 Let me start, you know, there's a lot of things we'll say we have a very interesting and exciting panel here, lots of subjects to discuss. But, you know, one thing that I will say, Joe was very gracious in thanking others. And I think it's my turn to thank Joe, because Joe, you know, I know Joe quite well and I've known him for many years. And when Joe sort of decides he wants to do something, it gets done. And so that's, we need to thank him collectively for his leadership in this area. And I know the goal is never ending. You know, we can always get better. But to have someone like you leading this effort really is a real privilege, Joe. Now, you know, let me say a few words to kick this session off. And we'll talk a lot about data and interoperability and the use of data and artificial intelligence. But, you know, some things in healthcare remain the same. People who work in healthcare. Our collective desire to improve people's lives is why we're here, why we're in this industry, why we're in either a provider or some kind of participant in the healthcare delivery system, or a technology company of some sort trying to also make a difference in healthcare. It's something that I think, you know, we're lucky that what we have in front of us is an enduring goal. A goal that will never go away, even if you talk about this, you know, 100 years from now. And not only a goal and opportunity, that will never go away. And why is that? Well, the two things that I'll state is first, technology will continue to progress. I think you'll all agree that whatever we do now, 100 years ago, we couldn't have dreamt off. And next 100 years, you know, who knows what it'll be like. But I can tell you, technology will be different and more progressed than what it is today. The other thing that will never go away is our collective desire to improve people's lives, to live longer, to avoid issues, to make the healthcare experience completely safe. And when it goes beyond, when we are perfect in the hospital, if we are at any one time, we'll go beyond the hospital, to people's homes, to other places. So that desire will never go away. So you put these two together. The progression of technology, which is never ending. A quest to improve people's lives in the safest possible way that will also never go away. You have an enduring opportunity. There aren't many industries who can say that. Say that and then achieve a purpose. And so, this speech I can tell you every year. And remind everyone every year, because it'll never change. And I think I said some version of this last year, I'm sure. Maybe in different words, but that's how it is, and I'll probably repeat it. Because it is something that we should all be thankful for to be part of this whole movement. But what has changed, at least for me, in the last year, maybe it's more me than everyone else in that I've got more educated about this. But to me, the progression of the explosion of data in front of us, in a ubiquitous fashion, is something that is also an event, if you like, that'll happen and only increase over time. Now, that's used in many, many different ways, this explosion of data. Not just in healthcare, in our daily lives and in many ways. And other sort of institutions also continue to use them. But added to that is another thing that's happening. And that's another two things I'd say. One is our continuous learning of not only how to use the data, but use it intelligently. Use it in a way that a lot of data sometimes is very difficult to grapple with. But we're developing algorithms and methodologies through which that data can be used intelligently, largely using statistics and other new techniques, new computational techniques. But one, that'll happen. And we get better and better at using the data, at personalizing the data. And again, I'm sure there's a progression here that we cannot imagine what the answers will be 10, 20 years from now or longer. The third thing that's happening, which goes back to my original point about technology, is that the computational capabilities are also increasing and we're getting smarter. The use of processes to process data in an intelligent way five years ago was a starting point or 10 years ago was a starting point. Companies and technologists are figuring out how to customize processors to use data both locally as well as from the cloud in a much more intelligent way. And I'm saying all this because these things are really happening in front of us. And certainly to me, it's opened my eyes as to the opportunities that we all have to completely transform healthcare in a completely different way. The use of this computational power will lead us to different directions. It leads us to more data available locally, what they call edge computing, on site. It'll also allow us, through other technologies, to connect with the cloud and other sources and data centers to be able to access even more data. And both of these will increase exponentially or at least very rapidly over time. So the opportunities here are endless and it's something that we're all very, I'm sure the audience here and certainly the panelists are extremely excited about. It's something that I'm excited about, that our company is excited about. But at all times, let's make sure that we don't lose our central focus, why we're here. We're here to improve people's lives and to do it in as safe a manner as possible. And that's why we're here. Everything else follows, but that's why we're here. And this opportunity with data interoperability is a discussion we can have today but I wanted to give that context. So with that, let me ask our panelists to come on over. And as they're walking over, I'll kind of mention them one by one. It's Ed Kanfal, who's the, maybe this thing is going to change in a while. There you go. Ed Kanfal is the president and CEO of the Center for Medical Interoperability. Welcome, Ed. And then we have, let's see, who's next here. We have Kathy Kay, whose video we just saw. The patient who we'll enjoy talking to. Then we have Jan Kimpen, who's the chief medical officer at Philips. We have Dr. Don Rucker, who's the national coordinator for health information technology at HHS. And then finally, my good friend, Anders Wall, who's the president and chief executive officer for clear care solutions at GE Healthcare. So please, please take a seat and I'll join you here. And what I'll do here is start off with a series of questions and maybe you can kind of dive in. I've got some notes and stuff here, but we all agreed that we're free will to the degree that we can because it's a topic with all kinds of possibilities. I wanted to start with Kathy. From a patient perspective, the video demonstrated how you felt about it and the experience that you had. But as you reflect on it, specifically when you go home, when these alerts don't exist and you carry on your day-to-day living, how do you think about how these alerts in your own mind can progress in the next, you know, not two, three years, but 20 years? I hate to put you in the spot, but you can say what you want. I'm not sure. How do you think about it at home, for example? I'm sorry? How do you think about it when you're at home? And there's no alerts. About being home? Yeah. It was great. I honestly feel that I probably had it not been for the AA system. I probably would have been sent home sooner than I was because my temperature was not elevated enough from my experience of having been on RN, was not elevated enough to have kept me in the hospital. I could have gone home with pneumonia and who knows where that would have progressed. Pneumonia can be pretty dangerous. So that's what we're reflecting on. The fact that because of that condition you were in the hospital, in fact, you got treated. I had never been in the hospital other than to have my children back in the 60s and early 70s. However, as an RN, I was the caregiver for patients in the hospital. So when I was admitted to Kaiser, I was going to be the perfect patient. I wasn't going to complain. I wasn't going to use a call light any more than I had to because having been a caregiver, I understand how busy nurses can be. And it wasn't until this rapid response team came and quickly moved me to telemetry to monitor my heart rate and lung scan to check for possible pulmonary embolus. And that's when they, with the X-ray they found out. Pneumonia, everything just progressed. I can see having sat here yesterday and listening to the ideas of patient implementing ideas for patient safety between that and the technology of this AAM, I can see where the goal of zero preventable deaths can be achieved. I really do. I really see that as a great possibility. I think that's absolutely a worthy goal and one that we can get there. These are like Joe pointed out in the opening. It's a matter of people doing things that we know what to do. And we do it in other industries and so on. It's a matter of doing it in healthcare. It's not that simple because you've got more variables, but in the end it is an achievable goal. But let me turn now to Ed a little bit and talk about the liquidity of data on the same notion because I do think that, you know, it's tough enough actually to get to the zero goal of the hospital. It requires a lot of work and coordination and discipline and technology to be able to do this. But eventually, you know, the data liquidity is a critical factor and eventually this is going to go to the home. And any thoughts as a provider, and I know you've had some personal experience as well, but as a provider, what are your thoughts on data liquidity? Well, I think the average citizen that is in that hospital bed with that wonderful gown on assumes that all of the clinical modalities that are working to keep the patient alive has complete interoperability, which produces the term data liquidity if you've not heard of that term. It is the ability for data to go anywhere and everywhere. But the issue with healthcare is trust. Is there a platform that is designed that brings all of the wonderful clinical modalities and allows those modalities to interplay so that analytics and deep learning and machine learning can be applied, but in a trusted way, not only from the patient's point of view, but from the industry's point of view, from a litigation point of view and a liability point of view. So I think in many ways 2019 is going to be the year of trust. The CEOs on this panel, the CEOs on my board at the center have the ability to define what that means, what interoperability means, what data liquidity means, and more importantly, what trust means. You can get on a 747 for 17 hours and fly across the ocean. You trust the pilot, you trust the airplane, you trust the crew. So I think we've got to bring trust to the person. And what's nice about the person, the person's going to carry that trust with them, whether they're at home in their car, at work, or in the hospital. Thank you. You know, one of the things that enables that trust, which we all got to remind ourselves is why we're here. We're all here for a common purpose, and as long as we believe that, the trust will happen. I mean, it's easier said than done because you've got other things that get in the way sometimes, but as long as we keep focusing on that, that we're all here for a common purpose, that trust, I'm sure, eventually will occur. I agree. But let me now turn to Don a little bit. You know, you're in the government, okay? So you're in charge of regulation, okay? Amongst other things. And in many ways, a regulator has to trust but also verify and set policy. I have really two questions for you. One is your views on how do you make this sort of sense of togetherness that we can all have, but at the same time, you can have rules. Because even unintentionally, things can break down and what rules are there for are that people follow a certain discipline and a certain consistency and are held accountable for that. How do you, in your experience, how do you implement that in a way that that doesn't become only a stick as opposed to a carrot in some ways? So I'd love your thoughts on that. Yeah. So, you know, it's a great question. I think there's a fascinating interplay of technology and one piece of law that is coming together and I think in a good way here for patient safety. The law, let me start with that, is a 21st Century Cures Act passed almost unanimously December of 2016. You know, a lot of the underlying work by the Obama administration, I assure you that Trump administration is extremely interested in interoperability. I was over at the White House on Thursday with senior staff working on all of this and what we're trying to do is get the data that you talked about, Omar, get that out to patients on their smart phone. There is great technology. We all have smart phones. We all know. We want to get that, you know, restful Jason fire. Those are nerd terms. You can look them up. We want to get that modern technology stack to work on healthcare in the electronic medical record. So that's the center point is getting that modern technology stack out there. There's some rulemaking going on on prevention of information blocking so that clinicians have to share data and some of the APIs, application programming, interfaces and trust networks to do this. But I think it's an interesting combination and to make it not burdensome, what we're trying to do is use industry standards on computing to get this out to patients. We're also trying to get it out to researchers on a population level. So we're doing some things that we think will have a very light regulatory. I mean, it's never light. Let's not kid ourselves. But a manageable regulatory footprint and a lot of empowerment, that's the goal and we welcome people's comments on that and the rule will be out soon for formal comment as well. But one question that I do have, coming from an industry where we treat a lot of patients in an acute state, in a world like that, which I think will accelerate innovation in many ways because you've got more ideas working together, you'll have an end solution that is derived from different substitutions which are created by different entities or individuals for that matter. In a world like that, who reports an MDR? MDR is an issue that happens that causes a patient safety problem that gets reported, that industry is required to report. So who reports it? Well, obviously there's deep specifics in the FDA language on those things. I think in modern computing environment, we're asked that question a lot. It usually comes up as a security question as opposed to a security question as opposed to a litigation responsibility question. A lot of this is becoming increasingly auditable, which of course is also good from a patient safety point of view because we have a lot more data to understand, for example, how much it happened to Ms. Kay here computationally. So I think it's actually interesting going to be a lot clearer in the future, but I may just be an optimist. Yeah, it'll work itself out, I'm sure. Yeah. But it is one that is quite a change to the way in which regulations are structured. And I see Anders itching too. Yeah, I just want to make a couple of comments and for sure we will be battling with this for a long time going forward. I reflect on this based on the comment yesterday in the opening when we talked about physicians, nurses, healthcare givers who will be potentially be pilots in the future and think back to the aviation business where basically 99% is automated by now. So this is going to be a question about the black box when bad things happens or where are we with that? That's really the question because today the industry will be really very, very curious to know and careful obviously because it's all about the patient at the end of the day. Nobody wants to do anything wrong here. So anything you would like to say guide us a little bit on the industrial side. How can we do this better? Because I think we're thinking about bringing the right data and we're even thinking to the next level where we want to give you analytics and give the potential predictions but we won't make your decisions. So there is a step away from that part but there could be a lot of faults before we get there. Yeah, so the promise of analytics has been out there a long time as a grad student at Stanford and AI in the 80s. So the first heyday of AI and we know how that sort of turned out, I think right now it is still a challenge to do explanation on these algorithms and so I think we're going to have to have the things we rely on have to have multiple parallel approaches till we solve the explanation problem and that has not been solved in artificial intelligence or in machine learning. So until that happens in a robust way I think we're going to have to have very layered approaches. That's an unsatisfying answer but I think that's what it is. Let me bring Yan into this conversation. Yan, you know, Philips has a history, is focused on healthcare but also has a history with consumers. So compared to other sort of more, there's a starting point of pure medical technology company. You know, medical technology companies typically work with hospitals, providers, that's the stakeholder. And consumers are patients and as data becomes available to patients, like we just heard in this world, the stakeholders are different. Like to a physician, we provide New England Journal of Medicine paper with evidence and they read it and say this is a good thing and we're going to do it or certain processes. You know, a patient is going to read all that stuff yet they'll have the data. But you've got a history in consumer management and in your medical practitioner yourself so I'd love to get your unfiltered thoughts as to how does the world change as medical data becomes ubiquitous with patients who are not structured in the same way in which a physician or a hospital system is. Yes Omar, I think you are completely right that we are talking a lot about a hospital. Yeah. The hospital environment and that can be a dangerous place. Where mistakes can happen and everybody is talking about bringing the data to the patient at home, bringing the patient at home and leaving the patient at home and treating and monitoring the patient at home. And indeed we have learned from our deep consumer intimacy over the years how you can do that. And in our opinion, you need to go through three steps and the first step is really to engage with the patient to get by in. And I had a wonderful conversation with Kathy and her daughter the day before yesterday and there you see it. You need to convince the patient if you want to treat her at home to buy into your system and sometimes you have to bring in bystanders to help with that and sometimes you have to bring in family practitioners to do that. And we have learned that the hard way when we rolled out the home monitoring solution in one of our big IDNs here in the US that the take-up by patients was not big, not high until we asked the family practitioner to be part of the game and then it took off. So that's the first step. The second step is to make the experience very, very, very good. Give hardware, software and solutions that are attractive for the patient to use, easy to use. The patient experience should be seamless. Sleep solutions are a wonderful example of that where you create a closed loop that is enabled by artificial intelligence that gives patients who have to wear masks because they have sleep apnea or other sleep problems. They get immediately feedback in the morning back in the morning how they slept in the night. So that's the second one. Create an experience for the patient that is attractive to keep on using in a trustful and consistent way the tooling you deliver to them. And the third very important part is be transparent about the results, the outcomes both for the individual patient but also for the community at large so that we can slowly build the trust. I think these three steps will be necessary to go into more home treatment and home monitoring without the patient disengaging from this new tooling. Yeah, that's great. That's very appropriate thoughts, especially the closed loop one because that automates it to a degree and eventually over time personalizes it. So you can make it really very customized for an individual and it learns over time. I think that might have to happen in concurrence. Yeah, absolutely. Let me come back to you, Ed. You're in the center of medical, you're running the center for medical interoperability and I'm sure you've kind of at least in your mind wrestled with this notion of who takes accountability because in all these examples if you really want to optimize the system with the ubiquitousness of data you'll have different people coming up with solutions. In a closed loop system maybe that you're sensing from one company's device, you're using a cloud based algorithm from some other company and you're delivering treatment through another company's device. It can happen. You have three different companies or institutions involved in this and today that doesn't happen. First because the interoperability is not that clear. Second, I don't think data is moving that quickly yet but if you fast forward that's what we'll get to. So how are you thinking? Let's start with the hospital alone because at least you've got some sort of control mechanisms there but how are you thinking about that? If something goes wrong, who does what? One guy says it's his fault, the other guy says it's his fault, everyone's sympathetic but no one does anything. Then what happens? So almost within a month the Center for Medical Interoperability was created when Joe launched the first data pledge and we got the opportunity to study every other industry on how they went from analog to digital and how they made data, the currency of innovation and how the ultimate trust with the consumer was achieved. So I think in many ways healthcare is going through that same transition. We're going from analog to digital but because we were never designed to be a system, a national system, we have to untangle the spaghetti. Personally the Center was formed with the thought that the CEOs that represent the health systems which are similar to the CEOs of airlines have to step up and look at this as a system level problem. They have to do system level design where all aspects are considered before they operationalize the platform to think that we're going to not or be able to not come together as a platform I think is a fallacy and will stay as a low performing industry. So it's a bit of political leadership, it's a bit of technical leadership but it is leadership and the one thing that just amazed me when I studied the other industries is in the end it came down to between five and eight individuals that created most of the other industries where the consumer feels they're wrapped with technology and trust. So I think it's a design issue. What I'm excited about is we have the leaders that can sit in the room to do it. Sure. Anders, I had thought for you about technology. As technology progresses, there is another dimension which may be further ahead than what's appropriate right now but I'd love your thoughts on that. There's another dimension to this. I just give the example where there's data in the cloud to algorithms and go back and forth. The other progression that's happening is through the march of technology actually the computational capability and the data capability at the end point which they call this edge computing actually will increase and maybe what then happens is that this closed loop example that I gave resides within the same thing. So it's not interoperable it's all in one device that's put into somebody and it's all kind of closed there. And maybe there's another level of interoperability and another loop that might happen. But how are you thinking about the intelligence of the device on the patient and how's that going to change everything? Well, that's a great crystal ball question in a way but we certainly... You're right, crystal ball. We're working on a lot of these things at the moment. So let me just take one step back before you answer the question. And I'll relate to some of the other conversation here. Clearly, we think all the data is going to be there. It's going to be way too much data for anybody to interpret. So there has to be some analytics predictability around it. At the same time, there's one big missing point because we just look at pieces of the puzzle. So the whole precision health understanding needs to be adopted by the industry even though we operate in silos or pieces as we go. So that is one piece and that has to be personalized. At least the belief and what we see today where we have strategies in that direction but it has to follow with legislation, it has to follow with how we operate together, things like that. At the same time, to your question, there's going to be a huge win if we could improve things basically at the bedside or with the patient directly. And I think as we kind of dream of this big journey about precision health, we have to attack that in the meantime. So in our thinking, and I just take a very simple example, we all know that alarms is great in one way but if you look at the data, I think between 2010, 2015, FDA logged something like 500 deaths because people didn't react, understand malpractice alarms. That's something happening right at the patient, right there, the data was understood but not... So we can do something right there. Automated. Automated on the spot. That can happen. And we just have to be smarter about presenting it in the right way. I think the industry has a very simple way assuming that the operator knows everything, can deal with 100 different data points and make a decision. And we know that the operator variability, decision maker variance is really a big issue. So we can do a lot from the industrial point to do that. Yeah, I think that's a fair point. Did you want to comment? Yeah. I think you asked the question who is going to be responsible because we all bring parts of it to the hospital and also to the home. I think honestly that if you want to save lives, we can't afford it anymore to do it in silos. Nobody can do it alone so we will have to work together. Yeah. And we see it in our company and I'm convinced that you see it in yours and also Anders see it in GE. Our customers, our hospital C-suite, they don't want single products anymore, less or less. They want an end-to-end solution and somebody that's connecting all these building blocks for them. So whether we like it or not and we better like it because that's going to save lives in the end, we will have to work with building blocks from other companies being the integrator and each one of us will have these long-term strategic partnerships with the customers and it is our obligation to build in and tie in also the good stuff that other people are bringing to the market in order to make it an end-to-end solution. And I could talk on some of these partnerships that we have where we can prove that 40% of the building blocks we bring into the end-to-end solution for example in the imaging department comes from other vendors, from third vendors. And if we are not prepared to do that we will keep in the box-selling mode and we will keep losing patience on the go. I don't think if anyone is in this industry for any length of time it's clear that that's not a train you want to stop, you want to get on and use. I think you'll get general agreement there. I do think though your point about everyone being on board with a common purpose and trust and figure out together how the rules are I think we have to work together on this one. I just want to say one thing because the movement have done a fantastic job already but if I look at 89 companies signed off there are thousands out there and if you want to be successful with anything here we need to make that move much, much faster. That's the foundation for all we're talking about here. So if maybe a notch from legislation can help it in the right direction but I think we as an industry have an obligation here to drive that much faster to the adoption. I think we talk a little bit about the global view here. We have thousands of companies out there that need to find a standard otherwise it's not going to work. I think the other subject and I'll just a couple more questions and then we'll look at the questions from the audience here. The other subject at least that we've thought about a lot in this world of not only interoperability but also of data ubiquity is cybersecurity. There's people out there who can do things and that's happened in other spaces and we have to assume that it'll happen in healthcare. So, you know, I'll start with Anders and then actually ask Don a little bit. But how are you thinking about that? Oh, foundational. It's a very, very tough challenge as we've seen over the last few years. The one attack after the other and obviously our systems, they can't be a question on equipment. Just can't be a single question about how secure is the data, how accurate is the measurements, how accurate is the data in a single second. So we've taken this very, very serious and in fact in our company and I'm sure you all have the same, we have something like 4 million systems out there globally. And some of them are up to 20 years old. How do you protect that against data security today? So we have a monumental job just even to cover the existing install base of customers and take care of that. So that's the first line of action and obviously everything going forward, we have a huge team trying to protect against any malfunction basically. So this is the number one priority for the company before anything else we do. So that ties right back to patient safety. And Don, from a regulatory and a policy perspective, there are other groups in the government who are huge experts in this area dealing with all kinds of issues. So how are you thinking about this from a healthcare regulatory perspective, IT perspective? Love your thoughts. Yeah, I think there's it's obviously a vast daunting challenge everybody knows. I think we break it apart into a little bit of two areas. One is under the HIPAA privacy law. So there's a broad law that covers that. And those entities, there are a number of things with technology and with policy, right? Because most of the security breaches are really behavioral. They're not really brilliant exercises and hacking their behavioral things around passwords. I think there's one set of policies that are out there. And for that, certainly from our point of view, the thing that's most important is that we not put in any policies that prevent the best technology security from being used. We don't want healthcare. We don't want to anchor people to older technologies. We want to make sure the newest best security policies are used in our space and be very conscious of that. The second area that's very interesting, under cures, patients are going to have access to their own data electronically. Today, you can get your data on a portal, but realistically, it's still on somebody else's computer and somebody else's system. There's some ways to download it. In the future, when you get your data on your app, on your smart phone, HIPAA has stopped. That is your data. And I think we're going to have to have some national understanding of what shared. Just look at all the congressional discussions about Facebook and Google. All of that is ultimately data that we collectively have decided to put out there for whatever good or bad reasons. We're going to have a similar discussion I think around patient-controlled healthcare data and apps. We're from a regulatory point of view making sure those things have the state of the art security. I think it's still a work in progress for patients there. Those are the ways we look at it. It is, as everybody knows, very nuanced. And how do you bridge those gaps between patient empowerment and security when you have these highly distributed streams of data? Yeah, I think I'm looking around the questions here which has triggered another thought of that along those lines. The question here says, and I'll comment on it a little bit as well, how can we democratize patient data without compromising on patient privacy? Which sort of go against each other a little bit. But let me just throw out an example of a potential scenario and then let everyone comment on it. I'll take Kathy's example where she said that she was in fact lucky that she was in the hospital for an unrelated reason and then she had this issue where there were those things in place that took care of her. While if this happened at home it would be very difficult. Now, in today's world things that are highly controversial regarding individual privacy people can look at text messages and behaviors and where you are and what you're doing and actually predict a potential condition and save somebody's life. Someone is clinically depressed and maybe you diagnose that through the nature of their messages using AI and machine learning well before they actually go to see a doctor. In the holistic world of safety it's a good thing. But if I put a patient privacy or an individual privacy lens on that I can hear all kinds of discussions about you encroaching into my life and all this stuff and so how do we all collectively think about that? Well I think one area that we have to think about and I think this form is a great is to think about what consent means because ultimately do I choose to let my smart phone knowledge of whether I've moved or not moved or how fast I've moved or where I've moved we have accelerometers on ourselves 24-7 now almost not at night so I think collectively we have to think about what consent means we have not figured that out we haven't figured it out computationally and we haven't figured it out as a society and I think that's really the part of it and from a policy point of view we have to use very very primitive, very course consent mechanisms today that form you sign when you go to the ER let's say I agree to share everything right and of course you're sick you're not going to read this if you could read it it goes on for two pages so I don't know what the answer is but we're going to have to sort out consent Kathy I'd love your views on this because as a patient if someone, if you're at home and someone could have predicted what you're going to have without having to go to the hospital but to do that they'd have looked at where you are, what you eat what you do, what behaviours you have and who you're talking to all that stuff but to find out that you have a problem and if you get treated your life will be saved so as a patient how do you deal with that kind of dilemma of the trade off between privacy and actually upfront knowledge of your conditions so your life can be saved it's a tough question again you're just your free thoughts it's like being back in the hospital I really have to apologize because there seems to be a reverberation of the voice and I'm not sure what you had asked me okay so let me repeat that the conversation that we just had was the was the conflict in many ways between an individual's privacy and someone monitoring through your behaviour through electronic tools like your smartphone what you're up to and through that concluding that you actually have a condition for which you need to go to a hospital and without that monitoring you'd never know but it is an encroachment in your privacy so most people don't like their privacy encroached but in this situation your life could be saved so how do you think about that as a patient, as an individual I'm not sure to be honest none of us are don't worry about it if I would be your doctor if I would be your doctor and I would tell you listen Katie I can monitor you at home if you want then you have to give me access to your data maybe your Facebook data maybe where you live maybe on what you do all the day would you be comfortable with that I'm not sure to be honest with you I am not a technical technologically wise recently got rid of my flip phone but and don't know how to use the iPhone I've heard people talk about how the computer can be hacked and personal information can be taken from it that's a difficult question for me because I don't understand how it can be hacked I'm not sure that I have anything in my computer that I wouldn't want anybody to have as far as medical records they're available anybody in the hospital they really want to look at them you know what I mean it just I certainly know what you mean I think the answer to that is going to be big variance it depends it's going to be a lot of different things people have every view of no completely open share everything and then we have legislation depending on what country are in so it's not clear but I think what we can do and sitting here at this moment we should have much more conversation about this so people understand what is at risk what you can gain and what the risk is and I don't think that's clear to a lot of people if somebody is really interested in getting your information they're going to find a way to get it it's the job to be done at this point in healthcare because we've watched Facebook and Instagram go to the other extreme and invade your privacy but why isn't there a personal longitudinal health record trust platform that allows your personal trust to engage with your health system I mean that's a wonderful idea for an app because I think the it's up to this industry whether we gain trust or lose trust at the personal level and if you gain trust think who has a personal longitudinal health record in this room that's divorced from the portal that they go to with their health system provider that's a market opportunity and the industry that does that correctly is going to win and that's why the threat from the non-healthcare digital powerhouse players you know is so daunting to our industry so you know we're running out of time here let me just ask you each to say a few closing words a response to one of these questions shall summarize which is essentially how do you create affordability in data liquidity but I'll expand the question by saying how do you monetize because in the end there has to be some kind of financial valuation of all of these and your own thoughts as you're dealing with this as to how we should approach that and then add in anything else that you want as an institution you know it's a great question and of course in an industry we can't only think about the patient although that comes first and we want to make a difference in people's lives and save them but I don't think it's very different from what we have today if we put not data as a focus not equipment as a focus but the outcome as a focus if we can tie that again and come back to could we operate and get much more focus on outcome and have all the data in the outcome it is partly the precision health part but we can do much more in that direction so it's data plus the action gives us the outcome and that will be kind of the way I hope we can go yep that's great yeah we think the real problem healthcare is affordability I think often interoperability is a proxy for affordability and we think APIs can absolutely lead to new business models new ways of taking care of patients we've seen this in our lifetimes in industry after industry many of us took Uber or Lyft to get here you look at banking, you look at brokerage you look at media you look at printing, you look at music APIs have changed all of those businesses healthcare is absolutely right for that and from our point of view we are consciously working that the things the rule making, the policies we do actually allow new business entrance and new business models I think that will happen actually I want to be very short we started with the consumer and I think when we are revolving this field let's stay very very very close to the patient and try to understand what the unmet needs are there and the challenges are there in order to move this forward great thank you Kathy, any final thoughts? I don't have anything more to add well it's great to have you here thank you, thank you for your participation and your thoughts and your engagement I just have to say I'm so grateful to leave thank you the programs, the things that are done just thanks for your leadership I think it is going to be a year of leadership to Joe, your leadership because you who leads is the leader great well we are out of time right now thank you very much, we could talk for another hour on a whole variety of subjects in this area but there has been a very engaging discussions, we enjoyed it, hope it was useful thank you, thank you all very much