 as well. So, so pleased to hear your presentation today. Wonderful. I understand you've got a big event in Colorado. Yeah, we do. October 3rd and 4th, the Global Blockchain Summit, and yes, and I look forward to seeing you at Converge to Accelerate. I will be in Boston. Yes, awesome. Excellent. Well, we're just at the top of the hour, so we'll get started, and I suspect we'll have people joining the call momentarily. But first of all, I'm assuming everyone can see the screen that's shared with our agenda for the day. I'll take that as a yes. Yes, it looks great. Thank you. So, as always, we record these events, and so please keep that in mind as we move forward. As well, we always want to be sensitive to the antitrust policies of the Linux Foundation, and so I'll show you our slide here. Please feel free to read through that, and there are details in the URL within the notice itself. But in general, it means just be a good person, and so feel free to read that in any more detail that you need to. And with that said, I'm just looking through the list, and I don't see any new names particularly, although we have someone that I think that might be reasonably new, Septarshi. Did you want to introduce yourself? I think you were on one of the earlier calls with Stephen's interoperability subgroup. Yes, exactly. So, hi everyone. Septarshi Chaudhary here from Paramount Software Solutions, and I primarily take care of the blockchain initiative of Paramount, and we're mostly into the consulting area. Excellent. And tell me a little bit about the organization that you work with, Paramount? Oh, yeah. So, we started our blockchain initiative last year in April, end of April, by partnering with Hyperledger. We are a general member of the Hyperledger, and I do actively take part in some of the SIGs, like the public sector SIG, and the learning materials working group with Bobby, and the DCI with Dan, and David, and we just had one presentation last month in Japan, which I attended, and I'm based out of Bangalore in India. Thank you for saying that. Excellent. And then, are you using any of the Hyperledger frameworks, Fabric, or...? Yes, Fabric. It's Fabric. We are doing some of the projects in Fabric. Oh, excellent. Very good. And without getting too deep into the IP, can you share a little bit about what you're using Fabric for? Well, I can just say the specific operations or the projects that we are working, they are mostly into the logistics and supply chain. And right now, we're expecting to begin one project that's going to be into the health and wellness area, but not specifically within the health care. We are also exploring the payments within the health care sector and the interoperability to be precise. And that's true for the Atlanta region of companies. Oh, outstanding. Very cool. And you mentioned that you're out of India, is the organization located as well or represented in the United States anywhere? Yes. Our base location is in Atlanta, and I'm working remotely from India. I understand. Oh, excellent. Oh, very good. Well, as always, glad to have you. And I think we met previously, but it's always good to see sort of a new face joining the crew here. And again, as always, welcome. Thank you. All righty. So as people get on the call, I'll walk us through a couple of community announcements. I had something just recently come up that I wanted to share with you, which was that we do have the next Hyperledgic Global Forum coming up. That's going to be in Phoenix, Arizona. That's next year, early March of next year. And so we're looking really for the opportunity for folks here within this special interest group to submit proposals for talks. And that deadline for proposals is coming up next week, in fact, next week, Friday. So if you are interested, please feel free to contact me, and I'll put you in touch with David Boswell, who's my person on the leadership side of the equation here. And it'd be great to have you. I think what we're planning to do, at least at the moment, is we're going to be hosting a healthcare panel, excuse me, when we're hosting a healthcare panel. And that's going to be, I think, managed through one of my colleagues here in the Seattle area, Marissa Ionaroni. And I honestly don't know how many folks she's got on the panel quite yet. However, if you plan on attending the forum, let me know. And we may want to maybe do separate panels or a series of different panels circulating around the healthcare topic. So again, if you're interested, please let me know. And then, like I said, I'll find a way for us to coordinate that offline. But it is a great opportunity. And then it is kind of a nice, well, I'll speak for myself, it's a nice opportunity for those of us in the Pacific Northwest to go to Phoenix rather than all the way to the East Coast. Sometimes it's so very far away. So this is an opportunity to participate in a global forum that is actually here in the U.S. And then I've also provided the link to details for the forum itself. And that is located here. So feel free to go there. Oh, and I forgot to mention, for those of us that are newer to the organization, we do have a membership directory that if you haven't already, please feel free to fill this out. This is sort of kind of a virtual calling card of sorts or business card. It's just a great way for people to interact and connect with one another through the organization here. And so feel free. If you have your Linux Foundation ID already set up, you can do your own edits to this. There's a long way around to say that. Go ahead and edit the Wiki page directly with your information here. And you can just follow the format as it's listed on the sheet there. Okay. Does anyone else have any community announcements as it relates to healthcare and hyperelectric technologies in healthcare specifically? This is Wendy. I just wanted to remind the group I had sent an announcement earlier this week about the request for proposals from the HIMS 20 blockchain symposium. If you're working on a project and you have, especially if you have some data that you'd like to share, some success stories you'd like to share, we would love to hear from you. We'd love for you to become a speaker at the symposium. So please do, I sent an email earlier if you'd like. I can also ping the group in the chat box right now so that you're just aware of this opportunity to get your message out there and share your experiences with the larger blockchain community. Yeah, you know, Wendy, maybe we can send out to full membership that sort of reminder again, just to remind folks. And the deadline is, is it next week? It's September 30th. Oh, September 30th. Okay. Yes. Did that change, by the way? Did that deadline change? No, we were actually hoping for an extension because for most of the symposium, for HIMS 20, the deadline, the submission dates are September 6th through September 30th, except that the one for the blockchain symposium didn't go out until like the 12th. So we were hoping that it could be, the deadline could be pushed back, but that's not the case. So we're just really trying to get the word out and encourage people to submit before September 30th. Gotcha. And the reason why I asked, I just received something from Hyperledger Leadership and they had asked me about some sort of extension for a blockchain group. I thought it was through HIMS and I thought it was something that you and David had been working in. It just didn't seem clear to me that some dates had changed. And so I just was curious about that. We'll take this offline a little bit. Yeah. And I will certainly, I can certainly confirm with Caroline Kennedy who is organizing the symposium for HIMS 20 and just verify the dates. And then I can send it another, like a reminder announcement to the larger HIMS healthcare special interest group community. Okay. Somehow I am on the hook for a presentation at HIMS. I just don't know where and in what context or even what forum. So I'm just trying to figure it out. Sure. So there is a track, a blockchain track for the overall HIMS 20 conference and then there's a separate blockchain symposium that's a pre-conference activity. And I am talking about, yes, the pre-conference activity. Okay. Okay. Perfect. Alrighty. Well, thanks. Appreciate the clarification and the notification. And then yeah, we could probably ping membership again just to remind those folks that that opportunity is out there. Okay. Any other community announcements before we get started? Alrighty. Well, I'm really thrilled to have Susan on the call from Spiritus. Is Bob on the call as well or is it just going to be, is it going to be you Susan? It'll be just me right now. Ah, okay. And so I'm going to make you host. And so I'm going to hand over to you and feel free to take control of the screen and go ahead and set up for your presentation. And so just as Susan is getting set up, again, we wanted to thank both Susan and Bob for their participation. And we're going to have, I think, a really good conversation about really medical devices and how blockchain as part of a larger strategy is used for tracking medical devices through their life cycle. And so I'm very excited to see how this all comes together. And we'll give Susan about a half an hour or so, maybe a little bit more time to give her presentation and then we'll get into discussion. Thank you. And can you see my screen at this point? No, just I still see, I still see me. Okay, let me go back. And if it's a real problem, I could, I could display the PDF here and I'll, you could just drive me through that. Oh, here we go. Perfect. Okay. I think it's still wanted me to confirm that I was taking it from you, which is always good in a cockpit. Yeah, there you go. You're good to go. Okay, well, thank you. And thank you to those who've joined us and those who may catch the recording later. Bob Clinton, I founded Spiritus some three and a half years ago with an eye to how we might improve medical device safety quality and compliance across the life cycle of medical devices. We come from different backgrounds, perhaps, than some. My business background in financial services, extending back about a quarter century, comprehensives to enterprise sales, product management, technology strategy, corporate development and actually the last eight or nine years as head of enterprise risk at a $9 billion financial services firm. So among other things, I had to deal increasingly with personally identifiable information, cybersecurity risks to operational infrastructure and the like, as well as strategic risks introduced by innovative and emerging technologies like artificial intelligence and ultimately blockchain distributed ledger. Bob's background is a data background, a number of years with big four IT consulting firms doing work for Fortune 50 companies and government agencies around their data and business intelligence needs. So as those tools have evolved over the years and the needs and awareness have evolved, Bob's been able to maintain that focus. We began our journey by exploring a hypothesis about information we'd seen and certainly with the introduction of a lot of innovation and medical devices and the sheer growth based on a greater affluence and demographic aging across nations that medical device safety and quality were significant problems. And in fact, the evidence bears that out, the volume and complexity of devices is exploding from point of view with health systems, manufacturers as well as payers and providers, a lot of great innovation there, including a increasingly connectivity software enablement and in some cases, introduction of algorithms, which has increased the importance of addressing any cybersecurity vulnerabilities and interestingly quite a number of the recalls that in terms of volume and percentage that have been announced in the last two or three years, large proportions of them related to software vulnerabilities that might be exploited by bad actors and certainly could compromise a person identifiable information, but also the clinical resilience of people, the operational resilience of devices that are central to care and interventions. We're seeing the impact more broadly of adverse events in terms of unnecessary injuries, complications and deaths. McKinsey's done a study that suggests as much as seven to nine percent of revenues are lost by manufacturers, defines penalties, litigation, loss of top line revenues competitively as well as reputational damage. The original study done in 2011 was recently updated in 2017. So the numbers are in excess of $30 billion annually in an industry that's growing in the high single digits globally. And then from a health system standpoint, certainly the extent devices are not available for use in routine care. Here I'm thinking infusion pumps, ventilators and surgical instruments. You've got some challenges around managing clinical outcomes, but to the extent there actually are adverse events or recalls, you need that transparency and visibility to manage in a very challenging budget setting one where unreimbursed costs particularly in value-based care are going to figure large when margins are a problem. Certainly putting patients at the center of poor patient experiences to the extent that you have complications or issues and clinician frustration. So all the parties involved need to be concerned. I'd like to put an exclamation point on the connectivity element of this. Devices are increasingly connected, interoperable with other devices and or systems like pharmacy systems and EHRs. I've mentioned the algorithmic enablement, so introduction of AI and ML. The Mayo Clinic's Chief Information Security Officer shared at a regulatory workshop some two years ago the FDA conducted that he has across the three major facilities that Mayo maintains over 100,000 assets, if you will, of which 25,000 are connected. Those connected devices comprise 6,000 unique makes models and versions and over a dozen. So from his view every device is a snowflake to have the visibility and maintain a cadence and rhythm around routine upgrades, maintenance and repair activity, understanding how the software and connectivity plays with the device function and performance. All of these have put a tremendous burden on information security teams to work with the clinical operations, clinical engineering teams, network management, as well as third parties to ensure that the devices are up to date and patched. So I've alluded to these four major areas of problems, yes volumes and complexity. Regulators here in the United States, the FDA started initiative about a decade ago across the life cycle to have manufacturers assign unique device identifiers to improve traceability in the supply chain and in post-market settings. That regulatory change has been largely implemented in the United States and now adopted in the EU. Likewise, regulators are converging on improved post-market surveillance and adverse event management by device manufacturers and in the EU requirements around distributors to perform that activity and clearly there's greater emphasis on real-world evidence to support the clinical utility as well as safety and effectiveness of devices, whether from a pre-market 510K standpoint or in a post-market setting. Transparency is a problem because of the number of players that are involved over the life cycle of the device. Many of these devices, whether they are an implantable defibrillator, a glucose monitor or more mundanely a best bed or hoist dialysis equipment involve a number of parties and here's where you start to say to yourself, do I know and understand across the the life cycle and service history of a device, whether it's safe in good order. Our journey over the last three and a half years has taken us to focus on the health system as being at the center of this ecosystem that I've depicted here. Yes, in a supply chain sense to the extent there are issues that are recognized, manufacturers want to be able to traverse their supply chain both upstream to their contract suppliers, their own work in terms of design production and then ultimately distribution. But once in use, if you will, at the point of care, you typically have some combination of clinical engineers that are employed by the health system, manufacturers, representatives, and or remote servicing that are occurring and third parties, third parties that may be certified and contracted directly by the health system or third parties that are representing the manufacturer. They all are involved in playing in the service maintenance and repair and actioning of recalls and medical devices. You dig more deeply and you find out particularly in those areas like surgery operating theater and endoscopy units around diagnostics that surgical instruments and endoscopes are often in a context of outsourced sterile services. They are moving off site where third parties are coming in to perform decontamination sterile services. Devices in trial will involve CROs and often third party labs. As you move to service delivery models, the emphasizing acute care and putting your front foot on preventive management and self-management. You'll either have people working with home care specialists and the associated devices and equipment and applications there and often clinics or outpatient facilities. Devices are subject to audit and inspection. Ultimately, they may be decommissioned and disposed of or submitted to auction and those auction houses which are growing in size will go in often and buy up inventory hospitals that are either opening new facilities or shutting down and make available online and in person full gamut of devices and equipment. There are limited warranties and representations as to the condition of the devices and equipment and this concept of having a service history is germane. This is the answer to wide distributed ledger blockchain in this case. If you look at what health systems are confronted with, they are well served by point solutions but they do create silos. So what I've done here is break down examples in various areas. So service management capabilities supported by what are known as CMMS system, computerized maintenance management systems or asset management systems, the use of UDI tracking, cyber security, management systems, recall management systems. I've referenced sterile services and reprocessing services, integrations into the cash case to cash life cycle, ERPHR, supply chain management systems, risk and compliance reporting. If the slide was wider, I probably could add some more and certainly to the extent manufacturers are introducing service models that support remote servicing, they are reinforcing the silo and the fragmentation at the same time as they are helping with response times and potentially uptime for men for health systems. It is nonetheless from the standpoint of seeing across the device's service history a challenge to bring together the data across those silos. What we've done is built on blockchain. I do not want to say that we are a distributed ledger blockchain company, rather that we have taken advantage of the enabling technology and brought it together with a leveraging of unique device identifiers, any kind of coding and or tracking technologies such as RFID, RCLS, R code systems and then the appropriate scanning in a facility, API integrations to ERPHR claims and other systems. We have as well taken advantage of geospatial services and analytics to deliver the timely actionable insights. I've represented here this concept of an operating life cycle and you can see as I've talked about the various stages that you go through with the medical device or equipment over the life cycle. Stepping back from that, we are pleased to say that we have consistently focused on data standards and the use of identifiers. GS1 has done an extraordinary job with this. Anyone who is working in the medical device or pharma area, consumables or otherwise will recognize that the work that GS1 has done there, they do have a healthcare working group and certainly on their innovation side are looking at distributed ledger technology as well as AI, IoT and other technologies. We work as part of the startup program with ESRI, it's ArcGIS, geospatial data analytics and dashboarding is quite robust and can accommodate extension of our strategic roadmap and product suite over time. We have been working with Microsoft as part of their program as well. As regards the distributed ledger side of things, we started on Ethereum and certainly can maintain that protocol reference, but we migrated to hyper ledger fabric some months ago. We have been in continuous discussions around sawtooth as well, likewise giving consideration to R3's quarter. Our philosophy is to try to maintain flexibility not to have vendor lock-in generally as a matter of principle and certainly with regards to blockchain, we know and understand that there are some growing pains, maturity issues, so we're looking to both capitalize on the value of community and focus such as Linux offers with hyper ledger, but also be protocol agnostic so that we can both future-proof the solution and the services we deliver, but also provide that flexibility. I'll come back to that in some of the later slides, but let me catch your breath here and ask if there are any questions. I just have one question for you. Is it for reusable devices or is it for all devices independent of the lifecycle as well as the reusable ones as well? Well, so manifestly you want to have a service history, if you will, that would contemplate reusable. Now reusable, remanufactured, reprocessed, there are a lot of conversations and regulatory find points around that, but single use as well as what you'll call reusable would be included absolutely. Some of these devices, let me take an infusion pump by way of an example, so commonplace, typically in the hundreds and then two or three hundred bed hospital, complex in the sense that it's everything from the gurney, if you will, that it's on to the power supply, the software, the syringe sets, the electronics and mechanics of the inner workings. Infusion pumps have unfortunately got a lot of cranky issues as well as recalls and the urgency of being able to both have efficiency and get those to the beds and ensure that their saving good order is central to the efficiency and the ability to get people in and out of beds, if you will. Unfortunately, with the advance of technology, it becomes a real problem over time. Those service histories typically will extend as far as 10 years. Health systems that are challenged will not just for infusion pumps but other devices look to extend life. Warranty issues certainly will play into that, but end-of-life management is also a picture that sometimes is difficult to sort through, particularly without the transparency we're able to provide. Thank you. Hi Bob, this is Kamlesh. Hi there. Yeah, hi. Is this solution live in production and what is the volume and how many channels in the fabric? Sure. Some of our history, two and a half years or so ago, we're in discussions with Scotland's Inward Development Marum Scottish Development International about our solution and not only awarded a grant to set up a development center in Edinburgh, Scotland, which we did do as part of the discussions. We were introduced to the National Health Service in Scotland, specifically National Services Scotland, and decided that it made sense for my co-founder and I to move over to Scotland so that we might work more closely with some of the boards over there. We've also received and we're party to another grant that brought together National Services Scotland and a leading cybersecurity researcher who is well known in the distributed ledger blockchain community to work with us on a pilot that extended about 18 months with National Services Scotland, a three-way partnership, if you will, to build out a pilot of the technology and address what issues they saw. What's interesting for us is these were common issues and common challenges. We're able to demonstrate enough there that we continue our discussions about how we might assist Scotland in deploying a solution that goes across its 14 regional boards that embraces and is able to support what they call digital health and social care, so that acute to outpatient to home-based settings. We've been able to bring that back to the United States as well as I have interest in Canada with leading health systems about how we might bring together that ecosystem I'm talking about and a minimum viable consortium involving manufacturers and third-party service providers as well as other health systems. Okay, thank you. Hi Susan, this is Nisarg. I'm actually a connected health entrepreneur and very very interesting topic so thank you for this. I had a few questions specifically related to you know telehealth and maybe connected devices so firstly you know just to clarify are these deployments of yours within a clinical or provider environment or do they extend to maybe devices which might be involved in any telehealth you know use case for example and secondly what did you encounter any specific or could you elaborate a little bit more on your specific challenges with respect to connected devices given that you know obviously there's API's data and many other components of that which could involve various service providers. On the first point decidedly our strategy and sensible strategies whether it's what we saw in Scotland or by health systems here is to focus on home care you know not only preventive but self-management of care as well as involving home care specialists what are known as social care specialists in Scotland and if you will the array of medical devices and equipment as well as applications call them apps you know sensors whatever it is in a home setting so let's talk about that geriatric patient that may have had several falls you know they may be related to neurological issues or otherwise there may be a frailty app or something that does a detection of changes in gate that is deployed as well as a bariatric bed or a home dialysis machine those kinds of things if you consider that array as well as environmental sensors we know and understand that from a test bed setting you want to be able to know and be able to track what's there who's provided service whether it's directly at the location or through remote patches or upgrades whatever it would be so you put your finger on a very challenging area but an important one whether it's in the home setting or an acute care setting one of the areas that we're working on is the development of for lack of a better term a model profile so back to your your second question about connected devices whether it's attributes related to the network connectivity firmware AI ML algorithms that might sit on a device from a clinical standpoint whether or not it's interoperable what it's interoperable with what it's integrated to this model profile is increasingly pertinent to the extent that vulnerabilities exploitable vulnerabilities and or cyber threats are identified and being able to canvas your inventory if you well match it against those threats go through some kind of risk analysis and assessment from a clinical and technical standpoint and then make decisions as to prioritization now that might be the information security team working with the clinical engineering team at a hospital oftentimes it's going to involve third parties I had the same experience when I was in financial services we had hundreds and hundreds of applications some cloud based some on-premise lots of integrations and we needed to have a working list not only of apps but also the associated vendors and be able to communicate with them to identify what if any vulnerability they may have and whether or not they had a plan of action and to what extent we could share information as to regards to whether or not they were going to proceed with that patch and to what you know when it would occur and then track that that was a manual process email always needing to update the information and then really no means by which to confirm that action had been taken we had a lot of effort on our part you can compound that I mentioned the Mayo Clinic example in fact studies have shown anywhere from 15 to 20 percent of the assets in a in a health facility call that device or equipment is now connected and those numbers are rising and they're rising significantly there are now smart beds that are through sensors able to develop information about vital signs and other attributes that are being rolled into words as we speak okay thank you and for any cloud implementations for example you mentioned mentioned the AI or machine learning algorithms for example you know obviously it's more efficient to do some of this processing and analysis on the cloud did you just to kind of drill a little further have any any encounter did you encounter that use case or did you happen to have any challenges for us I've certainly focused heavily on that that long poll if you will of where things are going for those who are close to distributed systems and AI and ML you'll know that there's a number of mechanisms by which folks are trying to preserve privacy as well as perform the kind of work that would be done by AI and ML at the edge that could be a combination of differential privacy it could be secure multi-party calculations it could as well be federated learning distributed learning which Google's been working on any and all of those I think we all are challenged and I'll not represent that we're far along with this but we will all be challenged with being able to provide transparency and interpretability about what is going on at the edge I'm not convinced that distributed ledger blockchain plays a role but I'm interested to explore whether or not it might play a role in providing transparency around you know not only what's been done but the evolution for those who've paid attention to the FDA about a month and a half ago actually it's a little bit longer issued it's proposed framework for AI and ML it's looking for the concept of good machine learning practices and consistent with its approach as a regulator demonstration that there is a process and there is transparency and part of the manufacturer in terms of the design the design of the initial algorithms the evidence behind it as well as the ability to track the adaptable algorithm over its life cycle if you will so it's a very interesting question it will be I think a core challenge and problem our view has been let's be pragmatic let's establish around perhaps something as mundane as an infusion pump but really central to care physical asset that's fairly well understood has a fair amount of moving parts as well as that connectivity and over time step into the models that are emerging as we've discussed here whether it's home care or AI ML in the cloud thank you thank you that's wonderful thank you any other questions I do have another slide I wanted to really have be a subject of discussion so this is something I came up with a few months ago it was really my effort to articulate for health systems manufacturers and others who are interested in blockchain may not fully understand it may conflate blockchain with a lot of other things but to talk about the the potential evolution from minimum viable consortium um to a robust production implementation and what I've done here is create two axes one of which is moving from a pilot environment to a path to production and then concepts like changing your operating model and only a transformation of business models very deliberately using ellipses here rather than concentric circles because just to take a use case for example with us you might go from implant tracking initially to broader medical device management as I've alluded to it ultimately in acute care setting at our home and then over time in terms of actually delivering value be able to track and trace to manage demonstrably safety and outcomes to improve those to actually getting into preventive care and even predictive analytics um I don't believe that as we establish minimum viable consortium build out networks and actually have those networks uh organically evolve we'll be able to knock these things off systematically I believe it will be iterative and what I've tried to do is represent here sort of as you step out across time the areas that you're likely to want to focus on and be able to focus on but as you add parties and complexity you move from initial decisions for example about governance models to a better idea about commercial terms similarly as you step out over time and start to introduce those other parties a better understanding from an operating standpoint what you need to be able to support technically as well as internal to the various organizations that are participating how their workflows are going to change what it means for their legacy systems and integrations and then step out over time to really start to address issues around performance network operations who's doing those operations what do the economics look like back to commercial terms and ultimately to scale um I found this helpful for discussions and I'm interested in any reactions to it too much to absorb it's it's early in the morning I think there you go there you go well my contribution back to the general community I know we all spend a lot of time deep around the technical issues there are challenges in having those conversations whether it's with clinical people or senior technology executives or business executives if you will on the clinical side I've found this helpful and if you're interested in talking about it more or interested in using it let me know again as long as there's a source in an attribution it's my contribution back to the community any other questions this is when I was just curious this is quite you know quite a great roadmap or evolution path also actually quite ambitious as well what do you anticipate to be a you know I guess a timeline to maybe getting to the second phase of this because I'm assuming I guess you've already been in operation for three and a half years and what were you able to tackle in the last three and a half years and what what do you think is is going to happen the next couple good question I think we've been able to demonstrate that there's more than a foothold that you are delivering value pulling together a consortium is something that's in process right now from there we have some working assumptions about consensus mechanisms and certainly that concept the pluggable consensus makes sense we're keeping an eye idea an eye on interoperability certainly but if I look and step out I'm thinking we've still got another two to three years before we either are adding meaningful numbers to parties to a consortium and exploring those areas that I've suggested here in this part of the arc to going broadly to and ambitiously to a wide range of devices now you'll prioritize those based on a variety of things and your network or above it'll be more health systems more manufacturers more product lines more geographic expanse and some combination thereof so this is not surprisingly a long journey we'll be probably pulled in one direction or the other but I would suggest that even some of the established consortia I'm thinking of provider credentialing or provider directory and physician credentialing there are a couple years in now and they're at that point where they're looking to add players and refine their commercial terms and extend the performance characteristics and also open to changes in the thinking from a technology standpoint around the value around different consensus mechanisms security and so forth so it is I don't think we're unique in that sense and that's one of the reasons I wanted to share this you could take those three main dots on the the diagonal axis and take other use cases say clinical trials and step them out and I don't think you come up with a lot a lot different in terms of exploring these relationships and hammering these things out from a maturity standpoint timescales may differ and that's why I offer it up okay thank you I have another question regarding I was looking at the dot preventive care it is you position it over there which is very much in the future right yes and why is that so I mean I would also put it there but I would like you to explain why why is preventive care not you know more urgent or that's a great question I'm going to suggest that while distributed ledger is an element of that that to be ambitious around being able to predict and clearly are implying the use of demonstrated real-world evidence around the devices that have been introduced that will fit into what we all now understand is an array of inputs and information that's pertinent to preventive care so whether social determinants of health things we may understand that are more in the precision medicine area that allow you to go and stratify populations and tailor that care to an individual that's the long pole at some level I'm suggesting that there's an intersection between the evolution of distributed ledger technology and what it will enable in terms of traceability and verifiability around physical and digital assets and other major initiatives in health care and medicine does that yes thank you that that is along the same I'm no no I'm thinking along the same ways and I would have as I said I would have posted it added it there too I just wanted to hear what would you have to say I agree with I agree with what you said thank you appreciate that I'm a little guarded because sometimes I'll hear folks suggest that blockchain is the thing that's that's doing the predictive analytics at the edge or something like that and I think I alluded that to book to that before it is an enabling technology that will support other technologies as well as insights we have that are converging around getting to that aspirational preventive care and from the standpoint of our use case being able to deliver in a home base setting is part of that any other questions I have another question I hope you didn't talk about it before I had like some technical difficulties so for 10 minutes I had to turn this off I don't know if you discussed you mentioned that you started with Ethereum and then are now looking to sawtooth or fabric or you have solutions for both I don't know if you already talked about that but can you describe your experience with trying two different hyperledger platforms why are you doing both at the same time and what have you learned from it good question I wasn't clear on what I said so we started on a theory and we migrated to hyperledger fabric we're an API enabled platform we've had conversations and gotten under the covers around sawtooth we haven't moved to sawtooth I think what's important and it comes back to what we were just talking about the sawtooth as originally intended by intel really particularly contemplated a world of iomt an internet of medical things at least from a healthcare standpoint but an internet of things and volumes of sensors and devices in the tens of millions if not billions it's sgx chip that was you know to sit underneath it as well to provide for that secure secure enclave so from my standpoint it's important for us to know and understand and stay up to date with where sawtooth is going we're pleased that it's within the hyperledger linux rubric because that allows us to to have that visibility around what's going on but if you think about a 5g world with as many as 10 to 15 percent of sensors and devices out there that are on networks arguably healthcare related you have to start to think about whether or not you'd have the scale and and at least from this standpoint we felt important to be aware of what's going on with sawtooth does that answer your question yes um well partially so you you you did um you did not develop a solution for sawtooth you just um my phone here okay um you your solution is now you're using fabric right that's correct and we are um under understanding underneath the covers where sawtooth is going they're they're uh they're a little behind in some areas but we continue to monitor that and we monitor it with an eye to um what i'll call machine to machine world and understand that to the extent we're working with medical devices uh and and apps that we are going to be in that machine to machine world in a meaningful time horizon okay thank you so i'm going to one last question uh maybe a little bit more strategic so you mentioned that uh you moved to squatland uh because i guess from what i captured is that you were getting a lot more support for your um for your idea and also your business model there could you kind of just speak a little bit about the receptive how receptive um providers or um you know you know customers are in the us versus other markets that you might be exploring right well i'm back here on the east coast because of the receptivity um everyone's gone through a journey um around uh distributed ledger and blockchain those who've been around it in health care for some time know that the some of the initial focus and hype was around patient data uh and uh medical records on on blockchains um we've always been a little bit skeptical about the timelines around that so we took that time to really prove things out and we find there is a growing interest from health systems and what we're doing as well as uh device manufacturers so the education that others have been doing has been very important some of the visibility the FDA has provided as well as the various associations and surely the this hyper ledger SIG group has really laid the groundwork for us that said i think we can all appreciate them when you go into meetings with executives there's still uneven understanding and still um some uh some need to address uh cryptocurrency and and broader uh open uh decentralization what that means what permissioned and permissionless mean that's education that will continue to go on i experienced it in finance and i think it's a welcome opportunity to always revisit our assumptions great thank you okay rich can i hand it back to you absolutely uh and and again thank you so much uh for uh for presenting today uh phenomenal presentation i think it really gives us uh a lot of interesting thoughts around how uh how your team particularly at spiritus have uh taken advantage of uh some of the technologies out there uh that exist particularly including blockchain and i think what i what i what i really enjoy hearing about is the notion that a blockchain solution and in your case dlt isn't uh isn't the end all be all i mean it's an aspect of the work that you guys are doing but it isn't necessarily uh the panacea that a lot of people have been talking about as it relates to blockchain technologies and in fact it's it's really uh it's in support of the work that's being done uh through spiritus and so the you know the great takeaway there for me anyway uh is that uh you know you look really at a a handful of different technologies to support uh the work moving forward um just real quickly i have a kind of a high level question that i wanted to ask uh before before we sort of and and that really is uh stepping back a bit and and looking at medical devices uh in toto do do you see a trend or pattern uh towards a standardization of uh of software apis or software backends uh that uh ultimately make it easier for the management uh and lifecycle uh management of devices or is that something that's still quite a far quite quite far down the road um a good question um we all like standards and the problem is that everyone wants their own yeah my co-founder bob clint has been active in two i triple e related initiatives around what i'll call iomt a pre pre standards group and now a standards group um i'm involved as well we're just breaking into subgroups there has been participation from medical device manufacturers they're active as well over on the uh the gs one side trying to arrive at some standards as well that tie back to the unique device identifiers and so on but when you get into the nuts and bolts of the technology i'm not sure that anyone's going to go to that level around uh the apis at this point um the flip side of that is if you look at some of the um job postings among the major manufacturers around data science ai and machine learning uh they're moving aggressively and at pace because there's such promise and opportunity um so it's a bit of a chase and it will be for some time um i don't like to to um to over forecast how quickly we might get to some things but i think the the major manufacturers know and understand that prioritizing um strong software development lifecycle practices uh with an eye to uh security uh as well as performance is going to be really important as they extend their business models and the delivery of these kind of interventions okay it looks like um i'm the only one that's not muted right now