 Good morning everyone and welcome to day two of the genomic medicine 14 meeting on the topic of genomic learning healthcare systems. We're all looking forward to another exciting day of presentations and discussion. And I'm going to introduce our first speaker who may not need any introductions but it's Dr. Terry Manolio. Dr. Manolio is the director of the division of genomic medicine at the national human human genome research institute and the leader of the genomic medicine working group that is coordinating this meeting. Terry. Yes, thank you. And turn off all these notices. Super. So what we wanted to do in this session was just a little bit of a recap of what we had talked about yesterday. And also, to maybe point out that one of the things we'd really like to do in these sessions is to identify solutions and that's what we'll be going to focus on in the summary and next step session at the end of the meeting. So if we could ask the moderators for the next sessions today to really focus on identifying those solutions and even if participants could identify those solutions as they talk that would be great. What we did here was just pull out a few things from each of the sessions in terms of some key points as well as potential solutions and we'll go over these at the end of the day and let people sort of add their input or modify them as needed. So session one was laying the groundwork Peter who did a fabulous job on kind of bringing us all to a common level on what a genomic learning healthcare system is. And I talked a little bit about proposed solutions as identified from the 10 systems that we surveyed key points included looking for genomic underpinnings of disease or health disparities only after accounting for structural and social factors. We're going to genomics first since they are heavily confounded by structural and social factors, recognizing the sustainability is key and remains poorly addressed, and we need to find successful sustainability models that we can then implement. And relying on smartphone and internet based processes will inevitably perpetuate an excessive exacerbate disparities in terms of solutions. We need to enhance and expand the data donor culture across all aspects patients, providers, healthcare systems, payers, etc. We need to automate and a new verb for me dashboard clinical management steps. This is a critical and effective way to make implementation work and improve uptake. We also need to improve integration of measures of structural discrimination and social determinants of health, and very important to share educational content across organizations more than we're already doing we are doing some of this but we can always do it better. And I'm not advancing. There we go for session to some key points included the vast inequities as mentioned earlier and access to it resources and tools will perpetuate and exacerbate genomic health disparities. Equity and engagement must be built in from the start. And the systems for genomic integration and implementation have to be relevant to low resource settings. Also infrastructure has to be customized to serve different user communities and users will need education and using the results. Some solutions include genomic health information exchanges so we learned yesterday 92% of locks are covered by HIV so I didn't know that. And Mark Williams gave us a very interesting patient driven example from Dyson. Also, we need to disseminate broadly data standards and methods we have them. Now as we heard from several of the speakers and methods for integrating genomic data into care and selected centers. Those those have been developed. They've shown they've been shown to work and now we need to disseminate those more broadly. Similarly interoperability has been demonstrated on a small scale. We need to expand and extend that we want to continue to facilitate the sharing for research and potentially create national policies around reuse analysis of data for clinical care. And as always expansion of training of clinical providers. In the first session, some key points included certain measures of quality or robustness of data sets including missing data small sample sizes and measurement error lead to bias, and they disproportionately affect minority populations in our country and probably elsewhere. Equity based implementation science requires monitoring evaluation stakeholder engagement and consensus. Sometimes we skip over some of those steps. And interestingly patient consented EHRs will enable natural history data sets and studies at scale, which is, is being demonstrated in a variety of systems but not useful to keep in mind. And solutions were interesting approaches to potentially leveraging the HIPAA right of access to obtain patient records if that can't be done through providers, you know, get requests initiated and consented by patients and there have been some models of that that are, that are quite effective in the general and general resource of Genome Connect and others. We can leverage federal information blocking rules to obtain clinical data more effectively and HIE is mentioned here 92% of lies are covered by by these patient and community engagement are essential will be hearing more about that today to reducing inequities in genomic research and genomic learning healthcare systems. You know, it probably are essential to effective implementation, even outside of disparities, but particularly important in those communities. And investigators should incorporate and funders should require effective engagement plans and should devote adequate resources to support efforts and engagement. Logistical lessons from from yesterday discussion has been quite robust, which is super, and particularly around issues of health equity and health disparities but really in all aspects of yesterday that was great. We could potentially use more engagement from a broader swath of attendees so don't be shy about raising your hand, we will call on you, or putting questions that you want addressed into the q amp a. If you're willing to identify yourself rather than remaining anonymous which you're free to do obviously feel free to remain anonymous but if you're willing to identify yourself with your question. We'll try to call on you and I would ask the moderators to do this to raise your question live. There's lots of great parallel discussion going on in the chat. It's not always easy for us to capture that live and comment on it. It's sometimes difficult to see so again don't be shy about raising your hands or using the q amp a. I did want to say that Gerald and colleagues are doing a fabulous job of making sure that everything works, even when they run into techno, the others also like myself so thank you very much. And presenters and moderators are doing a fantastic job of sticking to time so thank you very much. And with that I will stop sharing. I can ask if there are any comments or modifications we'll get a chance to do more editing of these later today but any initial comments on this. And there was a question will the slides from yesterday sessions yesterday made available actually all of the slides will be made available. If you go to our actually if you just Google because I can never find it otherwise if you just Google NHGRI genomic medicine meetings, it will bring up all of the meetings that we've held all the way back to GM one. And, and there will be there is a website for GM 14 it has the agenda and the background materials on it currently, but it will have these videos as well as slides and the agenda and a bunch of stuff. And I think that's all we have in the chat in the Q&A. So with that I will introduce the moderators for session for they are Suzanne Haga from Duke and Rob Rowley from NHGRI please take it away. Good evening, everyone from Durham Suzanne co moderating with session or Rob here from NHGRI. Thank you to the organizers for a fantastic meetings so far and first electing us or inviting us to co moderate the session. So it's the first session of the day the fourth session of the meeting entitled enabling providers to implement genomic knowledge. So we've already heard and Terry has already mentioned that there is a lot of importance and discussion around workforce preparation and education. Certainly the rapid advances in genomic medicine pose challenges to providers to stay current in order to appropriately implement genomic applications in practice. Furthermore, when we talk about providers there are huge differences between curricula between roles institutional supports. When we talk about development patient needs, all of these factors will impact efforts to enhance and engage providers and making sure they're ready to deliver genomic medicine so this session is devoted to this topic, but certainly with just four speakers we can't adequately address all of the challenges and ongoing initiatives happening to enable providers to practice genomic medicine. We encourage you as Terry just mentioned to participate in the discussion and let us know other strategies that are working or not working to enable providers to implement genomic knowledge in a learning healthcare environment. Perhaps what the future point of care or just some time learning and continuing education will resemble. A brief overview you have the agenda. There's four speakers they will each discuss very distinct programs and challenges and essentially highlighting there's not a one size fits all approach to enabling providers to provide genomic medicine. If you are new to the meeting and just joining us this morning welcome. I just wanted to cover that if you have any clarifying questions we will open it up immediately after each presenter. However, if you have an in depth question we asked you hold it for for the discussion period. You are most welcome to post your question at any time in the Q&A. We will try our best to watch that and to make a list of questions for the discussion. I think that feature is usually accessible on the bottom of your screen in the zoom bar. So I will turn it over to Rob to make the first introduction and then see you at the second introduction, the second speaker. Great. Thanks. Thanks, Suzanne. I'll introduce our first speaker who is Dr. Nora Abul Husson from 23 and me and an associate professor of medical medicine and genetics at the ICANN School of Medicine at Mount Sinai. We'll be giving a talk on genomic medicine track for internal medicine trainees. Nice to see you. Welcome. Thank you. Let me share my screen. Hopefully everyone can see. Excellent. Thank you so much and delighted to be part of this session and this amazing today and which I've really enjoyed so far. I'm going to talk about a relatively new initiative we have a Mount Sinai called a genomic medicine track for internal medicine trainees. And here are first my disclosures and mainly that as of two months ago I am employed by 23 and me and have financial relationships current or past with the other entities on the slide. Okay, so my background is as an internist and medical geneticist by training. And so I think about this with that in mind and with the lens of, you know, internal medicine and medical genetics and those are obviously two very different types of programs that are focusing in different specialties and specialists and subspecialists. So I'll just start by pointing out what is a relatively current landscape of US clinical geneticists. And I'm always struck by these numbers. As of at least this was from two years ago I believe in 2019 there were four certified clinical geneticists per 1 million individuals in the US. 40% of those are located in just five states. And there are 14 states that have five or fewer certified clinical geneticists. And at the time one, Wyoming, which had none and curious to know if that remains the same today. But obviously, a really small specialty. And although it has grown over the years it remains quite small and to put it in relative comparison if you look at primary care physicians today in the US, I think the most recent numbers are that they're around 700 PCPs, counting only physicians so not other types of practitioners like nurse practitioners, etc. But about 700 per 1 million individuals. So really big difference here. So what does that mean in terms of practicing genetics, while there are clear geographic barriers to care. And there's a really nice paper on this and genetics and medicine a couple of years ago, showing that about three quarters of clinical geneticists, had been practiced in academic medical centers, which of course results in barriers to accessing that type of care. There are substantial wait times for people to see a geneticist to the about 40% of non emergency patients, waiting over three months to be seen, and strikingly this, this is increasing over time. So those numbers were around 30% in 2015 11% in 2003. Okay. So the number of clinical geneticists today cannot keep up with the demand for even traditional clinical genetic services. And meanwhile, we are talking about this large expansion and scale of genome sequencing that we've all seen, and that continues to rapidly transition into routine clinical practice. So, what does that mean when we're really a workforce that's highly specialized in genetics, and how do we support that. And I'm pointing here to one of NHGRIs bold predictions from a couple of years ago, that by 2030 the regular use of genomic information will have transitioned from being boutique to mainstream in all clinical settings, and look similar to complete blood counts. So if clinical genetics is such a small specialty and clinical geneticists themselves are not going to be able to completely support genomic medicine as the practitioners who are who are highly specialized in the field. What about the non geneticists is the current standard of genomics education for non genetics trained physicians adequate. And I'm not going to go through this in depth because I think that this audience is well aware that there is general agreement today that the physician workforce is not really being prepared for large scale applications of genomic medicine. There are many changes in curricula on the medical medical school level and so on to try to address this, but even today there are not real requirements for non genetics professionals to have specific knowledge or competencies in genomics and as a result most non genetic specialists are not as familiar as they could be with genetic testing options indications for testing have probably never ordered a genetic test for a patient are not comfortable interpreting genetic results and we've seen these and studies at Mount Sinai and many others have noted this and are relatively unsure of how to use genetics in their practice and I put some references down here but you know there are many many others for this. So how do we address this gap and enable and empower the non genetics clinical workforce to appropriately use genomic medicine in clinical care. Well, I mentioned primary care physicians and I want to go back to the role of primary care physicians and genomic medicine I think others in this session are going to touch on this. More, but you know, PCPs are generally the frontline of care in adult medicine and pediatric medicine. And it, it seems really clear that a basic knowledge in genetics and general medicine will be needed in a primary care setting in order to educate and counsel patients to obtain consent for testing to coordinate care, including referrals to geneticist genetic counselors and appropriate other specialists based on genetic conditions to know how genome guided treatment works and use those evidence based treatments were appropriate and to engage with their patients and make sure there's appropriate surveillance and follow up for those with genetic diseases. I put on the right here a figure from a recent paper that was talking about common rules of primary care physicians and general medicine and I thought this was a really nice way of laying out the different functions that PCPs would have in this new realm of medicine. So I'm going to start talking now about what we've been doing at Mount Sinai and in our attempt to start to address this gap. We have a really big Mount Sinai residency program in the Mount Sinai health system in New York City, and a couple of years ago, we started implementing a new curriculum for all internal medicine medicine residents so everybody enters Mount Sinai in the internal medicine categorical residency track now receives genomic medicine primer as part of their standard didactic sessions. And this primer basically covers the introduction of medicine is a genomic, a basic understanding of principles like penetrance and expressivity and so on. We covered genetic testing and genomic testing options so people understand the differences between panel tests, sequencing modalities, genotyping, etc. And we spend a lot of time talking about interpretation of genomic results we talk about what a variant is what variants of uncertainty significance are what do genetic reports look like what do they tell us and what do they don't what do they not tell us. This curriculum has been really well received by the residents, it's become part of the standard didactic session so this is scheduled every year so that every intern in medicine so these are PG Y one medicine residents take this curriculum, and it works as part of the outpatient medicine blocks so the residents are divided up into smaller groups during that time and all of them get to access to this coursework as part of those blocks. So I think this alone made a big difference in exposing medicine residents to genomic medicine, and I haven't even gotten to the track yet so this is just this broader curriculum that we implemented recently. And then those same interns are asked whether or not they'd be interested to enter a genomic medicine track so this is something that is available for anyone who's interested in applying there is a very brief application process into the track. And residents can self select if they're interested in learning more about genomic medicine, they can apply and they can enter the genomic medicine track this was launched in July of 2020. I know this is really small and not trying to get you to read what's on this page. But this was more to remind me that we were very lucky to be able to do this at Mount Sinai because we had some examples that we could learn from in terms of these specialty tracks in the categorical internal medicine residency program. There was already a health care leadership track and a medical education track. And so we used those examples for what had worked in adding a curriculum on top of a very busy residency program to develop the genomic medicine track. So what is the curriculum for genomic medicine. These are some of the major topics that we cover and we really tried to think about what would be most applicable to folks who are in internal medicine residency and like thinking about common diseases with genetic features that would be exposed to even on the inpatient side. So we start with an introduction which really continues what they started to learn as interns in their broader genomics one on one curriculum so they get an introduction or recap of the basics of genomics that we're going from there. We focus on a couple of disease areas as real examples for how this is applicable much more broadly than they probably ever imagined in cancer and in cardiovascular diseases. We cover pharmacogenomics which is a you know really important topic that our residents feel that they don't learn enough about. We could talk about genomics and population health including population screening efforts how this is turning into a public health question about how to use genetics most appropriately. We cover polygenic risk scores genetic ancestry we talk about race ethnicity and ancestry population genetics in that realm this is a very popular topic among residents today. And we've added recently gene therapy so that people are really understanding how this is very much the future of medicine we're at the leading edge of understanding how do we use genetic information to guide therapies. These are the basics of the curriculum and it takes a lot of work to put together a new curriculum for a new training program. Luckily there are some resources and I just wanted to give a shout out to NHGRI's genome and resources, which are really fantastic. There are a few others that we found to be available when I don't have on here there was an ASHG boot camp a couple of years ago on cardiovascular genomics was that was really nice and talked about the flipped classroom setting. That's really great. And there's this pathology learning universal genomics instructor handbook so we were able to draw some ideas from people who have thought about expanding genomics knowledge across different specialties from these available resources. So what are the goals of the genomic medicine track. We want to enable our residents have a deeper knowledge of genomics and it's applicability more broadly to patient care. We want them to be able to identify and appropriately care for patients who are at risk score or who have a genetic condition. We want them to know how to incorporate genetic testing into clinical practice I think this is really key because there are a lot of barriers to getting access to genetic tests and the more we can expand the knowledge around this and comfort with using genetic testing appropriately. The better we're going to be able to use genomic medicine to its full potential. And we want them to be able to critically assess and communicate genomic results so when they have patients who've had genetic testing either because they've ordered it or it's in their medical records or they're coming to them to understand something they've obtained. They should be able to see a report and understand what it means and that I think that's again a really critical aspect of this program. What we are not trying to do is transform internal medicine residents into medical genetics residents or medical genetics specialists. That is not the purpose of this medical genetics is a really important specialty in and of itself. The idea is really to see the genomics knowledge in internal medicine residents who may go on to become generalists or subspecialists in the medicine realm. All the residents are required as with the other tracks that we have to complete a genomics focused research project, and this could be any project of their choosing with any mentor of their choosing but we try really hard to identify potential mentors in this space and help the residents achieve this goal. These are just a few examples from residents who have been in the track on on types of projects that they've undertaken and you can see they're really very broad and diverse in their scope, including drug response, understanding penetrance of genetic variants in a in a bio bank that we have access to Mount Sinai with that's very diverse and a great resource for these types of research projects, and one on a pedigree analysis, for example, and by the way all of our residents learn how to draw and interpret pedigrees which is really fun. Okay, so this is to remind me that we started this and 2020 and the pandemic had just hit New York, it was really New York was the epicenter of the COVID pandemic at the time. And it was a time of enormous stress, particularly for our trainees. And so it was so delightful that people were excited about genomic medicine, despite the huge challenges that COVID was posing on the health system and the strain on our residents and, and on all of us frankly. So we we survived we had the first class go through mostly virtually. And then we were able to meet in person one year later which was really great and those hands on sessions that we had a few times a year were really such a highlight for us as the people who were part of designing the curriculum and training and the residents themselves. And so this is the future this is our graduating classes was they finished two years, sorry, two months ago. And I just wanted to point out how interesting it is that people are going on to various sub specialties of medicine. I hope that some people will continue on to be in primary care but this is a really nice way I think to seed genomics knowledge and just comfort across specialties. And these residents were really excited that we're going to take genomics knowledge into the future of their training. So what's next with this program. Well one of the things that we haven't done yet and we're really thinking about is how do we assess if this is working. We could think about assessing residents perceive knowledge and comfort with genomics before and after the track so that's something that we're considering. Is there a need and should we think about assessing competencies and I'm really interested to hear people's thoughts on on what we should be doing to figure out what's working what's not. There is broad enthusiasm about this in Mount Sinai and across from other institutions people have been reaching out to want to apply this framework to other residency programs and to fellowships as well. So I'm going to end here. I would like to acknowledge two people that have been key in this track and who have actually handed the reins to since I left Mount Sinai a couple of months ago Emily so per who's a senior genetic counselor and assistant professor in medicine, who really helped design this curriculum and I you go Iverson who's a fellow internist in medical geneticist thinking very deeply about education in the space members of the Institute for genomic health. Barbara Murphy who is the chair of medicine when this program was launched and unfortunately very sadly passed away last year but Barbara Murphy was a real proponent of genomics and just I think speaks to the leadership that's needed and the investment from a leadership level to be able to put a program like this in place so a lot of this is due to Barbara's desire to see genomics in the Department of Medicine. Congratulations for the first class of genomic medicine residents really really nice event two months ago. And I'll stop there unfortunately I cannot stay on for the panel discussion later but please if there are questions about this track, feel free to email me and I'd be happy to respond there. Thank you. Thank you Nora that was very exciting. We do have a lot of questions in the chat some are pretty broad and some are very focused. I know we have limited time with you I guess some overall kind of questions and then I guess we can have the other questions that are more detail sent to you, but one of the questions is really is in terms of the format for the residency primer, and also are these small groups and cases that are review. And do you do that and how many for the excuse me the primer itself for all of the interns is a three hour primer. It's broken up into three sections that were highlighted there an introduction around and then more on genetic testing. We include case based discussions we cover a really nice case around BRCA one or two and direct to consumer testing so we do that all in three hours it's pretty concise but it mimics other major topics that the interns are exposed to the track itself. We started off doing things in person it's really hard to schedule residence time after hours. I know you asked me about this rub on email and and that's the big challenge Mount Sinai has a program that does allow some flexibility. So, and we learned from the other tracks that are in place. What we've done now since the first year is make the lecture parts asynchronous so we have our lecturers or experts in each of the fields that I outlined, pre record their lectures, so the residents can watch that at their own time before we have a hands on session which is now a shorter one hour session where we are focusing on answering their questions and doing a hands on activity. So that that makes it a lot more manageable in terms of scheduling. Great. One of the other questions was in terms of your curriculum and based on your last slide I would guess that it's broadly available but what is the availability of that information and your curriculum. Yeah, I've been asked this before and and because we do these like small hands on sessions, we haven't made this broadly available. I know there's a lot of interest though and I do want this to spread so we are thinking about it so for those of you who asked that question. This is top of mind for me and for the folks who are really are really now the people driving this curriculum, how do we make this more broadly accessible. We're going to work on that I think more this year to try to spread this around to those who are interested. Great, we have a lot of more questions here. I guess with losing you I guess we'd probably need to move on to our next speaker but I'm sorry about that email me. Again, I'm happy to answer other questions are Rob you feel free to follow up afterwards. We'll do. Thanks. Thank you. Suzanne I'll hand it back over to you. Thank you. Excellent start. So our next speaker and all the buyers I remind you are in. Meeting handbook is Rizwan Hamid is there. I'll hand it off to you. Oh, great. Thanks. Let me share my slides. Okay, and Okay, thank you so much. And a GRI and Terry to for invite to invite me to give to talk about something that I think we at Vanderbilt have been trying to work very hard at. And it's a work in progress. And I what I want to focus on today is actually focus my talk on from the point of view of the physician who is in clinic a busy physician neurologist or rheumatologist who is seeing, you know, who messy 20 patients in that afternoon. And how do they think about genomics and what can we do to make their life a little bit simpler. So we have all seen a version of this slide sort of the ideal idolized sort of genomic vision vision. And there are obviously various versions of it but in an idolized vision of let's say NHGRI 2030, you will have data moving seamlessly physicians and genomic scientists are interacting at point of care, almost immediately patients are getting their results and everybody's understanding everything perfectly. And the reality is that we are not there yet, and we are a long, long way off in in that sort of vision. And I would just say that we have done a less as a field have done less than ideal job of doing our frontline medical providers utilizing their utilizing genomic information in a meaningful and efficient way. And I guess I would just say here is that less than ideal is maybe putting it softly I would say we have really done a terrible job of doing that and and there are multiple reasons of that. So, so how do we get there so how do we how do we get our attempt to get to us to a place where our frontline doctors nurse practitioners are feel more comfortable in utilizing genomic information so obviously we have to identify the problem, which we already kind of know exists, geneticists know about it and if you talk to other providers they they many times do not understand the nuances of the various issues involved. We have to get institutional buying so you have to you cannot do this, this sort of strategy apply that strategy working out of a department and or a division within a department. Because the resources required are institutional so you have to have all the players and institution in the institution buy into what you want to do. And that leads to a uniform strategy your strategy has to be uniform so all the pieces of the puzzle have to move towards a common goal you have to have the right teams to address different things. And then you have to think about the most difficult part which is implementation. You have to iterate and iterate and iterate and do to devise a work scheme. You, you run it, you, then go back and change things. So, so before I kind of talk, kind of tell you what we are attempting to do just let me kind of present a simple clinical scenario and this scenario plays out pretty much in every institution that we can think of, and multiple things in the day but this is a real life example of something that that I knew from one of my colleagues. So, a patient represented to a rheumatologist abdominal pain and history of my algea and the rheumatologist and experienced rheumatologist saw the patient thought okay, I don't really know what this patient fits in but maybe I will do a familial fever test, because maybe that patient has that. And they, they thought about it however the patient already had that testing done previously by another rheumatologist. And the rheumatologists told this patient that you know it, he doesn't really have anything else to offer maybe it's a GI problem, maybe some infectious disease problem but really from a rheumatology point of view, he's at its sort of patient. And several weeks later over lunch in the cafeteria. This rheumatologist started to one of my colleagues, and he brought this case up, and my colleagues said oh wait a minute let's kind of put these things in OMIM and see what comes up. So, the first map smart phone entered the phenotype in OMIM and OMIM, you know, as OMIM does generates a French old list of 3050 hundred things. In this case it generated I think about 69 different things. And one of the things just by luck on the first page was this TNF RS F1 a associated associated presentation. So, the, the, the, my colleagues suggested this rheumatologist that maybe this is, he could think about ordering this test so this test was done. And lo and behold guess what happens, it comes back as the variance of unknown significance. So the rheumatologist interpreted this as, okay, this is not diagnostic so he met with the patient told them that sorry that test was negative. And that is it. There's really nothing else to do. But again, sometime later, I think three months later he runs into my colleague again. My colleague asks, asks him about, hey, did anything come out of the case we discussed three months ago and he said well you know we did get a report of the V us and the gene that omitted identify, but it was a V us so there's nothing to do and my colleagues said, hey, let's go to my office is around the corner and just look at that variant and maybe do some simple PubMed search to see if there's more information. So, not surprisingly that the US is not a B us. It has been reported pathogenic there have been two papers published. And the key thing there is that if the patient, if that is a variant and that is the gene disruption that is happening there is a specific that can be used to actually treat those symptoms and the patient was put on on that and his symptoms have since resolved. So I think this illustrates something that Nora just mentioned and I think she mentioned all these four points that I mentioned that I are listed here and which are that most frontline providers even today have no clue as when and how to do a genomics test they don't just they don't know it. They don't know how to interpret a genomic tests. They don't even know where and how to get help. And most of them rely on word of mouth information so many times it's like oh I know Rizwan or I know, you know, person XYZ in genetics, and if I have time I will call them and I will ask them what is going on. Imagine how most frontline providers work seeing 1520 30 patients in a day or sometime more how difficult it is for them to stop and and think about a patient to to to and then get a better outcome. I think we get back to this slide which is, we have done less than ideal the job of preparing or helping our frontline providers. So we thought about it as an institution. And I think Travis yesterday presented parts of this and Travis and I belong to the bigger group that is trying to solve it at Vanderbilt and I think our goal was that can we seamlessly integrate genomics in patient care across the BUMC health with the goal of improving essentially eventual goal is improve outcomes in patient. And so what I'm going to describe now is how we thought about implementing in implementing it in our system. And essentially what that was that we actually had an institution by strategy session and this included our Dean of School of Medicine our CEO of the hospital systems. The Children's Hospital, all the chairs were part of this and we thought about this problem and it was a, I think it was a two day. It was one day all day session. And we realized as we kind of thought about it that it is, if you want to implement it in a logical way across our system. It is not just going to be a genomics or genetics driven project. We have to bring in all the different pieces that impact that impact this project from bioinformatics to IT to services that utilize genomics at a large extent, like oncology pathology gym, our own in house genomic laboratory neurology gyro counselors ethics finance, etc, etc compliance. So, clinical operations. So this was, this is going to be, we have to get buy in for all all these things and this buying then started with defined institutional high leadership who were assigned specific roles as how they're going to help this pipeline so from our chief strategy officer to chief of staff to executive vice president to executive vice president of clinical research to chairs of various departments including chair of bioinformatics, etc, etc, etc, and overseeing them. All of them were our with our CEO and Dean of School of Medicine Dr. Jeff Balser, and he was really involved in all of this. And I think that helped us propel forward and helps and helped us kind of mitigate some of the sort interdepartmental and division tensions that can develop in an institute in a project like that. So we thought of several things we thought you know in the in the strategy session we thought about okay so what what what do we need to do what are our sort of how what are the design considerations so we need. We need to figure out a way that this has to be sustainable, that the organizational structure should be able to support it it must be adaptive so you meet me so we can iterate or iterate. Based on the data we get back it must be accountable meaning it needs to support various missions of various departments and divisions and the institutional hierarchy. It has to be manageable we cannot design a system which is, which is unmanageable meaning it is like a pie in the sky so it has to be feasible in our context. It has to be inclusive in meaning it should involve all the all type of patients we see all type of providers we have in the system. It must be effective it must be efficient and it must be responsive. And our clients, we thought that we have three different types of clients we have the medical journalist who is super busy messy 35 to 40 patients in a day in their clinical scenario and those patients sometimes are complicated sometimes straightforward. They have no clue us as to when out when to even consider if there is a if there is a genogenomic question to be considered in the phenotype that they're seeing. So they look at the test testing options, they're confusing to them, obviously forget about any interpretation, and they are uncertain about next step so the end result in those scenarios is typically genomic testing never gets ordered. The bigger problem many times is also medical specialist so these are people who let's say are specific neurologists or cardiologists who have some knowledge of molecular testing, but again, they have trouble deciding which test to do and how to send it and how to send it because they get super confused about the plethora of choices that are available out in the community of multiple panels. You know copy number variant testing, etc, etc. And then the biggest problem for these folks is that if they passed that first hurdle. They really have difficulty analyzing the test report because many of the panels these folks order sometime will have 300 genes, and they get a list, they get a report back which has 15 us, and they have no idea what to do with that. And so essentially, patients are told pay your test is negative, and they move on, even though the answer may have been there and then obviously the last important puzzle is patient patients want to know. They are obviously unable to understand the results. They don't know how to proceed forward. They can go to our patient health portal and actually not find genomic test results or have no clue as to what to do with these results. But we are not going to be able to solve the patient problem until unless we solve the medical journalists and medical specialist problem. So without this version of a version, a more complicated version of the slide that Travis present presented, which is essentially our overall strategy at Vanderbilt and I'm going to, I'm going to talk about the left side of the screen and Travis I think yesterday alluded very well to the pharmacogenomics and somatic mutation part and I want to talk a little bit about the germline mutation, because you know one of the things we should think about implementation. Physicians need more typically, I'm talking about frontline providers and physicians they are very comfortable with with definitive information. Yes and no so pharmacogenomics works great. You tell a physician you cannot use this drive user lower dose of warframe, etc, etc. And that's information they can use right at the sort of point of attack when they're seeing the patient. Similarly for somatic mutation you have a patient who has a specific tyrosine kinase in activating mutation oncologists can tackle that information about a particular agent to use in that patient's lung cancer. But when you get into germline testing. It is much, much more complicated. So we thought how do we kind of even start to think about how do we help our sort of frontline providers at Vanderbilt to solve this issue so when we looked at it. What the workflow is and this is somewhat a complicated slide and I'm going to quickly run you through it so you know you see the patient who enters who is seeing the clinical team clinical team reviews the EHR sees the patient they come to a decision decision support point which is, hey, is should I do a genomic test or is this a patient that doesn't require a genomic test and either the clinician understands that question or they don't. The idea is if they understand the question and they know that the genomic test is needs to be done then they will proceed down the central line where they will share with the patient what test needs to be done to do the test. The test in our system gets reviewed by genetic counselor this was implemented several years ago and works very well. And then you get the results back and then you end up with the problem right at the end, which is they have no idea what to do with ourselves, either they do or they don't and many times actually they don't. Early on if, for example, if you go back to the clinical decision support point, what happens if they have no clue or whether they should be doing a test or not. So they end up in this sort of pathway where they actually need help in ordering a genetic test or thinking about the patient in a genomic way. So we call that as genetic test ordering consult or GTOC, and we talk about the genetic test interpretation console or GTIC. And today I'm not going to talk about all of this because we don't have time I'm just going to focus on the GTIC part today. I'm happy to discuss GTOC and our attempts to solve that at a later time. So how we thought about it we thought okay this system, this system needs to be in place where the provider can actually ask us that question through our EHR which is epic. And we can supply the answer back to him or what the report means and what the next steps should be in epic so that becomes part of the patient's report. And if a physician later on another specialist sees reviews of medical record they get the benefit of that interpretation or that advice that the patient got. And so just a quick how we designed it so it's essentially you can order it through Epic. Those of those of the attendees who use Epic in their as their system, they will kind of recognize some of this I do recognize that Epic can look different and different institutions. It's essentially a drop down menu they are they are this e-console for genetics and the request comes to us. It services the current human by two genetic counselors and a geneticist and I will just give you some very preliminary results because we are in the middle of essentially you can say our launch. And what we found was 14 unique non geneticist especially specialties utilize the service and 42% of the cases were able to provide an alternate interpretation which resulted in please increase clarity couple of times a diagnosis few times better testing options. 28 times resulted in a suggestion that this patient actually may have a genetics phenotype and that they need to go see a geneticist. Our average around time was 36 because if you are tackling a report of report of 15 us is we were we were trying to answer each of them so it was less than ideal 36 hours. And the most common recommendations we made were, hey, directing the physician to genotype phenotype correlation, meaning that hey, in this case, it's a dominant disorder your B us. It may not be a B us if you think about what your patients phenotype is. Sometimes in cases where we actually overrule the lab in the sense that we had more current information just by doing a simple PubMed search. We directed them to the publish study where the variant was linked to a now linked to the phenotype. Other recommendations I already mentioned suggesting next steps are suggesting a different test. So, in conclusions. I think we need to think about this problem in many ways as a genomics value pyramid and institutional sort of buy in needs is critical to this. Now our health care institutions are different stages. Many health care institutions know that genomic may impact health care and the question is underlying may they but they lack the processes and organizational structure, which are somewhat rudimentary, which then leads to failure to address this issue and more often than not they have no budget to do this. As a percentage, I would say the majority of its station falls into the second category which is the realized genomics is going to impact health care. But, but, and they have some organization, but not complete organization. Some structures are in place other structures are not placed and they're thinking about whether they should invest any money in it or not. Usually, genomics ends up getting the short shaft where at the end of the budget season when all the budgets are tally, it's probably better to have a new MRI machine then then dedicate resources towards this, and then several institutions. I think we're leading the charge in the top category which is they feel like genomics is critical to optimal health care they have. They have sophisticated tools in place in the organization and the institution is willing to commit budget resources to it. For us, I think we obviously are just starting, but I think and you know we are, there are significant issues still remain and some that were actually mentioned yesterday by several people, you know one for us is a console time, ideally, and if the system is working ideally, we will get the pay report back to the patient instantaneously. So that requires some it and and computer resources. We talked to the physician in these early cases from their point of view is still not efficient enough that feel like it still requires an extra strap they still have to go to the epic that still have to click up bar. What they want is information instantaneously, and I think, which will be at least a tough, tough, tough hill to climb at least in the next few years. But we are hopefully eventually going to get there. There is significant knowledge gap in genomic knowledge, and I'm talking about our front I'm talking about our specialists and forget about I'm not I'm not talking about our internist and our providers. And I think Nora mentioned that and I totally agree with her there's a major gap. I mean, our, our very smart specialist don't even know what short read and long read sequencing is, and what is, why do we sometimes anger confirm or why don't we sometimes don't say I confirm and what's the difference in old genome whole exome so that is a fundamental knowledge gap that we have to to essentially overcome. We have problem in our work we figured out a lot of a lot of a lot of providers send genomic testing outside our institutional workflows, which again results in results and also some different problems. And even though physicians find this service every time they reached out, pretty much every time that we have provided them with an answer or given, given them more confidence as to how they're interpreting their report. This still need to be still need to go back and over and over again and requires a lot of reputation and cajoling for to convince them to keep repeating the to keep using the service. In the end I want to thank I think you guys saw this slide from Travis. It was, I think there are probably twice as many people who are helping are in the different process of helping us with this. And if I have a chance to come back, a couple of years down the road, both Travis and I can probably tell you what the how successful we have been in in in implementing that in Vanderbilt and I will stop here. Thank you so much. That was excellent. Sorry for the delay in my unmuting myself. We have just a few quick clarifying questions and I'm going to defer a few others to the discussion. But what is the composition of the GTIC team the interpretation team. You mentioned counselors. Yeah, so there is a bioinformatics specialist. There is a PhD genomic scientist. There are two counselors and a, and a clinical geneticist. One more quick clarifying question. If the outcome of the GTIC review conflicts with the original report is that information communicated back to the testing laboratory. Yes, we actually have many times had them issue a modified report. Because you know part of the problem we, and all of us have encountered is sometimes the databases that many genomic labs use are not up to date sometimes they're six months behind sometimes they're a year behind. So we actually reach out to them say hey listen this report was published two years ago I mean a recent case report was actually published two years ago and this is a well recognized lab that a lot of us use and they just the database was not updated. So, yes, and the labs obviously them are obviously glad to receive that information and will then issue a modified report. Oh, sorry one more possible question on Dr. Jonathan is your question a clarifying question are going to be held until the discussion. Well it's a little bit of both. So, I wanted to just kind of comment on the experience with the e consults is Jonathan Burke from UNC Chapel Hill. We've done something very similar with our cancer genetics, where it used to be a genetic counselor met with a patient in the multidisciplinary clinic and did the pre test consent and all of that that really has become an unmanageable process and what we've done is to try to put the testing into the hands of the oncologist and surgeons with ncc and guidelines that are available to identify patients that are at, you know, at risk and should have chat testing. But but the slight difference from your process which I think is helpful for us is we are embedded in this clinic, and when the oncologist and surgeons order the test they order the econ simultaneously. So it's all it's part of the order set that we provide them. They have a specific panel they order for the specific cancer type, and then our genetic counselors are able to see that test as soon as it comes back, not waiting for them to consult us to give a an interpretation of it. Right, so then we're able to do that, almost in real time when the result comes back and they're able to provide it. It's turned out really well. Exactly. And now I totally agree. I think what we're trying to do is, you know, when it will has a lot of sort of expansion plans and there are plans in place to bring a lot of this testing in house. We already do a whole exome sequencing in house. And the idea there would be that this could then this could apply at the point of action, meaning as soon as the report is generated by the lab. There is a team or the lab team itself does these next steps that we can do and issues a more nuanced report, more meaningful report with concrete steps already built in. I mean, I do realize, you know, the testing various testing laboratories. You know, their hands are tied in many ways. They have to appeal to a bigger audience, and they don't know their, you know, the systems at Boston, maybe different systems in Nashville. So, so, but not every, you know, the flip side of that is that not every institution can afford to have an in house genomics lab that is doing majority of the testing. So it's, but yes, that would be the ideal sort of vision. And the question though is sustainability, right is how do we support the teams that need to be available to give that sort of case level interpretation, meaning the genetic counselors and geneticists who can really look at those results and give that kind of So I think, so your argument to form from my point of view and we are collecting some data on that is that argument that may to be made to be made to the institutional leadership is what is the cost saving from a bad outcome. Right. And we have examples in our that we have collected in, for example, in one case we collected found out that the patient was actually ready to undergo bone marrow box in bone marrow transplant due to a misinterpretation of the results. So that was caught. And, but if you think about it. So I think that's the way you, I think that is the selling point because we know from our system and sort of as a clinical geneticist and gives me nightmares. Having been involved from the get going this sort of in this design and thinking about this is that I know we are missing missing cases. That are just, you know, nobody knows about this. I think this is a great discussion. We definitely want to move this to the end when we have a little bit more time to go through this so I definitely think we need to put this at the end to revive this conversation, because it's very important and often asked about sustainability, but thank you. Thank you to our next speaker, which is Dr Cynthia James, and I'll hand that over to you. All right, thank you. You're welcome. All right, well thank you all for the opportunity to be part of this really exciting session and the opportunity to share with you. I have a lot of thoughts about a topic near and dear to my heart, scalable solutions for genetic counseling. For those of you who I don't know, I am a genetic counselor of course and a PhD geneticist. I've spent my career at Johns Hopkins, largely in cardiology and I'm the research director of the Center for inherited heart diseases there, where we have seven genetic counselors. And what I'm going to spend the next 15 minutes or so today doing is talking a little bit about the challenge related to scalable genetic counseling solutions. Focus on a couple areas with potential solutions and I'm going to divide those between genetic counseling models, which you can think of as the actual interaction that's happening between the genetic counselor and the patient or client. You can think of your POTUS test long or short, where in the genetic testing process, and also about scalable solutions for genetic counseling service delivery you can think about more of that is the how, how are genetic counselors interacting with clients. So chat bots, telemedicine and so on. And then I'll end with a few thoughts on filling the gaps in our genetic counseling research agenda, particularly in the context of genetic counseling embedded in a genomics learning health system so here we go. I think this audience is well aware of the fundamental problem that while genetic counselors training has increased really relatively dramatically in the last decade or so we're still a relatively scarce resource. There's something like 5600 ABGC certified genetic counselors as of 2021 and a quarter of us are in a non patient care role. But I think is this group is well aware of genetic testing and genetic counseling is increasingly recommended, particularly in specialty medicine. And I think we all know why this is an example from my own area of expertise which is in inherited heart disease particularly arithmetic cardiomyopathies, and that's of course, because where once genetic testing was largely useful and diagnostically increasingly across specialty medicine. This is being recommended for prognosis and therapeutics. I think some of us as genetic counselors have done a great job communicating the importance of genetic counseling in the context of genetic testing but there's rarely very many specifics on how this should optimally be done. Finally, in our own field in genetic counseling, we have a need for a considerably more robust genetic counseling evidence base genetic counseling is a communication process, but a lot of our data conflates genetic counseling outcomes with genetic testing outcomes. So when you're trying to decide how to scale genetic counseling, that's challenging, we need to figure out what genetic counseling outcomes in this context are we optimizing the medical outcomes the family outcomes the sake of social outcomes. And then we need to ask, okay, given that outcome, what genetic counseling service delivery and counseling models, you maximally optimize those outcomes given available resources and that fundamentally, in my mind is what we need for scalable solutions and a little bit more about that at the end. All right, so I'm going to start with a discussion of genetic counseling models, and Dr. Hamid set me up really nicely to address this issue, because indeed he was talking about genome guided medical care. I think this audience knows this. However, the lived experience for genetic counselors is there has been a fairly significant shift in the clinical characteristics and goals of the person, typical person seeking genetic counseling, certainly over the last 10 years. And I think as we all know, and this is actually as my colleague Layla Jamal, who's an NCI described really well. Today, many counselors are asked to assess health risks and facilitate decision making and a variety of medical sub specialties, particularly for the purpose of genome guided medical care, which we all know can impact disease morbidity and mortality which is partly why we're doing it. This is a change historically you can think about where genetic counseling group out of working in pediatric clinics where diagnosis was one of the main goals, working in reproductive genetics where we had genetic tests associated with risk of fetal loss, facilitating decision making for you know genetic testing for Huntington's disease that's where the initial genetic counseling models came out of. And so I think there's a lot of reason to think that in this context of genome guided medical care, genetic counselors, particularly in specialty medicine can be deployed more effectively post test. And that was sort of how Dr needs layout happened so that was appealing. However, currently, based on data from this year, the emphasis and genetic counseling practice remains on pre test genetic counseling with close to a three fold time spending that pre test genetic counseling process, which for a lot of adults seeking genotype genome guided medical care in my opinion doesn't make a ton of sense. So I would pause it that it may be time to rethink the genetic counseling model primary indication from pre to post test and I think that has a lot of potentially beneficial downstream impacts. I'm not the only person thinking about this obviously this is the cadre framework which emerged out of an NHGRI project this is the work of my colleague Adam Buchanan who you heard from on the panel yesterday. And you know he's saying that look, you know for patients coming for a suggestive personal family history or familial variant testing. Pre test communication can probably done briefly or through targeted discussion, maybe not with a genetic counselor. Despite that being the traditional practice pattern that allows us to focus our genetic counseling effort post test, we're particularly for people with a positive variant pathogenic or likely pathogenic variant. It's a great chance to work with that family with that patient to help them understand next steps. And of course this means that for individuals with a benign or likely benign variant or genetic, or sort of a negative result entirely these are individuals who probably don't need genetic counseling services. We are in the fortunate position at Johns Hopkins to be launching a randomized clinical trial of counseling models specifically evaluating two complimentary approaches to shifting the primary genetic counseling indication post test for adults with cardiovascular genetic counseling indications. And one thing that we spend a lot of time and energy doing was making sure we took a look at the impact of shifting the genetic counseling model across types of genetic counseling outcomes so we have outcomes in changing patient empowerment and engagement those are fairly standard genetic counseling outcomes, patient satisfaction psychosocial impact also standard outcomes. But importantly, we're leveraging the Johns Hopkins health system to compare adherence with medical recommendations impact, as well as metrics of genetic counseling efficiency. This is just a slide of the study design I am not going to walk through it I would be very happy to discuss any details about this with you in the discussion section. But at core, the study is designed to compare usual care, which is pretest genetic counseling with results typically returned by phone or a quick telemed visit with what we call an efficiency arm, where we have online video based tailored pre test genetic count education with an optional phone call the genetic counselor formal post test genetic counseling report appointment, and a flipped arm which is the same as the efficiency arm, where the phone call with a genetic counselor is required. So that's what we're doing. We like this as I said again because we're able to leverage our health system in order to get to patient outcomes fundamentally genetic counseling is a communication process and linking, optimizing that communication process not only with a patient care experience which is relatively straightforward, but with actual medical changes is difficult and takes quite a lot of thought and study design. And it's worth mentioning that I'm really fortunate to be collaborating with Dr over be Taylor who you met with yesterday, and as part of the study, we are optimizing measurements of metrics of cardiovascular adherence family communication and metrics of genetic counseling efficiency, which we're looking forward to deploying across the institution which we think will be helpful overall. All right, so that was my thoughts on counseling models on the service delivery. Fortunately for us, the genetic counselor practice guidelines committee commissioned a systematic evidence review and meta analysis of the utility of telemedicine that was finishing up right as coven hit. And the take home message was results from our evidence synthesis suggested telegenetic counseling is non inferior or comparable to in person genetic counseling across many domains, which was very encouraging I will say that much of this evidence is from the oncology space and almost none from cardiology and other specialty medicine. Indeed, in work done since the pandemic. It's been clear that genetic counselors on the whole have been fairly satisfied with using telemedicine. And it has also increased patient volume, and I'm here to talk about scalable solution so this is good news for us. There's also numerous studies of novel service delivery models, as you all know, particularly in the context of family cascade testing family notification and identification of individuals with variants for tier one condition so these are these population initiatives, and these are just two examples from my own field so this is a study out of Europe by some of my good colleagues that were testing a direct notification option for relatives for cascade screening they found no change in uptake, but increase in family vaccination they're now looking at association with long term adherence. And this is a study out of NHL BI done by my colleagues at Geisinger it's a private perspective pragmatic observational trial to develop and optimize FH screening particularly in the context of family variant testing So again, this is using a chatbot model for pre test genetic counseling as an option. So that is ongoing now. We touched on this yesterday, then another novel service delivery model is corporate genetic counseling for lack of a better term the company number of companies, offering this is growing all the time I'm not entirely share my slide is perfectly up to date but this is what I've got now. I think there's a lot to like about this option certainly in the context of a new efforts certainly in the context of a research study. If you use these genetic counseling services you're able to scale up your delivery quickly with, and that makes sense if you have a short need. These are good people certified genetic counselors working here. I will say that I suspect and we heard a little bit about this yesterday that there is a downside in the context of the genomic learning health system. If what you want to do is have a learning system where you're embedding genomic knowledge patients understanding of genomic knowledge and having them take a step to the next step along the care pathway. I think it's harder to execute well if a key element of your services outside the institution so that's just you know I don't have proof of that but I strongly suspect that's the case. I've had some challenges with the quality of genetic counseling provided particularly for specialty disease in this context but that's just our own experience. All right, and then ending to the last part of my talk so where do we go from here. If my goal is to put forth evidence based scalable genetic counseling solutions. What do I need for a genetic counseling research agenda. And again, need to answer the question what outcomes in this particular effort are rescaling genetic counseling for, and then what genetic counseling elements are most amenable to scaling remember genetic counseling is at heart, a communication process its strategy. And I would pause it, the genetic counseling outcomes that are least tied to the quality of the genetic counselor patient relationship, and or the nuances of genetic counselor patient communication are the most amenable to some of these types of cognitive service deliveries. So this is just a proof of concept study our group did a couple of years ago. This is a pre post genetic counseling study of patients with arrhythmia genetic cardiomyopathy. Importantly the post questionnaire was administered prior to any genetic test results being obtained and here you are seeing in this slide that we found that patient empowerment was strongly tied to the strength of the genetic counselor patient relationship in a dependent manner. So people in the top quartile and relationship had the most growth pre posted empowerment. That's important empowerment is theoretically tied to medical adherence. In contrast, I'm not showing you this but change in knowledge had absolutely nothing to do with the strength of the genetic counselor client relationship, suggesting, we can get to knowledge and a lot better ways a lot more efficient ways than using a master's tool fairly expensive genetic counselor, which I think we're seeing in the chat box and certainly in our own video study. I'll also say that for those of us not in oncology there's a substantial need in the subspecialties, and maybe even an oncology as well for a genetic counseling evidence base if we need if we need evidence based decisions on scalable solutions. We have a better grip on what we're doing now and how variables are associated with each other, how they're associated with the patients we're seeing demographic characteristics, service delivery models, and so on. And so something I'm leading right now is a multicenter cardiovascular genetic counseling outcome centers that has genetic counselors in cardiology at numerous academic institutions in the US, Canada, and Australia. We are enrolling now we're coming close to finishing up enrollment. And I think this will give us the sort of evidence we need in the future as baseline data as we scale up solutions for at least cardiovascular genetic counseling. I'm going to end there. These are all the people involved in those multicenter studies. This is near and dear to my heart I am very happy to answer questions talk more about this with anyone don't hesitate to reach out and again thanks so much for this opportunity to talk about genetic counseling today. Thanks Cynthia wonderful talk, just one note in the, in the chat that I would share is that Mark Williams notice that there was a ACM G just published a points to consider with telegenetics, and the references in the chat. And then we had one question is, how do you measure the strength of the GC patient relationship. So we have been developing actually in collaboration with Laurie Irby who is an intramural investigator at NHGRI use of it's called the WAI it's a model out of psychotherapy we've modified it for genetic counseling Laurie's modified other versions of it. And that actually has worked pretty robustly and there's a series of studies doing that I'm happy to send people the reference as well as the version we're using. We've disseminated that the multicenter genetic counseling outcome studies and I know some genetic counselors on some NCI projects who are about to implement it as well. Well thank you everyone and we'll go on to our next speaker Susan, Suzanne. And that is Jason Bassie. And here he is. Well hello everybody I'm absolutely honored to be able to present this forum. Let me get my slides here. Great. Great. Well so I'm going to talk a little bit about genomic medicine implementation in the VA, which is the healthcare system where I practice. I didn't focus the talk specifically on provider needs although certainly some of those issues will be illustrated and we can, we can discuss that certainly in the Q&A part but I do want to give you an overview, as challenging as that is in 15 minutes of a lot of initiatives within the VA healthcare system. And it's important to say, I'm going to speak about the VA but my views do not represent those of the VA, although I am an employee of the Department of Veterans Affairs. So I'm going to first start with talking about VA as a learning healthcare system as an integrated healthcare system, apart from genomic medicine just to give you kind of a sense of some of the learning healthcare system methods and cycles that are already in place in the VA. And then I'm going to use some examples from genomic medicine to illustrate how some of that infrastructure and that culture can come to bear for genomic medicine initiatives and how it's being done so. Quick overview of the VA, a lot of those of us in the biomedical community when we say VA, we actually need the VHA, which is a part of the Department of Veterans Affairs so the Veterans Health Administration is the largest integrated healthcare system in the US, cares for more than 9 million veterans annually in every US state and territory, divided into about 18 geographically defined networks or visions across the country and territories, which is comprised of more than 1200 medical facilities, including outpatient facilities where primary care mental health are delivered and medical centers with inpatient facilities and subspecialty care. And because of the kind of integrated federated structure, much policy is decided at the national level at the DC level. But then the management and the implementation of those practices and policies occurs both at the regional or vision level the network level or at the individual facility level. And you can imagine their strengths and weaknesses of that kind of model. If something is really thought to be of high value to the healthcare system there's a huge opportunity for spread. It's also a big organization so spread is only going to occur if the real value has been demonstrated, and it can move slowly as a big, as a big institution. Now, one element of the learning healthcare system in the VA is its intramural research program. I'm going to make the case that that's not the only way. But the VA does have an intramural research program that is pretty robust available to VA investigators such as myself. In FY 22 there were 880 had a, the Office of Research and Development had a budget of 882 million divided into the services that are shown here. So biomedical research, clinical science research, health services research and rehab, which is of high priority to veterans. And they're also major programs you might be familiar with that are a part of the Office of Research and Development, such as the Cooperative Studies program which is funded large clinical trials and epidemiology studies and the million veteran program, which I'll talk about at the end of the study at the end of this presentation. In the last five or so years, ORD has has reiterated or has has reconfigured some of its strategic priorities and those five strategic priorities are listed here. And ORD has really made a point of making sure that all of its activities point to one or more of these these strategic priorities that it has defined for itself. And I've highlighted number two and three but just primarily because they really do illustrate this idea of the learning healthcare system, where the research that is done within the VA is really intended to have a real world impact. Not only for generalizable knowledge outside of the VA but also for the veterans themselves who are receiving VA healthcare. So specifically, strategic priority number two to increase the substantial real world impact of VA research is thought to be a mandate from the 2018 Foundations of Evidence Based Policymaking Act. And in that Office of Research Development sees as a part of its mission to develop a learning agenda for the healthcare system, and to provide the technical assistance to other offices inside VHA for both evidence based activities and how to evaluate those activities. I want to point you to the query initiative, which is the Quality Enhancement Research Initiative. So this is within the Office of Research and Development, but it really is taking that evidence to practice or evidence to outcomes pipeline seriously, in that investigators apply for funding to study various aspects of the implementation pipeline of research that has come from the VA. So, for example, research that can study how best practices evidence based practices can be implemented, evaluated and if proven to be effective, how they can be disseminated and sustained. So really showing that we don't want the research to end with the publication and stay on a bookshelf but really impact not only VHA care but also care outside the VA if applicable. So what I've just spoken about has been the research side of the house, the Office of Research Development, other research funds that are available to intramural investigators. It has a huge interest in other ways of innovating and improving and learning about its healthcare and how to improve the healthcare of veterans so I give one example here of many but the Office of Healthcare Innovation and Learning is one office within within VHA. It has a VHA innovation ecosystem that catalyzes discovery and spreads mission driven healthcare and innovation. So as an example, they have a seed spark spread funding mechanism. So this is not really research but it is grassroots level VA employees if they have an idea for how something could work better in the VA can apply for seed funding to develop an idea for some kind of new program. If that meets certain metrics, then they can apply for then spark funding to actually pilot and evaluate that program. And if it really has shown to make a big difference, then apply for additional spread funding to spread that program regionally or nationally if applicable. And I've listed a few examples here such as telehealth for rural health, virtual reality therapeutics for pain management, remote temperature monitoring for amputation prevention. Just to name a few. All right, so with the last half of my talk I want to now take focus on some of the initiatives of genomic medicine in the VA that is a huge ask, and by no means am I going to be able to do this topic justice. I'm not going to be able to talk about genomics precision oncology and then the million veteran program. Unfortunately, things I'm not able to cover include the VA's real leadership for the last more than a decade in telegenetic councils counseling services in kind of a very hub and spoke model. So I'm not going to be able to talk about that. I'm not going to be able to talk about my NHGRI funded implementation project in polygenic risk scores that I'm leading. And I'll look for another invitation to be able to talk about that also. But let me do tell you about these three initiatives and then we can talk more in the chat about in the in the discussion about other activities if it comes up. So genomics is clearly important. We've talked about that in this meeting already as kind of some of the low hanging fruit, especially for primary care physicians where the result is very linked to a potential action. That's kind of a nice feature of pharmacogenetics. So the VA has funded at least two randomized controlled trials of pharmacogenetics and more kind of classic research. I led the I pick study which was a randomized trial of statin pharmacogenetic testing. I believe the prime care study results were published earlier this year of using a panel based pharmacogenetic test to guide monotherapy for the treatment of major depression. Both of these funded by VA as kind of traditional investigator initiated trials, but but still nested within VA care. So with the idea that the results could be immediately translated to the VA. If they were shown to have some benefit. It's an example of kind of the more traditional research research path to generating evidence. But I want to also point you to another pharmacogenomics program that actually is national across VA. And new sites are coming on board every month. So the phaser program some of you might be familiar with is funded as a partnership between the VA center for strategic partnerships and Sanford Health which gave a large donation. So to create an end to end solution for implementing pharmacogenetic testing broadly across the VA with the goal of ultimately reaching a quarter of a million veterans. It has now become the largest integrated pharmacogenetics program in the US, led by my colleague Deepak Bora out of the Durham VA and Duke University. So here with the more than 40 sites that are engaged or soon to be engaged in phaser and as I said this number is growing growing by the month. And I've put some of the many activities here that are that are a part of the phaser program and they really illustrate what is required for a for a program of this scope. So this audience is familiar with a lot of the challenges and, you know, to Terry's request to try to propose some solutions here are some of the solutions that that that phaser is implementing. So this is rare to many of us but you know, making sure that we've all floated a lot of the work of pharmacogenetic testing off of the providers when appropriate and how appropriate so in this case the phaser program is the one who actually returns results to patients although clearly providers are in the loop, educational modules and materials are provided for the patient and the provider level. So there is a pharmacogenomics e consult that is national so anyone who is at any provider at a participating phaser site anywhere on that map that I showed you can enter in a consult that is sent to a clinical pharmacist actually in Durham, North Carolina to do chart review and assist as needed. There are monthly, monthly case conferences with listservs to have continuous ongoing provider education and at the point of care and I'll show you on this on the next slide. Recently they've started over the last year rolling out national clinical decision support within the EHR at the point of prescribing, which is really key for that last mile of, of acting on pharmacogenetic testing. So here's a screenshot of one such pop up or interruptive clinical decision support that's currently implemented. This particular one on the on the right is for CIP 2d6 and, and coding opioids being a high priority medication were the first CDS to be implemented a year ago, and since then we're at more than a dozen different classes of medications and more more coming online. Dashboards allow the national phaser program but also individual phaser sites to track the number of tests the number of providers they're engaged. And also the characteristics of both the patients and the providers that are engaging with the program. Are these orders coming from cardiology are they coming from primary care mental health. What are the demographics of the patients that are that are benefiting from this testing to allow for continuous monitoring of the program. Deepak provided this slide of just preliminary evidence that we in the first 6000 or so patients that had undergone testing. We do see a temporal trend towards greater concordance with C pick level recommendations for medications based on pharmacogenetic results after the test compared with before having undergone the test so we do start to see they were actually moving the needle in prescribing behaviors among among providers. And I mentioned query early on. Corrine Boyles in the Madison Wisconsin VA actually applied for and was awarded query funding to evaluate phaser. So, you know, again, now we've got a clinical program and now research has an opportunity to evaluate it and decide what's working and what's not so query program will be to identify factors both at the facility level provider level and patient level about who are the adopters of pharmacogenetic testing. What are the barriers who are the, who are the ones that are not adopting what what factors are associating with actually engaging with phaser as a program. I'm sorry to interrupt. We're running short on time. You wrap them up or speed ahead. Yeah, I will. Yes. Yeah, thank you. So and you know, that's that's probably appropriate because I do, I wanted to at least alert everyone to the precision on ecology program although I'm not the right person to speak to it in detail but suffice it to say, this is another phenomenal example of high priority to the VA. This is a real partnership between clinical and research. There are certain activities and making sure that veterans getting get connected to the appropriate either germline or somatic testing as appropriate. Some of these activities funded by clinical dollars some of them when appropriate funded by research depending on what exactly the program is. So phaser takes advantage of national resources such as e consults or national tumor boards. So that being another solution in a, at least in a system like this with the organization that we have for for really enabling genomic medicine. I'll skip ahead then to the million veteran program I think this this audience is familiar with this program really a flagship in the VA. To date has enrolled almost has enrolled almost its goal of a million if any of you in the audience or veterans and have not yet enrolled. I encourage you to do so because we're almost there. But it really has become the world's largest genomic database linked to a healthcare system really has come into its own as a really mature resource now for genomic discovery is illustrated by the number of publications you'll see on a weekly basis coming from the data, but just now we're starting to explore what would it look like to read to return this information back into our healthcare system. So I lead a project, returning results with in familiar hyper cholesterol Bruce Montgomery at the Puget Sound VA is is beginning to return results related to metastatic prostate cancer. Reconsenting these MVP participants to get these results clinically confirmed, get the appropriate genetic counseling, and get them get the results connected to their VA providers as appropriate. So we're hoping that this also contributes to our genomic learning healthcare system in figuring out best practices for doing this. So I'll put up my summary here in that VA has a has an established culture of being a learning healthcare system. And I think there are a lot of features of the system that are that position it well to to help evaluate and disseminate genomic medicine with thought to be high value and high priority. So, with that, let me thank you for your attention. The, some key people that helped contribute some content for these slides and of course the veterans that we serve. Thank you very much. Great. Thank you so much. So there are quite a number of questions that we've heard to the discussion and I seen there hopefully will be more coming through the q amp a please continue to post them and Rob and I will bounce back and forth. Let's start off. You want to kick off the discussion. Yeah, you can go ahead. So there have been a lot of questions regarding sustainability of these programs that have been mentioned. Sorry for the interruption. So, Dr. Berg touched on this with the Vanderbilt program but I'm wondering if we can open that up that question up to all the speakers and if they could weigh in on sustainability. And also, recognizing that there's still a lot of patients across the country who do not have access to these programs so how do we begin to respond to that in the stance and potentially have the outreach of some of these programs to areas and whether it's geographic or because there's no counselors or specialists in the state. Okay, so I will take a crack at this. So I think, so I think, if you know, I think it depends upon how you look at the sustainability question I think we have to look at this question from the other way which is, which is how does having a having a having genomics integrated in our system saves a system cost. I think that is the way we should look at and we have to get our institutional leaders to buy into that. And sometimes it's easy because I think if you if you go to an institutional, any institution doesn't matter how big an endowment or how small an endowment they have, and if you take him a proposal saying okay we want to design a system from it point of cost us $1 million here from a manpower point of view is going to cost us $500,000 each year, you are not going to get anywhere. Pretty much every institution will say okay well write an NIH grant maybe do a little project. You publish a paper and we know how what happens it's a great paper we all get excited reading it, but it never gets really implemented. So I think in our institution and it's in which we have been lucky I mean, while we started this, I would just tell you that the groundwork for what we did and how we got our institution buy in was not was not was laid out years ahead of time, it was a constant sort of feedback iterative loop about getting our leaders to realize the potential of genomics and I think a lot of this work started with Dan Rodin, nearly 20 years ago, and even before that in the late 1990s. And the next generation of folks kind of carried it on. So I think that's the way to make the pitch is, is that, and those cost studies can be done, all of us have examples you can extrapolate how much a lawsuit for inappropriate mastectomy would be compared to if we actually, you know, I'm just talking about that sort of published example of bad outcomes, or the example that I mentioned where a pediatric patient was within a month of getting a bone marrow transplant for a test that was not, you know, I think that's the way to make that argument because I think that's the only way to make it sustainable the other I would point out is the issue of disparity is a major issue right so what. While we can think about genomics at Vanderbilt but what happens in a patient in rural Tennessee, who doesn't have really access. So our approach so we have thought about it and I and locally what we are working with is we are working with the tennis. We are lobbying the state of Tennessee to the Tennessee Ray disease advisory council to think about this problem statewide. So our local Medicaid patients, how do they actually, how do they come to get the latest genomic services. So that is that's not the top of the topic but we are actually having a lot of discussions with our state legislatures. A little bit akin to what Dr Corf mentioned yesterday but in a sort of different way. So I think those are the sort of things that we think we need to think about. Thank you. Senator Jason. I guess I'd say, I mean our projects are all embedded within the clinical services we provide and we have something like, oh my gosh, almost 50 genetic counselors and our success in that process has been making it easy for the specialty clinic needs example of the rheumatologist is a great one and maybe someday Hopkins will get there that will have a full on genomics learning system we're not there yet. But making it easy for rheumatology to buy one genetic counselor from the Department of genetic medicine one day per week to be in that clinic yeah it's low tech, but it's what we can offer now and it works. And that's maybe less exciting, but it's sustainable because it's systems people already understand. I would just say that I think that's a great example Cynthia, I would just say that as a proponent of our institutional. Sort of outside the this program that are we having for me going around encouraging our various departments and divisions to think about how they can integrate genetic counselor and their workflow is been like hurting cats. I'm talking about people who understand they their departments do a lot of genomic testing. And I think the way people think about, and this is where institutional buying comes in from the Dean's who then forces everybody to align their visions together. And I think that somebody else's problem because if genetic, if genetics or department genetics or division of genetics and institution is kind of doing a little bit of work and they can get some of their patients in and some of their providers can pick up the phone or email somebody personally or etc etc. It's just like, well, you know, I don't know whether I want to allocate $150,000 for a general counselor. I'm not generous about the salary actually genetic counselors are not paid enough and I'm paid much less than they should. But, but you know the point is that people. So I think from our point of view we think that we are fortunate through through actions of a lot of people through the framework that Dan started a long long time ago and through effort of, you know, people like Travis and etc etc. that we at least have institutionally aligned vision, which makes our job a little bit easier and at least us gets us to some degree of sustainability, because these services do not generate revenue directly right they just make everybody else better. Lead to better diagnoses lead to better patient outcome, but don't generate any revenue and most most clinical leaders think in terms of revenue. You have a genetic counselor who is providing informatics support are, but not generating any, not generating any revenue. No, no, no, why don't want to see patients in clinic. So you want to get past that. Okay, thank you. I thought that was great. There have been a number of questions regarding or about going or expanding the services provided by genetic counselors and genetic specialists to other providers, perhaps PAs. Nursing. Can anyone comment or wish to comment about that because clearly we have deficits in some areas, particularly in the country that that certainly don't have the access to the specialist says we have fortunate to have some of the great, the larger academic medical centers. Yeah, I think there's a lot of models that and a lot of work being done. And again, probably not the ideal person to speak to that but certainly within the oncology space there's all sorts of models of patient navigators and empowering sort of nurses already in that clinic. And again, sort of as a pretest model and then maybe you need to see a genetic counselor on the back end depending on what the results are. And I think that's been very successful. And there's been chat back and forth about the genetic counseling assistant programs that again for in our setting has been very successful. Those are often young individuals trying to decide what to do and that's that's been those individuals are key. We work in cardiology we work closely with PAs and P's members of the device team. And actually I think, and again I'm going to speak for the embedded model I know it's old fashioned, but some of that genetic education, even if it's two days a month or something. What you're doing in embedding a genetic counselor is building those relationships giving them that go to, and sort of by nature, educating the staff, which again I like knowledge is way easier in an academic institution, no doubt. But I will say that yeah, the genetic counseling assistants, the clinical nurses, the PAs are key members of the team. We work at Johns Hopkins with the School of Nursing to develop a whole curriculum for nurses with all of that in mind. We have a genetic counseling assistant online program that my colleague Carolyn Applegate the people in genetics developed so yeah. Our partners are critical to success at this endeavor we can't do it ourselves as genetic counselors. I think if I understand the question so I think I would just say that at least one advantage of embedding the of making this service available through an EHR. One of the things that I think is the way we are thinking about it Vanderbilt is that anybody who has access to EHR can access a service so in our clinic depending if there is a nurse practitioner in neurology, and he or she are, you know, seeing a patient, they can access essentially the same service. Same service through the epic honorable, but it doesn't really matter where they are up genetics provider or a specialist, if they are, if they are a whatever their role in clinic could be taken access, they can access our service. I think the other thing to, I think Cynthia raised a good point I mean in our, we actually also have genetic counseling assistants. And if you think about, you can actually have different levels of service that you provide some answers are very straightforward. Hey, where do I send the test doesn't need a genetic counselor, maybe but a genetic counseling system can answer it. So I think those sort of things are, we are trying those things in our system, also to be more efficient. I just also think that I think technology to a degree is going to be a would play a big role because we are never going to be able to have enough genetic counselors and genetic counselor but I think, while we think about technology I think given the uncertainty about genomic data that changing the environment the way we interpret the data the new sequencing technologies coming down the road. Some are already here in the lack of knowledge. None of these in front of none of these informatics base approaches are automated approaches are going to be completely self sufficient in that they will all require some sort of human intervention at some stage or the other to make sure that the correct nuance is in the feedback that goes back to the provider. I think a lot of the, a lot of the some steps can be automated, but those automated steps what we found, for example, is that need to be almost continuously iterated on because you have new tool people report new tools that are maybe a better way to analyze a variant, our own expanding by every data set gives us additional capabilities so I think, again, you need institutional resources you need institutional buy in and you need constant iteration, certain parts of this can be certainly automated. And I think that is has to be a key part, but then other parts. I don't see how we automate other parts of this feedback. And I think those. There will be some sort of human, human interaction in these feedback, whether it's by a by a provider by by a specialist who actually understands genomic it doesn't have to be a genetic, you know, a geneticist, or a PhD level genetic scientist or a genetic counselor, etc. Thank you. Mark. Yeah, I just wanted to make one point about a way that I think we as genetics professionals tend to harm ourselves from the sustainability argument. We're very open about the idea about how much we don't know. But, and I think we do that to the detriment of what we do know. And, you know, I liken this to, you know, radiologists don't, you know, expand on well here's all the things about this new imaging technology that we don't know they say well this is what we can do with the new technology. Surgeons when they have a new surgical technique don't talk about well here's what we don't know about it they say well this is how it's going to improve what we can do. And I think we need to be a little bit more proactive about the value that we can bring, and less about the fact that well there's a whole bunch of stuff we don't know because eventually, particularly in a context of a genomic learning healthcare system. We're going to rapidly learn new things and be able to incorporate that so that's I think one thing that as we have these arguments about sustainability is we have to really point out the idea that you've got big care gaps right now that you know people with genetics and genomics knowledge can close and you can't be comfortable with the idea that these care gaps are acceptable. But we, you're impacting patients and you're impacting outcomes. And we can improve that now, as Rizwan has appropriately pointed out, we have to think about this from a scalable perspective and we have to be innovative in terms of how we deliver that knowledge. I don't think we can let people off the hook and say that just because genomics is somehow different or new or unfamiliar that it's not impacting the care they're delivering to patients today, and then we can help those patients today. I completely agree with your mark I think that is, and I think that is an element of the pitch that we made with our leaders was that rather than dwelling on the negative that saying that you are the uncertainty that comes with genomic testing that all of us know very well. I think we want to point out all the pluses you and all the wins that the institution as a whole, or as a genetic community or as a medical community around, you know, in United States that we can have. You're absolutely right. They are very strong points to be made with clear data to back how important this sort of how early utilization of genomic information in patients can lead to better outcomes. I think that's the seminal pitch we need to make in a positive way over and over again. And we have another question in the chat what are potential solutions for broader sharing cross institution of these training initiatives as well as a program implementation lessons learn do local investments prevent giving away our IP, or are the programs not generalizable. So I would just say that there's really nothing to we, for example, we are happy to share our sort of pipelines and how we are doing it there's really nothing. There are no sort of proprietary tools that we are using we are actually working based on published databases that are already free to to use I mean we are obviously happy to share. With anybody, how we designed our system based on us and they can then, then people can think about it and then think about their institutional hierarchy and how, how they will go about designing the system and or modifying the system in there. I think the, the, what would be interesting, I think for us would be how as we now in the next phase try to automate some of this, whether that automation is going to be based on already published tools or is that automated is going to be brand based on either funding or institutional resources and I think that is an important different question. But I think personally I think it what we are trying to do actually is we are in early communication with with another with a couple of other institutions about while we see this kind of semi working in our at Vanderbilt, how, how exportable is this sort of approach. And we will see whether we can get the buy in there to to for that institution to actually then essentially essentially we have a control group, where another institution is trying something similar with a sort of similar goal and we get to see whether what the outcomes are in both cases. That'd be great. Very helpful. Mark before I come to your question that we have to in the Q&A that I'm going to share because I came in before your hand went up. Actually was related specifically to the response to this question. Okay, I'll make it very quick. We're not competing quality. This is a repeated in treaty from quality expertise that healthcare systems that develop improvements and care need to share those widely would be like airlines competing on what we don't crash as much as the other guys. It's really stupid. So we shouldn't be thinking about this as IP we shouldn't be thinking about this as proprietary or a market differentiator. We should be sharing what we're learning. Great point. Thanks Mark. Jonathan, do you want to go ahead and ask the question about genomic medicine boards. If not, I can go ahead and read it. He has one topic that has not been discussed very much in the session is the idea of genomic medicine boards where the scarce MD and genetic GC geneticist often centrally concentrated at an academic medical center can make the expertise available to specialists across the medical center or health system for discussion of cases and test results. At UNC we have had very successful interactions with our neurology colleagues and helping with case level test interpretation. Do any of the panelists have any experience with these types of outreach and their own institutions. So I will, I will just say that, you know, we, for example, we actually have some experience. So we have a UDN program and undiagnosed disease program, and it has a sort of diagnostic board, which meets at a defined time every week. And while many of the cases are cases that are referred to that board for sort of undiagnosed patients, people will actually utilize the capability of that board and 15 or 20 members that are assembled there. To get answers to the question. But I would just say the bigger initiative that I earlier alluded to with our Tennessee Ray diseases widely committee and I'm actually a member member of that and I was able to convince the committee to focus on that is to actually the real vision is maybe in a couple of years to have a genome board that is partially funded by the state of Tennessee, akin to how they find the state newborn screening program. And of course being from from the educational institute or other institutions across state of Tennessee available through a web portal to pretty much any provider out there in state who's practicing in state of Tennessee, so that they can actually go to the board and ask these questions so the framework of that is already in place. So we are, we are going to be starting a trial run of that. And this would be without any state funding this will be funded institutionally by UT Memphis and Vanderbilt. And we want to generate some data to take back to the legislature that was their advice to generate some data come back to us and show us what the, you know, what were the outcomes. We will see. Great. That's Jason do you have any experience with that and then I'll move on to another question. Well, I mean the, the, the phaser and precision oncology programs that the VA kind of have that national board, you know, there's essentially the precision oncology tumor board. There's a, it's not so much a board as much as the individual pharmacogenetic clinical pharmacy specialist a farm D with with specific expertise in pharmacogenomics who can provide consultation, not so much the convening of a multi specialty or like the precision oncology board would be but I think that model is clearly important and also well worn in oncology, you know, for decades that's been when you've got the radiation oncologist them like the medical oncologist the surgeons, putting their heads together about how to take care of a patient for for a complicated disease. So I think that model has a lot of legs and it really will be a piece of the sustainability. One thing we found really useful in that context is to really deter bad referrals to our clinic. Right, we can look at a test result with them we can talk about their v us that they found and say why or why not to follow up on that. Or we can say, you know, hey, it looks like maybe you should try some metabolic testing right why don't you order those labs and see what happens right so we can kind of help them along with the work up without having to necessarily have the every patient getting referred to genetics once somebody has hit a roadblock right I think it's a really useful tool and some institutions call that just an e consult, you know just a quick chart review before you make the patient wait three months to come see you. Yeah, exactly. Yeah, it could be done as an e console but I think just from a standpoint of education also helps to have all of the neuromuscular neurologists, you know, on a teleconference at the same time we're talking about their cases, they're learning and we're really, I think helping so it's been a good experience. I have one other question the Q amp a Cynthia I think this is be very helpful from your standpoint, especially as you look to improve the efficiency of genetic counseling. Currently Medicare doesn't seem to recognize genetic counselors as providers which can impact the reimbursement of genetic counseling sessions how do you experience that, and your experience. This is a recurrent problem and any genetic counselor on this call knows are ongoing sustained push through NSGC to get us recognized as providers so that is certainly a professional goal. I'm not the ideal person to answer this I'm the research director of our program you need the clinical director to talk about the nuances. I will say that it does limit in rare cases the patients we can see but usually there's workarounds, usually there's workarounds at least in cardiology. I don't know if there's other genetic counselors on the call who are more knowledgeable about access. I'm not the ideal person to talk about this but it is a problem. And it is something we need to solve. So I would maybe just comment that. Yeah, it is a problem and the way we solved it solved well. Our work around at Vanderbilt is to eat the cost our patients still get services, our genetic counseling team and does provide services, but they don't get reimbursed. And the way we have, and we continue to expand our genetic counseling services but again it's the same model, the model that we pitched to our leadership. And this is would be the departmental level leadership is that it what is the added cost value of having a genetic counselor. It's available to, to answer either patient questions are our physician questions. So I know that's not the ideal solution now in state of Tennessee genetic counselors get can get licensed, and they are able to bill, but they bill on a time based code and again, the revenue that we don't. I think that their contribution is significantly more than the revenue number would indicate now hopefully one of these days they will generate revenue as much as it's clinical geneticist does, but right now that is not the case. Right. Renee, I see that you have your hand up. Thank you. I was just going to say that the, not being recognized through Medicare is also having impacts on things like, you know, different states have different laws. So, in one state a genetic counselor can order a test and another state and genetic counselor can't order a test, which is really making it hard for us to create scalable solutions for genetic counseling, because one solution in one state might not fit another state where it may fit the federal government but not another place. So I think it's really important for us to really as a nation think about what genetic counselors can and can't do and how we're going to regulate that, so that we can actually start thinking about solutions that we can implement in multiple institutions. Another, another comment that I will make here I think that's an excellent point but in, in thinking in terms of, you know, genetic workforce, let's say genetic counselors. We then end up with a problem of state licensing, right so you may be a genetic counselor who is licensed in state of Tennessee and Mississippi doesn't have a genetic counselor but you cannot provide services in Mississippi. So unless you get a license to state of Mississippi that is if you can and you have the same problem so which, so you know an ideal solution would be that at a national level there's a policy that certain specialties who are considered mission critical and are in such short supply would have, would able to get licensed in multiple states. Much easier so that they can actually provide services so if I'm, there is a urea cycle expert or in, or a neuro geneticist in Seattle, and there isn't one in Tennessee that they can actually see the patient. All in medicine. Same as well. Well, thank you for your comments I know we're coming to the end of the session we have about two minutes left. It's been an excellent discussion. It's really highlighted to you know what is possible in terms of genomic medicine. to enable all providers to be able to implement genomic medicine knowledge. And I think the talks today have highlighted the novel approaches that are being offered. I know we originally started off with talking about training and genomic medicine to residents in the time of COVID, which was had, it seems to have good enthusiasm for that program, which I think underlines what everyone else is saying about the enthusiasm for genomic medicine training. And really the key challenge that we have is training a wider range of clinicians in genomics and in getting the healthcare system to adopt it. And something Mark said that I think resonates is we really should focus on the great things that we are doing and not necessarily things that we can't do yet with genomics. And there was some discussion and a question earlier about polygenic risk scores that we didn't even touch upon. So with that being said, I wanna get each of the panel members to make some closing remarks. Jason, do you wanna start us off? Sure, I think what I would have taken away from the two days of talk so far is, this is the first time I think I've heard us talk about sustainability in these four. I mean, what a nice place to be in, I guess. What a new challenge. I think we often talk about implementation. So it's refreshing in a way, I guess, although challenging and inspiring to now think about how do we sustains and improve upon some of the models we've been working to implement for 10, 15 years. I don't have the solutions yet, despite Terry's charge to propose them. But I think I'm inspired by that new call to action, I think. Cynthia? Sure, well, thank you all for these opportunities to share thoughts on genetic counseling and the multidisciplinary team that I think is necessary to make this go. There were a number of comments in the comments section from nurses, from other genetic counselors. And so I think as we think about sustainability, as we think about growth, as we think about training, including these other healthcare providers as team members, I think is vital. And again, I'm excited to be at this point scientifically where we are implementing these efforts and developing the evidence base we so critically need. And then I will end this because Terry is suggesting we make our comments point. Right, yeah, thanks everyone for the excellent session and I'll turn it over to you, Terry. Great, thank you very much. And sorry to cut things off, but it's when you have a robust discussion that's what happens. So just a reminder, we have a 20 minute break now. This is the longer of the breaks that we have. So please come back at 1.30 and we will see you soon.