 Great. All right. I think I'm going to kind of walk through a report for you after I turn this on. You may remember that we established a working group of our council about two years ago or so to address genomic medicine and the efforts that we were undertaking to kind of move that forward. And we give a report to you every year, and so September is the time that we do that, so that's what this report is about. Just to take some of you who may not be aware, certainly everybody's aware of the strategic plan if you've come in this room more than once, but in terms of how the Genomic Medicine Working Group came about, it came from the strategic plan. We recognized that there were things that the institute had not been doing in the past in terms of disease and genomics, and these were the kinds of things that we wanted to do in that. And so these were kind of the goals that are outlined in the strategic plan for the genomic applications in medicine, and then there are some specifics here and some initial steps that all of which were in the plan. You may remember about a year ago we brought to you a definition of genomic medicine, and this was primarily an emerging medical discipline involving genomic information about an individual as part of their medical care, and it was a purposely narrow definition and we explained why that was. So that's kind of what we're calling genomic medicine. I heard earlier this morning that there was a little bit of confusion as to the various domains in our strategic plan, particularly the fifth one, which is improving the effectiveness of health care. I have to admit that's probably not the best name for it. I think initially we had talked about using it in clinical care or using genomics in clinical care, and it kind of morphed into this as will often happen in committees. And these are the kinds of things that are in the plan that are described for that. So I was supposed to, they told me to put it on the right so that when I turn, so I will do this, and then I know that you'll hear me. So hopefully that's a little bit better. So what's in the plan is things such as delivering genomic information to clinicians and patients. So that's not educational material. That's that patient's information for use in their clinical care, and that's probably the main aspect that makes something into domain five, demonstrating effectiveness. So if you do that, do outcomes differ, and if it's effective, our outcomes better. Educating health care professionals, patients, and the public. There is a part of the strategic plan that's specifically dedicated to education and training, and that's become a cross-cutting area. But this was an area as well in this domain. And increasing access to genomic medicine, there's a lot of concern that this will only be available to the elite or those who are near a particular medical center, et cetera. So might there be ways to increase the role of non-geneticist health care providers, which is something that we're working very actively in, perhaps using telemedicine or enhancing genomic education for future health care providers. We established this group in about September of 2011, and their initial goal were to help us to plan what we were calling, sort of listening sessions or consultations with the community that was doing this kind of work. At the time, we thought that community was small, and we wanted to help it become bigger. And so the idea was to have meetings two to three times per year in this area and also to provide guidance to us in other areas of implementation, such as what are the infrastructural needs, how can we identify related efforts for future collaborations, and can we review progress and next steps. So this is the current makeup of the genomic medicine group. We've been in existence for about two years. We haven't had people rotate off, but we probably do need to do that at some point. You'll notice several former council members on this list. And Howard Jacob is our current council member representative. How we began this effort with a colloquium in June 2011, a meeting in Chicago that I've described to this group before. I was basically an outreach to many groups that we happened to be aware of. We're using or beginning to use genomic information in clinical care. Not the cancer aspect, since we knew that a lot of places were doing that, but some of the more complex diseases and other things. And we asked them to help us kind of define the landscape and to develop an implementation roadmap that other groups who were thinking of getting into this area might be able to follow and then identify common infrastructure and research needs. Out of this, we were very grateful to have the group actively participate in coming up with a summary that was published recently in Genomics and Medicine. And that was a very useful exercise to go through. From that came a number of things that we recognized we really need to do. And the first thing was that we found that each one of these groups were getting genomic results back and were saying, my goodness, what is it we should report to patients and clinicians? What shouldn't we? And they all had committees that basically were sitting down and trying to figure this out. And we said, well, gee, seems like many of us are coming to the same conclusions. But we do this in a more systematic way and make it more effective. So that led to what we called the Clin Action Workshop led by Aaron Ramos just a few months after the June meeting, in fact. And the idea of that was to consider processes and resources to identify clinically relevant variants and decide whether they're actionable and what the action should be. And from this, there were several discussions in council about initiatives in this area that we did go forward with the clinical relevant variants resource that was discussed in council in May. And it's just about to be awarded once the paperwork can be done. We followed that actually two days later with a general, more general genomic medicine meeting, the second meeting, which was really designed to identify potential collaborations among the various academic sites that were doing these things. And also we brought a few institutional leaders in and said, okay, in the places where this has been effectively implemented, what was it that was convincing to you and how might we help others to make those cases? So that was a useful one and followed about six months later in Chicago to look at the initial groups that we had brought together to try to develop some collaborative projects, as well as we brought together payers and other stakeholders and got their input. Because one of the things that you wouldn't be surprised institutional leaders said is that a major barrier is that a lot of this isn't reimbursed. There are good reasons for it not being reimbursed. But we wanted to talk to the reimbursers and find out what would it take in order to get it to be reimbursed. That was followed then by a payers meeting which was held in October and was specifically to identify the potential for collaborative research and possibly even joint funding. This is one that has taken a bit of a back burner to a number of other issues that are facing reimburses at present, not the least of which is the Affordable Care Act. And we hope to be able to pursue it again before too long. So these were the meetings that had either been held or that you all we kind of gave you heads up about at the last time that we updated you. It was one of my favorite Larson meeting slides, the Association of Prevericators yesterday. I was told the meeting was today. So luckily we didn't have too many of those happen. And as we were holding meetings and listening and considering, we also were developing programs. And so there's a number of funding opportunities that were released just within the past year, including the Genomic Medicine Pilot Demonstration Products, both the sites and the Coordinating Center, the reissue of the Clinical Sequencing Exploratory Research Coordinating Center and Clinical Sites, the Clinically Relevant Variance Resource, the CRBR, the Genome Sequencing and Newborn Screening Disorders that were just announced as you saw in Eric's slide, and the Coordinating Center for the Undiagnosed Diseases Network, which has become a common fund program to expand the intramural undiagnosed diseases program into a network. And in fact, this one has had four solicitations for Coordinating Center and Clinical Sites, Sequencing Core and Gene Function Studies, all within the space of a few months. And so the folks working on this, particularly Anastasia Wise, Carson Loomis, Nick DiGiacomo are doing a fabulous job on getting these things out. In addition to formal RFAs, we also were able to supplement some programs to kind of jumpstart new projects, in particular the collaboration that we're very pleased with with the NI-GMS-led Pharmacogenomics Research Network and the Emerge Network where the PGRN brings us a state-of-the-art pharmacogenomics array and a variety of other expertise, and we bring to them more sort of real-world settings for doing pharmacogenomics as well as expertise in electronic phenotyping and privacy concerns. And you heard about that, I think, February or May or so. And those are in progress. So those are the programs, getting back to meetings then that began now since we had reported to you in January of 2013. January of this year we met in Dallas for our fourth meeting, and this one was focused particularly on educating physicians in genomic medicine. This was organized by Mark Williams at Geisinger and Jean Passimani, a colleague here at NHGRI, and they did a wonderful job in recruiting eight professional societies as shown there, as well as two accreditation councils, actually the major accreditation councils for physician education, both at the resident level and at the medical school level, and then once people are finished with residency and out in practice. There were very active discussions. Everybody sort of showed what materials they had, what challenges they're facing, et cetera, and a number of areas of consensus. One was that you're scaring physicians away by presenting this as a revolution. It really is an evolution. Think of it as a lab test, and of course that breaks our heart. What do you mean, just a lab test? But actually, for most physicians, that is indeed what it is, particularly when you're only looking at one or two variants that are clinically applicable at present. We were advised to find ways to, or they all agreed that we should find ways to embed genomics education at the point of care where possible with clinical decision support technologies, and you heard a little bit about that earlier. Sharing genomics education materials produced by many societies amongst those societies. Now there obviously are some barriers to that and that costs them a lot to put those materials together, and so what kind of a licensing or, you know, it's possible to get a discount when those are conversations we're having. Utilizing other kinds of educational resources, or their checklists, or their ethical guidelines, case studies, et cetera. A strong consensus that if this is going to sort of make it with clinicians, it needs to be in their certification and licensing exams because there's already so much that's in those exams that they don't have time to really look at much of anything that isn't in those. So obviously we wouldn't want to put things into exams that are not efficacious and important and applicable and so working with the boards that develop these exams to figure out what should be there is another issue. And allowing some specialty tailor training rather than general programs in genetics. So there were a lot of interest among oncologists, you know, isn't there a way to become an oncology genomicist, or oncologic genomicist, or could you be a genomic cardiologist, or something along those lines where they wouldn't have to learn as much as is needed in many of the pediatric developmental syndromes and things that really aren't relevant to many medical specialties, but they still could get some kind of added certification. There was also a strong feeling that we should develop a coordinating committee among these societies, which we've hence dubbed the Inner Society Coordinating Committee for Practitioner Education in Genomics. And that group is really focusing first on physicians, not necessarily primarily on physicians, but because physicians, as Eric said this morning, have tended to lag behind other ancillary medical personnel. We felt that that was a group that we really needed to focus on and much of what they might do as well as much of what is being done in other ancillary personnel, such as nurse practitioners, et cetera, physician's assistance would be relevant to each other. So sharing would be very important. And so the charge to this group is to facilitate interactions among the societies to enhance their efforts at increasing the understanding and expertise of practitioners in using genomic results of clinical care. This is just sort of the structure and how we plan to go about doing this. And we've kind of laid out about a dozen desiderata that we would like at some point to be able to do. We picked four of those to start with, and that's, again, taking a bit of a page from Niche Peg's book, Can We Identify Competencies for Physicians? You know, a physician needs to be able to read a genome sequence. Well, probably not. But they probably do need to be able to interpret a candidate gene test or to know what tests to order or things like that. So develop those competencies, educational products, what's out there, what could be made available rapidly, what's the best way to make that available, what needs to be developed, engaging specialty boards to determine which ones are really ready to incorporate this, what would be ready, what would help to make some of the others ready if that's appropriate. And also developing use cases to kind of reach out to those who may feel that this isn't relevant to them to point out, oh, you know, when a patient comes in with colorectal cancer, particularly in early age, but not necessarily, there are important considerations for Lynch syndrome and family history and testing that you should be aware of. Oh, well, I wasn't aware of that. And these are some metrics of success that we improve communications among the societies. We identify best practices, we generate competencies, we get good estimates of physician use that are increasing and that there are increasing interactions among other relevant efforts. So Eric, I think, showed you this list in text form. In blue, what are added are those that have joined us and almost all of these have approached us and said, we understand you're having this group, we'd really like to be part of it, which is fantastic. That's exactly what we were hoping for. And then these are the various institutes that are also actively participating with us when we meet by conference call. Once a month, and as Eric mentioned, we had a webinar meeting back in June because we couldn't clear the approval some time in order to have an in-person meeting, although up until two weeks before, we kept hoping. But we'll now be having a meeting after two weeks or so to do some of this work face-to-face. Another favorite Larson cartoon, Innocent Care Free Stewards, Left Hand Didn't Know What the Right Was Doing, and you see here a memo, Tonight I Strike Death to the Left Hand, Death, Death. One of the things that you find in the government is that often you have left-hand, right-hand disease and we certainly are accused of having that. And so what we thought we would do next is to try to engage some of the other federal agencies that might be or perhaps should be participating in this area, particularly in terms of implementation because NIH is a research arm. Obviously research then leads into dissemination and implementation, but where does that become the role of other groups and where can other groups kind of help out with that? And so what we wanted to do was to engage the various agencies to discuss potential strategies for genomic medicine implementation, find out what they're currently doing, what obstacles they're in running into, identify some common interests and opportunities that we could collaborate. And this is basically the model that we've had for these meetings throughout when we started with the academic centers. We thought we would include groups who were doing direct medical care in the federal government. There's a fairly large care provider in the Veterans Administration and perhaps even larger care provider in the military medical system. We actually got all four of the military medical services and the Marines get their care through the Navy. And we also included the NIH. We like to think that we provide a little bit of medical care in our clinical center, even though that's tertiary care in general. We also included groups that are working on reimbursement in regulatory efforts such as CMS, the Food and Drug Administration, AHRQ, Blue Cross Blue Shield is not a federal agency. I wasn't confused there, but they were very interested in attending and participating and they were quite active. And then there are other groups that are supportive or facilitative such as the CDC, PCORI, Patient Centers Outcomes Research Institute was there, two of the Assistant Secretary's staff and the Institute of Medicine Genomics Roundtable. So we spent two days really discussing kind of what are the opportunities and ways in which we could work together. One thing that we did was to kind of extract major issues that actually have been identified by other countries. So they're in the UK and in Italy and I believe there may be another one I'm blocking on which there are already sort of published strategies for how one can implement genomics in medical care. These are some major components of them and these were things that were identified in our meetings and we just asked the various agencies which of these are key for you and we included our list there so you can see AHRQ up at the top left. And for us all of these were important issues as for the VA and then there were some that were really quite highly relevant to just about everybody. So equitable access is one of those sort of motherhood and apple pie that everybody agreed we want to be sure there's equitable access but it's not kind of something that you can just make happen you have to do these other things and then hopefully it will be helped to come along. But evidence of clinical validity and utility was pretty much far and away the big issue in this field and how do we generate that kind of evidence and it's not there now and we really do need that. So given that that was a concern we talked about are there potential projects and evidence development that we could work on together. The military medical services were actually very very enthusiastic about this and the VA as well the VA as you know has a number of programs already ongoing how they might be able to collaborate with us and with the DOD is a topic for discussion later this month where we can look at potential projects to find some obstacles eventually but first we wanted to kind of discuss is this even possible engage scientific and clinical contact experts in project design and we may be calling on some of you if this goes forward and explore the potential for funding because this probably wouldn't be a simple thing to get funded. We also have discussed with the NIH leadership and we'll be talking with what we should be doing NIH-wide because as we've discussed very often as soon as you get a little bit down the road in terms of implementation you get very disease-specific and so those are things that we would want to work closely with the disease-specific institutes or have them take the lead in and we can play a supportive role. So again we'll be talking about current efforts looking at challenges and common needs. This is the kind of list of components that are identified from the various international efforts and you can see them listed up there. Canada was the other one I'm sorry that I had forgotten as well as some more central U.S. bodies such as the IOM and the AMA and again looking at those that seem to be commonly of interest bioinformatics infrastructure was one that was cited repeatedly by these groups not so much by the federal agencies and the health economics, cost-effectiveness utility and utility we saw as sort of being the same thing and again being this issue of utility. So that was the fifth meeting and then recognizing that there are international efforts in this area and that we're trying to do something along these lines in the U.S. we thought it would make sense to bring together some of the international groups that are doing this work and so that's planned for January here in Bethesda to again engage what they're doing, find out what they're doing to be able to collaborate. So far the invitations for this have just recently gone out but we have multiple continents and about 15 representatives from about a dozen countries so far who are interested in coming and we're not in a position really to be able to pay much in the way of travel internationally and so a lot of these folks are coming on their own dime and are actually willing to bring a couple of people from health ministries from the universities from their funding agencies so this should be a fun fun experience. So just to kind of summarize what we've done, this again is about this three year process here and looking at meetings, this is kind of the lead up I should mention the DOGM, the disease oriented Genomic Medicine Working Group which was one of three working groups that was established after we put the strategic plan together and Rick Wilson was a member of that and I wanted to cite you Rick to see you again and we can't thank you again for having done that work. The consortium meeting the first meeting was held in June and then in about September we had the GMWG formed and then lots and lots of meetings that are actually sort of increasing in pace it seems at least to the point where we've need to back off a little bit because it's just too much for us to be able to handle and it's also one of the reasons we've reached out to NIH as a whole and said just a little institute we're doing our best but really some of these things are things that we feel should be taken on for NIH as a whole. So here's where we are today and we have two meetings coming up in a couple of weeks and then the January meeting in 2014 and who knows what to follow and then looking at the programs that have been initiated these are the release of the various RFAs that I pointed out to you as well as the awards many of which you've seen and some of which you'll be seeing in the discussion today. So just a final list of the programs that we have in genomic medicine is just a sampling of them to give you an idea of the magnitude showing the amount of dollars and the fiscal years that are covered in the small print at the bottom you can see that the seven year average for NHGRI is about 23 million a year invested in this area it's going up slightly not a great deal the percentage of the budget is just 7% depending on which denominator you pick and project out into the future and whether you include Elsie Set-Aside funds some of which have been dedicated to this I think that's it except I'd like to point out that all of the efforts in bringing forward these RFAs, getting them funded and awarded, etc. are the work of many, many people and particularly thank the review branch and grants management genomic medicine investigators and those who come to these meetings and pay their own weight and actively participate and of course the genomic medicine working group so I'll stop there and be happy to take questions Terry can you go back one slide I just want to go back to that I just want to clarify a couple of things the slide that showed all the initiatives just to be clear UDN being in parentheses it's because it's not our dollars so we get partial credit for it but it's not coming out of NHGRI dollars it's being equally matched by child health I don't know if there's any other I should have explained that there's some co-funding in CSER I believe that's the only other one CRVR there was a discussion but I don't think it ever came to pass and then Emerge PGX brokers dollars with GMS we're not totally on our own in pharmacogenomics area we're using their tools but they're not contributing funding alright and while I have the microphone I guess the other thing that you started to point out that we realize that this growth area is consuming us in some way I mean we don't even have staffing to follow up on all these things we're dealing with national leaders federal leaders, international leaders we really feel we're setting the table and now all of a sudden realize we've put a feast in front of us that's even too big for us we've reached out to NIH leadership because so much of what we're doing is on behalf of NIH I mean every institute is interested in all these things and I think they love it that we're leading but it's also we just can't keep doing this so we've had meetings with Francis Collins and other NIH leadership including Kathy Hudson and they realize that we've been an incredibly valuable reconnaissance team but we can't carry the water on this forever because it's bigger than us and in fact we're getting to we're getting two hours at an upcoming next month retreat of institute directors we do a big scientific retreat once a year or so and we get two hours Terry is collecting information from other institutes what they're doing in this space and we're going to have strategic discussion we're doing this jointly with a couple other institutes in this two hour discussion and I don't know what will come out of it but one thing that we hopefully will come out of a recognition that we're really going to on behalf of NIH we need more muscle from other institutes I'm not even just talking about dollars I'm even just talking about staff time and help with just carrying all these things forward it's getting bigger than us so I just want to point that out so and building NIH leaders it's receptive I mean the fact that we got on the agenda got two hours shows that they are very interested in appreciation of about this so thank you this was great I have a couple questions related to the amassing of data that could be mined both for the genetic and just in general for health outcomes research so I'm thinking particular B Cori Pippa Cori and and the projects that you talked about bringing together the sort of federal agencies is there a sort of task force that's working or these just conversations that are starting is that you know is that something that I mean because that to me sounds really exciting you know if we think about again you know where the U.S. tends to not have the advantage right I mean the U.K. has a centralized biobank and that that dot but you know if we could bring in together some of the federal that that seems really exciting well it does and we learn actually one of the things that made this even more exciting was that the defense the military medical services are all conglomerating in a few months as I understand it into the defense health something agency I think DHA and they are eager and already at working closely together so so that's you know basically for big medical practices well one that's kind of small Coast Guard but the but the other three are quite large that have huge numbers of people because remember they you know once somebody's been in the military after 20 years they get their medical care for life as do their their dependent spouses and children up to a certain age so so that's a you know really large swath of the of the population and so we were thinking this might be a way to kind of galvanize and energize the the other agencies to kind of come in with us if they see that this is something we can pull off I you know recognizing that there are huge issues in terms of sharing and plus there are security concerns and privacy issues and remember that that the military is not covered by Gina so so there are there are major obstacles to this but we thought let's give it a try let's see what we can come up with and kind of go from there thank you Terry that was really interesting I have a question that might be too specific but if you have come across this so in terms of the collaboration with DoD a lot of the research that DoD some of the research that DoD has been interested in in genomics has the potential and and I think on their part even a stated interest of going far beyond what more medically oriented service or agencies would do in terms of pushing these things to enhancement and pushing these things to be able to use the knowledge that they gain to select people for certain kinds of jobs and so they just have a very potentially I mean some of it is very similar to what everybody else is interested in in terms of medicine but they have a whole other sphere of their of their motivation for this and I'm just curious if that's come up or if people have thought about that some degree more in terms of this issue and more I think in terms of you know is this really that big a readiness issue for them there are many other things that they need to be concerned about sleep and obesity and lots of other things like PTSD and substance abuse etc I think where this is coming from is mainly their practitioners who are facing this either their patients are coming to them or detail people are coming to them and saying you really should be doing this test plus they're watching their costs really so how we can fit this into their agenda I think is a challenge I'm not sure it's our challenge as much as to help them you know as Eric sort of said set the table for them show them what's what's possible and if they can make that work within their system great if we can provide expertise to help them to do that we're happy to do that they recognize that research is not their their strength the VA is quite different in that regard but in terms of you know the active military services and this is just something we're talking about but they are extremely interested which we're just delighted to see Terry I had a question for you about the Inter-Society Coordinating Committee for Practitioner Education and Genetics where is that material being organized where is it accessible at present it's probably not as accessible as we would like it to be or it may not be accessible at all we're still in the organizational phases of this where we would like to see it go is in the resources G2 and Laura is going to come to the microphone and tell me the G2C2 and the G3C and I can never know what the two of them are so Laura maybe you could comment on that a bit you know at the I was going to say at the intramural branch chief meetings we used to have this rule that everyone sitting at the table could have a little yellow card which you could raise when the alphabet soup just got too much for anyone to even understand so I'm raising my yellow card right now is that on now? so we have a couple different ways we are reorganizing our health existing health education pages so that when you go to health professionals you can find your favorite discipline and then below that when you go to physicians or you go to nurses all of the information will be organized for you that will be the broadest net in addition we have G2C2 which is genetics competencies and I can't even remember exactly what the this particular moment in time but that is a place where again as Eric mentioned earlier in his director's report we have four disciplines that have now come together to put together collaboratively across their field through their professional societies competencies for education continuing and in training and then educational resources that are reviewed through an editorial board process that map to those competencies and that's there now for nurses physicians assistants pharmacists are coming and genetic counselors are also already there we're hoping that through the ISCC work we'll get physicians into that portal as well and then G3C is an interactive case studies resource where we have videoed case studies where you can walk through different choices with a scripted health professional in a setting for different specific issues right now we're filming six around different pharmacogenomic examples and Howard's going to help with some of those later this week I think so we're building that again through the ISCC we're hoping to work with the groups to bring the case studies that are developed from the use cases working group into that resource so I think and then we will cross link everything so you can find it no matter which door you come through but because these two other resources have been developed and again particularly with GTTC where there's some professional standards around the vetting for the professional societies to come together that will be perhaps some more refined materials whereas on our genome.gov section we can put up lots of links to different agency resources to talks on genome TV to a lot of different materials that won't have the same standard but where it might be useful for people to have and again it'll still be organized by discipline if that helps so the G2 I'm sorry the G2C2 is now available on genome.gov okay okay turn it back on okay so there Laura was saying there are three sets of competencies there currently that have been vetted nurse practitioners physician assistants and who is the other thank you we're also exploring with a consulting group basically that you know how we might be able to make this a self-sustaining effort so are there groups out there that would be willing to co-fund it might we get the societies to help to fund it those kinds of efforts one more thing Terry this talk is really interesting it just strikes me that you're playing a really critical role as being a convener and getting people to sort of join together but there isn't really a structure where this stuff is actually going on and I'm racking my brains trying to think where could such a structure live and like I'm having trouble thinking of anything Bob it is exactly losing sleep over I mean it's exactly why when Laura and Terry and I went to see Francis and the other deputy director it was sort of like this just doesn't feel right I mean it's we're being too successful in some ways and people are expecting so much of us and it's sort of like they think we're going to totally solve this with inadequate staffing and certainly inadequate resources and you feel like it's all very exciting you get these folks these all extremely energetic and you just feel like something needs to partner with us and sort of start carrying this load and I don't know what the answer is it's one of the questions I'm sure we will bring to the institute directors when we have our two hours with them but it's exactly what you were saying which was making me very uncomfortable which is why I said to Laura and Terry we've got to get a meeting and figure out because they were looking to us as if we were speaking not only on behalf of NIH people are looking at us like we're speaking on behalf of the federal government and it's I just feel like we really can't do that not just that you're speaking on behalf of the entire genomic medicine educational effort in the country exactly exactly so if you have any ideas I think you hit spot on what I was feeling comfortable it's as if we need a structure to partner with us and of all that list that I looked at it's from a practical point of view I don't know how sense it makes from a conceptual point of view I think ACGME I mean they should they and the CME group really should be elements of it I think you're going to carve out elements but I'm talking about the whole maybe it has to be broken down but Laura you want to comment? I just wanted to redeem myself with the acronyms G2C2 is genetics genomics competency center so the twos just refer to the number of letters before it and G3C is the global genetics and genomics community so and I'll send I'll send the links out so we can let everybody know what they are and Terry and Lord you want to make any other comment I mean I just went off on what Bob says I agreed with it completely but I don't know if you want to add to that yeah well I think we've we found AC actually the ACCME group even more enthusiastic than then so the continued medical education for practicing clinicians because remember that you're only in in medical school most of us for four years and then and then you have a lifetime of practice and and so so that group seems to be you know quite eager to do this recognizing that getting CME credits for materials has been a major barrier for genomics groups to you know to try to traverse and many groups have just sort of given up and said well you know we'll come back to you so they've heard that and they're trying to you know lower the barriers for that but that's a good idea Lawrence? No I wouldn't add to that I would just say that some of these groups are very eager and I think we're at that tipping point where we now have some the right amount of material to go forward specifically whereas before we were talking in theory and that made it very hard to to get the momentum to move forward in specific ways so I think we're about to overcome that it's a little bit for good or ill yeah exactly alright thank you Terry next we're going to hear from Vence Bonham Vence's senior advisor to NHGRI director on genomics and health disparities he's had a direct involvement for I guess almost two years now in the development of the genome exhibit at the museum and he's going to give us an update on some museum activities