 Good morning. I was asked to speak about frameworks. Can you put the microphone closer to your lips? This is going to be fun. Okay. So I was asked to speak about different frameworks for implementation science. So I'm going to go through a little bit about the different models and frameworks that exist, and then I'm going to give you the experience that we had in Ignite with one specific framework. I do want to say that my starting slide pretty much touched off of what David said. So the idea that implementation is important is that if you go out and you take your research project and you figure out how to make it work for your study, which is what we've been doing for years and years and years, what you've figured out is how to make it work for your study. And what you really want to gather is how do you make it work for anybody who wants to do it? And that's where implementation science can create a framework to allow us to do that. So it takes that knowledge that's personal and internal to your project and generalizes it. And a great example of this is Peter Pranivas's study. So some of you may have heard of this. It was a very famous study that was published in New England Journal of Medicine, and basically they went out to 108 ICUs and they said, we're going to decrease central line infections. Okay. Or it's catheter-specific catheter-related infections. And so they said, okay, here's a checklist. There's a whole bunch of items that you can do in your ICU that are going to decrease infections. And you guys are going to sit down and implement certain things on this checklist, and then we're going to come back and see how you're doing. And in a year, they had decreased 80% of those infections across all sites. It was amazing, amazing. And so people, he would talk about this and people would say, what was on that checklist? My God, I need that checklist, right? And he's like, you missed the point. It's not the checklist. It was the process of creating the checklist at each site. They took the items that they thought were most pertinent to their sites and they implemented them. Everybody did something different. It was the process of bringing those people together, looking at their site internally, figuring out what they could do, and implementing it. That was the key message for implementation science. It's not the what, it's the how. So this is exactly what David put up before. So what we've been focusing on until now is outcomes. How you get to outcomes is really important, so we really need to focus on this how part, the implementation part. And so I'm going to go through a couple of models here. There are a lot of models as David alluded to, so I am not going to discuss them in great detail. I'm just going to give you some illustrative ones that have been sort of leading in the field. So this is the Prism Trial. And as you can see, does this have a pointer on it, Taji? Maybe. The green button? Ah, okay. So it's a little awkward to do this from the speakers thing here. So up here you can see they focus on what are characteristics of the intervention, the organization's perspective on the intervention, the patient's perspective on the intervention, who's going to be receiving the intervention and sort of the characteristics of the organization and the individuals who are going to be on the receiving end, what's the external environment like, the infrastructure is like, and then going through this adoption, implementation and maintenance phase that sort of led to the re-aim framework later. One thing I would like to say is you're going to see the term models and frameworks a lot here. So the difference between them is a framework just to list you a bunch of constructs that says they are important, but they don't describe any relationship between them, whereas a model says this affects this affects this. So they describe a pathway where those things interact. This is the Paris framework. In this framework you can see how much simpler this is. It essentially says that if you understand the context and the context has a strong infrastructure for implementing and the evidence base is strong, that you're more likely to have an effective intervention. This is very simple. This is re-aim. Anilana is going to talk to you about this, so I'm not going to go over it in any detail, but as David said, there's these components reach effectiveness, adoption, implementation and maintenance. This is the coordinated implementation model. This is a knowledge translation model. The Canadians love knowledge translation. I actually like it a lot as well, and it just describes a pathway for passing off knowledge from research to enter to the local system to the broader system and using that to engage all of these key players. So your administrative environment, the personal educational piece to it, the economics, the community, and then at the center is the practitioner. And then there's this one, which is extraordinarily complicated and has many pieces to it, but it's very much an educational model. It's called the pre-seed proceed, and it basically has these eight steps. So you start here, and then you go to the epidemiology components of it, and then the educational and ecological, the administrative and policy, and then you come down to the actual implementation part, a process evaluation, impact evaluation, and outcome evaluation. So there are many, many different models out there that describe different ways you can look at doing implementations using implementation research frameworks. So what I'm going to talk to you now about is an example. So we used INignite, which is the implementing genomics and practice network, a model to help guide the network interactions. And so this model was the CIFR. We had six projects in this network. Each had a very different genomic medicine intervention. So we had three pharmacogenomic trials. We had ours, which was a family history trial. We had Mount Sinai, that was a disease risk assessment. And then University of Maryland had a sort of a diagnostic for Modi for genetic causes of diseases trial. And so they were very different. And so how are we going to bring together the knowledge and the learning of these different types of studies to be able to tell other people who are interested in genomic medicine, how might you do this at your institution? And so we settled on this CIFR, Consolidated Framework for Implementation Research. CIFR is a framework. It just lists a whole bunch of constructs. It does not tell you exactly how they interact with each other. They leave that up to you to figure out. But basically they took a bunch of existing models. So at the time there was 19, they're very common implementation models. And they pulled all of the constructs from those models together and said, here's everything. Here's everything that these models say is important. And they just put them into these categories. They call them domains. Whoops, no, go back. So these are the domain domains. So things about the intervention, about the inner setting, which is sort of the hospital or health system. Outer setting, which is your city, your state, your politics. The individuals involved, so the providers, the clinicians, patients are actually notoriously sort of absent from this. This is one of the drawbacks of the CIFR. And then the implementation process that you went through to get your constructs. So there are different constructs under each of these that they said were important in all of these different models. And so you could go through and select what you thought was relevant and then focus on that for your intervention. So what we did was we said, okay, we're all doing different genomic medicine projects. We're gonna go through a process where we're gonna identify what we think as the six different projects are very important in CIFR for genomic medicine. And these are the things that we identified as high-ranking, important constructs for people who are doing genomic medicine studies to consider measuring as they do their studies. Okay. So the slides are available, so I'm not gonna go through each of these. But we came up with a good number that we thought were very relevant. And in addition, we said, there's some things missing from CIFR. We think these are also important and we would like people to also think about integrating these with those implementation measures. And as I said, it's largely the patient measures that were missing from CIFR. Things that we think a lot about already as trialists are who the patient is, what their barriers are, and so on. And so we felt like this was important to incorporate into the CIFR framework. We've actually published a paper on these findings. And it was in genetics in medicine last year. And at the end, we came up with this draft genomic medicine implementation research model. And we said, here are these high-priority CIFR constructs and the non-CIFR constructs that we identified. We want everyone to look at the implementation process. And these two things would inform the effectiveness of the implementation and then the clinical effectiveness. And here, what we said is, we have this list of things that we identified, but we would like each project to go through that process and identify things that they think are missing from that list or that they would not have on that list. We created a draft model with the idea that we would get feedback from people on what they felt should be incorporated and refined as time goes on. So overall, the benefits of the implementation research are that we can generalize what we're doing in our individual studies. But it also increases the reach of the intervention, so the generalizability, and increases its effectiveness. And it provides a broader framework for assessing health disparities, in particular bringing in those social constructs about patients into the framework. So if you're interested in learning more or you have a desire to look at what the different implementation models are that are out there right now, there's a lovely site that's at this website right here. And it basically lists all of the existing published models. And you can sort them based on different criteria that you have. So I think this is not going to work, but I had, yeah. So I had integrated a live version of the website into that next slide. But anyway, if you selected the select button and then you put in search criteria, you can actually come up with different models that might fit the needs of your particular study. So in summary, including system measures with traditional measures and outcomes will help us create more sustainable interventions. Implementation models and frameworks can be adapted to meet the needs of the genomic medicine community. We feel strongly that they weren't derived with the needs of the genomic medicine community in mind, but they can be developed so that they do meet our needs. And that we publish this draft genomic medicine model as potentially a starting point for people to think about how to do this in genomic medicine. So with that, I'll take any questions. Thank you, Laurie. Thanks. So again, we'll reserve more discussion-based questions for a bit later. But if anybody has anything, any clarifying questions for Laurie, this is a good time to ask them. Great. That means everything was perfectly clear. So thank you again. Next up is Alana Rahm from Geisinger, and she's going to discuss using the RE-AIM framework to evaluate genomic medicine implementation.