Thanks for your unstenting efforts in this regard, Josh. Why don't you go ahead and sit down and we'll open up our discussion periods. Lynn, you mentioned one of the barriers to patients getting access to pharmacogenetics at your community hospital setting was price and cost. But we haven't really discussed what you're seeing, everyone's seeing out there in the marketplace. What are you seeing typically for a pharmacogenetic test? So a few years ago, they were $3,000 to $5,000. Yeah, I don't think there's anything called typical. When I first started, they were $750 for a panel and then went down to $499 and then to $330 and now we can get them for $249 if it's a cash price. So they've come down quite a bit in price. $249 out-of-pocket expense for an underserved individual? Yes, definitely it's a barrier, especially if they're Medicare or Medicaid. But we also select laboratories based on not just price and quality, but also based on patient assistance programs. And so the ones that we've chosen to work with have really good patient assistance programs so that if the income is X, all you have to pay is $10. So that works really well in our clinic where we get patients from all over. Some will say, oh yeah, I don't want to go through insurance. Here's $249 pay-out-of-pocket versus others who say if I can't get this covered, there's no sense in me getting this testing done. There's one other component to that which is in many, if not most, institutions when it's a send-out test, the laboratory will generally add a multiplier to the cost that the patient actually sees. And that can range anywhere from three to ten times the cost of the test. So a $250 rack price test might be $2,500 with that additional thing. So it's, again, the cost is very difficult to get a handle on. So there's lots of issues that we really have to pay attention. I see knowing nods from people that have been down that route. And I'll just say just so that there's no confusion, we as an institution don't do the billing. It's the laboratory that does the billing. So whatever the laboratory charge is, that's what it is. And we luckily don't have to, it's not institution billed. So it goes to the insurance company. And then Julie. First, just one clarification. I was asked by Dr. Johnson what our number was in 1,200 patients. Patients are actually getting a prescription and then having an actionable result. Ours was about 15% and that's not far off of what Todd's reporting. My question is around what can we learn in the germline pharmacogenomics field from what's happened in cancer? Three of the presentations we just had talked about foundation medicine. Their test is now in front of the FDA and CMS for clearance. And it's a panel-based test, multiple genes on it. And we've been talking all day about, you know, can we take a multiple gene approach in germline pharmacogenomics. So how is it that the foundation test is being considered like that, where I would argue, you know, I'm a medical oncologist, most of the genes on that panel have much less evidence than what we're been talking about today. And those tests are getting paid for. I've sent them hundreds of times on my patients. All of our institutions have homegrown oncopanels and nobody ever asked how those are paid for. And then why are we facing something different with germline? So let me give you a direct answer to your question of, are we asking if it's been paid for? Yes, we are asking that question. I will tell you we're asking a lot more of those questions in terms of what's being paid for and how are we paying for it in genomics. Then we have ever have done. And part of the problem in this space is, well, there's three fundamental problems. And we'll talk about it a little bit more later, but just to give you a synopsis of not only the answer to your question, but also the fundamental issues. And this we'll talk to some of the earlier speakers' issues about reimbursement. There is a fundamental issue in this domain around coding. I don't mean coding the drug. I mean coding for reimbursement. We see, our belief is there's about 65,000 tests on the market. We see about 10 new tests per day. And for those folks that are in the weeds here, there's only about 200 CPT codes. For folks that know what a CPT code is, that's what we will largely pay off. So there is a fundamental mismatch between the number of tests that everyone is working with and the number of codes that a payer is making a decision on what gets reimbursed. That is, in my opinion, out of all the discussion I've seen, I've been part of most of it for today, the most fundamental issue that this community needs to resolve is that. Because then we will start paying for things in a more precise way with great accuracy and we're going to reduce a lot of friction in the system. The second thing that we worry about to push on your coming around pharmacogenesis quality, we worry about the variability in the wet lab side and the dry lab side of quality. When we think about a lot of these lab tests, it is very difficult to get a measure on what is good, right? We really worry about it on the interpretation side. Most of the academic medical centers we've seen in the last eight weeks tell us that they're the best. I'm sure you're all wonderful, but by definition not everyone can be the best, but that's okay. So we need to have better measures on quality. So if you think about it, what are the key themes around the limitation of pharmacogenomics and why aren't more payers paying for it? Number one, you've got to get some lubrication in the system. You've got to get the coding right. We need to figure out a way of solving the coding problem. And when that gets solved for, a lot of these issues will be much easier to address because we can figure out, I've seen this claim come in with this code. This should be reimbursed. Right now, there's only 200 codes and given how many tests there are, it's very difficult to know. This is the pharmacogenomics test. It maps to the CPT code. We should reimburse for it if we have a policy for it. There's a practical issue here. On the foundation medicine piece, those CPT codes are clearer, so it's easier for us to run through our own internal systems. That makes sense to everybody. I cannot stress that enough if there's one thing this group of people, and you're all super smart folks in the room, there's one thing that you try and figure out is how do you help solve the coding problem from 65,000 tests to how a payer can actually pay for it? Right? Secondly, solve the quality problem. Thirdly, and we'll talk about this a little bit more later on, is how do you solve the health economics? There is an absence of health economics in much of this space. I think it's some work going on. I'd love to learn a little bit more about it. But we need to get better communication to the pairs around what some of the health economics are. For other tests in other areas, that evidence is clearer to us. In this area, I think it's still fairly nascent. So to summarize, coding, quality, health economics. That makes sense? A long answer to your question. But that drives how we make those kind of decisions. So let me move along, and thanks for that. The coding and the quality are things that are being attended to by ACMG and CAP and AMP, so not particularly... Well, they are. So I mean, you can disagree, but that doesn't change the fact that they are actually addressing those issues in as much as they can within the system, and we can talk offline about what's actually happening. But specific to the research questions that are really... and the implementation questions that are relevant here, I think the economic piece, which we'll hear some more about tomorrow, is relevant. But I think Scott, to answer your question a little bit more directly, which was about the differences, there are also some issues about tests that are brought to market as laboratory-developed tests, which don't undergo an FDA approval process, but can still go out into the market versus those that are submitted for FDA approval that can either go through a full approval process or if they look vaguely like another test can go through an expedited 510K process. So there's different ways to get to the market, and there's inequity on the test developer side in terms of, do we really go the full FDA route versus if we can get into the market and decrease our cost? So that's another big issue that's being talked a lot about in the laboratory community. So, Julie, I think you were next. Yeah, and so, perfectly situated. It was a cost question. So, Josh, on one of your slides, you had a list of... What is Josh? It's like right between me and this camera, right? You had a list of, I think, reasons that physicians did order the tests. So, at the top was something about evidence that the bottom was about an alert. You know what slide I'm talking about? So number two on the list was absence of out-of-patient... absence of out-of-pocket costs for the patient. So, again, just sort of thinking about this, this is a real barrier if the only way it's attractive to physicians, if it's free, because it can't possibly be sustainable if it's free, right? So, again, there's this artificial thing that's been created in some ways by the grant funding, but it's not sustainable and it's not scalable. So, I mean, I'm not sure if it's a question for you or if it's just a question for all of us. How do we get past that where physicians only value it if it's free, but otherwise they worry about it? Yeah, no, I think... I mean, it's obviously a bigger question, but it's a huge point. I mean, and so internally, that was at a time in which it was all paid for in our institution before we started switching to billing insurers for the test. And as with you, I think we found that there's reasonable reimbursement for that, but then there's just a variety, just as Lynn has talked about, sort of a variety of potential costs and even a couple hundred dollars, 200 dollars could be a lot if the patient doesn't have the wherewithal to pay for it. I think it's the... But in our perspective, it's almost more the uncertainty about knowing what will happen. I think that drives some of that as opposed to you sort of know exactly what's gonna happen with the CBC or any other sort of standard tests and you know that if they don't pay for it, it'll be a pretty cheap cost and things like that. You know, the provider generally doesn't know what a test costs and in this environment, this could be an expensive test. So there becomes more uncertainties about things like that. Yeah, I think that's a good point and I think a lot of times whenever we say genetic, everybody automatically assumes us thousands of dollars. But Josh Peterson in his work is beginning to incorporate some willingness to pay analyses and I think we also need to look at other approaches like value of information analysis to really start to get at some of these questions about where do we really need to be positioned to be able to have something where we could check off some of those things and eliminate some of those cost concerns as being the primary driver. The inequity of healthcare services is manifest across all the issues. It's not specific to genetics, but at least if we can get some specific information on that, that should be something that should be included in further economic analyses. I had Heidi next. So I did want to go back to some of John's points because I think they are really critical for us to actually proceed with implementation and that is around the coding question and the quality of interpretation. On the coding side, I think mainly organized by AMP, there has been efforts to develop new codes, but it's been incredibly slow and I think some of the barrier is just getting the volunteers within the community to come up with appropriate codes. But I've seen it work well where I was part of a few different groups that came up with hearing loss codes and cardiomyopathy codes. The idea was not to come up with a code for every test because there's just too many tests that will continually be iteratively developed with small incremental changes, but to come up with codes that can be generically applied to say, all right, if this is the broad indication, let's say hearing loss, you need to test at least these 10 genes, but it could be 10 or it could be 100 or it could be anything above 10. This is the minimum to make it a clinically useful test. If a lab wants to add as many as they want, that's up to them and this code is okay to use for all of these different. So I think incumbent upon this group in pharmacogenomics would be bringing together a group that can say, okay, here's some, not completely generic, but slightly more generic code sets to use in pharmacogenomics that doesn't require a brand new code every time somebody makes a minor snip change to a test that can be applied broadly and I think that that would help the transparency in the coding process without an enormous burden of a new code every time somebody launches a test. So that's one thing that I think this group could help with implementation is actually to help with that code definition working with existing efforts that AMP and others are leading. Another thing is around the accuracy of the interpretation, which is extraordinarily hard to objectively deal with and I would argue that no one is really tackling it with one exception and I obviously am a bit biased as a PI of ClinGen, but I have watched extraordinarily or extraordinary improvement in the quality of interpretation from laboratories submitting to ClinVar. A couple of labs that I won't name but I don't think did a very good job and when they started submitting to ClinVar there was a bit of an out of the problems, but it made a huge difference in them changing their practices and in one case going to their CEO and saying we need to actually hire people who know what they're doing because we just really messed up here and I've also seen, and this is somewhat anecdotal but it's been validated by many of my colleagues, a correlation between quality and whether you submit to ClinVar at all and so I would argue that simple requirement of submission to ClinVar to create a transparent, peer review of your own interpretations has a huge improvement in the quality of interpretation but I can tell you that having gone to CAP multiple times to say please put this in as a quality assurance requirement just like all of our labs have to check temperatures on every PCR machine and every freezer and 8 million things I do for quality assurance reasons that probably have little to impact the quality of my test. That is one that I think has a huge impact yet CAP has not agreed to do this so I think it's going to have to come from the healthcare providers and frankly the insurers and the biggest movement I've seen beneficial is when Aetna required laboratories to submit to ClinVar to reimburse BRCA too all the laboratories all of a sudden submitted on that gene and I think the insurers are the best to push this issue because I haven't succeeded in getting CAP to do it. Great, I think there was yes please. Hi, I'm Melissa Clark from Howard University so in listening to some of the presentations there were some cost data and cost effectiveness data in some testing arenas and so I'm wondering if anyone especially those who might be from accountable care organizations have been looking at the idea of using pharmacogenomic testing as sort of a loss leader absorbing that cost and seeing what kind of effect that can have prospectively on your cost as an ACO either on your own as an ACO or in conjunction with a payer as partnered with you. Not everybody at once. I think it's an interesting question I think the the challenge as we've thought about this is you know the the confounders you know it's particular for people that are on a lot of medications where they're more likely to have a pharmacogenomic benefit it's there's a lot of different things that are happening a lot heterogeneity it's it would be difficult to capture the data the only group that I know of that is doing um I don't think they're capturing the outcomes data so I'm not sure I know I probably Josh do you want to comment in terms of how whether or not this is something and you know all of us that are capturing the outcomes I think are dealing with this this issue but in terms of being able to sell that as this is you know using a loss leader concept I think that's a little bit different I don't know that have a lot to add to that I mean we're certainly we're modeling it but you know it still has a I should say we Josh Peterson but you know it still has a cost and there's some cost per outcome and the whether or not it actually leads to an actual difference we haven't actually talked about it with insurers across a group um it is interesting though that we have these visions of how things like this could work across a network of hospitals and we're certainly thinking about it but we haven't had those discussions and I'm aware of well I think one of the examples that I heard earlier um I believe there was a quote of a four percent um potential avoidance and readmissions for those individuals on plavix I mean that would be for example a cost model that could be expanded to look at okay if the hospital prospectively paid for this how much would be saved in the readmissions rate for adverse drug events or failure therapy in that particular example for instance is built into the simulator and you can you know try different things and actually I think that might have been on one of my slides that um I actually did do an observational study a cost effectiveness study to say okay if we had to test um in in patients all 1400 patients and compared that to the amount of money we were spending because these were 30 day readmissions you know would we at least break even and you know there's a lot of assumptions you have to make in that and with those assumptions you know I had evaluated that we would even be ahead by 50k uh now what they're asking me to do and rightly so is to have their cardiology decision support people within their own cardiology group identify the patients go through the medical records and look to see if those um cost savings and expectations and estimates you know are still on target um but I still think that until they see the data on what the testing helped them do they because there's it is multifactorial and there's other reasons why a patient may not have you know may have gotten another MI um a lot of the work in that area is um how you define a failure a plavix failure and so a stent that's been from boast as a plavix failure that's that's one component and asking Lori about that in some of her studies it is a small component but what about the MIs and what about the strokes and so people are also defining failures differently and so the economic analysis um is different based on what they're considering a failure and I can't stress enough that this behavioral economics um idea of why we make the decisions that we make as physicians as patients etc in terms of you know what we're looking at what is our cost benefit so even when you give numbers it doesn't always motivate someone to make a change I think the other thing to remember is that avoided cost sometimes is also avoided income uh from the hospital perspective I mean that's the perversity of our system the patient that Josh presented they got paid for all those stents and uh and so you know we have real issues uh depending on your perspective and I I'll talk a little bit about that in my talk tomorrow about how different perspectives gives you different answers so I'm going to go to Todd and then to Howard and then to Julie I think the discussion that Lynn brought up and what we're just having is is really relevant what do we really you know when you say you want to cost uh estimates or analysis being a pharmacogenomics guy when we first started talking about uh you know we're going to do a cost effective analysis well you then realize what that means to a geneticist is completely different than what it means to an economist because we engage in economists and within the ignite network when we were we got the data from the copitagral study it's like okay let's do a cost defectiveness analysis on it well we had like 12 different opinions as to what that cost effective analysis really was um and it it's different with you know between economists and and geneticists and it's even different within so I think any sort of guidance that we can get from you know from whether it's insurance companies or CMS or whoever as far as how we really should run the trials you know for some of these things do they mean cost of illness do they mean cost to prevent a death does it go greater than one year are you only interested in you know up to one year because of their so I think there's a lot of things like that that you know and I think a collaboration with us with any of the payers would be really helpful in trying to hurt so we can understand what it is that we really want and it goes back to designing the clinical trials we're talking about what clinical trial do we really want well depends on what the question is and what the really end points are so we've had a Moffat said at accountable care organization that's oncology specific for the last four and a half years and so in that context we use pharmacogenomics a lot because we're in shared risk models and we in that model could almost care less about CPT codes because you're holding the risk jointly with united or wherever else the partner is but it's a it's a very different dynamic and so it's very much is the testing going to avoid an event that is both bad for patients and bad for the bottom line and having both of those things is a real stick and carrot to make change happen and so a milo leukemia patient that gets a fungal infection costs us $29,000 extra in the first year to manage we lose $29,000 a year giving someone an event they don't want that can often be fatal so lots of incentive to not do that as opposed to the Josh Jenny model where you want to give nine stints to everybody but the idea that we're in a situation for that and so it's been quite valuable when we go into price our bundles we go in and say well a breast cancer patient who gets neuropathy from taxings costs $8,000 a year more to manage than a breast cancer patient without neuropathy let's model that and do preemptive work to try to avoid that so it changes that dynamic a lot and becomes institutional value becomes more important than insurance or these other things so I think we probably won't get to a time when it's all accountable care stuff nor will we get to a time where it's zero but it definitely has introduced a greater appreciation in our leadership of why pharmacogenomics can be valuable to them now and later Julie well and I think the thing that always gets lost in the conversation and in the Clopidoregal example the events that you didn't capture are death and we know that from the larger Ignite project and of course in an economic analysis I mean that's a cheap outcome and so going back to Mr. Anderson's presentation we cannot lose the patient at the other end of this and death is the worst outcome and our economic models don't necessarily put value on that so how we start to pay better attention to the outcomes that these patients are experiencing and not just the health economics part I mean I think again part of this culture shift and it's not just in pharmacogenetics it's in all of healthcare but a fair portion of the events that we saw in the Clopidoregal study which Laurie will present were deaths so we just can't forget those So I had a question for Nick and this is relevant to some of the work that we've been doing and emerge in others where we actually have some longitudinal information on patients and I was thinking about your exceptional responder study and thinking about ways to identify those patients out of transactional electronic health record data and it seems to me that if you have a longitudinal record the good news is that we have pretty specific codes for things like metastatic breast cancer that type of thing and so in going you could presumably identify a cohort of patients with that code and then look to see who's still around after a set period of time and I'm wondering if you've been using that type of a method or whether that would be something that we could take advantage of some of our collaboratives that have electronic health record data where we could potentially identify those for some type of research related question but I think that's a great idea one proxy that we've used for exceptional responses so you mentioned how long they've been alive or how long they've had that code so that's one but when you're looking at a specific exceptional response to a specific drug we've had definitions per subtype of metastatic breast cancer for how long you're on a particular drug that might be an outlier so in certain subtypes if you're on a particular drug for more than two years that would be pretty unusual and so you could do a pretty quick search that way in longitudinal emerged data with codes so we've talked to some folks that have had that type of electronic data but I don't think we've ever talked to emerge about that that would be a really good discussion to have Howard, you end up finding some very unusual practice patterns as well especially in a tertiary center we've had patients who have been on hepatitis and kinase inhibitors and found some patients who have been on the drug for several years four or five months into their treatment the drug stopped working but the patient felt more comfortable staying on the drug and so it was continued to be prescribed and other things were added to it you know these steps of things which you don't want to find thankfully it wasn't a patient manager at our institution but there's still a lot of cleaning that has to be done because in the real world you get these unusual things where even though disease might be progressing there might be another reason to stay on the drug right or wrong yeah that was $9,000 a month Mary I have an unrelated question for Todd so you're 30% of patients who were already on a high risk drug that had a high risk genotype is that the right way to interpret that so the 25% of the patients that got one of the trigger meds and then were genotype about 25% of them had some sort of an actionable note that was sent back to the provider and what accounted for the majority of those was that PPI's and 2C19 I mean was it something that is going to make a big difference or a little difference in clinical outcomes I don't remember exactly the distribution of those to be that common it seems like it must have been 2C19 there was some of those that I would have to actually go back and look I don't remember I mean there's a wide variety of not even 25% of the total prescriptions were PPI's so that wasn't the majority of them because there was a really broad distribution there's a fair number of pain meds to tram it all was the most there's some statins and stuff so it wasn't dominated by any one specific thing and we're actually as we were enrolling we were a little concerned that we're going to have the first out of the first 500 patients you know 450 would be PPI's but that's actually not the case it's a pretty wide distribution Jeff so I'm wondering what we could do with all the wonderful implementation sites and projects that we've heard about today you know I'm impressed as you'll hear about tomorrow what Julia and Lara did with the Cip 2C19 work and to aggregate a number of groups that are doing similar things so I guess the question is how do we harness the sites that we've heard from today to band together to build evidence bases to build economic models to actually drive this over the goal line because I think the effort seems to be somewhat distributed and not as coordinated as it possibly could be to have kind of impact that we want to see so I'm just curious as to how all of you who presented today could think about you know another model that would allow these types of measures to have impact. The one thing I think that could help that is what I mentioned earlier about knowing exactly where the goal line is that we're trying to get to so what is it from a cost standpoint or from at least a reimbursement standpoint what is it that we really need to get done to actually get it to a point where it's reimbursement which will drive a fair amount of it if that's the case. I'm not sure that at least I don't know exactly what it is from the cost standpoint or how many deaths need to be prevented per $20,000 of genotyping or those sort of things so that would help I think. So what you're saying is that even with everybody in the room here it's an incomplete type of model because we don't have the some of the payers or other groups that are going to make the decisions but we saw in JASA's presentation that right after the American Heart Association meetings it was a significant uptick in ordering of CIP 2019 so even though that wasn't necessarily a payer driven model the provider community really saw this as valuable. Well I'm sure there'll be more information tomorrow when we go over the cost effectiveness but some of the things that Todd and I have interacted about is that we have a self-insured employee population at mission and we have other groups in the area that are self-insured and in trying to pilot out a study to say well when you say cost effectiveness what parameters are you collecting and so for our employee health program they're really wanting to know should they be covering a panel of pharmacogenetic tests and so working with one ohm we're trying to identify what are the different pieces of information where do they come from, how do we get it and working with you and others to say well these are the parameters that we looked at total cost of care is kind of huge for me to think about but having specific parameters to say how are we going to get this information in and collected and survey it and then monitor it and evaluate it I don't want to have to come up with my own end points and yet that's what I've been doing and why haven't I reached out again to talk with you so I think there should there can be much more of that we're all busy and we don't always think about it and that's why these meetings are so important Terry well I might also address this issue of what evidence is convincing it's not only convincing the payers and probably John we'll talk about this a little bit more in the panel presentation but it's also convincing the physicians as we've heard around the table physicians tend to be convinced by they say randomized clinical trials although more than half of what we do in clinical medicine probably vastly more than half has no clinical trial evidence behind it I think one thing that we might want to consider is whether as Jeff suggested there's a way to bring these QI projects that are already going on in hospitals and medical centers around the country to bring them together and this was actually raised in our eighth genomic medicine meeting back two years ago and yet we haven't figured out a good way of doing that so if the collected heads around the room can help us with that that would be I think a tremendous step forward to try to harness what you guys are already doing I think one thing that should be mentioned is that there is an ongoing effort between Ignite Emerge and Caesar to try and harmonize outcomes that we're all looking at in our different studies and I think that the intent is to have an outcomes repository as part of the Ignite program but with ownership distributed across those groups but there's no reason that it should be restricted to that because all of the things that we've talked about all of you are going to be measuring certain outcomes of care and you're going to be defining those outcomes in certain ways and by getting those out into the public then people that want to do a similar study can at least begin to choose similar outcomes so much as we've looked at promise for example for patient reported outcomes we're going to land on that set to use across these studies we could presumably use these types of outcomes across multiple studies and then at least we don't have to then have the argument about well you measured your outcomes this way and I measured them this way and how can we actually then reconcile what we think we found. I've heard a lot of comments about you kind of want to know where the goal post is particularly for payers you know I think that's a question that people ask a lot and obviously it's often payers specific but we did a study taking a look at many coverage policies across large private payers looking specifically at those for sequencing based test and looking at multi gene panels and payers are still at least for publicly available coverage policies they're still making their assessments based on the framework of analytic validity clinical validity and clinical utility and still looking at large randomized trials or well conducted observation large observational studies as the evidence base going to professional guidelines technology assessments the same sort of evidence base for their assessments and it actually complicates things in to make to get a positive coverage decision for multi gene panels because their view is they're still looking at the clinical utility of individual genetic variants and actually the pharmacogenetics panels were some of the ones that had the few affirmative coverage decisions unlike some other gene panels so it's still they're lagging behind in sort of the assessment of these things but again it's still the evidence base is the evidence base of what people are making the American College of Cardiology American Heart Association deciding about pedigree it's the same evidence base but if you stick it in a cardiology panel with 50 genes it's going to make we might think that that sounds efficient but they're still worried about what are the downstream possibilities of having to act on the 49 other things that you might find in that panel that there's far less evidence about what to do rather than to see 19 so that's the story and inviting them to the table and having them part of the study design process is certainly an important model and I would I think that we should consider that Laura not to spoil my presentation for tomorrow too much but one thing I've thought a lot about for PGX where we're trying to look across many different institutions is we tend to focus a lot on outcomes we can measure at the individual level and then that gets really hard because our implementation is so different and we have all these caveats I think that we have a lot to learn from implementation science and looking some more at outcomes that we can look at at the institutional level and I think bringing in the payers who can talk about what institutional level outcomes would be most meaningful to them would be a really great way to sort of engage them in the conversation what gives you hope about that what's your example of what well I'll talk about this tomorrow but we tried to do a project looking at response to CDS and trying to compare it across institutions and we were pulling our hair out so we can't make this comparison and this isn't valid because we look at this and we sort of rolled back and made some conclusions and then I started reading the implementation science literature which sort of made all the conclu- if I'd read the implementation science literature more carefully before trying to do that project I would have come to all these conclusions before we tear our hair out for seven or eight months so you know but it's tough but I think there are some institutional level outcomes that we tend to overlook that could be meaningful and can help synthesize these really different projects that we're doing across lots of different sites I mean in some ways we have a model out there and that's PCORI because PCORI as part of their investment invested in a methodology service where they have an aggregation of methodologies that if you apply for PCORI funding you're expected to identify methodologies that are already represented there that you're using and that you're mapping to or to provide justification why the methodology you're using because it's not there and they've also invested in developing new methodologies as part of their they've funded researchers to research new methods and so it's an interesting model it's not one that I'm aware of that has really been used in other funding sources but it is a way that they've tried to get some consistency across the tremendously heterogeneous projects that they're funding so I think it's a valid point to at least think about Mary So in terms of thinking about a big project that we as a community could take on I guess I go back to the Vanderbilt story where you looked at your 53,000 patients whatever it was and you had real data on what percent of them received a high risk drug and real data on what percent of them had a high risk genotype we might quibble with exactly what those genes or drugs were but let's say we could do that again at least really carefully catalog the drug use in big groups of patients what were the criticisms that you got of that I mean it seems to me your conclusion was that you saved 383 serious adverse events you could have saved had you saved a high risk genotype prospectively and acted on it we don't need to genotype 53,000 people to know what their genotypes are going to be we can use all the population data that's available and estimate the frequency of all of the serious actionable variants in actionable genes can we merge those estimates with real data on drug use in these large populations additional estimates of how many bad events are prevented and thereby avoid doing another negative poorly planned clinical study I mean I'm just curious what kind of pushback do you get on when you state that that finding that you saved so many serious adverse events because to me that seems really impressive you genotyped people it didn't cost you that much money and you saved hundreds of patients from having something bad happen I mean what more do we need to see interesting question I mean that was published a couple years ago so I can tell you with Inning Knight we are doing another ecological study that we're looking at I think we've changed the name of that actually again now to think about it but the the ACPIC prescribing study we're looking at the same sorts of things across a broader group of hospitals and we certainly would others can join too and with that we could do the same calculations for to calculate adverse events and what the potential outcomes would be hopefully you tell the story of our larger community maybe it becomes more convincing and perhaps even with that can be intersected with some of these cost effectiveness models where you could even for a subset of those maybe we could actually put some data behind behind some of those questions around other corollary questions like cost effectiveness we haven't thought about those next steps but I think it's important to bring up the question now and start to think about what they are one of the comments I want to bring out Heidi mentioned sort of the multiplex pharmacogenetic testing question we actually did submit a CPT code early in the night maybe our second year in the night or something like that or something for that it was it was up to me to argue and I didn't do a very good job arguing its existence apparently but the idea was for a panel based test it had minimum criteria in the very same way we said genes had to be tested that would have pharmacogenetic indications with evidence and the panel just didn't feel like there was enough evidence to recommend this sort of this combined panel perspective test and there's a lot of reasons why that's hard but part of the reason why is there's not a lot of studies out there to support it the study that I talked about I think is one of them and that's one of the things that led to the CPT prescribing study that we're undertaking now is to try to say across the community there really is the advantage in fact in that study 14% of the people had four drugs that they were exposed to so basically one fourth one out of four people that get one get four so there is an opportunity to test because the hard data to get are the drug prescribing data but now a lot of you in these large centers healthcare systems have data on thousands and thousands and thousands of patients and the pharmacy benefit managers have millions can you get access to it though? a lot of that is publicly available so we're working with an economist that's actually used that publicly available data to do some work we're now using it on our own but it is out there can be used and I think you could probably answer some of those questions I mean Josh's point about arguing to the CPT committee having done that myself it's a very idiosyncratic process and it's generated by most of the CPT panel are surgeons so it's the way it's set up and it's under the control of the AMA and so the decisions that are made are not always particularly rational so I have in the back I have Todd and then I have Heidi and then I have okay so you asked the question about what made this researcher hopeful and I would say about getting payers at the table I would say payers are people too and we had a positive experience here in DC we looked at a cohort of about 180 patients on buprenorphine who were not adhering as judged by urine talks and we did CIP3A4 testing on them and were able to show that with pharmacogenomic testing guiding dosing recommendations that there was increased compliance with their buprenorphine regimen and we were able to successfully lobby the Medicaid agency in the city to change their prior authorization around that medication and our next step is really to see whether Medicaid will actually now cover the cost for testing for all buprenorphine patients so there's hope even with small cohorts my question was why was she hopeful that knowledge of implementation science would have resulted in better outcomes because it does no it's axiomatic no Todd another thing we don't want to underestimate is the fear of the providers for the liability of genotype data being available right now there's a lawsuit against Quest for somebody who was genotyped and they weren't acted on appropriately based on there was apparently two publications, I don't know all the details but it sounds like way less information than there is available on a lot of these other things and very often there is a lot of fear among physicians like maybe I now know what to do with 2D6 encoding if that's the drug I'm giving them but if I later give them some of these other ones what is their real liability what is their chances of being sued for that and some sort of clarification other than me saying well it's usually the guidelines from the expert societies and stuff that's not very reassuring to them and some sort of hard evidence or hard document or something that clarifies that I think would be very helpful yeah I think liability is an interesting beast because clinicians are three times more comfortable with an error of omission versus an error of commission and some of it has to do with the attribution of that but you know the adverse event is is real for again as Julie said for that patient whether we omit something that we should be doing or commit something it would be my argument that it's not going to be too long that we're going to see a stent patient like Josh is saying why didn't you do this test because the evidence is out there so you know it's a comfortable barrier to hide behind but I think it's one that's intellectually not defensible particularly if we take a quality and safety approach to this because again they would never make that argument for a drug-drug interaction they would never make that argument for an allergy so it's back pretty strongly when we hear that I think I had Heidi and then I have Julie so I just wanted to go back to Josh's example so although I understand your argument for the utility of a multiplex panel no no no I'm saying I understand it although I can see why insurers are still you know not convinced but my argument wasn't actually around arguing the utility of a multiplex panel it was actually to say if we can define the drug indications and where there is actual you know clear utility you know from CPIC guidelines etc even if it's just for one drug but then the idea is that the code says at least this marker and then it's up to you if you want to for the same price throw in 100 more because today for most of the platforms we work on it's not much incremental additional cost to throw in the rest of the entire panel for the cost of the few snips you're doing for whatever drug and we at Brigham and Mass General worked with we being the pathology departments worked with Ithabrelucross Blue Shield to define 20 cancer genes that there was felt to be sufficient utility that that would be paid for and a price determined around those I think it was 20 and I don't know if you were involved in this next genes but then they agreed that we you know we could add as many other genes as we wanted as long as the price didn't change and that that code could you know could be applied for the set that was had utility and documentation but it was you know up to us to continue to add whatever we wanted and that would be irrelevant so that's the kind of argument I'm making is you define your code based on what is clinically defined as useful but the labs can keep adding content to their hearts to light as long as the price and reimbursement doesn't change which is what should be controlled by the insurance and you know utility questions does that make sense we need some data around are there any real downstream costs the pushback is always going to pay for all the stuff you're going to now find with the extra content but I've yet to see data nor have we created any of our own to show that it does or doesn't create extra cost and you know there will be the unusual patient there but just like with imaging you find that unusual blip but you know there's always that pushback you know you're going to do a panel you're going to find a leaf from any syndrome now we have to scan them for well do all these extra things and you know right yeah the whole thing I mean but there's that acute argument our approach to insurance companies and you can correct me if I'm wrong but our approach has been only look in the first 12 months because after that the patient may have switched to a different insurance company so in that 12 month window are there a bunch of extra things that we've added that would harm the insurance company and that's as a field we haven't answered that yet and I should clarify that it wasn't necessarily agreement that we would return the results of those additional genes so I you know they wanted a very clear protocol around the implementation of this what was the criteria that patients would get this test that they would then pay for and making sure that we had a workflow in process to evaluate those patients to make sure they were appropriate for the test and I but I think addressing the issue on the downstream end is also important so what of these genes will you actually give back and what's the criteria to determine that and creating that sort of workflow so that it's clear you won't have just return willy nilly and then all of these downstream things happen which is unclear because it's a very frustrating discussion to have with the treatment we're doing a lot of partnered pilots now never say the word research with the insurance company they'll pay for pilots but not research so do pilots but that's always the thing that comes up is well what costs are we adding what problems are we creating yeah Julie so just back to the liability thing I wanted to completely agree with Mark when we were beginning our clopidogrel program the conversation came up with our interventional cardiologist about what was the liability and we brought the at the system our institution in and we came to the exact conclusion and the cardiologist actually rapidly agreed which was the fact that you don't know their genotype doesn't change their genotype their genotype is there and the absence of knowledge doesn't protect you and so I agree I mean I think if you're getting that you should push back hard because it's you know the fact that they don't know it doesn't mean it's not true I think the concern where I'm getting is not that initial event it's the later if six months later they get you know if there was originally a 2D6 encoding thing and then six months later they get you know and they did not actually look back because we don't have the alert system in the EHR to notify them and then they have an event it's like and then they go back it's like well doctor you should have known because this genotype was in the EMR EHR and you didn't do anything about it so it's not so much liability of the actual the initial event it's the getting the alerts and stuff getting to the patient or to the doctor in time. Yeah so you can fix that then by just building alerts for all of the drugs in that alerts when they have the genotype plus the drug? That links up to in real time and they can get at the data but it's got to be something that the genotype data's got to be structured in the EMR so they can do it right and today we can't do that or we don't at least we don't have all of our genetic data in a structured format in the EHR so we can actually do that eventually yeah I agree but tomorrow here today and tomorrow it doesn't work maybe in a couple months yeah I mean my view would be is that you know you if you can't do that you don't return because I think the obligation then is a systematic one because with the difference with the the one exceptional aspect of genetic and genomic data compared to most other data is the persistence of the relevance of the information it doesn't matter if the sodium you know is you know you're not going to go back to it you're going to do another sodium but for this we're going to go back to the different on the implementers to build in those systems and if you really aren't at a point where you can do it then you can say well we're going to return to C19 but we're even though we've done this chip we're going to suppress the rest of those results until we have that infrastructure into place and that would be the covenant that I would make you know with our clinicians I'm not going to put you in the position of you having to try and remember to it's great for Julie and Todd and Josh to Dick and Ollie to have systems in place to do this but you know when people move the question of what who how does the obligation follow the person does the does the person take on the obligation of knowing their own genotypes or does do we think of a way of creating a national infrastructure that allows people to access their data from wherever they are and access current clinical decision support so it's easy to say well you know you have 50 genes just develop 50 pieces of clinical decision support that's easier said than done too but I think that if one of the things that comes out of this meeting is thinking about things that we ought to be doing to move the field forward that is something that seems to me to be a priority. And on that note we'll draw our conclusion to a close for this particular session and I would think that ending on a patient centered note and the fact that the information has to follow the patient wherever they go is a critically important take away so with that I'd like to thank all of our speakers and all the discussants.


How to connect two or more routers to one network, the router we are going to connect to in the bridge mode should be configured already. Before you move on to configure the second router, it is necessary to change the settings of the main router's wireless network, so that the channel for this network will be static instead of automatic. Let's move on to configure the router that will operate in the WDS node. You need to change the IP address of the second router. You have to avoid the situation of having two devices with the same IP addresses within one network. Go to the tab Wireless – Basic Settings. Select the network from the list that your router will get its Internet connection from. After rebooting, it should say Enabled in the line WDS status. How to build a network of several routers with a cable connection? There are two ways to do this.


Oh hey Teddy. Oh hey AJ, what's up? How you doing today? I'm actually kind of sick today, so not my best. So how do you usually set your day? Well, on a good day I wake up around 9.30, sleep into a whopping late hour as you can tell, and then this morning I actually woke up like a mess. What's your go-to breakfast item? Go-to breakfast item. Well, my mom's gonna kill me, but I don't eat breakfast, and usually I just have a cup of coffee and maybe some water if I'm feeling really healthy. What song do you usually set your day off with? If I'm feeling super energized, I like to start with So Emotional by Whitney Houston, and if I'm feeling more like about work, I listen to Nine to Five by Dolly Parton. Are you dating anyone right now? Yeah, but don't tell her I was talking about it. She'll like it. Someone you look up to in life? Oh, let's see. Oh, Juniper Angelica Cordova. If you could have lunch with any historical figure, who would it be? A historical figure. Oh, Beyonce just owns Carter. Coffee or tea? Coffee. Star sign?  Make one of me if you want. Where are you from? I'm originally from the San Fernando Valley. Go-to bubble order? Oh, wow. Okay, so I like the ones with passion fruit and coffee. Favorite play or musical? Okay, so my favorite play would have to be Shakespeare's Othello, and my favorite musical I think is Sweetie Todd. Any hidden talents? I didn't tell him. I can put my tongue in my nose. Can you show us? We'll keep it a secret. Best role you've ever played? Okay, the best role I've ever played was actually J.D. and Heather's. A dream role of yours? I want to be Roger and Rent one time, but I also kind of feel like the gender vent, teddy, tenor thing is getting a little tired at this point. So many people don't know about you. I didn't cry when I was born, and I've eaten two scorpions. Favorite cafe to study at? Oh, I'm hardcore Milano. I never go to strata, ever. Favorite place to actually eat? I mean, other than the chambers and the lounge, I do love the fifth floor single-store bathrooms, because it's a great place to cry after a senate meeting. If you could make a documentary, what would it be about? Oh my gosh, I think I would actually make a documentary about the Girl Scouts who sell cookies on Sprout. They're super hardcore. You can't live without them. Well, it's actually two. It's my guinea pig's rosemary and persimmon. The last person you texted? I think it was New Hawk Colfe. She's the external Affairs Vice President of UC Berkeley. What major are you? I'm a political science major, which I know is super original. What year are you? My third year. Other than being a senator, what else are you involved with on campus? Okay, so I'm currently the graphic designer for various stage productions. I make posters, social media, graphics, all that stuff. And I also, last semester, when I had a little more free time, I was in a show with them. I was Winston in 1984. Favorite place to hang out on campus? My favorite place to hang out... Oh, well, it's raining, so I'm a little jaded. But when it's not raining, I like to sit outside barrels in that little grass patch that's facing GBC. The sun hits it perfectly. Best class you've taken at Berkeley? English 100. It was your Shakespeare class. It was awesome. Worst class you've taken at Berkeley? I don't have to say stats, too, but there's nothing wrong with it. I just eat math. General advice for Berkeley students? I would say that whatever it is, it's not that deep. Any plans after graduation yet? Oh, my gosh. I hate thinking about that. Because my plan right now is to graduate. But I would say that after I graduate, I'm looking forward to calling my parents who are often asleep a little bit more. Now moving to things relating more to your Senate office. Sure. What's one exciting part of coming to your Senate office this semester? Well, we have a bunch of exciting stuff coming up, but I would say the biggest thing and the thing I'm most excited for and nervous for is the QD Health and Wellness Summit. It's a major conference we're planning for April. What is one thing you look for and someone who's going to work in your office? Well, I mean, I came in with no experience, so I think the only thing that matters is passion. One thing you love about your community? I love my community for so, so many reasons, but I think the QD community is especially special because we are the community that never happens. That's in every community. What tips you've motivated in your position? The only thing that keeps me going at the end of the day is seeing the work I do impact the lives of the students I represent for the better. How many meetings do you usually attend a week? Like, between 7 and 12. What are some things your office has done this past semester? Okay, so I'm really proud of all the work we've done. We hosted, like, 15 community engagement events. Some of my favorite of those were God is Love, which is a photo shoot we did on Sproul. We hosted National Coming Out Day, which was super fun. And we also hosted a free flu shot clinic, which was really, really helpful for low-income, uninsured students. We passed three resolutions. Some of them ended by-law, some of them about trans-student protections. I was able to help Chancellor Chris draft a statement. She issued to the whole campus about trans protections. We established the QD Student Needs Survey and we established GMAG, which I'm really excited about.  Possibly. How can people get more involved with your community? Well, my office has an open-door policy. We're really intentional about that. And I think that the QART also always makes opportunities available. Any events coming from your office this semester? This semester, yeah. I mean, next week, we are hosting the QD Communities of Color panel. And I'm really excited about it. How can non-trans-slash-core people help the community? I think when you're not identifying is to listen and to show up in solidarity when you're asked to. How late do you usually stay out? Stay out for Senate meetings. Last night, we were there until about 11. On average, I would say between 11 and 12. How do you de-stress after a Senate meeting? I, like, almost always rant to my girlfriend, make some pasta and feed my guinea pigs some spinach. How many times have you gotten tea with the Chancellor? We don't get tea, but we email.  I would say bureaucracy, red tape. The thing you like best about being a senator? Like I said, the community that makes it, like, worth working for. If you had to pick three people to be stuck in the Eshelman elevator with, who would it be?  Iconic. I'll see you later. Bye, Teddy.


What's going on guys got Kyle here with late in sports cards, and we are ripping two boxes for Chris M I've got a 2022 2023 mosaic basketball and a 2023 pristine baseball, but Chris Start with the mosaic Mow bleep mosaic monk red scary Terry, and we got a white It is Tyrese Halliburne on the white montage to 25 Sick-looking card there silver Adams got Jeremy Sohan red Red mosaic breakaway Keegan Murray and a so a swagger Jaden Ivy. Yeah, I appreciate that hookup Appreciate that. Yeah, there is I know there was a way for sure somewhere within the orders Jalen Durran, we've got Shaden Sharpe nice one here on our collage mosaic. Rookie Otto nice hit there Chris We'll take a Shaden Sharpe Rookie Otto Blazers silver Michael Porter Got blue Jeff green to 199 Yolk itch and breakaway Trey bad there Chris great hit on the auto Great hit on the auto rookie Matheryn Mosaic herder and red and bead and a montage Paolo Jalen Williams PJ Washington to 99 Stairmasters of Kyrie Nope, just a silver there Alondes Williams Alondes Williams nets thought we had another auto had pink to 149 job Stairmasters and Matheryn on the montage rookie mosaic Kawhi red Claxton Decent introductions. Come on. Come on, Chris Donnie Bruey got red Malik Beasley. I Was told some seven and stairmasters their storm chasers KD. You can't sub in if there's nobody here.  Okay, it's a Keegan Murray rookie base Blake Wesley Rookie of Kennedy Chandler and blue Michael Porter and mosaic stairmaster every say hey, Donnie Oh, you already did Mosaic Malik Beasley got red John Collins Introductions of chat righty that I'll do it for the mosaic there for you Chris And we got a pristine pristine Chris says hey like this Good luck. Mr. Chris Come on see something else here for you Chris factor Schwabber and orange nice one there rookie Oscar Gonzalez The guardians on the orange rookie not bad there number to 25 nice 140 Chris Taking orange rookie Sammy Sosa going going gone refractor Luba maglio or dome. Yes Judge going going gone. Oh, come on. Jimenez and blue is Hideki to 99 Or 75 sorry Hideki mon suey How you doing today Donnie? Good That's fair Paul Goldschmidt still feeling going on got a dent in that one Chris We'll send a box with that gold. He got a big old dent in there ripped it apart You forget about that. I mean that's what you have to do with pristine Part of a box this is how it works most of a box you have all three There's a okay line and auto is gonna be it's a 99 around the diamond Jonathan India Not bad there on the relic auto reds. I think rushman rookie Blinch JJ Bledet fresh faces a Couple more packs for you Chris. Then we got our mags Contreras to 99 we got Byron Buxton Frankie Lindor oh snap factor McCovey and Ruiz I mean going going gone rowdy now for our mags here, Chris We had to 50 te Oscar te Oscar Hernandez mariners Gold to 50 we've got CJ chrome refractor Rockies Got auto this is Max Castillo Max Castillo rookie auto for the Royals not numbered We got a pink Tyler O'Neill number to 15 nice low numbered O'Neill like those pinks number to 15 Got Aaron judge on the refractor and nice gold to 50. We got Kyle Tucker on the auto Nice auto there Astros You go Chris nice Kyle Tucker at the back. Oh righty there sir that will do it for your two boxes one mosaic basketball and One tops pristine baseball. Thank you sir. We'll get that right out to you


Sure. Probably about almost 12 years ago I got into coaching. It was about the time when my oldest son was getting into sports. He was about five. I figured it was time to start signing him up for soccer, starting at the indoor leagues and then put him into the recreational programs. My dad was a coach for me growing up. He coached for 20, 30-some-odd years. So I knew that if I wanted my kid to be coached, probably need to educate myself and go volunteer here to do that. So I got into it that way. As my kids kind of progressed through and moved on to club soccer, I ended up helping out some directors at local clubs here in town. Eventually got pulled in to do team coaching myself. And then as parents, we started to get to know them as part of my kids' teams, asked if I would do private training, started to do a little bit on the side, and then finally realized I probably should formalize this into a business. Did that a couple of years ago? I've been running Fletcher Soccer Academy since 2020. Okay, love that, love that. So what does their Fletcher Soccer Academy specialize in then? We specialize in a lot of technique work. So I'm really big on an importance of proper technique.  But coaching the teams also with the local clubs, kind of understanding the younger ages all the way through the high school groups, being able to see where we're actually struggling with some of our player development and seeing just some of the fundamentals, you know, proper passing technique, passing over distance, weight of pass, being able to, you know, rotate hips and body. So all those kind of basic fundamental technique stuff, kind of think those are core and foundational to everything that we do. So those are our primary things. And we do some position-specific defender, striker, winger side of training as well. But technique is at the core of everything that we do. Okay, love that.  Because I know a lot of coaches that are in the club environment, they just want to stick with teams and just they're comfortable doing that. So what motivated you to start your own thing? Yeah, I think the individualized attention, you can provide a player that you can, the team environment. When I coach a team, obviously you've got, you know, depending on what 77, 99, 11, 11, you could have a whole bunch of kids in the field. They'll get some personal interaction, but you're more teaching the team concepts, the tactics as they get older, seeing the need for the individualized attention to hone in on those techniques, sort of aspects. And I've always loved the development aspect of it. I'm big on growth mindset. So being able to do that at a smaller scale, we don't do very large groups. We typically do eight or less just to keep that personalized attention and loving seeing those kids kind of progress as time went on. And the initial kids we had in the academy, the first summers they went through the programs, the first winners, seeing the difference when they came out for the next season and hearing it from their parents and families, they could kind of see those light bulb moments go off. So then that just kind of springboarded them. And I think it ties into the confidence aspect. We actually do a lot of surveys to our customers too. And confidence is one word that is in a lot of the responses that we get. I think that's an important part of the individualized training is not just the technique aspect of it, but you're really helping them build that confidence. So they are competent to do that in the games when they get back to their teams. I love that. So currently, how many clients is your company working with at the moment? We have about 30 players within our summer program. And for the last, probably winter and summer, that's about the number that we've been at. Okay, so good. So in terms of taking you back to where you said confidence, because this is a very common one with a lot of athletes and a lot of clients that that the coaches are working with. So what is confidence to you? What's confidence development? Is it a technical side? Is it a mental size, a combination of both? Definitely a combination of both. The technique aspect of it, I think, is kind of building that muscle memory. So doing it the right way repetitively. There's a quote by Andrew Apirlo of don't practice till you get it right. Practice until you can't get it wrong. And that's kind of one thing that we kind of drill into our players of. That's great. We just had success. We did that movement perfectly. Let's do it again. Let's get another rep. Let's continue to build that success. And I think as they do that internally, the mental aspect starts to build the confidence in themselves to where you see the smiles on their face. They feel good about what they've just accomplished. And then they feel more confident mentally and they're trusting their mechanics that when they get to the game, maybe something they wouldn't have tried before. Maybe they're taking a shot from outside the box. Maybe they're closing down a defender. Now they know that they've done it in training and they feel that the internal confidence to go implement that in the game. And I think it's that combination of the physical and the mental aspect. Would you say that's something that's missing in club teams? I don't know that it's necessarily missing. I just don't think the coaches have an opportunity being one myself to always spend as much time on that aspect of it. Just because, again, you're not getting that individualized attention. You might have multiple players playing the same kind of position. And if one player is just not at that right level yet, you'll go through the training aspects and the activities you're doing in training, but you don't have that full time to really dive in and break down what's going on in their technique that would give them more success the next time through. So you're moving on to the next tactic where the private training, we can focus on it for that full hour that we have them. And we know, okay, let's carry that concept into the next training also for this one individual or this group of individuals. And we can really drive that home. I love that. So Tony, I'm going to take you back to when you first started your Soccer Academy. What was the biggest obstacle you faced at the beginning? Well, that's a good question. I think externally it was more name recognition a little bit. There are some other trainers here, some from the club that I work with. So they already had existing presences. So knowing that that competition's out there, I think externally too, just I started close to the winter time. So teams are going back in the facilities, there's not a, there's a lot of facilities, but not enough to where the team training and the private training can take use of all that. So I think that was a little bit of a limiting aspect. And then bring it maybe internally, the imposter syndrome a little bit, feeling internally, just making sure, you know, we coaches like to project that we're always confident in the field, but internally, even some of the best of us still, are we, are we good enough to do this? Are we doing the right things? Are my providing the right value to those clients? So I think those two, those two things that the externally internal were, were things for me. Awesome. So as a coach and a business owner, how do you self evaluate your performance? Kind of, I also work in technology. So I've had a pretty, pretty long career and part of that is in product management. So part of that process is always trying to evaluate, are we building the right things? Are we returning value to our customers, to our shareholders? Kind of constantly doing that implemented that into the academy business as well. So we do regular surveys after each kind of group, the winter training blocks, the summer blocks to get feedback from the parents. And then also just, you know, even as I'm going through a session, I'm trying to evaluate, is what I've planned for this session, actually making through and translating to the, to the players, or maybe I'm sitting down the night afterwards and maybe jotting down some notes about, Hey, I tried this with a younger age group. It really wasn't working. That might be a little bit too advanced for them. Let's figure out something else that can do that same concept, or maybe even with an older group, maybe I haven't challenged and pushed them enough with something. So kind of just always going through my plan, always evaluating daily, weekly, and then obviously after the summer and winter blocks. So it's just constantly asking yourself questions, right? Absolutely. Absolutely. So how did you get your first client then? First client was actually from a teammate of my youngest son. They saw that, you know, he was playing well, knew that I had worked with some players before and asked if I would work with their son on a regular basis. So kind of brought him in quickly thereafter, his sister joined up, formalized everything from there. And then they've kind of been one of the biggest champions and word of mouth referrals that's kind of helped grow to where we are right now. Love that. And what did you look for when you bring in a new client into your business? Definitely look for someone that's, it's not just the parents asking for that the kids want to be invested in it, that they're looking to be on that development journey, that they know that there's areas they want to improve on, that they have an idea of what that is. But then they're also willing to put in the work to get there. You know, you'll have scenarios whether you're on a team or individual where the kids are there because maybe mom or dad signed them up, but you really want the kids that are invested into their own growth and development, both the soccer portion of it, but also that kind of mental aspect of it as well. Cool. So tell us a couple of ways that you keep your clients accountable for their development. So we do regular check-ins. We always ask how we have some clients that train with multiple trainers. So how are their other trainings going? How have their games been going? Kind of get a rundown before and after sessions of, you know, have they implemented anything that we've worked on in training in any of their games in a tournament? What success are they having? Hear back from the parents about, you know, obviously, if they've done really well in a tournament and they've scored two or three goals or they've played outstanding on the defensive end, we try to engage in those kind of conversations. And then we have some things in our pipeline that we're kind of working on from a virtual standpoint to add some additional value. But that'll be coming. We're in the works of creating some of that content right now. That's good. I like that. Perfect. So where do you see private training going in the U.S. in the next two to five years? I think it's going to continue to explode. I think even in the last year, I've seen it grow exponentially in the area that we're in. There were a handful of well-known trainers when I kind of got into the arena. Myself and a few others have kind of popped up since then. And now you continue to see more and more trainers, more and more Instagram accounts. There's a couple of new facilities that popped up. So you see trainers start to go to those locations and kind of promote them as well. I've even seen some high school kids, some high school players starting to train as well. So I think it's just going to continue to grow and explode. Not just in soccer, but I think across sports in general. So where in the world are you currently at for those that are watching? A little bit north of the Cincinnati, Ohio area. So kind of the Mason, Ohio. There's a big amusement park, Kings Island. It's kind of well known up in this area. So that's the part of the world we're in. And what's soccer like in that area? Soccer is definitely a hot thing here.  We started it in the lower leagues and it quickly grew from there. And we went into one of these expansion teams. Soccer in general has kind of always been hot in Cincinnati and it just continues to grow. The club I work for has some teams in the national competition right now. So there's a lot of good players and a lot of star power here. So what would you say to another coach that's watching this interview or listening to it? And they're in that startup phase where they want to start a business, but I don't know, it might be because of fear or they feel like they're not ready. What would you say, what would be your number one piece of advice before starting a business? I think number one piece of advice is find your why. So make sure you're doing it for the right reasons. If it's just to make some additional funds on the side of whatever else you're doing, whether it's soccer training or otherwise, that might not be the long-term success you're looking for. If you're truly invested in helping kids grow and grow the game and whatever country or area that you're in, I think then you're probably in it for the right reasons. I would say next, go to the resources like this podcast to what Ben's put out there previously about making sure you're formalizing things in the right manner. That was a good resource for me when I was starting out, making sure you have your business insurance, you have your business entity set up, you have all of your technology things kind of squared away to make sure you're legal and all that's taken care of. And I think you've got to jump in at some point. There's no perfect time to start a business. If you're in it for the right reasons, you're prepared as much as you can. You just got to jump in with both feet and trust that you'll make it happen. Yeah. So talk to us a little bit about the importance of having a proper legal business set up. Why is it an advantage rather than doing it as like a sort of side thing where you don't have anything legal set up? Yeah, I think it gives you some legitimacy to what you're doing, right? I think that helps project that image out to parents in particular. They're the ones who are paying for their players to sign up with you.  This is a real company. It's not just side of desk kind of stuff. You're not collecting just money on Venmo and trying to stash that away. Yes, you'll hit some additional fees if you set up credit card payments and whatnot. But I think it's well worth it to make sure from a legal standpoint, you're set up to make sure you're protecting yourself and your clients too with things like insurance, just should anything happen. It's always there. It's, you know, to do things the right way. Excellent. So how long have you been in business, Tony? Been in business about two years. We started, I think it was October of 2020. 2020, excellent. So how did you find the COVID and how did you overcome the COVID times? Yeah, it was definitely challenging. I figured if there's any good time to start an academy during COVID, and if you can prove it out, it's no better time to try then. We were kind of in a lull, I think, when I started it. So the facilities were just opening back up again. And I started with some small clinics that that first winter time. So we had to be masked up indoors. The players didn't yet. They were allowed to, if they were training to be unmasked. So there was definitely some hesitancy. Some clients who wanted to sign up for some of the clinics or some of the other indoor training we were doing, there was hesitancy from some parents there. But I think overall, everyone was kind of still wanting to keep their kids moving, keep things going. So as much as we are allowed to per the protocols, I didn't see too much of a hindrance at that point. So talk to us a little bit about your current sales process then. So how do you guys market sell your business? How do you generate leads? Where do you get leads from? Probably the majority of the leads have been word of mouth. So a lot of our existing players talk to other family members, talk to other players and families. And we've had a lot of kids come in the summer as a result of that. Just whole groups coming in together from teams. Do some email marketing. So we have a growing email list, a pretty good number of folks right now. So we do send marketing out regularly to through that channel. Done a couple of Facebook ads to kind of some mixed success, but those are kind of small denominations, nothing too crazy there. We've actually found more success on the Facebook communities. So there's multiple Facebook groups for the neighborhoods and local communities out where I am or for some of the schools if my kids happen to go there. So we'll do a lot of advertising in those and get a lot of responses in that regard too. And then obviously just generalized our Facebook page, our Instagram page. And then we have a website. We collect information of a lot of contacts come in through the contact form and set up phone calls and make sure that we're the right fit for them and they're the right fit for us. So how important then is it to be a good communicator with parents? Oh, I think it's critically important. Part of probably one of the benefits of being able to do that in my technology job too and doing a lot of presentations is not just the presentation aspect, not just the communication to a specific person, but communicated different levels. Communicating to a U8 is a lot different than communicating to a U16 player. Similarly, communicating to a player and communicating to a parent, there's different skill sets involved there too. And even within that group, you might have a player, a parent that played at a very high level. They have a much greater understanding of it and a parent that didn't grow up playing the sport, but they love it. They enjoy it. They see their kid doing it. Being able to storytell at those different levels of communication, I think is highly important. Excellent. Yeah, because some coaches that we speak to on a regular basis, they want to run Facebook ads, but a lot of them forget that even if you run Facebook ads, at some point you have to speak to the parent. Sure. So it's about repetition, right? So getting on the phone, talking to the parent, asking the right questions. Was that something you'd say you struggled at the beginning or because of your work, that's something that just came naturally? I wouldn't say it came naturally. It was definitely nerve wracking the first few phone calls I took, just not having gone through that process before, the kind of sales process of it, but try to prepare as much as you can ahead of time. So writing down the kinds of questions you want answers to, making sure you kind of have a script that you're going off of, that definitely helped me out a lot. And then I think to your point, the repetition of it, the more you do something, whether it's skills and soccer or sales with parents, the more repetitions you have under your belt, the more comfortable you get. And then it's kind of second nature.  It's not you reading off of something any longer. Perfect. And also, what's the difference? Because some coaches, they're scared to get on the phone with parents, but instead they want to communicate via text. Would you say there's a difference between actually making the effort to get on a call with a parent or just text messaging? Yeah, I think it's a cultural thing too. Everyone wants a text message these days, that getting on a phone call seems like a foreign thing to a lot of people, but I think that personal connection is important for them to hear your voice, for you to hear their voice. And I think it's also that kind of deeper connection of if they really want this, or if they're really invested in it, a phone call is not much to ask of somebody. If they are really hesitant, they want to push that off. They only want email, they only want text, just send me your info and we'll make a decision. I really want that conversation, so I'll understand what they want for their player, what their player wants to get out of it. Can't always get that through to text. And then just that conversation, right? There might be things that you're communicating to them that might spark a question on their side that wouldn't in a text thread. So I think that personalized communication is critically important. Yeah, I agree, 100% agree. So Tony, tell us then, where do you see your business in the next five years from now? On the next five years. We'd definitely like to begin some camps over the next couple of summers. I think in accordance to do that would have to be bringing out some additional trainers to do that as well. So those two aspects, one of the parents who I'm quite close friends with, we've talked quite a bit about investing in some real estate and having a facility. So that's something that we're kind of constantly evaluating. If there's existing buildings and structures we can repurpose, or if there's land where we can do something like that. But those are kind of the main three things over the next five years I'd like to implement. Very lovely. How many facilities do you want to have? Ideal road, I'd like to have multiple of them across town and across different locations. My partner and I, we go back and forth on the smaller locations specialized in training, or the larger ones, the whole tournaments and whatnot. So we've got different visions for different purposes. We're trying to narrow down what that would look like. Awesome. So how many decision makers are there in your business? Just me right now. I kind of run solo. My wife helps out as an admin. She's got an admin background. So she helps out in that regard. Okay. So in terms of making decisions, do you find it hard when you're by yourself or who do you kind of ask for advice or what would you do, et cetera? For the most part of decisions myself, bouncing things off of my wife, making sure that it sounds good from another parent aspect. And then some other parents I'm close to that were friends with outside of just the soccer part. If it's something else marketing wise, hey, does this resonate with you? Does this make sense? Is this the virtual training we're talking about kind of pitching that to them, explaining what it is to get their feedback of it? And then again, we'll send out surveys too of at the end of the season, it's not just a recap and asking for feedback on how the sessions went. We'll actually ask our folks in our academy also, here's some things we're looking at potentially for the future. Would these be interesting to you or not? Just to gain the kind of broader perspective. Love that. Perfect. All right, Tony, I'm going to finish off with two questions, two final questions. These are a bit more personal questions. So the first one is what does failure mean to you? And the second one is how important is taking risks in business? Okay. Failure to me is a learning opportunity. I've read a lot and watched a lot of Carol DeWick and the growth mindset. And definitely something I believe in and I want my players to believe in is that just because you didn't have success in whatever the activity was or in a particular game, what can I learn from that? And what can I take to improve that next time? So I think that's a huge important aspect of the mental side of the game and the training is making sure that it's only failure if you let it be permanent. But if you're continuing to figure out what I did wrong, how do I correct that? How do I make myself better in that development aspect? Then failure is just another part of the process. Love that. And the second question was how important is it to take risks in business? I think it's definitely important. I'm a little risk averse, I'll say at times. So I'll say it's more important to take calculated risks. I think you can do a good job of mitigating as much as you can by being prepared. So things like having your business entity and all your legal stuff taken care of is a measure to make sure that no matter what else you've kind of taken a preventative risk or you're mitigating some risk there. I think you can do as much research and analysis as a part of my job too in technology. So analyzing data as much as you can, but then at some point you have to trust that you've done as much as you can. Don't have analysis paralysis. Get a good foundation and then trust what you're doing and go take that risk and do it knowing you've done the homework in the background. Love those answers. Perfect, Tony. So if any coach is watching this interview, how can they follow your journey? How can they follow your academy? What would be the best way to do that? Best ways are probably Instagram. So FletcherSoccerAcademy.com or Fletcher Soccer Academy on Instagram, Fletcher Soccer Academy 2020 on Facebook, website FletcherSoccerAcademy.com and email is always great too, Tony at FletcherSoccerAcademy.com. Okay, perfect. And what we'll do is we'll add that to the video below. So if any coach wants to get in contact with you or follow your academy, they can do that there. So Tony, thanks again for jumping on here, taking the time out to share your journey with us. Love what you're doing. Wish you all the best in the future. Continue to grow. And I hope to see some Fletcher Soccer Academy facilities opened in the near future. Sounds good. I really appreciate you guys having me on here. Okay, take it. Thanks you too.


you see and by the way gang just a heads up for those of you that only watched this content on YouTube YouTube just sent out a notification today saying that they're gonna start deducting 24% taxes from the revenue we get from there right which is not much but they're gonna start knocking off 24% because I'm not gonna fill out the tax forms that they want that's too much personal information to Google alphabet ink Wall Street hell no right also patrons sent out a message a couple of days ago and I'm gonna announce this on patrons saying that they're gonna start deducting taxes from patrons from certain places so the technocrats the governments they're they're gonna squeeze humanity hard right to you know get blood out of stone right because they've been handing out trillions of dollars to their Wall Street croc cronies right so they're coming after us do what you need to do to go around what they're doing Chico long time no see young Pollux how are you doing long time indeed crisper hello hello Italy will break the dream how the God says to Starsky Sterling has one ability run down the wing perhaps dribble past two players and as soon as he is in the box dies no he does he's fast for a little guy he's crazy fast I can't believe how fast it is Google can go to Hal indeed indeed Starsky YouTube why H if Italy win that will be funny hello mr. Chicho Putin roaster how are you doing and Chicho is fine I'm no mr. Oh my god it's the main reason I am moving to subscribe star yeah it's crazy it's absurd you'll be my first subscriber on subscribe star all these broke Democrats need to be taxed is what they get I'm not a Democrat I'm not a Republican I'm just a Canadian why is the United States taxing my revenue as a Canadian that is insanity right and they want my tax information as far as I'm concerned I don't supply my tax information to anybody else I work with right like my students don't have my tax information why would they and if anybody wanted my tax information for me to work like do work for them I don't give it to them if I'm employed by them yeah you have to give them your social security number and stuff like this but I'm not employed by YouTube or Google or alphabet ink right Waco it is nuts I'm not a number I'm a free man I'm a free man that's a nice land thanks