 This session is to have taken the 20 or so ideas that came out from the tables. We have this extremely Delphic endowed panel here that with great wisdom has selected the top six. And then you're going to hear what those top six were from the panel, just in a very concise statement that will be hopefully not completely obscure. Then you will be given a chance to vote and you'll each get one vote and from that we'll determine which are the top three and then we will engage everybody in a little bit more discussion about those top three and end in 40 minutes. Just to preface this, there is no money on the table. At least I didn't see any, I don't know. This does not have profound ramifications for anything getting funded, anything suddenly appearing in the next grant renewal. This is really an exercise to get us thinking about some of these concepts. Clearly if something is a brilliant idea that emanates from this, it may trickle through the process at CTSI, but just don't feel that all of this has a high stakes game where we've just done an NIH review in about 20 minutes and we'll now make a final decision with you as the council in the next 10 minutes and suddenly this will have tremendous implications for people's future careers and research projects. And a lot of this is around not thinking just what's worthwhile projects but trying to think about how do we think about sustainability and not always just assuming there will be NIH or other grant funding to support this. Okay, so without further ado, I'm going to turn it over to the panel and what we're going to do, Rachel, can you go ahead and display the six? Well, let's shoot them up because then people can follow along as they're reading them. All right, people can hear me. So you're going to get one minute. Everything you need to know about the initiative from each of the panelists. We will have about two minutes for any clarifying questions and then we will vote. So let's start with, let's go in the order here. Let's practice. Let's see. Don't vote yet. Don't vote yet. All right, first let's go in the order that they are on the screen. First up, San Francisco Health Improvement Partnerships and Personal Technologies. Which of them are on the screen? Bill Baulke. Thank you. So I'm Bill Baulke with the Clinical Research Services Component of the CTSI. And this is from Table 14, which is a really nice idea that combines two initiatives, biomedical informatics and community engagement in health policy to collaborate to improve San Francisco Health Improvement Project through personal technologies. The customers are many including the entire San Francisco population, particularly targeting youth who are more adept at these personal technologies. The impacts are broad with monetary savings for the city and measurable improvements in health and significant reductions in savings on lower rates of obesity and things like that. Ideas for sustainability were support from the city because we have such a budget surplus. Demonstrate efficiency with the partners. Some of our technology partners might be willing to donate some of the technology. Other potential sources would be the Department of Public Health and other San Francisco departments who would impact on many of these health initiatives that could be targeted with personal devices. Second one. That's it. Perfect. All right. All right. Next up, the Balanced Surgeon, June. All right. Hi, I'm June Lee. I'm the Director of Early Translational Research at CTSI. And my initiative is from Table 1, the Balanced Surgeon Initiative. I'm going to rename that a little bit. No, don't vote yet. All right. Hold back those votes. Somebody's waiting. Somebody's premature voting happening out here. All right. All right. Hold back, folks. But you can if you'd like. Go ahead, June. I'm going to rename that a little bit to call that sort of a device acceleration initiative. Since the CTSI infrastructure has supported clinical trials and clinical research training for the community, but often the surgeons are less engaged in those programs that are available. And so the suggestion here is to tailor and modify those programs that are currently available to enable more engagement from the surgical community. And that missed opportunity here is that the surgeons that we have bring unique perspectives and expertise that are valued by the outside world, but really actually has potential to impact in patient care downstream that's not being fully leveraged. The sustainability part would be through potentially getting sponsorship opportunities from device companies or other surgical instrumentation sort of companies, but also opportunity for co-development collaborative opportunities with those companies and also inventions and patents with downstream revenue generation capabilities, as well as the potential to generate bigger NIH grant making opportunities. And then really the other fringe but more important benefit is enablement of our faculty career growth. All right. Thank you. Beautiful. And we're not going to penalize this. They did three cards instead of one to explain it all, but the handwriting was so impeccable we accepted all three. All right. Next one. Early transitional research. Okay. That's me. I'm Elizabeth Boyd. I'm the director of the regulatory knowledge and support program. This proposal comes from Table 19. And I think Table 19 really thought carefully and creatively about the presentations that were made this morning. And they have really tried to conceptualize an idea that would combine for-profit and non-profit activities. And the idea is for a non-profit organization or entity to be developed under the early translational research group. And this entity would facilitate early stage research by partnering and bringing together industry partners, researchers, non-profit patient advocacy groups, et cetera. The customers, of course, would include our UCSF researchers, industry leaders, patient groups, as well as the general public. The impact would really be to encourage and foster relationships and collaboration with researchers and industry partners that would help promote and advance early stage research, put devoted funds toward that, and thereby stimulate and promote these developments much earlier and much faster into the public domain. Ten seconds for sustainability. Finally, it would generate industry dollars from industry. It would generate in-kind donations and sponsorship from patient advocacy groups. And, of course, downstream, there would be profits generated from the products that were created. Great. Thanks. Next, online education. Online education. Hi, everybody. I'm Sally Mead. I'm the Chief Administrative Officer for CTSI. And I'm here to talk about an idea that also came from Table 19. The anarchists who submitted more than one idea. So this has to do with the continuing expansion of online education, which is an initiative we already have in the works. Beyond UCSF, to the United States, international implications with this, we can redefine curriculum, re-adapt, figure out new ways for people to learn. The customer base could really be anybody with a state of higher education as it is in the state of California. We could think about that, or we could try to expand our work into developing countries. Kind of the table's wide open, and there's lots and lots of opportunity for growth and development in this area. And revenue-generating possibilities are limitless. And varied. And I think the real challenge with online education has to do with figuring out how to tackle it and what our responsibilities are as a public entity to the world. Brilliant. Thanks. UCSF Profiles and Public Health. Hi. I'm Ralph Gonzalez. I'm the Co-Director of the Program in Implementation Science that lives within Clinical and Translational Sciences Training, CTST. So I'll present to you an initiative to align public health and UCSF researchers through profiles. And the customers here would be the San Francisco Department of Public Health faculty and investigators are not currently within the profiles. And so the proposal here is to put them into profiles so that UCSF researchers and Department of Public Health can find shared opportunities for funding. The impact is to be on the San Francisco City and County residents, as well as the faculty and investigators. Their idea for sustainability is that basically there could be some funds flowed through successful grant and other contracts that were successfully obtained to support the scale up of profiles. Thanks. All right. People are gone. So you see how this works. All right. You made up your mind. Last, but do you hear out the final proposal, which is electronic medical records sharing, Mark? Yes. Please hear this one out. This is an important one. Because you can't retract your vote once you've done it. I'm Mark Pletram with Consultation Services, CTSI. And this is not a new idea, electronic medical records, and developing an interconnected EMR that integrates data from UC medical centers and partners. But it's a really, really important one. I think this is one of the major things that's changing in our research landscape. And this is a key area where CTSI can help translate what's going on, the health information revolution that's going on right now into better research and therefore better health. The customers here are the UC researchers and patients. I'm going to just focus that to UC researchers and really think about how we can use the EMR better to further research and do research better and more efficiently. For example, by using EMR for recruitment and also for using it for obtaining measurements, baseline measurements, follow-up measurements that we usually think we need to develop a whole new infrastructure to get these other measurements for clinical trials, etc., and also for using it for event surveillance, which is something that we also usually have to develop infrastructure for in clinical trials and observational studies. So this is a big opportunity to help research get better, and it's a very sustainable one because it's fundable. And we're paying a lot for it now. We can divert some of those funds to pay for it much more efficiently through this mechanism. Great. Thank you. Okay, Rich, I mean, I think they've gotten the hang of it, but you get one vote, right? So the text you can submit anything or you have to write code? So for you non-American idol whizzes out there, we've already started to vote. You can just one vote, so if you already voted, it's taken. But just to quickly walk you through this. So you'll see, you're going to be texting a code, so most of you should have your phones out by now. You're going to be texting a code to a five-digit number. It's 37607. And what you're going to be texting is a code, and the codes are given to you, and as you can see, they're on the right-hand side where the bars are. If you don't have your phone, you actually want to do this over the web. You can go on to pollTV.com and a little box will pop up, and you can submit your code into that box. So as you can see, it's already moving in real time. We have about 63, so actually there's a lot of you that haven't voted yet, but we'll give you a little time to do that. It's also to let you know, so regular text charges apply here, so I have lots of dimes. It could cost up to 20 cents if you don't have a plan and some carriers. Also know that this system is really serious about privacy, so they don't keep your phone numbers. You're not going to get a follow-up response unless you try to vote twice, and then it'll yell at you that you can't vote twice. Otherwise, I think that's all you need to know, and we'll give them a few more seconds to visit. If you have a question, ask your neighbor if you're not sure how to vote, or any of you youngsters that are really good at this. We're moving. Those bars are moving. A few more seconds. A few more seconds. Can I just... Because the next vote is how many want to see a reprieve of Bill Bawke doing Running Man from last year's retreat? Retreat doing the... Oh, no, that was the side. That's just between Bill and me. Because we were going to get the deans back up to do it again as well, but we signed a promise that they wouldn't have to dance again if they came to the retreat. I think that was the deal, to get such a good turnout from all the deans. Joe, you could have been initiated as part of a first-time dean at this. All right, the polls are closing. Nope. One more? One more left? Close. Oh, yeah. We need... We need a recount. Did everybody have their ID when they voted? We may need to check some IDs, Rachel, to assure that there was no fraudulent voting going on here. Wow. I see... Do we have the absolute numbers? No. Top four. No, I was just... We're going to do... No, all right. Conomeco record. All right. Early translational research and... I don't know, I'm biased on this, so... All right, we can try four. Let's see how far we get with four. Okay, so the voters have spoken. What we're going to now do is take these four, and we have about 25 minutes. And the key is to try to... Again, we're not going to have, then, a final vote to say which is the top, but really think through and to hear from you all. Say, how could these be done in a way that maximizes their impact, as well as has a pathway to sustainability? So, electronic medical record. Mark, you were last, but did it with great feeling and passion that obviously persuaded a lot of folks out there. So, Mark, do you have anything you want to add to embellish on what you said already about thinking through? Really, what's... There's all these EMRs out there, both at UCSF, other systems. I mean, what's a funding street to pull that together with much more usable database, usable infrastructure for researchers? Well, it's a good question, and I feel of two minds about this, and I think this, for one, could be a very sustainable thing because it's going to add a lot of value to research projects. So, as I said, research projects are spending a lot of money on this already, and if we can provide much easier and more efficient ways of gathering the same types of data, then we should be able to fund these things very easily. On the other hand, I feel like these things are core pieces of what the university and CTSI, et cetera, should be doing, so I feel like we shouldn't. Charging for it is going to impede, to some extent, the translation. But let's say, is it like CRS? Is it a mixed model where there's some core infrastructure provided? But, you know, you want access to pull some data down. Clay has a project on strokes and wants to see how many of those folks with TIAs show up with strokes over a five-year period that that investigator should pay for those data, you know, or access to those data? Yeah, I agree. I think that's reasonable. Have some core funding and charge for some of it. One of the things, I'm a consultation services person, so we could charge for consultation on how to use this or how to set up systems for your research project. Now would be a way to recoup some of the costs. Anybody, so anybody out there, any questions? Anybody want to challenge this idea that this has legs? Anybody from the group that was proposing it want to have anything to add about this? Kevin, can I pose a question? Yeah, of course you're on. I'll pose a question to the group or to people from Informatics. How does this dovetail or how does this differ from what we're doing with the IDR? The integrated data repository, which has already had five years of extensive funding from CCSI. Any folks? Anybody want to speak to that from Informatics? Yeah. With a group that's trying to aggregate community records and there was a brief introductory conversation about introducing an exchange between that community database and the IDR. But right now the IDR I think represents UCSF data. So one question, are we already there with just UCSF Medical Center data? Is this really about linking with other UC Med Centers or a health information exchange more broadly among multiple hospitals or providers? Anybody want to speak to that or have something to say? Well actually we're not very well there yet. So the IDR is still struggling. And it is just UCSF. When we thought about this, I was sort of thinking of this in terms of ideas that would be kind of cool to do. We don't actually have a choice about this. If we want to stay in clinical research, we kind of have to do this. There won't be a lot of tolerance for not being able to do this because if you had a choice as a funder, do I pay for this research to happen in a place like Kaiser or group health or the ACOs that are going to form where they can follow a person from soup to nuts or do I want to go to a place at UCSF where they're going to struggle to recruit? UCSF right now. Where they're going to struggle to recruit and they won't be able to follow them in the outpatient world or whatever, you're just not going to be able to get the funding. So this is a very basic task that we have to do. Would you pay for this as an investigator? So I can imagine an institutional recharge mechanism and somehow it has to get paid for either indirect or on clinical research or an institutional recharge. Would people comment? Please introduce yourself when you make a comment or have a question. Listen, any one last comment thought on this? So just a question. I'm sorry, I was going to ask a question for others as well. So IDR is UCSF only and I agree with Adams, that's just a necessity. But the piece that's interesting is to think about the five UC medical centers and what putting our data together across five institutions provides us that one doesn't. So we go from, you know, three million records to 12 million. So if you have 12 million records, is that an opportunity for something that maybe three million wasn't? I don't know the answer to it. But I think that's a possibility. That's something to think about that's over and above the basic providing us an electronic medical record here in IDR. If we don't do this and combine with other people, we won't have the scale. Why would anyone fund us to do something when they could fund Sutter to do the same thing and Sutter has a zillion more patients? So except for very rare diseases where we managed to achieve concentration, you know, pediatric cancers and stuff like that. For the most part, this door will close to us if we don't do this. All right. So let's close on that for now. I think I'm going to close on... Yeah. All right. One last. Please introduce yourself. Hi, Kim Kirkwood. I'm a pancreatic surgeon at Parnassus. And we generated the idea because we felt that by being able to combine the campuses, it provides opportunities to look at patient populations that in any one center you can't ask and answer a question because you can't power the study. We felt that it was actually going to really be attractive to investigators, particularly who don't have NIH funding because this is a much cheaper way of accruing patients and asking and answering important questions. And we were thinking about metrics that would both be to improve quality of care because you could say you wanted to check, say, an albumin level in every patient over the age of 80 who was hospitalized. And also to, at that time, study questions that would be related to the same patient population. How does that correlate with functional outcomes, for example? So we felt it was a really powerful way of looking across centers. Good. All right. This one seems fairly clear. And Jonathan and Victoria in the panel with the clay, early on, encouraged us to think, who's the end users? I mean, who are users and engage them? The users really are the research community, and it sounds like there's a general sense that people are paying for this one way or the other, that there's maybe resources that can be redirected in a more efficient way. A prerogatives of the director. All right, clear. Yeah. So this is... I can't mention Colorado. No, nothing about Colorado. So fabulous idea. Gotta do it or we'll die. Gotta work across institutions. So the UCREX project, five campuses coming together sharing data for research purposes. But the key to this is, you know, that's $5 million. Sounds like a lot. It's going to be gone before you can blink. And it's going to be inadequate to meet all the needs that you listed. And so then, in thinking about, well, who are the other partners? Well, as you just mentioned, it's also useful for quality of care. It's also useful for operational issues. And in fact, you could save money and make each of the hospitals and medical centers more efficient. And so that's the tactic that we're trying to take to say, okay, medical centers, you're also a customer and you're a deep-pocketed customer. Can we build this with you, meet your needs, and also address these research needs on the side. And so that's kind of the way we've reframed this question to try to deliver on it. We'll see where it goes. So it sounds like sort of some movement there. Okay. We have three more to go and we'll do quickly. SFIP and Personal Technologies Bill. You talked about this. So this is around communities with disparities. Maybe it's around physical activity nutrition. Maybe it's oral health issues. These are the kind of things. An app could be put to use. Do you think people would... I mean, the end-users would want, is it the community that would, you know, people would want to buy this or they already have it and would they buy the app for their diet self-monitoring in the low-income community for $1.99 to put on their smartphone or is it the tech companies we're partnering with? I think the answer is all of the above. And so I want to congratulate Table 14 and please, wherever that table is, if you want to correct anything that I may have misinterpreted, please do so when we get to the questions. This is a nice marriage of several of the initiatives of the CTSI to really advance, in my mind, where the rubber hits the road in clinical and translational science and that's in the community engagement and its larger aspect of health policy. And there's actually precedence for this. In my other life as a cardiologist, there are a number of applications of personal technologies that really help lower recidivism for a variety of re-hospitalizations like heart failure. So this is proven to work and if you do a value calculation on checking of weights and using that to adjust medications rather than come into the emergency room, the savings are astronomical. We're talking tens of thousands of dollars per year per patient and this ties right into what Clay just said with respect to the previous topic. The potential funders for these kinds of apps, for these devices that could help monitor the things that our community is concerned about, which is obesity, which is addiction problems, all can be either apps or devices that can connect electronically, medication reminders, any permutation of those kinds of applications have enormous implications for the health and well-being of our community. And the savings that they generate really enables a long list of potential contributors like, as Clay said, the medical centers would benefit enormously. Emergency room visits would drop, recidivism would drop. Lots of other manufacturers that do these devices would benefit because their applications could be spread not only through the San Francisco Bay Area, but we, this would be a wonderful opportunity to use our incubator here in the Bay as a proof of principle for the nation. And I can't think of anything that makes my skin tingle more than that kind of generalizability which we could accomplish here. You may make you dance, though, if you really want the tingling. I'm not being facetious. This is really where it is, and it's very exciting to discuss it, let alone think about implementing it. So we didn't actually ask people to have to champion this. They were just sort of on their own pickets. So this clearly resonated with Bill. So any other comments, questions from the audience? Are you sold on this? Does this seem like this is again? James, please introduce yourself. I am James Rousingheism, the program coordinator for community engagement and health policy, and SFIP is one of our, it is our primary initiative. I think one of the things we're challenged with and something we spoke, there's one of our coordinating council members at our table as well, and more Santiago is the notion of legacy with a lot of these partnership working groups that we're working with. What do we leave behind? What's the impact of our partnership with them? And something like this sustainable, it's coming from a sustainable partnership. It can be these personal technologies and it's part of what we leave behind and part of how we solidify those partnerships by making investments like these. And he really did. So thanks again. Introduce yourself, please. The developments in sensors are really tremendous. It's not just going to be about phones. This is personal technologies, distributed technologies, embedded technologies, your clothes are going to be sensing everything. The kind of data that we're going to be able to collect is going to be tremendous. And actually the value of this also to us as researchers is huge because it's another avenue to get data that we couldn't otherwise get. Very high density, ambient, modalities of data like environmental pollutants, expenditures, how people are spending their money, where they're going, social network, just data that we've never had before that can enable us to ask questions that we've never been able to ask before. So there are multiple benefits. And I think the trick with something like this is to build in a way that can evolve opportunities. We have no idea what technologies are coming down the pike. The business models are unclear, but I think we're very well placed to provide the scientific foundation and the focus on what's really important and try and bring groups together to go for it in a way that adds value all the way around. I think it's a great opportunity. So we're going to have to move on. I'm going to give Bill a final word if I could. And I just want to be really clear that if I understand Table 14 correctly, the phone is only part of this. There's so many other kinds of technologies that are out there. Some of them are already proven. And just to give you one example of the potential where I don't think the business models are all that far from being implemented, you go to a large manufacturer who provides health insurance for their employees and you find a way through a simple app and technologies that they already have for their workplace to remind them of their medicines or to do this sort of thing, you're going to decrease the expenditures of that healthcare enterprise for that corporation. They will pay handsomely for you to advance that technology, prove it, and scale it. So I think the potential partners in the sustainability is huge, probably more than any of the ideas we've talked about so far. That's just my app going off. Tell me it's time to stand up and stretch. Okay, all right. Just joking. All right. Next. Brilliant. The balanced surgeon. June, as our kind of early translational expert, you did a beautiful job of sort of advocating for the sense of surgeon engagement. Do you want to add to that or the sustainability argument? Yeah, and I'm not sure that the table that came up with this idea was limiting it to device development. In fact, that would be confining what our surgeons do more than I like. But I do think the dynamics around how devices get developed is very different from how therapeutics get developed, and therefore that special perspective, clinical expert perspective that surgeons bring is one that's valued by potential industry partners in a very different way than target identification in the therapeutic space, which is why I think making, and because surgeons have very different kind of demands on their clinical time that precludes them from being able to participate in a lot of the training and training opportunities and other opportunities that are offered, thinking through what those limitations are and trying to engage that community in a more active way would be of great value, I think. Dr. Brindist, stop typing so you can answer a question here. You've gotten surgeons involved at the Institute for Health Policy Studies on sort of thinking in a way that I think is rare at an academic health center, have surgeons involved. Do you want to comment on your approach to engaging the surgical community in these research activities? Well, one of the leaders that we have on our campus is Kevin Bozik, who has recognized that if you don't engage patients in shared patient decision making around surgery, that you may actually be losing the opportunities to improve outcomes and reduce costs. So he and Jeff Belcora, another IHPS faculty member and also member of the surgery department, are joined together in an RWJ funded project to see whether having an opportunity to inform patients, getting them engaged and understanding what the potential outcomes will be if they decide to do back surgery or not do the back surgery and quality of life. So I really think that shared decision making is a very important part of this and it's very transferable to other areas of medicine as well. And partnered with joint appointments and things like that, I mean at the policy level. Other folks from that table? Yeah, please introduce yourself again, please. I'm Karen Lew and I'm a pediatric heart surgeon that just recently joined the faculty and our advocate did a great job in elucidating our proposal but I think our initiative actually is a much broader, pronged initiative and really what we meant by the balanced surgeon is trying to develop a method whereby we could pioneer a model which we could then successfully disseminate to allow the application of surgical trials in America and really from a pediatric heart surgeon perspective we have one successful clinical trial in the last 50 years, a randomized clinical trial and that is because of the limitations that surgeons have and I think if we could package a way to sell methodology or develop methodology to standardize and overcome the barriers which are the heterogeneity and the delivery of care so a surgical trial is limited because surgeons are all different and so it's not just a drug that you're trying to evaluate it's a surgical, sometimes a surgical technique and so trials are confounded by that. It's also limited by personnel. Junior faculty have a lot of demands on their time as we elucidate it so what we are actually proposing is a way to allow junior faculty access to resources, a consortium-based research methodology and a way to train and standardize clinical trials in a broader surgical sense. So make then 30 seconds on the sustainability case. Would the surgical community put skin in the game to support this from the investigator? Is there a sense that there's external funding? I'll just give you a quick anecdote. There is in, again, my particular field there is something called the Pediatric Heart Network which is they have an RFA about every three years and there are nine centers that have successfully submitted and gained basically they are part of this nine center consortium so if you can develop a way to get a successful initiative launched you have access to NIH funding you also will have access to device companies wanting to partner with your center if you have successfully done a clinical trial patients we've just talked about so I think there's a lot of sustainability. I think we have five minutes I want to do the last one so I'm going to arbitrate although it is on those clinical trials and randomized trials it's always a trip when you wake up with a sham scar on your chest. All right, the early translational research. Elizabeth, yeah. I would like to hear a little bit from Table 19 who came up with this idea but I think it is on the face of it at least a very creative effort to bring together around early translational research a variety of partners who would all contribute from the get-go, the financial support to make it happen it also then has the downstream effect of potentially generating income itself through the entity I guess if we could ask Table 19 Anybody want to speak up for this one? Table 19? I'm here Hi, I'm Tracy Strickroth from CTSI I work in the participant recruitment service actually but we thought of this idea just because we've seen the success of early translational research in the T1 program and we thought that basically what was talked about earlier this morning was building a for-profit business within a non-profit umbrella and we really like that idea and thought that this is the most promising program to do that by creating a non-profit academic as well as industry partnership and we thought that we could get buy-in from patient advocacy groups to support the research and collaborate that way and that's kind of the idea of how it came from June is this fit? Do you want to comment? Yeah, so I can make a comment there in terms of what's going on in the T1 Catalyst Program and more broadly in the early translational research efforts within CTSI there is a lot of engagement with the external world including the industry and this is based on a number of different things that are going on in the world around this and one of which is that the industry is looking more and more towards academia to enable its development pipeline for a lot of reasons which we don't need to go into here and we do believe that a place like UCSF is uniquely positioned to be a productive collaborator and partner in that endeavor so we are out there and we have people coming to us to find more creative ways to partner and collaborate and co-develop a variety of different sort of models Last comment, Deborah T1 Program so I mean there probably are some reasons why that would be helpful but it'd be nice if somebody could explain those Is there a 30 second answer to why a company is a distinct company? Bill? Alright We do have our expert Alright So the shortest way to say this is there's been a lot of work with philanthropists just a handful of them right giving enough money to organizations that they can develop drugs and when those organizations have leads and there are vaccines and devices and diagnostics too when these non-profit organizations step forward to engage with for-profit companies they're negotiating with one arm and one leg behind their back I mean it really is you're a non-profit and you're not about profit so our deal terms in engaging you this is just one of the reasons we don't speak the same language so having a for-profit entity that speaks the same language for-profit to for-profit that is fully owned or majority owned or whatever and full control we didn't talk about how to control that was one of my issues over time and it's been an issue with even some board members and with governance questions is how to not lose control but we're talking about getting on the same level footing and negotiating and offering licenses and deal terms for-profit to for-profit which probably means different individuals even we have cultures in academia and in non-profits that lead us to prioritize mission over other things and that's very important but when you're doing business you need to really do business when you people to do business for us and I believe we can do better we can do better than we have done this is an experiment I think I think that allows us to come full circle sort of bringing you back to the panel and Victoria's contributions there so many called me up to propose this and I thought what an absolutely insane idea this is going to be for a session and it's true this was wonderfully insane but weren't these tremendous ideas I can't believe how people in such a short time on this little index card and with our panelists trying to make sense of these scribbles came out with a really stimulating discussion about some really good ideas I'm really impressed so bravo to Minnie and Rachel for organizing and to all of you for making sense out of all of this