Rector by chenmeixiu

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									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 <
                       involves Bone
                       hasUniqueAssociatedProcess FracturingProcess
                       hasSpecificLocation (Collum which

                           isSpecificSolidDivisionOf (Femur which
                              hasLeftRightSelector leftSelection ))>))))
                                                                           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

								
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