Innovation, Investing, & Partnering in the Digital Space | LSI Europe '22

Transcription

Ken Nelson  0:03  

So really appreciate the the really nice event that Scott Pantel and the LSI team together. When you think about this, this digital health medtech ecosystem and the fundraising ecosystem that he's built around it, it's fun to have a mix of some venture capitalists here with some startup founders and CEOs. So have a fun group and maybe I'll hand it off to you and to make some introductions.

Iwan van Vijfeijken  0:31  

Okay, thank you. My name is Iwan van Vijfeijken. I'm the CEO of Pulsify Medical, we're Belgian medtech startup company, founded in 2019, are developing a totally novel ultrasound, wearable patch, to continuously monitor the cardiac performance.

Simon Turner  0:52  

Hi, everyone, Simon Turner, I work with Sofinnova Partners. So we're one of the oldest Life Science venture capitalists, they're really focused in on early stage innovation in the life sciences, space, biotechnology, medical devices, and such. And of course, very interested in seeing how this digital space is also evolving.

Amos Ziv  1:07  

I was privileged to be here, thanks for inviting me, again. I'm the founder and chief scientific officer of CardiaCare. It's a wearable device that actually treats patients by delivering non invasive nerve stimulation neuromodulation, we're targeting the vagus nerve, and we're doing that from the wrist. And we're targeting atrial fibrillation as our first indication by reducing atrial fibrillation burden, incidence and symptoms for these patients. Early Stage startup on the one hand, clinical stage, on the other hand, and really happy to be here. Great.

Omid Akhavan  1:42  

I'm Omid Akhavan, I lead Anthro ventures based out of DC, investing across the life sciences, but mainly in med tech, digital health, and healthcare services.

Ken Nelson  1:55  

So when you think about this evolution of of digital health and med tech, and now that they're kind of overlapping, you started out with different devices, such as patches that may be single parameter patches, now they're evolving to multi parameter vital signs, devices, there's multi dimensional multi parameter, implantables wearables. Now that connects into different software platforms. And it's created a whole new problem of too much data flowing into, to the practice to the clinic. And so there's this question of how do you deal with that data? And so I'm interested maybe this question will go to the venture guys first, when you're evaluating a digital health investment versus a pure med tech investment? What are the things you're looking for? And how do you evaluate that a little differently than a pure med tech investment?

Simon Turner  2:54  

It's really interesting. I mean, from from our perspective, what we've seen is, there's a fundamental change as well, when you think about the digital health space versus for example, med tech, and that, on the one hand, med tech tends to be much more focused on developing a product. And that's it, it's a product component, when you're looking towards the digital health, these tend to be much more in line with a service model. So in fact, it kind of completely revolutionizes the approaches that one you have in terms of development of the services. And secondly, also the business models that you're able to develop with it. I guess, these are one of the kind of core components that we see.

Omid Akhavan  3:27  

Yeah, and I think, you know, the key is, as I look at digital health, and you know, various diagnostic signals, the real question comes down to what clinical utility exists from, you know, the biomarkers, the digital biomarkers that you're using, and what's the application? And how do you think about the, you know, even if you can figure out, okay, you have heart failure? Well, what what treatment can follow, and how does it fit within the context of healthcare delivery, and actually resolving whatever the underlying disease is. And so what's the utility of those markers?

Ken Nelson  4:04  

So as startup companies who are trying to raise capital, what are some of the challenges you're facing when you're going to events like this, and you're trying to raise money?

Iwan van Vijfeijken  4:14  

Right. Yeah. So I think I think you're right, what you said earlier, as a startup company, you have to be focused, you have limited resources, our differentiation, our unique IP is in the area of the of the device. Having said that, we are aware, of course, we're fitting, we need to fit into an overall system. And our data needs to somehow connect with existing infrastructure, and indeed, be prepared for emerging and multimodal wearable healthcare space. So we are thinking about that today in terms of our specification, not just of our device, but also what type of data what kind of flexibility the data that we offer, do we need to build in today and also revenue models, we sell a device. But indeed, we are well aware that data and the value of data will also be a major contributor for the future. So indeed, I think that's also your point about services. Now, how that will pan out that that is really difficult, and we need partners for that.

Amos Ziv  5:21  

Yeah, I think that the perspective of VC is basically varies. One of the things I can't say there's one single thing that that everybody gets, I want to say latched on, I think that we, as an early stage, stage startup, we progressed by understanding that we need to be they need to be able to V check these boxes starts with IP, clinical data and mechanism of action. And lucky for us, as we finished our first in human study, that's when things kind of started moving forward really fast. And, and I agree market validation, market entry, reimbursement is always a huge, huge deal. So but on the other hand, I just had a discussion with a VC that said no to us, but when they heard that we're moving forward with some strategic deal, I said, Okay, we'll want to reassess. They will look, they said no, for different reason in the past, but now. So it's very, very, it varies between the VCs and the outlook, obviously, the team, the greatest thing, maybe, if they don't connect to the team, then yeah, there's nothing going. But so not only does it vary between the VCs, we're seeing that it actually changes within the VC sometimes depending on your on your maturity.

Ken Nelson  6:34  

So one of the things we're seeing as a company at Biotronik, is there's this evolution of you have the silo of medtech, you have the silo of digital health. Now there's this overlapping of the two. And so for us, it's changing that mindset of a pure medical device company, to also evolving into a digital health and diagnostics player. from an investment standpoint, how do you value the two? And do you place a higher valuation today on some of these evolving digital health technologies, or on the pyramid tech companies that are that are out there?

Simon Turner  7:16  

Should I take a first crack at four. So it's interesting. And again, it comes back to the the kind of core fundamental differences, products and services, but also, when you think about it, this whole new digital health space, it's kind of an amalgamation of several different components, you have life science, pieces of that regulatory clinical evidence, need for reimbursement, et cetera, being built into it. But you also take learnings and lessons from the tech side of things. So rapid product iterations, this notion that actually the valuation of companies in most cases will be driven by commercialization, you know, ARR, and maybe even get to profitability. This is something that we traditionally haven't seen in med tech and even in biotech, because normally tend to de risk along a relatively stable curve, you look at what is it in terms of a discounted cash flow for the actual indication. And then that's basically how you derive your valuation of the company in in the digital health space, what we're seeing is, it's much more about the potential platform and the revenue generation that platform can entail, you know, is it a single standalone product, or it's just having multiple service streams that can be developed from it? That all kind of gets baked into the way we're looking at it?

Omid Akhavan  8:25  

Yeah, I mean, I think is, as I look at the convergence of med tech and digital health, one of the big challenges and having previously been at Becton Dickinson, we struggled with this as a company is, you know, how do we use data to our advantage? How, and how can we enhance our pull through of products, you know, into our customer base. And I don't think med tech companies have figured it out yet. It's not like Google and Apple and Facebook that, you know, can monetize data and you know, have, you know, 1000s of engineers working on, you know, products and iterating. Quickly, you know, if you think about the informatics budget for most of these companies, it's you know, it's insignificant. And so I think one of the big challenges as we look at this convergence is even if you can collect the data, how can you analyze it and use it? And then ultimately, how does that translate into revenue? And I don't think we figured that out in med tech yet. Because we understand how you sell a device, right, you know, but even you look at the healthcare IT space, you know, other than, you know, the EMR space and because you had meaningful use and you had this big push to, you know, move from paper to digital. It's, you know, convincing a hospital to go spend money on a on a license and annual license for software like, that's, you know, good luck, right, especially as a startup and so I think that that's one of the challenges Is that I've seen in the digital health space is, you know, how do you actually convince a strategic there's revenue to be had from the data? And then it really comes down to reimbursement. Right. And so I know we'll talk about that a little bit later in the panel.

Ken Nelson  10:14  

So any other thoughts on that topic before we move on a little

Iwan van Vijfeijken  10:17  

bit? Well, yeah, I want to, indeed a reimbursement. You both mentioned it. And this is indeed, a challenge. Personally, I'm happy we're selling something that you can touch, right? It's a device, right? In our case, it's the patch. And we know that there are money flows associated with selling a device. And as a small company, you have to follow the money, right? We cannot, in theory, we could try and generate new revenue streams. But really, the best strategy is to follow the money as it is today. And so it is, indeed, I think a great challenge, if you talk about digital is to get reimbursed for the digital part of the total offering.

Amos Ziv  11:00  

I just want to say one more thing without regard due to the fact that it's all new, even to the reimbursement folks at CMS, from what we're hearing from the KOL. Is that true clinical value and health economics, if that can be shown over time since this is making the art moves by CMS for reimbursement. So focus, you can really show your clinical, the clinically valid, and you're clinically significant and your health economics works and reimbursement will come.

Simon Turner  11:39  

Maybe just one point on that. I just wanted to make it clear, I think we've seen it all that reimbursement is not the only kind of driver of potential value, at least because you have pharma, you have other med tech players, you have other services that are interested in this healthcare data. We're seeing it more and more. So it's just interesting, again, to think about it that, you know, reimbursement isn't the only goal, you could have there multiple different sources.

Omid Akhavan  12:01  

And to add to that, I think, you know, the question is, do you think about, you know, just basic vital signs monitoring, right, and pharma trials? I think, you know, one of the I've looked at companies have said, Oh, like this is a segment of the market that we can go after, which is how big is it right? And you look back 10 years ago, and companion diagnostics, and oh, Pharma is gonna spend all this money, and they'll go spend $50 million dollars on trial, well, how much are they really spending on the diagnostics piece, like 2 million bucks? So you know, like, how big is your TAM? And what's your SAM? And does the pharma company see utility? And and so I think that's, that's one of the challenges as well is, you know, are you? And are you really adding to that study in a meaningful way that's going to help accelerate approval or get the FDA comfortable? I think that that's something that as a startup, you have to really think about, it's easy to do broad brushstrokes, generalities, oh, there's money in this in this bucket and that bucket, but when you get to the brass tacks of who's going to pay for it, and why? Well for hospital, it's going to come out of their p&l, right, unless you know, or it's going to eat up a part of their DRG. And, you know, for a pharma company, it's just adding to their expense to the clinical trial. And so it's got to be meaningful for them to actually want to spend the money.

Ken Nelson  13:21  

So it's interesting when you think how far wearables have come 10 years ago, when I left guidance in Boston Scientific, Cardiac rhythm management world had been in it for maybe 10 years, to go to IRhythm take that risk in a start up. I had many people ask me, you know, what, why are you giving up your medical device career? And why would you do that? And they look it out far the wearables world has come from a diagnostics area to now there's wearable therapeutics, and we'd love to both get your take on this Amos as developing a wearable therapeutic technology. You know, how as investors are you guys looking at digital and wearable therapeutics today as versus what you might have thought of them 5-10 years ago,

Amos Ziv  14:11  

I think that the challenge of being or foresight or looking quite ahead in the distance has to do with the fact that you're actually proposing value that the market may not be ready for that's what happened to us initially, when we started, we always had the vision that wearables will become will switch from from consumer grade to medical grade, initially as sensors, you know, the east the apple ECG came was noted and no surprise to us. And, and it's always been our vision, you collect all this data, but you need to manifest some therapy to it and if you can show therapy so we always believe that the natural evolution of wearables is going towards wearable therapeutics and that's that's what we're doing. And we're in wearable Therapeutics is not new, you know, you have insulin pumps there. There's there's a cardiac pacemakers that the not the notion of treating patients at home has been out there. But the novelty of doing it non invasively, low risk, and especially now the post pandemic, when everybody sees the need for home care, not just monitoring, but also therapy. So it's always been, it's always been our vision. That said, it's challenging, you want to talk to VCs? Because almost the world is not just yet ready for that. But it's, it's, it's the risk that we do as

Ken Nelson  15:40  

I feel like in cardiology, they're, you know, they're a little bit cowboys. And so they were doing remote patient monitoring before the pandemic, and it was a 10 15 year old space. And so now post COVID, there's so many other wearables, there's so many other wearable therapeutics now that are evolving. But because of COVID, it's taken away that question market, will an older patient, use this technology now we know that if they need to, they can do it, they can figure it out. And it is a model that that's worth pursuing. So as investors, how do you how do you see that space continuing to evolve? I think earlier today, people said that we've retracted a bit. Maybe we have a little, but I still feel like we're, we're really moving forward. And that whole world has changed now that we're in this post COVID environment. But as investors, how are you? How are you seeing things today? versus maybe a year ago, when we're in the middle of the chaos of COVID? Is it the same? Or has it changed?

Omid Akhavan  16:50  

Yeah. So I would say I'd go back, probably, you know, five years. Yeah. And as you think about the value, so I would say COVID, put us into a sprint in terms of telemedicine, right, and remote patient monitoring. And I would say kind of in the mid to late 2000s, you had all these companies came out trying to do remote patient monitoring, many of them failed, raised a lot, you know, hundreds of millions, if not billions of dollars of venture capital. And I think that the challenge there was, you know, how are you getting paid, what's the business model, you have a services business model, okay, you're really, you know, an operating business, it's not a, you know, tech enabled service where you have, you know, 90% 80%, gross margins, you have people that have to monitor those patients. And so it's not like the medical device field where you're making 7080 90%, gross margins, and your feet on the street selling, and then you get ramp and profitability. But really, for every dollar of revenue you're collecting, you're spending 5060 cents on manpower, right to manage those patients. And that's not being passed off the clinics. And so, I think with COVID now, and this decentralization of care, and this push to move to the Patient Centered Medical Home, which, you know, I was talking about in like 2008, you know, like the UNC Health System was doing in North Carolina, in general is doing a big push to the patient centered medical home. I think now you've gotten better sensors, better technology, better understanding, I think the question becomes, how do you get paid? And are insurance companies willing to pay you the same way that they pay for an in office visit, and you're seeing that shift? And I think payers are starting to realize, actually, maybe there's something here. But that requires a policy shift? And it requires, you know, both payers and providers and integrated delivery networks to really focus on, okay, what's in the best interest of our patients? And how do we incentivize startups and big med tech companies to innovate, to deliver better care for our patients? And I think that's, it's happening, right, and COVID I think, jumpstarted that for the next five years, we're gonna see how it all plays out,

Ken Nelson  19:11  

I think with the evolution of of our the RPM code, so remote physiologic parameter codes for vital signs, the remote therapeutic monitoring codes, our TM codes, we're headed in the right direction. Not that that's necessarily enough to reimburse for some of these solutions. But I think we're starting to head in the right direction. You know, you go back 10 years ago, and we had to get new codes higher than we had to get a totally new code, which was not a fun process. But you fast forward and you look at the valuations of some of these companies, and it did work out. It's just the more expensive and longer road, but with the RPM codes with the RTM codes, at least there's a pathway and hopefully CMS will continue to come out with codes like that. So as as start up companies on the diagnostic front. And in therapeutic front, how are you guys viewing? The way the reimbursement is going?

Iwan van Vijfeijken  20:08  

No, I think I think we all see this broad trend towards telemedicine home monitoring wearables replacing more and more invasive solutions. But indeed, as you indicate it's a slow moving, it's a broad trend, but it's very slow moving, I think I can say, luckily, at Pulsify, we're in a situation where our roadmap calls for our first product in the hospital, in the ICU, in fact, and then the hospital ward, and after that, we go to Home Monitoring, also, because we have quite a novel concept. So we really need to start at the beginning. So in a way, I think that makes it a little bit easier. And I hope by the time we have a home monitoring device, that all the money streams are there, because I'd rather follow at them, then lead it. So your example, I would hate to have to go that route, because it takes a lot of time and money. Right.

Ken Nelson  21:04  

So any thoughts on the therapeutic front? Amos?

Amos Ziv  21:07  

Yeah. So as I said before, first of all, we're not we're not alone in the therapeutic or the external, non invasive therapeutic realm. So there's companies out there that I have, have had do have actually product on the market. And some of them are big companies that are fighting some of the battle for us, some successfully, some not. But I think our view since CardiaCare, the cardiac care device has both monitoring aspects and therapeutic aspect, in fact, and therapy. Again, if you'd asked me what the next evolution of a therapy will be, it will be optimizing therapeutic care by monitoring. So combining the the, this is what we're working on in terms of AI today on optimizing stimulation. Anyway, so So we're tackling both of these aspects of we're looking at the RTMs and the RPM codes and the existing codes. And we're trying to build business models and projections, starting from the lowest, and again, reducing the cogs and making sure that we you know, we're profitable even even with lower reimbursement. But so we're looking at both aspects, external nerve stimulation devices, and then also the the remote patient monitoring codes, and there are expanding I think, is it $320, for I was already for a test, so

Ken Nelson  22:31  

something like that. So when you think about this continuum of care from the consumer, the worried well, consumer, to the symptomatic patient, and different devices that are used to monitor whatever vital signs, and then the diagnose patient, the treated patient, and then the post therapy monitoring of those same patients. If you're tracking that data across that whole care continuum, you start to see patterns. And then you can eventually start to develop predictive analytics, and then risk management tools and chronic care management tools. What's the most exciting part of that care continuum? As an investor? Is it the whole continuum data across the whole continuum? Or are you most excited about the treatment side? The the diagnostic side? Where do you guys stand today?

Simon Turner  23:27  

It's interesting, because I think over the last 510 years, what we saw were kind of individual bricks being built and developed, and they were already a massive leap forwards. But when we start thinking about it, ultimately what we're looking to and Ahmed, you said this, it's it's outcomes, it's that impact on patients on care. So today, what we're seeing is a general shift towards actually it's a full bore solution that you're looking for, from the moment patients start coming into the healthcare system, how are you able to integrate them into your, if it's a platform, or at least your care pathway management, so that way you capture the patient, you manage that patient throughout the journey. Ultimately, you can even build potentially more value streams into that by integrating third party providers, if it's a digital therapeutic, or if it's some sort of a monitoring system. This is really where I see a lot of innovation, a lot of promise going forwards. But ultimately, it's it's kind of the platform owners, not necessarily the individual brick or feature developers per se.

Omid Akhavan  24:24  

Yeah, so it's interesting because when I look at, where where we are and where we're headed, so I think the opportunity is around personalized health care, right? Because everybody has different set of biomarkers, you know, and there's, you can think about it in two ways. One, you have your genetic markers, right, which there's been a lot of work in genomics research, but then you also have you know, the the digital biomarkers right. And you think about lifestyle change, and so much of you know, curing disease comes down to change in lifestyle. And I think the The the trend is going to be towards taking that data, trying to interpret it trying to come up with algorithms or solutions or care interventions along the pathway that can actually improve outcomes. The challenge I think we have in the US healthcare system is in you know, Europe is a little bit better, but we don't really pay for prevention. Right. And so really, it's you get paid for intervention, it's still a feat, you know, I look at Obamacare, and the whole drive was, you know, to value based medicine, and how do you get paid to provide better outcomes and better care? The reality is, we've never shifted away from the fee for service model, right now. Now you look at the ideas are moving in that direction, the at risk providers, and there's a whole wave and movement to try and improve profitability and health care for providers that deliver better care. But the reality is, the majority of the system is all about, you know, do a procedure get paid. And so I think the the risk, and the challenge is an investor looking at the digital health space is, you know, how can you encompass, and then get paid for actually this whole continuum of care, and managing, you know, and looking at the patient, and coming up with predictive signals. And for whatever reason, we talked about this yesterday, we don't value diagnostics in the healthcare system, right, and you look at the value that pharma takes in treating a patient, you know, 20,000 $50,000, for a drug, or even in a procedure, right, you know, 20 50 $100,000, for a surgery, you're getting, you know, and this was the struggle with like, molecular based diagnostics, where they're trying to charge $3,000, so they can make a business and the DOJ came after them, you know, and so, and everything's being pushed down to like, 10 to 50 bucks, you know, per diagnostic, which doesn't become sustainable for companies. And so I think that's the struggle that we have, you know, that the dichotomy in the US healthcare system is, how do you ultimately navigate that I think the Europeans have done a better job, right, because there's more focus on primary care. And so there's a push towards, you know, of Siri, always listening. And, you know, European healthcare system, I think, are more conscious of that, and how do you actually keep the patient at home and keep them healthy and engaged in preventive medicine? So I think that's gonna be an interesting shift in the US healthcare system is how do you pay for prevention. So it's

Ken Nelson  27:42  

interesting, at the beginning of 2021, there was a 45 day period, where three of the four biggest players in cardiac monitoring, got acquired, basically got announced that they were going to get acquired. And I had spent 10 years trying to get the big device companies to acquire one of these companies, to your point they didn't have they didn't value diagnostics. Now all of a sudden, you see, value in diagnostics, you start to see these acquisitions. And that's a perfect example, three of the four biggest players in 45 days getting acquired. What is that next area that you all see, to have a run on some of these startup companies? Is it is it vital signs, monitoring companies? Is it wearable therapeutics? Do you guys have a pulse for that? Or do you have an opinion on that? I'd love to hear both the the investors and the startup guys what your take is?

Simon Turner  28:43  

So I'm not necessarily sure it's going to be in any one particular indication more in terms of a what is the field trying to achieve? One of those is probably going to be much more about personalized medicine. So this notion that we need to understand patients better to be able to identify, you know, one, when are they going to get sick? To when should we intervene? And three, also, what is the intervention we should use and in what dosage if it's a therapy or if it's the medical device that's bespoke to it. And the entire idea is cutting out the inefficiencies that we see. Because we're being very reactive today, what we're going to head towards hopefully in the future is going to be something much more proactive. So we're able to predict, therefore take an action on basically an intervention before the patient really gets ill and crashes into care rather. So I see that being a huge piece. And I guess, as a kind of other secondary area. I mean, mental health has been growing substantially in terms of uses. I would again, though, think it'd be much more about how can you get a full bore solution in terms of identifying patients early and then providing them preventive care as they move through rather than you know, here's a GTX bespoke for major depressive disorders, for example.

Amos Ziv  29:52  

Yeah. Yeah, so it's really exciting to hear that from you guys. I'm sitting in between two tier one VCs and the talking about exactly what we're doing. So I don't know about, but so you think personalized, personalized approaches, I think AFib is a great example age fibulation, aging Fibulation has lifestyle triggers, it can be stressed that can be meal, it can be post exercise, and can be entered can be organic crops in the heart, one of the things that we are aiming to do is to identify these personal triggers, and actually to actually treat these patients and prevent an upcoming event with that, we're betting on that. So we're betting on on personalization, much, much more difficult task from a clinical perspective and subgroup analysis when you do that, for sure, but we're still betting on that as a big thing. And also, and also prevention, what we're doing right now is we're working on algorithms that predict an upcoming AF event, and then treat in order to prevent an upcoming event and in that regard, actually prevent the progression of afib, which is a progressive disorder. So that's kind of our bit,

Iwan van Vijfeijken  31:01  

if I may, because I'm actually a physicist by training. And so entering into the medical world, it never ceases to surprise me how poor the data is that doctors have available to make very important decisions together with the patient's right. The paucity of data is staggering. And they need to make decisions. And I think this is where wearable technology can really make a difference by providing much more longitudinal data that you can link to outcomes. Because in your speaker, yes, we are a brick, right. And of course, it's all about, ultimately, the outcomes in the whole continuum care pathway. But also within our pillar, so to speak, our break, we can also really demonstrate that outcomes are changing for the better. So it's not just I think the continuum is also providing that that evidence of improved outcomes, just by having much better information. And of course, you need to demonstrate a better information leads to better clinical outcomes, no doubt and cost savings, etc. Blah, blah. So I think there's both ways. Yeah.

Ken Nelson  32:10  

So So you hear people say that there's a softening of investments in digital health. And, and I disagree with that. So you see that 2021 was a huge outlier, obviously, much bigger than any other year. But if you compare 2022, and the trajectory that we're on, it's still much higher than 2019 or 2020. So we're heading in the right direction. I think 2021 was just an outlier. But to say that it's, you know, it was a huge bubble, and it's softening. Yeah, it's not as high as 2021. But it's still much greater than than prior years. When you think about where you are putting your money in, maybe can't talk to this, I don't know. But But how much of the excitement is around digital health today, versus versus medtech. Pure medtech.

Simon Turner  33:04  

I mean, I'd say from our perspective, it's, it's extremely interesting. We look at this field, and we think, Wow, this is set to grow, in many ways, shapes and forms. I mean, part of it is also because when you start looking even at biotechnology, medical devices, pharma services, etc, you're seeing more and more digital health integration into it, you know, as a fundamental component of it may not be the only asset driver and accompany. But it's there, it's present. It's it's gaining traction and momentum. So I think it's, it's only set to grow the big shift, I guess, we've seen a lot. And this comes down to also kind of valuations of companies, and also the speed at which deals are being executed. It's that it seems to become a bit more professionalized in terms of understanding these digital health companies, because they incorporate both tech and life science needs. Before you could probably get away with doing these Well, being companies which drove up valuations, which created kind of a frenzied cycle, that seems to have slowed down a lot more now, because some people have gotten burned. But there's also a lot more understanding that you need to get commercialization models, you also need to get the fundamental needs for life science company, which is quite different.

Omid Akhavan  34:12  

Yeah, I think I would agree. And I would say, probably a lot of the dollars. So if you think about the business that Fitbit built, right, starting with just counting your steps, right, something so simple as that, and, you know, building a lifestyle around, oh, you know, like, get your 10,000 steps. And then you look at, you know, Apple and Garmin entering into the market. You know, I think it takes and we didn't talk about this on the panel, but thinking about like consumerization of healthcare, and really consumer driven demand. I think, over time, this desire for personalized medicine and, you know, personalized interaction with digital health apps and, you know, care management using tracking of these digital biomarkers. When become the standard of care. The question is from a dollars perspective, you know, where do you as an investor take the risk? Is it in building another, you know, wearable? Right? Is it in validating the algorithm? Right, and, you know, the clinical signal that can then, you know, be put on to the Apple Watch, or the Fitbit or something else? So I think that's a question that's still to be answered as, like, does the world need another, you know, thing on your wrist? Right? And, you know, and that's a, that's a question, right? But also, how willing are these incumbents like Fitbit and Apple willing to integrate, and make it worth their while, because as I think about the commercial channel, right, trying to go and spend hundreds of millions of dollars trying to reach a consumer base and educate them on what you have, it's an impossible task that I don't think any, any healthcare VC will take that risk, you know, maybe on the tech side, they will. But as you think about in the clinical setting, right, it's it's a, it's a smaller market in terms of like locations, and, you know, stakeholders, but then it's really your, you have to prove the clinical value, right. And I think you have to work within the reimbursement scheme to make sure that you can actually fund your company and grow. And then ultimately, strategics. And we talked about this, all the acquisitions they did, I don't know if they necessarily, I mean, it's a profitable business. But I think a lot of them looked at it as a defensive play, and a way to stay relevant. And to actually capture more data on their end customer, which is the patient.

Ken Nelson  36:45  

And I think, as you see this evolution continuing to happen, we just did out Biotronik just announced a partnership a few weeks ago, with AliveCore and with Pacemate, because now you have all this data from all these implantables, these wearables, these consumer grade technologies, and now you want it to all be connected and flowing into one common platform. That's bi directionally integrated to EHR. And so I think that's the next next phase of where we're going with digital health. So I know we're out of time. Appreciate you guys all doing this panel. A lot of fun. We could talk for hours. I appreciate it. 

Unknown Speaker  37:23  

Thank you very much. Thank you very much. Thanks.