 Okay, we've reached the point of the council meeting where we're at the council initiated discussion phase, and I think you've all Been there and done that. I don't need to provide you any instructions So if you've been saving up a message to deliver now is the time we're all ears When you start planting ideas among council members there Is there an area you would like to hear a report from us? Yeah, I'm sorry for September council We'll have plenty to talk about we'll be bringing the sequencing Grants to you, but for you said that I think you'll be an outstanding We need to continue the conversation this morning. I think we wrapped up and had a closure this morning But but I think it's extremely important conversation I don't know how we can pick up momentum or how we can give it structure. I'd like to see us continue that discussion Eric which topic are you thinking of when you say their conversation this morning? So I'm trying just to get the conversation going here a little bit It's interesting that that topic came up because Two weeks ago at a staff meeting three weeks ago to staff meeting Eric said well the five-year plan is about the street strategic plan is about five years old at this point and Internally we're organizing a little retreat. It's purely internal. It's only four hours But it's basically a look at the strategic plan and ask is it still serving as well? Are there technologies that are going to overrun it? How are we positioned and maybe something will come out of that that will start this conversation going? We need to think of a way to engage you in this process rather than just throwing something at you in September And have you say no, it's not not really what we had in mind So let let us think about how to do that about Rudy. I think I think what I'm here to slightly Overlapping but it's not the same. So I think if I'm hearing right I mean one one our exercise we're going to do internally is just sort of how vibrant how fresh is the strategic plan for the field of genomics From our earlier discussion. I think there's some questions around Priorities vision what what's the identity of NHGRI within that very broad landscape? And I think more specifically what you're talking about Eric is you know How do we want when we go to implement that vision? How much of this do we want to have the investigator initiated versus crafted around top-down managed RFA driven? Big projects. I mean all of that all that but it's especially on the implementation side more than the big Opportunity side, of course. Yeah, sir, and maybe you know just to Sort of Continue with a theme. I'm thinking back to Some earlier conversation in the day when their question was raised, you know What would be what's the one thing you'd most like to do? I might almost flip that around and say When we think about NHGRI having many programs ongoing at present What is the process by which programs get sun-setted in other words And they might be sun-setted because of wild success or because of clear failure Actually, the wild successes are the ones that are perhaps the most interesting to think about You know, what are the what are the what are the endeavors that NHGRI has set in motion? that have acquired their own momentum and their and their own sources of success outside NHGRI's budget or purview and it would be very interesting I think to hear even a short list of those things that are Clearly succeeding so well that it's time to let them go free. I suspect that will end up being an interactive discussion Which is what this group should be helpful in Helping us think through other thoughts So I actually found this This exercise that Mike and Jeff made us go through for the for the webinars to be very useful of You know kind of we had a discussion I think a number of things were heard and then everyone had to go back and and quantify their priorities Right and rank and you only had so many check marks and and you had to use them wisely And I think at least from some of the emails that followed that the results were were surprising relative to the Conversation that was had I Guess I'm just kind of wondering if you guys ever as a staff quantitatively Try to actually put things on top or on bottom and whether that would be a useful exercise in a non-subjective way Way you're forced to make decisions not in a quantitative way I think one of the wildly as successful things is certainly as stating the obvious has been the sequencing We deal with clinical level moving whole exome sequencing from research in the clinical where where it's actually paid for by Be for service and So I think that's one of the areas I was I like the discussion with Gail and last because it did that does start moving some of that Sequencing technology into actually patient care and when we can start Start off loading some of that from research costs into Medical care cost. So I think that needs to be part of the conversation at any rate and and we should probably deal with Least moving towards Scaling down some sequencing efforts so I Think that you know, we all really like the heat map and we like the idea that Genomics will permeate the rest of medicine Towards the right end of that spectrum. I think a really hard thing that NHGRI is going to have to figure out and it really Kind of meshes with what Val says is How much do we see how do we see our role as an Institute in Promoting enabling and evaluating that permeation and what I'm getting at is it's gonna be expensive. I mean when you start doing clinical Studies that involve lots of patients and looking at things like outcomes which Is important, right? I mean somebody needs to do it. I don't know whether an HGRI needs to do it But but if you're gonna start looking at at real outcomes patient outcomes and does Genome sequencing improve outcomes etc. It's expensive, right? So It's only going to magnify all Of the struggles and the tensions that we have had over the past few years that I've been on council and I think it was a perfect formulation Articulation of our vision five years ago to say we want to see that heat map move over to the right But that I think NHGRI is now going to have to Kind of struggle with how much we want to pay for that and will it get done without us, right? And I don't know the answer to that I'm I'm it distresses me in medicine to see all the things that get embraced and then only way later Do you find out that? You you did a bunch of stuff that didn't improve outcomes And it does seem on the surface of it to me of a reasonable goal for NHGRI to be involved in that but It's gonna exacerbate the budgetary Tensions because it's expensive. I would second that Jim But I'd also say it's not only expensive it takes patience and time like these things are not going to be short term That's why your things right? I mean this is going to be have to be a long-term investment If we want to take that seriously and and the one thing I would add and this is something that I really do think there's a There's potential for to help Mitigate some of that budgetary tension and that is that we're experts in genomics We're not experts in outcomes by and large There are experts in those kinds of things in the NIH so it does seem to me that judicious partnerships Could make a lot of sense in that realm just Finishing off that thought I mean I think I agree with the the idea of thinking about if we don't do it Well, somebody else do it on the other hand If it's not done, what are what are going to be the implications of that? I mean I think um, you know There was a lot of thought put into let's do this in a controlled way that can be studied And we've sort of started to go down that path And it's it certainly hasn't you know, it's a long path to go down So anyways, and if it's not done then what's gonna happen is haphazard Adoption that's not and I evidence-based and I promise I'll shut up now after this. I it does scare me when I see Comments about pushing things into medicine, right? What we need to do is not so much push genomics into medicine We need to really demonstrate where it's valuable. I think we've begun to do that but but the The last legs of doing that are very expensive It's just that I don't want to see an H. E. R. I be in a snake oil Institute that says we've got the answer everything we want to push it into into medicine I think at least for what insurance pay insurance companies are paying for sequencing in hospitals are you know typing to the extent You're caring for patients that data could be very valuable to the Institute But I don't see that it has been a concerted effort in using that data in a more systematic manner And it might not be as expensive since it's being paid for by others, but the analysis in the storage and yeah It's not really We're having a hard time convincing third-party payers I think very legitimately to pay for the things we kind of want to do So I'm not sure we're going to be able to offload much of the cost Well, but if it let's assume some places already have that in place and some do for very limited Gene sats and so on so why is that not being more used or or at least systematically pulled together? I'd have to see what Kind of what constructs you're talking about you know who right where that's being paid So I think that following up on Lessa's point and Jim's point here. I mean there's no question that discovery You know, it's going to be sequence first ask questions later. I mean that's basically what less said more eloquently than that Is and I and I do think that as we look at some of the challenges that are coming We are going to have a tremendous number of variation and the variation Discovery then could be on a basic science how we've always done it But the other side to think about is is how do you do variation validation at the speed of the clinic? And I think that's something that that you know, how do you pre-position basic research to be ready to move? And to me that's maybe something that that could be done by this Institute, which is about scale It's about throughput. It's about speed Because I think that's going to be a major bottleneck I think we're going to have a huge number of variation a huge number of thoughts about this and then a gigantic gap between how do we prove that? Yeah, that's really true I mean one could split the clinical stuff into two things one would continue to be discovery and being a typical analysis and everything The other I don't know who would do it does seem important but it It's also expensive is is figuring out, you know really outcome-based research. They're two very different things, right? So I assume I mean to some extent, you know the Precision medicine initiative might fill some of these roles, right? Yeah, I just worry that you know so many people want to get their their claws into precision medicine You know, I don't if it's going to be the answer to all our problem. I just want to respond to Jim's comment Who's going to do it? I think we should do it I think you know to let the comparative effectiveness slash outcomes to sort of happen naturally I think is a mistake. I agree completely I mean with the Affordable Care Act these conversations are going on with many many technologies And I think there we need to form the right partners Both with experts in the field and also probably with commercial clinical labs And and begin to design these very long-term experiments that was we're just mentioned both the economics of it the clinical aspects of it and The social aspects and it's an ideal time to be in that conversation Yeah, I completely agree. It is the one thing I was just trying to bring up is it's gonna be expensive to do that Right where it depending, you know, I was interested in the budgetary Figures this morning. It's hard to get a handle on How much of NHGRI's budget is being put into that? You know categories four and five right because the one measure Deflates at the other measure inflates that I think Terry said around 27 27 million right It's gonna be you know, we're gonna need to put more into that if if we want to really do those things But I agree with what you say right completely I'm Leaving it to be done by others isn't a real good Option when the genome is kind of our baby and I don't think we can leave it to Private industry they have no interest in figuring those questions, right? But I think if we can if we can define what it is and also if we can form the right partnerships I'm convinced we can control costs Quite a bit and as opposed to thinking we're gonna bankroll the whole thing Which frankly I just don't think we can afford over time Could go back to one of the comments that Val made I mean in terms of setting up a discussion about some of these things I mean the fall will Bring us some very focused conversations along these lines on the one hand will be Bringing to this council the reviews from many components of the genome sequencing program and We'll have to get you know your assessment of those reviews and that will help probably calibrate the amount of resources We put into we have a penciled-in amount, but we don't even know if we'll have budget for that or not too much You know, we don't know so that'll help influence that at the same time in the fall Relevant to the conversation the presentation we had earlier. I don't know when it is I think September Lucy as a workshop. What is it? September 28th is a workshop critical workshop that will look at our clinic our Caesar program in a strategic way and and stimulated discussion about its future because if you recall that it was off is out of sync with the rest of genome sequence probably bridged Some of the groups to get them all synchronized to have this workshop to make a decision about going forward or not going forward Or if we go forward at what scale with what priorities what objectives and so forth So it's not that all these discussions aren't coming. We it's all being orchestrated and correct The problem of course is you know in some ways it makes it hard is that we can't just stop everything for six months and do a complete You know re-sync of every all these things have to come because they have a life cycle and And we have to juggle Decisions, you know sometimes out of sync where we may want to have a bigger picture discussion We have to sort of do our best as we go, but it'll be a very important fall for the very things that you just spoke about Okay. Thank you