Beyond General Surgery: The Next Frontiers in Medical Robotics | LSI USA ‘23

Transcription

Omar M. Khateeb  0:08  

All right. Hi everyone. How's everyone doing today? Very, I'm gonna ask him. How's everybody doing today? One One more time. How's everybody doing today? There you go. That's getting better. Are you guys ready to talk about some robotics or what? There we go. Fantastic. Well, thank you all for joining. My name is Omar M. Khateeb. I'm the founder, CEO of Khateeb & Co. All agreed, 1-3 sentences at max. We're not reading any CV so let me start off with my good friend and colleague, Christopher Prentiss.

Christopher Prentice  0:55  

I'm Christopher Prentice. I'm CEO of Harmonic Bionics where an upper extremity robotic system for rehab and assessment of the shoulder.

Bruce Lichorowic  1:04  

Good afternoon. I'm Bruce Lichorowic. I'm the CEO of Galen Robotics. We're an affiliate of Johns Hopkins University. So a robot came out of Hopkins and we are focused on ENT, spine, neuro and cardiac.

Addie Harris  1:19  

Hi, I'm Addie Harris. I'm the CEO of have venture which is an accelerator but also an umbrella company to about 15 companies in the robotics and digital space. And prior to that I was at j&j and brought, did all the r&d and then commercialize the Veloster robotic systems a long time in the robotic space.

Stuart Simpson  1:42  

Hi, everyone. I'm Stuart Simpson. I'm the CEO of Think Surgical, which is orthopedic robotic and digital surgery company. Prior to that, I lead strikers joint replacement orthopedic business globally, and took them into the robotic space in 2013, with the acquisition of Mako surgical Corporation.

Greg Fischer  2:06  

I'm Greg Fisher, I've been in the image guided surgical space for about 20 years since I did my PhD on enabling technologies in MRI guided interventions back at Johns Hopkins, I'm the founder and CEO of a medical robotics and our focus is putting robots inside MRI scanner. So we can use real time imaging to guarantee that you actually perform the procedures the way you want it to. And I've been in academia. So we've had about 15 years about $15 million has been a huge support that's really poured into the development efforts that we've been working on.

Omar M. Khateeb  2:31  

I love it. See, that panel did a better job with one intro than like most people this conference, but that's okay. So before we talk about the future of surgery, we're kind of talking to get some context around where we are today and how to get better. So Chris, I want to kick it off to you. When we think about the continuum of care. A lot of companies, at least in the robotics world start off focusing around one area one killer app, he talked about the importance of focusing on the full continuum of care and how companies should be thinking about that.

Christopher Prentice  2:56  

Sure, yeah. So I'll reflect on my experience. So prior to Harmonic was with Missouri robotics was a spine robot. Prior to that it was with Intuitive Surgical DaVinci surgical system. So when you look at the continuum of care, the the genesis of a lot of the robotic interventions that have happened, of course, intuitive being the biggest one, it's been a tactical response, it was something that was needed in the OR itself, coming up with solutions for arduous tasks, in the case of a lot of surgical approaches, the arduous task was visualization, you're looking at a 2d element, when you should be looking at a 3d. So that's one thing that DaVinci delivered, and then also maneuverability, you know, prior, you know, you had laparoscopy, but you had to learn a whole new way of movement in order to get things done, then your natural movement. So that's what it brought. So it was a really good approach to fixing those two key problems in the room, and it's opened up a full field. But as you're talking about the continuum of care, that's okay, you are already doing a case, why were you doing the case, it didn't matter, you were doing the case, you know, so the so you start getting into more of the orthopedic systems, like Mako, and Mazhar, and you're actually able to do a pre plan. So now you're upstream from the actual intervention. So from a continuum of care, you're starting to figure out what you should be doing and why are you doing it? So that's one way to impact there. So you'll see that and then art from a harmonic standpoint, we're looking at after the intervention as well you do, let's say you do, whatever company you are, you have a perfect implant in the shoulder, you have a perfect system, the surgeon does it perfectly. But there is a whole host of things that happen afterward that affect the quality and to go back to that so don't don't waste that intervention without controlling that aspect after so, you know, when I when I look at I look at it from a process standpoint, you have your inputs, you have your process, you have your outputs, and you need to enter into all of those to make sure you have high quality across the continuum.

Omar M. Khateeb  4:58  

Fantastic And as you know, Chris actually did a fantastic job talking through a baby crying. That was my son, so apologies. He is investment banker, he's been writing some checks later. I want to, you know, go to you from him, you know, you have you have a fantastic experience across a variety of different robotic companies. You know, a lot of investors always have the statement of like, what's your killer app, right? They want to know about a killer app, because they see billions of dollars of an opportunity there. The problem is that it's no longer 2002. And hospitals see that as a really expensive one trick pony. So how do you think about robotics innovating in the future in terms of going on beyond just like one clinical application?

Addie Harris  5:37  

Yeah, absolutely. I mean, great question. And, you know, really big kudos to Stuart, when he was at Mako, you know, at intuitive as well, as they figured out how to get robots into hospitals and make them really be known for yes, they do improve medicine. And the real proof there is that patients want robots to do their surgeries, because they feel like there's a better outcome. But we've evolved over 20 plus years, and hospitals are looking at these investments. And they say, Hey, we can't buy a new robot for each killer app. The same way, you know, you're not going to buy a new phone, you're not going to buy a new computer just for that one app, and has that on it. And we have to start looking at robots. I think in the same sort of way. It also doesn't make sense for the really big companies, it doesn't matter if their company is you know, as big as Johnson and Johnson are, I think Intuitive has done a great job with it, which where they're taking on many, many different indications are looking at clinically, where is their where's their clinical need, where a procedure is either difficult to access a space is difficult to access or certain procedure is really difficult for a surgeon to do so by adding that that addition of the robot that additional surgical intelligence, that addition of the automation, were able were able to augment and essentially like improve surgeons abilities, so that they can deliver that care. And that's what hospitals want. That's what patients want. And I you know, I think the the big players as well as the small players are seeing like, that's the way we can get more product to market, because that cost of the r&d, that cost of the MPI to get into the market is so high for the single single killer app, robotic solutions.

Omar M. Khateeb  7:14  

You know, and on that, on that same token, so Stuart, you and I, we we actually got together while I was at ws I came by our booth. And you know, we talked a lot about technology, adoption technologies, options are, you know, very dear to my heart. So what are some lessons that we can take from general surgery in terms of why the adoption isn't what it is? You know, I think Adam Sachs yesterday showed a slide where only 3% of all procedures done worldwide are done robotically. So knowing that, what can we think about when it comes to adoption, beyond just general surgery into other medical robotic areas?

Stuart Simpson  7:49  

Well, I'm gonna answer the question from an orthopedic perspective, because that's the perspective that I know and understand. You know, we're now 15 years since May could, excuse me, performed its first surgery or was used to perform the first surgery. And the killer app for Mako was a total knee, which was introduced in 2016. That was a procedure that's performed in high numbers, where patient outcomes had a big opportunity to be improved. So that was the killer app that really took Mako and turned it into the thing that it is today. But 15 years after the introduction of maker to the market, our estimates are that the markets about 12% penetrated. In other words, 88% of the market still hasn't adopted orthopedic robotic joint replacement. And why is that? I think there are two very important reasons for the challenge to get out of the innovator and early adopter community and into the mainstream orthopedic community. Number one is the size of these robots. These robots are a 900 pound pieces of equipment. They're controlled by a camera system, which is on the other side of the operating room table. So 50 60% of the workspace for a surgeon is given over to the robotic system and the surgeon and other assistants have to squeeze into a small space, it's very disruptive to the workflow. We're addressing that thing because our product, which we're going to launch in the second quarter of this year, is seven pounds, not 900 pounds. It's a seven pound handheld robot and I think that miniaturization of robotics, which performs the same functions and features, as the larger robots will help the majority start to embrace the technology. The second thing in orthopedics is the business model. The four major companies that control 90% of the joint replacement market all have robots. Now, they're all closed systems, if you use my robot, you can only use my implant. And that is challenging the customer who doesn't want to be forced into one particular brand of implant. And that conflict that's been created in the hospital executive environment is really a limiting adoption. With think we've decided to go an open platform, path to market, we are not an implant company, we will never become an implant company, we hope to become ubiquitous technology platform that all implants and all implant manufacturers can put their products on. And I think that that will also accelerate. So I think the two biggest things in my experience are the, the size and disruptive nature of the current robots, and the commercial model.

Omar M. Khateeb  10:58  

Fantastic. You know, piggybacking off that, the concept of the workflow and you know, I actually got to try it, I wasn't excited about it first, which is the robotic drill you guys have been when I tried. It made, it made a lot of sense because it fits into the workflow. Bruce, kind of a controvertial question that you know, is often asked is assuming that you can replace a physician with a robot. The question is, should you and if so, where?

Bruce Lichorowic  11:23  

Thanks for that question.

Omar M. Khateeb  11:25  

I'm sorry, man.

Bruce Lichorowic  11:29  

Yeah, I think the biggest fear surgeons have with anything that's automated robotics, whatever is the fact that you're going to try to replace me. And I think that's a that's a, that's a generation or two away. Right now, the surgeons are looking for. If you can make them if you can make me faster, if you can make me better if you can make me do things I can't do. I'm in with, with general surgery with surgeons in general. There's about whether you like it or not, there's a bell curve. And the bell curve of surgeons is on the right side, you've got surgeons who are brand new, who haven't honed their skills yet who haven't got their dexterity down. And they are now climbing that that curve to where the majority of the surgeons are where they're mostly in their peak, and they're working day to day in their skill. And then on the left side, you got the hands from God. Those are the guys that don't need robotics. So from a general robotics standpoint, what you're trying to do is flatten the curve, and bring everybody that allows so you want the early guys to be as good as the guys with 10 years experience, the 10 year experience plus want to be the guys with hands from God and the hands from God, you think, Well, I don't need robotics, you know, I'm in my 50s, or whatever, they're looking for career Extension. So because everybody ends up shaking, everybody ends up having some type of tremor. And and that's what kills a lot of really great surgeons in the peak of their career. So get whether it be in orthopedics or soft tissue or whatever. So one of the things that the these robots in general do is eliminate tremor issues, increased accuracy, precision, and in some cases can help these surgeons you know, perform their jobs better, faster, quicker. And that's really the whole thing. So when surgeons look at our particular robot, we don't talk about automation, we don't talk about you know, we're going to replace you, we're talking about how we can assist you, in your job of, of maybe if we can speed you up, and you're doing five, four cases a day, if we can save 20%, you can add a fifth case, that is real, that's real money, that's real, that's real time stuff to these guys. And so there is a fear that you know, you act like if you're going to end up taking their job, we're we're a long ways, real long ways away from that, that ever happening.

Omar M. Khateeb  14:04  

Yeah, and I think, you know, as surgery has evolved, I mean, look, even me as a marketer, like my job is evolved with something like chatGPT coming out, which is, you know, you can fight it as much as you want. But at some point, at least in the world of medicine, you know, there's this concept of, you know, having a father as a surgeon of the art of surgery, but people don't want, you know, art anymore, they want science, and that's what they're paying for. You know, Greg, you have a very interesting background in the sense that some people spend some time in academia, and then they go into industry, some people spend some time in industry and go into academia, and then go back into industry. You've had a foot in both of those industries, academia and private for a long time now, you know, what are some things that you're seeing and what kind of gets you excited in terms of what the future can, you know, look like when it comes to medical robotics beyond just general surgery?

Greg Fischer  14:45  

Now, thanks, a lot. Very good question. And, you know, at first I just like to make an appeal to folks here to really try to understand what's going on in the academic settings. There's a lot of really, really interesting work if you go to these academic conferences, medical robotics conferences, image guided surgical intervention conferences. There's so much interesting work but it's really unfortunate that can take you know, 1020 years before these technologies get out. So if you actually think of Galen, Think, AiM, we actually share a lot of common ancestry, they all came out of Central the same labs at Johns Hopkins effectively, right. So these things now, you know, 10-20 years later, we're finally getting to the market. So I think it's really, really important to start supporting these technologies, I see there's a huge push towards more compact devices, as we talked about, for application specific devices that we can bring into the OR, they don't take up a lot of space, you can wheel them in, you can wheel them out, you can use them potentially, for multiple different procedures are not necessarily tied into the same vendors instrumentation, there's gonna be a lot of work on how can we close that feedback loop? How can we use interventional imaging, you know, AiM's focused on MRI, but it's not just gonna be that there's going to be more interventional ultrasound, more interventional imaging using camera based systems with intelligence in it right? How can you use real time imaging and real time feedback to guarantee perform the procedure? You want it to perform that procedure? And then obviously, there's this automation task we've been talking about before. But I think there's a huge spectrum of automation, a lot of people are like, are we gonna automate this procedure or not? There's a huge, huge spectrum there. And it's all about how can we provide the level of assistance that's needed for the surgeon at this particular case of what are robots good at? What are surgeons good at? How can we provide cooperative systems that help with those particular tasks? Right. So that's really what I would think is like, the key areas where there's going to be huge changes coming?

Omar M. Khateeb  16:17  

Absolutely. See, you know, with this panel, we all kind of talked about these questions. So for the rest of the time. Now, it's kind of like I get to have some fun, because I have no idea what I'm gonna ask. It's really based on what I'm in the mood for. But you know, I want to start with one interesting thing. So earlier, there was a great panel moderated by Henry Peck with Dr. Fred Moll, and Daniel Hawkins, about robotic surgery. And I was speaking to Daniel after the talk. And he made a good point about digital ecosystems. So if you think about intuitive, surgical, Intuitive Surgical is not a robotic company. It's an ecosystem. And so if you're in the world of general surgery, either you're going to develop something that's going to be added into that ecosystem, or it's going to completely replace it. So knowing that, and again, I'm going to leave it open to the panel. So whoever wants to jump in, jump in, if you're building a medical robotics company, outside of general surgery, you know, how does that influence the business model and the scientific model that you build for the company that you want to want to go to whether it's, you know, in primary care or anything else? Don't all go at once.

Addie Harris  17:19  

I can jump in there a little bit. I mean, you know, when I was at j&j, we're working on velis. We thought about this question the ecosystem quite a bit in and we call it like the bookends of care, like, what are you doing pre and post? How do we connect it all the way through? One thing we found as we develop the the knee robotic solution, and working very closely with surgeons, we're focusing, you know, really so deeply on the procedure, and, you know, the need to be as seamless and fit into their workflow as possible. What we found is we added in balancing, so balancing of the soft tissues and knees, which is something that's really done by feel, sometimes some little knee tensioning devices when you're doing a manual procedure. We digitize that in the OR. But But I think where that actually became really interesting is we started to look at pre and post so that continuum of care that ecosystem with, okay, how can we have apps or tools that the surgeons can use, so that they know when they go into that procedure, really what they're trying to do for the patient, in my role at at have injure. We have seven robotic startups across the orthopedic space, most of them looking at lower volume procedures, but procedures that have a high potential for growth are either difficult to access, or the procedure itself is really difficult. And one of the questions that's coming up is really that continuum, like they need to understand how the patient either wanted to be moving behaving, what their their health should be like in a normal healthy state, and how that gets fixed in that interoperative space with the robot.

Stuart Simpson  19:02  

So I think you're absolutely right about the position, that Intuitive hold and how you describe what they are as a company, they're more than just a robotics company. The question that I wrestle with is whether customers and I'm thinking about hospitals and hospital systems at the moment, whether they think holistically or whether they think by service line, my experience thus far has been that they're more service line oriented. So I think the general surgery service line is dominated by that ecosystem that was built by Intuitive when I think about the orthopedic service line. I don't think anybody is anywhere close. And I think the commercial model where you've got a robot and an implant tied together prevents any of the big major companies from establishing that standard for ecosystem And, you know, I think that that's an opportunity that my company should be focused on, given our approach to the market, but I think it's a great question because the robots themselves can be built by great innovators, engineers and scientists. But the commercial model is the really hard bit to do. But when you do it right, it becomes such a huge barrier to competition.

Bruce Lichorowic  20:31  

There's, there's also, there's a way to look at this in a in a, in a very similar to, to what's been said, we look at the robotic robots as a as an industry or as our robot as, as a platform. I'm a crossover CEO, half my career was in high tech, I did SaaS and everything else. And so there's a lot of similarity. And so I keep saying is deja vu all over again, from way where the hardware and software business came in Silicon Valley to where we are today. And, you know, my lesson was, in the 90s, we went up against Cisco. And the biggest thing that John Chambers said, is Cisco is a software company that happens to sell a router. And so when I look at Galen, where it happened, we are a software company that happens to sell a robot, it's the software that becomes the ecosystem becomes the platform, where you don't want to constantly be changing your hardware, per indication or per surgery or whatever, you want to have a standard platform and what changed.

Omar M. Khateeb  21:46  

I mean, now they're back that answer. Hey, I was like, man, Bruce, he got the whole panel canceled, man, come on. Brent is coming.

Christopher Prentice  21:53  

Yeah, so I'll, I'll go back to the whole process as well, when we talk about, you know, outside, whether you call it general surgery or surgery, as well, I mean, even today, well, as big as intuitive is, as they still have the inputs handed to them, they're not upstream. They're not in the diagnostic realm. So they're still beholden to those who are getting diagnosed, and then come to them for the intervention and the surgeons. So you have in and what you'll see now outside of that realm is you have some of these diagnostic companies in the big players in Siemens, and so forth, that had the ability to act before that point. So you'll see robotics in the interventional space, in the diagnostic space where they're helping with the biopsy for a prostate Takumi, whether you should have one or not, but then you're already there. And maybe at that point, you immediately can interact in, in in fix instead of going back and then having to wait for a surgery to come. So I think you'll start to see that merger of of diagnostics and intervention happen with the same equipment. So you asked, you know, as somebody comes forward, if you have a diagnostic device, or a diagnostic type robot intervention, doesn't have the ability to immediately be switched into treatment at that point. And then additionally, are you looking at, you know, the the problems in healthcare as well, you know, cost quality access? Access is a big one in where do you can get these technologies? And how fast can you get to the technology. If you look at the genesis of Intuitive way back, it's DARPA, it was trying to get a, a combat wounded soldier fixed on the battlefield and not having to bring them back and losing time and that golden hour to get to a surgeon who has to be safe in the back to do it. It didn't work out that way. We didn't have the bandwidth. We didn't have the robustness of the of the product at that time. But it ends up becoming feasible now. So you've heard we talked about, you know, there's been talking about stroke stroke that Time is Brain. So is there are there robotic systems that would expand our stroke center. So it's not centrally located in an urban center, you can actually have maybe a expert in a console in a control room, who can then be doing many different procedures are in day out in the community where it's important and time matters. So I think you have to take a look at that from you, are you expanding the access and bringing forth your technology to more patients? So that helps the healthcare system instead of continuing with this old model of everything central in the big house in the OR

Omar M. Khateeb  24:33  

you know, oh, sorry, go. Go ahead, Greg.

Greg Fischer  24:35  

No, I just want to pull it back to this platform technology that we were talking about before. And I think there's a huge opportunity for having systems that can be used in different disciplines with different types of procedures. So for example, having a base platform on the hardware, I know you talked about the software but on the hardware as well, that you can readily add for this clinical application, this clinical application without having the new learning curve without necessarily having to go through all the new training and getting it system set up. So like when I talk about our system, you know, we have a robot for doing neurosurgery, but I don't tell you is that in the lab, we also have a robot that does prostate applications that uses the exact same robot controller, same cable, same sensors and actuators 90% of the same software. And I think that's where you could go with having very easy to add on different types of robots for different types of clinical applications. And you can really get more for your money, if you will, as far as the hospitals are concerned with these platforms.

Stuart Simpson  25:18  

Yeah, just a watch out from an innovator or investor perspective. I've seen too many attempts to do that to expand indications to the limits or beyond the limits of the what the device is capable of. And you end up with difficult challenging solutions rather than elegant solution. So as long as you're, you know, the technology is capable of creating value in the procedure that you're expanding into. I would agree, but I've seen too many people step over that line.

Omar M. Khateeb  25:50  

Absolutely. I mean, no offense to the people in pharma med devices, not pharma, and I feel the same frustrations were a technology and it puts a lot of pressure on the r&d team to push the indications beyond what it's supposed to. And that's when you end up having a lot of issues happen. To kind of a controversial question that's always been brought up is around data, right? So if you go back 10-15 years ago, before we had all this consolidation, at least, you know, the United States with health systems, you know, you can go and leverage yourself into certain hospitals and regional hospitals and everything. You know, they weren't very savvy into its sign agreements, and the company would own the data and you collect a lot of the data and you sit on it and makes your company valuation go up. Can't do that anymore, especially these hospitals. They're, they're owned by larger health systems. So my question to you is, imagine that you have medical robotic company that comes out, has some automation collects data? Who owns that data? And why? Don't all go at once.

Addie Harris  26:46  

Well, you know, so this is a really interesting never gonna get on a panel again, with Yeah, it's a really interesting question. Because there's an element to it of, there's several parties who own the data, right? You know, the, the patient certainly has a right to their own data. The hospital or the center, where they were cared for is also going to claim like they have a right to that data. And the surgeon may claim, you know, they have a right to the data to and then I guess you could also add the device the data was collected on certainly, to some extent has a right to the data, as long as they're caring for it appropriately with with HIPAA. You know, my answer to that question is the data has to be shared. It's we can't say one of those, definitely one of those four parties only owns the data, I think there probably be legal challenges to say the patient doesn't have a right to their own data. But yet, what's the patient, besides on a personal level really going to do with their data unless their data scientists, they can't really make far reaching changes or affect care. And that's where those other three parties start to come in. And I think where we can see the most from data, is if those three parties start to agree that it shared. Now the problem is, it's worth a lot of money, right? So each one has an advantage, or has a reason to want to say they want to own it, and they want to own it all.

Greg Fischer  28:10  

So I'd like to put a different spin on that, that even if you have the data, what can you do with it? And one of the reasons it's really, really useful is can we start doing things like learning how procedures are done making them be better adding automation by automation? I don't mean, you know, press a button and do a procedure, but doing task automation, or sub task automation, right. So I think there really needs to be an effort to try to do standardization. And again, this gets back to us about the industry and academia. You know, there's a lot of actually funding and initiatives to try to have, you know, open data collection standards and standards, what is actually collected by surgical robots? Because at the end of the day, if we're not collecting it the same way, we're not collecting the same types of points, right? What are we actually able to do with it? So I think it's really important to start thinking about what are we want to do with the state? And how can we standardize that?

Stuart Simpson  28:50  

Yeah, the who wants to own the data, everyone who actually owns the data that depends on each individual contract negotiation, which is the reality that we're in at the moment. But I do agree with what Addie was saying. The best eventual solution is an agreement where everybody has an access rights to the data, but maybe different views of the same data, depending on what purpose or need, the data fulfills for them. But it's a long way off, you know, that's probably the single biggest negotiating point in a conversation when you're putting a robotic system into a hospital system in the US right now. And it's no easier in Europe or any other parts of the world.

Addie Harris  29:41  

Right? Yeah. It's the thickest part of the contract. To get through if you're going to say there's any level of data that is stored on your system, especially if that data is going to be passed outside the hospital.

Omar M. Khateeb  29:53  

You know, when we think about medical robotics, again, beyond general surgery, well, we've all gotten used to over the decades. Ah, is this, in my opinion, very outdated business model sorry, everybody have the razor razor blade, right? So the robot to sell more disposables, right or implants or something. But if you go outside of surgery, right, you have a lot of cases where you don't really have too many disposable or implants. Is there a case where this is the opportunity where you feel that there's going to be some innovation on the business model side in terms of let's say, a SaaS service or something else? So in terms of, let's say, medical robotic, and let's just say in the primary care setting, it's no implants involved? What can be added to that business model to help that company grow its revenue, and obviously invest more in itself?

Bruce Lichorowic  30:40  

Yeah, yeah, yeah. I applied, I crossed over my SaaS background into into Galen. So we're gonna launch as a digital surgery as a service model, we actually are going to be placing the robots in the hospital, charging a usage fee, and charging a disposable fee, both are covered under reimbursement codes, we made sure the cost of the robot was to our favorite, we're losing our shirt. The same time, we're looking for a guaranteed number of cases back from the hospital that we estimate cuts almost three months, four months out of the sales cycle, dealing with the back committees, because if you're going to come in with a heavy $500,000 Plus robot, you're gonna go through committee, and you're going to go through the grind on that. And that can be anywhere from six months to 12 months. So our idea was to at least get the first one Dotto Galen's out there, get the surgeons using it. And then at the same time, start adding applications or apps similar to an app store on your iPhone, where if they wanted navigation, they wanted AR they wanted VR, we can then add those as a service to the to the computer in the in the robot. And eventually, you know, if they want it, they can customize whatever they want for the case. And so that's the idea of, of getting robots out there. The problem with a lot of the robots where they're at today, they're on the big teaching hospitals, what the ASC's the surgical centers on buy, you know, for surgeons, they're not, they don't, they're not going to go pop, you know, $1,000,000, $800,000 for a robot, but that's what the volume is. So you want to hit the ASCs, you want to hit the community hospitals, you want to hit those kinds of places where surgeries are being done. And so we're we're targeting we know, we're gonna get the teaching hospitals, that's a, that's a, that's a, that's a given. It's the secondary hospitals and ESC is where a lot of the volumes done. And that this is where that model is pinpointed that, that, that that target. And so that's the whole premise of how to get these things out. Quickly and at the same time safely.

Addie Harris  33:05  

Oh, add a piece there just having worked in SaaS industries, having worked across robotics in different industries, I think and when you look at digital revolutions, they all eventually put value and monetize on a SaaS sort of model, whether it's a fee per case, whether it's a licensing fee, you have to add value, you have to attribute value to the software. And when that is done in an industry, you suddenly see software take off, when software takes off, you start to see the limits of where the or the the lack of limits of where the software can go in terms of really driving everything forward. You know, the iPhone is like an overused model. But you see, like the way that apps work in the iPhone perspective, you go to almost any other industry. And the same sort of thing has happened when you start charging for the software as a service. It's a recurrent fee. You start to see more innovation in the industry. And then the software just go crazy in terms of what it's what it's able to do.

Stuart Simpson  34:15  

So we're going to have a go at disrupting that razor razor blade model. And I'll come back in a year or maybe two years and let you know how we got on. But baby steps. I think ultimately, the SaaS type of model is where you end up. But I don't know whether in the industry that I'm competing in whether we can jump straight to that, or whether we need to take the first step which is just disrupt the razor razor blade model which exists today.

Addie Harris  34:46  

Yeah, I mean, it has to be baby steps. I mean, you would just shock the whole medical industry if you suddenly turn this on its head. But you know, you have to take baby steps to get there because some of the existing models today I mean they've done fantastically, they've made a ton of money, they've gotten robotics into the hospital and the procedures, improved care. They're also starting to be challenged from a payment perspective. So figuring out other ways to get these technologies to continue to expand that care, I think is where SaaS is going to start to creep its way in, and then we'll see what it really does.

Christopher Prentice  35:23  

And we'll go with a subscription model as well, we don't, there's no, we'd have to make a razor willing to do it. And it's like that there was even a while we have patient attachments, I'm like, I don't want to have patient attachments that get thrown away every time just so I can have a razor blade, you know, so you have to think about those things. But then you have to build in your, from a subscription as well, you're looking at what are the needs of the healthcare system? The economics of it, what is the CFO, whether it's the CFO of an ASC, which is usually the doctor who owns it? Or the CFO of the hospital? What are they really looking at? What are the pain points, and you're gonna see a different different medical robots affecting that. So outside of surgery upstream, from like diagnostic robotics, trying to help with the ER triage. You have logistic robots, they've been in the pharmacy for a long time, you know, helping with the labor. And there, you have diligent robotics out of Austin, who's trying to do the logistics in the hallways not having one person be a runner? Why does this matter? It's not taking jobs. I mean, there's a labor shortage, there's an issue there. So can you bring forth, you know, in your subscription, some way to prove out that you're helping them with that, that labor? That's the arduous task of a of the administrator or the CFO, is how do I run this entity with stress on labor? And if you're relying on the labor, labor, then that's gonna be a rate limiting factor for you. So how can you force multiply? And that's where, you know, robotics can come in. And that's what I mean, you move upstream from the actual intervention, you move downstream, you look around the whole eco system of where the intervention happens. How do you make that more efficient?

Addie Harris  37:04  

Sorry, at iRobot, we used to say, do we used to say robot should be anywhere where things are dull, dirty or dangerous? Because that is generally where humans don't want to be?

Stuart Simpson  37:15  

Yeah, and I think one of the truths that is often miss overlooked at the moment is that robotic surgery costs more per procedure in the vast if not all cases, and the industry has had a hall pass for the last decade or more, because that's, you know, it's got this sort of cachet about it, everybody wants to do it. And there's this sort of inner belief that it must be good, right. And there's a focus on better clinical outcomes, but not the overall health economics and the cost benefit analysis, I think, over the next 10 years, there's going to be much more focus on robotics actually reducing episode cost, not just relying on better clinical outcomes, to justify their existence.

Omar M. Khateeb  38:10  

Do you think that's a good case that for the next, you know, let's say 10 years that? I mean, we'll see some innovation, obviously, on the technology side, but do you feel that this is the time where we're going to be forced to see more innovation on the business model side because of that?

Stuart Simpson  38:24  

Yeah, I think the focus on the continuum of care needs to become far more sophisticated. It's mostly about engagement and workflow right now. It needs to become around the total cost of care across the continuum. And I do think that it's going to be a big topic for discussion in the years ahead. And, you know, we're ready for it. We're partnering with a company called definition health, we're going to be presenting later on today very interesting company out of the UK, which if you have a chance of sitting in their presentation this afternoon,

Greg Fischer  38:58  

they can just chime in on that a little bit. Because there seems to be this misconception that robotics are either going to add cost and or add time to the procedures. And honestly, I really think these ones that are going to be coming down the pipe over the next several years, it's all about how can we streamline that workflow? How can we reduce the costs? How can we reduce, you know, recurrence rates? How can we take steps out of that procedure to make it run faster, and make it run more reliably? So I really think all these robots that are coming down, it's really gonna be about how can we reduce that cost and get better outcomes?

Omar M. Khateeb  39:22  

And I'm happy you mentioned that I feel that you know, you know, even 10 years ago, a lot of the innovations we've see robotics are not we're more focused on just radical disruption and not being empathetic towards like the people. We're actually using the technology and how does this fit into their current workflow? And nice thing I've seen with everybody's, at least everybody on this panel is company is this empathetic approach of how do we innovate that fits into the workflow and either reduce the steps and make it easier versus you know, making people do radical changes because, you know, that part of the procedure is like one of many things that the people were doing was so with the remaining time with each panelists, tell me one thing that you're very excited about when it comes to the future and you know, with regards To the things that you've seen it on both sides. So Greg, we'll we'll start off with you

Greg Fischer  40:03  

Sure, is that I'm just really excited about using imaging to guide procedures. It's all about like, you know, being an engineer, I think about like closed loop interventions, right? How can we actually make sure you do what you want to do?

Stuart Simpson  40:13  

I'm looking forward to telling my kids I was on a panel with a great Omar.

Addie Harris  40:24  

I'm looking forward to telling my kids I was on

Omar M. Khateeb  40:26  

The fruit basket. Okay.

Addie Harris  40:28  

I know, you know, I think, again, back to the closed loop thing, but that data perspective in AI, and I'm really excited to see where procedures start to advance. And we start to see an improvement to patient care, to outcomes to that whole episode of care, because of the technology that we're bringing in, to the medical space.

Bruce Lichorowic  40:52  

Not to give too many things away, but I'm, we're really excited. We're actually very enthused of what's coming out of the research lab. Of course, we're affiliated with Hopkins, and the whole idea of where we're AI is taking, taking robotics. So you're gonna see it look at look at chatGPT. And we, my God is all of a sudden just took off in the last three months, out of nowhere, and, and so you're gonna see, I think more intelligent software now start to help these surgeons either either a feedback loop or whatever, in real time, which can make which I think will have a greater impact on outcomes.

Christopher Prentice  41:35  

Yeah, I'm excited. So data data to help optimize the process, you know, lift the Val on a lot of things and get to the truth so that you can iterate and get better. And I think we've been hiding a lot of that it needs to come forth. And that's why everybody should own the data, we should aggregate it and we should take a look at it. And then that will lead to better decision support. You know, this, this thing of the the hands of God or you know, you need to have a person in the room. Why is that? You might not actually, you know, if you if you've done enough and sample size and proved it out enough, you can automate certain things, and that will be for the betterment of all.

Omar M. Khateeb  42:14  

Well, thank you all please give a warm applause to the panel. Thank you all very much. Thank you very much.