 It's an honor to be up here representing the fantastic team led by Jeff and I that are talking about what we've been doing about diversity in IGNITE. So one of the priorities from IGNITE from the very beginning has been how do we understand and address how to disseminate genomics in diverse practices for diverse patients and in diverse populations. And for many of us we see some of these both providers, practices and patients as having the fewest resources, the greatest challenges, the most disparities in health. And from the beginning we felt that underrepresented populations should benefit equally from genomic discoveries. They shouldn't be the last. In fact, in several of our projects, they should be the first. So IGNITE is a beautiful blend of all sorts of different folks where we have an opportunity to look at, to test and disseminate programs for translation. For me, I'm part of the April 1 study Dr. Kittles was talking about. And what's interesting about that as an example of how important I think IGNITE is, is that it began with Irwin Bodinger who is a nephrologist, genomic, mostly basic scientist who has a biobank, who came to me as a primary care doctor, health equity, community engaged researcher that does population and public health and said we found this genetic variant that looks like it increases kidney failure in people of African ancestry and African American people. What should we do? I don't know public health and I don't know community. I went to someone who runs a network of federally qualified neighborhood health centers, the real safety net in Harlem and the Bronx and said what do you think about this in your setting? And he said finally someone who's not going to put us at the end, they're going to put us in the beginning in translational research. And then we went to a board that we formed of people of African ancestry from Harlem and the South Bronx. And when we came into IGNITE, I who know very little about genetics, Irwin who doesn't know a lot about population health, Neil who doesn't know a lot about research and the community partners who aren't sure about the whole thing, we're all welcomed and the way that we come together in IGNITE I think is where the success really happens. You know that saying if you're not at the table, you're on the menu, we're all at the table. So here's our diverse composition and you'll look at this and you'll see both our diversity and see opportunities for the future to further diversify. You can see of the about 30,000 patients we have to date in IGNITE about half are female, we have a reasonable number of African ancestry black patients, not as many Latino, Asian and not as many children. Our practice settings we have academic, we have urban, we have some rural and we have a good amount of safety net and low income settings. And in terms of our diversity also, we have all sorts of people in the due translational research which is nice because when we come together we can suggest to each other, somebody who knows how to do clinical trials, somebody who knows how to do digital health, someone who knows how to do qualitative research and so on. In terms of our providers at the top right, we have a reasonable diversity of providers to date. We have a little more than half female and we have some with African ancestry and Latino ancestry moment providers and you can see on the box we have lots of different kinds of providers in the IGNITE network, all different kinds of health professionals. And our geographic diversity is not great but it's pretty good. You can see there might be a swap in the middle that we could work on a little bit in the future. So what's the good news? What have we learned together? You know, this idea that, you know, there is race and there is ancestry. So like Erwin Bodinger would be looking at, ancestry is a biological construct. I came into this looking at race as a social construct and we didn't know what our community would say. And I think a lot of folks in IGNITE weren't sure what people are going to say. And across IGNITE what we're finding is that our diverse patients tend to have a high interest in race, in ancestry, in genomics and in taking part in this research. In fact, we've had times that the outsiders have been more worried than the insiders. We found lower concern about genetic discrimination about what would happen if people had a genetic variant than people thought we would find. We know because we asked. We have very diverse clinicians. And what we found is that a lot of them, like me when I started, didn't know a lot about genomics, but they were willing to incorporate testing and return of results into patient care if it made sense. Not true of all of them, but true of a lot of them. They said, well, show me how this is going to help my patients. I've got 15 minutes. Should this be on the menu for that 15 minutes? And we have these diverse stakeholders, from payers to advocates to patients, all sorts of folks, who seem to be really interested in getting involved. Not just as participants. Our patients are not saying, thank you for the 40 bucks. I'd like to be in your study, and good luck with your paper. They're saying, I want to be at the table. So here's some of the challenges we found as we're growing as a network together. And here are some of the ways that we've responded. First of all, implementation challenges. We had to first figure out what our challenges were. We came into this and said, well, where are we going to get stuck? We didn't really know. That's what we were funded to do is figure out what happens when the rubber hits the road. So we did some things. We did mixed method research. We did qualitative and quantitative. So we could do some hypothesis generating and testing. We had the C for implementation framework, which we stretched beyond its traditional boundaries to look at what was going on when we tried to disseminate. Another challenge that we had is recruiting diverse patients. So this can be hard in many ways. How do you find patients? How do you introduce this to patients? How do you engage patients? We've had pretty good luck. And we've learned quite a few things. So Triviano, I have time to talk about today. Partly it's because we've been actively involving both patients and clinicians, like through boards, through meetings. Each one of us in Ignite has a way to go to the end users. The clinicians and the patients and say, am I doing this right? What should we do? And every all of us have this philosophy of let's test this before it goes out there. Let's make sure we're doing this right. And we're really working hard to not only develop innovative things, but evaluate things. So we can go out to people and say, this worked. This is better than this. The next thing that I alluded to a little bit already is that our clinicians had limited knowledge in two ways. One is limited in terms of genomics. Another is limited in terms of research. So those of us who are going further and further out into places that are not academic health centers will have researchers say, we'll have clinicians say to us, well, I'm happy to involve my patient in the study, but can you guarantee them they're going to have benefit from it? We say, well, no, that's not what research is. There's no guarantee of benefit in research. And then they go back again and say, is this worth my time out of my 15 minute agenda? So we've worked really hard with the clinicians to understand what they want, what they need. And each of the Ignite sites has had different ways of going out into clinical communities, where there's through larger kind of CME trainings, to short, you're having a clinician meeting, let me have five minutes in your agenda to putting things on electronic health records that are little prompts with educational information. We're getting lots of experience in how to bring clinicians into this. The next issue is practices. How do we implement them practices? A lot of what we're doing is looking at electronic health record integration. And we have several very interesting strategies to do this. And again, we're really looking at current practice environments. We're surveying the different practices. We're trying to see what people need. And finally, our challenge is we don't have, as the other folks have said, enough comparative effectiveness research to see how things vary across geographies, across practice types, across clinician types. So we decided as a group early on is let's figure out what shared elements we can collect across our networks so we can start looking at how things vary. So we've been discussing a lot where we think some of the future could lie. And here are a few things that we wanted to share with you. First of all, we think that somewhere we feel fairly strongly that there should be somewhere that there's a genomic medicine diversity resource center. And that we need to have put together activities, experiences, and expertise, a place for tools for diverse patient and clinical populations and practice environments. And that we really need a formalized translation service so that different kinds of folks can know how to use it. What kind of surveys do we want? What are the EHR platforms that are working? Let's see some good educational materials, load literacy, multi-level tools. We feel very strongly that we could help inform a resource center. So people in Ignite, in NHGRI, and beyond can utilize it. The other thing is I am only doing genomics right now because Erwin Bodinger knew I did disparities and he tapped me on the shoulder. For those of you who know people like me who are general internists, we don't learn anything about this really in medical school. And I knew embarrassingly little about it when I started in this. We are underrepresented in genomics research. So health services researcher are underrepresented. Disparities minority health services researchers are underrepresented. In addition, when I look around this room, I'm not seeing the diversity in researchers that we're researching. So we really need a diversity of populations. Where are the underrepresented? The researchers are underrepresented in medicine and in research. Where are they at our tables? So not only do we need to do the wide net, so we're looking at genomics researchers and bringing them to translation and non-genomics researchers and bringing them to genomics. But also, fellows and junior faculty, particularly from diverse backgrounds, should be joining us. And we feel really strongly about this. We also want to look at specifically how to enhance research for diverse populations. What can we do? What kind of tools can we use? What are the best educational tools for the providers, for patients, tailored to their genomic literacy? We all have different levels of genomic literacy. How do we hit people where they live? What topics do we want to do? You already heard a little bit about that before, and I want to thank the two gentlemen who went before me for really great talks. This idea of the genetic-epigenetic connections. In our project, for example, we're really looking at social-environmental, cultural interactions, and we're looking at the multiple determinants of health, genetic, social, behavioral, clinical, biological. How can we put these together? Looking at cultural competence, looking at things like literacy and numeracy, which are going to come out as we diversify how we engage people in genomics. And what kind of methods and instruments can we use to study diversity? Geomapping is something that some of us are using. Personal mutility. I talked a little bit about using quantitative, qualitative. What are the kind of ways we can make this research better? The next opportunity we have is looking at implementation science. How do we figure out, identify and build the best ways to engage and inform all these diverse stakeholders? And we're working on that, but it needs more work. And again, continuing, pushing forward this comparative effectiveness research, we've begun as an ignite network. So as you can see from the slide earlier with some of the tables, ignite is a great network, but we think if there's a future, it might be great to expand it even further. We think it might be nice to have stakeholders with a focus on diverse populations, patients, clinicians, payers, advocates, industry, not just back home, but also as co-investigators, as co-authors, as co-presenters. Let's welcome them more strongly into the network. The practices, we don't have a lot of small groups. We might wanna look at whether or not people have electronic health records and look at more electronic health records, more rural practices, other types of health professionals. Other patient populations are not adequately represented. Someone already mentioned Native Americans. We all South Asians, linguistic diversity. Pediatrics could be more representative. And we think that engaging the affiliates that are starting to really be excited to join us will be one great way to diversify. And finally, we wanna think about targeting genomic medicine opportunities in diverse populations. So where are the sweet spots where you can actually find somewhere where there's a population-specific disease like what we're seeing for April 1 in blacks with hypertension? And with that, I thank you all.