeci f i ed act i vi t y V 92 Pedal cycl i st i nj ur ed i n col l i si on

13. i hi or

w t h car , pi ck- up t r uck or van, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e w ki ng f or an i ncome V 59 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, pas senger , t r af f i c acci dent , dur i ng unspeci f i ed act i vi t y

15. i ay ay

11. i

V 9 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, unspeci f i ed pedal cycl i st , t r af f i c acci dent 13.

V 93 Pedal cycl i st i nj ur ed i n col l i si on i hi

w t h car , pi ck- up t r uck or van, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n ot her t9 Pedal cyclk st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, unspeci f i ed pedal cycl i st , t r af f i c acci dent

11. i

V 90 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n s por t s act i vi t y

hi V ypes of w i

15. or i ay ay

V 91 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n l ei sur e act i vi t y

11. i hi V 94 Pedal cycl i st i nj ur ed i n col l i si on

13. i hi

w t h car , pi ck- up t r uck or van, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e r est i ng, sl eepi ng, eat iV or engagi ng i n st her ur edali nact i vii t i es w t h r ai l w

ng 90 Pedal cycl i ot i nj vi t

15. col l si on i ay ay hi

t r ai n or r ai l w vehi cl e, uns peci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n spor t s act i vi t y

V 92 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e w ki ng f or an i ncome

11. i hi or V 98 Pedal cycl i st i nj ur ed i n col l i si on

13. i hi

w t h car , pi ck- up t r uck or van, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n ot her speci f i15. 91 Pedal i es i st i nj ur ed i n col l i si on w t h r ai l w

V ed act i vi t cycl i ay ay hi

t r ai n or r ai l w vehi cl e, uns peci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n l ei sur e act i vi t y









activities

11. i hi

V 93 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n ot her t ypes of w k or 13.

V 99 Pedal cycl i st i nj ur ed i n col l i si on i

w t h car , pi ck- up t r uck or van, unspeci f i ed pedal cycl i st , t r af f i c acci dent , dur i ng uns peci f i ed act i vi t y V 92 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w

15. i ay ay hi or

t r ai n or r ai l w vehi cl e, uns peci f i ed pedal cycl i st , t r af f i c acci dent , w l e w ki ng f or an i ncome

11. i hi

V 94 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

14 i

V Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus 15.

V 93 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w

i ay ay hi or

t r ai n or r ai l w vehi cl e, uns peci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n ot her t ypes of w k

11. i hi

V 98 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, unspeci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n ot her speci f i ed act i vi t i es

11.

V 99 Pedal cycl i st i nj ur ed i n col l i si on w t h ot her pedal cycl e, unspeci f i ed pedal cycl i st , t r af f i c acci dent , dur i ng unspeci f i ed act i vi t y

i V 0 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t

14. i vehi cl e or bus, drafverc,

nont r i f i acci dent 15. i ay ay hi

V 94 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, uns peci f i ed pedal cycl i st , t r af f i c acci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

12 i o-

V Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- wheel ed mot or vehi cl e V 00 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy

14. i nont r i f i hi

t r anspor t vehi cl e or bus, drafverc,acci dent , w l e engaged i n spor t s act i vi t y 15. i ay ay hi

V 98 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, uns peci f i ed pedal cycl i st , t r af f i c acci dent , w l e engaged i n ot her speci f i ed act i vi t i es

12. i o-

V 0 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w nont dr i f i c,

heel ed mot or vehi cl e, r af ver acci dent

14. i

V 01 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy nont r i f i

t r anspor t vehi cl e or bus, drafverc,acci dent , w l e engaged i n l ei sur e act i vi t y

hi 15. i ay ay

V 99 Pedal cycl i st i nj ur ed i n col l i si on w t h r ai l w t r ai n or r ai l w vehi cl e, uns peci f i ed pedal cycl i st , t r af f i c acci dent , dur i ng unspeci f i ed act i vi t y

12. i o-

V 00 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w e, r af f i c, hi

heel ed mot or vehi clnont dr i ver acci dent , w l e engaged i n spor t s act i vi t y

12.

V 01 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

i o- heel ed mot or vehi clnont dr i ver acci dent , w l e engaged i n l ei sur e act i vi t y

e, r af f i c, hi V 02 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy

14. i nont r i f i hi

t r anspor t vehi cl e or bus, drafverc,acci dent , w l e w ki ng f or an i ncome

or 16 i ot her

V Pedal cycl i st i nj ur ed i n col l i si on w t h nonmot or vehi cl e

12. i

V 02 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

o- e, r af f i c,

heel ed mot or vehi clnont dr i ver acci dent , w l e w ki ng f or an i ncome

hi or V 03 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy

14. i nont r i f i hi

t r anspor t vehi cl e or bus, drafverc,acci dent , w l e engaged i n ot her t ypes of w k or 16. i ot her nont

V 0 Pedal cycl i st i nj ur ed i n col l i si on w t hnonmot or vehi cl e, dr i ver , r af f i cacci dent

12. i o-

V 03 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w e, r af f i c, hi

heel ed mot or vehi clnont dr i ver acci dent , w l e engaged i n ot her t ypes of w k or 14. i

V 04 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy nont r i f i hi

t r anspor t vehi cl e or bus, drafverc,acci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her V t 00 act i vi cycl i st i nj ur ed i n col l i si on w t h nonmot or vehi cl e, dr i ver , r af f i cacci dent , w l e engaged i n spor t s act i vi t y

vi

16. al Pedal t i es i ot her nont hi

12. i o-

V 04 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w e, r af f i c, hi

heel ed mot or vehi clnont dr i ver acci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

14. i

V 08 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy nont r i f i

t r anspor t vehi cl e or bus, drafverc,acci dent , w l e engaged i n ot her speci f i ed act i vi t i es

hi 16. i ot her nont hi

V 01 Pedal cycl i st i nj ur ed i n col l i si on w t h nonmot or vehi cl e, dr i ver , r af f i cacci dent , w l e engaged i n l ei sur e act i vi t y

12. i o-

V 08 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w e, r af f i c, hi

heel ed mot or vehi clnont dr i ver acci dent , w l e engaged i n ot her speci f i ed act i vi t i es

12. i

V 09 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

o- heel ed mot or vehi clnont dr i ver acci dent , dur i ng unspeci f i ed act i vi t y

e, r af f i c, 14. i

V 09 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, drafverc,acci dent , dur i ng unspeci f i ed act i vi t y

nont r i f i 16. i ot her nont hi

V 02 Pedal cycl i st i nj ur ed i n col l i si on w t h nonmot or vehi cl e, dr i ver , r af f i cacci dent , w l e w k or

12. i o-

V 1 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w heel ed mot or vehi cl e, nont r af f i cacci dent

passenger , 14. i

V 1 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t passenger ,

vehi cl e or bus, nont r af f i cacci dent

12. i o-

V 10 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w passenger , hi

heel ed mot or vehi cl e, nont r af f i cacci dent , w l e engaged i n spor t s act i vi t y

14. i

V 10 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy passenger , hi

t r anspor t vehi cl e or bus, nont r af f i cacci dent , w l e engaged i n spor t s act i vi t y

12. i o-

V 11 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w passenger , hi

heel ed mot or vehi cl e, nont r af f i cacci dent , w l e engaged i n l ei sur e act i vi t y

V 12 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

12. i o- heel ed mot or vehi cl e, nont r af f i cacci dent , w l e w ki ng f or an i ncome

passenger , hi or 14. i

V 11 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, nont r af f i cacci dent , w l e engaged i n l ei sur e act i vi t y

passenger , hi

12. i o-

V 13 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w heel ed mot or vehi cl e, nont r af f i cacci dent , w l e engaged i n ot her t ypes of w k

passenger , hi or 14. i

V 12 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, nont r af f i cacci dent , w l e w ki ng f or an i ncome

passenger , hi or

12. i o-

V 14 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w passenger , hi

heel ed mot or vehi cl e, nont r af f i cacci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t iV 13 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy

es

14. i passenger , hi or

t r anspor t vehi cl e or bus, nont r af f i cacci dent , w l e engaged i n ot her t ypes of w k

12. i o-

V 18 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w passenger , hi

heel ed mot or vehi cl e, nont r af f i cacci dent , w l e engaged i n ot her speci f i ed act i vi t i es

14. i

V 14 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy passenger , hi

t r anspor t vehi cl e or bus, nont r af f i cacci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

12. i o-

V 19 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w passenger ,

heel ed mot or vehi cl e, nont r af f i cacci dent , dur i ng unspeci f i ed act i vi t y

12. i o-

V 2 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w heel ed mot or vehi cl e, unspeci f i ed pedal r af f i cacci dent

nont cycl i st , 14. i

V 18 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, nont r af f i ,c w l e engaged i n ot her speci f i ed act i vi t i es acci dent

passenger , hi

12. i o-

V 20 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w nont cycl i st ,

heel ed mot or vehi cl e, unspeci f i ed pedal r af f i cacci dent , w l e engaged i n spor t s act i vi t y

hi 14. i

V 19 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy passenger ,

t r anspor t vehi cl e or bus, nont r af f i ,c dur i ng unspeci f i ed act i vi t y acci dent

12. i o-

V 21 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w nont cycl i st , hi

heel ed mot or vehi cl e, unspeci f i ed pedal r af f i cacci dent , w l e engaged i n l ei sur e act i vi t y

14. i

V 2 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t nont cycl cst ,

vehi cl e or bus, unspeci f i ed pedal r af f i i acci dent

12. i o-

V 22 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w nont cycl i st , hi or

heel ed mot or vehi cl e, unspeci f i ed pedal r af f i cacci dent , w l e w ki ng f or an i ncome

V 23 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w

12. i o- heel ed mot or vehi cl e, unspeci f i ed pedal r af f i cacci dent , w l e engaged i n ot her t ypes of w k

nont cycl i st , hi or 14. i

V 20 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, unspeci f i ed pedal r cycli icacci dent , w l e engaged i n spor t s act i vi t y

nont af f st , hi

12. i o-

V 24 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w V t al Pedal es i

heel ed mot or vehi cl e, unspeci f i ed pedal r af f i cacci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi14. 21act i vi t icycl i st i nj ur ed i n col l i si on w t h heavy

nont cycl i st , hi t r anspor t vehi cl e or bus, unspeci f i ed pedal r cycli icacci dent , w l e engaged i n l ei sur e act i vi t y

nont af f st , hi

12. i o-

V 28 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w nont cycl i st , hi

heel ed mot or vehi cl e, unspeci f i ed pedal r af f i cacci dent , w l e engaged i n ot her speci f i ed act i vi t i es V 22 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy

14. i nont af f st , hi or

t r anspor t vehi cl e or bus, unspeci f i ed pedal r cycli icacci dent , w l e w ki ng f or an i ncome

12. i o-

V 29 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w nont cycl i st ,

heel ed mot or vehi cl e, unspeci f i ed pedal r af f i cacci dent , dur i ng unspeci f i ed act i vi t y

14. i

V 23 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy nont af f st , hi or

t r anspor t vehi cl e or bus, unspeci f i ed pedal r cycli icacci dent , w l e engaged i n ot her t ypes of w k

12. i o-

V 3 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w hi

heel ed mot or vehi cl e, w l e boar di ng or al i ght i ng

14. i

V 24 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy nont af f st , hi

t r anspor t vehi cl e or bus, unspeci f i ed pedal r cycli icacci dent , w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

12. i o-

V 30 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w hi hi

heel ed mot or vehi cl e, w l e boar di ng or al i ght i ng, w l e engaged i n spor t s act i vi t y

14. i

V 28 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy nont af f st , hi

t r anspor t vehi cl e or bus, unspeci f i ed pedal r cycli icacci dent , w l e engaged i n ot her speci f i ed act i vi t i es

12. i o-

V 31 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w hi hi

heel ed mot or vehi cl e, w l e boar di ng or al i ght i ng, w l e engaged i n l ei sur e act i vi t y

14. i

V 29 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy nont af f st ,

t r anspor t vehi cl e or bus, unspeci f i ed pedal r cycli icacci dent , dur i ng unspeci f i ed act i vi t y

12. i o-

V 32 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w hi hi or

heel ed mot or vehi cl e, w l e boar di ng or al i ght i ng, w l e w ki ng f or an i ncom e

14. i

V 3 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t hi

vehi cl e or bus, w l e boar di ng or al i ght i ng

12. i o-

V 33 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w hi hi

heel ed mot or vehi cl e, w l e boar di ng or al i ght i ng, w l e engaged i n ot her t ypes of w k or

14. i

V 30 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy hi hi

t r anspor t vehi cl e or bus, w l e boar di ng or al i ght i ng, w l e engaged i n spor t s act i vi t y

12. i o-

V 34 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w hi hi

heel ed mot or vehi cl e, w l e boar di ng or al i ght i ng, w l e r est i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

14. i

V 31 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy hi hi

t r anspor t vehi cl e or bus, w l e boar di ng or al i ght i ng, w l e engaged i n l ei s ur e act i vi t y

12. i o-

V 38 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w hi hi

heel ed mot or vehi cl e, w l e boar di ng or al i ght i ng, w l e engaged i n ot her speci f i ed act i vi t i es

14. i

V 32 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy hi hi or

t r anspor t vehi cl e or bus, w l e boar di ng or al i ght i ng, w l e w ki ng f or an i ncome

12. i o-

V 39 Pedal cycl i st i nj ur ed i n col l i si on w t h t w or t hr ee- w hi

heel ed mot or vehi cl e, w l e boar di ng or al i ght i ng, dur i ng unspeci f i ed act i vi t y

14. i

V 33 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy hi hi or

t r anspor t vehi cl e or bus, w l e boar di ng or al i ght i ng, w l e engaged i n ot her t ypes of w k

14. i hi hi

V 34 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, w l e boar di ng or al i ght i ng, w l e r es t i ng, sl eepi ng, eat i ng or engagi ng i n ot her vi t al act i vi t i es

14. i hi hi

V 38 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, w l e boar di ng or al i ght i ng, w l e engaged i n ot her speci f i ed act i vi t i es

14. i hi

V 39 Pedal cycl i st i nj ur ed i n col l i si on w t h heavy t r anspor t vehi cl e or bus, w l e boar di ng or al i ght i ng, dur i ng unspeci f i ed act i vi t y









17

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



18

Conceptual Lego… it could be...

Goodbye to picking lists…

Structured Data Entry

File Edit Help





Cycling Accident



What you hit





Your Role





Activity





Location



19

Intelligent Forms









20

And generate it in language









…a great missed opportunity in SNOMED

21

Logic as the clips for

“Conceptual Lego” gene

hand protein

extremity polysacharide

body cell



expression



chronic Lung

acute infection



abnormal inflammation

normal bacterium

deletion polymorphism

ischaemic virus

mucus



GALEN, SNOMED-RT/CT 22

Logic as the clips for

“Conceptual Lego”

“SNPolymorphism of CFTRGene causing Defect in MembraneTransport of

Chloride Ion causing Increase in Viscosity of Mucus in CysticFibrosis…”









“Hand which is

anatomically

normal”









23

Species

Genes





Protein







Function

Gene in humans





Disease

Protein coded by

gene in humans

Build complex

representations from Function of

Protein coded by

modularised gene in humans

primitives Disease caused by abnormality in

Function of

Protein coded by

gene in humans

24

Normalising (untangling)

Ontologies

Structure

Structure Part-whole Function

Function









Part-whole









25

Problem:

System may be perfect

…but

Users still fallible







26

User Problems

variability

Inter-rater Headcloth X X

Cloth X X X

Scarf X

Model Person X X X

Woman X X X X X

Adults X

Standing X X X X X

Background X X

Brown X X X X X

Blue X X X

Chemise X

Dress X X X X

Tunics X

Clothes X

Suitcase X X X X

Luggage X

Attache case X

Brass Instrument X X X

French Horn X

Horn X 27

Tuba X X

User Problems

Inter-rater variability



New codes added per Dr per year

READ CODE Practice A Practice B

Sore Throat Symptom 0.6 117

Visual Acuity 0.4 644

ECG General 2.2 300

Ovary/Broad Ligament Op 7.8 809

Specific Viral Infections 1.4 556

Alcohol Consumption 0 106

H/O Resp Disease 0 26

Full Blood Count 0 838

28

Repeatability

Inter-rater reliability

• Only ICPC has taken seriously

– Originally less than 2000 well tested rubrics with proven

inter-rater reliability across five languages

• As it has been put into wider use, has grown and is less tested





• Includes the delivery software

– Confounding, but we can‟t ignore it





• …but we all have ignored it

– GALEN was at least as bad as the rest







29

Where next?



The genome / ‟omics explosion

• Open Biolological Ontologies (OBO)

– Gene Ontology, Gene expression ontology (MGED), Pathway ontology

(BioPAX), …

• 400+ bio databases and growing



• National Cancer Institute Thesaurus

• CDISC/BRIDG - Clinical Trials

• HL7 genomics model…

• …









Coming to an Electronic Healthcare

Record near you! 30

Key issue 1:

Creating an open community

• Centrally created terminologies have succeeded for

three reasons

– Coercion - use them or don‟t get paid

• ICD-CM, CPT, MEDDRA, Read 2

– They belonged to the community and were useful or key to

software

• LOINC, HL7v2, Gene Ontology, Read 1 …

– They gave access to a key resource

• MeSH, BNF, …









31

Logic + Web liberates users to “own” the

ontology: Open ‘Just-in-time Terminology’



• If you can test the consequences then you can

give users the freedom to develop

– New compositions

– New additions to established lists









32

…but logic & formal ontology

scare users

• Require months to train even to a minimal level

• People make errors

– Even experienced people

• Logic inferences can be directly contrary to language maxims

• Make logic (& formal ontology) the “assembly

language”

– Give users high level languages

• Ideally built with meta-authoring language construction kit









33

Intermediate Representations

“Close to user forms”

Before:

SurgicalProcess Õ

(Ô which

isMainlyCharacterisedBy (performance which

SurgicalFixing Õ

isEnactmentOf (Ô which

SurgicalAccessingÕ

hasSpecificSubprocess (Ô

hasSurgicalOpenClosedness (SurgicalOpenClosedness which

hasAbsoluteState surgicallyOpen))



actsSpecificallyOn (PathologicalBodyStructure which ))))

34

Intermediate Representations

“Close to user forms”

After:



"Open fixation of a fracture of the neck of the left

femur"

– MAIN fixing

ACTS_ON fracture

HAS_LOCATION neck of long bone

IS_PART_OF femur

HAS_LATERALITY left

HAS_APPROACH open





From 3-6 months training

to 3-6 days training

35

Supports Loosely coupled distributed

ontology development







global

local cycles:

cycle &

work by users

work at

centre



From authoring

From 80% central/global effort to meta-authoring

to 10% central/global effort & managing QA

including doing QA

36

Key issue II:

Applications centric development

• If it is built for everything it will be fit for nothing!

• Must have a way to see if it works

– If it is built for just one thing it will not be fit even for that

• Change is the only constant





• Cannot predict which abstractions needed in advance

– Even very large ontologies tend to be missing 50% or more

when applied in practice

• Compose them when you need them and share









37

Key issue III:

Binding to Applications & the EHR

• HL7 v3 + SNOMED = Chaos

– Unless we can formalise the mutual constraints

• The documentation is beyond human capacity

– To write or to understand





• Templates/Archetypes + SNOMED = Missed opportunities

– Unless we trivialise the terminology

… or chaos if we attempt to use the terminology





• Requires new tools

– Formalisms probably inadequate





38

Key issue IV:

Decision support

• Meaningful decision support is still rare

– Terminology is not the only problem

• But it is one barrier



– Terminology/ontology should be the scaffolding

• But requires the terminology to be reliable & computable



– Inter-rater reliability crucial

• Can we afford GIGO for patient management?



– Semantics of combined EHR+Terminology must be well defined









39

Key issue V:

Avoiding “Pregacy”

• Prebuilt legacy

– Obsolescence or known errors built in from the beginning



• ≤ .01% of SNOMED coded data to be held in 10

years time has been collected

– Fixes now will be less expensive than fixes later

– Quality should be dealt with now

• Rigorous schemas rigorously adhered to

• Conformance and Regression testing

– Cannot depend on people to do it right

» Must be formally verifiable



• It‟s software - Let‟s have some basic software engineering!







40

Key issue VI:

Empirical data

• Need empirical data on

– What‟s worth doing - what‟s essential

• Language used by doctors

• Terms used

– What works

• Reliability of terms used - errors made

• Effect on Decision Support and other applications

– What scales

• What are the consequences of design decisions

– Effort required to develop software

• Usability of development tools

– Effort required by users

• Usability of interfaces and clinical systems



• Where is the science base for our work?





41

Key issue VII:

Human Factors-

Helping with a humanly impossible task

• Language technology will help

– But will always have limitations

• Tailored forms will help

– But we must beet the combinatorial explosion

• Language generation will help

– And why aren‟t we using it?

• Also one of the best means of QA









• The best people may not be informaticians, medics, or biomedical scientists

GET THEE TO A USABILITY LAB!

RECRUIT ETHNOGRAPHERS!

42

Key Issue VIII:

Sustainability

There is no free lunch!

It will have to be paid for somehow

• Maintaining any national/regional system will cost money

• Regardless of cost of SNOMED membership, there will be

costs for

• Translation / Localisation / Europeanisation

• Coordination with centre and other bodies

• Liaison with professions and outreach

• Training

• Quality assurance locally

– Guestimate: €1.5M/year/centre … + “free” professional time

• IF we are convinced of the value,

trivial in comparison to total healthcare IT costs

– … but real money that could be spent on something else

– … or be spent anyway in bits inefficiently and ineffectively

– … and the issue is really shortage of skilled people

43

Key issue IX: Internationalisation



• What is needed?

– Translations?

– New „concepts‟?

• How many?

• What for?

– New Processes

• New Authorities

– New Quality assurance

• Does it meet specific countries‟ requirements?

• You tell us?







44

Key issue X: Quality…









45

Part II:Quality and Quality Assurance:





• Quality assurance Process

– It is the process of that assures





• Quality of Product

– The goal and evidence for the process









46

Quality against purpose

• A controlled vocabulary -

Can a configuration engineer can put identifiers behind a form?

– Management of identifiers / change management

– “Coverage” / “Sensitivity”, Inter-rater reliability

• A browsable index and term finding -

Can a user can choose a code reliably?

– Lexicon of “Terms”

– Specificity, Inter-rater reliability

– Organisation and structure

• Classification/retrieval for epidemiology -

Can the codes be transformed into required classifications reliably

– Can it be used on its own or must there still be manual coding?

• Formal representation: Intelligent interfaces and applications -

Can the right inferences be drawn - can applications depend on it?

– Sound formalism & schemas consistently applied

– Correct definitions and hierarchies

47

An orthogonal quality assurance framework

• Product

– Context

– Content

– Consequences

– Maintainability, evolution

– Transparency

– Human factors

• Process

– Technical

– Organisational

– Sustainability

– Inter-community acceptance





48

Some specific issues of Quality:

Content



• A Priori Coverage just a matter of size

– Test against what purposes

– Are the constructs there? Are the building blocks there?

• Every application needs different abstractions

– Leeds to 25% - 50% raw coverage in clinical systems









49

Consequences: Inferences and Engineering



• Ontologies are mathematical theories and engineering

artifacts

– They are tested by

• whether the „correct‟ inferences follow from them

• whether they can be engineered robustly





• Manifest in hierarchies and ‘inheritance’ of definitions

– First test is whether things are in the right place

• It is easier to see commissions than omissions

– Classification should help - turns omission into commission









50

Product and Process:

Ontologies are living artifacts



• The test of process is change, evolution & update

– What is required to make a change

• How long does it take

• Can we test that the results are still sound after the change

– “Regression testing”



• Test designs for change before use

– Design the process for

• Updates, tracking, provenance, metadata









51

Thinking about SNOMED & Quality, for…

• A controlled vocabulary



• A browsable index and term finding



• Classification/retrieval for epidemiology



• Formal representation for applications & inference



The view of an informed outsider

with respect for many of the individuals and work

but grave reservations about the process and current product



… who is concerned that at a time of change we get it right

52

…who would be pleased to have critiques refuted

SNOMED Quality:

As a controlled Vocabulary (pre-coordinated)

• Product

– Content: Good but patchy - but bigger than anything else 

– Maintainability, evolution - good tracking of identifiers, etc. 

– Transparency: delivery file formats well documented 

– Human factors / inter-rater reliability: largely untested 

• Some very worrying evidence

• Complexity makes reliability difficulty

• Virtually no text definitions / paraphrases



• Process

– Organisational

• Openness: process restricted; 

• Responsiveness: slow 

– Sustainability - probably good if widely accepted 

– Acceptance - still in only limited use 

Serious problems with links to the bioscience community 

• Not sufficient on its own for clinical research

53

SNOMED Quality:

Browsable Index & Lexicon

• Product

– Specificity: Size a major problem 

• Long, long lists, especially for systems developers

• 450K terms for ≤10K in use?

– “Subsets coming … Real Soon Now”

– Potential confusion between 

• … Associated condition, History of … etc.

– Findings and Observables mixed 

• Makes a user interface based on guidelines does not work

– “Findings” and “Observables” not used consistently

– Context dependent terms separate from main hierarchy 

• Everything must be searched for in at least two places

• Reliable search confined to “gurus”

• Process

– Largely deemed “out of scope” ???

• Subset mechanism appears to be largely top-down

• Currently, Largely dependent on CLUE Browser

– but see other papers in this conference

54

SNOMED Quality:

Classification for epidemiology

• Translation to ICD 9/10 

– Accuracy of data collected via SNOMED and then translated to ICD remains

to be proven

• Not easy - especially if ICD volume II rules included

– Requires a major training effort for coding staff

• But first requires the proven methods on which to train them

– Requires active collaboration with WHO, Secondary Uses and its equivalents,

MEDDRA, …, …, …

• FDA use a major plus 



• Major questions remain about secondary use of routinely collected data

– At what level are the goals of clinical care and epidemiology/ clinical research

compatible?

• A bigger question than SNOMED

• But important to SNOMED

– Where are the epidemiologists in the SNOMED Organisation?





55

SNOMED Quality:

Applications, hierarchies, inference

• Content 

– Hierarchies seriously flawed

– Large number of errors that would be caught by any effective QA

– Errors that would be picked up by published methods

• “Lexically assign logically refine” but “Severe asthma” not a kind of “Asthma”

• Unable to find users who will depend on them

– Public statement by First Data Bank triggered this talk

– Modal comment from commercial and provider users: dismissive



• Process 

– Fundamentally a management problem - no quality culture - no software

engineering culture - required resources not allocated

• Attitude from SNOMED: “Nothing is perfect”

– No public process or declarations of what has, and has not, been QAed

• Individuals can get things fixed, but no dependable process

• No one publicly in charge of quality

– This should be an ISO 9000 issue



56

Quality best addressed by Openness

• Under the SDO SNOMED has so far remained closed,

at least in the UK (a special bad case?) 

• License still highly restrictive 

– No acceptable UK academic license

• At least Manchester, Oxford, and Cambridge have refused to sign

– Not used in major clinical and genomic research projects

– “Re-engineering” contravenes license -

• Most research on structure of SNOMED is currently illegal !

• Opaque - no specifications 

– No specification for formalism published by SDO or CAP

• Major questions remain

– Role Groups, Right identities, … …

• No conformance testing of tools possible

– It does what we say it does - as shown by what it does

– Sources unavailable -

• The stated form is the source code, the delivery form is the object code

• No research on alternative formalisms possible

• Discussion restricted but opening up

– CMWG site is not public but less closed  57

Other issues

• Technology lag - a fact of life in a changing world

– SNOMED built on 1980s technology

• Mature

• Idiosyncratic & nonstandard

• Many restrictions due to constraints that are no longer necessary

• ”Electronic paper” in the age of the Web



– Should be updated

• To Web Speed urgently

• To consider social computing, Web II, … soon

• To new formalisms and Semantic Web Technology carefully

– Could use standard constructs for “role groups”

– Could include true negation carefully

– A standard formalism would make standard tools applicable



– Migration plan needed sooner to avoid “pregacy”

• Even though „events‟ will overtake it





58

What to do?



• Greatest tragedy

– Waste the opportunity and effort so far



• Second greatest tragedy

– Go forward without fixing problems

• Waste future resources coping with problems

– Squander future opportunities - it won‟t work well enough

– Impose a tax on future healthcare

– Obstruct realising the benefits of IT for healthcare









59

What to do?

Overall

• Accept that this is fundamentally a matter of process

and management!

– Individuals are working very hard and often well.

• Management must make quality assurance the top priority





• Accept that there is no free lunch!

– Admit that there are serious problems

• fixing them will cost resources and the discomfort of change

– Other things will be delayed





• Therefore the structure of the new SDO is critical

– This is the time to make changes





60

What to do?

Quality

• Changes in SDO organisation

– Member of board for Quality Assurance - sole responsibility

– Senior member of operations unit for QA- sole responsibility



• Changes in process

– Fully open and honest QA process

– Public statement on problems and public health warning until fixed

– Public commitment to specific quality criteria and success in specific

applications.

– Engagement with providers, vendors on key criteria for QA



• Major technical effort

– Set up an independent quality assessment unit

• The developers can‟t lead it because they can‟t see it!

– but also use existing skills - 50% of CMWG time

– Invest in crash effort at improvement of quality

• Initial goal of say 25K guaranteed QAed & reliability assessed codes

– Use effort as experiment to investigate:

• Hierarchies: “Rebuild or repair”? 61

• Use of social computing?

What to do:

Openness

• Process

– Provide open licenses

– Establish a fully open process

– Public engagement with community

– Engage with outside experts



• Product

– Publish specifications for formalisms

– Publish stated form

– Publish conformance & regression tests

– Publish of bug lists and errors and health warnings

– Build to tools to make large scale collaboration realistic





62

What to do?

Human Factors



• Take on usability and inter-rater reliability as a core

responsibilities

– Add Text Paraphrases everywhere they are not trivial

– Adopt language generation techniques for presentation and

QA

• Do the studies!!

– Involve epidemiologists & behavioural scientists









63

Perspective on costs:

…the real costs are people not money!

• How to build up the cadre of trained people?

– How to improve skills of those already engaged

– How to recruit in the expertise from elsewhere

• Biosciences

• The Semantic Web

• E-Science

• Logic and terminologies are hard

– And the subject of religious wars

• Training and retraining are critical

• We must make it easier

– Better tooling

• Intermediate representations and close to user forms

– It can be done!



65

The bottom line:

Will SNOMED help to realising my dream? Yours?



Or will it be a barrier? Irrelevant? A tax? Or…?

Clinical research

Clinical Data Clinical & Best

Terminology Entry Record Decision Support Practice



Healthcare

Mr Ivor Bigun

Dun Roamin

Anytown

Any country

4431 3654 90273









SNOMED Clinical research

Data Electronic Best

Ontologies &

Description Entry Health

logics Decision Support & Practice

Records

Knowledge

Presentation



66

Conclusion

• For a controlled vocabulary

– Identifier & term management is a major success to build on

• But there are questions about inter-rater reliability and re-use





• There are major problems with structure and hierarchies for browsing,

user interfaces, secondary use , applications & decision support

– Many claimed and desired benefits depend on fixing them



• There is no free lunch

– Costs to every option

– But costs modest compared to Healthcare IT spend

– People (“capacity”) is a more serious constraint than money



• It‟s a management issue: Acknowledge problems & make changes

– Fundamentally a matter of process:

• Can the SDO change to be the vehicle for the needed change?

– I hope so.

Grasp the opportunity!

Make the changes! Demand that the changes be made! 67