>> MY FIRST DUTY IS TO WELCOME NEW OFFICIAL MEMBERS WHO HAVE BEEN CONSULTANTS UP UNTIL NOW, SO DR. SUZANNE BAKKEN, WELCOME. DR. CLAY JOHNSON ON THE PHONE, I THINK? >> HE HAS A FAMILY EMERGENCY AND HIS SON HAS NEEDED HIS ATTENTION THIS MORNING. HE'S GOING TO BE IN AND OUT THROUGHOUT THE DAY. >> OKAY. AND NEAL RAMBO. >> I'M ON THE LINE BUT WILL HAVE TO DROP OFF LATER SCWHR. THANKS FOR TAKING THE TIME TO BE WITH US. I KNOW YOU HAVE A LOT GOING ON. >> I'D ALSO LIKE TO WELCOME EX-OFFICIO MEMBER PAUL WESTER, NATIONAL AGRICULTURAL LIBRARY. >> LONG-STANDING COLLEAGUE AND FRIEND OF THE LIBRARY. THANKS FOR BEING HERE THIS MORNING. >> AND WE HAVE NEW ALTERNATE EX-OFFICIO MEMBERS, DR. GREG MILLER, WHO IS SCIENCE ADVISOR, DIVISION OF BIOLOGICAL INFRASTRUCTURE AT THE NSF. AND REAR ADMIRAL ERIKA SCHWARTZ, DEPUTY SURGEON GENERAL WITH THE PUBLIC HEALTH SERVICE. WELCOME. THANK YOU. I NOTE THAT DAN IS -- EVEN THOUGH IT'S VERY EARLY IN THE MORNING -- IN CALIFORNIA, DAN MASYS IS ON THE LINE. ARE YOU THERE, DAN? >> YES. GOOD TO SEE YOU ALL AGAIN. [LAUGHTER] >> SO I WOULD LIKE TO ASK DR. SCHWARTZ TO GIVE HER -- >> HI, EVERYONE. ON BEHALF OF THE SURGEON GENERAL, HE SENDS HIS GREETING, HE IS IN ALBUQUERQUE TODAY, HEADING BACK TODAY SO HE COULD NOT ATTEND THIS MEETING. FOR THOSE WHO DO NOT KNOW WHO I AM, I AM ADMIRAL IRICA SCHWARTZ, THE NEW DEPUTY SURGEON GENERAL. I AM ABOUT TWO MONTHS AND 13 OR 14 DAYS OLD, MY GESTATION PERIOD IS PRETTY LONG. PRIOR TO SERVING AS D SSM G, I WAS FORMERLY THE CHIEF MEDICAL OFFICER OF THE COAST GUARD, PRIOR TO THAT, I WAS A NAVY PHYSICIAN. I'M AN OCCUPATIONAL MED CANE PHYSICIAN BY TRADE, BIOMEDICAL ENGINEER AND ALSO AN ATTORNEY. [LAUGHTER] IF I START GETTING LEGAL, I APOLOGIZE. I WANTED TO SHARE WITH YOU THE SURGEON GENERAL WANTED TO SHARE WITH YOU HIS PRIORITIES. YOU'VE HEARD THESE BEFORE BUT AS YOU KNOW, AN ELECTION IS COMING SOON, AND HE IS REALLY FIXATED ON THESE TOP FOUR PRIORITIES TO TRY TO GET THROUGH HIS TENURE DEPENDING ON WHAT HAPPENS WITH THE ELECTION. SO THE FOUR PRIORITY AREAS THAT HE IS FOCUSING ON AS YOU KNOW, NUMBER ONE, FIRST AND FOREMOST, IS DRUG MISUSE. IF YOU KNOW ANYTHING ABOUT THE SURGEON GENERAL, TALK ABOUT THIS A LITTLE MORE IN DEPTH, HE IS REALLY FOCUSED ON THE OPIOID EPIDEMIC AND E-CIGARETTE USE AND TOBACCO USE IN THE UNITED STATES. I'LL GET INTO THAT A LITTLE BIT MORE. NUMBER TWO, HE' FOAS FOCUSED ON COMMUNITY HEALTH AND ECONOMIC PROSPERITY. I'LL TALK TO YOU A LITTLE ABOUT THAT. AND THE THIRD PRIORITY AREA FOR HIM, LOOKING AT MILITARY MEMBERS IN THIS ROOM, IS, BELIEVE IT OR NOT, NATIONAL SECURITY. ONE OF THE MORE STARTLING STATISTICS IS THAT 71% OF AMERICAN YOUTH 17 TO 24 CANNOT JOIN THE MILITARY. AND THEY CANNOT JOIN THE MILITARY BECAUSE ABOUT THE MAJORITY OF THEM CAN'T JOIN THE MILITARY BECAUSE THEY CAN'T MEET THE PHYSICAL FITNESS REQUIREMENTS OR THEY CAN'T MEET THE HEALTH REQUIREMENTS AND THAT IS A SHOCKING STATISTIC AND THE SURGEON GENERAL WANTS TO PUT AN EMPHASIS ON THAT. THE FOURTH AND FINAL ONE WHICH IS REALLY SURPRISING TO A LOT OF OF FOLKS IS ORAL HEALTH. SO IN 2020, HE WILL BE RELEASING HIS ORAL HEALTH REPORT AND I'LL IT TALK TO YOU A LITTLE BIT ABOUT THAT. ONE OF THE SURGEON GENERAL'S MOTTOS IS BETTER HEALTH THROUGH BETTER PARTNERSHIP, AND THIS THEME IS WEAVED THROUGHOUT EVERYTHING THAT HE TALKS ABOUT. HE REALLY RECOGNIZES THAT THE OFFICE OF THE SURGEON GENERAL IS NOT A PARTY OF ONE, THAT IN ORDER FOR HIM TO ACHIEVE WHAT HE'S TRYING TO ACHIEVE, HE HAS TO REACH OUT TO PARTNERS, BOTH PRIVATE AND PUBLIC THE PARTNERS. SO YOU'LL SEE THAT WEAVED THROUGHOUT WHAT HE'S TRYING TO DO IN HIS PRIORITIES. AS WE FOCUS ON HIS FIRST PRIORITY, WHICH IS SUBSTANCE MISUSE, HIS REAL KEY AREA, AND I DON'T KNOW IF YOU KNOW THE SURGEON GENERAL'S STORY BUT HIS BROTHER HAS A SUBSTANCE ABUSE PROBLEM AND HIS BROTHER, IN FACT, IS IN PRISON SERVING A 10-YEAR TERM BECAUSE OF UNFORTUNATE INCIDENT THAT OCCURRED DUE TO SUBSTANCE MISUSE. SO THIS IS SOMETHING THAT'S VERY NEAR AND DEAR TO THE SURGEON GENERAL'S HEART, IS SUBSTANCE MISUSE, SPECIFICALLY OPIOID ABUSE. HE ISSUED AN ADVISORY LAST YEAR AND THIS WAS THE FIRST SURGEON GENERAL'S ADVISORY IN MORE THAN 10 YEARS AND THIS HIGHLIGHTED THE IMPORTANCE OF NALOXONE AS A WAY TO CURB OPIOID MORBIDITY AND MORTALITY. ONE OF THE THINGS HE DOES WHEN HE GOES ABOUT THE COUNTRY IS THAT HE ASKS PEOPLE IN THE AUDIENCE TO RAISE THEIR HAND IF THEY KNOW BLS. GENERALLY IN A HEALTHCARE AUDIENCE, PEOPLE DO RAISE THEIR HAND. THEN HE ASKS THE AUDIENCE HOW MANY OF YOU CARRY NALOXONE? AND SURE ENOUGH, A NUMBER OF THE HANDS WILL FALL DOWN BECAUSE NOT EVERYONE CARRIES NALOXONE AND IF THERE'S ANYTHING THAT YOU CAN TAKE FROM THIS DISCUSSION THIS MORNING, I WOULD URGE YOU AS HEALTHCARE PROFESSIONALS TO CARRY NALOXONE. THE STAT THAT HE LIKES TO QUOTE WHICH IS REALLY QUITE STRIKING IS THAT THERE'S A PERSON DYING OF AN OPIOID OVERDOSE EVERY 11 MINUTES, AND MORE THAN HALF OF THESE INDIVIDUALS DIE AT HOME. AND THESE DEATHS ARE PREVENTABLE DEATHS. SO IF ANYTHING FROM THIS BODY HERE, I WOULD ASK THAT EACH ONE OF YOU GET YOURSELF A KIT OF NALOXONE. SINCE THE SURGEON GENERAL RELEASED HIS ADVISORY, MORE THAN 2.7 MILLION 2-DOSE MEDICATIONS OF NALOXONE HAVE BEEN DISTRIBUTED TO STATES AND LOCAL COMMUNITIES AND AS I SAID AGAIN, WE NEED YOU AND ALL OF US TO CONTINUE TO BE PART OF THE SOLUTION BY CARRYING NALOXONE PROMOTING THE IMPORTANCE OF USING IT. THE OTHER THING THAT VICE ADMIRAL ADAMS ISSUED WAS A DIGITAL POSTCARD AND I HOPE EVERYONE CAN GO TO SURGEONGENERAL.GOV AND SHARE THIS INFORMATION OH OTHER FOLKS BECAUSE THIS DIGITA POST POSTCARD REALLY IS EDUCATING AMERICANS ABOUT THE OPIOID CRISIS AND HE WANTS EVERY AMERICAN TO RECEIVE THIS POSTCARD. SO IF YOU JUST AGAIN ANOTHER TALKING POINT FOR YOU AS YOU GO ABOUT YOUR DAY TO DAY LIVES IS TO SHARE THAT POSTCARD WITH YOUR COLLEAGUES AND WITH YOUR FAMILY MEMBERS BECAUSE IT REALLY IS A VERY CLEAR AND SIMPLE WAY TO UNDERSTAND THE OPIOID EPIDEMIC. SWITCHING GEARS TO TALK ABOUT E-CIGARETTES, THIS IS STARK. I DON'T KNOW IF ANY OF YOU HAVE CHILDREN, I DO NOT HAVE CHILDREN BUT I CAN TELL YOU THAT MY COLLEAGUES WHO DO HAVE CHILDREN WHO ARE TEENAGERS, E-CIGARETTE USE IS IS ABSOLUTELY PREVALENT AMONG OUR YOUTH. IT'S STRIKING HOW MANY CHILDREN, TEENAGERS, USE E-CIGARETTES. TOBACCO USE IN GENERAL REMAINS A SIGNIFICANT ISSUE FOR THE HEALTH OF CIVILIANS, EVEN MORE OF A THREAT FOR MILITARY MEMBERS, IS A THREAT TO MILITARY READINESS. CIGARETTE SMOKING IS STILL THE LEADING CAUSE OF -- REDUCES SLEEP QUALITY AND FITNESS. SO IN AN EFFORT TO REDUCE -- TO ADDRESS THIS EPIDEMIC, THE SURGEON GENERAL WILL BE RELEASING A SURGEON GENERAL'S REPORT ON SMOKING CESSATION THIS SUMMER SO STAY TUNED FOR THAT AND WE'LL BE CALLING ON EVEN OF YOU TO HELP PROMOTE THAT REPORT. ONE OF THE NEW TWISTS ON THIS OLD EPIDEMIC IS THAT -- WHICH IS IMPACTING OUR CIVILIAN AND MILITARY COMMUNITIES ACE MENTIONED IS E-CIGARETTE USE. LAST DECEMBER, THE OFFICE OF THE SURGEON GENERAL RELEASED AN ADVISORY OFFICIALLY DECLARING E-CIGARETTE USE AMONG YOUTH AN EPIDEMIC IN THE UNITED STATES, AS 1 IN 5 HIGH SCHOOL STUDENTS HAS USED E-CIGARETTES. THAT IS JUST ABSOLUTELY STARTLING. SO IF THERE'S ANYTHING THAT YOU GET FROM THIS DISCUSSION THIS MORNING IS TO LOOK AT THE SURGEON GENERAL WEBSITE FOR THE NALOXONE POSTCARD AND HIS ADVISORY THAT HE RELEASED ON TOBACCO USE AND NALOXONE. SWITCHING GEARS A LITTLE BIT HERE TALKING ABOUT COMMUNITY HEALTH AND ECONOMIC PROSPERITY, THIS IS ONE OF HIS TOP PRIORITIES. HE CALLS IT CHEP. HE RECOGNIZES THAT HEALTH AND ECONOMIC PROSPERITY ARE INEXTRICABLY LINKED. WHEN WE RECOGNIZE THAT -- WE RECOGNIZE COMMUNITY HEALTH IS POOR, WE ALSO RECOGNIZE THAT THEIR COMMUNITY PROSPERITY IS POOR. THE FACT IS, THE NUMBER ONE ISSUE PEOPLE VOTE ON, IT'S HEALTH, IT'S JOBS AND THE ECONOMY. HE RECOGNIZED THAT IMPROVED COMMUNITY HEALTH MEANS IMPROVED EMPLOYEE ACTIVITY, INCREASED ECONOMIC PROSPERITY, REDUCED CRIME AND A A MYRIAD OF OTHER BENEFITS. I CAN TELL YOU IT IS AN ABSOLUTE INEX-TRICKIBLE RELATIONSHIP BETWEEN WORKERS' HEALTH AND THEIR ACTUAL PRODUCTIVITY ON THE JOB. SO I WOULD RECOMMEND THAT EVERYONE HERE IN THIS ROOM, WE NEED TO HELP OUR EMPLOYERS, OUR POLICY MAKERS UNDERSTAND THAT INVESTING IN COMMUNITY HEALTH IS A DRIVER OF ECONOMIC PROSPERITY AND SAFER COMMUNITIES. SO IN 2020, ANOTHER REPORT THAT'S COMING OUT WILL BE THE CHEP REPORT, THE COMMUNITY HEALTH AND ECONOMIC PROSPERITY REPORT, AND THAT REPORT IS GOING TO DEMONSTRATE THE LINK BETWEEN COMMUNITY HEALTH INVESTMENTS, ECONOMIC OUTCOMES AND IT WILL PROVIDE TOOLS THAT HEALTHCARE, BUSINESSES, FINANCIAL INSTITUTIONS, AND OTHERS CAN USE TO IMPROVE COMMUNITY HEALTH AND WEALTH. THIS OTHER THIRD PRIORITY IS A TOPIC THAT'S NEAR AND DEAR TO MY HEART AS A FORMER MILITARY MEMBER, WHICH IS NATIONAL SECURITY. IT'S NOT NATIONAL HEALTH SECURITY, IT'S NATIONAL SECURITY. AND AS I MENTIONED THAT STARTLING STATISTIC, 17 TO 24 CANNOT JOIN THE MILITARY. AS I LOOK AT MY MILITARY COLLEAGUES IN THIS ROOM, I KNOW SURGEON GENERALS ARE VERY CONCERNED ABOUT THIS START STARTLING STATISTIC AND NOT JUST THE SURGEON GENERAL BUT YOUR MILITARY CHIEFS. WE CANNOT MAGICALLY MAKE THEM HEALTHY WHEN THEY SHOW UP TO THE RECRUITER BOOTH AT AGE 18. THEY'RE UNHEALTHY FROM THE BEGINNING, SO THERE'S SOMETHING THAT WE NEED TO DO AS A NATION TO ADDRESS THE HEALTH OF OUR YOUTH. AND SO THE SURGEON GENERAL IS WORKING WITH THE MILITARY SURGEON GENERALS TO ENCOURAGE EFFORTS TO INCREASE COMMUNITY HEALTH AS A WAY OF INCREASING RECRUITING, READINESS AND RESILL YEN SEES. RESILIENCY. WE DO NEED YOUR HELP BECAUSE THIS IS A NATIONAL SECURITY ISSUE. FINALLY ON ORAL HEALTH, ORAL HEALTH IS CONNECTED WITH BODILY HEALTH. WE FAIL TO FOCUS ON ORAL HEALTH, AND IN FACT, MORE THAN 90% OF ALL SYSTEMIC DISEASES PRODUCE ORAL SIGNS AND SYMPTOMS THE IN LINKED TO HEART DISEASE AND STROKES. -- PRETERM BIRTHS ARE DUE TO ORAL INFECTIONS. WE ARE OVERDUE FOR THE LAST SURGEON GENERAL REPORT ISSUED IN 2000. THE SURGEON GENERAL COMMISSIONED A NEW SURGEON GENERAL'S REPORT AND AS I SAID, IT WILL BE RELEASED IN THE FALL OF 2020. THIS REPORT WILL UNDERSCORE THE CRITICAL NATURE OF POOR ORAL HEALTH AS A PUBLIC HEALTH ISSUE. SO AS THE NATION'S DOCTOR, THE SURGEON GENERAL RELEASED -- EVIDENCE BASED SCIENCE. WHAT HE'S TRYING TO DO IS REALLY COMMUNICATE THAT EVIDENCE BASED SCIENCE TO OUR NATION, TO THE PUBLIC, SO WHAT YOU'LL SEE FROM THESE REPORTS, THESE ARE ALL EVIDENCE BASED REPORTS. THESE ARE ALL REPORTS THAT ARE NOT JUST BASED ON SOMEONE'S OPINION, THEY'RE BASED ON ACTUAL SCIENCE. SO I WOULD ASK FOR YOU IN THIS ROOM WHEN YOU LOOK AT THE ORAL HEALTH REPORT, WHEN YOU LOOK AT THE COMMUNITY HEALTH ECONOMIC PROSPERITY REPORT, THAT YOU SHARE THIS MESSAGE THROUGH TO YOUR BROADER COMMUNITY. THE SURGEON GENERAL WANTS TO ALSO RECOGNIZE THAT HE IS FOCUSED ON EMERGING DISEASE THREATS. AS YOU KNOW, YOU CAN'T TURN ON THE TV WITHOUT LISTENING, LOOKING AT THE MEASLES EPIDEMIC, SO HE WANTS FOLKS TO UNDERSTAND HE IS ABSOLUTELY FOCUSED ON MAKING SURE TO REMIND FOLKS ABOUT THE SCIENCE OF VACCINATIONS, HOW IT'S IMPORTANT FOR THOSE VACCINE-HESITANT PARENTS TO REALLY UNDERSTAND SCIENCE THAT THEY CAN ENSURE THAT THEIR CHILDREN ARE, IN FACT, VACCINATED. THIS IS A PREVENTABLE, TRULY PREVENTABLE DISEASE, AND WE HAVE A SAFE VAC SEES THAT PROTECTS THE COMMUNITY FROM GETTING MEASLES. HE WANTS TO LEAD THAT NATIONAL DISCUSSION, HE WANTS US ALL US OF TO BE PART OF THAT DISCUSSION. THAT IS ALL I HAVE. IF YOU HAVE ANY SPECIFIC QUESTIONS ON HIS PRIORITIES JUST TO RECAP, NUMBER ONE IS DRUG USE AND MISUSE IN AMERICA, NUMBER TWO IS THE COMMUNITY HEALTH AND ECONOMIC PROSPERITY REPORT COMING OUT NEXT YEAR, NUMBER THREE IS NATIONAL SECURITY AND NUMBER FOUR IS REALLY FOCUSING ON ORAL HEALTH. SO IF YOU HAVE ANY QUESTIONS, I'M WELCOME TO ANSWER ANY OF THOSE QUESTIONS. THANK YOU. >> THANK YOU VERY MUCH. WELCOME TO YOUR FIRST MEETING WITH US. >> THANK YOU VERY MUCH. >> QUESTIONS. >> CAN I START? >> YES. >> SO TWO THINGS. THE MEASLES. WE GOT MOST OF THE CASES IN NEW YORK, AREN'T WE LUCKY. AND ONE OF THE MAJOR SOURCES OF THIS PROBLEM IS MISINFORMATION. HOW DO WE COUNTER THAT? >> I THINK THE SURGEON GENERAL WILL TELL US THAT IT'S REALLY PROVIDING INDIVIDUALS WITH INFORMATION, WITH CORRECT INFORMATION. HE WAS ON A PLANE HEADING TO THE NORTHWEST REGION TO TALK ABOUT VACCINE HESS HESITANCY, AS HE WAS LEAVING THE RESTROOM, A WOMAN CONFRONTED HIM, A VACCINE-HESITANT PARENT. SHE WAS ACTUALLY COMING BACK FROM WASHINGTON, D.C. WHERE THERE WAS A HEARING ON VACCINE USE, AND SHE WAS -- SHE SPENT 10 TO 15 MINUTES REALLY VERY ANGRY WITH THE SURGEON GENERAL ON, YOU KNOW, WHY HE WAS NOT SUPPORTING THOSE VACCINE-HESITANCY PARENTS. HE LISTENED AND HE JUST INFORMED HER ABOUT THE SCIENCE RELATED TO VACCINES. NOW WHETHER HE GOT THROUGH TO HER OR NOT, HIS MISSION IS REALLY TO JUST CONTINUE TO INFORM PEOPLE ABOUT THE SCIENCE OF VACCINES AND THE SAFETY OF THE VACCINES. ONE OF THE THINGS THAT WE WERE THINKING ABOUT IS RECRUITING THOSE PEOPLE, GRANDPARENTS, WHO'VE ACTUALLY LIVED THROUGH, YOU KNOW, TO TALK TO THOSE INDIVIDUALS WHO LIVED THROUGH THIS TO SAY THIS IS NOT SOMETHING YOU WANT YOUR CHILD TO GO THROUGH. SO IT IS REALLY JUST ABOUT INFORMATION, BEING OUT THERE, AND I CAN TELL YOU, THE SURGEON GENERAL IS PROLIFIC, HE LITERALLY WANTS TO GO TO EVERY SINGLE STATE TO HAVE THOSE CONVERSATIONS ABOUT THESE PRIORITIES AND IN PARTICULAR, VACCINE-HESITANCY PARENTS. >> SO I TOTALLY AGREE WITH YOU. JUST WANT TO TELL YOU AN EXPERIENCE I HAD THAT MADE ME THINK SLIGHTLY DIFFERENTLY. I WAS AT A MEETING IN NEW YORK CITY, I WAS GIVING A TALK ON PUBLIC-PRIVATE PARTNERSHIPS, SO I WAS THE ONLY SCIENTIST THERE, EVERYONE ELSE WAS AN MBA, BUSINESS, WHATEVER. AND BASICALLY THEY SAID THAT -- WE WERE TALKING ABOUT MEASLES AND BASICALLY THEY SAID THAT PUBLIC HEALTH AND THE ADVICE THAT WE GIVE IS GIVEN IN A PATRONIZING WAY. YOU KNOW, THAT WE'RE PREACHING. AND THAT WE SHOULD THINK ABOUT DELIVERING OUR INFORMATION IN A DIFFERENT WAY. AND WE'RE NOT GOOD AT THAT. >> I'M GLAD YOU BROUGHT THAT UP. WITH THE CHEP PROGRAM, WE ARE BRINGING IN BUSINESS LEADERS AND PUBLIC HEALTH LEADERS AND HEALTHCARE LEADERS, AND WE RECOGNIZE THAT WE ALL SPEAK A DIFFERENT WAY AND SO GETTING THOSE INDIVIDUALS IN A ROOM TO HAVE THIS CONVERSATION HAS BEEN VERY DIFFICULT, AND I THINK THAT IT'S WHY WE'RE ENLISTING OUR GRANDPARENTS, PEOPLE THAT CAN ACTUALLY SPEAK THE LANGUAGE THAT OTHERS IN THE COMMUNITY SPEAK AND SO IT'S NOT THIS PATRONIZING WAY AS HEALTHCARE PROVIDERS THAT WE SOMETIMES TALK TO OUR PATIENTS IN, IT'S REALLY ABOUT SPEAKING PLAIN ENGLISH AND I'VE WITHIN THERE AND I HAD THE MEASLES AND LET ME TELL YOU, THIS WAS A VERY UNFORTUNATE THING, RIGHT? SO I THINK THIS IS A WAY THE SURGEON GENERAL, THE OFFICE OF THE ASSISTANT SECRETARY FOR HEALTH WANT TO START COMMUNICATING TO THE AMERICAN PUBLIC. DOWN AT THEIR LEVEL, NOT AT THIS SORT OF PATRONIZING WAY. >> I THINK ALONG THOSE LINES THAT -- HOW DO WE RECONCILE THE FREE SPEECH OF AMERICA WITH THE FACT THAT WE NEED TO GET THESE MESSAGES OUT. REALLY WE'RE WRESTLING, WATCHING WITH EMOTION, EMOTION USUALLY TRUMPS IN THE NEWS, OR WE'RE WRESTLING BETWEEN THE VOCAL MINORITY, VERY SMALL MINORITY, WITH THE SILENT MAJORITY AS WE FREQUENTLY HEAR, WE HAVE TO FIND A DIFFERENT APPROACH, NOT SURE WHAT THAT IS, BUT A DIFFERENT APPROACH TO GET THIS MESSAGE OUT BECAUSE WE'VE BEEN DOING THIS FOR A CENTURY, THESE ISSUES, EVER SINCE THE FREE PRESS TOOK RISE, PROBABLY 2-CENT REE REALLY. >> IT'S WORSE WITH SOCIAL MEDIA, I KNOW THE SURGEON GENERAL HAS ALMOST 500,000 TWITTER FOLLOWERS, YOU KNOW, SO I KNOW HE IS REALLY TRYING TO COMBAT IT USING THE SAME TOOLS THAT OTHER FOLKS ARE USING TO SAY, HEY, LISTEN, I'M SPEAKING AT YOUR LEVEL, IF YOU'VE EVER SPOKEN TO THE SURGEON GENERAL, HE IS A VERY HUMBLE PERSON, IF YOU REALLY CAN GET DOWN TO JUST A VERY NORMAL CONVERSATION ABOUT HEY, THIS IS WHY IT'S IMPORTANT. HE'S NOT TRYING TO TELL YOU THAT YOU'RE WRONG, HE'S JUST TRYING TO PRESENT YOU WITH ANOTHER CHOICE. >> I THINK IT WAS IN THE "NEW YORK TIMES" THE OTHER DAY, A VERY WELL WRITTEN, WELL ARGUED POINT THAT WHEN YOU ARE SAYING TO SOMEONE ABOUT THEIR CHILD, THERE IS A SMALL RISK, AND THEY MIGHT TALK -- I HAD MEASLES AS A CHILD. I TONIGHT REMEMBER IT DIDN'T REMEMBER IT BEING IT THAT BAD. THAT HE MAY BE WHAT THAT MAY BE WHAT THEY' RE HEARING FROM FAMILY MEMBERS, SO AN APPROACH TO TAKE, IT'S NOT JUST ABOUT YOU AND YOUR CHILD, IT'S ABOUT INFANTS, PREGNANT WOMEN, IT'S ABOUT THE VULNERABLE OLDER PEOPLE OR PEOPLE WHO HAVE HAD TRANSPLANTS, PEOPLE VERY SUSCEPTIBLE TO AN INFECTION MIGHT POSSIBLY DIE FROM IT, SO WE WANT YOU TO TAKE THIS VERY SMALL RISK IN ORDER TO PROTECT THOSE PEOPLE, SORT OF APPEAL TO PEOPLE'S BETTER NATURE. >> ABSOLUTELY. >> SO THIS IS VERY INTERESTING, INFECTIOUS DISEASES, AND I SPENT SOME TIME AT HHS, AND IT'S A GLOBAL PROBLEM THOUGH, IT'S NOT JUST A DOMESTIC PROBLEM. IT IS NOT JUST MEASLES, IT'S ALL INFECTIOUS AGENTS THAT ARE EMERGING AROUND THE WORLD, WHETHER IT'S IN A DEVELOPED COUNTRY OR DEVELOPING COUNTRY, AND SO IT SPEAKS ALSO TO -- AND I KNOW YOU'RE FAMILIAR WITH -- PROBABLY WITH THE CHALLENGES OF DEVELOPING VACCINES, WHEN I WAS AT HHS, I WORKED ON INFLUENZA, AND INFLUENZA PANDEMICS, AND I WORKED A LITTLE BIT WITH THE GLOBAL COMMUNITY. SO THAT'S ANOTHER CHALLENGE TO ADDRESSING THAT TYPE OF PROBLEM, ESPECIALLY WITH THE WAY PEOPLE TRAVEL THOOS DAYS. I THINK SOME OF THE MEASLES CASES -- IT WAS ALSO -- >> ISRAEL -- >> IT WAS INTERNATIONAL AIR FLIGHTS, AND I'M SURE -- >> THE OASH [INAUDIBLE] >> AND IT TAKES TIME TO DEVELOP THE VACCINES AGAINST AGENTS THAT ARE EMERGING FROM THE ANIMAL KINGDOM. >> ABSOLUTELY. >> I'M NOT SURE THE PHARMACEUTICAL INDUSTRY IS -- THE INFRASTRUCTURE IS SUCH -- THAT WAS ONE OF THE CHALLENGES WITH INFLUENZA, TO QUICKLY BRING A VACCINE TO MARKET AND HAVE IT AVAILABLE FOR POPULATIONS AROUND THE WORLD. >> VACCINES ARE NOT A MONEY MAKER BECAUSE IF YOU USE IT, YOU DON'T NEED IT. >> RIGHT. >> SUZANNE. >> I WAS JUST -- THE NATIONAL ACADEMIES HAVE A PROJECT ON MISINFORMATION THAT IS ACTUALLY A PARTNERSHIP WITH GOO GOOGLE HEALTH, SO IT'S BEEN A PRIVATE PROJECT IN VACCINATIONS, A LOT OF EMPHASIS OF IT, BUT ONE OF THE OTHER STRATEGIES IN THE GOOGLE PROJECT IS ON THEIR END TO CHANGE STRATEGIES SO THAT THE MOST CREDIBLE INFORMATION IS LIKELY TO COME OUT AT THE TOP OF THE SERVE SEARCH, SO ANYWAY, I JUST WANTED TO MENTION THAT THAT'S ONGOING AND IT'S GOING TO BE MORE BROADLY ACROSS OTHER TOPICS AS WELL BUT JUST TO LET PEOPLE KNOW THAT'S ALSO GOING ON. >> IS THAT A REPORT, SUZANNE, THAT'S OUT? >> IT'S AN ONGOING -- IT'S NOT A COMMITTEE -- IT'S NOT A CONSENSUS COMMITTEE REPORT, IT IS ANOTHER TYPE OF ACTIVITY THAT CROSSES THE THREE ACADEMIES. >> SO IT'S NOT THROUGH HND. >> NO, IT'S ACROSS ALL THREE. >> THAT'S GREAT. >> THE MISINFORMATION IS ALSO THE INITIAL THINGS HAVE FOCUSED ON HEALTH THAT ACTUALLY IS INTENDED TO BE BROADER THAN HEALTH SO I CAN JUST SAY IT'S BEEN PILOT FOR A COUPLE YEARS OR FOR YEARS AND I THINK IT'S BEING EXTENDED FOR TWO YEARS. I'M ON THE COMMITTEE. >> CAN YOU SEND A LINK MAYBE TO -- >> I'LL TRY TO FIND THE PROPER LINK FOR IT, YES. >> SO I DON'T HAVE MUCH EXPERIENCE HERE AT THE DOMESTIC LEVEL BUT I'VE HAD SOME PRIOR EXPERIENCE WITH INTERNATIONAL HEALTH ISSUES AND I THINK ONE OF THE LESSONS DID VACCINATIONS IN OTHER COUNTRIES IS THAT VACCINE UPTAKE IS VERY OFTEN -- THERE'S A CORRELATION BETWEEN HOW MUCH THERE'S BEEN ENGAGEMENT WITH THE COMMUNITY IN QUESTION IN TERMS OF THE BASIC HEALTH SERVICES BECAUSE IF A COMMUNITY -- I'M TALKING ABOUT OTHER COUNTRIES, BUT IN MANY OTHER COUNTRIES, COMMUNITIES THAT DON'T HAVE ACCESS TO BASIC SORT OF WHAT WE WOULD CALL PRIMARY HEALTHCARE IS VERY HARD TO KIND OF BLOW IN WITH A VACCINATION CAMPAIGN AND BASICALLY TELL PEOPLE, YOU KNOW, YOU NEED TO LINE UP, YOU NEED TO GET THESE JABS, BUT WE'RE NOT GOING TO DO ANYTHING TO ADDRESS YOUR MATERNAL FETAL ISSUES, WE'RE NOT GOING TO DO ANYTHING TO ADDRESS YOUR OTHER CHRONIC HEALTH ISSUES, WE'RE JUST HERE FOR THIS VACCINATION CAMPAIGN, AND THEN WE'LL LEAVE AND YOUR GOVERNMENT WILL NEVER SEE YOU AGAIN. JUST SORT OF MENTIONING THAT I THINK -- LIKE I DON'T KNOW HOW MUCH I CAN TRANSLATE TO THE AMERICAN EXPERIENCE, BUT ON THE INTERNATIONAL LEVEL, THERE IS, I THINK, SOME LINK BETWEEN DELIVERY OF BASIC HEALTH SERVICES AND THE SUCCESS OF VACCINATION CAMPAIGNS. >> I THINK WE'VE SEEN THIS IN THE U.S. AS WELL. I KNOW AROUND THE CTSAs, THERE'S BEEN A LOT OF CONVERSATION ABOUT THE NEED TO ENGAGE THE COMMUNITY. IF YOU'RE INVOLVING THEM IN A RESEARCH PROJECT, IT'S THE NOT JUST YOU'RE HERE AS OUR SUBJECTS, BUT WHAT'S IN IT FOR YOU, WHAT BENEFIT WILL ACCRUE TO THE COMMUNITY AND BUILDING THAT RELATIONSHIP SO THEY CAN BUILD A TRUE PARTNERSHIP GOING FORWARD. >> I HAVE ANOTHER QUESTION. YOUR APPROACH TO THE HEALTH OF OUR YOUTH AND ITS IMPLICATION FOR NATIONAL SECURITY, CAN YOU BREAK DOWN THE PROBLEM A LITTLE BIT, IS IT MEN AND WOMEN, IS IT OBESITY, IS IT -- >> SO I DON'T HAVE ALL THE STATS AND I DON'T WANT TO SPEAK FOR MY MILITARY COUNTERPARTS BUT MY UNDERSTANDING IS IT'S MEN AND WOMEN, IT'S ALSO WHEN BE LOOK AT THE 71% AND BREAK THAT DOWN, MY UNDERSTANDING IS ABOUT 30% OR MORE OF THAT IS THEY ARE UNHEALTHY, MEANING THAT THEY ARE OVERWEIGHT, THEY CAN'T MEET METEOROLOGIST THE MEDICAL ACCESSION STAN DARDZ THAT ARE SET BY THE MILITARY SERVICES. SO IT COULD BE A VARIETY OF THINGS. AND THEN THE OTHER -- THERE'S ANOTHER 30% OR MORE OF THAT 71% THAT COULD NOT MEET THE PHYSICAL FITNESS REQUIREMENTS. SO IF YOU BREAK THE MAJORITY OF THAT 71%, IT'S TRULY DUE TO A HEALTH OR A PHYSICAL FITNESS-RELATED ISSUE. WHETHER IT'S OH HE BEES IT BEES OBESITY, WHETHER THEY HAVE SOME TYPE OF MEDICAL CONDITION THAT WILL NOT MEET THE STANDARDS SET BY MILITARY SERVICES. I KNOW AT LEAST THE ARMY, THERE ARE ACCESSION STANDARDS FROM A PHYSICAL FITNESS STANDPOINT THAT HAVE GOTTEN MUCH TOUGHER OF LATE. I DON'T KNOW ABOUT YOUR MEDICAL ACCESS STANDARDS BUT THE MEDICAL ACCESSION STANDARDS ARE PRETTY TOUGH TO GET INTO THE MILITARY SERVICE. I DON'T KNOW IF YOU'VE CHANGED IT OF LATE BUT I DO KNOW IF YOU LOOK THROUGH THEIR MEDICAL ACCESSION POLICY, IT IS PRETTY HARD TO BE HEALTHY ACCORDING TO THE MILITARY. >> WE KEEP THE STANDARDS HIGH, IF YOU LOOK ON THE FLIP SID OF IT, YOU ACCESSION SOMEBODY AND THEY FALL OUT, THAT'S A LARGE COST TO THE TAXPAYER. SO IT IS VERY CONCERNING FROM A HEALTH PERSPECTIVE THAT 70% DON'T QUALIFY. ON THE FLIP SIDE OF THAT, YOU HAVE 30% POPULATION OUT OF WHICH YOU'RE ONLY TALKING ABOUT 1 TO 3% ANYHOW, SO YOU'RE LOOKING FOR THE TOP 10% OF HEALTHY PEOPLE, SO IT IS A NATIONAL SECURITY ISSUE MORE FROM THE FACT THAT A LOT OF PEOPLE THAT ARE JUST NOT HEALTHY BUT FROM RECRUITING STANDARDS, WE SEEM TO BE HITTING MOST OF THE MARKS FOR NOW. WE'RE NOT DROPPING THE STANDARD BECAUSE WE CAN'T GET PEOPLE BUT ON THE FLIP SIDE, YES, IT IS A CONCERN THAT MOST PEOPLE DON'T EVEN QUALIFY TO BE IN THE MILITARY. >> ONE OF THE THINGS THAT WE'RE FINDING OUT IS THAT FOLKS THAT ARE COMING IN TO THE MILITARY, THEY'RE ALREADY ADDICTED TO NICOTINE. SO IT'S NOT THAT, YOU KNOW, THE MILITARY IS CAUSING THEM TO BE ADDICTED TO NICOTINE, IT'S THAT THEY'RE ENTERING THE MILITARY SERVICE ALREADY ADDICTED, AND SO HOW DO YOU STAVE THAT OFF, ESPECIALLY WITH E-CIGARETTES AND INCREASING USE OF TOBACCO PRODUCTS, IT'S QUITE STARTLING AND I'M NOT SURE -- I KNOW WE'RE TALKING TO THE SURGEON GENERAL IN TRYING TO FIGURE OUT HOW DO YOU PREVENT THIS, HOW DO YOU SOLVE THIS. >> THANK YOU. I WAS WONDERING, WHAT ARE THE VIEWS OF THE SURGEON GENERAL ON THE ROOT CAUSES OF ALMOST ENTIRE COHORT OF YOUNG INDIVIDUALS, TEENAGERS IN THE NATION, BEING UNHEALTHY? >> I THINK HE WOULD POSTULATE THAT PHYSICAL ACTIVITY IN YOUNG PEOPLE -- AGAIN, I DON'T HAVE CHILDREN BUT THOSE WHO DO HAVE CHILDREN, THEY DON'T LIKE GETTING OUT. I KNOW MY GENERATION, WE WERE ALWAYS OUT AND ABOUT, PLAYING BASKETBALL OR PLAYING -- RUNNING IN THE STREETS. UNFORTUNATELY THIS GENERATION, THEY DO NOT DO THAT. I MEAN, AT LEAST IN AMERICA, THEY ARE SITTING AT HOME, THEY'RE PLAYING VIDEO GAMES, THEY'RE VERY SEDENTARY. SO THIS NEWER YOUNGER GENERATION, THEY ARE JUST NOT AS PHYSICALLY ACTIVE, AT LEAST THAT'S WHAT HE'S POS TEUT TEU LATING, AS PREVIOUS GENERATIONS. WHY THAT IS, I DON'T KNOW BUT CERTAINLY THERE IS A SEDENTARY NATURE FOR THIS YOUNGER GENERATION. WHICH IS CAUSING SOME OF THOSE HEALTH THREATS. >> THANK YOU AGAIN. HAS THERE BEEN ANY PROGRESS WITH MODIFYING THE PRICE OF NALOXONE? >> THAT'S A GREAT QUESTION. >> IT'S EXPENSIVE. >> IT IS VERY EXPENSIVE. I THINK THE MORE CONCERNING DISCUSSION THAT WE'RE HAVING IS THE FACT THAT WE'RE HEARING FROM HEALTHCARE PROVIDERS THAT WHEN THEY DO GO TO OBTAIN NALOXONE, THEY'RE FINDING THEIR INSURANCE COMPANY ACTUALLY STARTS SAYING, YOU KNOW WHAT, WE'RE GOING TO START RAISING OUR PRICES BECAUSE YOU ARE AT A PERCEIVED HIGH RISK. THEY'RE NOT ONLY GETTING IT FOR THEMSELVES, THEY'RE GETTING IT JUST FOR ANYONE, AND SO THERE IS SOME DEBATE AND SOME CONVERSATIONS HAPPENING WITH THE SURGEON GENERAL AND INSURANCE COMPANIES AND THE FDA AND INSURANCE COMPANIES TO -- HOW DO WE PREVENT THAT, HOW DO WE PREVENT MAKING SURE THAT -- ENSURE FOLKS CAN CARRY NALOXONE WITHOUT HAVING THIS SECOND ORDER CONSEQUENCE OF THEIR INSURANCE COMPANIES ACTUALLY PENALIZING THEM ABOUT THAT. >> RIGHT. >> SO THE COST IS CERTAINLY ONE THING, BUT I THINK THE OTHER SECOND ORDER OF CONSEQUENCE IS REALLY THE INSURANCE COMPANY'S -- >> [INAUDIBLE] >> EXACTLY. SO WE'RE HAVING THOSE CONVERSATIONS, WE'RE VERY CAREFUL BECAUSE WE DON'T WANT TO GET INTO THAT PRIVATE SECTOR DISCUSSION BUT WE ARE DEFINITELY HAVING THOSE CONVERSATIONS. >> I'M GLAD TO HEAR THAT. THANK YOU. >> CAN I JUST -- >> I JUST WANTED TO GIVE A PLUG TO NLM AND ITS ROLE IN COUNTERING COUNTERING MISINFORMATION AROUND HEALTH TOPICS. I WAS AT THE NATIONAL LIBRARY'S SMOKING CESSATION LAST WEEK AND PARTICIPATED IN A WIKIPEDIA -- A THON AND GOING IN TO ADD CITATIONS TO MEDLINE, GENETICS HOME REFERENCE, MEDLINEPLUS, INTO WIKIPEDIA ARTICLES, AND TO MAKE SURE THAT THERE WAS ACCURATE INFORMATION IN THERE, AND THAT WAS SPONSORED BY THE NATIONAL NETWORKS OF LIBRARIES OF MEDICINE AND THEY'RE ENCOURAGING LIBRARIES AROUND THE COUNTRY TO DO THIS. SO HOPEFULLY THIS WILL BE A LITTLE SMALL WAY THAT MANY OF US CAN CONTRIBUTE TO COUNTERING HEALTH INFORMATION. >> SOMEONE CREATED MY WIKIPEDIA PAGE AND THERE'S SOME MISINFORMATION. >> I'D BE MORE THAN HAPPY TO FIX THAT. [LAUGHTER] >> DON'T FIX IT YOURSELF. >> THANK YOU SO MUCH. THAT WAS REALLY AN AMAZING PRESENTATION. >> YOU'RE ABLE TO BE WITH US MOST OF THE DAY TODAY? >> I'M HERE TODAY AND TOMORROW, AND FOR DINNER. >> THANK YOU SO MUCH. >> GREAT. OKAY. SO NOW WE HAVE A LITTLE BIT OF OFFICIAL BUSINESS. I'D LIKE TO BRING YOU TO THE MINUTES OF THE FEBRUARY MEETING. AND I'M SURE YOU ALL READ IT, AND COULD WE HAVE A VOTE, PLEASE, TO ACCEPT THOSE MINUTES? >> SO MOVED. >> AND SECOND? >> SECOND. >> THANK YOU. AND ON YOUR AGENDA, YOU HAVE -- OH, SO I'M SORRY, WE HAVE -- CAN WE HAVE A VOTE TO APPROVE THESE? >> AND DAN, YOU WERE WITH US? >> [INAUDIBLE] >> THANK YOU. >> THANK YOU FOR KEEPING ME ON TASK. AND THE FUTURE MEETING DATES ARE HERE AND FOR THOSE WHO NEED TO BE AWARE OF THESE MEETINGS, PLEASE PUT THEM IN YOUR CALENDAR. >> FOR THOSE WHO ARE NEW, WE TRY TO ROLL THE CALENDAR AHEAD TWO YEARS AT A TIME SO YOU CAN PLAN FOR US. >> NOW, WE HAVE OUR REPORT FROM DR. PATTY BRENNAN, THE NLM DIRECTOR. >> GOOD MORNING, EVERYONE. THOSE YOU HAVE ON THE PHONE, THANK YOU FOR BEING HERE WITH US. WHAT YOU CAN'T SEE IS WE'RE SIGNATURE AROUND A BRAND NEW TABLE. THOSE WHO ARE ON THE PHONE ARE NOT ABLE TO NOTICE IT, IT'S ACTUALLY NOT THE SHAKY OLD TABLE AND YOU CANNOT FIND ANY LIPS WITH CHEWING GUM UNDER THEM. [LAUGHTER] IT WAS A FUN PRODUCTION TO REMOVE THE TABLE, BRING THE NEW ONE IN, WE HAVE NEW IT TECHNOLOGY SO WE'RE REALLY VERY PLEASED WITH THIS. OUR NEXT STEP WILL BE TO GET RID OF THE BLUE CHAIRS AS SOON AS WE FIND SOMEONE WHO WANTS TO BUY THEM FROM US AND WE HAVE YET TO FIND A BUYER. WE MAY HAVE TO GET RID OF THEM ANYWAY. WE HAVE ALTERED THE STRUCTURE OF THE BOARD THISSER YAO AND WE HAVE A WORKING GROUP STRUCTURE. LATER THIS MORNING, THERE WILL BE WORKING GROUP SESSIONS, EVERYONE IS ASSIGNED TO A SPECIFIC GROUP. IF YOU'D REALLY PREFER TO BE INTERACTING WITH A DIFFEREN GROUP, JUST LET ME OR CHRISTINE KNOW AND WE CAN WORK THAT AROUND. THE WORKING GROUPS HAVE BEEN QUITE IMPORTANT TO US AND THEY'VE BEEN REALLY HELPFUL IN GETTING SOME INTERESTING CONVERSATIONS. OUR PLAN IS TO HAVE ABOUT 90 MINUTES ON THE FIRST DAY OF THE BOARD MEETING TO WORK IN SMALL GROUPS AND THEN ABOUT AN HOUR ON THE SECOND DAY OF THE BOARD MEETING TO SHARE ACROSS THE GROUPS TOGETHER. SO YOU'LL NOTICE IN THE MINUTES OF THE FEBRUARY MEETING, WE HAD AN EXTENSIVE REPORT OUT. PLEASE LET ME KNOW IF THAT STRUCTURE IS WORKING WELL FOR YOU. -- IS NOT HERE TODAY BECAUSE HE'S BECOMING A GRANDFATHER. THAT'S WAY MORE IMPORTANT, CARLOS JAEN, AND GARY PUCKREIN HAS HAD AN EMERGENCY COME UP BUT WE EXPECT TO SEE BOTH OF THEM BACK IN THE FALL. CALL YOUR ATTENTION, IT'S ON YOUR AGENDA, AT OUR BOARD MEETING IN THE FALL, WE DO LOTS OF THINGS. WE HAVE A GALA WITH THE NATIONAL LIBRARY -- THE FRIENDS OF THE NATIONAL LIBRARY OF MEDICINE BETWEEN THE TWO DATES OF THE MEETING AND ON THE -- AT THE END OF THE SECONDED DAY, WE HOST THE LINDBERGH -- THIS YEAR ED FEIGENBAUM WILL BE KEYNOTE SPEAKER, WITH A VERY INFLUENTIAL THINKER. TODAY I WANT A REMIND -- I'LL BE JOINING YOU AT LUNCH SO WE CAN HAVE A LONGER CONVERSATION. THE STRUCTURE OF OUR BOARD OF REGENTS IS DEFINED BY STATUTE. WE HAVE MEMBERS OF ALL THE UNIFORMED SERVICES ON THE BOARD OF REGENTS AS OUR FELLOW FEDERAL LIBRARIES. FOR TODAY, I WENT TO MEET WITH OUR UNIFORMED SERVICES TO FIGURE OUT HOW WE CAN WORK TOGETHER BETTER. IT'S A SMALL CONVERSATION, WE'LL REPORT THAT BACK TO YOU. I HAVE LOTS AND LOTS OF INTERESTING THINGS TO TELL YOU ABOUT BUT AS I USUALLY DO, I HAVE A VIDEO THAT OUR DEVELOPMENT STAFF HAS DONE FOR US, AND I THINK YOU'LL ENJOY THIS. I'VE BEEN ASKED TO SPEAK MORE THIS YEAR ON THE RELATIONSHIP BETWEEN THE NATIONAL LIBRARY OF MEDICINE AND THE USE OF ELECTRONIC HEALTH RECORDS AS A RESEARCH RESOURCE, SO THIS IS A VIDEO WE'VE USED TO STIMULATE THAT CONVERSATION. IT SHOULD BE PLAYING. THERE WE GO. CAN WE HAVE THE SOUND UP? * >> IT'S THREE KEY POINTS, FIRST THAT ELECTRONIC HEALTH RECORDS ARE NOT A SINGLE ENTITY BUT THE INFRASTRUCTURE REQUIRES BRINGING TOGETHER A NUMBER OF RESOURCES. THE SECOND PART IS, OF COURSE, THERE IS A LINK BETWEEN CLINICAL CARE AND RESEARCH AND THAT GOES INTO DIFFERENT DIRECTIONS. I'VE ALWAYS APPRECIATED HAVING THESE ONE MINUTE VIDEOS, THEY'RE HELPFUL AS I'M WATCHING NEW CONSIDERATIONS. ALL OUR VIDEOS ARE AVAILABLE ONLINE AND YOU'RE WELCOME TO RE-USE THEM TO THE EXTENT THEY WOULD BE USEFUL FOUR. NOW I'VE GOT TO TELL BUT ALL OF THE EXCITING THINGS THAT ARE GOING ON HERE. THE VIDEO IS REALLY GOOD BUT NOT THAT GOOD. SO WE HAVE -- WE'VE BEEN BUSY SINCE WE LAST MET WITH YOU IN FEBRUARY. WE'RE REALLY GETTING A LOT MORE TRACTION ACROSS NIH AS THE NATIONAL LIBRARY OF MEDICINE BEING A THOUGHT LEADER IN KEY AREAS AND MIKE HERDA'S GROUP IS LEADING A CONVERSATION ABOUT HOW DO WE PROVIDE CRITERIA FOR SELECTING GOOD DATA REPOSITORIES, RECOGNIZING THAT NIH IS MOVNG TOWARDS THE IDEA THAT DATA SHARING SHOULD BE A BASIC RESEARCH PREMISE, WE NEED TO GUIDE PEOPLE AS TO WHERE TO PUT DATA. AT THIS POINT IN TIME, IT'S POSSIBLE FOR INDIVIDUAL RESEARCHERS TO ATTACH A DATASET TO A PUBMED CENTRAL ARTICLE. WE'RE ENCOURAGING INDIVIDUALS TO USE PUBLIC REPOSITORIES AND THAT'S WHERE THIS SET OF RECOMMENDATIONS COMES IN, HOW DO YOU PICK -- OR ANY KIND OF A PUBLIC REPOSITORY, IN ADDITION, I'LL TALK ABOUT THIS IN A FEW MINUTES WHEN WE GET UP TO THE NEXT SLIDE, WE'LL BE TALKING ABOUT HOW THE NIH IS INVESTING IN A PROGRAM CALLED STRIDES, WHICH IS A MAJOR LARGE SCALE CLOUD RESOURCE. WE'VE BEEN WORKING WITH THE NATIONAL LIBRARY OF MEDICINE AND THE NIH LIBRARY TO EVALUATE THE NLM'S INVESTMENT IN OUR INTRAMURAL AND EXTRAMURAL PROGRAMS LOOKING AT BIBLIOMETRIC ANALYSIS, SO WE'RE HOPING TO PROVIDE STEWARDSHIP RESPONSE AND I THINK THAT'S GOING TO BE REPORTED TO THE RESEARCH GROUP TODAY. ARE YOU GOING TO BE DISCUSSING THAT WITH THE RESEARCH GROUP TODAY? YES. AND WE MAY BRING THAT BACK TO THE WHOLE GROUP TOMORROW. VERY EXCITED TO SAY THERE ARE 1 MILLION NIH SUPPORTED MANUSCRIPTS NOW IN PUBMED CENTRAL AND OVER 1 BILLION DOWNLOADS OF THOSE 1 MILLION RESOURCES SO THIS IS REALLY SHOWING PUBLIC ACCESS, PARTICULARLY FEDERALLY FUNDED RESEARCH IS GROWING. WE HAVE A NEW PARTNERSHIP WITH THE NATIONAL INSTITUTES OF DIABETES AND DIGESTIVE DISORDERS AND KIDNEY DISORDERS TO BRING BETTER CONTENT INTO MEDLINEPLUS CONNECT, SO THIS IS ALLOWING -- THE MEDLINEPLUS CONNECT RESOURCE IS A SEAMLESS API THAT ALLOWS YOU TO EXTRACT PATIENT-SPECIFIC INFORMATION FROM WITHIN AN ELECTRONIC HEALTH RECORD SYSTEM DIRECTLY INTO A PATIENT'S PORTAL OR PATIENT'S INFORMATION SHEETS, AND PROVIDING -- GETTING INFORMATION DIRECTLY FROM SOME OF OUR SISTER INSTITUTES IS REALLY QUITE HELPFUL. AS YOU CAN IMAGINE AROUND ALL THE RESEARCH WORLD, WE ARE ALSO GETTING -- ACCELERATING OUR USE OF CLOUD SERVICES. BLESS YOU. STRIDES, AS I INDICATED EARLIER, IS AN NIH FUNDED INITIATIVE TO PUT VERY LARGE DATASETS INTO CLOUD SERVICES THAT WILL ALLOW FOR BOTH PUBLIC ACCESS AS WELL AS COMPUTE IN A MORE EFFICIENT WAY, YOU DON'T NEED TO DOWNLOAD THE RESOURCES. OUR PARTICULAR CONTRIBUTION RIGHT NOW IS TO MOVE THE SHORT READ ARCHIVE INTO THE STRIDES -- UNDER THE STRIDES MAN TELL, IF YOU WILL, UNDER THE STRIDES INITIATIVE. WE ARE MAKING 100% REPLICATES OF THE SRA IN GOOGLE AND IN AWS, SO INDIVIDUALS ARE ABLE TO ACCESS THIS AND THEN THE STORAGE IS AT A VERY, VERY LOW COST TO NIH. THE USES WOULD BE THEN AT THE COST TO AN INDIVIDUAL. WE'RE MOVING THE STRIDES -- THE SRA, THE STRIDES AT ABOUT 150 TERABYTES A DAY, SO IT'S GOING TO TAKE US ABOUT FIVE MONTHS TO ACTUALLY MAKE THE WHOLE MOVE. IT'S A SIGNIFICANT RESOURCE BUT YOU THIS IS ALLOWING US BOTH THE TO TEST OFF OUT WHAT IT'S LIKE AS WELL AS WHAT WE'RE EXPECTING. INTERNALLY OUR OSIS GROUP HAS SET UP AN I.T. SERVICE DESK SPECIFICALLY FOR CLOUD RESOURCES SO THAT AS OUR INVESTIGATORS WITHIN THE NIH AS OUR SERVICE PROVIDERS WP THE NATIONAL LIBRARY OF MEDICINE START TO USE IT WE HAVE A CENTRAL PLACE FOR THEM TO GO FOR RESOURCES. OUR GEN BANK ACCESSION HAS EXCEEDED A BILLION RECORDS THIS YEAR. LOOK AT JILL, SHE'S JUST SMILING AWAY WITH THAT ONE. AND I ASKED THE NCBI TO GIVE US SOME INFORMATION ABOUT WHAT THE UTILIZATION OF THAT LOOKS LIKE AND IT'S DIFFICULT TO TELL BECAUSE MANY TIMES THE GEN BANK RESOURCE IS DOWNLOADED THEN SHARED LOCALLY, SO IT IS NOT THE SAME AS HITTING A PUBMED REPORT HIT BUT WE'RE VERY PLEASED TO SEE THIS RESOURCE GROWING AND ABLE TO MAKE MORE EFFICIENT USE OF OUR OTHER RESOURCES NOW THAT WE'RE USING THE CLOUD PLATFORMS. WE HAVE A NEW PROGRAM CALLED SDDP, AND I'M SORE OOO IF THERE'S AN NCBI PERSON IN THE ROOM CAN EXPLAIN THE ACRONYM, I DIDN'T HAVE IT WRITTEN DOWN. WHAT'S IMPORTANT ABOUT SDDP IS THIS, IT'S A DEMONSTRATION OF ACCESSING MULTIPLE UNIQUE DATA RESOURCES FROM A SINGLE POINT OF ACCESS AND THEN INTEGRATING THEM. œAMAZON TO DO A TEST CASE OFITH THIS, AND THE ENVISIONED WILL COMPUTE IN THE CLOUD ACROSS LARGE DATASETS IS ACTUALLY NOW POSSIBLE. SINGLE POINT OF ENTRY AUTHENTICATED GIVES A TOKEN TO A USER TO ALLOW ACCESS TO PARTICULAR DATA RESOURCES AND THEY ARE ABLE TO PULL AND INTEGRATE THOSE DATA RESOURCES. WHAT YOU'RE SEEING IS OUR DATASETS ARE GROWING AND OUR STRATEGIES FOR ACCESSING THEM, MAKING THEM USEFUL TO THE PUBLIC ARE GROWING. WE ARE NOT PUTTING HUMAN IDENTIFIABLE DATA INTO CLOUD RESORE RESOURCES AT THIS POINT IN TIME. WE DO RECOGNIZE AT SOME POINT IN THE FUTURE WE WILL HAVE LOTS OF CONVERSATIONS IT ON HOW TO SHARE DE-IDENTIFIED DATA, WITH SOME SECURITY, BUT AT THIS POINT IN TIME WE'RE FOCUSING ON OUR NON-HUMAN DATA. I WANT TO SPEND A LITTLE TIME TALKING ABOUT NCBI AND LIST TER HILL TOGETHER. AS YOU HAVE HEARD OVER THE LAST TWO YEARS, WE'RE TRYING TO INTEGRATE OUR RESEARCH PROGRAMS UNDER A SINGLE -- OUR INTRAMURAL RESEARCH PROGRAMS UNDER A SINGLE MANTEL, THE NATIONAL LIBRARY OF MEDICINE INTRAMURAL RESEARCH PROGRAM AND YET WE WILL CONTINUE TO HAVE TWO DISTINCT ORGANIZATIONAL UNITS, THE LISTER HILL CENTER AND THE NCBI, LOOSELY DIFFERENTIATED BY THE FACT THAT THE NCBI FOCUSES MORE ON MOLECULAR AND GENOMIC DATA AND THE LISTER HILL CENTER FOCUSES MORE ON CLINICAL INFORMATION BUT THERE'S ACTUALLY QUITE A BIT OF BLENDING, THERE'S CERTAINLY METHODOLOGICAL BLENDING. WE'RE VERY EXCITED TO LAUNCH NLM LABS, OUR VERY OWN LITTLE SKUNKWORKS HERE INSIDE THE NATIONAL LIBRARY OF MEDICINE. WE ANTICIPATE HAVING EITHER INVESTIGATOR INITIATED OR STAFF INITIATED PROJECTS THAT WE CAN TEST OUT IN A YEAR AND RUN. THIS YEAR WE'RE TESTING A COUPLE OF NEW WAYS OF ANNOTATING GENE INFORMATION AND LOOKING AND ANNOTATING THE LITERATURE. I EXPECT THIS YEAR WE PUT ABOUT A QUARTER OF A MILLION DOLLARS INTO NLM LABS, I'D LIKE TO PUT 500,000 INTO IT NEXT YEAR AND THEN DOUBLE IT SO WE GET TO A POINT AT A STEADY POINT OF ADDING ABOUT A MILLION TO MILLION AND A HALF OF REAL EXPERIMENTAL WORK, OPPORTUNITIES TO LOOK AT NEW IDEAS AND WE'RE ENCOURAGING ACROSS ALL OF OUR STAFF TO COME UP WITH CREATIVE IDEAS. THE NLM LABS IS ORGANIZATIONALLY HOUSED WITHIN THE LISTER HILL CENTER WHERE WE HAVE A TEAM COMING TOGETHER TO BUILD A STRATEGY FOR INITIATING AND EVALUATING PROJECTS BUT WE WANTED TO LET YOU KNOW WE'RE LAUNCHING. BUT AS WE'RE LAUNCHING, WEE ALSO STABILIZING RESOURCES. MANY OF OUR LARGE DATASETS THAT HAVE BEEN AVAILABLE AND USED AROUND THE COUNTRY QUITE A BIT HAVE BEEN NOW MOVED INTO AN ARCHIVE WHERE THEY REMAIN AVAILABLE AND ACCESSIBLE BUT NOT AS PUBLICLY MANAGED. WE'RE EXPANDING OUR DIGITAL COLLECTIONS AND PARTNERSHIP WITH THE LISTER HILL CENTER AND THE HISTORY OF MEDICINE DIVISION, WORKING TO MAKE SURE BOTH WILL OUR VIDEO RESOURCES AS WELL AS OUR DIGITAL COLLECTIONS ARE AVAILABLE. POINT NUMBER THREE, WE'RE IN THE MIDST OF A SEARCH FOR A SCIENTIFIC DIRECTOR. THIS IS EXCITING FOR US. WE HAVE HAD UP UNTIL THIS TIME TWO SCIENTIFIC DIRECTORS, ONE FOR LISTER HILL CENTER, ONE FOR NCBI, WE ARE SEEKING A SINGLE SCIENTIFIC DIRECTOR WHO WILL BE THE OVERSEER, THE INS IT TI GATOR, THE MOTIVATOR OF OUR RESEARCH -- IN THE FUTURE. WE ARE LOOKING FOR A HIGHLY QUALIFIED INDIVIDUAL WITH AN OUTSTANDING RESEARCH RECORD AND ALSO HAS AN INTEREST IN HELPING TO REIS RESHAPE AN INTRAMURAL RESEARCH PROGRAM INVESTMENTS IN HIGH LEVEL COMPUTING, ANALYSIS OF IMAGES. THE SER SEARCH OFFICIALLY HAS A DATE OF MAY 18TH BUT WE WILL KEEP OPEN UNTIL IT'S FILLED. IN ADDITION TO THAT, WE HAVE PI OFFERS. WHAT THAT MEANS IS WE'VE MADE OFFERS TO THREE NEW INVESTIGATORS THIS YEAR AND HAVE HAD POSITIVE RESPONSE, WE DON'T HAVE FIRM COMMITMENTS FROM ANYONE YET, BUT PART OF THAT IS THE HR PLO SES OF PROCESS OF THE GOVERNME NT JUST TAKES FOREVER. BUT WE'RE VERY EXCITED, A TEAM INTERVIEW DOLLARS INTERVIEWED A NUMBER OF CANDIDATES AND WE SETTLED ON THREE INVESTIGATORS WHO WILL BE JOINING THE INTRAMURAL RESEARCH PROGRAM. IN ADDITION WITH SOME OF THE EXPERIMENTAL WORK THAT'S BEEN GOING ON WITHIN NCBI RELATED TO PUBMED LABS AND PMC, WE NOW HAVE A DATA ACCESS BOX AVAILABLE SO WE'RE MAKING TATA DATA MORE VISIBLE FROM THE SITES FROM THE CITATIONS, RATHER, AS I INDICATED EARLIER, WE ARE ENCOURAGING INVESTIGATORS TO MAKE GOOD USE OF GOOD PUBLIC REPOSITORIES. WE HAVE A RELATIONSHIP WITH FIG SHARE AND -- WHERE DATA DEPOSITED IN THESE RESOURCES CAN BE BACK-PROPAGATED AND TAGGED TO ARTICLES THAT ALREADY EXIST SO WE'RE WORKING TO KEEP THE INTERCONNECTIONS BETWEEN THE DATA RESOURCES. THE LIST TER HILL CENTER IS WORKING ON ADMINISTRATIVE SIMPLIFICATION, NCBI HAS BEEN WORKING ON REORGANIZING THEIR ADMINISTRATIVE PROCESSES FOR ABOUT THE LAST YEAR SO WE HAVE A LOT OF THINGS NOT QUITE AS INTERESTING -- BUT NONETHELESS VERY EXCITING FOR US THAT WE'RE BRINGING IN MORE EFFICIENT USE OF OUR ADMINISTRATIVE STAFF AND WE ARE HOPING TO BE ABLE TO RENOVATE PART OF BUILDING 38 AS WE ARE ALSO CONTINUING OUR PLANS TO BE RENOVATING BUILDING 38A. 38A IS THE TALL RESEARCH BUILDING, WE KNOW TO BRING IN NEW INVESTIGATORS SWRE TO MAKE THE SPACE MORE ACCESSIBLE FOR THEM SO WE EXPECT TO BE MODIFYING THE NINTH FLOOR OF 38A, A LOWER LEVEL, THE B1 AREA FOR 38A WHICH WILL ALLOW FOR THE CLINICALTRIALS.GOV STAFF TO FINALLY MEET TOGETHER IN ONE PLACE. AS YOU CAN WELL IMAGINE, GETTING FEDERAL PROCESS, IT TAKES FOREVER TO GET THIS DONE. WE ARE VERY, VERY, VERY, VERY EXCITED ABOUT A LOT OF OF STRATEGY TO INCREASE THE NLM STAFF'S COMPETENCIES IN DATA SCIENCE. LED BY DIANE BABSKI AND A TEAM FROM ACROSS THE NLM, WE DID A DATA SCIENCE READINESS ASSESSMENT WITH OVER 750 OF OUR STAFF PARTICIPATING IN THIS, EACH PERSON, WE GOT A PERSONA, COULD TAKE SOME SKILL TEST. MY SKILLS ARE ACTUALLY NOT -- BETTER AS A DIRECTOR FRANKLY THAN AS DATA SCIENTIST. WE HOSTED A KICKOFF MEETING IN SEPTEMBER AND HAD A DATA SCIENCE BASIC COURSE FOR 90 MINUTES IN APRIL OF THIS YEAR. WE HAVE OVER 500 STAFF MEMBERS ATTENDED THAT. WE'RE JUST BEGINNING TO LAUNCH AN INTENSIVE 120-HOUR COURSE FOR INDIVIDUALS WHO ARE LOOKING FOR REALLY DEEPENING SKILLS IN DATA SCIENCE AND WE HAVE HAD OVER 200 APPLICATIONS FOR THAT COURSE. ESSENTIALLY THE POSITION THAT I'VE TAKEN IS DATA SCIENCE READINESS IS AN NLM ASSET. WE NEED TO CONSIDER IT LIKE WE CONSIDER ANY OTHER ASSET WE HAVE THAT -- HAS TO BE SKILLED IN CERTAIN WAYS THAT WE DON'T HAVE THE SETS OF SKILLS WE NEED, WE NEED TO ADD THOSE SKILLS IN. YOU THE COMMEND I COMMEND THE GROUP, THEY WORK CLOSELY WITH BOOZ ALLEN HAMILTON, EVERY PERSON WHO PARTICIPATES WILL HAVE AN INDIVIDUAL EDUCATION PLAN THAT MAY TAKE THEM OVER SOME YEARS TO FULFILL. IN ADDITION TO WORKING WITH THE DATA SCIENCE, WE'RE ALSO WORKING THROUGH THE NATIONAL LIBRARIES OF MEDICINE THROUGH THE ALL-OF-US PROGRAM AND TRAINING EDUCATION CENTER IN PITTSBURGH HAVE BUILT A SERIES OF RESOURCES TO SUPPORT PARTICIPANTS AND CLINICIANS WHO ARE ENGAGING PEOPLE IN THE ALL-OF-US RESOURCE. WHAT YOU SEE HERE ON THE LEFT-HAND SIDE, THOUGH, WAS A VERY EXCITING EVENT WE HOSTED HERE, A YOUTUBE LIVE BROADCAST WITH DR. COLLINS, AND -- THEY SPENT ABOUT A HALF AN HOUR ONE EVENING IN MARCH TALKING TO THE COUNTRY AND WE HAD OVER 500 PEOPLE TUNED IN, WE GOT SIMULTANEOUS ENGLISH AND SPANISH TRANSLATION AND HAD A CONVERSATION TO ENCOURAGE PEOPLE TO KEEP PEOPLE MOTIVATED AND ENGAGED WITH THE PROCESS. WHAT YOU SEE ON THE RIGHT-HAND SIDE IS AN EXPLANATION OF HOW OUR TRAINING AND EDUCATION PLATFORM IS BUILDING OUT THE INFORMATION NECESSARY TO SUPPORT THE ALL-OF-US PROGRAM. ONE OF THE OPPORTUNITIES THE ALL-OF-US PROGRAM HAS ALLOWED US TO ENHANCE OUR NATIONAL LIBRARIES OF MEDICINE PROCESS FOR OVERALL TRAINING RESOURCES. SO THIS PARTNERSHIP HAS BEEN A VERY POSITIVE PARTNERSHIP FOR US, AND WE'RE REALLY PLEASED TO BE WORK OHING WITH THEM. WE ARE DOING OTHER TYPES OF ENGAGEMENT AROUND THE WORLD, ESPECIALLY SPECIFICALLY TO DO MORE OUTREACH THROUGH THE WEB AND MORE OUTREACH TO SPANISH-SPEAKING COMMUNITIES. SO WHAT YOU SEE HERE IS A MODIFICATION OF OUR MEDLINEPLUS MAGAZINE STILL AVAILABLE IN PAPER, PAPER IS PROBABLY GOING AWAY AT SOME POINT BUT WE DON'T HAVE A CLEAR TIMELINE FOR THAT BUT WE'RE ENHANCING OUR MEDLINEPLUS, THE MAGAZINE WEBSITE. NOW THIS IS A LITTLE CONFUSING HERE BECAUSE WE HAVE MEDLINEPLUS AS A BASIC CONSUMER LEVEL INFORMATION, MEDLINEPLUS, THE MAGAZINE IS ACTUALLY A MECHANISM BY WHICH WE SUPPORT NIH IN GETTING NIH DISCOVERIES OUT TO THE LATE PUBLIC. WHAT YOU SEE IS IT'S AVAILABLE ON THE WEBSITE IN MULTIPLE PLATFORMS INCLUDING TABLET PLATFORMS THERE SO WE'RE ACTIVELY GOING INTO OUR ENGAGEMENT. WE CONTINUE TO DO A NUMBER OF DIFFERENT OPPORTUNITIES AROUND WORKFORCE DEVELOPMENT AND TRAINING. WE HAVE MADE A MAJOR STEP WITHIN THE INTRAMURAL PROGRAM TO HARMONIZE THE TRAINING ACROSS THE N WITH NCBI AND LIST IT TER HILL PROGRAMS SO WE HAVE A NUMBER OF SUMMER TRAINEES THAT COME THROUGH THERE AND WE'VE MOVED TO A SINGLE POINT OF APPLICATION, COMMUNICATION. WE'VE HELD A COUPLE OF WORKSHOPS WORKSHOPS, I-SCHOOL WORKSHOP, WHAT OUR SCHOOLS ARE INTERESTED AND ABLE TO DO FOR TRAIBING IN DATA SCIENCE AND HOW WE'RE ABLE TO SUPPORT THAT. THE REPRODUCIBILITY WORKSHOP IS OUR SECOND OCCURRENCE OF A STRATEGY TO HELP SEE IF WE CAN ENHANCE REPRODUCIBILITY OF SPECIFIC ARTICLES, WORKING WITH A SMALL GROUP OF -- SWORD OF A CODE-A THON ACTIVITY, TO PRODUCE THE ACTUAL ANALYTICS. WHAT WE'RE FINDING IS REPRODUCIBILITY IS REALLY HARD UNLESS YOU CAN TALK TO THE INDIVIDUAL WHO WROTE THE ARTICLE AND EVEN THEN, IT DOESN'T WORK VERY WELL. WE'RE WORKING TO FOSTER THE IDEA OF LIBRARIES INFORMATIONISTS, WE PARTNER WITH THE MEDICAL LIBRARY ASSOCIATION SOME TRAINING ACTIVITIES. ALSO CONTINUING TO SUPPORT INFORMATION APPLICATIONS SUPPORTED ON ADDITIONAL RESEARCH GRANTS AND WE'RE LOOKING FOR BETTER WAYS TO ENHANCE THE DATA SCIENCE PREPARATION FOR OUR LIBRARY PARTNERS AROUND THE COUNTRY, IN PARTICULAR, THE LIBRARY SCIENCE COMMUNITY REALLY HAS BEEN CALLED ON MORE AND MORE IN THE ACADEMIC HEALTH SCIENCE CENTER TO BE THE POINT WHERE INTEGRATION HAPPENS AND NEED TO UPSKILL THE LIBRARY SCIENCE. I WAS AT EMORY UNIVERSITY, THEY ARE GETTING CALLED ON ALMOST DAILY TO LOOK AT THE UTILIZATION AND IMPACT OF RESEARCH OR TO FIND -- TO DEPOSIT DATA AND WE ARE WORKING TO MAKE SURE THE MEDICAL LIBRARY STAFF HAVE THEIR TOOLS. THEN AS I SAID, OUR DATA SCIENCE AT NLM IS ONE OF OUR BIG AND EXCITING INITIATIVES LEER. WE CONTINUE TO BE SUPPORTING OPEN SCIENCE POLICIES AND PRACTICE. I MENTIONED TO YOU EARLIER HOW OUR RESEARCH IS GROWING IN PUBMED CENTRAL, 1 MILLION ARTICLES THAT ARE NIH FUNDED. THAT'S ONLY 25% OF WHAT'S IN MED CENTRAL. THERE ARE ARTICLES FROM FULL PARTICIPATION JOURNALS, WE SERVE AS PUBLIC ACCESS REPOSITORY FOR OTHER FEDERAL AGENCIES AND WE CONTINUE TO GET A VERY LARGE NUMBER OF USERS, ABOUT 2 1/2 MILLION USERS A DAY TO PUBMED TRAL, ABOUT 5 MILLION A DAY TO PUBMED SO GETTING QUITE A BIT OF USE AROUND THE COUNTRY. MY REMARKS ARE GOING TO CLOSE BY TELL YOU GO WHO THINGS THAT'S HAPPENING IN OUR EXTRAMURAL PROGRAMS. ONE IS SPECIFIC TO WORK THIS COMMITTEE DID IN THE LAST MEETING AND THAT WAS TO -- WE PROVIDED A SPECIAL -- A NOTICE OF SPECIAL INTEREST AS A MESSAGE TO THE PUBLIC THAT SAYS NLM IS INTERESTED IN PARTICULAR KINDS OF RESEARCH, THIS ONE HAS TO DO WITH BIAS AND INCOMPLETENESS IN HEALTH DATASETS. POOR REPRESENTATION, AS WELL AS INCOMPLETE OR BIASED DATASETS THAT MIGHT CONTRIBUTE TO ERRONEOUS ANALYSIS, AND WE ARE ACCEPTING -- WE HAD NOT SET ASIDE SPECIFIC FUNDS, WE ARE ENCOURAGING PEOPLE TO WRITE TO PROPOSE UNDER OUR GENERAL RESEARCH PROJECTS, GENERAL RESEARCH FUNDING ACTIVITY IN THIS AREA. I'M PARTICULAR PLI INTERESTED IN HOW THIS MIGHT HELP US YOU, BOTH MAKE USE OF EXISTING LARGE DATASETS AS WELL AS CLINICAL DATA RESOURCES. FINALLY I WANT TO CALL ATTENTION TO SBIR AND STTR. WHAT VALERIE'S GROUP IS TO I VOT OUR SBI R/STTR INVESTMENT, WE MUST SPEND A CERTAIN AMOUNT OF OUR MONEY EVERY YEAR ON ESSENTIALLY BUSINESS STIMULATION, AND WE PUT OUT A NOTICE TO EXPLAIN, WE'RE REALLY LOOKING FOR TOOLS AND AREAS THAT MAY BETTER HELP AND ENHANCE THE DATA SCIENCE INITIATIVES SO RATHER THAN BROADLY TAKING ANYTHING THAT COMES OVER THE TRANSOM, WEE REALLY FOCUSING SPECIFICALLY IN SOME KEY AREAS. YOU SEE DECISION SUPPORT, CONSUMER SUPPORT, USE OF FORMAL AND INFORMAL DATA SOURCES TO TRACK DISEASE OUTBREAKS, SO WE'RE LOOKING TO STIMULATE INDUSTRY IN THESE AREAS AND I WILL CIRCULATE THESE SLIDES FOR YOU. I BELIEVE I'M READY TO TURN IT OVER. DINAH, IT'S YOUR TURN. >> THANK YOU VERY MUCH. WE'LL HAVE TIME FOR CONVERSATION AFTER DINAH'S REPORT. >> GOOD MORNING. I'M JUST GOING TO GIVE A VERY BRIEF OVERVIEW OF A FEW LEGISLATIVE ACTIVITIES AND POLICY UPDATES THAT WE HAVE. OH, BUDGET FIRST? OKAY. SO AS YOU MAY KNOW, THERE HAS BEEN THERE HAS BEEN QUITE A OF ACTIVITY IN THE APPROPRIATIONS REALM. THIS PICTURE DEPICTS THE AMOUNT OF MONEY THAT NLM IS PROPOSED TO RECEIVE FOR THE UPCOMING FISCAL YEAR 2020. SO THIS GRAPH SHOWS WHAT THE FUNDS HAVE BEEN OVER THE LAST FIVE YEARS OR SO WITH ABOUT $344 MILLION APPROPRIATED TO NLM IN 2015 WITH A PROPOSED -- WITH THE 442 MILLION FOR 20 NEEN. THE PRESIDENT'S BUDGET REQUEST IS TYPICALLY LOWER THAN THAT, THAT WE'RE APPROPRIATED BUT WE'RE LOOKING AT ABOUT 20 MILLION MORE -- I MEAN, 20 MILLION MORE THAN WHAT WE'VE RECEIVED IN THE PREVIOUS BUDGET YEARS. >> ACTUALLY I DO DO THINGS OUT OF ORDER, I APOLOGIZE. I'LL SPEAK TO THIS ONE FOR JUST A MOMENT. WHAT YOU SEE ON THE SLIDE HERE IS PART OF OUR THINKING TOWARDS THE FEW YOU TOUR, IS A REORGANIZATION OF THE NATIONAL LIBRARY OF MEDICINE OPERATIONS AND WE DO HAVE -- GONE THROUGH A PERIOD OF ABOUT 18 MONTHS PRESENTING A CONCEPT PLAN, IDENTIFYING NEW SPACES AND US A MAY RECALL IN THE FEBRUARY MEETING, WE IDENTIFIED THAT WE HAD CLOSED THE SPECIAL -- AND INTEGRATED STAFF ACROSS THE LIBRARY AND CREATED ALSO SOME OF OUR APDBR AUDIO VISUAL PROGRAM DEVELOPMENTS BRANCH ACROSS THE LIBRARY. HERE YOU SEE OUR CURRENT ORGANIZATION. WE NOW HAVE FOUR MAJOR DIVISION AND OUR STAFF HAVE JOINED IN LIBRARY OPERATIONS, SOME IN THE LISTER HILL CENTER AND THEN ACROSS THE IT TECHNICAL PART IN OSIS AS WELL AS THE COMMUNICATIONS AND THE OH OFTION OF COMMUNICATIONS AND PUBLICLY YOU PUBLIC LIAISON. WE'RE MOST EXCITED TO ANNOUNCE TO YOU THE OPENING OF A NEW OFFICE OF TRAINING AND ENGAGEMENT WITHIN THE LIBRARY OPERATIONS AREA. SO THIS WILL BE A FOCAL POINT FOR INTEGRATING INFORMATION OUTREACH SERVICES, COMMUNICATION TRAINING COORDINATION, WHICH HAS NOW BEEN DONE AT VARIOUS POINTS ALMOST ALL THE WAY ACROSS THE LIBRARY. WE ARE NOT MOVING TERRAINING STAFF INTO THE LIBRARY OPERATIONS BUT RATHER WE HAVE A POINT OF COORDINATION AND EVALUATION AND THERE WILL BE A BETTER AND MORE FOCUSED ENGAGEMENT WITH OUR NATIONAL NETWORK OF LIBRARIES OF MEDICINE SO WHAT SHOULD BE DONE IN THE LOCAL COMMUNITIES WILL BE DONE IN THE LOCAL COMMUNITIES, WHAT NEEDS TO BE DONE NATIONALLY WILL BE DONE HERE. THANKS, DINAH. I'M SORRY ABOUT THAT. >> NO PROBLEM. OKAY, HERE WE GO. HERE ARE THE NUMBERS AGAIN, NOT IN THE GRAPH FORMAT BUT YOU'LL SEE THAT THE FISES CAL FISCAL YEAR 2020 PRESIDENT'S BUDGET IS WITH $33 BILLION FOR NIH AND ABOUT $380 MILLION FOR NLM, AND THAT WHICH IS PASSED IN THE HOUSE IS 463 MILLION FOR THE NLM. WE ALSO WANTED TO BRING TO YOUR ATTENTION A FEW LEGISLATIVE AND POLL WILL SEE UPDATES AND SOP TOPICS OF INTEREST THAT WE'RE FOLLOWING. THERE'S MUCH MORE INFORMATION INCLUDED IN YOUR E-BOOK WITH REGARDS TO PRIVACY LEGISLATION AND ALSO SOME INTEREST IN HEALTH INFORMATION EXCHANGE AS WELL AS ARTIFICIAL INTELLIGENCE BUT WE DID WANT TO BRING TO YOUR ATTENTION. SO MOVEMENT WITH THE FEDERAL ADVISORY COMMITTEE ACT AMENDMENTS. THIS BILL WAS INTRODUCED, IT HAS PASSED IN THE HOUSE, AND IT WOULD MAKE A NUMBER OF CHANGES TO THE FACA STATUTE WHICH WOULD AFFECT THE PROCESS OF APPROVING AND APPOINTING FEDERAL ADVISORY COMMITTEES, INCLUDING COMMITTEES SUCH AS THIS ONE, VARIOUS WORKING GROUPS AND ALSO THE PEER REVIEW SYSTEM. THROUGH THIS ACT, WHICH NIH AND HHS ARE VEMENTLY OPPOSED TO AND HAVE EXPRESS THREUD LETTER, ADVISORY COMMITTEE MEMBERS WOULD, IN ORDER TO BECOME A MEMO BERKS WOULD HAVE TO GO THROUGH A PROCESS OF BECOMING A SPECIAL GOVERNMENT EMPLOYEE. THIS WOULD INCREASE TIME AND EFFORT AND PAPERWORK IN ORDER TO BE ABLE TO APPOINT MEMBERS. ALSO DR. WOULD BE A LOT OF DISCLOSURE THAT THE PUBLIC WOULD BE ABLE TO COMMENT ON AS WELL AS WHAT'S -- EXCUSE ME -- RELATED TO WHAT THESE MEMBERS -- WHO THEY ARE AND WHAT THEY DO, AND SO WE'RE REALLY TRACKING THIS TO SEE HOW THIS WOULD AFFECT OUR COMMITTEE APPOINTMENTS, AS WELL AS OUR PEER REVIEW SYSTEM. SO WE'LL BE ABLE TO KEEP YOU UPDATED ON THAT AS THIS MOVES FORWARD, BUT THERE IS A LOT OF CONCERN, NOT ONLY FROM HHS BUT OTHER AGENCIES AS WELL. THE SAVE THE INTERNET ACT OF 2019 HAS ALSO PASSED IN THE HOUSE. WE'RE WATCHING THIS. IT WOULD RESTORE NET NEUTRALITY REQUIRING INTERNET PROVIDERS TO TREAT ALL CONTENT THE SAME. THIS IS VERY IMPORTANT TO US BECAUSE OF FREE AND OPEN INTERNET IS ESSENTIAL IN ORDER FOR US TO BE ABLE TO SHARE TRUSTED HEALTH INFORMATION WITH THE SCIENTIFIC COMMUNITY. WE REPORTED AT THE LAST BOARD OF REGENTS MEETING ON THE FOUNDATIONS FOR EVIDENCE BASED POLICY MAKING ACT. THIS INCLUDES THE OPEN GOVERNMENT DATA ACT WHICH REFERS TO ADMINISTRATIVE OR ENTERPRISE DATA. THE IMPLEMENTATION OF THIS IS IN PROGRESS. WE'RE CURRENTLY WORKING WITH HHS AS WELL AS OMB TO DETERMINE WHAT THE DEFINITIONS ARE OF DATA AND HOW THIS WOULD APPLY TO THE RESOURCES THAT NIH AND NLM MAINTAIN. YOU ALSO MAY HAVE HEARD US MENTION BEFORE A POLICY DEVELOPMENT PROGRESS -- DEVELOPMENT FOR DATA MANAGEMENT AND SHARING. NIH RELEASED A REQUEST FOR INFORMATION LAST FALL. COMMENTS HAVE BEEN RECEIVED AND THERE HAVE BEEN A LOT OF ONGOING NIH DELIBERATIONS REGARDING THE COMMENTS THAT WERE RECEIVED AS WELL AS HOW WE CAN MOVE FORWARD IN RELEASING A DRAFT POLICY, WHICH WOULD BE AVAILABLE AGAIN FOR A LONGER PUBLIC COMMENT PERIOD, WE'RE HOPING FOR 90 DAYS. WE'RE VERY HOPEFUL AT THIS POINT THAT MAYBE A DRAFT POLICY WILL BE OUT LATER THIS SUMMER. SO WE'LL KEEP YOU UPDATED ON THAT AND HOPE THAT YOU LOOK FOR THAT SO THAT YOU CAN PROVIDE COMMENTS TO US. AND I THINK THAT IS IT. >> WE HAVE TIME NOW FOR QUESTIONS AND COMMENTS. THANKS VERY MUCH, DINAH. >> FOR THE FACA LEGISLATION, WHAT'S THE GENESIS ON THAT? WHAT DO YOU THINK IS MOVING THOSE GLSH THE NOTION OF THESE CHANGES OR THE AMENDMENTS TO THIS BILL HAVE BEEN ONGOING FOR A VERY LONG TIME. IT'S NOT NEW, PER SE, BUT IT SEEMS TO BE GETTING A LOT MORE TRACTION. I'M NOT EXACTLY SURE WHAT THE IMPETUS REALLY IS BEHIND IT OTHER THAN BEING MORE TRANSPARENT AS TO WHO COMMITTEE MEMBERS ARE, WHO PEER REVIEWERS ARE, WHAT CONFLICT OF INTEREST IS AND THINGS LIKE THAT. >> ON A POSITIVE SIDE, I THINK THE IDEA OF TRANSPARENCY, ESPECIALLY AROUND CONFLICT OF INTEREST, IS IMPORTANT. ON THE LESS THAN POSITIVE SIDE, TO ME ONE OF THE CONCERNS WE HAVE IS IT IS A MISGUIDED ATTEMPT TO PUT OVERSIGHT OORND SCIENTIFIC REVIEW. OUR CONCERN HERE SPECIFICALLY, YOU ALL HAVE TO GO THROUGH THIS PROCESS, NOT OUR FEDERAL EMPLOYEES BUT ALL OF OUR APPOINTEES, YOU HAD TO GO THROUGH ALL OF THAT FINANCIAL DISCLOSURE, BUT WHEN YOU'RE A REVIEWER, YOU DON'T HAVE TO GO THROUGH ALL THAT FINANCIAL DISCLOSURE. IF YOU NOTICE TODAY WE FINALLY GOT YOU APPOINTED AFTER OVER A YEAR, AND IF WE HAD TO DO THAT FOR ALL OF OUR 38,000 REVIEWERS, IT WOULD PUT -- IT WOULD JUST BASICALLY -- THE PEER REVIEW PROCESS. SO WE ARE A BIT CONCERNED THAT PART OF THE STRATEGY IS AN ATTEMPT TO REALLY PUT A DIFFERENT MODEL OF DECISION-MAKING IN FOR RESEARCH REVIEW. >> I HAVE A QUESTION. >> OKAY. >> SO YOU'RE DOING A LOT OF TRAINING CLEARLY IN DATA SCIENCE. >> YES. >> AND I THINK THIS IS WONDERFUL BECAUSE THERE'S WHOLE LANGUAGE THERE THAT MOST OF US WITH TRADITIONAL -- SO JUST UNDERSTANDING THAT IS FANTASTIC. THEN YOU USE THE WORD LIBRARIANS AND INFORMATIONISTS. >> YES. >> SO NOW SPECULATING A LITTLE BIT, DREAM A LITTLE BIT, WHERE IS IT GOING, WHAT'S THE NEXT STEP? WHAT DOES THAT MEAN PRACTICALLY? >> IF I CAN WAVE MY MAGIC WAND TODAY, IT WOULD MEAN THAT WHAT LIBRARIANS KNOW ABOUT ORGANIZING AND CODIFYING DATA WOULD ACTUALLY EXTEND TO CLINICAL DATA AND SCIENTIFIC DATA. IT WOULD ALSO MEAN THAT OUR OUR LIBRARY SITES AND OUR LIBRARIAN STAFF AROUND THE COUNTRY WOULD HAVE THE RESOURCES AND FRANKLY THE CAPACITY TO SUPPORT DATA MANAGEMENT AT A VERY SOPHISTICATED LEVEL ON THEIR CAMPUSES: CAN YOU FIND THIS, SUDDENLY MUSHROOMING, WHERE I SEE THE BEST PROGRESS IS IN INSTITUTIONS THAT HAVE A CLOSE RELATIONSHIP BETWEEN THE LIBRARY AND THE CTSA OPERATIONS, THE CLINICAL AND TRANSLATIONAL SCIENCES GROUP. I WOULD BE VERY INTERESTED IN SOME GUIDANCE FROM THE LIBRARIANS ON THIS COMMITTEE OF WHAT THE NLM COULD DO TO BETTER SUPPORT THE LIBRARIANS ON THE CAMPUSES. AT THE SAME TIME, THE NEED FOR THEM AND THEIR DESIRE FOR THEIR SERVICES HAS NEVER BEEN GREATER AND THEY STILL SUFFER FROM THE NICE LADIES WITH BOOKS MODEL OF LIBRARIANSHIP. SO ON ONE HAND, [INAUDIBLE] THEY'RE FUNDED STILL IN MANY PLACES, THE ISSUE IS WE DON'T NEED THE BOOKS IF YOU CUT THE BUDGET SO -- >> SO YOU'RE LOOKING ACTUALLY THEN, IF I'M UNDERSTANDING CORRECTLY, THE LIBRARIAN IS BECOMING THE COLLABORATOR WITH THE RESEARCH. >> ABSOLUTELY.& -- START THE INFORMATIONIST PROGRAM? >> ORIGINALLY I WAS STILL [INAUDIBLE] AND EDITORIAL WAS PUBLISHED IN A MEDICAL JOURNAL ABOUT BUILDING ON THE VALUE OF CLINICAL LIBRARIES AND SAYING THIS COULD EXTEND INTO ALL AREAS OF SCIENCE AND RESEARC WHERE THE LIBRARIAN IS A KEY PARTNER IN DECISIONS THAT ARE MADE ABOUT WHAT TO CAPTURE ABOUT METADATA AND STUFF LIKE THAT, SO FOLLOWING FROM THAT, NLM HAD A FELLOWSHIP PROGRAM FOR A WHILE, SUPPLEMENT PROGRAM, RESEARCHERS FROM OTHER INSTITUTES TO ENCOURAGE THE DEVELOPMENT OF THIS. AND I THINK IT DOESN'T SCALE EASILY, BUT IT'S STILL -- THERE ARE PEOPLE WHO WANT TO DO IT AND THERE ARE PEOPLE WHO NEED THE SERVICE. >> I THINK THIS IS FANTASTIC. OUR INSTITUTION WAS BUILDING A -- GROUP DEALING WITH GENOMIC [INAUDIBLE] AND WE HAVE A LIBRARIAN WHO ALSO WOULD LOVE TO DO MORE DATA SCIENCE WORK. HOW DO YOU ROLE THIS OUT TO THE NEXT LAYER -- >> I THINK THAT'S A GREAT QUESTION TO WHICH WE DON'T HAVE AN ANSWER. AND I'M NOT SURE IT'S SOMETHING YOU CAN SIT DOWN AND ADVANCE AND IMPLEMENT, IT'S SOMETHING YOU HAVE TO FIGURE OUT AS YOU GO ALONG. BUT THIS IS NOT SOMETHING THAT NIH JUST CAME UP WITH IN A VACUUM. THIS IS VERY MUCH WHAT'S GOING ON IN LIBRARIES. FOR YEARS, LIBRARIANS HAVE BEEN POSITIONING THEMSELVES -- RESEARCHERS, PHYSICIANS AND EDUCATORS AND GOING FORWARD, THAT'S ONLY GOING TO INCREASE. THE VALUE IN A LIBRARY IS IN ACCOMPLISHING ITS PARENTS' INSTITUTION'S GOALS, AND NOT BY BEING A STANDALONE UNIT WITH ITS OWN AGENDA AND ITS OWN DRUMMER TO MARCH TO. >> SO THIS IS A MESSAGE THAT I HAVE TO GET OUT TO OUR RESEARCHERS BECAUSE THIS IS A WHOLE -- >> AND I BET YOUR YOUNG ENTHUSIASTIC LIBRARIAN WOULD LOVE TO HELP WITH YOU THAT. >> I THINK SHE'D LOVE IT. AND I'LL PUT HER IN TOUCH WITH THE NLM AND SAY THEY HAVE TRAINING COURSES FOR YOU OR ARE YOU NOT THERE YET? >> NATIONAL NETWORK OF LIBRARIES OF MEDICINE HAS A WHOLE PAGE ON DATA TRAINING. SHE CAN GO DIRECTLY TO THE PAGE, YOU CAN HELP HER GET CONNECTED. >> THERE'S AN EIGHT-SESSION COURSE THAT WAS OFFERED IN THE SPRING, ALSO SELF LEARNING ACTIVITIES. I'M SURE THE MLA IS GOING TO HAVE A CERTIFICATE IF THEY DON'T HAVE IT YET, I'M SURE THEY'RE GOING TO HAVE SOME CREDENTIALING FOR THIS. >> I UNDERSTAND THAT'S IN THE WORKS. >> THEN WE HAVE OUR OTHER -- SCHOOL CONNECTIONS BETWEEN OUR TRAINING PROGRAMS AND INFORMATION SCHOOL, KIND OF SMALL SCALE NOW, WAYS OF TRYING TO BILTD BILD THAT INTO INFORMATION LIBRARIES' CURRICULA. >> [INAUDIBLE] >> I THINK AS YOU MENTIONED, VALERIE, THE REAL ISSUE FOR THOSE OF US WHO HAVE BEEN INVOLVED IN THIS AREA FOR A LONG TIME, AND JANUARY AND I ARE AT INSTITUTIONS THAT HAVE BEEN DOING THIS IN MANY WAYS FOR QUITE SOME TIME, AS WELL AS MANY OTHER ACADEMIC HEALTH SCIENCE CENTERS, BUT THE REAL ISSUE IS SCALABILITY. YOU CAN DO THIS IN VARIOUS WAYS AND BE FAIRLY SUCCESSFUL BUT THE LIBRARY IS LIMITED IN TERMS OF NUMBER OF PEOPLE, NUMBER OF FTEs AVAILABLE TO DO THIS. WHAT WE SORT OUT WILL BE VERY DIFFERENT FROM ONE INSTITUTION TO ANOTHER. SOME IBS INSTITUTIONS WILL GET ON BOARD AND SAY THE LIBRARY NEEDS TO SUPPORT THESE INFORMATIONISTS, WHETHER IT'S CLINICAL RESEARCH OR BASIC SCIENCE OR CLINICAL MEDICINE, NEED TO BE ABLE TO PROVIDE PEOPLE TO DO THIS. OTHERS WILL SORT OF SAY, WELL THIS, RESEARCH GROUP NEEDS TO JUST SORT OF BUY ONE OF THESE PEOPLE, ROW THEIR OWN KIND OF THING, HYBRID VERSIONS OF THAT, WHETHER WITHIN THE LIBRARY OR WITHOUT, IT WILL GROW IN MANY DIFFERENT WAYS. THINK THE NEED IS BEING INCREASINGLY RECOGNIZED THAT THERE NEEDS TO BE SOMEBODY THERE WITH THIS EXPERTISE WHEREVER THEY'RE BASED. AND HOPEFULLY THE LIBRARY WILL HAVE SOME CONNECTION WITH THAT. BUT IT MAY NOT BE FROM WITHIN THE LIBRARY IT SELF. >> ONE OF THE KEY CHALLENGES SEEMS TO BE WHETHER OR NOT THE LIBRARY IS FUNDED THROUGH A CENTRAL LIBRARY OH RANGE OF MOTION OR IT'S FUNDED THROUGH THE PARTICULAR SCHOOLS AND IN OUR CASE PUBLIC HEALTH NURSING MEDICINE AND THERE APPEARS TO BE -- THE RECOGNITION THAT LIBRARIAN AS A RESEARCH PARTNER SEEMS TO BE MOVING A LITTLE FASTER IN PLACES WHERE THE LIBRARIES -- THE MEDICAL OR HEALTH SCIENCE LIBRARY IS PART OF THE LARGER SYSTEM. I DON'T KNOW IF THAT'S BEEN YOUR EXPERIENCE BUT WHEN THEY'RE PART OF THE MEDICAL SCHOOL, THEY DON'T ACTUALLY SEEM TO HAVE THAT MORE BROADER BASE. >> I THINK ALSO AS YOU MENTIONED, PATTY, THE CTSA CONNECTION. THAT IS A HUGE BOOST TO BE ABLE TO HAVE AN INROAD WITH THE RESEARCH COMMUNITY. AND AGAIN, THAT MAY BE MORE CLINICAL IN SOME CASES AND MORE BASIC SCIENCE IN OTHERS. BUT THAT'S A REAL KEY TO SORT OF, I THINK, GET KIND OF THE PLATFORM AND THE CREDIBILITY TO BE SEEN AS BEING A PARTNER. AS THE RESEARCH COMMUNITY. >> ALSO WITH THE I--SCHOOL COULD NECK, I WANTED TO MENTION THAT THE AMERICAN LIBRARY ASSOCIATION HAS A PROJECT UNDERWAY LOOKING AT WHAT LIBRARIES -- LIBRARY AND INFORMATION SCHOOLS ARE TEACHING AND WHETHER THEY ARE GRADUATING STUDENTS WHO ARE PREPARED TO STEP INTO A ROLE IN A LIBRARY. I KNOW TUFF UNIVERSITY SCIENCES LIE BREAB IS ON THAT COMMITTEE, SO HE WOULD BE A GOOD PERSON TO CONNECT WITH AROUND THIS ISSUE OF DATA SCIENCES TRAINING IN THE I-SCHOOLS. >> DR. FEDERER. >> I WANT TO SPEAK TO TWO SPECIFIC ACTIVITIES RELATIVE TO THIS ONE. ONE IS -- WE HAD A WORKSHOP HERE AT NLM THAT BROUGHT TOGETHER ABOUT A DOZEN PEOPLE THAT ARE WORKING IN LIBRARIES DOING THIS REALLY ADVANCED DATA SCIENCE WORK AS WELL AS HIGH SCHOOL FACULTY WHO ARE INTERESTED IN DEVELOPING THIS IN THEIR STUDENTS, AND THE DAY AND A HALF WORKSHOP HAD AS ITS SORT OF GOL TO FIGURE OUT WHAT ARE THE SKILLS THAT LIBRARIANS WILL BE NEEDING TO DO THESE SORTSZ OF SERVICES. IT'S NOT NECESSARILY A SET OF SKILLS THAT YOU HAVE THAT ARE PART OF YOUR JOB THAT YOU'RE GOING TO DO RIGHT NOW SO MUCH AS SKILLS TO KNOW HOW TO DO COMPUTATIONAL THINKING SO THAT YOU'RE ABLE TO LEARN WHATEVER THE NEW PROGRAMMING LANGUAGE IS FIVE OR 10 YEARS FROM NOW. SO WE WILL BE ISSUING A REPORT ABOUT FINDINGS FROM THAT WORKSHOP. THE OTHER PIECE IS THERE IS AN MLA SPECIALIZATION THEME BEING DEVELOPED FOR DATA SERVICES. I AM CHAIRING THAT COMMITTEE WITH SEVERAL REALLY EMINENT DATA LIBRARIANS LOOKING AT AGAIN WHAT ARE THOSE SKILLS AND THAT WILL BE USED FOR DEVELOPMENT FOR THE MLA OVER THE NEXT COUPLE YEARS. >> ALONG WITH THIS IDEA OF HOW THE LIBRARY -- MAKING DATA MOVE, CLEM AND I HAVE BEEN WORKING WITH THE SCIENTIFIC DATA COUNCIL OF THE NIH TO UNDERSTAND THE IMPORTANCE OF STANDARDS BASED DATA, WHETHER THEY BE RESEARCH DATA OR DATA EXTRACTED FROM THE CLINICAL AREA AND BROUGHT INTO THE RESEARCH PROCESS. THERE WILL BE A NOTICE IN THE GUIDE SOMETIME SOON, CLEM? >> YES. >> THAT WE THINK IS A LITTLE PREMATURE BUT IS RIGHT MINDED IN THE SENSE THAT THE NIH SUDDENLY DECIDED THEY SHOULD ASK ALL RESEARCHES TO EXPORT THE DATA FROM THEIR RESEARCH PROJECTS USING THE FIRE STANDARD WHICH IS A DMEUNCATION COMMUNICATION STANDARD, IT DOES MAKE SOME SENSE BUT WE'RE NOT QUITE AT THE POINT OF HAVING TOOLS FOR THE RESEARCHERS TO DO THIS SO WE'RE ANTICIPATING NIH, WE'RE HOPING TO GUIDE NIH TOWARDS MAKING SOME INVESTMENTS THIS SUMMER TO BUILD TOOLS THAT WOULD ALLOW RESEARCHERS TO BEGIN TO EXPERIMENT, WHAT DOES IT MEAN TO EXPORT YOUR DATA IN A FIRE STANDARD AND HOW COULD THAT BE USED BY OTHERS. >> I HAVE A QUESTION FOR COLONEL -- SHE MENTIONED MEDLINE CONNECT AND I WAS JUST WONDERING, IS THE MHS GENESIS PRODUCT ASSOCIATED WITH THAT OR IS THAT -- >> WE'RE STILL WORKING ON DEVELOPING -- CONNECTIONS BOTH FROM A REF RENGS CONTENT VERSUS CONTENT DEVELOPING STANDARD EVIDENCE BASED MEDICINE -- TO THE AUTOMATION OF THE TOOL THAT HAD TAS. >> IS HAS. >> THAT BECAUSE THE VENDOR ITSELF HAS NOT MADE THAT CONNECTION? >> THE VENDOR ALREADY HAS ONE BASIC CONNECTION MOSTLY AROUND HEALTH, PERSONAL HEALTH -- I DON'T THINK THEY USE -- I'D HAVE TO GO BACK AND LOOK WHICH ONE THEY USE FOR PERSONAL HEALTH INFORMATION SO FOR THE PATIENT,& BUT NOT YET FOR THE PROVIDER. THE ONLY THING THEY HAVE RIGHT NOW FOR THE PROVIDER IS MORE TOOLS TO AUTOMATE THINGS LIKE CONNECTING -- TO ICD10 TO MAKE IT EASIER FOR YOU TO DO THE CROSSWALK, WHICH IS VERY EXPENSIVE BY THE WAY, WE NIED KNEAD TO FIND A CHEAPER VERSION BECAUSE WE CAN'T AFFORD IT. THAT BEING SAID, WE HAVE MULTIPLE ISLANDS OF ACCESS TO THE REFERENTIAL TOOLS FOR THE CLINICIANS UP TO DATE, PUBMED, IT REALLY DEPENDS ON WHAT HOSPITAL YOU'RE IN, WHAT SERVICE YOU'RE IN, WHAT PART OF THE COUNTRY YOU'RE IN, AND WE'RE TRYING TO CONSOLIDATE THAT SO IT LITERALLY IS ALL RIGHT WITHIN THE MEDICAL RECORD SO THAT AS YOU'RE INTERACTING WITH THE PATIENT, YOU DON'T HAVE TO GO SOMEWHERE ELSE TO DO IT. IN MAKING IT HAPPEN. SO DEFINITELY WOULD LOOK FORWARD TO FIGURING OUT HOW TO PARTNER TO MAKE THAT WORK. >> JUST TO CLARIFY, THANK YOU FOR YOUR QUESTION, MEDLINEPLUS CONNECT DESPITE THE MEDLINE NAME, IS CONSUMER PATIENT LEVEL INFORMATION THAT PROVIDES PATIENT LEVEL INFORMATION, NOT THE CLINICIAN. THANK YOU. >> OKAY. WE HAVE A BREAK NOW, BUT JUST A LITTLE BIT OF LOGISTICS BEFORE THEN. AFTER THE BREAK, AT 10:30, WE BREAK UP INTO OUR WORKING GROUPS. THE PUBLIC SERVICE AND STRATEGIC PLANNING GROUPS WILL BE IN HERE AT EITHER ENDS OF THE ROOM, RESEARCH FRONTIERS IN CONFERENCE ROOM B WHICH IS ACROSS THE MESS MEZZANINE, AND COLLECTIONS WILL BE IN JERRY'S OFFICE, WHICH I THINK IS -- >> JUST BEHIND THE DIRECTOR'S -- HERE. >> SO YOU WILL BE GONE. >> . >> GONE SO WE'RE IN OUR WORKING GROUPS UNTIL 11:45, THEN WE GO DOWNSTAIRS TO IE21. IS THAT THE ROOM RIGHT BELOW HERE WITH THE LOVELY FLOOR? >> I DON'T KNOW. IS IT? YES, THAT IS THE ONE IT IS. >> HISTORY OF MEDICINE, TAKE A PICTURE ON THE BENCH? IS THAT THE PHOTO? >> YEAH, IT IS, IT'S HMB. >> AND WE HAVE A PHOTOGRAPH TAKEN AND THEN THE LUNCH IS DOWNSTAIRS IN THE ROTUNDA. >> YES. >> PLEASE ENJOY OUR BANNER EXHIBITS THAT ARE UP. I BELIEVE THAT IF YOU WOULD -- IT'S STILL UP. >> OKAY. THANK YOU VERY MUCH. COFFEE. >> WE ARE GOING TO START AGAIN, THANK I SO MUCH FOR THE WAS VERY GOOD AND SO WERE THOSE- KHOBGALATE TREATS. SO WE HAVE A GUEST AND DR. DON RUCKER IS THE NATIONAL COORDINATE FOR HEAR TPELGT INFORMATION TECHNOLOGY FOR THE DEPARTMENT OF HEALTH AND HUMAN SERVICES, OFFICE OF THE SECRETARY AND HE'S BEEN IN THAT POSITION SINCE APRIL OF 2017. HE COMES TO THE POSITION FROM THE OHIO STATE UNIVERSITY WHERE HE WAS CLINICAL PROFESSOR OF EMERGENCY MEDICINE AND BIOMEDICAL INFORMATICS AND FROM PREMISE HEALTH A WORK AREA WHERE HE SERVED AS CHIEF MEDICAL OFFICER. HE'S A GRADUATE OF HARVARD COLLEGE AND UNIVERSITY OF PENNSYLVANIA SCHOOL OF MEDICINE, BOARD CERTIFICATIONS IN EMERGENCY MEDICINE, INTERNAL MEDICINE AND CLINICAL INFORMATICS. WELCOME DR. RUCKER. >> THANK YOU. >> YOU MISS THE MOST IMPORTANT PART OF MY BIOI WAS IN THE FIRST COHORT OF MLM FELLOW FELLOWS. [ APPLAUSE ] >> YOU CAN COMMENT IT ON AND WAS ALSO ON THE BOARD OF SCIENTIFIC COUNSELORS AND SPENT MANY HOURS IN THIS ROOM. SO LET ME GIVE YOU A BIT ABOUT WHAT ONC IS DOING AND SORT OF WHERE WE ARE AND I THINK MAYBE MORE BROADLY WHERE THE ADMINISTRATION IS ON THE HEALTHCARE INFORMATION TECHNOLOGY. YOU KNOW I THINK THE FIRST OBSERVATION WHICH IS BLISTERINGLY OBVIOUS IS THE WHOLE COMPUTER WORLD HAS CHANGED AND WE'RE ALL ON SMART PHONES SO THE VERY CAPABILITIES, YOU KNOW THAT WE HAVE NOW BASICALLY ARE REDEFINING THE LANDSCAPE. WE'VE ALREADY REDEFINED THE CONNECTICUT SAOUPLER LANDSCAPE--CONSUMER OUTSIDE OF HEALTHCARE, IT'S BECOMING COMPUTING AND RESOURCES AND BEHAVIORS AND SO WHERE WE CAN SHOP WITH IMPUNITY, YOU KNOW ONLINE, YOU KNOW BUY AIRLINE TICKETS, DO OUR BANKING AND HEALTHCARE, WE REALLY HAVE ALMOST NONE OF THAT AND OBVIOUSLY THERE WAS A BROADER PICTURE BECAUSE WE DON'T REALLY HAVE ANY KIND OF REAL FREE MARKET IN HEALTHCARE, I MEAN IT'S LARGELY A CREATION OF ESSENTIALLY GOING BACK TO WORLD WAR II, BUT CERTAINLY WITH THE ADVENT OF MEDICARE AND 65 JUST LAYERS AND LAYERS AND LAYERS OF SORT OF VARIOUS INCENTIVES THAT HAVE DRIVEN--DRIVEN OUR IT SPACE TO BE A VERY EMR CENTRIC KIND OF WORLD, THAT'S AS WE ALL KNOW THE BELT ENVIRONMENT, THIS HAS NOT ESCAPED THE NOTICE OF CONGRESS AND SO, IN DECEMBER OF 2016, CONGRESS PASSED THE 21st CENTURY CURES ACT. NOW YOU MAY BE MORE FAMILIAR WITH THAT ACT FROM WHAT IT DID FOR CLINICAL TRIALS WITH THE FDA, AND SORT OF EVIDENCE YOU KNOW, THE WAY THAT GUIDANCE AND THE WAY THAT FDA SHOULD THINK ABOUT EVIDENCE BUT THERE'S A SECTION THERE TITLE FOUR THAT REALLY IS PURELY ABOUT HEALTHCARE IT. AND IN THAT SECTION, THERE ARE TWO BIG GOALS. ONE GOAL IS LET'S JUST REDUCE THE BURDEN ON PROVIDERS, RIGHT? SO ALL THE OFFICES ON THE HILL ARE LOBBIED INCESS ANTLY ABOUT THE WHOLE STACK OF BURDENS, YOU KNOW, MEANINGFUL USE, ALL OF IT AND FOR DOCS, IT ALL TRANSLATES INTO ONE BIG GOOLOSH, THAT NOBODY WHO'S JUST AN AVERAGE CLINICIAN CAN TEASE OUT WHY THEY DON'T LIKE IT AND THEY THEY JUST KNOW THEY DON'T LIKE IT AND SOMEHOW THERE'S BAD STUFF IN THERE SO THEY DON'T THINK ABOUT IT BUT YOU KNOW WE HAVE TO THINK ABOUT IT SO FOR THAT PART, WE DID WHAT CMS, A CLINICIAN BURDEN REPORT. I THINK THERE ARE THREE INTERESTING AREAS ONE IS ON DOCUMENTATION, RIGHT? MOST NOTES, AND THE PRIVATE SECTOR AND THE MEDICARE SECTOR ARE BASICALLY FAKE. RIGHT? MOST OF THE LANGUAGE IS JUST THESE LEVEL FOUR AND FIVE BOILER PLATE NOTES AND FINDING ACTUAL DATA IS NEAR IMPOSSIBLE. SO WE'VE TAKEN A TKPWAPBDER AT THAT, THAT WAS AN INTERESTING POLITICAL EXPERIENCE. TO SAY THE LEAST, BUT THERE ARE ALSO SOME INTERESTING COMPUTER EXPERIENCES AROUND PRIOR AUTHORIZATION WHICH THEN GOES INTO DECISION SUPPORT AND PRICE TRANSPARENCY, THERE'S ALSO A VERY INTERESTING OPPORTUNITY IF WE DO APIs RIGHT IN TO THINK--INSTEAD OF HAVING ALL THESE QUALITY MEASURES THAT ARE BUILT, THAT ARE PURPOSE BUILT FOR QUALITY BUT DON'T REALLY HAVE ANY MAJOR USE BEYOND THE METRICS THEMSELVES, IF WE GET ALL THE APIs RIGHT AND HAVE THE DATA STANDARDIZED ENOUGH, ON SOME LEVEL WHETHER THAT'S TRUE STRUCTURE NLP, WE WILL BE IN A POSITION TO ACTUALLY GIVE REAL QUALITY MEASURES, HAVE THE APIs WHERE THE PAYORS GO BACK IN TO THE UNDERLYING EHR, GET ALL THE DATA, UNDER MACHINE LEARNING, THEY HAVE ALL THE DAILY BASIS THEA UNDER HIPAA, TREATMENT, PAYMENT, OPERATIONS AND THEN WE CAN USE THE TOOLS THE NLM HAS BEEN WORKING ON FOR ALL THESE YEARS TO REALLY PUT A LOT OF ANALYSIS OVER THE WHOLE PATTERN OF CARE. SO THAT'S ONE OF THE AREAS PROVIDER BURDEN, THE SECOND AREA IS INTEROPERABILITY AND WHAT CURES ACT REQUIRES THERE, CURES ACT PUT IN THREE BIG MECHANISMS FOR INTEROPERABILITY THAT HAVE BEEN ESSENTIALLY ONC AND TWO SOME EXTENT CMS'S WORK PRODUCT OVER THE TWO YEARS THAT--OF THIS ADMINISTRATION HAVE UPDATED BACK, TO DECEMBER OF 2016 AND TRUTH BE KNOWN, A LOT OF THAT WORK WAS PUT IN BY THE OBAMA ADMINISTRATION AND THE NATIONAL COORDINATORS THERE. SO THERE'S A REAL CONTINUITY. IN FACT ON THE PANEL WITH KAREN DESALVO, AT D ELL MEDICAL SCHOOL WHERE SHE IS NOW, THERE'S A REAL CONTINUITY OVER THESE THINGS BECAUSE THEY DON'T REALLY HAPPEN WITHIN SHORT PARTS OF THE TERM AND FOR INTERROPERABILITY, THE THREE CONSTRUCTS THAT WERE PUT OUT THERE, ONE IS THIS NOTION OF A TRUSTED EXCHANGE FRAMEWORK COMMON KPWRAEPLT AND SO WHAT THAT--COMMON AGREEMENT AND WHAT THAT IS IS THE SENSE THAT WELL WE HAVE A NUMBER OF HIEs AND THEY DON'T NECESSARILY TALK TO EACH OTHER AND THEY SHOULD TALK TO EACH OTHER AND SO THEREFORE THEY SHOULD HAVE A COMMON AGREEMENT TO TALK TO EACH OTHER. IT'S A BIT OF AN ESPERANTO APPROACH TO HOW YOU DO THIS, BUT IT'S CONGRESS. AND SO, THEY BASICALLY SAID, YOU SHALL DO THIS, SO THIS WE HAVE OUT AS WITH THE REST OF OUR ROLE, CMS ROLE FOR PUBLIC COMMENT AS WE SPEAK, THE OVERALL RULES, NOTICE OF PUBLIC RULE MAKING COMMENT CLOSES JUNE 3rd JUNE 3rd, QUICKLY, THEY THE TRUST EXCHANGE FRAMEWORK STUFF CLOSES JUNE 17th, BUT BASICALLY WHAT WE SORT OF TOOK OUT OF THE LAW, IS TO HAVE A SERIES OF HIEs THAT WE CALL QUALIFIED INHIBITORSS, INFORMATION THAT WORKS SO YOU GO THROUGH THE QUERY AND THROUGH THE COUNTRY AND FIND THE PATIENT'S CHART. SO THIS IS SORT OF BROAD BASED QUERY, TARGETED QUERY, MANAGING PUSH-PULL MESSAGING OVER THAT AND THEN THE LOCAL HIEs CAN GO ABOUT THEIR BUSINESS AS THEY SEE FIT CONNECTED TO THESE OVERALL Q-INS HAD--THERE IS A NOTICE OF FUNDING OUT FOR A RECOGNIZED COORDINATINGENTITY, THAT WILL BE RECOGNIZED BY ONC, TO ADMINISTER THE COMMON AGREEMENT THAT HAS TO BE SOMEBODY WHO'S NOT ALSO IN THE BUSINESS, THE Q-INs HAVE TO BE PREEXISTING ALREADY DOING HEALTH INFORMATION EXCHANGE SO YOU CAN'T DE NOVO DECIDE YOU WANT TO BE A Q-INHIBITORS, ALL OF THAT IS OUT ARE FOR COMMENT, ALL OF IT SITS UNDER HIPAA, THE IT'S IN THE LAND OF HIPAA AND THE TWO BIG OTHER AREAS OF INTEROPERABILITY THAT ARE SITTING IN 21st CENTURY CURES ONE IS A PROHIBITION AGAINST INFORMATION BLOCKING. SO THERE'S BEEN A LOT OF INFORMATION ABOUT WHAT THE BUSINESS MODEL FOR SHARING DATA AND THERE IS NO BUSINESS MODEL, THOSE KIND OF DISCUSSIONS AND I THINK INTUITIVELY CONGRESS REALIZES THAT IN MANY, MANY CASES, THE BUSINESS MODEL AND AMERICAN HEALTHCARE RIGHT NOW, IF YOU'RE ON THE PRIVATE SECTOR IS TO BUY EVERY HOSPITAL THAT COULD POSSIBLY BE A COMPETITOR AND THEN ONCE YOU HAVE A--YOU KNOW SORT OF MONOSOPONY, IF YOU WILL, PRICING POWER, STICK IT TO THE INSURERS, THAT IS THE BUSINESS MODEL AS YOU GO ALONG THE AMERICAN LANDSCAPE. >> IT WORKS FOR PARTNERS. >> IT WORKS FOR MANY OF THEM, NOT TO MENTION ANY PARTICULAR NAMES IN THE EARLY PIONEERS IN THAT APPROACH AND IT RAISES PRICES FOR THE APPROXIMATE UBIQUITINNATION LICK AND GOOD THING I WAS WITH BETH ISRAEL THAT WENT PRACTICES BEING IN THE RED TO BEING IN THE BLACK BECAUSE WE COULD UNDERCUT PARTNERS AND MAKE MONEY BECAUSE IT DYNAMICALLY CHANGED THE PRICING POWER FROM BLUE CROSS OF MASSACHUSETTS TO PARTNERS IN ONE INSURANCE CYCLE IF YOU REMEMBER BACK TO THE MID90S. OBVIOUSLY THAT KIND OF MODEL, WHY WOULD YOU SHARE, THE WHOLE POINT IS TO BUILD NETWORKS AND PREVENT LEAKAGE. SO CONGRESS HEARD THERE ARE INFORMATION BLOCKING COVERS CERTIFIED ELECTRONIC HEALTH RECORDS, HEALTH INFORMATION EXCHANGES, HEALTH INFORMATION NETWORKS AND PROVIDERS. THE EXCHANGES NETWORKS ARE EXTREMELY LOOSELY DEFINED SO THERE'S A MAJOR FOOD FIGHT IN D. C. AS WE SPEAK TO WHO IS AN EXCHANGER OR A NETWORK, FOR EXAMPLE, OUR PAYORS EXCHANGES OR NETWORKS. AND THEN WHAT IS ELECTRONIC HEALTH INFORMATION IN HIPAA HAS A DEFINITION THAT INCLUDES PAST, PRESENT, FUTURE PAYMENT SO THAT THEN BECOMES A QUESTION OF DOES IT MEAN THAT THIS LAW IMPLICAICATES PRICE TRANSPARENCY? RIGHT? WHICH AS YOU WOULD IMAGINE IS SORT OF PRETTY NUCLEAR KIND OF THING IN D. C. INFORMATION BLOCKING, WE ARE CHARGED. SO INFORMATION BLOCKING IS'LL LEGAL AS WE SPEAK TODAY, RIGHT, SO SOME OF THE OTHER THINGS I WILL TALK ABOUT APIs, YOU KNOW, FINAL RULE AND THEN A COUPLE YEARS TO IMPLEMENT THEM, INFORMATION BLOCKING IS ILLEGAL, AS A PRACTICAL MATTER WON'T BE ENFORCEABLE TILL WE FINALIZE A RAINFALL BECAUSE WE'RE CHARGED UNDER CURES ACT WITH COMING UP WITH ALLOWABLE EXCEPTIONS. SO THEY'RE ALLOWABLE EXCEPTIONS ON PRIVACY, SECURITY, SYSTEM FAILURE, THERE ARE ALSO SOME REQUIREMENTS THAT HR VENDORS AND PROVIDERS NEED TO IN VARIOUS SITUATIONS NEED TO LICENSE THE API ON COSTS REASONABLY INCURRED. WE HEARD FROM MULTIPLE, MULTIPLE STAKEHOLDERS THAT THERE'S NO REAL INTEROPERABILITY BECAUSE LET'S SAY THE VENDORS WILL CHARGE A MILLION DOLLARS TO OPEN UP AN API. SO, THAT'S INFORMATION BLOCKING. THE OTHER PART IS CONGRESS REALLY GOT THE LESSON ON APPLICATIONS MR. IICATION PROGRAMMING INTERFACES, SO BASICALLY, SO THE LANGUAGE THAT IS IN CURES IS THAT APPLICATION PROGRAMMING INTERFACES SHOULD EXIST WITHOUT KPERBL EFFORT. RIGHT, SO THE LEGAL COP STRUCTURALLY IN CURES, SO OUR PROPOSED RULE HAS THAT AND THEN WE'RE INTERPRETING THAT BASICALLY AS PROVIDERS NEED TO MAKE FREE FOR PATIENTS APIs USING INDUSTRY STANDARDS, BROAD INDUSTRY STANDARDS, NOT HL72, FOR THE MOST PART. TO PATIENTS APP OF THEIR CHOOSING SO THAT YOU CAN PICK WHATEVER HEALTHCARE APP YOU WANT, WHETHER IT'S MICROSOFT, I GUESS THEY'RE OUT OF THE HEALTH BUSINESS NOW, BUT YOU KNOW WHATEVER APP YOU WANT, YOU CAN PUT IT AT AN END POINT FOR THE PROVIDER AND GET YOUR INFORMATION FOR FREE AND THAT BUILDS--IT BUILDS UP THE VIEW, DOWNLOAD, TRAPEZIUS MITT AND THIS SORT OF FAIRLY KHRUFRPBGY PORTAL STUFF THAT WAS STATE-OF-THE-ART AS RECENTLY AS A COUPLE YEARS AGO, THAT'S MADERNITTY AND FOR THAT WE ARE PWAEFBGLY USING RESTFUL [INDISCERNIBLE] AND FIRE FOUR FOR DOING THAT. THAT'S REALLY WHERE THE WORLD IS GOING AND WE THINK THAT IS GOING TO BE TRANSFORMATIVE. WE THINK THAT IS GOING TO OPEN UP ALL KINDS OF STUFF ON THE INITIAL GO,A ROUND. IT WILL BE RIGHT AS OPPOSE TO READ RIGHT BECAUSE IT'S VERY COMPLICATED TO DO RULE MAKING INTO THE INEREDS OF AN EHR FOR A HUGE VARIETY OF TECHNICAL ISSUES, BUT WE THINK IT IS GOING TO BE ABSOLUTELY TRANSFORMATIVE THERE. YOU KNOW THERE WILL BE INTERESTING THINGS FOR NLM, I THINK ON DATA AND FIELDS AND FIRE, I SEE CLEM OVER THERE WHO I KNOW HAS BEEN INVOLVED IN THAT AS HAVE OTHER FOLKS HERE, LINDA IN THE BACK THERE SO A HUGE AMOUNT OF INSTITUTIONAL HISTORY HERE ON NLM'S PIONEERING WORK ON WHAT GOES INTO THIS AREA, SO KUDOS THERE. AN INTERESTING ADD-ON THAT WE HEARD FROM FOLKS IN PARTICULAR IN KEN MEADOW'S GROUP, IN THE FIRE FOUR FOR THE FIRST TIME ARE POPULATION LEVEL DATA SUPPORT. SO THE ORIGINAL CONCEPT OF FIRE IS REALLY QUERY FOR N-OF-ONE AS OPPOSE TO A POPULATION, YOU KNOW THE DATABASE CAN SUPPORT IT, THE DATABASES, RIGHT, BUT THERE WAS NO PROPOSAL, IT TURNS OUT THAT THE PAYORS ARE INCREDIBLE LOAMACYY INTERESTED, THEY ARE GETTING CHARGED FIVE DOLLARS A POP FOR ELECTRONIC DOWNLOAD OF A CHART. SO PAYORS ACTUALLY HAVE HISTORICALLY BEEN THE VERY POOR POSITION TO GET DATA TO DO ANY OF THIS STUFF THEY MIGHT REALLY DO AND SO, ALL--ESSENTIALLY ALL OF THE BIG U.S. PAYORS ARE WORKING IN THIS DA VINCI PROFIT NONPROFIT HLSEVEN SPONSOR GROUP, IT IS IN PART SPONSORED BY ONC AND WE ARE SORT OF, YOU KNOW JOINTLY WORKING ON POPULATION LEVEL QUERIES TO ALLOW THAT, THEY HAVE A NUMBER OF OTHER RELATED THINGS OUT THERE. THE BIG THING I THINK TO THINK ABOUT THAT I THINK WILL BE THE POLITICAL QUESTION DE JOUR ON ALL OF THIS IS HOW DOES THAT PLAY OUT WITH SECURITY AND PRIVACY, RIGHT? THE PEOPLE WHO DON'T WANT TO SHARE DATA ARE ALL OVER, WELL WE WANT TO PROTECT THE PATIENTS. SEEMINGLY THEY'RE INTERESTED IN PROTECTING THE PATIENT AT LEAST TO MY JADED EYE APPEARS TO BE PROPORTIONAL TO THE LACK OF TRANSPARENCY IN THEIR BUSINESS MODEL. BUT THAT MAY JUST BE MY VISUAL MISPERCEPTION WHO KNOWS. BUT IT'S INTERESTING. WHEN YOU THINK ABOUT SECURITY AND PRAOEUFSAY, SECURITY PEOPLE GET ALL TWISTED IN KNOTS, UNLIKE THIS GROUP WHO YOU KNOW JUST HAD CAREERS THINKING ABOUT TEASING OUT I.T. THINGS, IN THE BROADER POPPULESPOPULATIONS, YOU KNOW IT'S RUSSIANS, CHINESE, HACKERS IT BECOMES A MUMBO JUMBO OF STUFF, MEN WITH HIGHER YOU TEASE IT OUT IN TERMS OF PATIENT'S APPS, FIRST OF ALL THE API IS THE SAME API THEY'RE THEY'RE USING FOR THE PORTAL DOWNLOAD NOW SO THERE'S NO REAL DIFFERENCE OF ANYTHING, THE MECHANISMINGS GIVE PATIENTS A CHOICE AND YOU KNOW BECAUSE PATIENTS CONTROL THE DOWNLOAD, RIGHT? IT'S NOT--THE PATIENT HAS TO BRING THE APP, THE PATIENT IS THE ONE WHO HAS TO BE AUTHENT CASED SO IT IS REALLY A VERY PATIENT CONTROL STRATEGY FOR MORE DIRECTLY, THE--WE'RE USING O-OFF, TWO AND WE'RE USING BEST OF THE INDUSTRY STANDARDS HERE AND WE WANT TO BE IN THE POSITION OF HAVING IDIO SYNCRATIC HEALTHCARES THAT BECOME ONE-OFF AND DECAY AND ONE-UPPED AND THEN HEALTHCARE BECOMES A PREFERENTIAL AREA FOR,A TACK. THE BIGGER ISSUE THAT COMES UP WHICH IS A REAL ISSUE I HAD THE OPPORTUNITY TO HAVE A SENATE HEARING FOR MYSELF LAST WEEK [LAUGHTER] AS ONE COLLEAGUE FROM CMS IS, SECONDARY USE OF DATA. SO THE QUESTION IS ULTIMATELY CAN PATIENTS BE RESPONSIBLE WITH THEIR HEALTHCARE DATA THE WAY WE ARE WITH OUR BANKING DAILY BASIS THEA OR SOMETHING ELSE, RIGHT? SO THERE'S BEG YOUR PARDON SO MUCH PATERNALISM FOR SO LONG IN HEALTHCARE, THE BASE ASSUMPTION OF A LOT OF PEOPLE IS OH, WE AS ADULTS CAN'T TAKE CARE OF OUR DATA OR THINK ABOUT IT, THE PROVIDERS NEED TO DO IT, MY PERSONAL PHRAOEF IS THAT MOST PATIENTS WOULD RATHER BY AN MRI FOR $500 AND THINK ABOUT THEIR DATA RATHER THAN HAVING THE PROTECTED PROVIDER GIVE THEM THE MRI FOR 5000 AND YOU KNOW ALL THE ATTENDED PASS THROUGH THROUGH PAYERS, IT'S A REAL ISSUE, WE HAVE NOT FIGURED OUT AS EVERYBODY KNOWS CONSENT IN THE UNITED STATES FOR APPS. WE HAVE NOT FIGURED OUT SECONDARY USES OF DATA AND HOW TO DO THAT. THESE END USER--CLICK THROUGH END USER LICENSING AGREEMENTS, PROBABLY NEED TO ACTUALLY BE REPLACED BY SOMETHING LIKE HIPAA WHICH IS INTERESTING ENOUGH, IT'S 25 YEARS OLD, ACTUALLY GIVES PERMITTED USES AND PROHIBITS EVERYTHING ELSE, SO HIPAA ACTUALLY HAS TREATMENT PAYMENT OPERATIONS AS PERMITTED USES AND EVERYTHING ELSE IS PROHIBITED, SO WE MAY NEED TO GO TO SOMETHING LIKE THAT BUT THAT'S OBVIOUSLY MEANT FOR CONGRESS. I KNOW THERE'S BEEN DISCUSSION HERE ABOUT THAT A COUPLE NIH SPECIFIC THINGS ON CLINICAL DATA ELEMENTS AND FIRE THEY THINK NLM THAT I THINK IS HARD AT WORK ON, ONC DOESN'T WORK WITH NIH FOR SCIENCE, SAME FOR GENES, YOU KNOW WE'VE HAD DISCUSSIONS WITH THE FDA ON REAL WORLD EVIDENCE AND HOW YOU MIGHT GO ABOUT THAT. SO, LET ME--I THINK WE HAVE A COUPLE MINUTES FOR QUESTIONS, COMMENTS, THOUGHTS. >> WE HAVE TILL QUARTER OF TWO. , OKAY, ALL RIGHT. SO YOUR COMMENTS WE WERE HOPING TO GET--LET ME JUST SEE, AS DR. JOHNSON ON THE CALL RIGHT NOW? SO WE'LL HAVE AN OPEN DISCUSSION AT 1:30. >> OKAY, GREAT AND THEN IT'S ALL OPEN FOR COMMENT, SO THERE'S A CMS RULE AS WELL, A CMS RULE DOES A NUMBER OF THINGS. THE KEY PARTS OF THE CMS RULE ARE IT REQUIRES PAYORS ALA WHAT CMS IS DOING WITH 2.0 EXPOSING THEIR CLAIMS DAILY BASIS THEA THROUGH A FIRE INTERFACE FOR PAYORS TO DO THE SAME, RIGHT? SO MEDICARE OBVIOUSLY, CMS HAS BROAD POWERS, GIVEN THAT THEY'RE PURCHASING FOR MEDICARE ADVANTAGE, MEDICAID, YOU KNOW, S-SHIP, ALL THAT. ALL OF THESE ENTITIES, SO THEY'RE FOR EVERYBODY WHO OUCH TOUCHES THAT WHICH IS BASICALLY EVERYBODY. NOW, I THINK IT'S STILL A WORK IN PROGRESS, WHAT THAT API MIGHT LOOK LIKE AND THERE'S ALSO A COMPANION REQUIREMENT. THESE ARE AT THE MOMENT SUPPOSED TO START JANUARY 1st, THE PAYORS PROVIDE-SO IF YOU CHANGE A PAYOR THAT THEY--THE INCUMBENT PAIR WOULD PROVIDE THE NEW PAYOR WITH THE PATIENT'S DATA UP TO THE LAST FIVE YEARS. SO HAVING SOME CONTINUITY OF THINGS, AGAIN, IT'S NOT CLEAR WHAT THE MECHANISMS WOULD BE FOR THAT, IT'S, YOU KNOW, I THINK IT WILL NEED MAJOR THINKING IN TERMS OF WHAT THE I.T. INFRASTRUCTURE OF PAYORS IS, THAT WOULD SUPPORT THESE KIND OF THINGS. I THINK THEREYA A BROADER ISSUE THAT MAYBE WE CAN DISCUSS ABOUT THE WHOLE X-12 EVI WORLD, THE SEPARATION OF CLINICAL AND FINANCIAL DATA YOU KNOW THAT I THINK IS OUT THERE. WE MAY HAVE AN INTERESTING OPPORTUNITY TO THINK ABOUT HOW TO GET X12 IF YOU TALK WITH BILL STEDT AND HHS, HE'S HAD INTERESTING THOUGHTS ON CLINICAL AND FINANCIAL DATA IT WILL BE VERY HARD TO BUY ON VALUE, RIGHT? >> ABSOLUTELY. >> THEY'RE JUST SO DISCONNECTED FROM THE INFORMATION FLOWS, APIs, THE SYSTEMS THAT GENERATE THE DAILY BASIS THEA, THE SYSTEMS THAT INGEST THE DATA AND SO, THAT'S IN THE CMS RULE. THERE'S OTHER THINGS ON INFORMATION ON DISCHARGE TO PROVIDERS, TO PROVIDER DIRECTORS THAT THE CORE ONC RULE AND THE CMS RULES ARE NOTICE PROPOSED RULE MAKING UNTIL JUNE 3rd, THE TRUST EXCHANGE FRAMEWORK IS OUT FOR NOTICE OF PUBLIC RULE MAKING UNTIL JUNE 17th AND I THINK EVEN OTHER FEDERAL AGENCIES ARE NOT SAYING ANYBODY ELSE IS ALLOWED TO COMMENT ON THAT. SO I THINK--I WILL TURN IT BACK OVER TO YOU PATTY. >> THAT'S REALLY A LOT OF INFORMATION. I WANT TO PERSONALLY THANK YOU FOR THE COOPERATION WE'VE HAD WITH ONC, THAT NLM'S RELATIONSHIP WITH ONC HAS BEEN LONG STANDING AND ONGOING AND WE CAN'T DO WHAT CAN YOU AND THAT'S HELPFUL AND WE WANT TO SUPPORT YOU IN DOING IT. >> AND I'M A HUGE FAN OF ALL OF IT, [LAUGHTER] FOR THE LAST 35 YEARS OR SO. >> THAT'S GREAT. >> IT TKP-Z WITHOUT SAYING. >> TOM, WOULD YOU LIKE TO START THE DISCUSSION. >> WHERE DO I START? >> I KNOW YOU'VE BEEN EXCITED ABOUT THIS ONE. >> I'M THE CHIEF MILITARY OFFICER FOR THE MILITARY HEALTH SYSTEM, ONE OF MY DUTIES IS HELPING ROLL OUT GENESIS WHICH IS BASICALLY OUR NEW--I WOULDN'T SAY HEALTH MANAGEMENT SYSTEM, NONAPOPTOTIC TH--NOT EHR, BUT GOING TO PROVIDER BURDEN AND INTEROPERABILITY, IT'S ALL RELATED, WITH THE PROVIDER BURDEN PART, DO YOU FEEL OR HAS PEOPLE DISCUSS THE CONCEPT THAT YOU REALLY HAVE THREE DIFFERENT TARGETS WHEN YOU'RE STARTING TO USE EHR HEALTH MANAGEMENT SYSTEM, YOU'RE LOOKING AT REALLY HEALTH MANAGEMENT, HOW TO COORDINATE CARE WITHIN A SYSTEM& OR ENTERPRISE. YOU HAVE BILLING, IN OTHER WORDS HOW DO I CHARGE PEOPLE FOR IT AND YOU POINTED ON UTR THAT CAN BE SEPARATED OR INTEGRATED DEPENDING ON THE SYSTEM YOU'RE USING AND THE LAST PART WHICH IS A BYPRODUCT, YET IT'S THE MOST IMPORTANT THING IS REALLY THE HEALTH RECORDS SO THAT WE UNDERSTAND THE HEALTH OF OUR PATIENT AND THEN THE ABILITY TO DO RESEARCH ON IT, AND IT'S THOSE THREE SYSTEMS THAT OVERLAP THAT AND COP FUSES THE CORE PROVIDER AT THE POINT, WHAT INFORMATION DO I HAVE TO GATHER AND PUT INTO THAT CHART VERSUS WHAT SOMEBODY ELSE SHOULD DO. WHAT DO YOU THINK ABOUT THAT? >> WELL, I THINK--YOU KNOW, I THINK YOU HIT THE HEAD ON THE NAIL. IN THE PRIVATE SECTOR IT'S A LEGAL DOCUMENT SO YOU CAN GET SUED. MA INCREASE IN BODY NOT AN ISSUE FOR YOU ABOUT YOU I ASSURE YOU. >> IN CONGRESS IT IS BECOMING AN ISSUE FOR US NOW. >> SOMEBODY'S BEEN AN E. R. DOC FOR 30 YEARS, IT'S AN ISSUE. YOU KNOW, LOOK THERE'S A BROAD TRAGEDY BECAUSE OF INCENTIVES WE'VE CREATED, WE'RE NOT EVEN USING COMPUTERS FOR AUTOMATION. I WENT INTO THIS, I DID MY TRAINING AFTER RESIDENCY SO I WASN'T SOMETHING WHO HASSA LIKE A COMPUTER GEEK, LIKE ERIC, ERIC AND I WERE GRAD STUDENTS TOGETHER SO THINKING THIS IS PRETTY BROKEN AND ARE WAYS TO FIX IT AND THAT WAS MY MOTIVATING FACAS ACCOUNTOR AND I THINK STILL THERE'S BEEN ALMOST NO AUTOMATION IN HEALTHCARE WHEN YOU THINK ABOUT IT, RIGHT? WHEN YOU GO TO ANY OTHER BUSINESS IN THE WORLD, I MEAN, I WAS READING UP THAT MCDONALD SYSTEM STARTING TO USE CRYPTOG RAF SKPE BAKUGAN BLOCK CHAIN TO DO INVENTORY ON THEIR FOOD. LATENCY AND YOU KNOW, YOU KNOW WAL-MART IS USING IT TO MAKE SURE THE SPI SPINACH IS FRESH AND WHERE IT CAME FROM. I MEAN WE HAVE ALMOST NO REAL COMPUTING IN HEALTHCARE WHEN YOU GET RIGHT DOWN TO IT. SO THEN THE QUESTION IS HOW DO YOU UNTEASE THE THINGS AND FIX THEM BECAUSE YOU DO SORT OF HAVE TO FIX THEM ONE AT A TIME. THE FIRST EFFORT THAT WE WORKED ON IS THE ISSUE WITH DOCUMENTATION, I THINK THAT IS WHEN YOU JUST PUT CLOCK TO TIME WASTED, I THINK THAT'S THE BIGGEST, YOU KNOW TKPWRAT TUMOR SPECTRUMITOUS TIME SYNCH. IN 95, CPT RULES WERE PUT INTO AN AVERSIVE STIMULUS FOR PROVIDERS ON THE HIGHER LEVEL BILLING CODES. YOU KNOW THE LEVEL FOUR AND FIVE SO THESE TEN ORGAN REVIEW SYSTEMS AND INNATE ORGAN PHYSICAL EXAMS, YOU CAN ONLY--YOU CAN--IF YOU THINK ABOUT HOW DO I DEAL WITH THE MORAL HAZARD OF THAT, AS FAR AS I KNOW THIS ARE ONLY THREE WAYS THAT HAVE BEEN INVENTED OR THOUGHT ABOUT TO DEAL WITH THIS. AND I'M NOT TALKING ABOUT SOCIALIZING MEDICINE, THAT MIGHT BE A FOURTH BUT YOU KNOW IN THIS SORT OF GENERAL RUBRIC, CAN YOU EITHER PAY PEOPLE BY TIME, RIGHT, PUNCH A CLOCK. HERE'S THE THING, THAT BECOMES VERY COMPLICATED AND THESE CLINICAL ENVIRONMENTS BECAUSE EVERYBODY'S TIME SLICING, YOU CAN PAY PEOPLE WITH AN AVERSIVE STIMULUS, THE WAY WE DO IT NOW OR YOU CAN PAY PEOPLE ON SOME BLENDED AVERAGE RATE THAT HAS ITS OWN MORAL HAZARD AND NOT REQUIRE THE DOCUMENTATION. SO CAN YOU ADJUST FOR SPECIALTY, YOU CAN ADJUST FOR SEVERITY AND PAY FOR THINGS THAT SIT OUTSIDE THE DOCUMENTATION. WE ACTUALLY PROPOSE THAT IN LAST YEAR'S PHYSICIAN FEE SCHEDULE, THE AMA DREAMT UP AN ANALYSIS THIS THAT WOULD BE, WELL, I DON'T KNOW--YOU WOULDN'T BE ABLE TO REPLICATE THEIR MATH IF IT WERE IN A PEER REVIEWED PUBLICATION, LET ME PUT IT THAT WAY AND THE MATH YOU NEED TO REPLICATE WOULD BE ADDITION AND MULTIPLICATION OF TWO NUMBERS; TWO PAIRS OF TWO NUMBERS. ANY RATE, THEY CAME UP WITH THIS,AINAL SIS AND THEN FORMED IT TO ALL THE SPECIALIST SOCIETIES AND GOT EVERYBODY RILED UP AND YOU KNOW IN THE THEORY THAT YOU KNOW MONEY WOULDN'T BE PAID FOR SICK PEOPLE OR AS A SEPARATE THING THAT THEY DEPARTMENT CALCULATE THAT WOULD DO EXACT LYE THAT BUT THAT WOULD TAKE THE ENTIRE INCENTIVE FOR PERVERSE DOCUMENTATION AND TAKE IT OFF THE TABLE. SO THE WAY IT STANDS NOW, IT STANDS IN A METASTABLE STATE AND WOULD BE A BLENDED RATE, WOULD HAVE BEEN BLEND THROUGH TWO-FIVE CODES. THE WAY IT STANDS NOW IS THAT CODES ARE START NOTHING 21 WHICH OF COURSE IS THE NEXT ADMINISTRATION, SO, YOU KNOW MANANA, IS THAT THE TWO-FOUR CODES ARE BLENDED AND THE FIVE CODE JUST IS AS IS, WHICH OF COURSE IS WHERE MOST OF THE DOCUMENTATION, TIME PATHOLOGY LIES, AND LIES IN THE LEVELLIFIED CODE OF COURSE THERE'S BEEN [INDISCERNIBLE] INDEPENDENT OF PATHOLOGY ALONG THE AMA NOW HAS BEEN WORKING ON A PROPOSAL THAT WOULD--FOR FOLK WHO IS KNOW THE CODES BASICALLY PUT ALL OF THE DOCUMMATION REQUIREMENTS ON MEDICAL DECISION MAKING. I THINK FOR THOSE OF YOU WHO KNOW THAT, THINK OF THE CURRENT MEDICAL DECISION MAKING TURBOCHARGE THAT SO THAT'S WHAT THEY'RE WORKING ON RIGHT NOW. AND YOU KNOW THEY--YOU KNOW CMS WILL DEFINITELY TAKE A ELECTRIC AT THAT, SO THAT'S THE FIRST THING TO UNTEASE. THE SECOND THEPG WE GOT FEEDBACK ON, AGAIN PROBABLY, I DON'T KNOW IF IT'S AN ISSUE IN THE MILITARY IS THE WHOLE BUSINESS OF PRIOR AUTHORIZATION. OFFICES ARE SPENDING MANY, MANY MANY HOURS A WEEK ON THIS. THE PROBLEM WITH PRIOR AUTHORIZATION IS THAT IT'S NOT COMPUTABLE FOR THE MOST PART TODAY, I'M NOT TALKING--I'M COUNTING MACHINE TO MACHINE COMPUTING AND I'M NOT COUNTING LOGGING ON TO A PORTAL AND WAITING OR CALLING VOICE OVER IP IS COMPUTING AND THE ISSUE THERE IS THAT THERE'S NO DATA STANDARDS ON THAT TRANSMISSION AND YOU KNOW THE RICHNESS OF DECISION SUPPORT. SO CURRENTLY, YOU HAVE THE X12278 PRIOR OFFSET AND THEN I THINK 275 WITH THE CLAIMS ATTACHMENT THEY WANT, THE CLAIMS ATTACHMENT DOESN'T REALLY EXIST, IT DOES NOT USE THE PRIOR AUTHORIZE, THE BASIC STANDARD IS USED ONLY TEN% OF THE TIME WHEN YOU TEASE OUT THE USAGE OF IT, THERE'S INTERESTING WE'RE DOING A BIT FOR X12, CDS IT'S AND PRICE TRANSPARENCY FOR THINGS AT THE PHARMACOKINETICS AND SKPEPB THEY'RE AT THE SAME COMPUTING ACTIVITY, THEY ARE TAKING A FAIRLY RICH REPRESENTATION OF THE INFORMATION ABOUT THE STATE WHETHER THAT IS USED FOR PRIOR AUTH, WHAT'S THE PRICE OR CLINICAL DECISION SUPPORT WITH A FAIRLY RICH SET OF COMPUTING LOGIC WHAT'S THE DECISION SUPPORT ROLE, SO THERE'S A UNIQUE OPPORTUNITY AND NLM WE'RE STARTING TO KICK SOME OF THE STONES WITH ONC AND HIGH-TECH ON THAT BUT THAT MAY BE THE NEXT BURDEN AND THEN I THINK THERE'S DEFINITELY WORK AT CMS, ON TRYING TO MAKE THE WHOLE QUALITY MEASURE STUFF A BIT SMOOTHER. IT'S AS YOU KNOW A VERY COMPLICATED SPACE. IT HAS A LONG HISTORY, EVERYBODY WANTS TO PAY FOR VALUE, BUT RIGHT? VALUE IN A MARKET ECONOMY IS WHEN THE CONSUMERS MARGINAL UTILITY IS ABLE PRODUCERS MARGINAL COST, WELL, SINCE THERE ARE NO THIRD PARTIES, IN A MARKET EQUATION OF EFFICIENCY, AND HEALTHCARE, WE HAVE THIRD PARTIES SO YOU KNOW WE HAVE AND PHYSICS WHAT I BELIEVE IS UNSOLVED WHICH IS ETHREE BODY PROBLEM, TWO BODIES VERY EASY TO SOLVE, THREE BODIES NOT SO EASY, SO, BUT YOU KNOW THERE'S--I WOULD SAY GRADUAL WORK OVER QUALITY, I THINK OVER THE LONG-TERM, CAN YOU TOTALLY REVERSE THOSE DATA FLOWS AND SAY, I HAVE KHREUPB EUPGZS--I HAVE CLINICIANS HAND CURATE AND HAND MEASURE THESE QUALITY THINGS, YOU KNOW I THINK WE CAN PUT MACHINE LEARNING ESPECIALLY TO THE EXPECTATIONS TENT THAT ANY OF THE CURRENT MACHINE LEARNING ALLEGO ALLEGOR RHYTHMS ARE PRETTY EASY IF WHAT YOU WANT TO PROVIDE IS CLINICIAN QUALITY ARE CORTILES OR WHATEVER THE GRANULARITY OF CMS PAYMENT RULES THAT IS A VERY LONG ANSWER BUT THAT'S THE WAI THE GROUP HAS TRIED TO UNPACK PROVIDER BURDEN. >> I'D LIKE TO FIRST COMPLEMENT YOU BECAUSE YOU'VE BONE MORE IN THE COUPLE YEARS YOU'VE BEEN THERE THAN IN THE WHOLE HISTORY. SO IT'S WONDER EMPLOY SECOND, YOU DIDN'T MENTION TO CMS IS ALSO GOING TO REQUIRE THAT ANY DATA THE INSURANCE COMPANIES CARRY ON DATA LIKE LAB TESTS AND DRUGS ALSO HAVE TO BE MADE AVAILABLE TO THE PARBT WHICH COULD BE REALLY, REALLY NEAT WHEN IT HAPPENS AND THEN THIRD THING IS, WE HAVE SORT OF A GOAL TO FIND AN AUDACIOUS GOAL AND IT SOUNDS LIKE YOU'RE DOING SOMETHING FAIRLY AUDACIOUS AND YOU HAVE ANY IDEAS OF HOW WE CAN PLAY IN THAT AUDACIOUS WORLD? >> YEAH, I THINK, SO YOU KNOW THITHINK THE CHALLENGE HAS BEEN THE CHALLENGE AT NLM. YOU KNOW I THINK GOING BACK TO, YOU KNOW ALL OF THE STUFF THAT DON LINDBERGH DID, AS WE SIT IN THE LINDBERGH ROOM ON HOW DO YOU ORGANIZE KNOWLEDGE, YOU KNOW UMLS, RIGHT? ALL THAT, SO THE CORE THINGS ARE RXNORM, THE CORE REPRESENTATION ISSUES, I THINK FIRE OFFERS AN OPPORTUNITY, YOU KNOW WHETHER IT'S THE VALUE SETS, I THINK--I'M THINKING ABOUT FIRE, THINK ABOUT EVALUATING FIRE, THINKING ABOUT TENDING FIRE, YOU KNOW IS A VERSION OF STRUBLGTUREED VERSUS FREE TEXT CATA. I THINK THAT IS A GREAT OPPORTUNITY. I THINK IT'S SOMETHING THAT NIH, YOU KNOW IS BOTH AN OPPORTUNITY FOR THE COUNTRY, AND I THINK FRANKLY ALSO FOR THE RESEARCH ENTERPRISE, YOU KNOW I THINK IT'S AN OPPORTUNITY AS WE THINK ABOUT, YOU KNOW JUST FOR EXAMPLE, THE DOD, VA, YOU KNOW WHAT SHARED AND APIs AND A LOT OF WORK THERE, SO I DON'T KNOW, THAT STRIKES ME, I ACTUALLY WOULD BE CURIOUS WHAT FOLKS HERE THINK AND WHAT WE SHOULD BE DOING TO HELP EVERYBODY HERE AT ONC, FRANKLY. >> YOU KNOW THE INTEROPERABILITY WITH THE FIRE IS TRANSFER INFORMATION BETWEEN ENTITIES AND A TRUSTED WAY. WE'VE BEEN TRYING TO WORK WITH THE VA FOR YEARS TO DO IT AND WITH OUR JOINT LEGACY VIEWER TO EXCHANGE MILLIONS OF RECORDS PER MONTH. BUT WE FOUND THE ULTIMATE SOLUTION TO INTEROPERABILITY WE'RE JUST REDUCING RECORD BECAUSE WE DON'T HAVE TO WORRY ABOUT EXCHANGING IT AND IT MAKES IT A WHOLE LOT EASIER. >> IT'S INTERESTING SO A ROT OF THAT IS HAPPENING IN THE DE FACTO PRIVATE SECTOR AND IT'S SORT OF A WAY. THE CHALLENGE WITH THAT IS NOT REALLY AT THE D.O.D. VA, IT'S IN THE PRIVATE SECTOR, IF YOU DON'T HAVE COMPETITION, AND YOU RELY ON ONE VENDOR FOR ALL OF YOUR INNOVATION, AND 20% OF THE ECONOMY I'M NOT SURE THAT THAT'S A BACKBONE THAT MUMPS CAN REALLY SUPPORT. >> CLEARICALLY STATED OPINION. >> [LAUGHTER] >> YOU KNOW THERE'S A LOT OF OPPORTUNITIES OUT THERE FOR INNOVATION AND I THINK-- >> DON, DO YOU THINK THERE'S ANY HOPE THAT WE CAN GET TO A MUCH MORE DISTRIBUTED MODEL OF WHAT WE THINK IS THE INFORMATION FOR CARE SO THAT IT'S NOT THIS MONOLITHIC EHR AND THAT'S--WHETHER OR NOT THE MUMPS GENERATION OF THIS ONE IS GOOD OR NOT, IS LESS IMPORTANT. I MEAN HOW DO WE GET THE OTHER STUFF LIKE EXPOSURES AND FAMILY DYNAMICS AND STUFF. >> THAT IS WHAT WE'RE TRYING TO DO WITH THE APIs, THAT IS A WHOLE POINT TO HAVING PROBUST API TECHNOLOGY THAT'S BASED ON INDUSTRY STANDARDS AS OPPOSE TO ONE-OFF VENDOR APIs. CURRENTLY ONC PER BETTER OR WORSE HAS A REQUIREMENT THAT'S GOING TO BE UP IN THE 2019 OR THE NEXT PAYMENT FOR USING THE FIRST VERSION OF THE 2015 CERTIFIED EHRs THAT HAS OPEN API BUT IT'S OPEN APIs THAT DOESN'T ADD MUCH VALUE AT ALL. SO HAVING STANDARDS BASED APIs AND JASON AND THE TECHNOLOGIES THAT ARE DRIVING, YOU KNOW THE ECONOMY, I--I CERTAINLY HOPE PATTY THAT THIS STARTS FRACTURING THESE MONOLITHIC SYSTEMS, LETS PEOPLE GET IN THERE, LET'S, YOU KNOW CARVE OUT, YOU KNOW PIECES OF IT, MAYBE LEAVE THE LEGACY SYSTEMS, YOU KNOW FOR EMPI TYPE OF FUNCTION, YOU KNOW RECORD OF YOU KNOW OF THE LEGAL RECORD OF STORE AND REALLY START THINKING ABOUT AUTOMATION AND WORK FLOW AND DISTRIBUTED COMPUTING. I MEAN IT IS THE WAY OF THE REST OF THE WORLD, I DIDN'T KNOW HOW LONG WE COULD--I DON'T KNOW HOW LONG WE CAN,A VOID THAT, BUT YOU KNOW, WE'VE BEEN DOING IT PRETTY WELL. I DON'T KNOW, SHELLY YOUR THE LEADER OF THE COMMITTEE NYOU HAD A QUESTION ASK THEN I'LL GO. >> SURE, SO I WILL PICK UP ON WHAT YOU SAID, THE WAY OF THE REST OF THE WORLD, I'M WONDERING AND I KNOW VERY LITTLE ABOUT THIS FIELD BUT INSOFAR AS YOU WERE LOOKING AT THINGS LIKE THOU DO WE MEASURE USE AND PRODUCTIVITY AND SO FORTH, ARE THERE ANY LESSONS WE CAN DRIVE FROM OTHER COUNTRIES? WHAT ARE OTHER COUNTRIES DOING IN TERMS OF EMPELEMENTING ELECTRONIC HEALTH RECORDS AND WHAT--WHAT CAN WE LEARN FROM THEIR EXPERIENCES IN TERMS OF IMPACT ON PHYSICIAN DOCUMENTATION, ALL THE OTHER ISSUES BECAUSE MEDICINE, MEDICINE MUST BE THE SAME. SOMEONE WITH CHEST PAIN AND CHEST PAIN REGARDLESS OF WHAT COUNTRY THEY'RE IN, SO SOMEBODY SOMEWHERE LOOKED AT SOME OF THESE ISSUES. WHAT HAVE OTHER COUNTRIES LEARNED. >> SO WE'RE PART OF THIS THING CALLED THE GLOBAL DIGITAL HELT PARTNERSHIP, SO THEY'RE ABOUT 20 LIVE COUNTRIES AND THIS WAS STARTED WITH AUSTRAIL WRA AND ENGLAND, CANADA IS A MAJOR PARTICIPANT. AND SO THIS HAS BEEN GOING ON FOR THE LAST TWO YEARS, EXACTLY THE GOAL THAT YOU HAVE. I WOULD SAY A COUPLE TOP LEVEL OBSERVATIONS ON THAT. I WOULD SAY FIRST OF ALL, THE OTHER COUNTRIES TEND TO USE PRETTY MUCH THE SAME STANDARDS WE USE IN THE U.S. THE BIGGEST VARIETY IS IN THE PHARMACY, RIGHT? WHEN YOU LOOK TKPHROEBALL GLOBALLY BUT AT LEAST USING THINGS THAT AT LEAST SOUND FAMILIAR. I DON'T HAVE VISIBILITY INTO KABGT EXACTLEXACTLY ON THE KPWROUPBD BUT SEEM TO FIRST BLUSH TO BE SIMILAR, BUT THE FOLKS AT EPIC WHO HAVE A NUMBER OF INSTALLATIONS DID A CALCULATION EMPLOY SO U.S. CLINICAL NOTES OR PHYSICIAN NOTES IN THE U.S. HAVE AN AVERAGE OF 4000 CHARACTERS PER NOTE. IN EUROPE, PHYSICIAN NOTE VS AN AVERAGE OF 1000 CHARACTERS. IF YOU WANT THE--A COMPUTABLE DALTODELTA ON THE REGULATORY IMPACT, IF YOU WILL, AGAIN YOU COULD AURPG ABOUT ALL THE REGULATIONS THAT WERE THERE, OTHER LESSONS ARE, YOU KNOW NUMBER OF COUNTRIES OBVIOUSLY HAVE SORT OF NATIONAL IDENTIFIERS AND THINGS, I DON'T THINK THAT'S A BIG ISSUE IN THE U.S. ON A GO FORWARD BASIS BECAUSE THE REALITY IS, THERE ARE EASILY A DOZEN ENTITIES IN THE UNITED STATES THAT PRETTY MUCH BE EVERY AMERICAN. AS IT TURNS OUT, I MEAN PEOPLE SORT OF FORGET. >> YEAH,. >> AMONGST OTHERS, BUT YOU KNOW A NUMBER OF THE BIG INSURERS HAVE ORD OF OF HUNDRED THOUSAND, CREDIT BURROS, SURE SCRIPTS, YOU KNOW, A LOT OF BANKS, THERE ARE A NUMBER OF PEOPLE WHO HAVE VAST ABILITY TO DO THAT, FOLKS OFTEN FORGET, EVERY CELL PHONE UNIQUELY IDENTIFIES YOU AS A USER, YOUR CONFIGURURATION, EVERY BROWSER, EVERY BROWSER UNIQUELY SO WE'RE GETTING PRETTY CLOSE TO BE ABLE TO DO AUTHENTICATION, SKIPPING BIOMETRICS, THE OTHER LESSON THAT'S INTERESTING, IT'S NOT TOTALLY APPLICABLE TO THE U.S., BUT SORT OF APPLICABLE IS THE COUNTRIES THAT DON'T HAVE EIN LRs COULD MAKE REAL BIG PROGRESS JUST USING SMART PHONES AND INDIA'S DOING A BANG UP JOB, SO INDIA THEY HAVE THE SAME PRIVACY CONCERNS. THEY'RE COMING OUT WITH THE BRITISH LEGAL TRADITION IS OUR WAY BUT THEY HAVE A BIOMETRIC IEE, AUDIENCE DENTIFIER, WHOLE COUNTRY THAT CONSISTS OF AN IRIS SCAN, TEN FINGER FINGERPRINT AND THEY COMBINE THAT BECAUSE OF ALL THE WELFARE PRAUD WITH A BANK ACCOUNT FOR EVERY INDIAN ADULT. SO THEY COULD DO PAYMENTS INTO THE BANK ACCOUNT COLLECTLY SOPHISTICATED THAT THIS SYSTEM COMBINES THAT TOGETHER, THERE ARE A NUMBER OF COUNTRIES DOING SOME INTERESTING THINGS, THEY'RE LARGELY ON MODERN TECHNOLOGIES, MODERN APIs AND NHS FOR EXAMPLE HAS A SEBTERA--CENTRAL DATA STAT THAT IS STATE-OF-THE-ART OPEN SOURCE SOFTWARE. YOU LOOK AT CORE DATA STACK, THE SPINE THEY CALL IT AND THAT COULD BE AT ANY SILICONE VALENTINEDEE START UP AND ON'S THERE ARCHITECTURE, THEY USED TO HAVE A BIG BILLION DOLLAR THING. I BEING THIS THING COST THEM TEN OR 20 MILLION TO BUILD. >> SO I WANT TO CHANGE THE SUBJECT A BIT AND BRING UP SOMETHING YOU HAVE HAVEN'T BROUGHT UP THAT I THINK IS INCREDIBLY IMPORTANT IN THE EHR AND THAT'S PUB LIBRARY FOUNDATION HEALTH AND ULTIMATE GOAL HATELY WE WANT ON I UNIVERSAL SURVEILLANCE SYSTEM, SPECIALLY FOR INFECTIOUS DISEASES, THEN THIS IS THE WAY TO DO IT. AND INCLUDING, YOU KNOW ACCESS TO ADMISSION DISCHARGE TRANSFER DAT ATHE DRUG RESISTANCE, THINGS LIKE THAT SO JUST KEEP THAT IN MIND, PLEASE. >> WE DO A BUNCH OF STUFF WITH CDC, WE HAVE A GOOD COLLABORATION WITH THOSE GUYS THERE, AND ROBERT REDFIELD, IS INTIMATELY AWARE OF WE'RE DOING, THE HIEs DON'T DO ANYTHING WITH PUBLIC HEALTH. WE IN TEF CA HAVE PUT IN AS A PERMITTED USE TO MAKE NEW ADDITIONAL ONES, ONE IS FOR PAY ORS, NONAPOPTOTIC THE THAT THEY WOULD PUT THEIR PRICE INFORMATION THERE--SO WE'RE VERY MUCH TRYING TO GET THAT AGAIN AND AS YOU KNOW THERE'S A LONG HISTORY OF IMMUNIZATION REGISTRIES AND THERE'S A WHOLE BUNCH OF STUFF, YO BUT YOU KNOW WE'RE SORT OF IN A GRADUAL KIND OF WAY TRYING TO YOU KNOW PUT SOME OF THE STUFF TOGETHER. >> AND ANTIMICROBE KRAL RESISTANCE IS WHERE WE SHOULD START. BEAUTY INDUSTRY.& THANK YOU. >> ANY OTHER QUESTIONS. >> ALL RIGHT. >> THANKS. >> THANKS. [ APPLAUSE ] >> WE HAVE A QUESTION. , DATA AVAILABLE, YOU MENTIONED POPULATIOPOPULATION HEALTHCARE [INDISCERNIBLE] BUT A LOT THOF DATA ARE NOT PROTECTED BY HIPAA. >> SO HIPAA IS PRETTY CLEAR. HIPAA HAS TWO *EPT VITS, THEY'RE THINK OF PREVIEDERS AND BUSINESS ASSOCIATED AND THINK OF ELR VENDORS, PILOT PROJECTORS AND PEOPLE WHO TRY TO STRALGTS THE CLAIMS CLEARINGHOUSES BUT BASICALLY IN TRANSACTIONS AMONGST THEM ON PATIENT DATA, THAT DATA IS NOT ASHES LOWED TO LEAVE AND THERE'S A LOT OF CASE FALLING DOWN. WOPS A PATIENT DOWNLOADS THE DATA FOR EXAMPLE TO AN APP OF THEIR CHOICE, IT HAS UNDER THE HIPAA RIGHT OF ACCESS, IT HAS LEFT HIPAA, IT'S THAT PATIENT'S DATA TO DO WITH IT, TECHNICALLY THEY DON'T OWN IT, IT'S A LEGAL THING BUT THEY CONTROL IT, IT'S THEIR DATA AND THEY CAN CONSENT TO IT, SO THE ALL OF THIS BIG DATA STUFF, THE POPULATION STUFF IS STILL UNDER HIPAA AND NEEDS A COP TRACT, SO THAT IS JUST IF YOU'RE DOING ANALYSIS UNDER HIPAA TODAY DATA HEALTH CATALYST OR SOUND LIKE IBM OR PICK YOUR CONSULTING FIRM OR YOUR ANALYS ANALYTIC TERM, NOTHING HAS CHANGED EXCEPT THAT NOW THEY HAVE A STANDARD SO WHEN THEY DON'T WANT TO SHARE THE DATA BECAUSE WELL, WE DON'T FEEL LIKE IT OR WE CAN'T DO IT, IT PRINTS OUT WHICH IS A TINY LITTLE OPERATION, WE HAD A 190 MONTHLY DATA FEES WE HAD TO CUSTOM GENERATE TO PROVIDERS ON A ONE-OFF BASIS. SO WHAT THE POPULATION LEVEL DOES S&P TAKE AWAY THAT EXCUSE AND THAT FRICTION AND THAT COST. BUT IT DOESN'T CHANGE HIPAA, THOSE ARE ALL HUNDRED% TRANSACTIONS. >> WE HAVE TO MOVE ON. >> THANK YOU. >> THANKS. [ APPLAUSE ] >> SO NOW WE'RE CHANGING TOPIC FOR STEPPING UP TO OUR STRATEGY, BUILDING A CHANGE READY WORKFORCE AND WE HAVE MRS. JOYCE BACKUS AND CAROLYN KUROWSKI. >> I WILL TALK TO YOU ABOUT WHAT OUR CHALLENGES ARE, SO I'M HERE ON BEHALF OF PATTY AND THE LEADERSHIP TEAM AND IMPLEMENTING CHANGES AROUND THE STRATEGIC PLAN AND I KNOW PATTY'S BEEN TALKING TO YOU OVER THE LAST SEVERAL MEETINGS ABOUT THE PLANS THAT WE'RE MOVING FORWARD WITH, WITH OUR WORKFORCE AROUND MAKING THE STRAY JECTORY TAOEPBLIC PLAN GETTING READY FOR A WORKFORCE FOR THE CENTURY SO THE OVERALL VISION OF--ALSO SOME OF YOU HEARD ABOUT THE PORTFOLIO ANALYSIS, THERE'S ALSO BEEN TECHNICAL DIG-INS TO OUR WORK AND PEOPLE WORKING IN DIFFERENT ORGANIZATIONS WHETHER IT'S NCBI OR BIOTECHNOLOGY INFORMATION ARE LEARNING THE PLATFORMS THEY SHARE AND MAYBE SHOULD WORK TOGETHER AND MAYBE PLATFORMS THEY'RE WORKING ON THAT THEY'RE DIFFERENT THAT COULD BRING TOGETHER AND OF COURSE WE'RE LOOKING TO INSURE THE KUFT WORBGTYNESS OF THE NLM PRODUCT ANDS SERVICES AS WE DO THIS. SO PATTY HAD A VISUAL DESCRIPTION OF THE PHASE ONE EARLIER TODAY BUT BASICALLY THE DIVISION OF SPECIALIZED INFORMATION SERVICES STAFF OR BE INCORPORATED AND BECOMING PARTNERS WITH OTHER PARTS OF NLM, THE AUDIO VISUAL PROGRAM DEVELOPMENT BRANCH, THOSE STAFF ARE BEING MOVED INTO OSIS AND OUR OFFICE OF COMMUNICATIONS AND PUBLIC LIAISON AND UNDER DR. MIKE HURTA WE HAVE A NEWEL NAMED OFFICE OF STRATEGIC INITIATIVES THAT ARE LEADING US IN THOSE AREAS AND WE ALSO HAVE THE NEWLY ENGAGED AND NAMED OFFICE OF ENGAGEMENT AND TRAINING. >> WE WILL DESCRIBE THOSE AREAS AND THE STAFF HAVE BEEN INFORMED THOSE AND THEY HAD INTERVIEWS WITH OUR CONSULT AUNTS, SHARED THE HOPES DREAMS AND SKILLS AND WORKED THROUGH THE REQUESTS. ALL THESE WILL BE OFFICIAL BY JUNE FORTH BUT IT DOESN'T MEAN THAT WORK HAS BEEN DONE AND SOME OF THE STAFF, WHERE THE ALIGNMENT MADE SENSE HAVE MOVED INTO A NEW WORK AREA AND SOME CASES MOVED TO NEW DESKS AND IT INVOLVES QUITE A NUMBER OF PEOPLE I'D SAY ABOUT 50 I THINK OR ACTUALLY BEING REASSIGNED AND MOVED. NOVERALL--STPHEZ THOSE ARE PEOPLE THAT CAME OUT BUT WE ALSO HAD NEW ADJUSTMENTS INTERNALLY SO THERE WERE A LOT OF CHANGES TAKING PLACE AND THOSE PEOPLE ARE MOVING INTO NEW AREAS SOPHISTICATEDY THOSE THAEPLS ARE REFORMING AND THERE'S KHAEUFRBG TAEUGING PLACE AND THIS PROCESS WILL TAKE MORE THAN JUNE 24th. THE MIDDLE SOMEWHERE. >> GOOD AFTERNOON, ONE OF OUR REQUESTS AS WE'VE COME INTO THIS IS TO PARTNER WITH AND SUPPORT THE LEADERSHIP TEAM AND THE PROPLG ECTOMYOSIN TEAM ON FACILITATING THAT CHANGE. WE IDENTIFIED A CHANGE IT'S A ONE TIME INSTANCE BUT HOW DO WE TRANSITION AND SUPPORT AND MAKE ALL THE OTHER STEPS NEEDED TO GET PEOPLE INCORPORATED AND MOVING FORWARD IN A POSITIVE FASHION. SO, AS WE'VE COME IN AND REALLY TALKED WITH THE TEAM, THERE ARE TWO MODELS OF CHANGE THAT WE REALLY USED AND BEEN THINKING ABOUT HELP FRAME THE WORK THAT WE'RE DOING. THE FIRST ONE THAT WE'RE USING IS THE ADD CAR FRAMEWORK. IT'S NICE AND IT THINKING THROUGH IN A LOGICAL AND KIND OF MENTAL EFFORT, SO IT'S PLANNED AND METHODICAL, THERE'S GREAT RESEARCH BEHIND IT AS WELL AND REALLY WHAT WE'RE DOING THERE IS THINKING THROUGH FROM AN INDIVIDUAL PERSPECTIVE, DO WE UNDERSTAND WHAT'S THE AWARENESS OF THE CHANGE SO WHAT DO THEY KNOW ABOUT THE BIG CHANGE BUT ALSO SMALL CHANGE PIECES, RIGHT? SO THERE'S WHO MY NEW SUPERVISOR WILL BE, WHERE I WILL BE SITTING WHAT WORK WILL I BE DOING GOING FORWARD, A SECOND PIECE WE WANT TO BE THINKING ABOUT IS THE DESAOEURB, HOW DO I FEEL ABOUT THAT CHANGE? AM I EXCITED, NERVOUS, CONCERNED AND WHAT TYPES OF SUPPORT DO THOSE INDIVIDUALS NEED IN ORDER TO MOVE THEM TO A POSITIVE PLACE IN TERMS OF THAT CHANGE. WE'RE TALKING WITH THE TEAM ABOUT KNOWLEDGE, WHAT NEW INFORMATION OR SKILLS MIGHT I NEED IN ORD TO BE EFFECTIVE. WE WORKED WITH TEAMS ABOUT LEARNING NOW PROGRAMMING LANGUAGES, MAYBE LEARNING NEW PROCESSES IN MY NEW OFFICE SO WE'RE FOCUSING ON THAT AS WELL. WE'RE ALSO LOOKING AT THE ABILITY, THE INDIVIDUAL ONES THAT ARE IN THAT ROLE, HOW ARE THEY SUCCESSFUL? HOW ARE WE SUPPORTING THEM IN THOSE PLACES AND WE'RE WORKING CLOSELY IN THIS CASE WITH THE RECEIVING SUPERVISORS, WHAT KIND OF SUPPORT DO THEY NEED, CONVERSATIONS TO HAVE, TO MAKE SURE THAT PEOPLE ARE EFFECTIVE AS A MOVE INTO THOSE NEW ROLES. ANOTHER NICE PART OF THIS MODEL IS THE REENFORCEMENT AND THE IDEA THAT YOU NEED TO CONTINUE TO HAVE THESE CONVERSATIONS SOPHISTICATEDY WE'RE TALKING TO SUPERVISORS, NOT JUST ONCE, NOT JUST TWICE BUT ON AN ONGOING BASES TO REENFORCE WHAT WE'RE TRYING TO ACHIEVE AND WHAT THE MESSAGES ARE AND THE ACTIVITIES THAT NEED TO BE DONE. SO THAT'S THE FIRST ONE. ANOTHER ONE FOR THIS CHANGE THAT WE'RE USING IS WILLIAM BRIDGES MANAGING TRANSITION MODEL AND WE THINK THIS ONE IS PARTICULARLY IMPORTANT BECAUSE AS WE LOOK AT IN THE CHANGE FOR INDIVIDUALS WITHIN S. I. S. FOR INSTANCE SUCH A LOVELY JOB TALKING ABOUT SUCH AN IMPORTANT GROUP AS THEY NOW GO AND ARE DISPURSED THROUGH IT THROUGHOUT THE OTHER AREAS OF THE LIBRARY AND BRING THE SPECIAL SKILLS AND ABILITIES THAT THEY HAVE, THEY'RE GOING THROUGH A LOT OF THIS STEPS IN THIS TRANSITION MODEL, SO WE THINK IT'S VALUABLE BOTH FOR THE ORGANIZATION AND THEMSELVES, THE S. I. S. FOLKS AND THE OTHER AREA IS TO THINK ABOUT THIS. SO WE'RE TALKING ABOUT A LOT ABOUT HOW PEOPLE ARE EXPERIENCING THOSE ENDINGS, LAWRENCE SAYS WE'VE TALKED WITH HER ABOUT HOUR HER PRESENTATION DOES A WONDERFUL JOB OF VALIDATING WHAT THAT ORGANIZATION WILL ACCOMPLISH, SO DOWN IN THE BOTTOM IF YOU THINK THROUGH WHAT THOSE INDIVIDUALS NEED FROM THE ENDING PERSPECTIVE IS EMPATHY, WE UNDERSTAND THAT YOU MIGHT BE CONCERNED OR SAD OR UNCERTAIN ABOUT HOW OR WHAT THAT MEANS TO HAVE THAT ORGANIZATION MOVING INTO OTHER AREAS. THEY ALSO NEED THE VISION, WHAT'S COMING NEXT SO THEY CAN GET EXCITED ABOUT AND AS I TALKED ABOUT DESIRE EARLIER, WHAT AM I LOOKING FORWARD TO? I THINK AS JOYCE MENTIONED FOR A LOT OF FOLKS WE'VE DONE THROUGH AND ARE MOVING THROUGH THE ENDING PIECE, WE HAVE A LOT IN THE NEUTRAL ZONE, WE HAVE A LOT OF PEOPLE WHO HAVE THE CURIOSITY PETE SO I DID SKPWRAOUS AND SPOKE WITH PEOPLE, WILL I DO BE DOING AND WHAT NEW OPPORTUNITIES WILL I HAVE BUT ALSO UNCERTAINTY, WILL I BE APPRECIATED, WILL MY SKILL SETS WORK AND FIT IN THE NEW AREA THAT I'M IN. SO WE'RE TALKING WITH SUPER VISORORS AND TEAMS ABOUT GETTING INFORMATION OUT FREQUENTLY AND OFTEN, COMMUNICATING RIGHT IS THE BIGGEST PIECE OF THIS, SAYING A MESSAGE NOT ONCE, NOT TWICE BUT SEVERAL TIMES AND ALSO WHAT ARE THE PLANS. WORKING WITH THE TEAMS TO PUT TOGETHER GOOD PLANS ON THAT. THE GOAL OF THAT IS TO GET US BACK UP THAT, RIGHT? THROUGH THE DIP AND BACK UP TO THE BEGINNINGS PIECE WHERE PEOPLE ARE EXCITED ABOUT THEIR NEW ROLE ROLES AND SIGHTED ABOUT THEIR NEW OFFICE AND NEW TEAMS THAT THEY'RE WORKING WITH. THEY HAVE A SENSE OF CLARITY AND PURPOSE. REENERGIZING IS ONE OF THE NICE PARTS ABOUT THIS SO WHEN YOU GET PEOPLE THROUGH THAT IS GETTING THEM REENERGIZED ON THE BROADER WORK OF THIS ORGANIZATION. ONE OF THE THINGS WE TALK WITH THE TEAM A LOT ABOUT IS THIS WAS PHASE ONE, RIGHT? SO SKWROEUZ SAID PHASE ONE IS USING THIS AS AN OPPORTUNITY TO GET THE WHOLE ORGANIZATION AND WHOLE LIBRARY PREPARED FOR AND KIND OF CHANGE READY SO GOING BACK TO THAT TITLE IS TO PRIME THE REST OF THE WORKFORCE FOR CHANGES THAT NEED TO COME TO PETE THE STRATEGIC VISION THAT THE ORGANIZATION HAS. IN TERMS OF HOW WE APPROACH THE PROJECT,--STEPPING BACK IS WE'RE VERY FOCUSED ON AGAIN, I MENTIONED THE PARTNERSHIP PIECE BUT ALSO A VERY TAILORED APPROACH BASED ON THE NEEDS OF NLM, SO WE CAME INTO THIS NOT WITH A READY ANSWER OR AN OFF THE SHELF KIND OF PLAN BUT PUT THE APPROACH OF ACTIVE HREFRPBING SOPHISTICATEDY WE START FROM THE INTERVIEWS, WE INTERVIEWED SUPERSRAOEUDZORS WAORBGS MET WITH EMPLOYEES, WE TALKED WITH OTHER GROUPS TO REALLY UNDERSTAND WHAT'S GOING ON. WE ALSO AUGMENTED THAT WITH DATA. WHAT'S THE INFORMATION OUT THERE, WHAT'S PEOPLE'S PAST EXPERIENCES AND WHAT THEY ARE AND WHAT THEIR NEEDS MIGHT BE WITH THAT, SO FEDS DATA, ORGANIZATIONAL DATA, AND SOUGHT AUGHT INPUT, ARE THERE OTHER GROUPS WE SHOULD TALK ABOUT. OUR ROLE THEN IS TO BRING THAT TOGETHER AND BRING TO THE STEERING GROUP ANALYZING THAT INFORMATION HOW DOES IT ALL FIT TOGETHER? WHAT DOES IT MEAN? AND FACILITATE A DISCUSSION. SO WE'VE BEEN HAVING WEEKLY MEETINGS WITH THE GROUPS AND THE STEERING GROUP OVERALL TO FACILITATE DISCUSSION SO IT'S NOT THAT WE'RE COMING BACK AND FEEDING ANSWERS BACK TO YOUR ORGANIZATION BUT WHAT DOES THAT MEAN, HOW DO YOU WANT THIS TO PROCEED AND FACILITATE DISCUSSIONS AND EVENTUALLY SUPPORT DECISION MAKING AND THE PLANNING PROCESS OVERALL. WHICH BRINGS ME TO A BRIEF DISCUSSION OF HOW WE IDENTIFIED THOSE REQUIREMENTS AND THIS ILLUSTRATES HOW WE USE THAT,A PROACH. WE WERE CAREFUL TO USE MULTIPLE SOURCES OF INFORMATION. WE REVIEWED THE ORGANIZATIONAL DOCUMENTS, WOO PUT A LOT OF THAT TOGETHER, WE THEN DID SUPERVISOR INTERVIEWS FIRST TO UNDERSTOOD WHAT THEY KNEW AND THEN WE DID INDIVIDUAL EMPLOYEE INTERVIEWS AND AS JOYCE MENTIONED WHAT WE ASKED WHAT ARE THE AREAS WHERE YOU FEEL EXCITED ABOUT, WHAT'S THE WORK THAT YOU'RE WORKING ON NOW, WHAT WOULD YOU LIKE TO DO IF YOU COULD CHOOSE AND SOME OF THOSE AREAS, WHAT'S IMPORTANT TO YOU AND WHAT DO YOU VALUE, SO WE AGAIN, BEING CAREFUL NOT TO COMMIT TO ANY PARTICULAR OPPORTUNITY, ASKING THEM ABOUT THAT, WE ALSO LOOKED AS YOU GO,A ROUND, WHAT ARE THE PROGRAMS NEED AND THE ORGANIZATIONAL NEEDS WITHIN BOTH OSIS AND WITHIN LIBRARY OPERATIONS TO UNDERSTAND WHERE THOSE SKILL SETS CAN FIT AND WHERE PEOPLE COULD REALLY BRING THEIR APPROACHES, THEIR INNOVATIVE ATTITUDES AND HELP TO MAKE THOSE PROGRAMS BETTER AND STRONGER. WE IDENTIFIED OPTIONS, SO BASED ON THIS, WE ACTUALLY LOOKED AT BEST FIT, YOU WILL SEE THAT IN THE CENTER, IT WASN'T JUST ONE, BUT WHAT WE'RE--WHAT WERE THE MULTIPLE OPTIONS FOR EACH OF THOSE INDIVIDUALS WHERE THEY MIGHT BE A BEST FIT, BOTH WHY IT WAS GOOD AND WHAT MIGHT SOME OF THE PROS AND CONS OF THAT FIT BE. WE PROVIDED RATIONAL AND CONSIDERATIONS WE BROUGHT IN AND THEN WE FACILITATED THAT DISCUSSION SO THE STEERS GROUP SAT DOWN, THEY WENT THROUGH ALL THE INFORMATION WE HAD COLLECTED RILELY TO TRY AND BALANCE THOSE INDIVIDUAL FACTORS, TO IDENTIFY A BEST FIT AND THAT'S WHAT WAS COMMUNICATED THEN BACK TO THE STAFF IN TERMS OF WHERE THEY WOULD BE GOING AS JOYCE MENTIONED THOSE WERE ANNOUNCED. WHAT DOES THAT MEAN FOR MY WORK? WHAT DOES THAT MEAN WHERE I SIT? AND DETAILS TO WORK WITH THEM NOW? TO HELP WITH THAT, WE HAVE A TAYLORED COMMUNICATION PLAN, SO WHAT FIRST OF ALL UNDERSTANDING HOW DOES THE LIBRARY COMMUNICATE? WHAT ARE THE BEST RESOURCES AND TOOLS SO WE STOOD UP A WIKI, WE ARE ADDING INFORMATION THERE, GETTING INFORMATION THAT WAY, WHAT DO PEOPLE NEED WHEN, SO WE HAVE ALL KINDS OF SUPPORTING ACTIVITIES, PLANNING, TEAM BUILDING, DIFFERENT FEEDBACK SESSIONS ASSOCIATED WITH THAT PLAN, IT GOES TILL THE EFFECTIVE DATE BUT THEN ALSO THROUGH THE SUMMER TO CONTINUE TO REINFORCE THE ACTEUFRTS THAT NEED TO BE DONE. FROM A TOOLS AND RESOURCES PERSPECTIVE WE HAVE DONE CHECK LIST SUPERVISORS, SMALL TOOLS AROUND KEY MESSAGES AND TALKING POINTS TO MAKE SURE IT'S CONSIST EPT AMONG THE LEADERS. ONE OF THE MOST IMPORTANT THINGS CAN BE HEARING THE SAME THING FOR MULTIPLE SOURCES. WE'VE ALSO IDENTIFIED AND PROVIDED THE MANAGERS AND SUPERVISORS WITH TEAM ORIENTED ACTEUFRTS. HOW DO THEY GET THE NEW STAFF, SO RIGHT THEIR WHOLE TEAM TALKING TOGETHER. SO IT'S NOT JUST HAPPENING OF PEOPLE FROM THIS AREA AND THIS BUT WHAT THAT NEW TEAM IS GOING TO LOOK LIKE, HOW HAY WORK TOGETHER EFFECTIVELY IS A KEY ONE THERE, SO RIGHT? SO WORK STYLE IS A GREAT WAY TO DO THAT, WHAT ENERGIZES AND MOTIVATES THEM. WE DESIGN THOSE TO BE BUILT INTO THE WORK THAT PEOPLE ARE ALREADY DOING. EXISTING STAT RATES ARE NOT SPECIAL EVENTS BUT KPAEUFTING STAFF MEETING, EXISTING OPPORTUNITIES TO CONTINUE TO BUILD THOSE CONNECTIONS AMONG THE VARIOUS TEAMS. WE'RE ALSO PROVIDING TARGETED SUPPORT AND COACHING, IF THE SUPERVISOR WANTS TO TALK THROUGH A PARTICULAR ISSUE OR QUESTION. WORKING WITH THEM CLOSELY, STAFF AND DIFFERENT GROUPS THAT MIGHT NEED JUST TO WORK THINGS THROUGH. WE'RE WORKING THROUGH THAT AS WELL. THE IDEA IS TO FACILITATE THAT AS MUCH AS POSSIBLE. IN TERMS OF THE ROLES THAT WE THINK ABOUT AND THAT ARE REAL LOAMACYY IMPORTANT IS OUR SPONSORS ARE OBVIOUSLY THE NUMBER ONE KEY IN THIS PROJECT WE ARE VERY LUCK SKPE BAKUGAN VERY EXCITED BECAUSE WE HAVE SUCH ENGAGED AND ACTIVE SPONSORS, SO STARTING WITH JERRY AND PATTY IN TERMS OF SUPPORT FOR THIS PROJECT AND THE IMPORTANCE THAT THEY PLACE ON IT HAS REALLY MADE THIS ONE -FRT REALLY ENJOYABLE FOR ME PROJECTS BECAUSE PEOPLE KNOW IT'S REAL AND THAT THAT THEY HAVE THAT KIND OF SUPPORT. SO IT LEGITIMIZES THE CHANGE IN A REALLY BIG WAY AND PEOPLE KNOW THAT IT'S A REAL THING CAN THAT THEIR LEADERS ARE INVESTED IN THE SUCCESS OF THAT OVERALL. THAT THEN TRICKLE DOWN TO THE LEADERS OF THE GROUP. SO OUR STEERING GROUP IS VERY ENGAGED AS I MENTIONED, WE'VE BEEN ABLE TO MEET WITH THEM WEEKLY, MAKE DECISIONS ON A FREQUENT BASIS AND THAT'S BEEN A FANTASTIC PIECE. WE'RE NOW TURNING TO THE SUPERVISORS AND MANAGERS TO BE CHANGE AGENTS FOR US, FOR THEM AS PART OF THIS PRONG ECTOMYOSIN. THEY'RE RESPONSIBLE FOR EXECUTING THE PLANS, RIGHT IN WHAT IS SOMEONE'S NEW PERFORMANCE EXPECTATIONS GOING TO BE? WHAT WORK ARE THEY GOING TO BE DOING? HOW ARE PROJECTS GOING TO BE HANDLED SO WE'RE WORKING TO SUPPORT THEM RIGHT NOW AND PREPARE THEM FOR THAT ROLE. AS I MENTIONED EARLIER FOR THE TARGET AUDIENCE, WE ARE LOOKING RIGHT NOW AT THE PEOPLE WHO ARE DIRECTLY IMPACTED BY THE CHANGE AND WE HAVE THOSE ACTIVITIES IDENTIFIED FOR THEM BUT WE ALSO RECOGNIZE THE OVERALL LIBRARY AS A TARGET OUGHTIENCE, RIGHT? WHOLE WORKFORCE AS THESE GO FORWARD, WHAT LESSONS ARE LEARNED AND HOW IS THAT GOING TO IMPACT THE CHANGES THAT THE LIBRARY CONTINUES TO MAKE WHETHER IT'S THE RENOVATIONS ON THE BUILDING, ON PHASE TWO OF THE CHANGE EFFORT. WHICH BRINGS ME TO MY LAST LINE ON THIS CHART WHICH IS ADVOCATES FOR THE CHANGE. THESE ARE INDIVIDUAL WHO IS HAVE POLITICAL SWAY, HAVE A REPUTATION AND WITHIN THE ORORGANIZATION, RIGHT? SO THEY'RE SOMEWHAT OUTSIDE OF THE PROCESS ITSELF, BUT HOW THEY VIEW THE PROCESS, AND HOW THEY VIEW THE CHANGE HOLDS REAL POWER, THEY CAN RECOMMEND IDEAS THEY CAN SUPPORT THEM AND SO, THIS IS A NICE PLACE FOR US TO COME IN OUR CONVERSATION BECAUSE YOU ARE WONDERFUL AND CRITICAL AT ADVOCATES FOR THE CHANGE PROCESS AND FOR THE LIBRARY OVERALL. YOUR ROLE HERE, THE STAFF LOOK TO YOUR REACTIONS, THE SUGGESTIONS YOU MAKE AND SO YOUR INPUT ON THE PROCESS ITSELF AS WELL AS IDEAS ARE MANAGE WE VALUE AND I APPRECIATE THE OPPORTUNITY TO BE ABLE TO TALK WITH YOU A LITTLE BIT MORE ABOUT THAT. SO WHAT WE WOULD LOAMACYIC TO DO AS WE COME UP AND WE TIMED THIS OVERA BREAK. KIND OF A SLIGHTLY UNUSUAL WAY TO APPROACH A PROGRAM BUT WHAT WE WANTED TO DO IS GIVE YOU A CHANCE TO PROVIDE US WITH INPUT. SO AS ADVOCATES, YOU HAVE A UNIQUE PERSPECTIVE ON THE LIBRARY AND THE TRANSITION THAT THIS ORGANIZATION IS UNDERTAKING. WE ALSO RECOGNIZE THAT AS LEADERS WITHIN YOUR OWN ORGANIZATIONS, WHO I AM SURE HAVE EXPERIENCED SOME FORM OF CHANGE AND LEADING THAT CHANGE, LEADING YOUR ORGANIZATION THROUGH THAT CHANGE WE WOULD LOAMACYIC TO GIVE YOU TIME TO SHARE YOUR INSIGHTS WITH THE LIBRARY AS THEY NAVIGATE THIS TRANSITION. >> MY ASK FOR YOU IS I'VE PLACED AROUND THE TABLE SOME VERY BRIGHTLY COLORED POST IT NOTES, I REALIZE WHEN I WAS PUTTING THEM OUT THEY LOOK LIKE EASTER EGGS, BUT IF YOU COULD USE THE NOTES IN FRONT OF YOU TO WRITE DOWN SAY LESSONS LEARNED OR QUESTIONS OR RECOMMENDATIONS YOU MOOIT HAVE REGARDING THIS PROCESS, EACH NOTE MY REQUEST WOULD BE EACH NOTE BE A SEPARATE IDEA. YOU CAN USE AS MANY NOTES AS YOU WOULD LIKE. AND THEN IF YOU COULD PLACE THEM ON THE FLIP CHARTS THAT WE TRANSLATIONAL RESEARCH STIGIC PLEA PLACED ON THE ROOM AND BASED BROADLYOT TOPIC AREA. THAT THE NOTE RELATES TO. WE CAN DO THIS, WE HAVE TEN MINUTES TO WORK ON THAT NOW, WE WILL HEAD INTO A BREAK BUT CAN YOU DO IT DURING THE BREAK BUT CAN YOU PLACE THOSE UP DURING BREAK AND WE WILL REGROUP AND STUDIO LOWS LOOK AT THE COMMENTS TO DISCUSS THE THEMES AND INSIGHTS THAT COME OUT OF THAT. TO HELP YOU BECAUSE I KNOW IT IS AFTER LUNCH WE HAD SOME STARTER PHRASES TO KICK START YOUR THINKING ON THIS. SO THINGS LIKE GET IT HELPS TO BLAH, BLAH, BLAH, MAKE SURE YOU THINK ABOUT ... DON'T WORRY IF THE FOLLOWING HAPPENS, MAKE SURE YOU TAKE TIME TO ... I LEARNED THAT .... RESPIRATORY RESPIRATORY. DON'T FORGET .... WE WERE SUCCESSFUL WHEN WE ... OR WE WISH WE HAD ... I'M GLAD I ... OR MY ORGANIZATION TRIED ... AT THIS POINT DO I HAVE QUESTIONS FROM THE GROUP OR COMMENTS? >> [INDISCERNIBLE] >> [LAUGHTER] >> [INDISCERNIBLE]. >> NOW IT'S AN INDIVIDUAL JOB. >> [LAUGHTER] >> THIS SHOWS MY IGNORANCE DO YOU HAVE A UNIONIZED WORKFORCE. >> NO THAT'S A GOOD QUESTION. >> YES, YOU CAPTAIN DOJ THIS-- >> WHICH COMPLICATES EVERYTHING. >> WE HAVE A VERY DIFFERENT--WHAT WE HAVE REPRESENTS A CHALLENGE TWO FOLD, ONE IS 50% FED WORKFORCE, SO WE HAVE 50% OF OUR STAFF ARE NOT FEDS. AND SO WHEN WE SPEAK ABOUT REORGANIZATION AND REALIGNMENT, WE ARE SPEAKING ABOUT OUR FEDERAL WORKFORCE. THIS HAS OBVIOUSLY IMPLICATIONS FOR OUR CONTRACT WORKFORCE AND THAT'S BEEN DEALT WITH IN A NUMBER OF DIFFERENT WAYS, BUT OUR CONTRACTORS WORK WITH THE CONTRACTING COMPANY AND NOT FOR US, SO ALL OF THIS ACTIVITY BOTH GOES ON, ENGAGING WITH OUR FULL STAFF AND YET, SPECIFICALLY WHEN WE SAY 50 PEOPLE REASSIGNED, IT'S 50 PEOPLE THAT HAVE BEEN REASSIGNED SPECIFICALLY WITHIN THE FEDERAL REASSIGNMENT, SOME CARRY WITH THEM THEIR CONTRACTING PARTNERS AND SOME HAVE NOT. >> I WILL SAY WE DO HAVE AN NIH OFFICE OF REORGANIZATION? >> STRATEGIC REORGANIZATION. >> SO THERE IS AN OFFICE WHICH WE HAVE SENT A LARGE PACKET OF REQUESTS TO THE JUSTIFICATION THAT WAS DONE. >> ALL RIGHT. >> ENTIRE REORGANIZATION'S PACKAGE THAT NEEDS TO JUSTIFY AND EXPLAIN HOW BOXES AND PEOPLE MOVE AROUND-- >> YEAH. >> [SPEAKING AT ONCE ] >> IF WE DO A REALIGNMENT. WE HAVE TO TAKE IT DOWN TO BUILDING ONE. >> A UNION MIGHT BE EASIER THAN BUILDING ONE SOME DAYS? , I DON'T KNOW. [LAUGHTER] >> WE WON'T GET INTO THAT. >> THANK YOU ALL, REALLY DO APPRECIATE THE TIME AND THE THOUGHTFULNESS IN TERMS OF PUTTING THIS TOGETHER AND I WILL GO, I WILL ACTUALLY FINISH, IT'S REALLY GREAT NUMBER OF THOSE I'LL START OVER HERE, SO GO,A ROUND AND THAT IS SOMETHING THAT'S GOING ON RIGHT NOW. JUST THINKING THROUGH THOSE PIECES AND TO THE HELPFUL ONE, ON THIS IN TERMS OF SOME OF THE THOUGHTS, WERE, FROM A RELIGIOUS PERSPECTIVE SOMEONE MENINGED MAKING IT AS SEAMLESS AND EASY AS POSSIBLE AND YOU DON'T WANT TO UNDERESTIMATE THE VALUE OF HAVING THESE KINDS OF CHANGES BE EASY ON PEOPLE SO THEY HAVE TO MOVE THE DESK OR USE A NEW SYSTEM, SO THAT'S REALLY CLEAR AND THAT'S AN IMPORTANT ONE AND ALL OF US, THE PERSON INCLUDED A LIST WHICH IS REALLY VALUABLE BECAUSE EVEN WHEN YOU THINK YOU HAVE EVERYTHING ON THE LIST, YOU HAVE FORGOTTEN SOMETHING. SO WE WILL BE USING THAT AS WELL AND SAYING, BE CLEAR ABOUT PRIMATESSOR IS AGAIN BEING FOCUSED AND CLEAR AND THE SYSTEM WITH THOSE. THERE WERE TWO COMMENTS HERE THAT THEY THOUL TO BE DISCUSSING OH DENTIFYING FUTURE AND VISION THAT IS, TYING OR CHANGING BACK TO THE OVERALL INTENT, WHEN'S THE HIGHER MEANING AND THE HIGHER PURPOSE AND THAT SENSE OF WE'RE DOING THIS TO ACCOMPLISH X IS REALLY IMPORTANT AND REALLY CRITICAL AND THE TEAM HAS BEEN SPENDING A LOT OF TIME. WE ACTUALLY WORKED ON MESSAGES AND EACH PERSON IN THEIR OWN VOICE BEING ABLE TO COMMUNICATE THE VALUE AND STARTING WITH, WE WANT TO BE X IN THE FUTURE AND AS A RESULT, WE'RE MAKING THESE CHANGES, SO STARTING THE MEETING AND THEN MOVING TO THE METHOD THAT WE'LL GET THERE BY. I HAD ONE QUESTION, ONE EXPLANATION POINT AND I COULD GO IN SO MANY DIRECTIONS BUT IS SOMEONE WANT TO TELL ME MORE ABOUT WHAT THEY MEANT? >> THAT WAS MEAN AND IT WAS JUST THAT, YOU KNOW PARTICULARLY WHEN YOU'RE TALKING ABOUT VERY PRACTICAL THINGS HAVING CONCRETE REASONS, CONCRETE INFORMATION THAT YOU CAN SAY, YOU KNOW WE'RE MOVING ON WEDNESDAY BECAUSE OF X OR, YOU KNOW WE'VE LOOKEDDA THE THIS AND WE ACTUALLY CAN SHOW THAT THIS IS THE BEST WAY WE CAN DO THIS. IT'S NOT JUST SOMETHING WE PICKED OUT OF THE AIR. >> THAT'S REALLY GOOD AND I THINK THAT, YOU KNOW A LOT OF TIMES, YOU KNOW IT'S ONE THAT REFERENCED OVER PEOPLE, BUT ANYTHING ABOUT THIS WE ASSUME OR WHEN YOU'RE FURRINGER ALONG IN THE CHANGE CURVE, YOU SEE THINGS IN A CERTAIN WAY OR YOU UNDERSTAND THE REASON FOR THINGS, WHICH OTHER PEOPLE WHO ARE NOT AS FAR ALONG MIGHT NOT ASAR WARE OF BUT PUTTING YOURSELF IN THAT PLACE AND THINKING PEOPLE THROUGH AND WHY ARE WE DOING THIS AND OVEREXPLAINING ALMOST. YOU CAN SEE REASONS FOR THAT. THE LAST ONE WAS PROVIDING TIME FOR THE NEW TEAM BUILDING ACTIVITIES AND THE TEAM'S BEEN GREAT, AND THE SUPERVISORS HAVE BEEN VERY EXCITED ABOUT THOSE, SO WE'RE REALLY PLEASED AND WE THINK THAT'S ONE THAT WILL DEFINITELY HAPPEN IN THOSE. AND OTHER SIMILAR AS WELL. I COMBINED CUSTOMERS AND PARTNERS BECAUSE WE RECOGNIZE THE DIFFERENT GROUPS BUT THE THEMES THAT WERE GOING THERE WERE REALLY IMPORTANT AND I BROKE THOSE INTO TWO BROAD THINGS FOR THAT ONE SO WHAT WE'LL BE TAKING AWAY FROM THIS WOONE IS ALL OF THE CUSTOMERS AND IDENTIFYING THAT. SO TAKING THE TIME TO THINK ABOUT CUSTOMERS AND PARTNERS. MIC SURE YOU GET INPUT FROM THEM, NOT JUST THE MOST VOCAL AS ONE. ALSO THE WAITING, NOT ALL CUSTOMERS, ONE PERSON SAID THEY'RE NOT ALL CREATED EQUAL AND SO WHAT WEIGHT DO WE GIVE ABOUT THAT. PEOPLE MENTIONED ICs, OTHER MENTIONED CONTRACTORS SO REALLY THINKING BROADLY, AND INCORPORATING THOSE. DOWN HERE THE THEME WAS, IS ONCE YOU IDENTIFY WHO THEY ARE, TALKING TO THEM. RIGHT? GETTING INPUT EARLY, GETTING MESSAGES OUT, LETTING THEM KNOW FOR SOME OF THE SAME THINGS WE TALKED ABOUT, RIGHT? WHY, WHY IS THIS CHANGE MADE, WHAT'S THE LONG-TERM BENEFIT, WHAT CAN THEY EXPECT IN TERMS OF THAT, I LOVE THE COMMENT THEY CAN BE YOUR BIGGEST SUPPORTERS OR THEY CAN BE YOUR BIGGEST CHALLENGE DEPENDING ON HOW YOU APPROACH THEM. SO THOSE ARE GOOD FOR BOTH, THE CUSTOMERS AND THE PARTNER GROUPS. OKAY, I WILL GO DOWN--I MOVE THAT ONE THERE. I WAS LIKE, I MOVED IT. OFFERINGS WISE, I THINK AROUND THE OFFERINGS THERE WERE TWO PIECES, ONE OF THEM WAS THE HOW OF THAT, AND THE TEAMS ACTUALLY, WE MOVED PEOPLE SO WE IDENTIFIED WHERE PEOPLE WILL GO AND RESTRUCTURING ON THAT, AND THE LIBRARY IS LOOKING MORE BROADLY AT THE OFFERINGS THEMSELVES AND SO I THINK THIS FEED SPWOS THAT EFFORT AND WHAT ARE THE CRITERIA, SO IT ASKS WHAT ARE THE CRITERIA THAT ARE USED PARTICULARLY AROUND THE STRENGTHS AND THE STRENGTHS ONE OF THE THINGS, PERFORMANCES, EXCUSE ME, THE STRENGTH OF PERFORMANCES THAT ARE CONSIDERED AS THOSE DECISIONS ARE BEING MADE. THE OTHER ONE IS THAT MAKING SURE WHAT THE REQUIREMENTS ARE FOR OFFERING THAT CHANGES AND THAT THOSE GET CARRIED THROUGH THIS. I LIKE THE FORWARD LOOKING QUESTION WHICH IS WHAT SHOULD YOU BE OFFER THAGOREAN YOU'RE NOT. SO HAVING ONE OF THE NICE THINGS ABOUT CHANGE IS THAT IT GETS PEOPLE TO BE THINKING ABOUT THINGS DIFFERENTLY AND MORE INNOVATIVE WAYS WE TALK A LOT ABOUT THE NEUTRAL ZONE AND DOING AN OPPORTUNITY FOR LOTS OF DIFFERENT IDEAS AND I KNOW WE TALK WIDE THE SUPERVISORS WHEN THE STAFF COMES IN, THIS IS AN OPPORTUNITY TO REALLY START TO THINK ABOUT THINGS DIFFERENTLY. SO WHETHER THAT'S NEW OFFERINGS OR NEW AREAS, I THINK THAT WILL BE IMPORTANT AS WELL. WE REALLY HAD GREAT IDEAS AND NOT SURPRISINGLY BECAUSE THIS IS WHO THE CHANGE IS IMPACTING AND WHAT--THE MOST KIND OF CORE WHETHER OR NOT IT WILL BE SUCCESSFUL, SOME OF THE THEMES THAT I HOLD TOGETHER ON THIS ONE IS, THIS AREA AND THERE WERE SEVERAL OF THE COMMENTS THAT WERE KIND OF WITH THAT, IS THINKING ABOUT--WE GOT A GROUP THROUGH, HOW IS IT WORKING FOR THEM AND WHAT TO DO FOR FOLKS THAT IT'S NOT WORKING FOR AND THIS WILL NOT MAKE SENSE. I THINK THAT THAT IS REALLY IMPORTANT AND BEING HONEST WITH PEOPLE AND TALKING TO THEM ABOUT THE OPPORTUNITIES AND LETTING THEM KNOW HOW THINGS ARE GOING TO CHANGE. ONE OF THE GREAT QUOTES ISSUES RIGHT, DON'T SUGAR COAT IT, BE UP FRONT AND HONEST, THE K-FRGDZS AND SUPERVISORS AND RELATIONSHIP THEY'RE HAVING IS THIS IS WHAT WE WANT TO ACCOMPLISH AND WE WANT TO BE A PART OF ACCOMPLISHING THAT. HOW DO WE THEN ISSUES RIGHT, LET'S SEE HOW PEOPLE ARE GETTING ON BOARD WITH THAT, IT DOESN'T MAKE SENSE WHAT ARE THE OTHER OPPORTUNITIES THAT MIGHT BE AVAILABLE, AND SO, AT THIS POINT WE'RE GETTING GOOD RESPONSES AND PEOPLE ARE EXCITED BUT THAT'S SOMETHING TO WATCH AND MAKE SURE FOR THOSE THAT MAY BE ARE--IT'S NOT MAKING SENSE FOR WHAT ARE THEIR OPTIONS AND OPPORTUNITIES. AROUND THIS, THIS ONE IS WHY IS THE CHANGE NECESSARY? WHY ARE WE DOING THIS? THAT FEEDBACK IS--WHAT'S THE PURPOSE OF THIS, WHAT IS THAT BIG PICTURE THAT WE'RE TRYING TO ACHIEVE AND CONSTANTLY COMING BACK TO THAT. AGAIN YOU CAN GET LOST IN THE DAY-TO-DAY MESSAGING, YOUR DESK IS MOVING YOUR PHONE NUMBER WILL BE THIS, THIS IS THE PROCESS FOR INTERESTING YOUR TIME AND THIS IS WHY WE'RE DOING ALL THAT, TYING BACK UP TO THE BROADER NAME. IN TERMS OF MESSAGING ITSELF, A LOT AROUND HOW TO DO THAT SO WE'LL BE TAKING BACK I THINK THE QUALITY OF IT SO HONEST, RIGHT? UPFRONT GIVING PEOPLE AS MUCH INFORMATION USING THE ANSWER, I LOVED ONE OF MY FAVORITES IS, I DON'T KNOW BUT I'LL FIND OUT IS A COMPLETELY LEGITIMATE ANSWER AND NOT SAYING ANY ABSENCE OF INFORMATION PEOPLE WILL MAKE UP IN THE ANSWER AND THEY WILL MAKE UP THE WORST POSSIBLE. SO SAYING YOU DON'T KNOW OR WE'RE FIGURE THAGOREAN OUT, IT'S ENOUGH TO GET THEM INVOLVED IF THEY HAVE IDEAS OR SUGGESTIONS SO THAT WAS IMPORTANT, IT MENTIONED ALSO CONSISTENCY SO BINDING WAYS TO MAKE SURE ALL THE LEADER ANDS AND ALL THE INDIVIDUALS ARE CONSISTENT WITH THOSE MESSAGES. HERE IS ALSO SOME--A LITTLE BIT OF RELIEF FOR THE LEADERS THAT ARE MAKING THE CHANGES, BE CLEAR ABOUT IT, SAY IT BUT ALSO KNOW THAT NOT ERCH WILL BE HAPPY AT THE END OF THE DAY, IT'S OKAY TO MAKERS AND A MISTAKE OR HAVE AN ISSUE AND MOVE ON AND KEEP MOVING FORWARD. DON'T WORRY, THE SCORE FALL INITIALLY, IT'S THAT WHAT YOU'RE WORKING FOR, THERE'S THAT CHART I DIDN'T GO INTO IT AND YOU SAW THE DIP, CHANGE CREATE UNCERTAINTY AND INSTABILITY, THAT'S HOW YOU CAN AM OUT OF IT THAT'S REALLY IMPORTANT. OKAY, THIS ONE IS VERY MUCH A PEOPLE-FOCUS. KEEP NOTHING MIND THAT PEOPLE ARE MORE CONCERNED WITH THE CHANGE, MORE IMPACTED BY THE CHANGE THAN WE MIGHT REALIZE AS LEADERS AND SO KEEPING THAT IN MIND, THAT IT IS IMPORTANT WHEN PEOPLE ARE ASKING ONE MORE TIME WHY IS THIS HAPPENING TO HAVE THOSE ANSWERS AND TO PUT YOURSELF IN THAT PERSPECTIVE. >> DOES THAT GENERATE ANY OTHER THOUGHTS OR OPTIONS. I'LL PUT THAT BACK BUT I EE I REALLY APPRECIATE ALL THE SUPPORT AND GETTING TO TALK TO YOU AND PRESENT TO YOU. SO THANK YOU SO MUCH. >> WHEN WILL YOU BE DONE? DID YOU SAY THAT? >> I WILL BE DONE--[LAUGHTER] --OURS GOES THROUGH AUGUST. SO WE'RE DOING A LOT OF THE CHANGE AND THE HANDS ON WORK AND WE'RE ALSO HELPING WITH SOME OF THE ACTUAL UPDATING PDs AND THE HR WORK AS WELL. AND OUR PROJECT GOES THROUGH AUGUST. >> I'M GOING TO STILL THE FLIP CHARTS AND THOSE WILL BE COMING OUT AUGUST IN THE BOOKS AS WELL. THANK YOU. >> [ APPLAUSE ] >> THIS HAS BEEN AN OUTSTANDING SUPPORT FROM THIS TRANSITION FROM LAWRENCE AND JOYCE WHO WORKED RADIOLELY HARD TO HAVE THEIR TEAMS, DIANE, AND JANICE BUT WHEN YOU THINK OF THE NUMBER OF PEOPLE WHO ARE IN MOTION AND THE LEGITIMIZING OF THE AMOUNT OF DIFFERENT FEELINGS COMING UP FROM THE GRIEF TO EXCITEMENT TO ANNOYANCE ISSUES - IT IS BEEN--WE COULD NONAPOPTOTIC THE HAVE DONE IT WITHOUT THE SUPPORT. , THANK YOU. >> ENJOY THE REST OF YOUR DAY. >> SO WE NOW HAVE DR. GEORGE HR HRIPC SAK, AM I SAYING THAT CORRECTLY? >> YES. >> AND HE IS THE CHAIR OF COLUMBIA'S UNIVERSITY CHAIR OF BIOINFORMATIC ANDS DIRECTOR OF INFORMATIC SERVICES FOR NEW YORK PRESBYTERIAN HOSPITAL AT THE COLUMBIA CAMPUS, HE'S INTERESTED IN THE CLINICAL INFORMATION STORED IN ELECTRONIC HEALTH RECORDS, AND IN THE DEVELOPMENT OF NEXT GENERATION HEALTH RECORDS RESEARCH WHICH IS A REALLY GOOD THING, JUST ASK GRACE. WITH MORE THAN 25 YEARS OF EXPERIENCE IN BIOMEDICAL INFORMATICS DR. HRIPC SAK HAS A LONG HISTORY OF TKPWEPING, IMPLEMENTING AND STUDYING INTERVENTIONS TO IMPROVE HEALTHCARE. HE'S HERE TODAY TO GIVE A TALK AND DISCUSS HIS FUNDED RESEARCH ENTITLED DISCOVERING AND APPLYING KNOWLEDGE IN CLINICAL DATABASES. SO WELCOME DR. HRIPC SAK. >> THANK YOU SO MUCH AND IT'S AN HONOR TO BE HERE TO TALK ABOUT THIS. MY ROONE IS CALLED DISCOVERING AND,A PHRAOEUING KNOWLEDGE FROM CLINICAL DATABASES, 6910, I HAVE THAT WELL MEMORIZED. IT STARTED 29 YEARS AGO AS AN R29 IN 19 AND WAS FUNDED IN FISCAL YEAR 99, CALENDAR YEAR 2000 AND SO IT'S GOING ON, ALMOST IT WILL BE 20 YEAR YEARS WITHIN A YEAR. WE GENERATED ABOUT 232 PAPERS SINCE ITS INCEPTION AS IN R29. AND SO WE'VE DONE A LOT OF THINGS OVER THE YEARS, ONE OF THE EARLST SITES TO DO PHENOTYPING OF ELECTRONIC HEALTH RECORDS, NATURAL LANGUAGE PROCESSING, ORTPHAEUPBL ORIGINALLY DID LANGUAGE AND PROCESSING AND NATURAL LANGUAGE PROCESSING. TIME SERIES ANALYSIS, PHYSICS LITERATORS A, CHAOS AND SATURDAY I'M GOING TO THE SYMPOSIUM FOR INDUSTRIAL APPLIED SYSTEMS IN THIS. HEGT CARE PROCESS BI AS AND CAUSAL INFERENCE IS MY MOST ACTIVE AREA IN THIS RESEARCH AND WHAT'S BEEN FUN AND I'LL COME BACK TO THIS IS THE COLLABORATIONS DATE LIES WITH A FAMOUS MACHINE LEARNING PERSON, MARK WON THE WORLD STATISTICS PRIZE FOUR YEARS AGO, DAVID MAD EIGHT HOURS AN AND OTHERS, SO THESE I'VE BEEN DOING IN THE GRANT SO FAR AND IT'S ON INNOVATION. AND THEN I'M PROUD THAT YOU KNOW WE DO IT AND THEN IT GETS PICKED UP BY THE COMMUNITY AND MOVES ON, BUT SOME OF THAT IS, YOU KNOW YOU DON'T REAL REALLY SKIP TOEE IT COME AND HAVE AN EFFECT ON HEALTHCARE SO ABOUT FOUR YEARS AGO, I KIND OF CHANGED DIRECTION A LITTLE BIT AND SAID WE HAVE TO ACTUALLY DO SOMETHING WITH THIS STUFF AND I CAN'T JUST KEEP PUBLISHING PAPERS WE HAVE THAT DOWN PRETTY WELL BUT NOW WE HAVE TO DO SOMETHING ABOUT THIS. AND SO, OTKESZY WHICH I WILL DESCRIBE IN MORE DETAIL IN THE MOMENT IS THAT VENUE WHERE WE PUT THINGS OUT AND IT'S A COLLABORATION THAT'S NOT JUST ME BUT A LOT CAME ABOUT THROUGH ROONE AND THAT'S WHAT I WILL SPEND MOST TIME ON AND IT'S MOSTLY ABOUT THE IMPACT AND THEN I'LL COME BACK AND DO SOME OF THE FUN MATHEMATICAL STUFF, SO THAT'S DATA SIMULATION IN THE LAST TOPIC AND I WON'T GO ABOUT IT NOW SO I LEAVE MORE TIME FOR THE TALK. SO I WILL TALK ABOUT OTKESZ SKPE BAKUGAN SATTA SIMULATION. SO OBSERVATIONAL HEALTH DATA SCIENCES AND INFORMATICS AND INTERNATIONAL LABRATIVE, TO GENERATE EVIDENCE TO IMPROVE HEALTHCARE, THE COORDINATING CENTERS AT COLUMBIA UNIVERSITY, I'M THE DIRECTOR OF THE COORDINATING CENTER, WE HAVE 250 NOW RESEARCHERS FROM 25 COUNTRIES, WE HAVE HALF A BILLION UNIQUE PATIENT RECORDS AND OUR FEDERATED DATABASE. STRONG IN NORTH AMERICA, EUROPE, ASIA ISSUES WE HAVE RESEARCHERS ELSEWHERE,A ROUND THE WORLD BUT NO DATABASE IN SOUTH AMERICA OR AFFRIC AALTHOUGH I HAD A GREAT CALL WITH CHILE AND THEY AGROWED TO COME ON BOARD SO AS SOON AS THEY'RE DONE, I CAN PUT SOUTH AMERICA ON THE MAP.& JUST TELLING ME BRAZIL WAS MOVING FORWARD HELPED A LOT. WE HAVE ONE IN AUSTRALIA. WE HAVE THAT COVERED A BIT. IT'S AN OPEN SCIENCE EFFORT WHICH IS NOT JUST OPEN SOURCE SOFTWARE BUT EVERYTHING WE DO IS OPEN, SO THESE SLIDES WOULD ALREADY BE ON THE WEB, ALL RESULTS ARE ALREADY ON THE WEB, JOURNALS THAT CAN'T HANDLE THAT, CAN'T PUBLISH OUR RESULTS BAH BECAUSE EVERYTHING IS OPEN FROM DAY ONE. HOW DO YOU GET HALF A BILLION PATIENTS, IT'S ABOUT TWO BILLION RECORDS BUT THERE'S A LOT OF REDUNDANCY SO THERE'S HALF A BILLION PATIENTS, HAVE YOU EVERYONE STANDARDIZED TO A COMMON DATA MODEL. WE CALL IT THE MODEL BECAUSE THAT'S THE ORIGINAL NAME OF ODEGRADATIONSY, GREW OUT OF THE OMA HARPROJECT, IF WE CHANGE THE NAME, MAYBE NO ONE WILL USE IT ANYMORE, LIKE GOING FROM DOS TO WINDOW. SO THAT WAS A BIG MISTAKE. SO YOU CHANGE THE NAME TO THE DATA MODEL. TURN BACK THE RESULTS AND WE COLLABORATIVELY PUBLISHED THE PAPER AND EVERYONE'S A CO-AUTHOR. HERE'S A DEEP INFORMATION MODEL THAT WE USE FOR IT WHICH IS, YOU KNOW PHYSICAL MODEL SO THAT THE THINGS ARE ACTUALLY SEPARATED INTO TABLES THAT MAKE SENSE, WE FIND THAT WAS THE BEST FOR RESEARCHERS TO UNDERSTAND WHAT THEY WERE WORKING WITH AS OPPOSE TO SOME OTHER SCHEMES LIKE A FACT TABLE OR EVERYTHING'S IN ON THE FACT TABLE AND YOU HAVE TO FIGURE IT OUT. >> WE WORK AND THIS IS CLOSE WORK WITH NLM AND WE MAP OVER 100 DIFFERENT VOCABULARIES TO AROUND THE WORLD, WHAT ARE THE STANDARDS, WELL, RX NORM, LOINC, SNOW MED, SO THE ONES THAT US AND NLM HAVE CHOSEN IS WHAT OTKESZY HAS CHOSEN AND WILL MAP JAPANESE DRUGS AND GERMAN DRUGS AND EVERYTHING ELSE, SO WE PRODUCE SOMETHING CALLED RX NORM EXTENSION WHICH COVERS THE DRUGS WHICH ARE NOT COVERED BY NLM BECAUSE THEY'RE NONU.S. FORMULATION SAYS, USUALLY THE DRUG IS THERE BUT NOT THE FORMULATION, SO WE DO THOSE MAPPINGS AND THEN WE SUPPLY--I WANT TO GO BACK TO THE RESEARCH, SO I WILL MENTION IT BRIEFLY, WE SUPPLY TOOLS, TO MOVE YOUR DATA INTO THE MODEL, TO DO THE DATA CURATION, I WERB I HADN'T DROPPED THAT SLIDE BASED ON OUR PREVIOUS DISCUSSION IN THE WORK GROUP ON RESEARCH, INNOVATION ISSUES CREATE THE STUDY, VERBALIZE THE STUDY RESULTS SO LET ME GO INTO THE RESEARCH, SO THE FIRST LARGE SCALE STUDY WE DID, WE ACTUALLY THOUGHT OF IT AT LUNCH AT THE MEETING IN NOVEMBER AND WITHIN THE FIRST THOUGHT OF DOING THIS STUDY WITHIN THREE WEEKS WE HAD MOST OF THE RESULTS BACK FROM,A ROUND THE WORLD, IT TOOK ANOTHER TWO MONTHS FOR THE LAST DATABASES BECAUSE THEY HAD TO GET SEPARATE IRB APPROVAL. ONE OF THE FEATURES OF THIS IS THAT YOU FOLLOW YOUR OWN PRIVACY PROTOCOLS, YOU HAVE DEIDENTIFIED DAILY BASIS THEA, CAN YOU DO WHAT YOU, YOU MAY NEED TO GET PERMISSION AT YOUR INSTITUTION BEFORE YOU SEND THE RESULTS. THIS STUDY WAS TO SAY, HOW DID WE TREAT CERTAIN COMMON DISEASES AROUND THE WORLD AND WE DON'T REALLY KNOW THAT, WE KNOW WHAT FORM SUITICAL COMPANIES SELL AND WE KNOW WHAT ACADEMIC MEDICAL CENTERS GIVE BUT WE DON'T HAVE A GOOD FEEL FOR IT, SO WE SAID FOR DIABETES TYPE TWO, HYPER TENSION AND DEPRESSION, HOW DO WE TREAT IT. WE DID 12 DATABASES, 240 MILLION PATIENT POPULATION. I'M SHOWING JUST THE FIRST THREE DATABASES, FOR EACH OF THE DISEASES. FIRST ONE IS CCACE AND THEN JAPAN. >> CAN YOU SLEEP APNEA AND OBESITYY THAT. >> WE CAN SEE METAFORM AN, I CAN'T SEE MY OPEN FINGER RETPHREBGING SO THE BIG ROUND ARC THAT'S THE FIRST DRUG IS THE INNER SECOND QUARTERLE, SECOND DRUG IS THE NEXT CIRCLE AND SO ON AS YOU GO OUT. THE BIG GREEN ARC IS METFORMIN, SO 75% OF PEOPLE START ON MET FORMIN, IN THE UK, SOUTH COREE A75%, HONG KONG 75%, JAPAN 25%. ONLY ONE OUT OF OUR SAMPLE. I ASOUPED IT WAS FORMULARY OR THEY HAVE A DIFFERENT DRUG OR FINANCES BUT A JAPANESE PHYSIOLOGIST, DIABETES PHYSIOLOGIST BELIEVE THAT THEIR PATIENTS DON'T GET GENETICALLY DON'T GET MUCH INSULIN RESISTANCE THEREFORE DON'T USE MUCH MET FORMIN. AND MAYBE THEY ARE DIFFERENT DIFFERENT EPIDEMIOLOGICALLY AND THEY ONLY USE ONE-THIRD OF THE MET FORMIN, THE REST OF THE WORLD USES. HYPER TENSION SHOWN THERE, IS NOT AS MUCH AGREEMENT BUT THERE IS SOME AGREEMENT THERE. AND THEN LASTLY DEPRESSION ON THE RIGHT, YOU SEE THOSE ARE THREE U.S. DATABASES AND THEY DON'T AGREEN CELLS AT ALL AND THAT MAKES SENSE AS A DOCTOR BECAUSE WE DON'T KNOW HOW TO TREAT DEPRESSION, WE DON'T KNOW WHICH DRUG WILL WORK BEST IN A PATIENT. WE DON'T HAVE GOOD EVIDENCE BASE FOR IT SO IT ENDS UP BEING A RANDOM SAMPLE OF DRUGS, THAT WAS OUR FIRST LARGE SCALE STUDY PUBBISHLISHED IN PNAS IN TWEBT 16. SO NOW I WANT TO GET TO THE EXAMPLES. WHAT'S REALLY THE ROONE IS CONCERNED ABOUT REPRODUCIBILITY AND CAUSAL INFERENCE SO HERE'S AN EXAMPLE OF PAPER IN JAMMA AND A PAPER IN BMJ, NOT BAD JOURNALS, GOOD QUESTION, DO FOSTER NURSED FOCUSED ONINATES CAUSE GASTRIC CANCER--I MEAN ESOPHAGEAL CANCER? LET'S USE THE UK DATABASE. SO SAME DATABASE, SAME QUESTION, MONTH A PART, TWO TOP JOURNALS ONE SAYS YES, ONE SAYS NO. THE PUBLIC READS THIS AND REPORTS ON THIS, AND THEY DON'T KNOW WHAT TO DO AND HAY SAY, YOU KNOW YOU READ COFFEE CAUSES CANCER AND THE NEXT YEAR CURES CANCER AND IN THE IN ACCIDENT YEAR CAUSES IT AGAIN SO WHAT'S GOING ON. LET ME SHOW YOU THIS DIAGNOSTIC SO ONE MEANS NO, STANDARD, O I WILL PLOT A BUNCH OF IS IT STUDIES FROM THE LITERATURE, THE PURPLE TOP IS THAT IT'S NOT SIGNIFICANT, THE BLUE MEANS IT CAUSES HARM AND ON THE LEFT MEAN ITS PROTECTED BUT STATISTICALLY SIGNIFICANTLY SO, SO LET'S PARSE 30,000 STUDIES FROM MED LINE AND SEE WHERE THEY END UP. SO THAT'S WHAT WE GET. WE NOTICE THERE'S A TKEURGT OF STUDIES IN THE MIDDLE, NOT STATISTICALLY SIGNIFICANT. SO IT'S NOT SURPRISING BECAUSE WE KNOW OF PUBLICATION BIAS, WE ALSO SEE EVIDENCE OF P-VALUE HACKING THAT IS SOME EXTRA MASS RIGHT ON THE EDGE THERE SO IF YOU HAD A .051 YOU CHANGE A COUPLE VARIABLES AND WHICH ONES YOU INCLUDE AND THEN YOU GET TO .049 AND SAY SUBMIT. SOPHISTICATEDY WE PRACTICESSENT ISED THIS AND PEOPLE SAY, NO WE'RE GOOD AT GUESSING WHAT WILL BE POSITIVE BECAUSE WE WHY BOTHER WITH THE ONES THAT ARE NEGATIVE. SO WHAT I DID HERE IS I TOOK A SLICE THROUGH THAT DIAGRAM. THE BLUE IS THE LITERATURE AND YOU CAN SEE WHERE .05 EITHER CAUSING BENEFIT OR HARM ARE, P.001 HAS A SPITE BECAUSE WE ROUND OFF, SO IT'S JUST A ROUNDING OFF THAT SPIKE, IF YOU ARE PERFECT AT PREDICTING WHAT TEST YOU WILL DO, AND GETTING THE POWER OF .8. SO THE BEST YOU CAN DO IS THE RED LINE, YOU CANNOT GET A CLIFF EXCEPT THROUGH PUBLICATION BIAS AND WHAT'S THE PROBLEM WITH PUBLICATION BIAS, YOU DON'T KNOW WHAT THE DENOMINATOR IS, IF YOU DON'T KNOW THE DENOMINATOR OF WHAT'S THERE IN THE MIDDLE THEN YOU CAN'T SAY WHAT YOUR PREDICTIVE VALUE IS ON END, THAT MEANS WHAT'S POSITIVE IS NOT TRULY POSITIVE. SO, SO OTKESZY HAS SET UP TO DO REPRODUCIBLE RESEARCH AND I WILL DESCRIBE SOME OF OUR APPROACHES, SO ONE IS A STANDARD APPROACH INVENTED BY DON RUBEN IN THE 80S, I GUESS, PROPENSITY SCORE BALANCING, WE'RE USING STRATIFICATION BUT WHAT WE'RE DOING DIFFERENT AND WHICH IS NOT BEING DONE ELSEWHERE, IS DOING IT SYSTEMATIC LOAMACYY, NORMALLY WHEN YOU DO THIS, SO PROPENSITY SCORE JUST SAYS, I HAVE TWO GROUPS AND I COMPARE TWO DRUGS AND SEE WHICH ONE CAUSES MORE DEATHS, OKAY? BUT I WANT THE TWO GROUPS TO LOOK LIKE EACH OTHER, ONE'S OLD AND ONE'S YOUNG, THE OLDER ONES WILL DIE MORE, SO I WANT THEM TO BE BALANCED OF COURSE, STRATIFICATION JUST A WAY OF BALANCING THOSE TWO GROUPS BUT NORMALLY WHAT'S DONE IS THAT THE VARIABLES ARE HAND SELECTED TO BE VARIABLES THAT WE THINK WOULD BE IMPORTANT IN DOING THIS. WE'RE RESKWREBGING THAT AND SAYING WHAT WE DO IS THROW IN ALL VARIABLES WHICH IN THIS CASE IS 58,000 VARIABLES AND WE LET THE LAST REGRESSION, YOU KNOW RIDGE REGRESSION, REGULAR REGRESSION, PICK THE RIGHT VARIABLING, SO THAT WE DON'T HAVE A HUMAN BEING INTERFERED. NOW THE DIAGRAM ON THE LEFT YOU WILL SEE LATER WITH THE BLUE AND THE RED MEANS THEY'RE'S NOT PERFECT RO*EFR LAP. THE PURPLE IS THE OVERLAP. THE DIAGRAM IS PERFECT FOR PROPENSITY SCORE BALANCING BECAUSE IT'S NOT PERFECTLY BALANCED TILL WE NEED IT BUT IT'S NOT SO FAR PART THAT THEY'RE NOT POSSIBLE, IF IT'S TOO FAR APART I WOULD HAVE TO DO A RANDOMIZED TRIAL. ON THE RIGHT ARE YOU SEE THE BALANCING AND ALL THE DIFFERENCE MEANS ARE .1, MOST OF THEM ARE LESS THAN .025. SO WHEN YOU READ A PAPER IN MEDICINE, TABLE ONE IS WHERE THEY BALANCED ON AGE, WHERE THEY BALANCE OFFICE OF DIVERSITY SEX, BALANCED ON MORBIDITYS. OUR TABLE ONE IS 60,000 ROWS LONG AND EVERY SINGLE ONE IS 60,000 VARIABLES ACCORDING TO THIS TECHNIQUE, SECOND THING IS, THERE'S STILL THINGS YOU HAVEN'T MEASURED OUT OF THIS WITH THE 68,000 SO THERE'S RESIDUAL CONFOUNDING SO FOR THIS WE USE NEGATIVE CONTROLS, AND WE DO IN THE LITERATURE, JUST START IS TO TAKE A NEGATIVE CONTROL. SO YOU DO SOMETHING AND YOU CHECK ONE OR TWO OR THREE OTHER THINGS YOU THINK SH-BT BE TRUE BUT THEY'RE NOT AND WE ACHE A HUNDRED OF THEM AND SHOW THAT A HUNDRED AREN'T TRUE BECAUSE WE DON'T HAVE SOMEONE MANUELLY PICKING THE VARIABLES AND WE CAN DO THIS AT SCALE. AND THEN WE CAN DO A DIAGNOSTIC TO SAY, WELL, YOU KNOW, DOES ASPIRIN CAUSE AN INGROW NAIL, PROBABLY NOT. YOU MIGHT TAKE ASPIRIN IN THE OLD DAYS, SO YOU MIGHT TAKE IT FOR THE OTHER REASON BUT YOU WEREN'T CAUSING INGROWN NAIL SO THAT COULD NOT SHOW A CAUSAL EFFECT. WE CAN RECALCULATE OUR THESE. THIRD THING IS WE DO IT ON MANY DATABASES, MANY LOCATIONS, I SHOWED YOU THE OTHER FIGURE SO WE'RE DOING THIS ACROSS DATABASES AND COMPARING AND LOOKING TO SEE IF ADDITION TO OUR DAT BASE BY DATABASE DATA CURRATION, THEN WHEN WE DO THE STUDY, WE SEE HOW DATABASES AGROW WITH EACH AND WAOERB COMPLETE PLEA OPEN, PUBLISHING EVERYTHING INCLUDING RANDOM NUMBERS, WHEN WE REMEMBER, UNFORTUNATELY BUT WE'RE SUPPOSED TO BE PUBLISHING A RANDOM NUMBER, SO THE IF, DA PUBLISHED A QUESTION ALSO KNOWN AS THE SEIZURE DRUG CAUSING ANGIO EDEMA, SEVERE REACTION OF THE FACE. SO WE ENLISTED OUR NETWORK, SEVEN SITES AGREED TO DO IT ON TEN DAYS, AND DATABASES BRINGING UP TENS OF THOUSANDS OF PATIENTS AND WE FOUND OUT DOESN'T CAUGHT AVERAGEIO EDEMA BUT PARAFORMIN DOESN'T CAUSE IT BUT UPLEPSY JOURNALS, IT'S ONE OF THE TOP TEN NEUROLOGY JOURNALS BUT THE *EUPLT PACT FACTOR IS HIGH SIPPINGLE DIGITS OR SOMETHING, AND IT CAME BACK ADD A WORD TO THE TAOEULTS AND MOVE FROM THE SUPPLEMENT TO THE BODY, SO THAT WAS THE STATISTICAL EDITOR, ACCEPTED OR WITHOUT FURTHER QUESTION, THE WAY WE PUT IT FORWARD. PUTTING THIS OUT FOR A REASON, YOU'LL SEE LATER ON. SO NOW THAT WE CAN DO A STUDY AND WE THINK WE CAN DO A GOOD STUDY, LET'S DO A LOT OF THEM. THIS IS A STUDY FOR DEPRESSION, ALL DRUGS AND DEPRESSION, WHAT SIDE CENTER FOR EXCELLENCE ON AGINGS THEY HAVE, NOT THE EFFICACY OF ANTIDEPRESSION TREATMENT BUT THE SAFETY OF IT. THESE ARE ALL THOSE DIAGRAMS FOR ALL THE HYPOTHESIS WE DID, WHEN WE PLOTTED ON AX SESZ WE DON'T GET PUBLICATION BIAS, WE GET A FIGURE THAT'S LOOKING THE WAY IT'S SUPPOSED TO, AND SIX% ARE PROBABLY TRUE SIDE EFFECTS AND FIVE% ARE FALSE-POSITIVES BY THE DEFINITION OF A CONFIDENCE INTERVAL, IT'S MEANING THAT FIVE% ARE FALSE-POSITIVES THAT THAT MEANS MY POSITIVE BREAKTHROUGH DETECTION ANTIBODYIVE VALUE, I HAVE A 55% CHANCE OF BEING RIGHT WHICH DOESN'T SOUND THAT GOOD BUT THE LITERATURE IS LIKE YOU KNOW, I DON'T KNOW HOW LO LOW IT IS BUT IT'S VERY LOW IN COMPARISON, I MEAN THAT IT'S LIKE A DREDGING MACHINE ACTUALLY. SO NOW LET'S PUT THIS INTO A HIGH IMPACT, NOW THAT DEPRESSION IS HIGH IMPACT BUT THAT WAS JUST LOOKING AT SAFETY. NOW LET'S LOOK AT EFFICACY. THIS IS THE U.S. HYPER TENSION GUIDELINE. THERE ARE 58 DRUGS, HALF OF THEM ARE FIRST LINE DRUGS, HALF OF THEM ARE SECOND LINE DRUGS, IT'S BASED ON AN EVIDENCE BASE, THAT'S CLASSIFIED INTO DIFFERENT TYPES OF EVIDENCE LIKE META-ANALYSIS OF RANDOMIZED TRIALS VERSUS SINGLE TRIALS VERSUS EXPERT OPINION, IF YOU LOOK AT THAT GUIDELINE WHICH WAS OVERA HUNDRED RECOMMENDATIONS, IT WAS PUBLISHED A YEAR AGO NOW, IT'S BASED ON 40 RANDOMIZED TRIALS, WELL IF YOU HAVE 58 DRUGS GOING HEAD-TO-HEAD, AND YOU HAVE EVERY COMBINATION OF DRUGS, THERE'S A ZILLION HYPOTHESIS OF WHICH THEY ONLY HAVE 40 TRIALS TO GENERATE THE EVIDENCE OF THAT. A STUDY SHOWS THAT ONLY 11% OF RECOMMENDATIONS OF AHA GUIDELINES ARE BASED ON LARGE RCTs OR META-ANALYSIS, AND MOST OF THE DECISIONS ARE ACTUALLY EXPERT OPINION. SO THE POINT IS CAN WE FILL IN THE GAPS THAT DIAGRAM SHOWN THERE EACH DOT IS A DRUG AND AN ARC IS WHERE WE HAVE EVIDENCE. SO IF YOU TAKE EVERY DRUG, EVERY ONE OF THESE 58 DRUGS, THAT'S 58 TIMES 58 MORE OR LESS AND THEN YOU DO HEAD-TO-HEAD COMPARISONS, 58 TIMES 58 MORE AND WE HAPPENED TO PICK UP 58 OUTCOMES SO IT'S 58 TO THE FIFTH BUT MOST PEOPLE DON'T TAKE COMBINATIONS SO WE END UP WITH A HALF MILLION HYPOTHESIS THAT WE TESTED. SO WE RAN THAT, ACROSS OUR NETWORK, EACH HYPOTHESIS IS A FULLY EXCUED TRIAL FOR THE EPILEPSIA STUDY THAT GOT PUBLISHED WITHOUT FURTHER CHANGES WHEN IT WAS SUBMITTED TO THE JOURNAL. SO OUR BELIEF IS WE'VE DONE HALF A MILLION GOOD STUDIES, BUT IT'S NOT A HALF A MILLION BECAUSE WE JOURNAL YOU DON'T KNOW IF YOU'VE DONE A GOOD JOB AND WE FIND THAT HALF OF THEM ARE POSITIVES, WE KNOW WE SCREWED UP SOMEHOW SO BY DOG MANY STUDIESA THE ONCE, CAN YOU LOOK AT THE OPERATING CHARACTERISTICS OF OUR APPROACH SO HERE WE HAVE COMPARING TPAOURS ON MID TO AMNIPOOEDINE, SO WE WOULDN'T TRUST THESE RESULTS SO WE TELL OURSELVES DON'T TRUST THIS ONE BUT THERE'S STILL 300,000 THAT AREN'T TRUSTWORTHY IN THIS. SO WHO DOESN'T DO THIS WOULD PUBLISH THE RESULT, IT WAS THE PUBLICATION BMJ SAYING IF YOU GET THE FLU, YOU GET HEART ATTACKS. ANYONE SEE THAT PAPER IT WAS ABOUT A YEAR AGO,. >> I READ IT, YES. >> WE REDID, WE REDID THAT STUDY AND EVERY OTHER HYPOTHESIS, SO DO YOU GET THE FLU DO YOU GET X, WHERE X IS ANYTHING, ALMOST EVERY SINGLE ONE IS YES, THERE WERE ONLY LIKE THREE THINGS, IT WAS A LARGER NUMBER BUT THERE WERE A SMALL PORTION THAT UPONN'T BUT IT WAS NEGATIVE CONTROL. SO I DON'T KNOW THEY DID FISHING OR GOT UNLUCKY, GOT UNLUCKY, SEE WE FILL IN THE KNOWLEDGE BASE WITH 10,000 COMPARISON COMPARISONS AND IT DEPENDS ON HOW YOU KOUBT AND 40 COMPARISONS, 10,000 COMPARISONS AND HERE'S OUR RESULTS. SO, IN THE--ON THE LEFT FIGURE, YOU SEE RANDOMIZED TRIALS AND YOU SEE GRAY BOXES, THAT MEANS THAT THESE DON'T WORRY ABOUT THESE, THEY'RE JUST THERE NOW, BETA LOCKERS AND THIS STANDS FOR LARGE SCALE EVIDENT, GENERATION, CERTAINLY--CERTAINLY VALENTINEDUATION NETWORK OF DATABASES, IN THE KEY MEANS THE GREEN OF THE DRUG DID BETTER AND PURPLE MEANS THE DRUG BELOW DID BETTER SO WE SEE THE BETA BLOCKERS DO WORSE THAN THE OTHER DRUGS IN GENERAL AND IN FACT THE U.S. GUIDELINE SAID THAT, IT SAID THAT BETA BLOCKERS ARE NOT FIRST LINE BUT THE OTHER CLASSES ARE. THRA INCLUDED BETA BLOCKERS BUT THE ONE THING I WANT TO POINT LOWER LEFT CORNER OF THE RIGHT SQUARE THAT SAYS TZD VERSUS ACE INHIBITORS, DIURETICS DID BETTER THAN ACE INHIBITORS AND WHY IS THAT IMPORTANT? I DIDN'T SHOW THE PREGNANTS BUT IT DID BETTER IN SAFETY AND EFFICACY SO PREVENTING CARDIAC COMPLICATIONS. IF THEY USED THE IPADDA SWRAOEUD DIURETIC WE WOULD SAY ONE CARDIOVASCULAR EVENT PER THOUSAND PATIENTS PER YEAR, SO IF THERE'S HIHUNDRED MILLION PATES WITH HYPER TENSION AROUND THE WORLD THAT'S A HUNDRED THOUSAND CARDIAC EVENTS PER YEAR, NOW WE HAVE TO GIVE PEOPLE, BELIEVE IN IT AND GET PEOPLE TO BELIEVE IT. I'LL COME BACK TO THAT. HERE'S AINGS MORE DETAIL. THE BLACK BOX UPPER LEFT, IT SAYS THE HYPER TENSION GUIDELINE IS MOSTLY RIGHT BUT MOSTLY GREEN AND THE UPPER RIGHTEOUS IS THE 50 LINE IS BETTER THAN THE SECOND LINE. THE PURPLE BOX IS THE SAME BECAUSE IT SAYS THAT THE SECOND LINE ISN'T AS GOOD AS THE FIRST LINE. ALSO LOOKING AT SPECIFIC THINGS, I WILL MENTION LIKE CORE THALADONE, IT'S A DIURETIC, WE'VE BEEN USING HYDROCHLORIC DIASWRAOEUD FOR DECADES AND IT SEEMS TO WORK. RESEARCHERS TOP END CARDIOLOGY RESEARCHERS WANT US TO SWITCH TO CHLORRA THAT WILLA DONE, THEY DID AN IN-NETWORK TO PROVE IT WHICH WE DON'T TRUST, WE SHOW IT'S NO BETTER AND MUCH WORSE SAFETY. SO THE LAST TIME SOMEONE PUBLISHED THAT WITH A CANADIAN OBSERVATIONAL RESEARCH AND I GOT TEN LETTERS ONE OF THEM ACCUSING THEM OF MISUSE PUBLIC HEALTH SERVICE FUNDS BECAUSE THEY PUBLISH WHAT THEY DIDN'T WANT TO READ SO I WILL PUBLISH WHAT THEY DON'T WANT TO READ. SO THEY SAY DO WE TRUST THIS? WELL LET'S TAKE THE EVIDENCE THAT IS ALREADY OUT THERE WHICH IS DIRECT--DIRECT META-ANALYSIS OF RANDOMIZED TRIALS WHICH IS THE GOLD STANDARD. LEVEL A SEFD LETTA'S SEE HOW OURS DOES COMPARED TO THEIRS SO ON 30 STUDIES WE AGREE OFFICE OF DIVERSITY 28. SO BY CHANCE ALONE WE WILL AGREEN CELLS ON 29 OR 28 OF 30. SO OUR EXPECT AGREEMENT WITH BEING CONSISTENT WITH THE TRIALS. ONLY OUR CONFIDENCE *EURT VALENTINEDS ARE SMALLER THAN THE ONES THAT ARE GREEN OR RED, BET'RE BETTER THAT KNOW WHAT WE MISMATCHED ON. IN SOME CASES THE GREEN ONE WAS NOT STATISTICALLY SIGNIFICANT BUT IT LEANED ON THIS SIDE. OUR RESULT IS WITHIN THEIRS BUT IT'S ON THE OTHER SIDE AND STATISTICALLY SIGNIFICANT SO IF YOU LOOKEDDA THAT THE AND SAID WELL IT'S NOT STATISTICALLY SIGNIFICANT, BUT LET'S GO WITH THAT, NO, YOU HAVE GONE IN THE OTHER DIRECTION AND WERE CONSISTENT WITH THAT RESULT. SO THIS MAKES US FEEL GOOD AND DEPENDS ON THE METHODS ONE WAS 29 AND ONE WAS 28 BUT EITHER WAY IT'S CONSISTENT WITH CHANCE. THERE IS ON THIS STUDY AS I'M GOING BACK ONE SLIDE, A RANDOMIZED TRIAL COMING UP THAT WILL SEE WHO'S RIGHT. WERE WE RIGHT IN THIS EVIDENCE AND THAT WILL BE DONE INIA A FEW YEARS AND WE'RE GENERATING REMEMBER, LIKE A HUNDRED THOUSAND OTHER HYPOTHESIS THAT IF SOMEONE DOES A RANDOMIZED TRIAL, WE HAVE A PERSPECTIVE OF WHAT THEY WILL SHOW. SO OUR EVIDENCE IS CONCORD WIDE RCTs, HRARPLGLY SUPPORTS THE U.S. GUIDELINE BUT IF WE'RE RIGHT ABOUT ACE INHIBITORS PEOPLE SHOULDN'T BE STARTING ON IT FIRST AND WE COULD SAVE A LOT OF CARDIOVASCULAR EVENTS. SO I MEAN--IT'S FEASIBLE TO CREATE ENORMOUS NETWORK SITES AND WE COME UP WITH--SO FOUR YEARS AGO WHEN I SAID HALF A BILLION PATIENTS FROM AROUND THE WORLD, HALF A MILLION STUDIES ON THEM, THAT WOULD HAVE BEEN AN AUDACIOUS AND PROVE THAT HALF THE WORLD'S HYPER TENSION STARTING ON THE WRONG DRUG THAT WOULD BE AN AURBS TKAEURBS GOAL WHICH WE HAVE ACHIEVED AND WOULD THIS HAVE OCCURRED WITHOUT THAT ROONE, IT WOULD HAVE BEEN AT LEAST DIFFERENT IF NOT, NOT AT ALL. SO I THINK WE ARE ALREADY DOING AUDACIOUS THINGS. BY THE WAY, IT'S NOT JUST ROONE, IT'S THE WORK ON STANDARDS THAT OLIVIA AND CLEM WORK ON THAT SUPPLY THIS THING. SO NOW LET ME GET TO MY OTHER TOPIC, AND I WILL GO THROUGH A DATA ASSIMILATION, THAT IS PUTTING TOGETHER MECHANISTIC MODELS AND IMPERICAL DATA IN THE 1960S IF THE FORECAST WAS RAIN AND YOU WANT TO GO OUTSIDE YOU IGNORED IT BECAUSE THEY WERE PROBABLY WRONG ANYWAY, NOW IT HAS SEEMED TO WORK. WHY IS THAT, THEY COLLECT MORE DATA AND THEY USE DATA SIMULATION TO JOIN THE MODELS, THIS VALIUM NOWS DATA TO COLLECT AND THEY HAVE THE COMPUTING POWER TO PUT IT TOGETHER AND MAKE REASONABLE PREDICTIONS. THEY USE IT SOME SPACE TRAVEL. THAT'S HOW WE GOT TO THE PHAOUPB IS DATA SIMULATION AND IN THE MEDICINE WE DON'T USE IT TOO MUCH, BUT A BIT OF INFECTION TRACKING AND THE INSULIN PUMPS THAT YOU INSTALL ON PEOPLE'S BODY USE A LYNNIARY VERSION OF DATA SIMULATION. YOU GO INTO THE ICU, YOU'RE NOT A DIABETIC AND YOU ACT LIKE ONE BECAUSE YOU'RE GETTING STEROIDS AND YOU'RE UNDER STRESS AND WHAT DO THEY DO? THEY PREUBT IT OUT ON A PIECE OF PAPER AND THEY TRY TO FOLLOW IT BUT IT'S COMPLEX BUT IT'S NOT AT ALL TAIL LOR LORA LORA TAILORED TO THE PER SON. THERE'S A WHOLE CONTROVERSY ABOUT GLUCOSE MANAGEMENT IN THE ICU, AND WE KILLED IT. SO WE WANT TO ADDRESS THAT. HOW DO WE MANAGE PEOPLE TIGHTLY TO MAKE THEM HEALTHIER WITHOUT KILLING THISEM WITH HYPOGLYCEMIA. HOW DO DRS. USE PHYSIOLOGY, BY ANALOGY? WELL THE GLUE KOEZ WAS HIGH YESTERDAY, WHY CAN'T WE HAVE A QUANTITATIVE NUMBER, LIKE IT'S UP THIS MUCH. HERE'S WHAT WE SHOULD DO NEXT, SO THIS ROONE DID UNIQUELY THAT IS NOT ELSEWHERE, BUT IT'S IN PHYSIC SYSTEM DOING THIS IN THE SETTING OF SPARSE INACCURATE DATA, THE TYPE WE'VE SEEN IN EHRs AND SMART PHONES AND SO WE STARTED GLUCOSE CONTROL IS THE MEAL AND TRIEDIAN MODELS USING AN UNCOMMON FILTER, THE DATA INPUTS ARE GLUCOSE MEASURE WANTS FINGER STICKS AND MEAL RECORDINGS, INCLUDING CAN IMPROVE, THIS IS PART OF AN ROONE WE DID. COLLABORATORS AGAIN, THAT'S LIKE AN IMPORTANT PART OF THIS ROONE, SO DATA ALBERTS WHO GREW UP ON THIS, HE WAS A POST DOCK AND RESEARCH SCIENTIST, NOW IN TENURED ASSOCIATE PRACTICES FESSOR AT PRIMARY COLORADO, ARTY SHERMAN IS NIDDK RESEARCHER AND BRUCE AND WILL OTT, IS A MATH METITION. SO WE GET A LOT OF MATHEMATICIANS AND PHYSICISTS IN THIS, THAT'S A GLUCOSE MODEL TO SHOW WHAT YOU IT LOOKS LIKE, YOU CAN SEE THINGS LIKE GLUCOSE, INSULIN SECRETION RATE, BETA CELL MASS, INSULIN SENSITIVITY. HERE'S A BLOCK DIAGRAM THAT I WON'T GO THROUGH, BUT THE IMPORTANT THING, WHAT IS DATA SIMULATION, I HAVE A MODEL, I HAVE DATA I PUT THEM TOGETHER AND MAKE A PREDICTION, THE REAL THING GOES OVER THERE, I TAKE THAT DIFFERENCE, FIX MY MODEL A BIT, I BRING IT BEING BA, I MAKE ANOTHER PREDICTION, NEXT TIME, I FIND OUT IT REALLY WENT THERE AND I SEE THAT NEW DIFFERENCE, PIXELS MY MODEL A BIT AND YOU GET BETTER AND BETTER AND THAT'S WHAT DATA SIMULATION IS, AND THAT'S HOW THEY TRAVEL TO THE MOON AND HOW THEY GET TO THAT SPOT AT A WANT TO GET TO ON TRANQUILITY BAY? WAS THAT THE FIRST ONE? SO NOW LOOK AT THIS. I HOPE CAN YOU SEE THIS, THE BLUE CIRCLES ARE WHAT I AM TRYING TO PREDICT, ON THE BOTTOM OF THE MEALS THAT'S PART OF IT, I'M TRYING TO PREDICT THE PERSON'S TKPHRUICOSE, LET'S TRY IT OUT. HERE ARE PREDICTIONS IN RED Xs, YOU SAY, WELL THAT'S PRETTY GOOD BUT MOT OVERLY IMPRESSIVE RIGHT BECAUSE MOST OF THE BLUE IS IN THE MIDDLE. ANYONE COULD DO THAT, JUST THROW A DART AND THERE SEEMS TO BE A HIGH BLUE ONE OVER THERE BUT THE X IS NEAR IS SO THAT'S FINE BUT THERE'S ANOTHER HIGH BLUE ONE AND I SEEM TO HAVE IN EUSZED IT SO I SAID OKAY, WHAT'S WRONG HERE, LET ME SEE WHAT MY SYSTEM WAS THINKING SO THESE ARE MY PREDICTIONS. SO THAT'S WHEY WAS PREDICTING SO ANYONE IN MACHINE LEARN LEARNING SAYS YOU'RE TPHUFT OVERFITTING THE DATA BUT YOU'RE DOING SOMETHING TOTALLY STUPID AND I'M SORRY, I HAVE TO TELL YOU SO DAVE ALBERNEA DEETBERNEA AL--ALBERS SAYS T HEY DO THAT WITH THEIR TKPHRUICOSE. I SAID SHOW ME THE PAPER, HE SAID NO ONE PUBLISHES THAT, SO PEOPLE'S GLUCOSE IS DOING THIS ALL DAY LONG AND EVERYONE KNOWS IT AND NO ONE PUBLISHES IT, THAT'S RIDICULOUS, SO WE PUT SO THIS IS THE SAME EXPERIMENT AND WE PUT THE MONITOR ON THE PERSON AND DIDN'T SHOW OURSELVES THE RESULTS IN WILL WE WERE DONE, SO I'M GOING TO UNVEIL THE CONTINUOUS GLUCOSE MONITOR SO THIS IS WHAT PEOPLE ARE DOING ALL DAY LONG, AND IT'S GOING UP AND DOWN MAINLY TRIGGERED BY THE MEAL BUT THERE'S OSCILLATION AFTER THE MEAL IF YOU LOOK CLOSELY. FURTHER MORWE GOT THAT RED ONE RIGHT, THE TOP ONE BUT IF YOU LOOK AT THE BLUE ONE WE MISSED, RIGHT THERE, WE DEPARTMENT MISS IT, WE MISSED IT BY TEN MINUTES, MAYBE THEY LOGGED THEIR MEAL OFF BY TEN MINUTES, AND THE ONE WHERE WE OVERCALLED, THAT WAS ANOTHER TEN MINUTE DIFFERENCE. WE ACTUALLY GOT IT RIGHT BUT WE HAD THE TIMING OFF. SO I CHALLENGE YOU YOU GIVE THIS DATA SET TO A DEEP LEARNING ALLEGOR RHYTHM, IT WILL NOT LEARN THIS RED LINE OR THIS BLUE LINE MORE IMPORTANT. LIKE THE INFORMATION IS NOT THERE. SO THE MECHANISTIC MODEL CONSTRAINS THE SPACE SO THAT IT DOES WHAT A HUMAN BEING DOES BUT IF YOU HAD THE MODEL IT WOULD NOT LOOK LIKE IF I DID THEM ALL WRONG BECAUSE THEY'RE NOT THAT GOOD. YOU HAVE AN IMPERFECT MODEL WHETHER IT'S GLUCOSE METABOLISM OR ADD THE IMICAL DATA AND KEEP CORRECTING IT AND FIXING THE MODEL AND MAKING IT BETTER AND YOU GET GOOD PREDICTIONS AND ON LIKE 20-POINTS YOU CAN STRAIN BECAUSE WE WANT TO DO ON PRECISION MEDICINE AND WE DON'T HAVE POINTS ON THE SINGLE PATIENT, I CAN DO IT IF I CONSTRAIN THE SEARCH SPACE WITH THE INECANISTIC MODEL AND WE GET THE SAME RESULT NO MATTER WHICH GLUCOSE MODEL WE USE. AND SO THEN I SAID WE DID THE RANDOMIZED TRIAL WITH SMART PHONES, I WILL JUST SAY QUICKLY THAT WE PREDICTED AS WELL AS NUTRITIONIST ON SAYING WHAT THE GLUCOSE WOULD BE ON ONE HOUR AND BETTER THAN NUTRITIONISTS ON WHAT IT WOULD BE TWO HOURS AFTER THE MEAL. AND NOT SURPRISING ROUGH ATOMLELY IT'S UNFAIR BECAUSE YOU DON'T ASK WHAT THEY'RE GOING TO BE AFTER MAKING THOSE PREDICTIONS WE HAD AN ALLEGOR RHYTHM IMPEDIMENTS AND WE PUSH THE BUTTON AND GOT THE ANSWER. AND WE ALSO HAD ONE OF THOSE PATIENTS WE PREDICTED THE HEMOGLOBIN ACONE C WRONG WE WENT BACK ACCIDENT AND FOUND OUT THAT IT WAS FAITHS ACHEN AND WE HAD THE HEMOGLOBIN ACONE C WAS CORRECT SO DATAA ARE PREDICTIONS WERE BETTER THAN DAT AT ACCURACY OF THE DATA. >> WHAT'S THE VISION, SO RDSHERMAN AT NIDDK, HAD THESE TKPHRUICOSE METABOLISM DEEPLY AND BASICALLY THERE'S LIKE DIABETIC AND NONDIABETIC AND THERE'S LIKE A RIDGE OF ENERGY RIDGE TO GET BETWEEN THE WOAND YOU LOSE YOUR MASS, YOU MAY OR MAY NOT BE ABLE TO GET BACK. THERE ARE EXPERIMENTS AND ON THE FAR RIGHT IT SAYS ACUTE CALORIC RESTRICTION. THERE ARE PEOPLE WHO ARE MARGINALLY DIAET ABOUTIC THROUGH GASTRIC SURGERY WERE ABLE TO PULL THEMSELVES OUT AND GET THEM BACK INTO THE NONDIABETIC RANGE. THE QUESTION IS IF WE CAN MODEL IT WELL ENOUGH, CAN WE FIND A WAY FROM THE DIABETIC SIDE TO THE NONDIABETIC SIDE WITHOUT GETTING GASTRIC SURGERY, IS THERE IA PATHWAY THAT WE CAN DO AND ADDITION TO HELPING PEOPLE MANAGE THEIR DIABETES AS IS. SO MRI CONCLUSIONS THANK YOU TO THE NATIONAL LIBRARY OF MEDICINE. IT'S BEEN AN HONOR ON DO THIS WORK AND AN OPPORTUNITY, IT'S LIKE, I DON'T THINK LIVING IN LA, I LIVE IN NEW YORK, WHERE YOU GO TO RESTAURANT AND SEE ALL THESE FAMOUS PEOPLE, BUT I FEEL LIKE YOU KNOW DOING THIS RESEARCH, I'VE BEEN MEET SKP-PG WORKING WITH ALL THESE FAMOUS TPAOEPL THAT I SHOULDN'T BE ALLOWED TO MEET OR WORK WITH AND THEY GET THIS--IT'S JUDGE UTV BEEN SO MUCH FUN. AND NLM IS A DECADE AHEAD OF OTHERS BY FUNDING PROJECTS LIKE THIS, AND DISCOVERING DATA SCIENCE SOY ARE ALREADY AHEAD. SO THROUGH PROJECTS LOAMACYIC THIS IS HAVING AN IMPACT, AND HAVING IMPACT MAY TAKE OTHER STUDIES BEFORE PEOPLE BELIEVE OUR ACE INHIBITOR RESULTS SO ALTHOUGH THE DAT ARP LEANING IN THAT DIRECTION A BIT. IF YOU LOOK CAREFULLY AT THE TRIAL SO MAYBE IT'LL BE BELIEVABLE, THOSE PAPERS ARE GOING IN NOW. AND JUST TO POINT OUT THAT THE BASES OF PRECISION MEDICINE, I'VE DONE A WHOLE SECTION OF ON PATIENT LEVEL REDICTION WHICH I DIDN'T TALK ABOUT TODAY AND THESE NEW THINGS LIKE DATA SIMULATION, SO I CAN JUST SAY THAT THANK YOU AND IT'S BEEN A FUN 25 YEARS. [ APPLAUSE ] >> DO YOU WANT TO OPEN THE DISCUSSION. >> SURE. THE WORK IS FABULOUS AND INSPIRING AND IT'S A NICE DIRECTION. CURIOUS HOW--AS MUCH AS WE GRAPPLE WITH NORMALIZATION ACROSS MANY SITES WE HAVE A NUMBER OF EXOGENOUS VARIABLES YOU CAN'T DO INFERENCE ON, FOR EXAMPLE, WILE WE HAVE GREAT NOMENCLATURE, EVEN IN HOSPITALS CLOSE BY USING THE SAME TERMS THEY HAVE DIFFERENT MEANINGS AND GETTING INTO SEMANTICS IS SOMETHING THAT HASN'T BEEN DONE FOR A BEING NUMBER OF CENTERS SO THAT LEADS TO A PROBLEM WITH TRUSTING THE VORACITY OF THE DATA FOR NORMALIZING AND HAVING EQUIVALENT SETS. YOUR IC WORKING ON NEW METHODS TO DO THIS KIND OF PROPENSITY AND SO ON BUT IT'S HARD TO GET BACK TO THE ROOT IF YOU DON'T HAVE DEFINITIONAL GROUNDING. >> WELL, FOR THIS STUDY THERE WERE 58 OUTCOMES SO THE DRUGS OTHER THAN GETTING THE DRUG CODES RIGHT, YOU KNOW WE MORE OR LESS, WE THINK WE GOT WHAT DRUGS THEY WERE CORRECTLY BUT THE OUTCOMES, DID THEY HAVE A HEART ATTACK OR NOT. >> GOING BACK EVEN EARLIER IN THE DATA JUST IN GENERAL COMBINING DATA SETS? >> SO WE KNOW THAT ALL OUR DATA HAVE POTENTIAL ERRORS AND SO WE CREATE THESE PHENOTYPE RULES WHICH TRY TO ACCOMMODATE THE RAW DATA AND CREATE A MORE RELIABLE PHENOTYPE, RIGHT. SO THE SC NINE CODES, THEY HAVE A HEART ATTACK, THEY DON'T HAVE MANY OF THEM, YOU BUT THEY COULD BE THE WRONG PATIENT OR SOMETHING ELSE. SO WE GENERATE PHENOTYPES THEN WHICH TRY TO DRAW FROM MULTIPLE SOURCES SO IF THEY HAD A PROPONENT LEVEL THEN THEY HAVE MULTIPLE CODES FOR HEART ATTACK œAND THEY WERE IN THE U, YOU GENERATE IT MORE UNTIL YOU GENERATE THE EVIDENCE? , SORRY, BUT I THOUGHT THOSE RULES-- >> YEAH, SO EACH OF THOSE IS A LITTLE--MINIPHENOTYPE SO WE DON'T JUST USE THE RAW ICDNINE BUT FOR THE AEUFT OR OUTCOMES LIE HEART FAILURE OR HEART ATTACK, WE LOOK AT THAT CAREFULLY. SO IT STARTS WITH A SITE BECOMING AN ODESSY SITE. FIRST THEY HAVE TO DO IS CONVERT DATA SO THE FIRST THING THEY HAPPENS THEY LOOK AT DATAA AND LEARN WHAT'S GENERATED WRONG AND IN THE LAST TPAEUFT YEARS WE WERE MISSING ASTHMA IN 2005. WHY? BECAUSE A CLINIC WENT ONLINE AND THEY CHANGED THINGS IN THE CODING SO YOU DISCOVER THAT WHEN YOU CONVERT THE DATABASE. THEN WE HAVE A SET OF TOOLS THAT HELP YOU WITH CONSISTENCY CHECKS THAT LOOKS FOR PROBLEM, SO THERE'S DATA CURATION THAT DOES, AND THEY DO BECAUSE THEY'RE MOST FAMILIAR WITH THEIR OWN DATA. THEN AFTER THAT WE DON'T MERGE OUR HALF BILLION PATIENTS WE NEVER GET A HALF BILLION IN ONE STUDY BUT WE DID GET A QUARTER IN ILLEGALSION. WE KEEP THE DAT BASES SEPARATE SO NOW WE HAVE A POPULATION SO WE CAN SEE, YOU KNOW IF EVERYONE--IF EVERY SYSTEMATIC ERROR IN THE DATA THAT'S A PROBLEM, BUT I'M DOING JAPAN, HONG KONG, TAIWAN SO I HAVE DIFFERENT COUNTRIES PUTTING IN THEIR DATA SO LIKE THAT JAPANESE EXAMPLE, OUR FIRST GUEST WAS A DATA ERROR AND NOT AN ACTUAL PROBLEM AND WHEN WE DID THE STUDY, AT STANFORD, STAND FORD, TREATS DIABETES MOSTLY WITH GLUCOSE. SO THEY WERE DOING IS THEY WERE PARSING NOTES AND SAYING THAT EVERY GLUCOSE TEST WAS A GLUCOSE MEDICATION WHICH IS A DIABETES MEDICATION SO THAT'S AN AREA WE GOT BY COMPARING STANFORD TO THE DATABASES AND THE OTHER SCORE BUT THE NEGATIVE CONTROL CALIBRATION WHERE WE SAY, OKAY, HIRE'S A BURN OF STUFF THAT'S NOT SUPPOSED TO BE POSITIVE, THE DATA ARE BAD AND THEY'RE BAD FOR THEE GUYS TOO, AND LET'S SEE HOW WE SOLVE THEM. SO THE FDA HAS RULES IF ARE THIS AND THEY WANT TO BE ABLE GO BACK FROMMER CODE BACK TO THE CHART AND IN SOME CASES WHEN I DO AN FDA STUDY, I HAVE A PERSON SITTING THERE TYPING A LAB VALUE TO A SPREADSHEET AND THEY THEN AFTER THREE TIMES CHECK IT AGAINST THE LAB DATABASE, RIGHT THAT'S ACCEPTED BY THE IF, DA. I'M GIVING THEM THE LAB DATA BECAUSE AND IT'S NOT ACCEPTED BECAUSE THERE'S NOBODY ELSE CHECKING ANYTHING THREE TIMES. [LAUGHTER] , DO YOU DO ANY MUTATION FOR MISSING DATA? >> IF DROPPING THE RECORDS DOESN'T CAUSE A BI AS WE WOULD RATHER DROP IT. WE DESIGN OUR STUDIES BECAUSE IT'S MISSING WE DON'T HAVE IA FULL SET AND THEN WIRE MISSING A SET. YOU'RE MISSING STUFF. YOU ARE DESIGNING IT,A ROUND THE FACT THAT THIS IS MOSTLY MISSING DAT A. SO WHEN WE DID THE TREATMENT PATHWAYS WE LOOK FOR ANY DIAGNOSIS ANYMORE IN THE FOUR YEAR PERIOD OF STUDY ONE YEAR WASH OUT AND THEN THEY STARTED ON A DIABETES OR HYPER TENSION DRUG AND THEN THREE YEARS OF BEING ON MEDICATION WITHOUT MISSING ANY MONTHS OR SOMETHING. SO IT'S A LONG WAY OF SAYING--LET ME SAY THAT THE DATA ARE MOSTLY MISSING AND SO WE DESIGN OUR ALLEGOR RHYTHMS AROUND MISSING DATA. WE TEND NOT TO. >> YOU SEEM PRETTY CONFIDENT THAT THOSE DESIGNS AROUND LARGELY MISSING DATA ARE APPROPRIATELY HANDLING ALL SORTS OF BIASES THAT COME UPA THAT ARE LINKED TO THE MISSING NETS? >> EVERYONE IS CLAIMING EVERYTHING IF YOU LOOK AT STATISTICS AND EVERYONE'S GOT IT RIGHT, AND IN FACT, SO WHEN SOMEONE SITS THERE FOREVER AND MANICURES A STUDY THEY PUBLISH WHERE THEY'VE BEEN VERY CAREFUL ABOUT THE VARIABLE ANDS AND GO BACK TO THE SOURCE AND THEY SEND BACK THE STUDY AND SOMEONE ELSE DOES SOMETHING ELSE AND DO THE CANCER THEY'RE BOTH WITH THE GROUPS AND SO, I THINK THE PROOF OF THE PUDDING IS IN THE EATING AND THIS CASE THEEING IS FOR THE GOLD STANDARD SO FOR THE DEPRESSION STUDY, THE FIRST ONE I SHOWED YOU, WE HAVE FOUR OUT OF FIVE MATCHING THE EVIDENCE, THE FIFTH ONE THOUGH WE CHOSE BECAUSE WE KNEW WOULD GET IT WRONG SO I DON'T KNOW IF THAT'S 20% WRONG FOR ALL THE DATA WE KNEW WE WERE GOING TO GET WRONG, SELF-REPORTING OF SEXUAL DYSFUNCTION AND WE SAID WE WOULD NEVER GET IT RIGHT AND THE PROBLEM WAS THE DOCTORS WHO ARE USING A DIFFERENT DRUG THAT WASN'T FAMOUS FORCAUSING SEXUAL DYSFUNCTION AND WE COULDN'T ACCOUNT FOR THAT WELL ENOUGH. THE OTHER ONE WE HAVE--IT'S THROUGH TRIANGULATION THAT WE'RE TRYING TO GET IT. >> COUPLE QUESTIONS, THIS IS JUST SIMPLE ANSWERS AND THEN YOU MENTIONED A BIT--BUT I WANT TO CLARIFY THIS, THE DISCOVERY, WE HAVE A BIAS OF LITERATURE, SO SOME STUFF HASN'T BEEN DONE SO IT'S LIMITATION OF-- >> HONESTLY, SOME OF OUR OTHER WORK BUT MORE RELATED TO THE DATA SIMULATION I CAN TEST OUT THINGS THAT HAVEN'T BEEN TRIED BEFORE USING THE MECHANISTIC MODEL SO THAT'S BENEFIT OF DOING MORE THAN ONE WAY BUT HONESTLY CAN YOU ONLY TEST THAT THAT'S BEEN USED ENOUGH AND RECORDED,. >> I OFTEN THINK THERE'S QUITE A BIT OF BIAS BECAUSE WE LOOK AT STUFF WE'VE DONE AND THE--IT TELLS US MORE ABOUT WHAT WE'VE DONE VERSUS WHAT WE COULD BE DOING. >> SO THERE COULD BE A ANTIHYPER TENSION DRUG LARKING THAT WE DON'T REALIZE. >> RIGHT. >> BUT A QUICK QUESTION ABOUT THE DATA SIMULATION, HAVE YOU MODELS WITH VARIOUS KINDS AND STRUCTURE, AND DATA AND I THINK DATA SIMULATION IS INTERESTING PHRASE FOR TOP DOWN-BOTTOM UP KINDS OF THESE, BUT THE APPROACH OF TWO DIRECTIONAL MODELING IS GOING BEYOND DATA SIMULATION, IT'S EVERYWHERE SO WRAOUF BEEN IN NEURAL NETWORKS AND OF TOP DOWN, BOTTOM UP AND SO ON, BUT TODAY'S RELIGION IT SEEPS THE IDEA IS YOU TAKE A MODEL AND HAVE ACTUAL DATA, TO GET BETTER PATIENT OR LIVE DATA AND YOU SORT OF TUNE THE MODEL TO THE SITUATION AND UPDATE IT WITH THE DAT STREAM BUT YOU ALSO HAVE THE IDEA OF PERSONALIZING A MODEL OF THE PATIENT BY CHANGING THE MODEL ITSELF AND DOING DATA SIMULATION, WELL THAT'S JUST BECAUSE IT'S A BETTER MODEL AND I'M CURIOUS IF YOU DISTINGUISH A BETTER MODEL,. >> WELL WE COULD DO A COUPLE THINGS IN THAT REGARD, FIRST OF ALL WE HAVE NUMBER OF MODELS SO WE COULD PICK A MODEL WHICH WOULD BE USED LIKE THIS ONE THAT'S BASIC LYE A SPRAIN, THE MODEL IS MODELING AND THE PHYSICS OF A SPRAY AND THAT'S HOW USED IN THE FIRST ORDER SOPHISTICATEDY USE THE MEAL MODEL AND THE OTHER MOTEL SO THERE A FEW MODELS WE COULD USE, SO THESE MODEL VS A LOT OF PARAMETERS AND IN FACT YOU'RE NOT LEARNING THEM ALL, YOU'RE SETTING SOME ACCORDING TO POPULATION NORMS AND YOU CAN SET THOSE PARAMETERS ACCORDING TO A PATIENT BUT MOSTLY WE WANT TO LEARN THE MODEL FOR THAT SPECIFIC PATIENT, LIKE BUT I CAN'T LEARN TEN PARAMETERS ON 20 DATA POINTS SO I HAVE TO DO SOMETHING, SO YOU KNOW THERE'S A FEW TECHNIQUES WE USE BUT THERE ARE LIMITS TO HOW MUCH WE HAVE AVALABLE TO THE PATIENT DATA. SO NEURAL NETWORK IS DIFFERENT BUT THIS IS MECHANISTIC WELL NOT THE SPRAY ONE BUT THESE ARE MODELS WHERE I'M TELLING YOU, HERE'S YOUR RENAL FUNCTION, HERE'S YOUR INSULIN RESISTANCE AS OPPOSE TO THE NEURAL METE YORK WHERE IT'S A MODEL BUT IT'S AN EQUATION THAT DOESN'T MEAN ANYTHING. >> THEN QUICKLY, JUST TO SUMMARIZE, THE INVITES YOU'RE GAINING AND THE ARCHITECTURES YOU'RE BUILDING AND COLLABORATIONS YOU'RE ESTABLISHING HAVE IMPLICATIONS FOR WHAT YOU MIGHT SAY IS A DESIGN SENSE GOING FORWARD FOR NEW, NEW EFFORTS LIKE ALL OF US AND IS THERE ADVICE OR GUIDANCE COMING OUT OF WHAT YOU NEED AND THE HOLES ARE TODAY IN WHAT YOU'RE SEEING FOR THE ANALYTICS OR THE COLLABORATIONS OR DATABASES, THAT YOU TRANSFORM INTO GUIDANCE FOR THE COMMUNITY? >> YEAH, SO, WE'VE LOVED HAVING LIKE A PHYSICS CERN STYLE COLLABORATION, WE HAVE WEEKLY MEETINGS BUT OFTEN TWO OF THEM BECAUSE YOU HAVE TO HIT THE TWO MEMORY RESPONSEIS FEARS, ALL OF US ADOPTED OTKESZY AS A DATA MODEL WE'RE AN INTERNATIONAL CLASSIFCATIOINTEGRAL MODEL SOWHEN SOMEONE IN ALL OF US HAS A QUESTION, INSTEAD OF US ANSWERING WE HAVE TO PUT IT ON THE FORM, PWEB FITS FROM THE REQUESTY AND THE ANSWER SO WE ARE TRAO ING TO CHANGE IT SO THERE'S A MUCH MORE OPEN SYSTEM, AND THE NETWORK ALSO IS USING THE OLD OTKESZY MODEL DATA MODEL SO--AND YOU GO AND GIVE TALKS AND SOMEONE ASKS CAN I SHARE, CAN YOU SHARE YOUR SLIDES WITH ME, THE ANSWER'S ALWAYS YES, THAT'S KIND OF FUN BECAUSE THEY'RE ALWAYS ALREADY ON THE INTERNET SOMEWHERE. SO I THINK AN OPEN APPROACH IS VERY GOOD, ALTHOUGH, YOU KNOW PEOPLE ARE ALLOWED TO TAKE THE OTKESZY FRAMEWORK IS--OTKESZY FRAMEWORK AND BUILD COMPANIES ON TOP OF IT. WE ENCOURAGE CAPITALISM ON TOP OF IT BUT THE BASE IS OPEN. SOA ISO WHAT IS THE INCENTIVE FOR BEING ON THE PAPER. >> YOU'RE LOOKING FOR THE MODEL SO YOU MIGHT AS WELL PICK THIS ONE THAT EVERYONE'S USING, YOU HAVE TO PICK ONE SO WHY NOT THIS ONE WHICH HAS A LOT OF EFFORT TO KEEP IT MAINTAINED AND HAS A HUGE BASE OF PEOPLE HELPING YOU CONVERT YOUR DATA IF YOU ANSWER SOMEONE ELSE'S QUESTION, THEY WILL SECOND WORLD WAR YOUR QUESTION, AND YOU COME UP WITH A STUDY, THE REST OF THE WORLD WILL CARRY IT OUT IF YOU CARRY OUT THEIR STUDY BECAUSE IT IS ALL VOLUNTARY AND THERE IS SOME CAJOLING GOING ON, COLUMBIA ASKS US TO RUN IT AS LONG AS WE CHECK THE CODE TO MAKE SPHUR IT'S SAFE. >> NO IT'S REALLY COOL, IT'S ALMOST SANDERS LIKE. >> SO THAT'S THE INCENTIVE. >> WHEN I WAS AT ARC WE TRIED TO DO SOMETHING LIKE THIS AND I WILL SAY I LOVE YOUR APPROACH [INDISCERNIBLE] BECAUSE WE GOT INTO LONG AREAS OF TWEAKING THAT AND WE THOUGHT IT WAS PROBABLY GOOD AND WAYS THAT WERE PROBABLY WITHIN, AND MAYBE MAKE NO DIFFERENCE AT ALL BUT PEOPLE WERE FIERCELY FIGHTING IT. BUT I'LL JUST LEAVE IT AT THAT. THIS IS REALLY EXCITING. >> SO TO BE FAIR WE HAD A JUMP START, BUT THE JUMP START WAS FDA ASKING THEM TO PUT $30 MILLION THROUGH THE OMAHA PROJECT AND CLEAR THE DAILY BASIS THEA MODEL AND BECAUSE OF THAT, NOW WE GO AND WE HAVE FUNDING AND EACH OF US HAS OUR OWN GRANTS WE DON'T HAVE ONE CENTRAL FUNDING OTKESZY FUNDING ODORS FUND ING OTKESZY FUNDING ODESSY, AND ISSUES WITH THE DATA COME FROM THERE'S ISSUES ABOUT THE BIAS AND THINGS LOAMACYIC THAT, THAT CAN SERVE AS A STORE THAT'S BEEN BUILT THERE. >> OUR LARGE SCALE STUDIES ARE GOING CROSS THOSE POPULATIONS SO IT'S HRARPLLY TO BE HONEST NOT ADDRESSING IT YET, BUT OUR INDIVIDUAL STUDIES, YOU KNOW IS COUNTING EXACTLY THIS, SO SOME DATABASES SO WE HAVE THE MEDICAID DAT BASE FOR EXAMPLE, ONE SHIFTED A BIT AND TRY TO GET INTO COUNTRIES LOWER AND MIDDLE INCOME COUNTRIES THAT'S WHERE WE'RE ACTIVELY TRYING TO GET INTO THERE. WE HAVE SOME SOCIOECONOMIC DAILY BASIS THEA BUT A LOT ARE DEIDENTIFY SOOOSE NOT SO STRONG, WE HAD A STUDY OF INHERITANCE WHICH USES PEOPLE'S--NOT ON THE ODESSY NETWORK BUT PEOPLE'S INCOME OF KIN AND THEN FAMILY TREETREES AND NOT LOOKING THEM THEM SO THAT'S NOT SOCIOECONOMIC STUDY BUT WE ARE GOING ABOUT DEEPER INTO THE DATA AT INDIVIDUAL SITES SHARE THAGOREAN WE ONLY DO THE STUFF THAT'S SAFE THORS SHARE. SO I'M SAYING WE BRANCHING OUT AND DOING OTHER SOURCES OF DATA, SOCIOLOGICAL ECONOMEC STATUS AND AN IMPORTANT ONE FOR US BUT OTHER THAN DOING THE MEDICAID DATABASE AND STUFF LIKE THAT, WE'RE NOT ADDRESSING IT BUT WE KNOW IT'S IMPORTANT. THANK YOU. >> THANK YOU VERY MUCH. IT WAS EXCELLENT. >> [ APPLAUSE ] NOW WE'RE GOING INTO THE CLOSED PORTION OF THE MEETING.