 Well, thank you very much mark. I really want to thank everyone here for inviting me and taking a good chunk of your Time today to to hear this and I think it's hopefully going to be very helpful And I thought those last questions were really relevant about how you get this on to the Providers doorstep, and I do think this is one of the ways that you can do that The title of this is just opportunities for health care quality measurement in genomics. My name is John Bernard as he mentioned One of the senior directors with the national quality forum in the quality measurement division So I'll tell you a little bit about myself first. I had a bit of a torturous route to get to where I am I was actually biology major and undergraduate did some genetics research Which will have a chance to laugh out a little bit later today. I then got into information systems software development product development and Happened to be into a place where we were doing health care quality measurement in IT. I decided to make a career change I went to medical school Went to residency and family practice. I'm a part-time practicing family medicine. So I'm really liking this discussion I'm hearing about how can you get this on to the frontline clinician the primary care providers and what's the impact to us? And then lastly now I'm at the most part of my job is at the national quality forum And I'll spend a minute or two talking about that also Today I have a few things I want to try to get through I know I have about 20 minutes I'll try to be very Conscious of that time, but the first thing is and we're maybe the bulky part of the lecture is What is quality measurement and trying to give a good overview because I think if we don't build that? Base and that foundation it's going to be very difficult for us to have the discussions to go forward because there's a lot of nuances Much like your science measurement science is something that's really important And if you understand it better you can better get to the outcomes that we're looking for of all the things We're doing talk a little bit about the health care policy the quality-based environment that mark mentioned I'm Unfortunately at times a knee deep in a lot of these rules and regulations. We won't talk a lot about that today But then talk about my opinion why why there's a great intersection right now between the quality measurement field and the genomics field And then we'll talk about these very Specific things that I think could be really exciting to the field and hopefully we can work together or help the genomics Medicine work group move forward some of these measures into prime time So I'll be brief on this, but the national quality forum what we are is we're just down the road on K Street in Washington We're independent. That's also Nonpartisan which is important right now. We're nonprofit We're membership organization and we have our job is to take stakeholders and convene Multi-stakeholder groups and make expert panels on a topic. That's what we do That's what we pride ourselves. That is where our core business is So we don't want just the clinicians or just the researchers to be part of this We want to have all of those the insurance companies pull those people together and talk about a topic And so that is really our core business and we do this a lot through quality measurement So how does this help then health and health care? And I want to mention going back to my family medicine that What's really important here is going to be the patient and that's the outlook I have the patient and the patient's families is has to be the health and health care That's the root of everything we're doing and I think in the end there is a quest for pure science But really when we're trying to implement this we're thinking how does this affect the patient has effect the patient's family? So I'm going to go over some basics and this is really basic. So please bear with me I'm not trying to be insulting. I want to just go over a couple quick examples to show How we do measurement get everybody on the same page and then we'll start getting into some of the more Technical nuances of the measurement science. I like this slide. Don't forget measure is a it's a noun and a verb But the really the thing is it's either a base mark or it is a way to Compare yourself to a baseline and that's what I think we want to be doing This is again where I said, please Don't be insulted, but we really are looking when we're trying to measure. We're measuring numbers We're looking to get to a rate a percentage Coefficient something like that and we have to be able to find this this baseline so that we have some level of comparison This is an example talking about hemoglobin a1c and just how we would look at this whether this was measured In an office visit. This is just saying did we run the test or not? And the numerator is did you run it during some period of time? Denominator really should say really patients with diabetes and then we're excluding certain subgroups of diabetes where the test isn't appropriate So clinically what does this look like? I saw 10 patients this month two of them did not meet the criteria So I'm left with eight the ones in blue for example. I did the test on the ones in orange I did not do the test on very quickly plug that in my performance rate for whether for this process was 50% And you can certainly see how this will go in whether there's an appropriate time for a genetic test to be run and Getting to that question from the woman from Vanderbilt get putting something in front of a clinician if only 10% of the time My patients with this out-of-control cholesterol are being screened for familial hypercholesterolemia Why is it that across town? It's at 70% and that's where they start to get some value in here and something in front We realize that this needs to be more front and center in my practice for example so these are the types of measures and there are these are the basic categories you could you could subdivide or or Argue these but I think this is a pretty good representation And I'm going to talk about the structure of the process the intermediate outcomes the outcome and that these patient reported outcomes I will not talk about cost resource efficiency composite I think they're there for completeness sake that there are folks out there looking at these types of metrics, but they're probably less Significant to what we're talking about right here And I'm going to try to try to be quick here But I also want to highlight the importance of knowing what kind of measure you're picking while you're trying to get to an outcome So a structural measure is something that just is looking at the attribute of an organization So do you have a genetics counselor would be a structural measure? How many weeks does it take or days does it take to see the genetics counselor another measure? But in and of that self does that help the patient does that get to health does that get to health outcomes? Maybe maybe not it's probably not a strong indicator So that's why these are easy to collect they can be done in a survey. They're they're simple There's no arguing you either have it or you don't and then you can move on with it So so we use them because they're simple, but they're the utility is lower on the scale Next one is process measures now This is the lion's share of the measures that are being used from endorsement purposes This is the lion's share of the measures that are used in federal programs for quality and payment And the reason for that is because these are easy to agree on these are easy to get consensus Let's go to the hemoglobin example again Did this patient come to your office who needed the hemoglobin test and they got it they did not get it That's that's a pretty easy question to answer you can attribute this to me And I'm going to talk about attribution or responsibility a little bit later But that is a huge issue when it comes to some of the more complicated measures But you know who was responsible for running this test and it was me so people like it it's evidence-based We should do it. I'm the one who should have done it so you can give me a rate The flip side of this is does that help the patient just because I ran it does that mean my patients are any healthier than the Folks down the road who maybe are great about making reminding them to take their medicine take their insulin and forgot to do The check and their patients might actually be healthier, so so these are good measures But they're easy measures, but they still don't get to where we want does this help the patient patients family down the road So now we're moving into the outcome world in the outcome world. There's there's two the intermediate outcomes I always think these are the hardest to to figure out what's an intermediate outcome versus an outcome and really this is a Short-term indicator of something we're looking at and I think diabetes is an easy thing to follow a lot of us Know and the hemoglobin a1c if you're not familiar is the marker of blood sugar over a period of time And and we would like to say lower is better So if I'm treating a diabetic an intermediate outcome Maybe to get the hemoglobin a1c down the outcome is to not have cardiovascular disease not be blind not have kidney disease That's what we want for a patient outcome But what we can track in a small amount of time would be the a1c if I want to wait to my patients have Heart disease or kidney disease that might be a measure. It takes two decades to realize So we have to find a better way to get at whether we're treating these patients Appropriately and this is outcome. It's better better than the process. I think you'll find now Again when I said we have complications or complexities with these is Am I the only one responsible for this? What about the dietitian? What about the endocrinologist? So Attribution or responsibility gets harder when you get into outcomes because more people would probably be involved in that the patient's Responsibility potentially whereas I can control I ordered that test, but can I control that they took their medicine? Can I actually control all the factors here? Probably not and so these are why the better measures are harder to to harder to come up with Outcomes are the ultimate outcomes again. It could be heart disease It could be if you went in and you had a heart attack. Did you live or die? Mortality is a great outcome to measure readmissions Again though thinking about who's responsible if you had a heart attack. Is it the EMS? Is it the emergency room doctor? Is it the? The interventional cardiologist who did the cath on you so so they become harder and harder to attribute Who's responsible for these but it's the ultimate measure of what you'd want to know And another thing that's coming up that's becoming important now to to interweave in here is patient-reported outcomes I won't spend a lot of time on this but survey tools. What do you think perhaps if you had a back surgery? Patient-reported outcome would be do you feel better than you did before and if on your scale was a seven out of ten? It's now a four out of ten. That's a patient-reported outcome It doesn't really say anything scientifically about the the way the surgery was conducted But it's probably some ways what you'd argue more important than whether or not they did a timeout in the or Because the patient's feeling better X amount of months after the surgery All right, so that was quick I know I that was a lot of information I logged a lot and I think hopefully that was made sense And it's a foundation and now I want to transition into what the landscape and the United States especially but it does mimic What's going on internationally? I won't spend a lot of time on this But everything in the quality world revolves around the Department of Health and Human Services National quality strategy the short of it is it's just reminding us that when we're doing something for quality It's better care. It's healthier people and communities and smarter spending So that is what we're trying the triple aim of the national quality strategy thinking of what's quality? It should fall into this bucket. I always like this slide. It's hard to find. What is what's value? We keep saying we're gonna move the way we pay providers way we pray health care organizations from volume to value so so what is value and This is a slide that I found I think is really helpful And it's it's showing that the best outcome at the lowest cost is the value that we're looking for I know it's common sense, but at the same point This is what we're striving to do when we say health care value We want to find what drives towards towards this end goal And just to give you some real-world facts about this is Medicare specific payments that are going on again I doesn't mention them Needy but in a lot of the the federal rules and the payment side of the measurement also in addition to how well a measurement work a measure works scientifically and This is showing that payments to health care organizations or Clinicians going forward is going to have a larger amount of that tagged to how you're doing on a performance metric of some sort Or usually a series of performance metrics. So it is becoming Important but at the same point it's nine percent. It's not fifty percent. So it's it's an important part of the way We're going to pay people going forward Couple other considerations. I just want to mention anytime. We're thinking about Health care measures and if we're talking I heard a lot about outcomes and as it comes I totally agree the most important thing But these are related concepts the attribution of it is who is responsible for that outcome and and then the intended use Is what are you using this for it may be just fine for me to look at a measure that's not does not have good attribution If it's for self-study Why is the physician across the road do better with getting their smoking rates down on their on their patients? If I'm just self-studying and I find to have a lower rate That's a good measure and I can go see well They have a substance abuse counselor in there when it goes to a payment program That's not a good measure for me because I don't have it and I'm getting paid And it's not just the other clinician across town. It's them plus their substance abuse counselor that are doing it So so I wanted to make sure always what are we doing with this measure? Do we want it to be paid on it or do we just want to be researching this and seeing is the field doing well and moving forward? with with that type of Process that we think is important All right, and then I have to put this if there I know there are clinicians in the room and there's a Thought that we should be really benefiting from these metrics, but there's burden There is a lot of burden you have to report and you have to send data and you have to collect data And at some point the measures start driving the clinics instead of the other way around And the reason I bring that up is because we have to think of which measures matter And which measures matter is a very important topic right now in performance measurement because when we pick the right one With the lowest burden That's where I think we're going to get the biggest bang for our buck having a bunch of measures out there that are low yield checkboxes It's it's hard to get people to continually step up to the plate and start using those measures All right, so why do I think this is the right time? Why do I think it's probably beyond time where the quality measurement and the genomics or the precision medicine or the personalized Medicines comes together. I think we have there's a lot of reasons why this field should be more represented in the quality measurement space and This is from a recent qualitative analysis. We did an environmental scan and we're trying to prioritize what's important in the measurement field right now We came up with these among some other things, but anything. It's actionable and provable patient centered outcome focused integrated care Well minimally these genetics or genomics measures are going to be actionable and provable if we Find that a person has Lynch syndrome. Are they going to get a cold colonoscopy? So there's action to be taken is a patient center where you could not get more patient centered than your your own Genome and outcome focused. I think there's they lend themselves to that if we do it correctly Integrated care, maybe maybe not as much but but I do think three out of four is a pretty good hit for a lot of the things You would just imagine would be good genomics measures All right. Here's where I said we're going to laugh at me. So when I was in Undergraduate I spent a couple years doing genetics research and I use that to compare and contrast to how far Advanced you all are compared to what I had done in college. I worked on this maze project and genetics and I They the highlight of my career is learning to pour one of these polyacrylamide gels And they never never look like that like they're like crooked and then like they the teas are bright and the in the G's are dark or something. So I bring this up to say that in 20 years It's amazing that you just send out and the results are back and how much impact you can have because of these Advancements and so it's really ready for prime time and that would be hard if you're saying I want to measure that And you're and you're trying to get me to pour your gel and be a long time. So It was it was bad. It was bad Anyhow going getting back to it way we do we convene multi stakeholder expert panels and I highlighted a few of the Groups that we have ongoing or have had on a regular basis and why some of the stuff the genomics Medicine work group and us we had some time to talk and I heard some of their idea So these concepts in the in the text on the outside. These are not mine These are these are from from them But seeing how well they align with some of the projects So we have a diagnostic quality and safety group and I think that's more overarching when we start getting to Diagnosis is much more precise it when you can do it on a genomic level then then sometimes just running blood work and making inferences We have cancer projects. It's always a big project always runs a lot of measures through I think some of these Lynch Brecca EGFR testing go very well in there patient safety Are you testing? Genomics to see if a medication is the right medic medicine for a person Cardiovascular conditions family implications again on and on and on I'm sure you could think of a lot more topics in Genomics and a lot more projects at the NQF where there's a lot of room for alignment of the work You're doing here with the the quality efforts that are going on both at the national quality forum Which I'm biased towards but but across the country and many other quality arenas not just what we're doing And lastly I wanted to talk about a couple of these very specific things that I'm excited about and I really hope we can Find a way to move them But as I mentioned, I did have the chance in late 2016 to sit down a few times with this the genomic medicine work Group and talk about some of those measure concepts that you just saw and two of them We thought were potentially ready for advancement and part of that is scientifically and part of that is Financial opportunities we happen to have a project right now where we have a funder who is interested in cholesterol measures So what for the familial hypercholesterolemia? I think it's a good measure It's a little different outside this the spectrum But would be a nice thing if we can get them to to pay for a real good rich measure development I mean they've done a great job already, but getting the fine-tuned Part of measurement development and then Lynch syndrome they have a lot of data on this and something that hopefully could be funded going forward I want to I just want to mention about the funding It's it's really if you think of the measure development is analogous to doing a research project You have to present your data you have to present the testing that you did the concept It is it is it a something that's in the guidelines So it really is is that's why it's expensive just if I asked you to do a research project You'd say oh, yeah, I got to collect data. I got to do this I got to do this that's what the measurement folks are looking for to have a strong endorsed measure is that same type of science behind it so so it is costly and We also want to get the measure that matters to here because you don't want to spend that kind of money and then find out that That's kind of a softball. It didn't really seem to help outcomes in the end. Anyhow on an end here Trying to loop back to where we started that I think the most important thing with all of what we're doing is When in doubt remembering what is going on in my world and your world is we're trying to keep the patients and the patients Families as the true north and when we have that mindset I think we're going to be able to show that that we're really making progress and these outcomes are important I mean they're important to us But they're they're really important to the patients and their families and just keeping that in the back of our mind Sometimes helps me put perspective on a long day So that is all I have I don't know if I went over time or not Perfect and we have questions so as people are are moving to microphones to ask John questions I just wanted to add a couple of things to What was being said first of all some of the genetic professional societies have been Engaging in this area. I'll let Janet tell about one But also to mention that the American College of medical genetics and genomics So we started a quality special interest group about Ten years or so ago if it's not been particularly active more recently But there has been interest around this and I think there's an opportunity to potentially re-engage Maybe through measurement the other thing I wanted to our membership I should say the other thing I wanted to mention is in the emerge Outcomes group we are defining all of the outcomes that we're defining for our return to results as Process intermediate or health and so we are using the rubric that John presented to categorize the outcomes and as was explained most of the Metrics are going to be looking at are going to be processed or intermediate outcomes because the health outcomes are expected to probably be a Well outside our current funding cycle. So Janet. Yeah, I wanted to ask a little bit The National Society of Genetic Counselors recently became new members of NQF and we're looking forward to Working with the resources that you have as well as to shore to share our Knowledge and information and I wondered if you wanted to give just a really brief Overview of what it means to become a new member of NQF. Yeah, sure I think that's a good question. So I mentioned on the very first time I decided with the National Quality Forum that we are a member organization and so We rely on that membership for for our committees now We do go outside of the membership when we feel that we need to to get an expert voice that we do not have But there's a few things we have one is the priority of our members We know that these members are engaged Financially and time commitments to the National Quality Forum. So we certainly favor having our own members on our committee So that's the first thing to get really on to the the ground floor on here The second thing is there's a lot of educational materials that are provided around this webinars Seminars that are free. We're working on even trying to get some CME credits It for different places. So so those are some some of the benefits But it's really the involvement that then the members are very we encourage involvement and really really hope that they stay Involved in these process and then they get your voice into whatever might be from an endorsement side of things or whether it be on the Federal program side of things Great Bob. Yeah, so it then Bob will in the National Human Genome Research Institute in the genomic healthcare branch Jane Jenkins and colleagues organized in September a Meeting to begin to look at quality measures in healthcare and this was a Group of really experienced knowledgeable nurses that really blew me away with their ability to grasp this problem and use their backgrounds to go forward with it So I'm interested to hear that the NSGC is involved and the physician's groups are involved So I think that that getting maybe getting these groups together and trying to work together On these is a really great idea And I also wanted to make a comment about your statement about which quality measures matter The and the right ones with the lowest burden and I think that's really important as well And but I also want to plant the seed about how to lower that burden And and one of the ways is to be able to to use automated processes and information That's already in the electronic health record system to to do that and find think about ways to capture The quality measure information in an automated or or semi-automated fashion So it's not a bunch of manual processes putting that information in so sort of a hats off to not exactly clinical decision support but other kinds of computation to lower the burden and and I also wanted to ask is about the the goal being Is it incremental quality improvement or you really sort of trying to solve a problem once and for all? Okay, so let me take the second one first. So about the data Just let you know huge issue for sure having that the right data available is something that in our measurement Endorsement process. We're really trying to look at that as to what the burden of this the feasibility really of this So that's part one part two about that is we actually are just I just started a project recently on interoperability where we're working with the ONC as part of the of Health and human services who is in charge of a lot of the standards for electronic health records and working on interoperability projects and how we can better Measure the success of the interoperability So that that was the answer to that one the second one about the are we trying to improve quality or get to the end? I think the reality is we'd love to get to the end But no one thinks that's feasible at this point. So incremental is fine for us We were okay with incremental and a matter of fact We even look for we try to find areas that have gaps in performance when we evaluate measures because if everybody's doing the same Such especially on the payment side It's we want something where we know there's a difference and we can move and we know others are doing better And how do you move up towards that bar? And there's also on the flip side of that there's evaluations periodically on topped out measures Everybody got it the whole way up which gets to that the second part We solved the problem and then those maybe only would have periodic review to take the burden down to stop reporting when everybody's at 99.5% That if that helps yes Thank you, Jeff Pennington from the Children's Hospital of Philadelphia. This is a very welcome presentation. I'm we're working out toward Decision support in the HR on our project and Primarily to improve the dissemination and uptake and use of of the information that comes out of the diagnostic But we continue to struggle with how to measure something Other than qualitative, you know usability utility from directly from clinicians Are there existing domains of measures? Particularly in the structural and process area that we could pay attention to and think about how we would bake in the data collection for those Can you clarify the domains? I guess so we found that AHRQ has a Care coordination atlas with some very high-level descriptions of measures of what we call loosely medical hominess and So that's where we're looking because care coordination across multiple providers for complex Cases is seems like a pretty reasonable place to provide some decision support But so I think of that as an example of a domain. So, you know care coordination in medical home That's that would probably be I guess a process measure maybe Structural, but are there other existing? Sort of collections of measures that we could look to yes. Yes So good I insurance question So one of the things first of all we'd like that to be more robust So it's an actual quality form we've had a number of measures have come through our our company for endorsement or review And we have those catalogs and it's on our website And I really apologize that I don't have that information But I will make sure that it can be communicating my email in our website also but on our website we have all the measures that we've reviewed out there and we have by an actual Subject matter topic specifically diabetic measures But also some of those cross-cutting domains that you can look at patient safety care coordination And you can see what measures are out there and if it's an endorsed measure again Not to toot our own horn, but if the endorsement sure it's not because I stamped it It's because some expert multi-stakeholder panel said this makes a lot of sense And and I think I would encourage you to go out. This is public information on our website I would encourage you to go out and steal as much as you can from there and try to implement it So you're not reinventing the wheel on these things and there's a lot out there We hope our goal and this is not even funded or anything But I mean one thing we'd love to see is a more consolidated Database of measures and we had actually written a report recently about the variation in measures that you could have Three influenza vaccination measures and we're all just a little bit different and and how the United States whether it's through NQF or CMS or somebody else needs to have a little better handle, but in the short term. Yes We we have some information. I'd be happy to help walk you through it too afterwards. Thank you I'm sure glad we don't have any variability and genetics around our measures that we're always right on the same thing if the car If the car glue mayor clinic enjoyed the talk. I'm glad that we are prioritizing FH And emerge network. This is a high priority phenotype and we'll be glad to work with the NQF There's about 1.2 million of these patients in the United States only about 10% of them have been acetate so I mean there's a huge potential impact that we can make and one of the ways would be to have some You know quality measures where it's clear that the physician or the provider made an effort to Implement cascade screening or encourage the pro band to do it and the other would be potentially to look at clinical decision support Content which encourages providers to do this But I'm glad that we are highlighting this and I think there's some opportunities there to really impact public health Yeah, and I couldn't agree more that is something that we're always trying to keep is the population health of public health on our Radar and I think this is a good one and being a primary care physician. This is one that's important to me This is not necessarily stuck in some specialist bucket. I need to know about this I need to be thinking about this and I'd love to see so I have a day where I have a dashboard and says and say You know, I have all these patients with exceedingly high LDL levels and why am I not checking them for for the familial hypercholesterolemia? So I completely agree and I appreciate your comments Terry Terry Minolio from NHGRI and thank you to for coming and sharing this with us I Appreciate the conversations that we've had with you from the general medicine working group of NHGRI And you've described how basically developing a measure is well within your remit And is something that you do quite well and validating it is something else that you do quite well But I think you have said that you're not responsible or you can't do implementation So so can you help us understand if that's correct help us understand a little bit better How do these things get adopted? I mean do we do we then go out and say, you know You've got to be measuring this this FH measure or whatever. How does that happen? So so there's two different there's two different ways we get things what I would call implemented One of them is through the federal payment programs, and we're really talking about dollars and cents right there That is a program a specific way you do that. It's a submission to CMS and it's getting it into their their queue of which we also happen to Coordinate those committees that that are the gatekeepers to to the value-based programs. So that's one way on the financial side it's it's a little bit more nebulous on the clinical side or or the quality improvement side and It is usually Looking for sponsoring groups groups who will take it back to their organizations and try trying to Implement this and they feel value in it and they want to make quality improvement So I wish I had some magic way to say we this is important topic We're not ready to try to put this into a payment program and here's exactly how you deliver it We have experience that we could help how others and maybe Find other examples of measures how they were implemented that might fit a similar topic area, but We we don't have it. There's not one way that we do it I mean for example, we had probably approached the American Hard Association American College of Cardiologists would be one group probably the the AFP or the Board of Family Medicines the Internal medicine folks and I would expect that would be the way we would we would guide you towards getting this out there If I could just just follow yeah quickly I say have you pursued like using the maintenance of certification processes where we're in many professional specialties There's an expectation of doing quality work within your practice or in your hospital And that might be another way to drop them in this is so so yes a maintenance for those of you who are clinicians We have to get our boards Resertified periodically and part of that is usually a quality program So we are not directly going to those programs though many of those boards are members of us for example AB I am the internal medicine the board of family medicine a lot of the big boards are members of the national quality forum And often do like to utilize our measures or consult with us at times, but there's not a formal There's certainly no nothing formal I don't want to overstate our role that we're we're out there advising them that that would be an overstatement on our part But we definitely are involved with these organizations and they're most of them are members too It's a Bob sneak over to the other microphone thinking that I'll probably You know mistaken for somebody else because he's farther away, but but Relevant to to Terry's comment. I think it's important for the group to know That Bob does co-chair group called the intersociety coordinating committee, which is convened by The NHGRI where there's representatives from multiple professional Specialty societies where they've sent a representative that has specific remit or interest in genetics and genomics And so I think that this if we were to be able to develop some measures that would be another forum where we could say this is something that's happening and If you can take this back to the you're relevant professional society that that might be an opportunity So it's Katrina Armstrong from Massachusetts General I certainly live the implementation side of this and my roles there I mean, I guess I have a comment and a question or maybe a slight concern about it You know, I do think and maybe partly this is in response to Sharon's presentation earlier I think a lot of this really comes to how we pay people what we pay people for How much we pay them for things and I will push Sharon to say that I bet there is if we were paying people more to interpret secondary findings if that was part of their job if We had a workforce that actually was doing that that I think we would change this Dynamic a lot because right now it's really a lot of people working really hard in a certain setting And so I think as we think about enticing physicians to do the right thing I mean one of the things I've learned is physicians generally want to do the right thing What they don't they need to know how to do it and they need to not be financially harmed for it And so as I think as we move a lot of this out We need to really focus on the workforce and advocating for the workforce We've joked about creating a whole field of genomology at there We have radiologists they get played plenty to interpret a scan But I will tell you we need a field that is actually valued and rewarded for doing this. So that's a comment I guess my question is really about equity So a major part of quality as we think about and maybe an increasingly important part of quality is we're all facing it I think one of the concerns that we're facing right is that if we look at genetics And this has been a big part of Caesar is that there's a lot of let's say variation also and access to those Technologies in the interpretation of those technologies One of the challenges can be is if you create a quality metric that is really only accessible able to be achieved by groups that are Accessing tertiary care high income areas you can create a real Paradox in the pay for performance system We're actually the systems that are trying to build these programs are penalized as they try to build these different issues I know you think about this a lot and there's not an easy answer But have you thought about that as you think about genetics in particular because of the importance of really thinking about how we do Deliver this equitably across the country Great question. So have I thought about in the context specifically of genetics? No, I'd be lying I'd be lying if I if I said I we had that Detailed discussion, but I will say we have a lot of energy going into this To that I mentioned we have a lot of projects one of them that was just on social economic status Another one is on disparities that we're working with in part of what our concern is in general is how measures are applied to different Populations and how it may or may not be fair to be Applying the same rules without considering other factors. So I Hear your question loud and clear and I think there is a lot of energy in this work. There's not enough action There's a lot of talk in general I say that across the board I don't mean just around metrics, but I mean around both of those topic areas So I can say that it is it's on the forefront and matter of fact we have when we're looking at the payment program Measures that just came through we just did a cycle of this and I know it's a slight digression but all many of the comments had to do with disparities and Social determinants of health not being represented in these measures So I can just say that in a way that it is on a lot of people's radars at this point And we're seeing a lot of feedback because we take feedback both from our expert groups and public feedback on everything We do and we're seeing that come up as a theme a lot. So on the radar, but I don't have any specific answers Bob sort of yes or no question Bob Wildin from HGRI the familiar hypercholesterolemia and Lynch syndrome are two really sort of key Examples of genetic disorders, but there are thousands more So my question is if we if we move forward with these two great examples Is there evidence? outside of genomics in the quality process that Focusing on a couple of measures has a bystander effect for similar Kinds of thinking and similar kinds of system development affecting other disorders in the same domain There is At least in my opinion I can't give you data on this but the early measures of cardiology measures of cancer measures They were put out there as a matter of fact in our the national quality strategy at one point the chronic disease and cardiovascular Conditions was actually highlighted in that because it's such a major Topic to the to the United States But anyhow because they had they formed a small cottage industry around the measurement of Cardiovascular and cancer conditions and these are two of the big fields that continue they already have rich measure sets and continue to get More measures whereas some of the the underrepresented fields Interventional radiology really really doesn't have a lot of things we're measuring so in my opinion without having data is yes When you see activity in a field around this people get the hang of them and say oh this one's just like this and and they start to get their Their machinery working then it becomes much easier for subsequent measures to go into play and even even without putting additional measures in Providers may may feel like oh, I see that this is similar to what I'm expected to do with familiar hypercholesterolemia I can apply the same principle. I would think so being a From a family medicine not an NQF perspective But from a family medicine doctor if I was starting to start getting rates on a couple of these genetic tests that I should be doing I think I would be very quickly looking over my shoulder and saying what other ones of these should I be testing? So that's an opinion Sharon last question Well, just a comment Bob I think it's fascinating that you pick those two because one of them genetics is critical Right, there's no way to know someone has Lynch syndrome really without genetics until otherwise unless they've already had cancer and presumably you're talking about healthy people and For hypercholesterolemia my understanding is the cardiologist still argue whether you need genetic testing at all, right? So it'd be good to think about what you're doing And then how does the importance of the genetics and making the diagnosis fit into that like for what we're doing? Because I'm not quite you're really looking at once you have that diagnosis, right? What happens next not how did the patient get the diagnosis to begin with is that correct? No, and I don't want to also take credit that I'm the one with the measure because this is truly much smarter people than I coming up with this, but I understand the the Topic area the measure concept is really for people with high LDLs that are not responding to treatment that they we would want to see What percentage of people for example? What percentage of those are we actually getting screened? So trying to get down to those who deserve or deserve it or should have it in the screening and seeing how good of a job Are we doing getting to that screening which hopefully then you would link that or the goal would be to link it to an outcome Is does that actually make a difference in their cardiovascular health down the road? But my understanding is it is on the screening side the current concept and I think the other point to make here is that there's going to be much less argument in the cardiology community about this because of the paper by Kehar that came out last year that showed that for individuals to carry one of the FH Variants that they have increased risk of cardiovascular events that is independent of LDL cholesterol level So even if there's a LDL cholesterol level of under 130 if you carry a variant You have twice the cardiovascular risk of an individual that does not carry a variant Whereas if you move up to the high end that risk is approaching four and a half to five times So there seems to be risk that is attributable to having a variant and the assumed Reason for that is that it's a lifelong exposure to elevated cholesterol levels even mildly Elevated cholesterol levels that creates that lifetime risk and if the car will just correct what I said to make sure it's absolutely correct No, I agree with with Mark's point and Sharon the other reason we want to do genetic testing in FH You're right the diagnosis currently in this country can be clinical But the reason to do the genetic testing is it really facilitates cascade screening because you can't do cascade screening Unambiguously unless you do the genetic testing So having that mutation allows you to then go after the family members and ascertain whether or not they have FH That's the other reason and do the cardiologist now buy this Unfortunately, you know the gas cardiologist Sharon come on What's happened in this country, I mean the oncologist do that's the reason I said we've convinced the oncologist They're a little bit far. We were a little farther down the road. We've been the oncologist said it's important I just don't know. I'm not in that area. Yeah, we have a lot of work to do in that area. Unfortunately, okay It is changing. Yeah. Yeah, they are not impenetrable to evidence. So that's that's that's a wonderful things I'm gonna be watching watching mark set upon by cardiologists at the break here, which is where we're at So I'd like to take this opportunity again to thank John for presenting and John is going to be staying around through lunch So if any of you want to Interact with him and ask some additional questions. Let me know we have a 10 minute break and then we go to our first break out Take your stuff because you're going to be resetting the room and do you want to? Refresh where the rooms are okay the rooms are there so thank you