 There we go. Thank you. So thank you, everybody, for coming. And as Teri said, we're really going to be focusing on implementation of pharmacogenomics. There's been quite a bit of hype that pharmacogenomics should be ripe for clinical implementation and changing the way that we practice medicine that's been in the public and popular media since the Human Genome Project was announced its completion. And some of that hype is continued forth in the scientific literature as well. But the scientific literature also contains many examples of skepticism, that there isn't enough evidence for implementation of pharmacogenomics routinely in medicine. So I think what we hope to do today is to explore where the reality is between that hype and that skepticism. It's been known for many years, in some cases over half a century, that there's very strong associations between genetic variation and variability in the population and effects of drugs, but it is still true that the vast majority of cases pharmacogenomic testing is not used routinely for patient care. Our objectives today are to survey the national landscape of research programs in pharmacogenomics implementation to review current advances and clinical applications of implementation, to discuss limitations and obstacles in implementation, to identify gaps and studies that could address them and to potentially design strategies for large-scale evaluation of implementation in the U.S. And tomorrow afternoon it will be Terry and my job to try to summarize what we've talked about over this next one and a half days. One of the things we did to prepare for this meeting was to send out a survey about implementation and we sent it to people that were involved in clinical implementation. We had a pretty good response rate of about 50 percent, 64 percent were at university or academic sites. Interestingly about half of the testing was reactive based on patient presentation and about half was preemptive, more or less regardless of presentation. There were lots of different genotyping platforms and 63 percent of these sites are or will be filing for third party pay or reimbursement. And more detailed results of this survey are present in the packets that you received hard copies and electronic copies of. We've asked people what external resources they use and almost all 34 out of the 36 sites use CPIC as part of their clinical implementation and the vast majority also use FarmGKB and you can see some other resources that are used by these individual sites including interestingly our own website at St. Jude which even I don't use for clinical implementation. So people are hungry for resources I think. Another thing that was interesting is that to me to see the gene drug pairs that are being implemented most frequently and you can see that CYP2C19 and clopidogrel, SLCO1B1 and Symbostatin, Warfarin, TPMT, thiopurines and also interestingly CYP2D6 and codeine given 10 days ago the FDA released a contraindication for the use of codeine in children under 12 with no mention essentially of using pharmacogenomics to overcome that problem. And some other anti-cancer drugs UGT1A1 so I do think this is an interesting list of those that are being implemented most commonly and then also interesting to see those that are being implemented more rarely again these are in your packets. We ask people about the challenges and obstacles that they were facing in their implementation programs and if you look at your packet I think there's a lot of very interesting detailed comments that people provided but I summarize them as lack of funding or test reimbursement, lack of institutional support which probably is very tied in with lack of funding, challenges with either IT with the EMR system or clinical decision support which you'll see as CDS, issues with laboratory and genotyping technology, lack of education of clinical staff and of patients and lack of clinician buy-in to the idea of doing implementation of pharmacogenomics and what we hope is again over the next one and a half days I believe all of these issues are going to be considered in a bit more detail and we welcome audience participation in discussing what challenges we're facing and of course very usefully any strategies to overcome those challenges. Another thing I thought I would mention just briefly is and my definitions might not agree with yours but I think it would be useful to sort of try to get on the same page of what do we mean by research versus implementation. So I would say that pharmacogenetic research could encompass testing whether genomic variants are related to phenotypic variation in drug activity or pharmacokinetics and here I've made the distinction of essentially laboratory pharmacogenetic research. There's clinical pharmacogenetic research which does the same thing in phenotypic variability in drug response in patients or occasionally in volunteers and then there is probably the sweet spot that is applying most to this meeting which is clinical pharmacogenetic implementation research and here this could range from very big questions like in a randomized study of testing for genetic variation versus not testing for genetic variation is there a difference in outcome to other types of research such as process related studies on what works best for optimizing EHR use for getting good third party payer reimbursement which test types work best what makes clinicians perform best and adhere to recommendations best what's cost effective versus not etc and I think we'll hopefully talk about what research is going on in this area and what research we think needs to happen in the future and then to finally acknowledge that what we're all working towards or some of us are working towards is just clinical implementation of pharmacogenomics not that there's a need for research anymore but as for any laboratory test that we use in the clinic to try to improve patient care we want to implement pharmacogenetic testing so that it's more readily available for patient care and I think what we're all struggling with is the incredible amount of resources that it's currently taking to do clinical implementation of pharmacogenomics because of its complexity because it's new because we don't have everything that we need to make this easy and so how to fund clinical implementation has been a challenge for all of us. I'll talk in a few minutes about how to go this process of going from the raw genotypes from VCF files or from genotyping technology to actually coming up with what is the phenotype of the patient and what is the prescribing recommendation based on that genetic test result is a pretty complicated process that requires a lot of resources and I think that's what we're partly struggling with. This is a screenshot of my pharmacogenomics coordinator at St. Jude's Excel file. Every column is a new gene drug pair that she's implementing in every row or all of the steps that she needs to go through before we make a new gene test go live in our EHR and so it's it's been a very labor intensive effort and I'm sure that that's true for many of the others in the room. So I'll just remind us again of what our objectives are and then let's move on to the next speaker. Terry. Thank you, Mary. Any any questions or comments for Mary? Great. Thank you very much. And I might just note that we because we are webcasting this you can access the webcast if you have if you're a high myope like myself and have a little trouble reading some of the slides. So so unfortunately Howard Jacob doesn't seem to be here so I'll step in and take his moderator role until he arrives. We're trying something a little bit different with with this meeting. At previous meetings we were urged to include patient voices in our presentations and deliberations because they are so important in helping us understand and remember why we do what we do. So I learned of Mr. Anderson and the tragedy of the loss of his daughter about a year and a half ago after we held a meeting that arose out of one of these meetings on Stevens-Johnson syndrome toxic epidermal necrolysis and he contacted me about the potential for contributing to research in this area and and he'll tell you that story. But in in addition having him here today I think will really help us to focus on the discussions we'll have over the next two days. So Mr. Anderson.