 Oh, OK, good, good. I think it's O-L-S-E-N. OK. Check on my LinkedIn. But yeah, we can certainly tee that up. Just shoot me an email after this, and that'll trigger me to come up and make introductions. Perfect. OK. All right. Well, so we're just at the top of the hour, and I see folks are just getting on the call. So good morning to everybody. Good morning. Morning. Good morning to Wendy. I see Alan on the call. Good morning. I see someone on a 206 number. Who might that be? Hi, it's Karen. Yeah, Karen Stone from Seattle. Oh, hi, Karen. How are you? Hi, I'm well. Thanks, Rich. Glad you can make the call. Appreciate it. Logan's on the call. I see a couple of a Zeke. Do I see a Zeke? Who is Zeke? I don't know a Zeke. Hi. I'm just a curious person, I guess. So just getting into blockchain. Oh, excellent. Welcome. Karen is from the Boston area. Dave, I had sent you an invite recently, I guess, on LinkedIn to connect. But yeah, I'm just trying to get an appreciation on what hyperledger brings. And especially in the Boston area, there's a lot of health care stuff. So that's why I'm here. Excellent. OK. Well, before we go any further, everyone should see the screen. We should have the agenda ahead of us. And as folks get on the call, good morning to everyone. So as always, when we kick off our general meetings, I want to start with our antitrust policy. It's on the screen here. And please review it. In short, it means please be a good person. And that's what this is all about. And I would suggest that you read details if you need to do so. With that said, good morning to everyone. And great to have everyone on the call, particularly our guest speaker, David Holding. David will be speaking momentarily about blockchain and health care as he sees it from the point of view from Microsoft Corporation, which is where he currently works. And David and I were just chatting a moment ago. David's prior employer was Intel. So we have some really good insight on how blockchain is being used sort of at a global level, but particularly from David's perspective as it relates to security and health care as well, which is why David is here. So for today, what we're going to do is David's going to have the full hour available to him. He's going to present. And then we'll just sort of take his lead and feel free. David, you don't mind people just interjecting questions as needed? No, that'd be fantastic. Thanks very much for the opportunity and let's have a discussion. Excellent. OK. With that said, so I do want to ask, is anyone new on the call? Do they want to sort of speak up now and introduce themselves? Thanks. Yeah, I'm new. Karen Stone, I'm a physician in the Seattle area, new relatively to blockchain, but certainly seeing the potential in health care. Great. Thanks, Karen. And we just heard from Zachy. Go ahead. Yeah, I'm new to the calls as well. This is Brian Bento. I work at Instamed. Yeah. Yeah. And I'll just interject real quickly. Brian and I talked a little bit earlier. Brian, you want to talk about your company briefly? Sure. So Instamed, we are a health care payments company, Clearinghouse, but also very focused on patient payments as well. And we've developed a prototype using hyperledger fabric that we just open sourced this week. And we're interested in just sharing and talking about it and also getting more involved in this group. Excellent. And Brian and I talked a little bit earlier this week. And I just sent Brian an email this morning. And we're going to try to get together and maybe have Brian and his company do a presentation sometime in the near future. So thank you, Brian. Anyone else on the call that's new and wants to introduce themselves? Yeah, this is Carl Fellingham. I've actually been lurking on the distribution list for a little while. I'm in the health care supply chain space. I don't have any active blockchain work going on right now, but very interested to monitor how it develops. And I'm based in Dallas area. Out of Dallas? Oh, very cool. Background in health care or development? The technology. I'm an old software guy. Excellent. Oh, I'm one of you. Perfect. Good to hear. Great to have you on the call, Carl. And yeah, we could absolutely take advantage of your skill set. Thank you. Anyone else on the call? Yep, Kenneth Jensen from Centera Health Systems in Virginia Beach, Virginia. I'm a senior systems engineer. And I've been in blockchain, mainly crypto for probably about four years now. Excellent. Oh, good. Glad to have you, Ken. And how are you related to health care? I work for a hospital system, one of the largest ones in Virginia. Oh, outstanding. Very cool. Good to hear. Great to have you on the call. Anyone else on the call want to jump in? OK. All right. Well, good. Well, great to have everyone on the call. It looks like we'll just have people sort of continue to go and get added on as we go. And so with that said, I'm going to hand over to David. And David, you want to take over the screen and go to town? Sure. We'll do. Let me just share real quick. Let me know when you can see that OK. Yep. Good. All right. Super. Well, thanks again for the opportunity. And we'll keep this informal. So as I go through these slides, if you have questions, jump in and we'll chat. So being in health care over 24 years, covering provider, payer, pharmaceutical, life sciences. And my role at Microsoft is actually what we call health care partner enablement, which includes blockchain startups, but all different kinds of startups serving and partners in general serving health care, whether it's AI, whether it's internet of medical things, et cetera, a very cloud focused. I also currently serve as the chair of the HIMS blockchain and health care task force. So some of what I share today will be colored by perspectives from that group. And I currently have the role of advisor for the British Blockchain Association. So there's some input there too. So how we're looking at blockchain and health care is today, it's kind of a layered views. Layer zero is today. We have lots of data and silos. Digitization of health care data has been a great thing. But to some extent, its benefits have been stunted because it's holed up in these silos in this little of any sharing. So there's a lot of untapped potential to use that data to reduce costs, improve outcomes, improve engagement, improve experiences, et cetera. So layer one, blockchain steps in can enable secure targeted sharing of some of the health care data across B2B networks who are really looking at blockchain as a B2B middleware. Layer two, smart contracts can obviously add automation of transactions on the blockchain. Then we have cryptocurrencies and tokens where it makes sense. I'll be the first to say that the three facets of blockchain, one being cryptocurrencies, tokens, the other one being ICO fundraising and the third one being enterprise use of blockchain. We're mostly focused on enterprise use of blockchain, but there is some intersection with cryptocurrencies and tokens. For example, you may have a consortium in healthcare running blockchain and wanting to incent sharing and collaboration and cryptocurrencies and tokens can be a wonderful tool for that. Also, you know, incenting sort of patient engagement, patient compliance, you know, obviously cryptocurrencies and tokens can be a really useful tool. And lastly, I'll say, sometimes you end up in the situation where you have a consortium and there's an asymmetry in size. Some of the organizations are much bigger than others and you end up with this fairness thing where the bigger ones are like, why should we share all our data when that little one's only sharing a tiny amount of data? There's not an equal contribution, right? So cryptocurrencies and tokens can be used to get around that problem because they can reward proportionals to the contribution. Layer four, artificial intelligence machine learning there's some phenomenal opportunities around blockchain serving as a foundation to advance AI and machine learning. And the gist of that is AI and machine learning are very data hungry. And if you're drawing data just from one silo from one organization, you can only get so good with AI and machine learning the insights, the error rates. But if you can draw data from across a consortium, you can take that up to the next level, right? And not just draw training data but collaborate on shared models, collaborate on test results, validations of test results, basically any task you can do better as a group of healthcare organizations or consortium. Blockchain is an opportunity and certainly there's some phenomenal opportunities around AI and machine learning with blockchain. So how we're looking at blockchain in healthcare is again, as a B2B middleware. So here we have four organizations, think of them as healthcare organizations could be payers, providers, pharmaceuticals, life sciences or even business associates or data processors as we call them in privacy speak. But each of those organizations obviously has an internal firewall. That's the red dash line, the green squares of the enterprise systems. So think on the provider side, we've got EHRs, EMRs, et cetera. Payer systems to maintain membership eligibility, claims adjudication, all that good stuff. Pharmaceuticals are gonna have clinical trial systems. There's a whole myriad of enterprise systems but think of blockchain as something that connects in at the back end of those enterprise systems. So if those have a three tier architecture, it's sort of the server mid tier that's reaching out to blockchain as needed and transacting on this blockchain. Think of the blockchain as a sort of super highway for data exchange and collaboration and this sort of selective use of that blockchain based on the use case. And so the enterprise systems are connecting into the blockchain nodes. The blockchain nodes are like the on ramps off ramps to this data super highway. And so if you look at healthcare as having a huge amount of data in these silos, just a small portion of that data may be appropriate for sharing on a blockchain. And really that's the gist of how we see it being used. And that's an observation, not a religious statement is blockchains being used for very targeted use cases and the data on the blockchain is minimal but sufficient to support the target use case. We're not seeing a lot of organizations. In fact, I'm struggling to think of a single one which is putting more data than they need to on blockchain. It's minimal but sufficient. From a security standpoint, this data is living outside of the internal firewall. So it has a very different risk profile, a higher risk profile. So you wanna be frugal, minimal that's efficient about what data you're putting on. And obviously, so, well, let me make this point. So healthcare is very concerned with ensuring only authorized access to healthcare data per HEPA and other regulations and just good cybersecurity sort of hygiene. And so the vast, vast majority of healthcare is opting for private consortium type blockchain use. And so, and one of the reasons for that is they know exactly who's connecting to that blockchain and they're well known, they're highly trusted. They have a need to know they're authorized, right? And so permissioning, obviously, encryption's used to mitigate risk to confidentiality, et cetera, but we'll chat more about that in a moment. Okay, so if we take a cloud perspective, this is the little sort of blockchain, B2B middleware diagram I shared, but looking more deeply at one of the organizations and the blockchain nodes, the blockchain node could live, you know, it's really gonna have a heterogeneous deployment architecture, right? It's not gonna all be deployed in the cloud or all be deployed on-prem or all be deployed in a specific cloud. They're gonna run all over the place. It's a foundational layer, right? So just like the internet runs all over the place on lots of different types of hardware, so will blockchain nodes, right? Of course, they all have to speak the same sort of protocol to be able to coordinate the consensus algorithm and the protocol needs to be consistent, but some nodes might run on-prem in the DMZ, some might run in the cloud, they may run in different clouds, but if we zoom into a blockchain node running in the cloud, you know, blockchain is decentralized, right? So there's no single point of failure, which is wonderful for protecting the availability of a blockchain network, but blockchain really does nothing to protect the availability of a particular node. So think of healthcare as they're going from pilot to production and they grow to depend on this blockchain for mission-critical stuff. They're gonna make sure that blockchain nodes available because if their blockchain node is not available, they lose their on-ramp onto that superhighway, right? And so that essentially cuts off their access. So to protect the availability of their particular node, you know, they can have redundant nodes across availability zones, load balancing, automated failover, the usual tools backup and restore and business continuity disaster recovery, et cetera. We're really looking at blockchain nodes as not a standalone thing, but part of a sort of ecosystem of infrastructure, if you will. And these are some of the elements, but of course we've got analytics, AI machine learning. We've got, you know, if you need high-speed search and, you know, read, you could have a high-performance sort of index database. If you have a need to batch transactions into blocks, you can have a message queue on the front-end typically and to mitigate risk from DDoS and those kinds of attacks. You could have a cloud mitigation provider, redundant network connectivity, et cetera. So think of blockchain as a cog and a big machine in the sense of we have this consortium, we have these healthcare organizations, they each have their enterprise systems. And blockchain is this new sort of cog in the middle of this big machine. It's not a, it doesn't replace the other cogs. It's a new little cog in the middle that facilitates this sort of collaboration and coherent sort of sharing of data between these enterprise systems, but doesn't replace them. So it's part of an ecosystem in that sense, but then also blockchain nodes are part of a sort of infrastructure ecosystems in the sense of this cloud diagram here where it exists alongside of other cloud infrastructure. So one of the big, you know, if we look at it from a data standpoint, you know, healthcare, we've got three organizations in healthcare here. We've got, you know, private data in each organization and the data that is private, it's probably gonna remain private. Again, blockchain is not a panacea that solves the issues of not wanting to share. Healthcare has to want to share before blockchain will be useful. But I think one of the areas, you know, from a data perspective, how to look at blockchain is a lot of these organizations have common data. Think of yourselves, you know, us as patients having visited lots of different providers. They all know you. They have your demographic information. There's a lot of redundant information stored across those organizations about you. And so think of the maintenance. It's not the storage. Storage is cheap, right? It's the maintenance of that data. Each of those organizations has to maintain that data over time. The reality is, you know, that's n times the cost of maintenance collectively. And the other issue is sometimes that data doesn't get maintained and you end up with inconsistencies. And those inconsistencies cause friction in the system. For example, if you have provider directory information that's common across these organizations and it gets out of sync, if claims flow, you know, those claims will bounce because there's inconsistencies in data. So inconsistencies are not only inconvenient, but they actually cause extra costs, support, you know, and so forth. So blockchain, the idea is for that common data, if you could put that on blockchain, you can maintain it at one times the cost, not n times the cost. As is an updated ripples across the shared ledger in near real time, it's available to all the organizations. There is never any inconsistency because they're all drawing from the same master of truth for that common data. And I think I may have heard a question coming. Go ahead. Yeah, David, this is Rich. So this is a great point to talk a little bit about single source of truth, right? So I think what you're really promoting is the notion that rather than having duplicative data that could quickly fall out of sync, out of parity, a blockchain solution could really sort of help resolve this notion of common data sort of spread all over the place. So you can sort of honor the single source of truth concept, which is one location for common data that can be shared so that if that common data does get updated or in any way manipulated, it stays accurate across all access points. And a great example that everybody's familiar with is if you've ever changed your address or phone number, should I say when? Because most of us have at some point. You have to go to hundreds of different websites to update it, right? And you don't get to them all. And that data ends up being out of date and inconsistent. And first, it's a pain to have to go to so many places. We need to go to one and up to two places. Update it one time and have an eye. Is there another question? Sounds like somebody might need to mute. Yeah, I'll just interject and ask that anyone that's on the call, please be sure to mute your phone unless you have a question. OK, let's go forward. Good question. A good side note. Thanks, Rich. So is blockchain a missing cog in health IT? So we talked a little bit about this. We have extensive debate. There's a lot of concern that blockchains are started as replacing everything. We don't see that at all. We see it as synergistic and integrating with enterprise systems and, again, being used for that secure targeted sharing around specific use cases. I'll share the use cases that we're seeing getting early traction in health care. And the enterprise systems, whether they're EHRs or otherwise, will decide, OK, I've got this new piece of data or this new update. Is that relevant to blockchain? If so, reach out through the blockchain node. If not, it's going to remain internal. It's going to remain private. And the user interface for blockchain, well, it is the user interface for the enterprise systems. So actually, it's going to be hidden from a lot of end users. They won't even necessarily know there's a blockchain there. They'll just know that the address of the patient or whatever common data is magically kept up to date, which is awesome, right? There are some ethical considerations. Oh, question. Go ahead. Yeah. So how do you trust that? So this is supposed to be a trustless system. So how do you hide this and yet have transparency as the authenticity and provenance of that trust? Yeah, so I'll go back to a statement I made earlier. And again, this is not a statement of religion. This is a statement of observation is that the vast majority of blockchains we're seeing in health care is their private consortium. So the trust is established by virtue of the consortium and the organization's having a common mission and understanding what they're going to collaborate with, who are the other collaborators. They're very well known to each other. They're very highly trusted. And so that trust is there. And then the blockchain itself helps build that trust from the standpoint of immutability near real-time transparency, et cetera. So that trust has to be built. It's not something that magically appears. And it's built as the consortium comes together and understands that there's a business value to be had from collaboration. And getting to know the other partners and understanding that they're all going to be transparent and share and having a common charter, et cetera. That's basically how the trust is materializing from our standpoint. There's a completely different notion of blockchain and a public blockchain sense where completely decentralized. We see that being used in very few health care consortiums to date, mostly around if they have some notion of cryptocurrency. Sometimes they have that supported by a public blockchain. But the health care data, the health care centric use cases and data are being transacted more in private consortium blockchains. Again, not blockchain religion. We focus on what's real. And that's an observation, not a statement of religion. OK. So blockchain strengths, we see the strengths being recognized in health care as secured, targeted, used appropriate rather for secure, targeted sharing of data, where it makes business sense. So we'll talk about the business values that health care is looking to fulfill and use blockchain for. Data integrity, protecting data integrity. Blockchain does a fantastic job of that with the immutability and the chain hash codes, et cetera. Near real time transparency, some wonderful opportunities to mitigate fraud with that or have updates ripple near real time around the consortium to mitigate the need to or completely avoid the need to do duplicative maintenance. And remember that if you think about a consortium and they have common data, today they're all maintaining that data independently. There's people maintaining that data. If we're thinking about the cost of health care and how to cut out cost, how many providers have you visited in your life? Like 100 providers? So there's 100 times the maintenance cost. If you could do that in one place, that's one. So you could cut a lot of cost out of the health care system through this kind of collaboration via blockchain. Decentralization of single point of failures, obviously a strength, the resilience and availability of the network. But with the caveat that blockchain doesn't do anything extra rather to assure the availability of any one particular node. So you have to take care of that, right? We talked about that a little bit already. Anti-fraud is a strength. It's one that a lot of people don't recognize immediately. But most types of fraud in health care has many, right? We have prescription fraud, medical claims or medical identity fraud. We have financial fraud, occupational fraud. There's drug counterfeiting fraud. There's so many different kinds of fraud in health care. And some people estimate it could be as much as 10%. The cost of health care is fraud. And so most types of fraud, you can boil down to three attack vectors. We've got fraudulent deletion of records, fraudulent modification of records, which are both blocked by immutability of blockchain. And then fraudulent creation of new records, which is helped by the Neural Time Transparency. If you have a silo that only three people have access to, your opportunity to collude and get away with introducing new fraudulent transactions is actually quite good. But if you're posting a new transaction, which happens to be fraudulent on a blockchain where it's visible in the real time across a consortium, where it's a lot harder to collude, there's a lot more people. If it's properly decentralized, then you can really mitigate that type of fraud, from new fraudulent transactions being added. So fraud is almost not a use case in and of itself, it's a value of blockchain because it's evident in many different use cases. So how we're seeing the identification of use cases in health care and the business value propositions is, it's about the network of organizations, the consortium, it's not a database, not a single organization thing. If we see an organization looking at blockchain for just themselves for the internal use, generally that's not a good idea. It's more around collaboration across a consortium, that's one of the first things we look for in sort of vetting a blockchain use case, is there a consortium? But the business value that healthcare wants to realize is the front runner is reducing healthcare costs. Any blockchain initiative that has a strong value prop of reducing healthcare costs seems to be getting early traction. But longer term, improving patient outcomes is a recognized value, improving patient engagement, empowering patients with their data, their privacy, et cetera. Blockchain has some wonderful strengths there, improving the experience of patients, not having to update your data, lots of different places, not having inconsistent data and bad experiences with claims bouncing. These are indirect ways that blockchain could improve the patient experience, right? On the healthcare professional side, we've got use cases for blockchain like provider credentialing. If a doctor, let's say they have the MD credential, before they can practice at a hospital, that has to be verified, right? And then every two years after, and for every hospital they work at, so for every hospital organization they work at. So there's a huge amount of redundant effort in maintaining and validating those credentials on a repetitive basis for each organization. And the reality is if a doctor goes to a new hospital and needs to be credentialed, they can't practice until that's done. So it can be days or weeks, and that's a lot of waiting and inefficiency in the system. So improving the healthcare professional experience, one way that can be done is through provider credentialing, and that is using blockchain, and that is one of the leading use cases in healthcare that we're seeing. So building the consortium and getting the buy-in, the trust to where they're willing to connect to the blockchain and transact is the hard part, right? So existing healthcare B2B networks are low-hanging fruit or near-term opportunities. If you're looking for opportunities to apply blockchain and healthcare in the near-term, if there's an existing B2B network that's already transacting, albeit via an antiquated technology like faxing or centralized sort of hub and spoke architecture, emailing, those are opportunities for blockchain to drop in and add values. We talked about some of those values and then establish a beachhead, if you will, whereby once you've demonstrated business value with your first use case, your first killer app, if you will, with blockchain, it's relatively easy to grow that consortium network and then also add on additional use cases. The hard thing is to get the initial consortium, the initial business value demonstrated. So here's some of the key use cases, provider directory, some of you may know the Synaptic Healthcare Alliance, Optum United Healthcare, Quest, Aetna, Ascension, Multiplan, et cetera. They're doing provider directory use case. Drug supply chain, we see that as a leading use case. The partner we're working with called Adents in France, ADE and TS. It has a solution for that, it's blockchain-based. Medical device track and trace, this is medical device supply chain. I heard somebody introduce earlier that was interested in supply chain stuff, so tracking medical devices through the supply chain, but also through their use at healthcare providers or even multiple uses as they're resold. And the value prop there is if there's a recall, being able to go to the blockchain and look up very quickly and execute that recall within days instead of sometimes over a year, there's real patient safety benefits and operational efficiency cost reduction benefits. And then just tracking medical devices, things like maintenance of medical devices throughout their lifetime can really improve medical device quality and the quality of healthcare. Health information exchange, clinical trials. So, sorry, one more point, medical device track and trace. We have a partner called Spiritus, partners, which is spearheading medical device track and trace use case. You may wanna look at them. Health information exchange for clinical trials is another startup we work with, Grapevine World based in Europe that does this kind of thing. And it's all about health information exchange and IHE profiles. They're using hyperledger fabric running on Azure for the provenance information for the healthcare data that's being exchanged and tracking patient sort of consent and opt-in to participate in clinical trials. And then they use the action, this is one of the rare ones that also use a public blockchain specifically for crypto tokens, which they call grapes, which they reward patients for opting into clinical trials or clinical research. So, there's a direct value feedback loop there to incent patients to participate and then they can redeem those crypto tokens for various benefits. Provide your credentialing. There's a whole consortium or cohort piloting that right now. It's led by ProCredex. If you look at ProCredex.com, they're piloting that right now. And then the anti-fraud, obviously that is not really a use case in and of itself. I mean, there are blockchain use cases in sort of financial services and so forth that are purely directed at anti-fraud, but in healthcare, it's more baked in. Drug supply chain, for example, is all about mitigating drug counterfeiting and anti-fraud is obviously a key benefit of that. Reducing fraud. Go ahead, question. Hey, David, on that last slide there, yeah. So, how are you defining medical devices in this context? It could be any medical device. It could be an implant. It could be a wearable. It could be something in the environment of the clinical setting, the hospital room, for example. It could even be in the patient home, right? Increasingly remote monitoring. So, ranges from, say, IOTs or IOMTs, all the way up to larger devices in hospital situations. Think of an FDA regulated medical device. I mean, this is global and spurred us who we work with on this one is, they've already piloted in the NHS abroad, but in the US, we have FDA regulated medical devices, but they can be anything from a smartphone cardio for your smartphone, which does the EKG and detection of atrial fibrillation to diabetic insulin pump, pacemaker, right up to an MRI machine, right? Anything that has a medical function that's medically regulated by the FDA would qualify here. Yep, yep. Oh, good, thank you. And kind of on that note, there's also that sort of vast change or view of granularity in drug supply chain. It could be a container of drugs or medicines. It could be a single pill, right? Some drugs are so super expensive. They actually want to track individual pills. So there's a different granularities of tracking that can happen there too. And drug supply chain is kind of interesting as well from the standpoint that the blockchain application there also goes into the domain of internet of things in the sense that is this sort of sister use case called cold chain, where let's say you have a drug like a vaccine that's very sensitive to temperature. You don't just want to track it through the supply chain from a, you know, is this authentic, this drug or is it counterfeit in, you know, checking its provenance but also checking has it been within safe temperature parameters, right? Because if it's gone too hot or too cold, it could have rendered the drug useless or in a best case or dangerous in a worst case, right? And then you don't obviously don't want to take it. So some really interesting opportunities there too. Was there another question? Yeah. Hey, David, just gentle here. Just a quick question. So where does this use case fit in for the payer organizations? Is it in the health information exchange or is it another use case? Yeah, so the provider directory use case is very closely related to payers. This is a big payers participating in that one. The UnitedHealthcare, Humana, MultiPlan, Etna, they're all participating in that pilot. If you look up Synaptic Health Alliance, you'll see what they're doing there. But that one's very payer related but it's also got some providers in it. The drug supply chain is, you know, mostly pharmaceuticals is the manufacturers. You've got distributors like McKesson and Cardinal at the midpoint. We've got all the dispensaries or the pharmacies like the Walgreens, the CVS participating in supply chain and medical device track and trace. Think of the Medtronics of the world, the Strikers, et cetera. Anybody that makes medical devices and their distributors and some of them would involve vendors too because vendors often, you know, the way hospitals get like an MRI machine is they lease it through a vendor, right? So anybody involved in these devices through the supply chain right up to the healthcare providers at the end point. Health information exchange, the use case there. I mean, conceivably that could involve any organization that is a source or a sink for healthcare information just like you have the hub and spoke HIEs today. But this particular use case I talked about with Grapevine World is more on the pharmaceutical clinical trials side of things. But no reason that use case can't expand. We see HIEs, you know, traditional HIEs looking at blockchain but we haven't seen any immediate sort of piloting of blockchain by them. I think they're maybe looking at it where really as a disruptive technology we don't see blockchain disintermediating intermediaries. We see it changing their role. So where you might have a hub and spoke architecture with an intermediary that today is a sort of bottleneck of transactions adding cost and delay and single point of failure. Blockchain could step in there and be decentralized. So eliminate the single point of failure of the bottleneck, the extra cost delay. But there's still a role for that intermediary in terms of building consensus, building the consortium, providing support, being an enabler, being an assistant integrator, being a support desk if there's some issues. So really I think the opportunity for intermediaries is to adapt and this is super important, right? If you look at an existing sort of B2B network and it has an intermediary, you've really to make blockchain fly in that environment you've got to position it in the interest of the intermediary. If they see it as a threat they'll obviously veto it, right, or block it. So I think the opportunity is there for intermediaries to ride the blockchain wave, but if they don't I do think there is risk of them being disrupted in the long term. Yeah, so the most of the reason why, yeah, because when I say this to my customer that they think that we are going to add an additional middleware layer which is going to create an overhead for them rather than, you know, solving the current, you know, already exists, right, that B2B. So why you want to create an additional overhead and bring some complexity to it? Yeah, I think the way to explain the sort of, you almost want to go back to that diagram I showed with different organizations in the blockchain middleware versus a hub and spoke architecture. The irony is that with a traditional hub and spoke architecture, like think of a bank and transferring money, right? It could take days to do that transfer. Why? Because there's an intermediary that just sits on that money for a few days. So, you know, blockchain is going to essentially make that kind of transaction near real time. It'll be negligible the time versus the delay you have with hub and spoke architecture. So while they may initially think, well, blockchain is this additional layer it's going to add overhead, it's quite the opposite, right? It'll make things much more efficient. But you have to explain that. Was there another question? One, yeah, this is Brian speaking. So the exact, the project that we just recently open sourced is really targeting that question that was just asked. So why would somebody, why would a company like Instamed, you know, we're a clearing house, why would we want to participate in blockchain? Doesn't blockchain disintermediate, a company like Instamed? And so the way we're thinking about it is that there's already, as you said, there's already a network that connects clearing houses. It focused on, I call it clearing house 1.0, connecting the payers and providers electronically to submit claims and, you know, remittances and all process and transmit those, yeah. And authorization, all those great things. However, what was perhaps ignored and not focused on was the patient. So we have, you know, hundreds of thousands of providers, you know, thousands of payers, but we have hundreds of millions of patients in the United States alone. And because they're not on the network as it were, you know, I'm a patient, I have logins at many different providers, providers are sending paper statements to the patients. It's all those paper statements slowing down the payment process for providers and creating a lot of inefficiency. So clearing house 2.0, as I like to call it, where we think about it as, hey, not disrupting the clearing houses, but the fastest, most efficient way to get to a world where there's electronic connectivity throughout the network is to connect the hubs together. So I'm thinking a little bit one step ahead of where a lot of people are thinking. And it's, I was tasked with how could blockchain and, you know, instrument and, you know, be looked at as a sustaining innovation and not necessarily a disrupting innovation. How can it reduce costs and increase efficiency in the market? And, you know, it's very expensive to build infrastructure and connect entities together, let's leverage what's already been built and take it to the next level. Yeah, I think, this is just to add to that. I think there is one perspective of will it, you know, dissolve intermediaries, which is not the case, but then there is another, you know, perspective from healthcare standpoint. There does not exist intermediaries in number of use cases, which, you know, really blockchain can bring a few entities together to make those things happen also. Yeah, great. It just goes both ways. Yeah, you could have ad hoc sort of networks, even people faxing each other, emailing, et cetera. And, you know, there may not be any intermediary and you can not encounter that same resistance. So, yeah, great point. Okay, so real quickly, this is Rich. Just as a point of order, we have about 10 minutes. So just to give you some... Great, thank you, Rich. And Rich, I have sent you the PDF version of these slides, feel free to share. I'm gonna move over some of these case studies fairly quick, because we talked about Grapevine World with clinical trials. We talked about Spiritus with Medical Device, Track and Trace, but there's more information here. We talked about Adense with Drug Supply Chain. You guys can browse that as you're interested. So building the consortium, getting the buy-in the trust is by far the hard part. Startups that start with blockchain, develop a nice concept and don't have a consortium. They inevitably stall and many of them fail. So really need to start with the consortium, focus on the network, focus on the use case, and what's the data that you need to do on blockchain to support that use case, minimal, but sufficient for both performance and privacy security compliance reasons. So on the security side, we talked about how blockchain is strong in integrity, availability. It protects the network. The overall blockchain network is decentralized, no single point of failure. So resilient to attacks like DDoS or distributed denial of service, but you need to protect the availability of your nodes. We talked about how to do that. Confidentiality, you've got to do quite a bit to protect confidentiality on blockchain. The biggest lever is, what are you putting on blockchain from a data standpoint? Again, minimal, but sufficient is recommended. Most of healthcare is opting for private consortium where they know exactly who's connecting. They're well-known, they're highly trusted, they have a business need to know. But tools like encryption, obviously, even side chains can be used to protect confidentiality. There's also this notion of adequacy of security across the consortium. If we have a network of any kind in healthcare sharing data, we have this risk of a weak link where one organization can have weak security and data gets that organization and they have a breach and it impacts the whole network. So think of a healthcare provider working with business associates. Business associate breach is something we know from a cybersecurity standpoint. In blockchain, you have a similar concept where if you're connecting to the blockchain and there's a consortium and one of the members of the consortium has really lacked security, they have a breach, it's gonna impact them, of course, but it's gonna impact the whole blockchain consortium and the organization that was the source of that information. So there's a notion of adequacy and there's tools like risk assessments and audits which can be used to proactively measure the security of organizations connecting to a consortium, make sure it's adequate if it isn't proactively mediating. That's an important ingredient to building trust. So privacy, blockchain has some risks but also some wonderful strengths. So it's actually a double-edged sword when it comes to privacy. Generally, the guidance is to avoid any PII or PHI on blockchain where possible. That information can live in secure access controlled enterprise systems. That patients can have the ability to review and amend data, provide consent opt-in opt-out. We talked about some use cases where that's already being done. Being transparent, if you are using a blockchain, how is it being used for collection storage use, disclosure and disposal? How's data disposed of at the end of life? But the ability of patients to look at audit trails, patient access reporting, if you will, who looked at my data, when, why, et cetera. Blockchain gives an opportunity for that across a consortium. So compliance is gonna depend on what data you're putting on the blockchain, in particular, PHI, PII. Also the location of blockchain nodes. Think of short-term as well as long-term. You might start small within a state. You might go national at some point. You might go international at some point. All the data on the blockchain will be replicated to wherever you stand up a node. So you could end up with this data sovereignty, transporter data flow type of challenge. And that goes into adequacy on a national level. The whole genesis of things like safe harbor was because Europe doesn't view the US as strong enough as far as privacy and security. So be careful of blockchain nodes where you're putting them in the near-term and the long-term and make sure you have an eye on the regulations, the data protection laws and those various jurisdictions. Immutability and the right to be forgotten. This can be handled by keeping the PII, PHI, off of the blockchain. If a patient needs to be forgotten, request to delete their data, for example, as is compelled by data protection laws like GDPR, then if that data is off the blockchain, you can delete it and it essentially de-identifies any associated records on the blockchain. Performance throughput scalability. So blockchain, typically for private consortium where we're seeing most healthcare use, at the top end, it's going up to about a couple of thousand blocks per second. So you can batch transactions on blocks. So let's say you put 100 transactions on a block. You can multiply that block throughput to get a higher transaction throughput. But it's far shy of the millions of transactions a second. You might see in a traditional relational database. So keep a careful eye on throughput requirements for use case. The reality is some use cases just aren't well suited for blockchain today because they're too high throughput. Those bounds will be lifted over time, but today it's typically hundreds of blocks per second at the high end, it's thousands. So integration and interoperability. We talked about blockchain integrated with the enterprise systems. Obviously interoperability is a big part of that. You got to decide what data you put on the blockchain, what sort of format, what code sets, et cetera. And that's all about interoperability. And the good news is you can leverage existing interoperability standards to the maximum extent possible. But interoperability also applies to the sort of off-chain transactions. Like you might use a blockchain for a decentralized record location service, but once an organization discovers something on the blockchain that they actually want, there could be a pointer. They're gonna reach out direct, secure direct peer to another organization to get the actual data. Now that they've seen the metadata and there's interoperability there too. So that's kind of touching both sort of types of interactions. So we see a lot of piloting going on right now. There's some production use. Like in Taiwan, they're using blockchain for health information and a production use. But in the US, mostly we see piloting right now. We see very early signs of success. I don't know how many of you folks attended HIMS 19 in Orlando recently, but Synaptic Health Alliance did a really interesting report out. It was Mike Jacobs from Optum. Kyle Culver from Humana and Jason Amira from Quest. Reporting on their Synaptic Health Alliance provider directory pilot and long story short, thumbs up, all good. They're going to production this year. So as banner consortiums like that reach the end of pilots in a test to the business value and success. Look, there's gonna be things they learn that can be improved. But if the net of it is, this is delivering business value, which we expect because they're moving into production, you're gonna see them establish a beach head and grow their consortium, right? More organizations will join because they see trusted peers attesting to the value. And once they are successful with one use case, like provider directory, it's gonna be relatively easy for them to stack on other use cases. So over time, those consortiums like the Synaptic Health Alliance will grow and others will fail where they don't get a consortium or they don't pilot, they don't get the end of a pilot in those attestations. So what else have we got here? I think that's pretty straightforward. So right now we see a lot of blockchain islands, these different consortiums, but as like Synaptic Health Alliance reaches their case study and they will start to grow and the islands will get bigger and bigger. Some of them will get eliminated and over time we'll move on the spectrum from extreme fragmentation and archipelago blockchain islands, if you will, towards more of the public where the islands get bigger and bigger, the data gets richer and richer, you get more opportunity for smart contracts, DAOs, et cetera. But really it's an evolution. The ones that don't get the consortium or don't pilot will be naturally selected out. And the ones that do get there will be favored from an evolution standpoint and they will grow and evolve. Yeah, so David, what is the most recognized private consortium blockchain in today's world? Do you have any? In the US it's probably either the Synaptic Health Alliance around the provider directory use case or there's the ProCredex. If you look at procredex.com they're doing the provider credentialing use case. They have a very strong consortium there. The names of the actual organizations escape me for the ProCredex one, but you should find it on their website. Those two are both in pilot, they're both gonna wrap up their pilots this year and they're both looking really strong in terms of going to production and being early islands that will grow. Okay, thank you. Hi, this is Ken, did you say the name of the consortium that did the credentialing? Did you just mention? Yeah, pro, it's professional credentials exchange, but just look at procredex.com. And that's been out of hashed health. That's correct, it's collaborative with hashed health. So Anthony Begando is the CEO and then John Bassin team from hashed health are deeply involved. Now how about so I had some criticism for that approach which is really very much like trading physicians like crypto kiddies. And so I know Microsoft is involved in the decentralized identity foundation with Daniel Buckner. So this idea of self sovereignty comes into the play. And so where are you as far as like collaborating with Daniel at Microsoft with identity? Yeah, so I'm very aware of the work. I don't work directly on that initiative but I'm very aware of it. I don't see a whole lot of decentralized identity of self sovereign identity being used by healthcare today but it is something they're increasingly aware of and the hope is that they will integrate it at some point. I think it's a wonderful value prop in terms of patients taking ownership of their data. It's not a panacea just like any safeguard, right? I mean a patient, it's like today when you download a smartphone app, right? And it says, if you wanna use this app you have to grant all of these permissions, take it or leave it, right? And so with self sovereign identity you're empowering the patient but the patient's gonna be between a rock and a hard place they're gonna have to either provide that data or not get service, right? And once they provide that data it goes into the enterprise systems of the healthcare organizations and you end up in the same situation we are today. You could have the minimal but sufficient data going into those organizations which is a good thing maybe less data than is sent to them today. But at the back end of all those organizations you've got the same risk of cybersecurity hacking breaches like happened today and you've got the same risk of aggregators, data aggregators on the back end pulling all these tidbits of information from these different organizations. Patients have sent their data to and aggregating a big profile of you behind the scenes. So again it's a good thing and it needs to be built in and I'm not seeing a whole lot of traction with it in healthcare to date just to be candid with you but it's not a panacea. So it's one additional safeguard. Yeah but I think it's less so about patient identity more so about provider self sovereign identities. And so I think both the... Well any data subject, right? I mean any person it could be a provider like a clinician, it could be a patient it could be any data subject. All right, how much time do we have Rich? So we're about five minutes out. Yeah, if we can wrap up in just a few minutes because we are getting to the top of the hour. All right, cool. So there's some ethical considerations around blockchain. There's actually a blog on this if you guys wanna check it out. Six key ethical considerations. I did this as part of the collaboration with the Lifeboat Foundation. It's kind of an interesting foundation that deals with advanced technologies like blockchain but also AI and others. And yes we can do these new things but should we, right? There's some side effects and it's you know it's interesting to look at some of the material out there. This one looks at six of the sort of ethical considerations around blockchain. Things that can be really good but can have some barbs to them and things you wanna be aware of. And hopefully the intent of this is to maximize the good of blockchain and minimize the negative, right? So an interesting thing to dig into if that resonates with you. So at Microsoft we touched on some of what we're doing just to wrap it up. Obviously we provide platforms like Azure which run pretty much any blockchain but the three most enterprise ready ones we're seeing Hyperledger Fabric, R3-Corda, Ethereum and worldwide presence of Azure, 54 regions, 140 countries worldwide, very wide portfolio of certifications and attestations. So HIPAA, high trust, GDPR, they're all in their high set, 27,000, et cetera. So really good for blockchain obviously. Tools, so we have the Azure Blockchain Workbench, rapid development and deployment of blockchain apps on Azure. Currently supports Ethereum, future we're looking to add R3-Corda and Hyperledger Fabric. So not a requirement like you could essentially again run pretty much any blockchain on Azure but if you want the rapid development today it's Ethereum, future R3-Corda, Hyperledger Fabric. So we do a lot of partnership, our sort of MO is to partner and so if you're a solution provider in ISV, if you're a service provider, a system integrator or other type of service provider serving healthcare and you see an opportunity for collaboration reach out to me, would love to explore synergies and opportunities around that. Some links where you can go for next steps. So we have the Microsoft Azure Blockchain site, kind of the main sites to point one there and then the Workbench itself and you can see some of the architecture of that. My contact information, so blockchain's incredibly fast evolving and healthcare's application of blockchain. I do a lot of collaboration on LinkedIn and Twitter if you'd like to reach out and I think I'm connected to a lot of you already but if I'm not, feel free to reach out and obviously email me if you have any questions. I know this is recorded too, Rich. So for those that watch this sort of offline and have questions you need with the voice, feel free to reach out and we'll chat. Any last thoughts, questions? Great discussion. Thanks for all the questions and side nuts. Very interesting. Obviously you guys are deep in blockchain and there's some exciting projects going on. Excellent. Well, thank you so much, David. Very much appreciated. Thanks for giving your time today. And then as David mentioned earlier, he did give me the PDF, so I'll post that up on the Wiki so that folks will have access to that. And as well, this meeting has been recorded and so that'll go up on the Wiki for reference as well too. And in addition, David, since you've offered to sort of allow yourself to be sort of connected, one of the things that we may wanna do, and of course I'm putting Port David on the spot here, is we do have, we have Rocket Chat, our healthcare channel that's available too. And so we may wanna get David in somewhere in the near future to sort of follow up with some answers to questions that people pose there. And I'll talk with David separately on that point, just because this has been such a rich hour of good discussion. Yeah, sounds interesting. Never used that tool, but happy to explore it. Right, oh good, broaden horizons. It's open source, so there you go. It's open source equivalent of Slack is what it amounts to. Well, it is just a couple of moments before the top of the hour. Again, thank you, David, so much for your time. Very much appreciate that. Thanks for the opportunity. Thanks to everyone that's participated this hour in this week's general meeting. Our next general meeting will be coming up in exactly two weeks, which I wanna say, I don't have my thing in front of me, but it'll be two weeks from today, April, someone 18th or something like that. So it would be great to have everyone back again in two weeks, and in the meantime, please make reference to our wiki at wiki.hyperlige.org. And as I had mentioned as well, please keep in contact with the group here, either through the listserv or through Rocket Chat channel so we can all keep in touch. And then so in our next general meeting in two weeks, we'll get back to a regular schedule with updates for subgroups and so forth. With that said, thanks everyone. Have a fantastic weekend. And again, thank you, David. Thanks everyone. Thank you. Thank you. Thank you so much. Thank you.