 This is this is a refined circle Okay And I think that it what it what it what it sort of emphasizes is this idea that there's You know, so so no one else in this room is a rhythmic guy So you don't know what figure of eight reentry is but it's a big it's a it's a it's a big deal in my world And this is the one reentrant loop that you actually don't want to interrupt But so I leave it at that There's this feedback that goes on all the time between clinical and basic research and between and that goes on in the in the in the In the in the in the electronic record environment as well as anywhere else. So so Plans for me meeting was the real slide Terry and I and a bunch of other people thought about this problem last night and And we thought about themes for the meeting we thought about So what what are the barriers to executing this vision of genomic medicine? We all sort of seem to have in in in and at the 50,000 or 500,000 foot view We sort of share it and when you get down to the 1,000 foot view We all have different ideas of what that vision actually looks like but but the notion was to to focus the next meeting on On Barriers to executing that kind of vision so Let better navigating it's this one. So here's the the slide that Terry thankfully made up for me The original the original theme was going to be standardizing formats and and we we talked it through last night We've talked it through today, and I don't think we're ready to have a day and a half long meeting on standardizing formats And and these are so this is a proposal. This is not I don't think this is written in in Stone this has been bothering me the entire meeting this this electricity keeps on bouncing back and forth on this laptop so the notion was to focus on the barriers and how how we might Address them one of the barriers that we keep on hearing about But I don't think we have a good sense of how that how it really works in in real time is the payers I added the pharmacy benefits people to this list after we had spoken last night, and then and perhaps CMS is the sort of ultimate payer We talk a lot about clear and what that means but we thought it might be useful to hear from people who actually set those standards and then And then some of the genomic reference expertise as a as a as a way of dealing with again another barrier to Incorporating genomic information into the flow of clinical health care the notion of Seeing some early deliverables at the May meeting Is written down on this slide. I won't say who wrote it down Because we all take we all I'm standing here presenting it. So so I have to take some credit for it. I already see Debbie Notting her head. No Well, so so I think the the the way to think about this is to think about what it is we want to accomplish as a group and What it is that? What we could what we could Do is to think about the barriers to Executing the visions that we have and then deal with them so that was the proposal and and I think I'm open to comment for a for a I was about to say you're not even mark retain has anything to say but that was I spoke too soon mark So maybe maybe from the University of Wisconsin to start with right? I Okay, so I mean actually Yeah, Dan, I mean I'm getting back to the awesome Tiffany standards and the question really is We had come up with an awful lot you know in terms of Not only the sequencing data analysis, but also and what is actually Quite a substantial undertaking as you know The phenotype standards. Did you include the phenotype? Is that included in the Tiffany standards and how should we think about this between now and May? I'll answer that question. Good because I'm glad somebody's gonna Oh, so so so the well You were in the room last night So we talked a lot about that and and it wasn't a major focus of how he's talked this morning But I think it is part of what we want. We want to get accomplished now that that said I'm not sure that Tiffany standards, and I'm not sure where that I'm not even sure that where that word came from although we talked about I get it I get it I Get it I get it for those of you who weren't in the room It was not a well lit bright room with a table It was it was a little dungeon down in the third subbasement with a bunch of chairs around the edges and bad fluorescent lighting And that was it no pictures on the walls or anything Well next meeting what next time next time we're gonna meet in the ladies room so so so the Tiffany standards, okay Now I got I get it You know would probably include a section on phenotyping But I guess If we're gonna develop those kinds of standards somebody needs to start to work on them and and then they can present to us wherever they are When they are there and I will talk about that next steps, so we Debbie I think there are a couple things here. I mean I guess Clea and cap certification and experts would be interesting to engage them in the Tiffany Standards kind of thing. I mean because you develop a set of standards if they don't meet any guidelines then you're in trouble and We've heard that some people are considering the laboratory guidelines, but maybe not the analysis guidelines So I think it would be good to have some of this discussion ahead of time The other thing is I'm not really sure I understand engage Thousand G and genome reference is this genome centers. I just want to be More precise on that Yeah, NIST Yeah, so the I thought the idea came up in the breakout last night and also I was talking to Howard before Just it's not it's some of its genome center expertise But some of its analysis analysts that are with with various consortia So for example the thousand genomes analysis group have They have variant callers that they've actually compared to each other and they actually understand the performance and How it said well So So so I would make it more you had you had your chance. I was like really weird. I would make it more specific So experts experts engage experts on base calling indel and CMV calling and What is the the reference sequence that all that everything's compared to can I call it very much more? It's just more specific That's all so you know who you're going after If I make a spelling mistake, it's because This is fun. I might even make this a little more specific So I think like these ten genomes that people are talking about. I mean, I think one of the things that we've discussed At length in various sections of this meeting is the fact that we want to be able to combine data sets from numerous places that are generating You know cancer genomes for diagnostic purposes for treatment purposes and If we could get a set of ten genomes that we would ask everybody to Include so if they're using the Illumina platform It would be ten Illumina platform genomes if they're using the solid then it would be ten solid platform genomes That they would include in their analysis so that eventually there will be the collection of these from various sites I imagine at some point in the future and then when we could it's going to be difficult to take that information That we get from people and standardize it But if everybody had run through the same ten genomes through their pipelines Then we would have at least an idea of where missing data and stuff of that nature might be Yeah, so I mean this is really a recommendation of the sequencing working group and if I could get my computer to work I'm having problems, but Let me just try to see if I get my thing loaded up here and then address that question We shouldn't have got we shouldn't have gone out of order that mess things Cap cert certification experts. I'm happy to have them attend, but the AMP and a CMG laboratory guideline development groups around Exome sequencing whole genome sequencing are probably the more expert group So you want to include them and often There's overlap in the individual people HMP Sorry You got all this done and a CMG in addition to clear cap So towards those the issue about the thousand genome project And to follow on what Adam was was talking about This comes out of a conversation Scott and I had last night in in the bar After you're all in bed, so it was alcohol need alcohol induced But the issue was One of the things that's happening is part of thousand genome project and maybe other discussions that there's weekly discussions every week About analysis strategies and so for those of us that are interested in leveraging that information We'd like to be sitting right behind that So as those analysis strategies get firmed up and I'd love to be in a position where we could use those in the clinical type Laboratory and so I think that was one of the discussions around what Adam was saying is that how do we roll this down the Pipeline so that it goes from thousand genome project type doesn't have to be just thousand genomes down towards clinical So On the thousand genome side those weekly calls do have comparisons and what happens is immediately People who don't do as well start to make changes and so one of the things that you emphasized was Cassava 1.8 is 1.8 whereas gh2k has you know, you can do a nightly amp belt and the virgins change quite a bit and Then getting the message of burgeoning and some of the needs that you might have would be something That's important because I don't think they think about what you might be wanting on a clinical side They think nightly bills are great. So that if we're not involved in the discussion, there's not some freeze points that could be then Evolved downstream that could be used so so continue evolution is great But if there could be some freezes just like anything else that we freeze in the genome project that then enables those of us that Want to start implementing having that so some discussion around how to do that. I think is what we were trying to capture I think there are certain things like snip calling. That's already very good on say g atk And they could freeze that in Dell development, you know Is maybe 80% accurate right now and we're gonna have to keep changing until it's a hundred percent And then as fees is even you know further away from that I think also the kinds of things you're interested in are not The the genomics community is calling on a thousand individuals at once and getting probabilities of getting genotypes at low pass That's different than taking the entire genome of an individual and calling it in the way that you're suggesting for all variants So I think we need to be pretty clear on what we're asking for Information on but it's not doesn't mean that those things can inform this calling but But I do think that it is a different issue