The concept of Precision Medicine builds on the age-old understanding that humans vary in their disease susceptibility, presentation, progression, and therapeutic response. Modern large data analytics reveal that most of us have “average” susceptibility for most diseases, but each of us has high risk for a few. This finding provides the opportunity and challenge – addressed by this eMERGE Genomic Risk Assessment and Management (eMERGEgram) initiative – to identify people at high risk for common diseases to promote prevention or early treatment. We propose here a program that builds on over a decade of growth and knowledge in key enabling disciplines including informatics, genomics, bioethics, participant and community engagement, and clinical medicine, and of experience as productive participants in eMERGE since the network's inception. In Specific Aim 1, we will develop and validate Genomic Risk Assessment tools to identify people at high risk for common diseases. The Genomic Risk Assessments will incorporate polygenic risk scores, family health history, and clinical disease predictors. We propose that the eMERGEgram Steering Committee select diseases that are heritable; display variable impact across ancestries; are associated with available early detection, prevention or treatment interventions; and in which large multi-ancestry genome wide association studies are available to develop polygenic risk scores. Using these criteria, we present data that support a focus on coronary artery disease, chronic kidney disease, type 2 diabetes, uterine fibroids, and colorectal cancer. In Specific Aim 2, we will build on experience in eMERGE-3, All of Us, and our NIH-supported Recruitment Innovation Center to execute a program that will engage, recruit, and retain 2,500 subjects (>35% from populations under-represented in biomedical research), including family dyads or trios. We will compute Genomic Risk Assessments for network- selected target conditions; return results to participants, their healthcare providers, and their electronic health records; and track healthcare outcomes including disease detection or healthcare utilization and deliver these to the Coordinating Center. In Specific Aim 3, we will use the eMERGEgram experience to improve our ability to deliver Genomic Risk Assessment. We will assess the uptake and impact of Genomic Risk Assessments and the extent to which the components of the Genomic Risk Assessment provide independent information across populations and within subgroups. We will use a shared DNA segment map across >100,000 records in our biobank to develop the concept of a genetically-informed family history, a tool that can inform health risk in the absence of a large pedigree, as is the case for small or adoptive families. Additional research goals will be driven by participants, developed through community engagement by focus groups in Years 1-2 and highly intentional participant interaction throughout the project.

New tools in Genomic Medicine – polygenic risk scores, platforms to capture family history, and advanced electronic phenotyping – offer the prospect of early identification of people at especially high risk of common diseases. The eMERGEgram network is being formed to address this opportunity and in our application to join this initiative, we outline methods to allow the network to develop genomic risk assessments using these new tools; a plan to engage, recruit, and retain 2,500 subjects to receive these assessments; and methods to study outcomes in those designated high risk and those designated average risk. By enhancing our understanding of new methods to create and deliver genomic risk assessment, this project will enable prevention and early treatment of people at high risk for common diseases.