 So I'm actually going to talk with you about some of the key considerations that we make when we want to undertake a major strategic initiative, such as a program like Genomic Medicine, and from the C-suite viewpoint, which incorporates in our institution the fact that we are a physician-led, physician-driven organization. So I'm going to talk to you a little bit first about the assets of Geisinger because they actually were very key in our past 10-year buildup for a number of the programs that we've initiated. You can see here that the mission is driven all around patients and how we deliver care to our patients, and more importantly, the outcomes that we achieve for improving their lives, their clinical outcomes, and then overall, the value that we actually achieve, not only for the patients, but for the community, our providers, our health plan, and the employers of our region. Every five years, we do an update of our vision for the organization. And Glenn Steele, who is our president and CEO, leads at least 50 meetings across the entire system, in which we talk about major themes that will represent Geisinger for those five years. We do a five-year long-range financial model, and that cascades out to all of the components of our business, which I'll show you in a moment. The four themes that have driven us for the past 10 years always start with quality, focused on the patient, focused on their clinical care, coupled now with a major emphasis on innovation, much of which we have become known for in terms of clinical re-engineering and value to the payer. We also are very focused on our market leadership. That translates itself into growth of the organization. We've gone from 10 years ago being an organization of about $700 million top revenue to now $3.4 billion, and an employee base of about 1,000 employed physicians and around 15,000 employees across the system. We now are going to initiate a very large program in the scaling and generalizing of many of our initiatives around innovation, focused on re-engineering the way in which care is delivered. And then our fourth major theme is around the Geisinger family, improving the professional and personal well-being of our employees, as well as ensuring that we have the right skill sets of our employees to meet the future direction of healthcare. As I mentioned, Geisinger is about a $3.4 billion organization. We have a number of provider facilities. Currently, we have two major clinical campuses. The Geisinger Medical Center, which is located in Danville, incorporates the Hospital for Advanced Medicine, the Janet Weiss Children's Hospital, a level one trauma program for both pediatrics and adult, and then a series of ambulatory surgery clinics. Our research enterprise is actually part of the clinical enterprise. And I'll talk about that in a moment. Our Geisinger Northeast has two campuses. It's about a 50-minute drive from Danville. Also has a level two trauma program. It does now have a Janet Weiss Children's Heart Hospital within a hospital and a series of clinics that surround it. We also have an alcohol and chemical treatment dependency institution. We have now roughly 900 FTE-employed physicians and roughly translates to about 1,000 bodies. In our research area, we have gone from about 80 FTEs. That includes both researchers as well as support staff to over 300 in the past 10 years. We include in our delivery of care advanced practitioners. And this will become important in a moment as we talk about the Genomics Medicine Program. We also have a health plan. We have about 300,000 members in our health plan. And this is a very important component of our integrated delivery system. Roughly 30% of the business of Geisinger comes from the health plan. And in that 30% is where we really do a lot of our innovative work between the clinical enterprise and the health plan. Our system, the dark blue represents the counties in which the health plan has contracts. And the heavy white line represents where we provide clinical care, roughly in 43 of the 67 counties of Pennsylvania. These clinics that are coming up represent the 41 clinics, our primary care clinics and specialty clinics throughout the region who are actually providing care locally in the areas that they serve. Again, because Geisinger is located in a series of rural communities, many patients will not travel long distances to get health care. So the strategy way back when was really to establish a series of primary care clinics. Additionally, we work quite closely with a number of non-Geisinger physician sites and have actually provided electronic health record access to these providers. We have now six helicopters for our level one trauma program and service the entire northeast and central Susquehanna regions. Our regional demographics were important in considering the development of a genomics program. We have about just under 3 million patients that we serve in the 31 county service area. It is an older, poor population. It is fairly homogeneous. Most people have lived in their homes for over 30 years now. This makes it really an opportune locale to be able to do many different kinds of research. In 1995, Geisinger started the electronic health record development and initially they started it in the ambulatory settings, the various clinics that were not associated with the main campus. Over 135 million since that time and now on an annual basis, we spend about 4.4 percent of our annual budget in support of the electronic health record. The EHR is integrated not only in the community practice sites now but also each of the hospital platforms are fully integrated. And then we run a series of retail clinics in which the information flow back and forth to clinical sites is through the epic electronic health record. We also believe pretty strongly that we need to communicate with our community-based physicians. And so we created a portal in which the physicians who are caring for patients that they refer to Geisinger can access their patients' records. We have networked the patient health record. We now have roughly 178,000 active users and are trying to achieve a goal of 200,000 in the near term because this becomes an important facet for us around not only monitoring patients but also in terms of potential research opportunities. The regional health information exchange, the key high, Geisinger led this with about 18 institutions. Now we have about 500,000 active consented users and it will provide for us a community data warehouse which will connect to our overall data warehouse. We have a number of e-health initiatives. Again because we're rural, we've become the node for EICU programs where we monitor patients at other institutions through an EICU portal. We also have TELA Echo, TELA Stroke, TELA Derm and many other neurology and neurosurgery related programs by TELA Medicine. We were also one of the recipients of a $16 million beaking grant which is meant to connect five additional communities and achieve improvement in the health outcomes of that group of patients living in that area primarily around pulmonary disease. And then more recently we initiated a program called Geisinger MyCode which is a voluntary patient program seeking to biobank a number of blood samples. Right now our biobank contains both blood and tissue and you can see here the growth of that biobank. It was part of, and I'll show you in a moment, the development coming from our scientific advisory board recommendations back in roughly 2003 that Geisinger become a biobank as one of the steps in the development of our genomics program. We have a clinical decision intelligence or data warehouse system that provides near real-time data. It is system-wide, includes all the clinical research and business data. We use it quite often to both answer questions as well as ask questions around cohorts of patients. We clean the data. You can get quite granularized information. We're about to expand the core team that governs the data warehouse and as we've recruited additional clinical research leaders as well as those in our three centers, we will be advancing both the depth and breadth of the warehouse. So I'm not going to go through this entire complicated slide of how research was built at Geisinger early on, but if you look at the yellow area, Dr. Steele came to Geisinger in 2001. And clearly Geisinger has always been a great translational research institution, but mostly focused on clinical care in 2001. It had just come off the divorce from Penn State Hershey. And given the population, given how it was situated in a rural community with an electronic health record and a population that was fairly stable and homogeneous, he felt that one of the intellectual cores that we needed to build out were a series of efforts around research. We already had a very good basic science small core research team in the White Center led by Dave Carey. That group has moved towards a focus on genomics. The Biobank actually sits inside of the White Center for Research. We then focused on, we needed to have another intellectual core, which we focused then on outcomes research population health with the recruitment of both Stuart from Hopkins to lead the Center for Health Research. We also felt pretty strongly that we wanted to have a scientific advisory committee made up of external advisors who could help us focus on what the next generation of research would be. And really genomics was a key piece of that. You'll see some other milestones here in terms of recruitment, the recruitment of Peter Berger to lead our Center for Clinical Studies. But later on, we actually, moving up to about 2009, had talked with our board about our interest in taking the first 10 years of research to another level over the next 10 years. And at each of our medical affairs committees, which are committees of the full board, we talk about different aspects of research on a quarterly basis and give them an update on our progress. We had been laying the groundwork for doing a genomics medicine program. So in 2009, we put together a multidisciplinary steering committee led by our chief medical officer at the time and a consultant, and that was David Ledbetter at the time. And we had three of our board members involved in the weekly meetings for this committee so that we could debate, we could analyze, we could push back the development of what would be a recommendation to the full board. The vision for research at Geisinger is all around personalized healthcare, with a major emphasis on the genomics program. The board and this multidisciplinary steering committee believe pretty strongly that the clinical enterprise and our payer partner, Geisinger Health Plan, would be able to really take a translational research, translational clinical program development opportunity and really make it fairly strong. But there were criteria for that. Certainly doing a well-articulated strategic plan and business plan with a return on investment was key, and to know that the board would support investing in this effort over the first few years. Both the clinical enterprise and the health plan wanted to see that there was value created and through the discussion, and I would say off-cycle debates about it, many of our clinicians supported the idea that we would be able to change the way in which healthcare would be delivered. And that was key to have a core constituency who supported that mindset. And that became evident every time we reported out at the steering committee. And so the members of the board, none of whom have a science background, were really strong in their support then when we went to the full board. The key considerations in our overall process is that there had to be leadership at multiple levels. Clearly, Dr. Steele was a big champion of the concept of developing such a program. But no doubt he needed to ensure that the rest of the organization at the clinical levels, and not just the physician leaders, nursing leadership, and at many of the support levels, our clinical laboratories, would also be behind the development of such a program because it requires resources. It requires almost a communication campaign. It required the articulation and almost a full communication campaign, not only internal to Geisinger, but external to Geisinger. So we did talk to some of our community members about the development of such a program. We also had to formalize in writing our strategic vision and a 10-year business plan. Generally speaking, the first five years are the most credible, and that's what we actually use on our regular long-range financial model basis. But it had to be vetted at multiple levels of the organization and then ultimately presented to our finance committee for approval. Important also were some delineation of metrics, both for quality and value, as well as outcome and process. These components, again, had to be at multiple levels of the organization. And our first major milestone would be to recruit the inaugural Executive Vice President for the organization of the scientific area. We also had to identify for the board some of the risk and risk mitigation strategies, and one which the board was very sensitive to are all the aspects of ethics around a genomics program. And while some of this is still playing itself out in the development of a full campaign around such, we are developing our thought processes for communicating and for resolving issues that may come up. The other important factor for the board was to demonstrate that we had the capacity as an organization to take on such an initiative as well as a history of success and execution. So while it may seem a long period of time to initiate a program, you could see in previous slides the build-up of all of the assets and the success that Geisinger was having from a management viewpoint that the board felt quite positive when it came to supporting an additional $20 million a year to invest in the research enterprise over these next ten years. So where are we right now? Our first inaugural appointment was David Leadbetter as our Executive Vice President, Chief Scientific Officer. David has the umbrella responsibility for all three of our centers and for integrating specifically a genomics medicine program throughout the organization. David was able to recruit Andy to join us and that's been invaluable in helping us to develop the education program not only within the system but also externally. We were a recipient of the Emerge Award this year and we have three new recruitments that have been planned and we're quite happy with having Ann Moon who is a pediatric critical care specialist who does research in the genomics of developmental cardiac disease and then Mark Williams and Janet Williams who will be joining us in January. We are almost, I would say, in our infancy in really cohesing the genomics medicine program but I think within this past year, David's been with us a year, we have really made a number of milestone achievements that we'll be reporting to the board actually at our December meeting this week. And then finally we're developing a whole restructuring of a bioinformatics core which will be key in executing the genomics program as well as a couple of our other major strategic initiatives. So in summary, for us it's always important to lead with the patients and the patient focus. We communicated with our board early on that clinical medicine and research really were partners at Geisinger that research was not the icing on the cake, as Glenn would say, but more part of the cake. And that was an important facet for the board to hear especially the three board members on the steering committee for the 10-year vision for research. No doubt there has to be commitment at many levels of the organization. David and I as executive vice presidents partnered together along with our executive vice president and chief medical officer to ensure that the operational detail of the execution of this program is well managed and when there are hurdles we figure out how to problem solve those hurdles. We also feel pretty important that there is a commitment on the part of the organization to demonstrate improved outcomes for patients over time and to demonstrate for the board and other constituents the financial improvement and value to the patients, the providers, the health plan and employers by improving the health outcomes of the patients. Thank you very much. Questions? This brings an element of risk as an institution that you didn't have before. How do you... That comes up a lot. So in our weekly strategic meetings of the executive vice presidents our general council is part of our weekly meetings. So all of our strategic programs are in his limbic system, so to speak. We do not have a very specific program related to the legal side. We do go through all of the discussions about what the potential malpractice implications would be, but we're not at that stage yet in which we have developed a specific protocol. So you're really looking at the same way you look at a new energy approach. Absolutely. Absolutely. I would say it will probably be a combination of both. So right now for all of our programs we look at best practice at what exists and if something doesn't exist then we have to use our own baseline and compare it against our own baseline. So specifically... Simultaneously, contemporaneously. I mean of course outcomes are usually going to improve over time. Long term. We're going to be in trouble. Right. How do we differentiate what's due to individualization of medicine versus what would happen otherwise? I think some of the clinicians in the room will have to help answer that, but I think if we're tracking the clinical outcomes through the electronic health record, again we have generations of patient information to track, that's the primary way it will occur. Yeah and as a clinician is going to be joining the program I think this is where groups like Intermountain and Geisinger that have applied quality improvement methodologies which are in some ways somewhat different than more traditional highly controlled research protocols to determine improvement. This harkens back to the idea that we need to develop these types of real world methodologies to be able to understand how much is due to just incremental improvement over time versus something that represents a true signal from a program. The example I use at Intermountain was a ventilator protocol that within three months reduced time on Vant from an average of two days with a range of 12 hours to 14 days to average time on Vant of four hours with a range of two hours to 12 hours. Now did that protocol which involved the manipulation of 276 different variables and the clinical decision support system that was done at the bedside meet strict research rigor and criteria? No because randomized controlled trial would control 275 of the variables and very one doesn't work. Could you say well this is just expected improvement over three months that we would see that change? No that's clearly not the case. Something happened it's attributable to the program but it is a different paradigm in terms of how to actually do the work. And so we really have to be very thoughtful about how we do this. Now there's historical control approaches, there's implementation in different clinics in other words with our Lynch syndrome program we had early adopters that wanted to get involved versus those that are not involved and so you can look at the outcomes in clinics that adopt versus those that don't. There's different ways to go about doing it but you can detect these signals it's critical for us to be able to do that because we're not with the volume of information we're not going to be able to do randomized controlled trials for everything. And so we do see ourselves as a rapid cycle translational platform and knowing that it takes at least from our days at other institutions it takes you know years to bring something to fruition. Some of these things we will look at differently. Time for one last. Yes, Am I on? Yes. Yeah, okay. So I think this is one of the key issues that we need to address jointly. I think you know talking about generating the evidence which is I think one of the key aspects that needs to be you know facilitated over the next five years is what kind of level of rigor, scientific rigor needs to be applied to generating this kind of evidence in a best practice clinical care setting which is integrated not separate from it is not in a separate research setting. And then how can we disseminate that information I think you know can we go to New England Journal and publish this kind? No, because they would say well you know this is not randomized control so we need to break into some of these break down some of these barriers and I think this is an important topic to come up with the right level of protocol that is not prohibitive in terms of making progress but also has a level of rigor that is sufficient to base decisions on the outcome on the data. That's an extremely important part. All right I think we need to take our break now and we'll reconvene at 11.