 Yeah, so um, thanks Derek This was the one work group out of the in-person meeting that We were able to gain some traction on and they have been having a series of conference calls There is I think there's good reason why there's traction here is because it's a it's a major problem That we are beginning to quantify and it's something that We will disagree on what should be covered and what shouldn't be covered We will disagree on any number of things, but there are certain things that we can all agree on which is you shouldn't order the wrong test You shouldn't order a test that's already been done before And if you get the results of a test you should be able to understand and use the test appropriately and you know these are things that Take place in sort of the pre-analytic and post-analytic spaces, and I think in some ways This echoes what less was saying earlier that you know while there's a lot of focus and I think Appropriately so about some of the analytic validity issues relating to some of the new Tests that are coming down the road for existing tests that are using more traditional Methodologies, I think we're fairly confident that the what's happening in that analytic space is happening pretty well, and if we extend What we know about laboratory errors To genetic testing in virtually every Laboratory test that's done the majority of errors take place in pre-analytic and post-analytic spaces now some of them are fairly prosaic and are Across all cross-cutting which is you know you get the wrong specimen and the wrong patient and return the result to the wrong You know clinician or whatever, but There are things that are specific to genetic testing because of the nature of the genetic tests where The complexity the different offerings are available That are of great interest and from the payer perspective the this is a clear place where they can reduce costs By not allowing The wrong test to be done So the what we've been doing at this point is essentially teeing up a series of talks From members of the work group who have been exploring the space and Derek Listed then I want to give you a little bit more depth About that in the pre-analytic side We've heard I think in other venues about the molecular pathology program that Palmetto has been doing which is to try and get at The issue that was brought up by Steve yesterday, which is we don't know what the hell we're paying for and so we can't apply Utilization metrics to say is there medical incessity does it meet a medical necessity criteria to say this test is medically necessary and therefore should be paid for and and a lot of that relates to the lack of sufficiently a Descriptive codes that are specific and so they've been working on a Contract through Medicare to be able to develop some codes and have been piloting that and so we heard more about that and the potential impact and how the intersection of the Ordering process from clinicians can intersect with this type of what would essentially be a prior authorization Type of program would be able to make sure that the right tests are being done And that the ones that are supposed to be paid for are being paid and the ones that aren't supposed to be paid for Are not being paid so that's of some interest how and what whether that will go forward More broadly through Medicare is not clear at this point There are obviously a lot of private payers that have been coming up with their own localized Solutions in terms of how to handle this problem as well although I can tell you on based on my experience that the payers had gotten their nose is bloody not enough on pre-authorization process That many of them have gone to the kinder gentler route highly ironic and and Cynical version that will deny it on the back end when we do the post test So the test is done somebody's gonna have to pay for it and and so we denied on the back end and That leaves patients and providers and hospitals unhappy, so We're trying to find a good mix on how to be able to do prior authorization efficiently so that we can do appropriate utilization Chris Miller from ARUP has been doing some extremely interesting work looking at the role of genetic counselors In the pre-analytic space so that when they've done over the last 18 months something where they've had genetic counselors looking at all of the molecular genetic tests, so this is only Molecular genetic are not looking at chromosomal testing Or analytes such as a metabolic test that sort of thing only molecular tests Looking to see was the right test ordered looking at patterns of inappropriate ordering where they could change their order panel to make things clear that you're ordering a You know which Thalassemia test are you really ordering these sorts of things? their conclusions and and these are the there's a manuscript that's That is has been that's under review at genetics and medicine, so I anticipate that this will be coming out relatively soon There's a white paper that can can be made available. They're finding that 30 to 40 thousand dollars of testing per month is an appropriate Meaning that if it was let through that someone a payer a patient a healthcare institution would be paying for something that you know Has is just the wrong test a flat out Incorrect, and so there's a huge opportunity in terms of looking at the obvious places for return on investment You know to if you could have a process by which you could eliminate this type of testing that would be a huge thing And so the value proposition is is where does the value lie to institute that? ARIP is doing it really out of the goodness of their heart because if they let all those tests sale They would be generating income now they have some costs associated with doing the interpretation and this sort of thing But arguably the business model is to do more tests and so I think it would be naive of the field in general to say Well, we'll let the laboratories make sure that we're doing ordering things appropriately It's not necessarily never in in their best interest to invest a lot of time and Inexpensive personnel to make sure that this happens because there's a lot of time involved as you can imagine trying to contact the clinicians and the and the Offices and trying to sort out what exactly is going on But you know from the payer perspective as they're the ones that are ultimately going to be paying the bill You can see how a program like this might be something where they could really realize Most effectively the return on investment in terms of appropriate utilization. So there's been a lot of excitement about that We're going to be hearing about other programs in the pre-analytic space through the VA and through others that have implemented some things To look at how can we appropriately utilize genetic testing? So the hope is is that we will ultimately be able to take away from that Generalizable principles about how we think Payers and others can work together to make sure that on the pre-analytic side We're doing the right testing on the right patient for the right reason Ira Lubin presented on the work that he's done and Deborah has also talked about this from the CAP's perspective on How we can best format Genetic test reports to be able to allow people to understand what it is. They're getting back and how we can And they've done some work in conjunction with Martin Schumer when she was at Rand to develop up sort of a Draft genetic test report that shows a typical format that seems to be most acceptable. This has been in conjunction with Primary care and other physicians that could be ordering and receiving the test to say this is what we want This is what we don't want and then managing That along with the things that CAP and ACMG say you have to put in your report So, you know, it may be a seven page report But can we format it such that the clinicians get what they want right up front? And can we build into those reports information at the point of care that can allow for better and more robust interpretation? So there's been some very good work there. There's been some ongoing work groups like CAP ACMG and others are looking at ways that we can Implement that and for some of us at our own institutions We're looking at ways that we can actually tie this in then directly to clinical decision support So that we can actually embed Activated clinical decision support with active links that allow for interpretation Right within the body of the report. There are a number of challenges relating to not even just keeping the Formatting that is created in the laboratory information system keeping that format in transferring it to an electronic health record system The problem is is that the formatting in most cases just gets erased And you end up with a text blob that may look extremely different from what the laboratory sent out So these are things that are not trivial issues, unfortunately, even though you might think that they would be But this is something else where we think again from the perspective of the payer that If the clinicians are using the results of the testing in the way that they should be using them then in the long run That's going to lead to more effective patient care Which will have benefits for not only the patients, but also for the payer So again, we'll be looking to see are there ways that we can take away principles that This group the payer group could move forward and look to see can we more Can generalize these so that's the particular activities of our specific work group Bruce With regard to the reporting of Results one thing that has struck me as I've looked at various iterations of this is that the report forms no matter Seems who does it wind up being complex confusing to read and just frankly ugly and I keep feeling like the day we can Move not to a model of a medical record system, but to use Databases like iTunes as an example. That's the day physicians will use this and until it's in the typical medical jargon and complex reporting and 1990s Architecture by the way for reporting. This is never going to really get traction I guess my question is whether rather than talk to medical records experts and The various kind of the usual suspects, I guess are we talking to design experts? People who think for a living about how to present information so that it is really Transparent clear and a pleasure to look at instead of a burden to look at So I can answer that from my own personal perspective and then perhaps a little bit more broadly But one of the things that we've been exploring at geisinger has been to engage to those types of people and also work directly with physicians and with patients to develop a fully functional laboratory report that would include not only the result of the lab but also Embedded within that report Links to a variety of different content resources patient education resources Clinical trials resources that can all take place literally within half a page of a PDF type of document and Try to get a the look and feel and usability that would be much more Functional now the challenge of course is that ultimately we have to interact with the systems that we have which is you've characterized Are just not really up to the task and so the challenge then is is this something? where we can develop a workaround where we can perhaps Use ancillary system like a PAC system where we keep all of the complexity Within the record, but it's it's shielded We don't see all of the ones and zeros that go into characterizing that image But we interact with the system that prevents the presents the image and allows us to manipulate it We may need to use that type of an approach and we had a commentary that was published out of the electronic health record integration working group From e-merge in JAMA within the last couple of months that talked about different ways to store and present Information in such a way that it can be more usable and I think as Deborah has also mentioned the idea that you know There's no reason at least in our view that some of this can't also be directed at the patients and using patient Centered approaches to say, you know, what is it that you want to see how do you want to see it? How can you understand it so we can really create a team-based approach? So I think that we're clearly interested in this. I think that we were we in a an environment That would really allow all of the functionality that we have within The the web 2.0 and and the social media That would really allow us to do this very quickly But that is not the electronic health record and laboratory information system environment that we're currently residing in So we're going to have to find ways to Reconcile those those differences, but I don't think I Agree with you in the sense that I don't think that we should say if we can't make it work in the current EHR Then we should just forget about it I think we need to find other ways to if it and if it needs to be a workaround at this point Then I think we do that and if we can show that we can improve outcomes By doing it then that will provide some impetus to say here. We need to really ramp up what we can do Great. Any other calm. Oh, yes, Larry So, you know in the pre-analytic space, there's just a couple of comments You know, we've seen Chris Miller's work and we've tried to to replicate that and and the VA is a payer of healthcare in a Funny way because classically genetic services were fee-based out meaning that people would go across the street to their academic affiliates and So so we've been looking at that and and trying to do the same kind of pre-post Studies and in almost every case is when somebody was fee based out they would order every genetic test and Because that's in their financial best interest to do that and that's at institutions that some of us know and love And and in fact that included repeat CFTR carrier screening tests, which is about 1200 bucks Even even when a first-degree relative was negative for BRCA one the patient got a full sequence again You know things like that that that are not good, but then the the best example So, you know we can document that having that pre-test review is very good in another setting than than Chris Miller's But the funniest was sort of an experiment of a nature where one of the lab directors put all of the tests in by Name so that they could keep track of them what you would think is a very good idea and Within one week of doing that there were a couple of dozen tests ordered by people for complete sequences of genes Because they were on the pull-down menu And this happened immediately and so we had to take down those ordering facilities So so working with the electronic medical record can even even have you know That would of course make the tests available after the fact But but having that order there was made it horrible Yeah, and I think that there that's another really great place to do some studies, which is how do you present? Tests in pick list so that you can actually use the pick list to drive appropriate utilization And that's that's another type of user interface Operability type of study that fits well within the EHR research Environment that's something that would be very interesting again. That's a solution that if it's something on how you construct a pick list that would be readily generalizable within the different EHR systems because all of them are based on Lookups and and pick list to do order laboratory order entries. So Great. Okay. Can I can I do one additional thing? It can be very short but Derek did mention something related to an issue this come up a couple of times and that's genetic counseling and CMS and I just wanted to Put Janet on the spot to give a brief update in terms of the NSGC and other status about trying to Take this through the legislative process. So NSGC as a board has a task force that is working very hard at collecting data on this these examples particularly with BRCA and cancer syndromes on Expense with Ordering inappropriate testing looking at genetic counselors and their interactions with the Medicare population And that is moving forward in terms of cost analysis the first thing you have to do to get on any sort of Hill agenda so much progress is being made and look for something within this year Wonderful. Thank you We I'm just gonna make one more comment. We'd look for everyone's support for those efforts. Thank you. Great. Okay Next up we have Dr. Rodin who's gonna tell us a little about the European Science Foundation