atchedele. So, good, let's say, morning afternoon whatever, but I'm really happy to talk and continues another small country. So it's small country, so I'm moving ahead. So I have to, first of all, want to make sure that you all know where it's going, is it small country here. Yes, because otherwise sometimes we are here, and sometimes here. This is three Baltic, small Baltic countries, See on 3-bolti, 3-bolti nüüd. Meie on nüüd, kui Finland on, kui meie on. Elskaja, meie on 1 medikale ünne üldust. Elskaja on kõige peale, ja CCR budget on 1 miljoon Euro. 1 miljoon Euro, ja peale on Elskaja. Ei ole edukasioon, ei ole kõige. Last viik, 1. janari, Eksum sikõnselt on rimbust kõige siste. Tee, et tehtavad tehe sehtab siitemuse, kui teha peab in janu, ja tõta teha peab siin, saame teha valida. Tee, et teherab teha kood. Päris, ja päris on 1500 per exom, ja teha korjuusid. Ühle ma peab kõige lõhge, peab 3. Tee, et selle teha peab exom. So what I'm talking is that medical genetics, this is a newborn screening, microwave, this is going on and you know sequencing most recently is all colored. But I'm going to talk about medical genomics and this is a common complex disease. So first of all, we started about 14 years ago, year 2000, biobanking laws was adopted in Estonia and we started a biobank. recipe. It took many years you know 2010 we had about 5% of性 adult people of Orleans above and canopy use this research. We were publishing a small place. We have a binding center as 40 people under a publishing 32 saltig p forest per year and now because we have this resource. And saw this copy and try and Ja meid on koht teem kui päramaktisjons, tehtisjons. Ma see on, et me ei ole Estonea Biobank, Estonea Human Genes Research Act, kui on laajada, ja me ei ole, et me ei ole, kui pole uskime, et me ei ole, et me ei ole, et me ei ole, me ei ole, me ei ole. See on, see on, et me ei ole, me ei ole, me ei ole, Me ei see see põhreli kes, sain ei nii teed talud võist, kui see on kõige jõu sõtni põhreli, ma teed, et see on sõhvame põhreli, et see on ent, sõmvame teesending ja põhreli. Lõtest see on võimtida. Siis see on saab teid, sa enna mu loodavad pulla põhreli. Ma see teha, kui tuleb mele õtne, õtne õrvõi peal õrvõi. Näg mõtma Latvian, Litvianian, Poltan, Rusni, nori, Weston, Finn, Kuusama, üle õrvõi peal õrvõi peal õrvõi. õrvõi peal õrvõi. Mõtmule, et mõtmule õtne, on sellevastu õrgust, aga sellega läheb püüda või sellele juba see, et see on väga, et kui in Finland on. See on saab onnud järgi, kui ei meaastud. Kui ka, saab ka üle baabankast ja saab või osanud, see on seda ka juba iga, ah, mõtgub see on ka tehse, saab saab saab saab saab urmast, saab saab saab saab saab saab saab saab saab saab saab saab saab saab saab saab. Next thing, now we have a biobank, we can do research, we know a little bit already about the population and we know what is going on. Next thing, what is kind of needed in order to do genomic medicine for complex diseases, which is for the full population, we need e-health solutions and everybody has in our country so-called ID card. And as you see, we have active cards at 1.2 million and we have about 70,000 people don't still have this card for different reasons. And this is, now in addition to this one, we have also some mobile ID, so from my mobile phone I can do all what is needed. I can do bank transfer, I can go to my health records, whatever you can do, you can use a mobile ID also. So it tells you that in Australia we have all databases like here. So prescription database, all prescription are digital, all are recorded. So we have a national health information system, we have digital images on everybody and you can access this database from everywhere. So everything is connected with so-called X-road, which is a secure way to connect different databases and even things now actually took this over. And it's really shame to accept something from Estonia, but it's nothing to do because they have been doing it for so long and still couldn't do better. So we have a so-called national with a personal key infrastructure, which means that everyone can access and give a digital signature, which is legally binding using your phone or ID card. And what is good is that over 10 years nothing happened, no misuse. And people are very trustful and using this. Banks are closing offices because nobody is going to bank anymore. So this is a national patient portal, which everybody can access. And you know this is of course Estonian here, but this is my data. And here you can sign if you have accidents, you can donate your organs, so you can make an application here, vaccination, so on. Here we just would like to add one box, which is just genetic data. And I tell you how we are going to get this data. This is last side telling that by OSCD Estonians are really good putting health information into the internet. But what is missing is decision support, which is very small here. And this is almost every country, this is small. Because what we need is we need diagnostic support software, decision support software. So do we have enough information? So I don't have to explain, you know what it was, but combining several markers, I still believe that we can use this information in some use of way. So let's take this, all information here is coming from Biobank. We have a chat at all this, let's say type 2 diabetes patients here. And we have 20,000 arrays done. So we have no information. And you see that if you just plot the patients according to the genetic risk. So you see this certain number of patients have higher risk than others. And if you just take, it's more simple way. You see that actually genetic, of course BMI is important. But genetic information is also important. You see how much risk is increasing if you have a high genetic risk, let's say top 20%. So I guess this is the most telling figure. So if you are young, let's say 25 or 30 and your BMI is 25. And you are not in the risk group. Because in our country if you are 40 years old and your BMI is 25, above 25, then you are in risk group. And GP should do something. But they can't do because there are too many of them. And they have tons of other things to do also. So this type of analysis actually can restrict the number or they can focus. And if they focus for 20%, it's already probably a preventive measures kind of fruitful also. So if you are young here and your high genetic risk, if your BMI goes up or you just keep it low, you get it here. So probably five times difference in this. And so if you're young, I tell you it's much easier to keep your BMI lower than to reduce it when you have it already 35 or close to 35 like I do. So I tell you, this is something useful what we can do. Okay, rock curves don't tell you much also because they are almost the same. But still better if you use a genetic information. But again, genetic information is known already day number one. So BMI is going when you're already going on. Because tolerance test is already too late. You already have a pre-disease. So this is now a slide I borrowed from Markus Borola. And you see if you just take the myocardial infarction. And usually they have certain numbers of 20% risk. So they will be treated like normal. But then the ones which below screen here, if you analyze these extra genetically, you still find out certain number of patients which can be treated. And according to the finished data which is coming from fin risk, so they can prevent 135 tests in 10 years. So per year is 13, but this is only for 100,000. In the story I have 1.2 million. So almost every third day somebody is dying from myocardial infarction because they are not tested. So these are not our data just after this is finished. So what I proposed to the government plan that how to use a resource what we have and the information from the biobank. And how to really use genetics in public health. As the law is telling you have to use information in order to improve the public health. So I thought let's do the biobank project first and sequence 5000 people in order to get also upload types and variants up to down to 0.1%. And then use this information to build a new array with Illumina. Let's say add 200,000 markers to the existing 700 snip chip and to everybody on the biobank. We know the information, else information on these people in biobank. We know all events what happened after they were recruited because we got all information back from the different databases including hospital databases. So we can actually analyze the data what we see from the arrays and what are actually the real clinical picture. And put everything into this heal system and positions GPS can use it or where. Can access your patients owns the data. In our country patients owns the data. And they can tell who can actually get access. Also can make access or research. So if this would be, of course, we discussed it through many organizations including the Parliamental Social Committee. But then we decided let's do the pilot first and put everything into the health and people using. And then main brushing would go and we offer this test for everybody 35 to 65. And we did a survey and about 75 to 80% would like to have it. And so we have like 500,000 people in the database who is in e-health database of this only database. And basically we have genotypes, we have a family structure and we have prescription database, we are images. And it's updated daily, basically howly. And so now can you imagine we have a database of a million people. You see somebody is getting drug and after one month is finds the same drug or actually after one week happened to be in hospital. And so on you can something, you can see like from the airplane on the town you can actually follow the system. This can be used I guess both way for research and also for the real prediction. So type 2 diabetes or glaucoma, glaucoma is very easy. With few markers you can get the risk and just just send to the eye doctor same measure your eyeball pressure. We have 28,000 people blind because of glaucoma. So basically this is most important thing because we have only 10 medical geneticists in Sagantis, there is no way that we can offer genetic concern with everyone. So physicians and GP primary care provider have to learn a little bit more but basically we have to do everything. So chip analysis has to be in automated way in this software and when GP is opening the computer just have probably three lines. Glaucoma risk is high, go to eye doctor. Your barf are in risk is, barf are in metabolism very low. You just have to go into the, basically it has to go into the prescription database when doctors are prescribing, they see that they have to look for the dose and so on. Not so many things and not very complicated. When computer can land the plane 500 people in the fog. So computer can also help GP doing this decision. Okay, so basically what happens? We have a kind of circle and we just improve the database, learn or just make the database better or get better results and this is a circle that's already somebody was showing it before. I guess Dr. Rodden. So survey, a PC is actually interested in this and patients are actually the main trialers because patients are even more interested in this. So they would like to use it. Of course we have challenges and hospital directors are against it because they have to change their life. So they have to follow probably thousands of these pre-diabetic patients instead of doing some brain surgery and of course we don't have enough knowledge but we always learn and lots of things to do. But in small country like Estonia this can be a test set because we need one positive case, one positive example how things can work and this is one million people. I guess we can do it. So basically I guess also prerequisites are in place and the government decided basically to add some more educational part and of course some business part but this is mostly approved and we have to come up with more detailed plan by summer and in fall when EU new funding will be open we are ready to move on. So thank you very much. This is our early investment. That was very nice. Reed Pirats, we were talking amongst ourselves and I wanted to suggest to you that you market your electronic health record system to the rest of the world. My question has to do with the histogram of type 2 diabetes risk that you showed to the tail of high risk. How many of those individuals would be detected by family history alone? Do you have those data? No, I don't have it here and from the bar bank I mean history. I don't know the data now from my heart. It's a problem here is so I tell you what's the problem is. Now the problem is that 50% of kids are born a single parent. So further side is gone. This is one thing and basically I don't think that families are so good that we can really I believe that this is much better because half a family in many cases is gone. Yes? Yes, Mark Abramovits, Brussels. I understand the beautiful opportunity to have a nationwide database but I have a question about the Estonian gene chip that you devised with one million chips. I'd like to know how many of these are validated for clinical use. How do you intend to use them when you mention applications for the patients? We are going to validate to insert pilot phase. Mark Williams, Geisinger. A comment on the family history question that Reed brought up and then a question. The comment is that given the infrastructure that you've developed I think you have the opportunity to systematically collect family history and have that persist in your system which would allow actually linkage to develop over time so that you wouldn't necessarily have to rely each time on the patient in providing that information that could be actually systematically collected and updated as some have proposed not the least of which Dr. Ginsberg in the work that he's been doing. The question I had related to the clinical decision support which I think is elegant. What I wanted to know is do you have then a centralized clinical decision support group that when something is submitted that is approved, is that then automatically pushed out across the entire country or how is that adjudicated? There is a kind of task forces that have been discussed. It will be just one place and like sequencing, it will be in one place and we have a genetic testing this one place in hospital, in university hospital in small place. We don't have to divide everything by two. It's just one. But coming back to this family thing. Doctors are using family information all information what we can use today but the number, the percentage of type 2 diabetes is increasing. So why is not reducing instruments what we have? I believe that we need something additional in order to put the ceiling on this. And I tell you one more thing. If you just give this personal information to people so people are more likely to change the lifestyle than just put poster up and lose weight run more or eat whatever. So if you tell personally then it's different. And we did a survey, it's not yet published but Dr. Singh is published and it's interesting. Of course it's easy to put that box in a tick in the box but after one go to run but I still, they are also showing that people are willing to change something if they told personally.