Omar M. Khateeb Interviews Josh DeFonzo, Co-founder and CEO at Mendaera

Omar M. Khateeb  0:00  
Hey everybody, welcome back to another episode of the state of medtech. We are here in beautiful Dana Point for one of my favorite all time, favorite conferences, which is the LSI emerging medtech Summit. I look forward to this meeting every single year, mainly because of the way that Scott Pantel and his team put together these amazing panels. They bring innovators and VCs and investors from all over the world to one luxurious location. I'm joined by a very good old time friend of mine, second time on the pod. That's Josh defonzo, CEO and co founder of Mandera. Josh, thanks for joining us. How

Josh DeFonzo  0:31  
you doing? Omar, thanks for having me feel very similar sentiments to you about LSI and being here, in general and in particular, being here with you in this very moment. So thanks for having me absolutely

Omar M. Khateeb  0:41  
it's a magical place. Scott and his team and his team and Henry, they do such a fantastic job. You know, it's always like, when I come to LSI, I block out the whole week, and it's just a magical week, just in terms of the conversations I had and everything. Do you feel the same way?

Josh DeFonzo  0:53  
Yeah, on so many different levels. Just, it's funny how fast time flies. I was talking to Scott earlier today, and he's like, this is the fifth one. I'm like, only this is only this is only the fifth it feels like it's been 10 years, in a good way for me. I think, you know, I've fortified, built and fortified a lot of relationships here. I mean, you and I had a long standing relationship. I think it's gotten better in no small part because of this conference. You know, working with Henry Peck and seeing him do all the wonderful things here. And I think just being a part of the community, I often joke, and hopefully this doesn't, you know, read poorly, like, in some ways, you have to be a bit of a glutton for punishment to get into medtech in this day and

Omar M. Khateeb  1:30  
age, it's hard. That's very true. It's really hard. I think Jace Jay Watkins said that on one of his panels a couple years ago, yeah,

Josh DeFonzo  1:36  
and it's not, it's it's not. I mean, I do it, I do it. Still it's not to be disrespectful to be disrespectful to anybody here in the community, but the reality is, it's hard. There's a lot of other things you could do in this world to make a difference, but I think very few of them match what can be done with medtech. And so I point being is I really like coming and connecting, in particular, with a lot of the other entrepreneurs here, trying to give advice and feedback whenever I can support them, help them with fundraising efforts. So I don't know, all in all, it's a really special part of the year for me. And I think it does set up, you know, the next three quarters for a lot of interesting things to happen. No, 100%

Omar M. Khateeb  2:11  
and, you know, quoting, quoting Jay, I think he said something to tune of his. I mean, it's just very unforgiving, but it's a very rewarding field. So that being said, you have a phenomenal background in robotics. Robotics, as we've talked about, is really hard. It takes a lot of money and a lot of luck to be successful in it. You co founded mindera, which isn't, isn't exactly the type of robotics company most people are thinking about. The question I want to ask you first is one, what does Mandara do? But more importantly, why does the world need another robot?

Josh DeFonzo  2:40  
Yeah. Well, I think in general, robotics as a category, putting healthcare aside for a second, is really, if not, in its infancy. It's still in its pretty early ages, and I think that there's a lot of opportunities for robotics, particularly with the confluence of artificial intelligence to power and control things in the physical world in a way that's very exciting, and I think probably a whole separate conversation. We need to be really responsible with these things. But I'm really excited and bullish on robotics in general. Why the world needs another robot? I think, as it pertains to healthcare robot, a lot of what we're doing at mindera, I took inspiration from other industries that utilize robotics, right? So in our, my last company, we endeavored to do really difficult things in clinical robotics, and it was really rewarding. But at the same time, I stepped back from that and asked myself, like, why aren't we using and developing robots that not physically look like robots that you see in warehousing and manufacturing, but like, why aren't we developing robots to do simpler tasks in healthcare? And with that as the thesis, you know, if you could do that and you could deploy them more scalably, maybe you would actually begin to realize that robotics can help provision healthcare in a much more highly scalable way, while reducing cost. And so it was a little bit different view on what I think you see in most healthcare robotics, that kind of was the, I don't know, the germination or the early stage of the company, right, the genesis of the company, rather, yeah,

Omar M. Khateeb  4:11  
it makes sense. And you're, you know your previous company was, ORS health, which had a big exit to J and J, but it was all surgical robotics. You kind of went off the path a little bit, in the sense that, rather than going and starting another surgical robotics company, this is a medical robot. So take me back to that time that you, you were a patient, and something you had, you had an encounter that made you say, I think I'm going to look into this, because this should be done by a robot. Yeah. Tell us that story.

Josh DeFonzo  4:35  
Yeah. So, so, yeah. Go back to the original thesis. My co founders, guy named Jason Wilson, is an incredible guy, systems engineer, and I think before we even talk about the technology that that we are developing, he and I worked together to us and got along really well. We had this saying that we would bat back and forth all the time. It's like, you know, you can't make a good product and service for people unless you're solving a problem, and you can't even begin. To build those products and services if you don't have a good business, and you can't do that if you have great company. So Bandera, as first principles is like, how do you just build a great company? And then second, we went searching for meaningful things to do in the world. And so I told you a little bit about this whole idea of, like, how can we make healthcare robotics look more like those types of robotic systems that you see in other industries? That was sort of like the initial question that we had. We'd been thinking about different robotic form factors. We wanted them to look more like robots, not even physically, but performing simple, simple tasks. There's a saying in robotics, like robots are really good at the dull, the dirty and the dangerous, and so it was like kind of a first principles thing we started to think about, and I really wanted to stay in health care. Madero was not hell bent on doing that, but that's where I wanted to stay. And I was snowboarding with my kids, and if you're 40 plus and you go into the terrain park, be really careful. I wasn't wearing wrist guards. I shattered my wrist, and I snowboard off the mountain, and the emergency department at the bottom, urgent care department at the bottom the mountain says, Hey, I got good news and bad news. The good news is, I don't have to set your wrist. Bad news is, your wrist is shattered and just need to be reconstructed. It's like, okay, cool. Let's, let's do that. Let's, let's, let's stitch this thing back up. So anyway, I go down to Stanford, and my my orthopedic surgeon starts to describe to me how they're going to perform the anesthesia ahead of the case, and they were going to do what's called a regional anesthetic block. And so rather than putting me under with general anesthesia, they were going to either, do you know, interscalene block, or a clavicular block or an axillary block. And mine didn't take for a host of reasons, and it took about three hours preoperatively for them to do this. Now if you'll recall, I was at sales rep 20 some odd years ago, and I remember things like central lines, art lines, causing perioperative delays. So I was really struck by how 20 years later, with the ubiquity of handheld ultrasound imaging, that these things were still difficult. And so woke up from the procedure and started asking my orthopedic surgeon how often this happened, and he anecdotally said, 20% of the time we're having pretty big perioperative delays. So we then began to look at all of the ultrasound guided image, ultrasound based image guided procedures that were performed, everything ranging from organ access for the purposes of biopsy to vascular access, either perioperatively or in things like hemodialysis as well as pain management procedures. So again, regional anesthesia, joint injections, and as it turned out, we bought all the claims data across all those procedure sets, and we started to look at patterns of how the care was delivered. And there's about 500,000 healthcare providers in the United States that perform these procedures. It's literally 10s of millions of procedures, 3% of them, about 15,000 people provisioned 60% of the care. And we started like, Well, why? Why is that? And it turns out that the learning curve associated with things is really, really hard. And we also thought that, you know, there's not necessarily that badge of honor, so to speak, when you're like, hey, I did a PICC line, or I did a CVC, or I did this biopsy and it worked. These are procedures that should just work, and they should just work when provisioned by most anyone. And so that was the thesis, and that was the beginning of mindera. Is how do you build small form factor robots? Combine them with imaging AI and now connectivity, in order to enable highly repeatable, highly precise, highly scalable. We refer to them as gateway interventions. So all the interventions you need to have before the big intervention, whatever

Omar M. Khateeb  8:19  
that may be, fantastic. And so from there, you know, how did you go about? I just, you know, recruiting the team, designing the system. And, you know, first, you know, first use case of that application,

Josh DeFonzo  8:30  
yeah, so Well, recruiting the team. Feel really fortunate. We had a number of people who had worked together at oras. My co founder was at cruise autonomous vehicles, and we just reached out to a few people we really enjoyed working with that we knew were polymaths of sorts. So you get your first five to 10 people at a startup really need to be able to do most anything, at least to like a Grade B level. And so people who are polymaths are willing to wear different hats, but who believed in the vision and the idea like, hey, we want to develop robots that can be really pushed to the edges of healthcare to enable all providers to do more for their patients. That was the vision. And we for the first six people, we didn't even have a napkin sketch. It was like we had an idea what we were going to do. And so, you know, we were fortunate enough to recruit, let's say, our first half dozen to dozen people based on the vision, and then from there, it really became just tons of user research. I mean, in this conversation, I've described myriad applications that have different end users and different use environments with nuanced clinical needs. And so we did a ton of user research. So Alex Hassan leads product at my team. He's got a great group of clinical engineers that work with him. They have literally engaged more than 1000 healthcare providers. And by contrast, in my previous companies, like, if you get to 100 that's pretty good. And so we did that. And we, you know, why so many? Because it's such a heterogeneous thing, I mean, and this is one of the things that is so exciting. About what we do. But also, you know, challenging to sort of wrap your mind around and then wrap and operating a plan around is you can literally take this anywhere. I mean, if you are someone performing a vascular cannulation in a skilled nursing facility, this should work for you. If you need to be more accurate with your fine needle aspirations or your biopsies in an interventional radiology suite. This should work for you. And the reason is the common denominators that we're dealing with here is a real time handheld imaging device that needs to be utilized very fastly by the end user, right? They need to be able to acquire and interpret images. Those are the first two challenges. And then you need to be able to put a needle or a needle like device in the body, so you have to be able to plan and execute the procedure. And the common denominators are very similar. It's imaging and needle based instruments. So who uses needles and ultrasound based guidance? Tons of people, not just physicians, it's not physicians. And when you look at that Pareto that I was describing earlier, of the types of healthcare providers that do these techniques. It is not just doctors. Some of the highest volume people, in fact, are nurse practitioners, physicians assistants, certified registered nurses of anesthesia. And so that served as a Proust point to us that this can be done, but it's just not as approachable as it needs to be. And and so I don't answer your question, no, absolutely.

Omar M. Khateeb  11:19  
And of course, like you know, we share, we share, sort of Mediterranean sort of Mediterranean Health Heritage. So I'm glad that you mentioned the great Italian Pareto with the 8020 so looking at that, that you're trying to find, what is 20% of the whole that's going to give you 80% of the yield? Who was that in the in the clinical environment, was a pas? Was nurses? Yeah. So

Josh DeFonzo  11:39  
there's a couple, a couple of really important use cases. It's really about cases. It's really about empowering the group that is provisioning the care in a way that is more efficient right now, now that the beauty is in the eye of the beholder. So there are certain operating room based applications for this technology, where today, the standard of care two thirds of the time or more is to facilitate percutaneous access to the body through complex care coordination. So what does that mean? There are a number of organ access based procedures where, before the actual surgical procedure is performed, some other specialist could be a radiologist. An interventional radiologist will perform percutaneous access for the purposes of facilitating a plane for the insert surgeon to perform the technique like that. That makes no sense that that happens. You know, you should be able to do that in one shot. And a lot of the limitations are the fact that that some of the surgeons we're describing here are not necessarily comfortable using all types of, you know, radiologic imaging to facilitate access. But so how do you unlock that? So that's one example. There's another example, particularly in interventional radiology, where interventional radiologists provision care up and down the stack. They do everything from, like, high acuity embolization to, you know, oncology based work to ablation work, and then sometimes they're doing PICC lines, right as an example.

Omar M. Khateeb  13:00  
And so big spectrum of like, simple to very complex procedures. Yes, very big. And a radiologist with whom

Josh DeFonzo  13:06  
we were discussing our technology has been testing for us. Like, the metaphor he used is like, imagine I'm a race car driver, right? Like I should be able to and I should only be driving in f1 races all the time, but sometimes I have to drive an Uber X. No offense. Name is driving Uber X, but I have to do that, and that's not the most efficient use of my time. And when you think about some of the most prolific people that I described in that Pareto who are doing those 15,000 people who do most of the work, a bulk of them are IRS, and there are not enough to go around. So how do you scale the work? How do you optimize their day? How do you optimize the service line? How do you optimize the revenue for the hospital? Most importantly, how do you optimize the experience for the patient. It shouldn't be the case that if you're in critical care or emergency medicine and someone can't do an ultrasound guided percutaneous procedure, you should be like, admitted and sent to IR. That does happen. And so the whole goal here was like, how do you just more efficiently distribute and deliver that care? Right? So that's the other use case. And then, long term, for us, the two I've described thus far in the or and the IR that's in your traditional brick and mortar ASC hospital setting. We do want this longer term. The vision is to be able to empower people in alternative care sites, skilled nursing, infusion centers, home health. How do you enable some of these gateway procedures to happen more on the periphery of care, and keep them out of the hospital whenever clinically appropriate? So that's not our starting point, but that's certainly the destination, no, and it makes

Omar M. Khateeb  14:22  
a lot of sense of what I a lot of sense. So what I like about what minder is doing this is why, you know, I wanted to have you back on the show, is that I personally get excited about med tech companies who are not only solving a very important clinical need or clinical problem, but in that process, through, let's say, automation or data or the combination of those two, take the skill set of a certain expert and then put it at scale. So in this case, you're absolutely right. It does not make sense that for certain procedures that, say a surgeon's doing that you have to call IR somebody else just to provide access, because that's a very expensive procedure. So in this process, not only are you increasing the efficiencies of the or or efficiencies of those procedures, you're lowering the costs. Right? And the thing that you. I maybe I'm wrong about this, but sometimes we often forget we talk about the patient. We also forget the patient is also a customer. So as a part of like, customer service and experience that you have to go through, like being a patient, and again, what you went through with it, that was a real pain. Not everybody's a young guy. Sometimes you're older, and it becomes a huge headache, like if you get transferred to a different unit to just get certain access done. So I really like that you guys are doing that now. That being said, if we look at the technology adoption curve, okay, for every startup, the early early adopters, the tech enthusiasts, are super important, right? But more importantly is the beachhead. So in everything you just described, you guys have raised some money. You got some great partnerships, which I want to get to in a moment. What? What do you think is the beachhead?

Josh DeFonzo  15:44  
Yeah, so we're, for a couple of reasons. We're not, we're not disclosing that, right? I had to ask a question, yeah, yeah, like I said, there will be, I'll tell you the three call points. So sure we, you know, aspire to and assuming that everything goes well on the regulatory front, we'll be in market sometime next year, and we intend to place systems in operating rooms, in IR suites and in calfoots. And then there are specific procedures that we will focus on to at least demonstrate a proof of concept, but B clinical utility in the form of post market studies, and then, then from there, you know, we have to be really thoughtful about, you know, what specialists are we going to go to, and how are we going to develop those markets? So we hope to be more public about that. In the near future. We're just finishing up some final work, both with the FDA as well as with, like, the initial groups and practices with whom we will ideally go to

Omar M. Khateeb  16:38  
market, absolutely, and in which case, hey, come back to Shaman. We have a lot of fun. Anyway, yeah, we could do

Josh DeFonzo  16:42  
a couple. Could do it a couple weeks. We're moving in a different time scale here. Yeah, no,

Omar M. Khateeb  16:46  
definitely. You know, the other thing I wanted to ask you is, so to date, how much? How much have you guys raised total

Josh DeFonzo  16:52  
to date? Yeah, we, we just closed another round. So we raised approximately $44 million inception, to date,

Omar M. Khateeb  16:59  
fantastic. Now, what's unique about mendera, in my eyes, is that usually, you you end up seeing big partnerships happen a little bit later on in the life cycle of the company. For you guys, based on the technology, the team, which you know you all, I know you all, personally, very humble, but I will say it's a star, star stack, chain, yeah, they're, you know, incredible team. Few months ago, you announced a partnership with butterfly, which is a really fantastic handheld point of care ultrasound company, CEO Joe DeVivo was on the show. Tell me a little bit about that partner. How did that come about? Why not develop that tech in house versus partnering? And you know what was, what was the strategy behind that? Yeah, so

Josh DeFonzo  17:40  
we knew early on. I mean, some of the lessons learned from our previous robotic experience was, it's great when capital markets, private, public, otherwise, are amenable to totally vertically integrating everything and building it in house, but that's also a lot more capital intensive, time intensive. And so we knew early on we wanted to work with ultrasound in general. The main reason being, if you kind of go back to first principles and what I was describing earlier, had we chosen CT, had we chosen MRI? Have we chosen even C arms as our imaging modality of choice for our technology? You'd have far fewer locations where those could be deployed, because of the footprint, because of the footprint, they emit radiation. They're more expensive. And so by design, we said, well, the only real time imaging that can be more ubiquitous, but, you know, ironically, is harder to use, relatively speaking, to some of those other imaging

Omar M. Khateeb  18:30  
modalities, is ultrasound. And can you explain to the audience, why

Josh DeFonzo  18:34  
is it harder to use? Yeah, the way to think about it is, you know, if you were to take an x ray of the hand, right, you and I could look at that, and it's like the metaphorical equivalent of a flood lamp. Like, great. I can see this is a hand. My five year old would say, Dad, I think that's a hand. By contrast, ultrasound is a moving plane in space. And so without getting into the complexities of what type of probe Am I using, what are the settings, what type of where am I imaging in the body, just assume that that's all standard. You essentially have a plane that is moving through space. And so you're only seeing the equivalent of one slice of what would be an MRI scan or one slice of a CT scan, and you don't always have the resolution necessarily to even be able to interpret what that particular slice is. So again, instead of seeing the flood lamp view of my hand, imagine I'm now looking at any one slice of the hand, and someone gives you, it's a slit lamp, flood lamp versus slit lamp. So what am I looking at? How do I how do I understand what it is that I'm looking at? There's a lot more

Omar M. Khateeb  19:28  
variability in terms of interpretation based on very user depends, parents, very user dependent.

Josh DeFonzo  19:33  
People hold them differently. People cogitate the information differently. Some people are much better at spatial thinking and scanning and saying, Okay, I'm going to build a roadmap in my head of what I've viewed, both immediately and a priori, and where I'm going. And so it's just, it is a an imaging modality that is very elegant, but is left to more user dependency and interpretation. But we wanted to use it nonetheless. And so. Part of what wire software ideally will overcome are those image acquisition and interpretation challenges. Now we don't start there. We're starting on the procedural side. But certainly the goal is to have the entirety of the solution address both ultrasound specific challenges. And how do I acquire and interpret images, and then, when clinically appropriate, how do I do something about that diagnosis? How do I do something rather than reflexing and saying, I don't know, send them to IR, I don't know, send them to the endocrinologist for a biopsy, right? And so the whole idea is, how do you compress that care curve, and how do you use robotics to do the interventional side, and then software and AI to help with the interpretation piece? So

Omar M. Khateeb  20:36  
Pocus is a has been a big thing for the last decade or so. You have a multitude of companies that you can go with. What about butterfly made you say that this is the right partner for us?

Josh DeFonzo  20:46  
Yes, you were asking about that. So I've been fortunate enough to know the butterfly team even during my days at Orest. There's just a lot of overlap there network of folks with whom I worked at Oris knew people who were at butterfly, and so I got to know them early, and was compelled by their technology and John rothberg's vision to really democratize imaging. You know, it's been a journey for them. I've known them against Since 2016 we, when I founded Madera, we stepped back and with a great deal deal of naivete, said, We want to be an ultrasound. What does it take to make your own ultrasound? And we looked at butterfly, and we looked at Echo imaging, and we looked at and when I say, look at, we looked at the financial profile. Just to be clear, we weren't looking at the technology and all of those companies and others. We looked at, I think even looking at, like, sonicite, back in the day, taking their investment dollars to today's dollars, I think inclusive, their IPO, every one of them had raised north of $200 million a lot when we were looking at this, Mandera raised 2 million. So we're like, Okay, we gotta build a robot, and we're gonna build our own ultrasound. So we, day one said, you know, we really want to work with a partner. We don't want to make the ultrasound imaging ourselves. And so after we had prototyped, you know, we hacked together a couple of concepts. During that first, you know, period that I described earlier, we essentially worked with a couple of companies, where we were taking digital video out signals and HDMI signals out and showing that a robot could work interoperatively With that, but we thought it would be much better if we had a tighter integration. And so we approached a number of ultrasound companies, the first of which was butterfly. There's a lot of reasons to like their imaging. It's a single body scanner, right? So they have one scanner that will literally scan everything from the abdomen to find vessels for things like regional anesthesia. So being able to have one imaging system that could do whole body scanning when we were trying to do whole body intervention, and a compact system to that, it's compact, it's portable. There's some other really interesting things that Joe and Joe DeVivo, Daria, Shahida, Heather Goetz and the team just invited mindera to a New York an event with butterfly at the New York Stock Exchange. And so this is public information, but they've got some really interesting features. So unlike PZT or piezoelectric imaging that is sort of a fixed plane, butterfly has ultrasound on chip technology, which is an array, and they can essentially assign those individual channels to do things like beam steering and look at simultaneous views. So it starts to, in some way, become a little bit more like MRI, where you can look from different angles. Now, that's a lot for a user to interpret. I was

Omar M. Khateeb  23:12  
gonna say because, because that's in the hands of the right user, that's great. But most users, they're not going to be able to take advantage of those kind of features unless you automate a robot.

Josh DeFonzo  23:20  
Correct? Yeah. So that's the whole idea. So the whole idea, we are going with a handheld paradigm here. And so they are an important partner to us, because we believe that we can use their imager to help compensate for patient motion or user induced motion, to ensure that when you are delivering an instrument to the body, it hits the right target. And so there's a lot of advanced features that they're bringing to bear, which we're really excited about. That's

Omar M. Khateeb  23:41  
fantastic. And it's such fantastic. And it's such a nice I love seeing partnerships in medtech that really makes sense on paper. Let's face it. I mean, not all partnerships go well, and sometimes even on paper, before they get started, you say, like, why are they doing this? But when I saw that, at least the press release, I said, That makes so much sense. Yeah, I got to compliment you and the team on something, by the way, which is, you know, I think part of being a med tech startup is the ability and discipline to have focus, I think too often, especially, and again, I'm just interpreting from my from where I'm sitting, given your background, Jason's background, the team's background, you have every opportunity to raise up to that 200 million, say, Yeah, you know, we're going to build our own Ultra and everything. I feel like it took a lot of discipline and humility say, you know, what? Could we raise that money and do it probably, but we're not, because it's better for us to stay focused on building the best medical robot we can and partner with somebody who knows us better. I just want to compliment you, because you don't see it as often in the industry. I feel like it's a great example. Yeah, I

Josh DeFonzo  24:39  
think it's, you know, yeah, you got to take inventory in stock of where you are. So a lot of it is so, so where we are ambitious is we want to be able to do many, many procedures. Now, again, you're asking about beachhead. We can't boil the ocean and start them at once, but we want to make sure that this system doesn't have any sort of, like, unplanned obsolescence, right, where you're like, Oh, I didn't, I didn't think about that kind of. Future. So we spent a lot of time making sure that the workspace and the workflow is amenable to all the different techniques that we're trying to pursue. Having said that, I think we're all super ambitious. We would love to build our own ultrasound, but at the same time, it's like, Is that the best return on investment of time, capital, effort, and that, just for me personally, came with a lot of experience, and the fact that there was, there is an ecosystem of technology in the market, like I said, really like butterfly, we've got some other incredible partners that we hope to announce as well, but we really feel like the application of robotics here can transform pocus to it can elevate it to the next level, and it can do that by empowering people, not only to get information, not only to get answers. That's what you think about with a lot of pocus, is like, it's a digital stethoscope. How do I get answers about this? An answer in the clinical domain, most of the time with these things, is like, Oh, the answer is suspicious of X diagnosis. Go somewhere else. So what we want to be able to pair with those answers are action when appropriate. And so I think that this really will help people use the word democratize a lot, and it still makes me cringe when I say it, but it really will help democratize. And really it's care enablement. How do you improve access to these procedures by speeding up the time with which someone gets them? And so I just think that that particular segment, point of care, ultrasound, is ripe for innovation. More people are training with it almost everyday. Medical students beginning to train with this. And if you want to skate to where the proverbial puck is going, you should say more people are going to get comfortable with this, and they're going to start doing procedures. How do I accelerate that? Because we have a health care system that is just totally overburdened, like, and so this is a big part of that. It's like, how do you improve patient care? How do you help the providers from burnout, like, you have to be able to distribute these things better?

Omar M. Khateeb  26:40  
Yeah, because I think one of the problems with healthcare today, in my opinion, the last, like, you know, 30 years, with the explosion of technology, that also added more complexities to things, right? And add, as we added those complexities, we didn't fix some of the previous issues of healthcare. And so now, you know, for a patient to, let's say, go from one, from a diagnosis to procedure, there's all kind of things that happen that that increase that timeline. Yeah, it's hyper specialization, you know, for the action that you have to take.

Josh DeFonzo  27:05  
Yeah, it's hyper specialization. And it's like, we have this saying too. It's like, what we focus on is the messy middle of health care, right? And if you go from that initial consult where something's might be wrong with you, to that initial scan that suggests something should happen to everything between there and whatever your end of line care is, I don't mean end of life care, but whatever, like the resolution is, like that middle part is emotional. It's drawn out in terms of time. There's many consults patients are paying a lot of money, and I'm not so naive to think that overnight this is going to change, but I think you really do want to empower the system with technologies that can help streamline that care wherever possible. And that's what this was really geared towards, like a robot for the middle of healthcare, for gateway procedures that need to be distributed in a dramatically different way than they are today, you know, and will probably be misunderstood for a long time using some Jeff Bezos language. But I'm willing to fight that fight because it's something I think is really important

Omar M. Khateeb  27:56  
and, you know, and I do like that. It's a medical robot for the messy middle of healthcare, yeah, you know, as you kind of round things out, and I appreciate you coming on the show, and I always have fun. Yeah, I seem here, same here, you know, really, really exciting to see. I was sitting in a session yesterday at LSI, and you texted me some news, and I was like, oh, it's Josh checking me. I remember kind of almost jumping on my seat. I'm like, Wow, that's amazing. Is, you know, one of the companies that you know, I had the CEO on, Daniel Hawkins, on the show was avail med systems, which was a phenomenal, phenomenal technology, really exciting and very unfortunately, not to close up shop. And again, unvaried characters, not, not very characteristic, like of a startup you guys made acquisition which you acquired their assets, which was very exciting, exciting for me explain to the audience why make that acquisition, and how does that tech enable what your company's trying to do? And for those who are just learning now, tell them what avail does.

Josh DeFonzo  28:53  
Yeah. So we acquired the assets of avail med systems. Avail essentially developed a telepresence platform that enabled healthcare professionals, not just providers, to connect in and around the operating room. And so it's essentially a connectivity platform that allows remote healthcare professionals to essentially dial into an operating room, either for the purposes of case coverage, medical education, proctoring, you name it. So we really see it as a way to connect more healthcare providers together for Menderes purposes, one of the important things that we want to be able to do to really dramatically tap into this idea of care enablement. So, like highly scalable intervention, is one way to do that is to use AI and make the robots fully autonomous. Another way to do that is to scale a provider so that he or she can connect with more people. And so we do fully envision taking elements of the avail technology and enabling teleoperation of our robotic system. So there's a couple of different use cases for that. So if you think about the IR who's overworked, or an intervention. Personal nephrologist, or whomever it might be, being able to care for more percutaneous procedures, either remotely, in a totally different locale, or within a healthcare system. There's a need to be able to scale that and to use the robots to empower a frontline provider to do more. And when they have questions, call that professional and they can dial in and help. So that's really the destination for us. We saw value in avail for a number of other reasons beyond the destination. I mean, one, they are in a number of hospitals and healthcare systems that are important to us, that we expect will be partners with us. So being able to work with those, those facilities who have been working with avail, and then use it as a way to introduce Madera is also important. And

Omar M. Khateeb  30:37  
I love that, because when i That was the other thing I thought of, they'd already established a pretty nice footprint. So in a way, you kind of acquired, like, really good distribution, which is one of the big problems that a lot of medtech companies face when they're commercializing.

Josh DeFonzo  30:47  
That's right. So, I mean, in a wildly oversimplified view of the world, I mean, I think med tech companies face like, three big chapters in their life. The first is the development, the clinical, the regulatory, right? And not necessarily in that order, it could be, could be development, regulatory, clinical, that's chapter one. Then there's initial market development and market adoption, which is different from the third chapter, which is scale. And that second chapter is where things get really hard, yes. And so for us, it's, you know, there are no shortcuts in life. I don't think this is gonna gonna make that second chapter like easy for us, but it certainly will compress it in some ways. And so what we intend to do with the technology, is anybody who is using avails technology, we're certainly going to support. We are going to announce a program called Mandera connect, where we will work with a number of select facilities to essentially not only utilize and collaborate with us on next generation telepresence, but also teleoperation of the robot and initial adoption of the robot. And then we're going to explore strategic partnerships, obviously, for people who were using the avail technology for connectivity. So those are really the three efforts, all of which are a foundation for, a, introducing Madeira as a company, but B, also introducing the, you know, the pending launch of the robotic system. That's

Omar M. Khateeb  31:59  
fantastic. And I love that is that that, in my opinion, strengthens the thesis that you have about being in the middle of healthcare and all the problems that you see there. And I think that takes, in part, you know, like innovation on technology. In some ways, I don't know if you would call it operational innovation or business model innovation, but you're doing that essentially with that acquisition of avail, would you? Would you agree

Josh DeFonzo  32:18  
with that? Yeah, the real, the real big thing here for us to test is, I think, I think tele presence is important, but, but tele operation is equally important, and so. So this is an opportunity for us to go out there and not only work with previous avail customers, but new Madeira customers, and really co create and explore with them. You know, we, our portfolio now has, has, including our imaging partners, four key assets, right? We've got robotics, which we think are a highly scalable form of robotics. We have software to help with the interpretation and acquisition of ultrasound images. We have the imaging. We have the connectivity. And so whether you're talking about connecting people better at a complex tertiary care center, whether you're talking about connecting a network of community hospitals or IDN hospitals, or whether you're talking about connecting, connecting distributed. You know, home health and alternative care agencies like I do think that we in our portfolio have four key technologies that can be stitched together in different ways to really help scale. You know, you know, both intervention as well as diagnostics using imaging, fantastic.

Omar M. Khateeb  33:17  
And Josh, just as we kind of round out the interview. And again, thanks for coming on the show. I always have a great time with you. You know something I want you to, want to give you an opportunity to do one is, you know, as a startup, you're always raising money, but at the beginning, though, but Well, hopefully, hopefully, you know. And again, credit to your team. You found ways, because it takes a lot of money to take a medical robot to market, but you guys have found ways to be very disciplined and stretch $1 really far right at the very beginning. Who are some of the early investors that believed in you guys and funded you? Yeah? And if you can kind of tell us, tell us a little bit about them and maybe some of the things that they helped you along the way

Josh DeFonzo  33:55  
with, yeah. So we're really fortunate from seed and a onward. We've had great investors. So Lux Capital Management has led a lot of the effort. I've gotten to know some of the folks at Founders Fund who've been really supportive and guiding me, not only financially, but on operational matters. You know, how do you scale? What is the equivalent of like a prosumer product, and what sort of suppliers and vendors do you go to for? You know, future scale? They've been really helpful. Shout out to operator partners, Nat Turner, Zach, Olivia Benjamin and the team been super helpful to me. They are, like, they are founders turned investors that are, like, incredibly, incredibly supportive. I can't say enough good things about them and the others on the team. Some of the folks at Allen and company have invested investment bank, and they've been wonderful partners, and then we have a number of, you know, unnamed family offices that are also participating, in addition to Fred Moll, Jay Flatley and others. So we've been really fortunate to have wonderful backing. We are going to go out imminently for our series B, with the intention of raising capital and. Not only to support the launch of our robotic system, the regrowth and build of the telepresence platform, but also there's a couple of other acquisitions that we're really interested in adding into the bag. So fantastic.

Omar M. Khateeb  35:11  
Well, I'm really excited to sort of sit in the stands, sort of eat popcorn, and watch you guys do your thing. It's been, it's been exciting so far. And again, you know, you guys are, you know, coming out on the market soon. But Josh, I really appreciate it for those who are listening, especially those who are driving the car. Where can they go to learn

Josh DeFonzo  35:26  
more? Yeah, you can learn more about us@mendera.com

Omar M. Khateeb  35:29  
Can you spell it? Yeah,

Josh DeFonzo  35:31  
we suffer from spelling challenges. So the company is www, dot mendaera, m, e n, d, a, e, r, .com (www.mendaera.com). Fantastic.

Omar M. Khateeb  35:41  
Well, Josh, thank you so much. We look forward to having you back on the show with updates. Always

Josh DeFonzo  35:45  
a pleasure. Thanks for being here, and I hope you enjoy the rest of LSI. And thanks again to Scott and the team for having us as well. Big

Omar M. Khateeb  35:52  
shout out to Scott and the team. Yeah, absolutely awesome. Thank you everybody. Man, yeah, pleasure. You.