 Well, it's really a pleasure to be here. I appreciate the opportunity and I've been really impressed by the conversation this morning and by the models that we've already heard from They're terrific, and I'm excited to share a little bit about what we have done at intermountain health care and we really launched in We implemented genomics in cancer initially and then sort of blossomed from there and honestly five years ago when we started our Cancer genomics program. I didn't necessarily anticipate that it would Spread and grow the way that it has but we kind of caught the front of a wave and it's been a lot of fun And we have a long ways to go and a lot to learn so I just thought I would share a little bit about How we have gone about implementing genomic medicine and precision oncology and then share some of the outcomes that we have measured and I'll conclude by talking about how we have begun to spread outside of oncology into other medical verticals and disciplines For those who may not be aware intermountain health care is an integrated health delivery network Headquartered in Salt Lake City, Utah. It consists of 22 hospitals about 180 physician clinics You can see the license beds there and it has a health plan Much like you have heard from other health systems that it covers almost a million lives now Which is powerful and the other metric that I don't have up here is that We physically see in one of our hospitals or clinics 50% of the population every year. So we are touching People within the state of Utah on a regular basis, which is nice and gives us access When we initially launched the precision oncology program, this is the workflow that we built and I think a lot of people in this room could have a slide that shows a similar workflow Specifically on oncology patients are seen initially in the first day and over the course of the next several days We obtain their specimen and do this molecular analysis and what we are running is a tumor owner only panel in oncology Of about 170 genes. So it's targeted sequencing. It sees all of the relevant mutation types And we're not doing accompanying germline in oncology right now Although we are doing that in other settings and then ultimately We do a bioinformatics review and we implemented this step right here called the molecular tumor board Only after we had not launched our initial test offering and the reason that we did that is we found that frontline Community oncologists were not familiar with interpreting Basic genomic test results. They would receive a test result and outside of KRAS or BRAF the rest of it would read like Greek and We found that therefore they wouldn't utilize the information at all And we just turn the report upside down set it aside and say that made me feel dumb and I'm not going to do that again and so we implemented this molecular tumor board as a way to Distill down the Greek and what the molecular tumor board does is review every single case that comes through our system And we are now as a system. We have a goal to test all advanced cancer patients Meaning perform a genomic profile on the tumors of all advanced cancer patients, which ends up being about 1500 to 2000 tests per year and the molecular tumor board reviews each one and provides an interpretation that simplifies things and simply states You know consider targeting this gene with this drug and we'll offer one or two options for that front line provider to consider and doesn't include all of the You know amino acid substitution and precise location of the mutation and all of those things that confuse frontline providers That's included on the report, but it's down lower. So those who want to read it can but you have to look for it So this overall process now takes us about 10 days when we first started to mark's excellent point We knew that we had done it wrong and we guaranteed it or your money back And it took us 25 days when we first started and now we have whittled it down to about 10 days Business days, which is meaningful clinically for oncology patients This is an example of what the report looks like and I mentioned this molecular tumor board interpretation And so we we really distill it down by saying look here is a gene Here are some drugs that you can use if we were generating this report today You might see osomertinib and some other options as well And so it's regularly updated. I don't usually spend a lot of time talking about this But we even have an order button so that if a provider Sees a gene drug match that they like that they want to engage for their patient They can simply simply click on that button and we actually have a drug procurement team I like to call them the drug dealers and they love it They totally love that name and they engage and go about working with the payer to get a drug approved Or to find a clinical trial or whatever mechanism we can to get a drug for a patient And that's actually a dedicated couple of FTEs that do that full-time And it's really those two steps the molecular tumor board and the drug procurement team That has overcome what we think are the two major hurdles to implementing genomic medicine into cancer care Without those two pieces we found that tests were ordered and the information was never acted upon or utilized so just to You know highlight what everyone already knows is that we were able to find in Lots of these advanced cancer patients variants that we know are actionable from other disease types So here's an example of a colon cancer patient who had a HER2 amplification and we confirmed more for academic purposes than anything the high level amplification of her to and found that This patient's tumor harbored approximately 30 copies of her to so it was a very high level amplification and when we Provided targeted anti her to therapy In this patient who is refractory to chemotherapy You can see that there was this robust response So so while on chemo these two hypodense lesions in the liver of course grew and then when Providing an anti her to therapy these lesions shrunk and this patient did well for a very long time Had a dramatic response and we have come across anecdotes like this over and over again And of course the problem with anecdotes is that they are anecdotes And so we have to really generate more robust population-level data and so we have tried to do that and one of the studies that we published a couple of years ago Was this retrospective? matched cohort study where we took patients who had had genomic testing and Received targeted therapy and we matched them to other patients with in our system who had not received genomic therapy or Genomic testing or targeted therapy And these were patients that we pulled from our initial pilot study I failed to mention initially that we launched this as a pilot study across three hospitals And on the strength of the data that I'm going to show you we then Expanded from there to cover all 22 hospitals So these patients were matched according to age gender diagnosis and number of previous lines of treatment So to be a case in control you had to be you had to have two sixty two-year-old men with Metastatic pancreatic cancer who had both failed two previous lines of therapy as a way to control for where they were at in their stage of disease and then we assessed for progression freeze survival and also overall survival and then we did something that Intermountain health care and I think a lot of integrated systems love to do which is look at the cost of care Which we can do because we also have a health plan So we know what the charges are associated with these patients care And what we found is that there was a really dramatic improvement in overall survival in these patients And this was a small retrospective study. So I think you know take take these results accordingly But we did find that there was this not only progression free survival advantage but also this overall survival advantage and I know that this is a little bit of an atypical way to demonstrate survival data You usually see a Kaplan-Meier curve and we have those I'll show you this one in just a minute but the reason I love this particular figure is because We have the charge data accompanying it So these bars right here represent charge events during the course of a patient's care and a little red box would indicate that there was a very expensive Charge event so the patient went to the emergency room for some reason for example and then You know gray areas mean time has passed when no charge event occurred and a green box would mean that Some low-level charge event occurred and the overall picture kind of like a heat map that I hope is coming out here Is that there are more intense? Charge events happening here in patients who are receiving the next line of standard therapy Compared to those who are receiving this genomically informed medicine when you look at that More granularly We find that in fact the overall cost of care in patients who received standard therapy was a little bit higher than when we use this Genomic medicine approach. In fact, we ended up saving about $730 per patient per week and I always have to emphasize that it's per patient per week because of course they live longer and and I was in a meeting and one of our executive leaders said well Do we really want to be doing this if they're all going to live twice as long and we have to and I said stop just Don't think you're gonna want to say what you're about to say We should be so lucky that we have that problem to worry about and so It's it was very exciting and on the strength of this data where we saw improved survival and a cost savings We approached our health plan. Oh before we approach our health plan I'll just give you a little more breakdown on where we saved this money so we That survival data came from a small cohort But then we looked at a much larger cohort of patients from our health plan We took 2,000 patients those who had received a targeted therapy that were not necessarily In our study and there ended up being about a hundred of those who had had genomic testing and received targeted therapy and approximately 1,700 patients Who had not received a targeted therapy and when we looked at the costs of care in those cohorts? We found that We actually were saving money In the inpatient setting for patients who received Genomically informed medicine and we believe that's because they were having fewer severe adverse events Nutripenic events and other things requiring hospitalization on the other hand We spent more money in the outpatient setting and that's largely because of the expense of the therapies themselves So a lot of these patients were receiving oral targeted therapies and those just cost more, which is no secret so on the strength of that data with the cost savings across the a Little bit larger population of our insurance plan covered group We met with our insurance plan the team from select health is the name of our insurance plan And ultimately they came up with this policy where they are now covering Testing in all advanced cancer patients as long as they meet these criteria that include having stage 4 disease and having failed at least One line of standard therapy and so that that was really nice to see that our payers are interested in Analyzing data that we generated in our own health system and that they have been responsive in developing a policy that Benefits their members and I have found this to be the case over and over again generally that payers want to be at the table They want to have the conversation they want to do things that they think will benefit their members And I think whenever there's a breakdown in communications with payers it's because there hasn't been communication and And I think that we as providers and scientists can be more proactive in engaging our colleagues on the payer side So we have now expanded beyond cancer and are moving into other places To do this, you know, there's this question of Aligning the economics and the financial incentives to make it happen And we're starting to view these as products. And so we now offer this Cancer panel test that I talked about And we have gone on to now start offering pharmacogenomic testing Which we're using in all of the mental health clinics across intermountain health care Which has been really exciting and and I'll talk about how those patients are being selected for testing And then we've also recently launched a hereditary cancer testing panel that just includes the standard breast breast and ovarian cancer genes And a few others all of these are orderable within our EMR, which is a CERNR system And they're all reportable that same way Which is making the the research associated with that much more relevant which has been Exciting so as we launch each of these new products in these different verticals We've tried to have the discipline of saying, okay Here is a product that we are now offering and let's measure the impact and we can never launch something in my opinion unless we're also Unless we also have a really Clearly defined mechanism for measuring impact or clinical outcomes and that's that's one of the Promises that we've made to our payer and that we think is important for our patients as well and so I already demonstrated already Showed this data, but in our a cancer testing panel, for example We saw this improvement in survival and we saw this cost savings And so we have published that and returned that to the payer And that has given us additional credibility and we anticipate doing the same thing in mental health So we are now offering this Called Rx match, which is a pharmacogenomic test for all patients not only in the mental health clinics But also in the primary care setting And we worked with our colleagues in the mental in the behavioral health Clinical program to define which patients exactly should be offered this testing and where should it be conducted and ultimately we came up with Just these two criteria And we actually found that the primary care providers really wanted very specific criteria on how to implement this what they don't want At least in our system was for someone to show up and say you could consider ordering this test. It's now available That that throws them off. They don't know what to do with that and they want really specific criteria So working with our mental health experts We ultimately determined that all patients who have a new diagnosis of depression or anxiety and are going to be treated with an Antidepressant should have this pharmacogenomic testing In addition any patient that has an existing diagnosis of depression or anxiety and is not responding Should have this testing and so those clear criteria have really helped the primary care providers in knowing how to implement it And and the ordering rate is very high There is a third criterion that I didn't list here Which is if a primary care provider or any doctor just wants to order it they can so we don't We don't preclude you from ordering, but there is some specific guidance on which populations to target This additional product. I'm calling it is the hereditary cancer panel product and so Some of these slides if they if they look kind of like marketing is because our marketing team has gotten a hold of them And are sharing some of these with patients But the basic idea here that everyone in this room knows is that there is a percentage of the population out there of patients Who get cancer where that was an inherited There they had an inherited risk and we could have known that up front and so we're trying to Do better at finding who those patients are and we'll be measuring the impact of that we hope And then we have built a robust system-wide genetic counseling program I don't think we're as far along as geising or not many are But we know that we have to have a more robust program and so we've been really working on decreasing The the time to obtaining a genetic counseling appointment in anticipation of launching a more broad population-level genomics effort in the near future all of what I have talked about has Resulted in us making decisions about whether we should be doing this testing in-house versus sending it out of house And we do both we have some tests that we send out a lot of our germline testing goes out of house To other labs including to Bob's and other places And then we do a fair amount of testing ourselves in-house and we have ended up building a large Whole genome high throughput sequencing center that allows us to do whole genome whole exome whole transcriptome sequencing And we also have proteomic capabilities there And this has really enabled a lot of what we want to do in the future And that includes things like not only whole genome and whole exome sequencing And and partnering with external collaborators, but specifically clinically we anticipate launching Whole genome sequencing in the NICU later this year. We also are developing a precision nephrology panel with our nephrology team And we're embarking on an analysis of the four and a half million samples that are in our Biorepository for which there is a company in clinical data, and that will primarily be a research effort so the overall strategy or model that has really started with an effort in genomic or cancer genomics is to now broaden outside of cancer and take advantage of the Structure that already exists in our health system where clinical programs are organized Already and it includes, you know women in newborns behavioral health cardiovascular medicine Neurosciences pediatric oncology and all of these different vertical medical disciplines as well as services such as pain and management respiratory and sleep services nutrition services laboratory services and we are engaging with The leadership in each one of these clinical programs and services to identify Where the key genomic medicine? opportunities exist and how we can develop the capabilities to implement Genomic medicine in each of those disciplines and that's really the model that we're now working along And I hope to have even more results to share in the future With our success hoped to be successes in these other disciplines. So with that I'll just say thank you and acknowledge all of these people who have been doing all of the work And I'd be happy to take any clarifying questions Thanks, Lincoln any so Terry Okay, I Have a question about Molecular tumor boards in general are there standards across the the tumor boards and how they operate and and that have you or any of Them ever done an experiment to swap cases and see if you come up with the same recommendation Yeah, great question. I would love to answer that as a yes, but you know Howard and I were just talking about this the other day. There really are not standards across their molecular tumor boards all over the country Right every institution loves to brag about theirs There's one sponsored by ASCO that for their taper trial. There are other molecular tumor boards I Will say that There are not standards. I think we're coalescing around General agreements the biggest challenge. I believe where most discrepancies lie is on these in these Biomarkers where they're they're kind of soft, you know the the gene drug a correlation is not real tight There may be some preclinical or early clinical evidence, but they're beyond that It's it's not as strong. So it's you know things like AKT alterations You know do you use ever an mTOR inhibitor for example? And and these kind of soft targets we have not done the experiment of swapping with another institution Although I I can tell you that I'm on multiple Molecular tumor boards. I'm on ours, of course, and then I'm on one for taper and another Institutions molecular tumor board and while there generally is consensus around major driver Anka genes and and tumor suppressor Mutations, it's these these less well-known variants that where where it breaks down and there's frankly not consensus Yeah, I was curious about your cost data I don't know if we could bring your slides back up, but you may you may remember them So so you had one slide that had a table of cost per week and there there was really substantial savings in the outpatient realm And then in the next slide you had this histogram That was just costing the last three months of lives where there of life where there was increased cost in the outpatient setting So so my question had had been until I saw the second slide Why is there so much savings in the outpatient realm on the per week basis, you know Yeah, I think in that initial slide that it appeared to be there appeared to be a cost savings in the outpatient setting because those Patients weren't coming in as often. They were on oral therapy. So they would come in once a month and they weren't coming in for IV hydration or infusions of chemotherapies a lot of our patients getting chemotherapies will come in every week or every two weeks Not only for the chemo itself, but then subsequently for hydrations and other supportive care Yeah, so that that last three months of life data obviously it's very different period and yet the outpatient savings I think are something to emphasize. Yeah, so that's a great point I totally agree and part of the reason we came up with that last three months of life metric is because that's what our Pares where our pair was really interested in right? They wanted to know like they're constantly worried that they're dumping all their resources into the last three months of life for these patients And so they were actually quite pleased to see that see those metrics