Henry Peck 0:07
Perfect. Thank you, Scott. And thank you again, everybody for being here. Welcome to this morning's keynote, hope the event is going well for you. And thank you again for joining us in Dana Point. This is a conversation that, as Scott mentioned, spans not just one company in our community, and not just one pillar of the things that we try and do here at LSI. But what Dan and what Dr. Moll are doing is transforming the ecosystem that we're in and affecting so many of the companies that we that we work with. And so, before we jump into all of the the content, I want to let these two incredible gentlemen introduce themselves, and then we'll get right into it.
Daniel Hawkins 0:46
So I'm gonna go first, because I can't follow you. Okay, yeah, it's probably a bad idea. So, Daniel Hawkins, I've been in the med tech space about 30 years, started my career in angioplasty. And then had the privilege of joining Fred as the first non engineer at Intuitive Surgical. And I'll say we made some good progress, we did some pretty good things. Right? We went on from there. And I ended up earlier, an earlier stage involved in the formation of a number of companies was founder of a couple, just prior to this when I was the primary inventor and founder at shockwave medical left shockwave in 2017, to solve a fundamental problem in the industry. And that problem is some of what we're going to chat about today.
Fred Moll 1:27
Great, thanks, Daniel. I'm Fred Mall. And I'm a physician by training by best known for being a founder of Intuitive Surgical, since Intuitive, have done a variety of other initiatives in robotics, as well as other medical technology and was lucky enough to be one of the early investors and board members of Shockwave. As well as probably the other early very significant robotics entity, Mako Surgical, so have sort of grown up with the the industry of robotics and, you know, really excited about where we are in time. And what's next.
Henry Peck 2:14
Awesome. So, Dan, let's start start back in, you know, in the late 90s, when you in our earlier conversations told us this vision for the idea of a digital OR is not something that's new. And it's not something that is dated with the technology that we have, but we'd love to hear kind of when when does this start? Where's the genesis of this conversation of a digital OR?
Daniel Hawkins 2:38
Yeah, so really, in many respects, digital OR started off with the notion of how do we clinically enable what's not possible with the human hand and credit, Fred for the vision of remote, if you will, the battlefield surgery is actually remote, 10 feet away, and let's put a computer between the surgeon's hand and a patient enabling new clinical capabilities. Right. So that was, that's where we all started off, if you will, in robotics. And one of the things we quickly discovered with that is, it's hard, right? It's not not only hard, technically, it's hard. Operationally, it's hard in terms of workflow. It's hard in terms of, of, of creating the true clinical enablement from the technology that you've built. And there's an observation that Fred made in a cadaver lab in 1998, right after the cadaver lab, we finished we're chatting a little bit. And please note 1998, Fred said to me, you know, it'd be really cool. If this surgeons could work together on the system. That's what we called it before it was named the da Vinci. And when you really think about that, that's actually what we need. We needed a way for that to happen. And of course, in 1998, is when Google was founded. Right? So fast internet was a T one line, and you had to wait six months to get it. The digital awards, started initially with clinical capability, and then moved on from there to workflow capability. And now the future is technology leaps and bounds increasing from here and it has a foundation in robotics. It's well past robotics. I think we all understand that individualization workflow management and a whole lot, a lot of other clinical enablement. And it's really kicked off much more than robotics, where we started off with that intuitive. What are your thoughts here, Fred?
Fred Moll 4:24
Yeah, so it's really interesting to when Daniel says we had this conversation about wouldn't it be great to work together? And I'm sure all of you think well, surgeons work together, they talk about what they do. The fact of the matter is, you know, when I was in training in surgery, the operating room and to some degree, it's still true, but it's getting better. The operating room was sort of a black box, you know, it's sort of like Las Vegas. What happens in the operating room stays in the operating room, you know, and there was a lot of communication after words. But what all the information of what happened in the operating room was lost. And I think just the most powerful part actually, of robotics and robotic technique is not changing technique so much as having a computer between surgeon and patient. And therefore having the opportunity to record when I was in training and it endoscopy first got a TV screen. In other words, they put a camera on the endoscope, rather than looking through the lens manually. And they put it up on the on the screen. And they said, you know, Dr. X, we can record this, he says, Turn that damn thing off. Because it was more of a liability than an opportunity, right? And, again, this idea of what happened in the OR is my business well, it's no longer your business. It's everyone's business, because it does represent the opportunity to take information and process it and feed it back into the cycle of the patient journey. And, you know, I really think that is, that is a huge step in improving outcomes, quite honestly.
Henry Peck 6:33
So you mentioned, you talk about these things that these discussions you were having in 98. And you referenced the world of technology that was around I mean, my earliest technology memories, playing on a home computer, like using Club Penguin on dial up, right, things like that, where you're having conversations about surgeons, being able to collaborate, the reality of the situation and the world that you're in, talk to us a little bit about what was what's going on at Intuitive at that time? And what are you building? What are you working on? How is this thought of a digital OR pervasive through the work that you're doing? And the conversations you continue to have? You know, well, before the technology catches up?
Daniel Hawkins 7:12
Yeah. So you know, it's interesting to think about Jacque Moresco of IR CAD, you know, whenever you talk to him about the history of, of development of robotics, what he's most proud of, I think, in his career, is the experiment of doing a gallbladder transatlantic gallbladder procedure, which was done in what 2000 Yeah. And it was done once, and it was never done again. Because the technology, the digital technology was not ready to make that procedure. Both safe, and something that was practical, we have come a long ways from there, we're still not doing telesurgery in the way that, you know, you know, I think it can be done, and we'll be done. And in that sense, it really has demanded the development of a lot of capability and a lot of technology that just wasn't around. And I think one of the things that Avail represents is the ability to take that step towards reliable communication that can safely integrate itself into communication of doctor to doctor, no matter whether they're six feet away, or 600 miles away. So one of the things I'm interested in you and I spent some time chatting about with Fred is the evolution of Intuitive started with a robot. And over time, that got more and more into clinical practice. And then there was this realization that that robot now has computing power you can bring other technologies into and then there started to be this ecosystem around that robot. I think it's useful to try to lay a little groundwork to how you think about the evolution of robotics, the ecosystem and where we're ultimately headed in terms of digital enablement. Really, it started off with what you did with Intuitive and through other robotics efforts. Now we're what 30 Plus robotics companies that are out there right we were just in Dubai at a conference that they put on talking about all of that that it's is more now seemingly to me around what can you do not only with robotics, but as a foundation of robotics. Where can you take it further and what is the what does a digital OR actually look like?
Fred Moll 9:57
Yeah, so you It's, it's interesting to think about the progression of the technology. And obviously, the technology has two pieces, it has hardware, and it has software. And it's easy to say, it's not about the hardware anymore. It's really about the software and enabling the software to do more things. The robots have, you know, 1998, the intuitive robot was, you know, was not an intelligent device, it was a capable device, because it gave the clinician the ability to do things, in a way they were unable to do in a minimally invasive fashion. But the opportunity to create true intelligence of a robot is something that obviously has everything to do with with the software. But there's a there's a necessary component of hardware as well. So, you know, and I think the, the progression is, is a very interesting sort of dance between what what's the minimum hardware capability that you need in the OR, to then advance the intelligence, the software, that really takes the capability of that hardware to a whole different level? And so, you know, I think, you know, there's sort of the sky's the limit. And, you know, some of this, you know, conversation when you start talking about AI and ML and what everybody wants to talk about the future of, of that of those capabilities, you know, in surgery, it gets down to, okay, what is the surgeon going to do? And what is the machine going to do, and where is that bright line, past which you don't want to cross because, you know, at some point, it isn't about capability, it's about knowledge and wisdom, that, that make sure that you're doing the right thing on the right patient, for the right result. So we're entering that phase. And, you know, we were just talking earlier, I use the example of, of colonoscopy, a very simple procedure that absolutely, positively could be automated today. And why do you want to do that, and, you know, the very real data around why you'd want to do that has to do with the software programs, that tells you something about a manual colonoscopy, and if you use it, how well you did or what spots you missed, what you could have, you know, focused better on what you might want to go back and look at. So that's, you think about that's extraordinary, that it is a teaching tool, that can be real time. And if you combine that with a robotic technique, you really have the ability potentially, to automate a procedure that doesn't require. And this is kind of where you have to obviously start doesn't require an enormous amount of fine technique, but can lead to a situation where you have dumbed down the technique enough, and you've increased the intelligence enough so that you have a procedure that potentially could be handed to, you know, in a in a diagnostic format, to a physician's assistant with oversight. You know, from a gastroenterologist, that's a huge societal change that maybe we're not ready for. But it's certainly the technology is knocking on the door of that capability. And, you know, it only, you know, gets more interesting from there.
Henry Peck 14:15
This vivid picture that you guys paint from the robotics evolution from those early days, to where we are now, kind of fast forward a little bit, 2017, you mentioned this, this inflection point after Shockwave, you're starting this new company, you're building Avail and and this is now the moment what are the key inflection points along the journey from the 1998 conversation to that 2017 moment, or maybe the moments that preceded in 2017 where you knew the technology is ready, the you know, it's ready for this to happen now and we're gonna start to really catalyze it.
Daniel Hawkins 14:50
So, you know, the technology in and around what became ultimately Avail really was was available in the consumers space. But what's more important, I think, in our view here is within the digital OR there's a fundamental set of problems we were trying to solve way back in the Intuitive days, right? I mean, the very first DaVinci sold was sold into hertz interim Dresden in Dresden, Germany. And one of the people on this stage was asked to go there for a month. That would be me. Right, so there's there was a workflow problem we had to deal with. And we needed to solve that problem, it was to take a closed chest limit led sorry, left internal memory ascending artery to LED single vessel bypass, from the original experience of 12 hours, take it down to 45 minutes in my deal with ven CEO Lonnie Smith was I need to do three of those in that OR before I was allowed to come home. Right. So we were able to do three of them in 28 days. But there's a process flow that had to change. And that became a core underpinning of, really, my understanding and my belief system. And, Fred, I'd love your comments on this. But, you know, as technology leaps forward, the need to bring that technology into clinical practice, then requires an enormous amount of technical support, clinical support, workflow change, and as an industry, we can push tech forward. But the reality is, it ain't gonna get taken up. Unless we support the devil out of that. And as as a plain proposition, those people don't grow on trees, it's really, really hard to be able to scale those things, those kinds of capabilities and bring clinicians from, that's really cool, too. I'm using it every day.
Fred Moll 16:43
Yeah. I mean, I think, you know, a very good example of this is, you know, in the early days, Intuitive little known fact, you know, when we said, Yeah, prostatectomy, rather than heart surgery might be a pretty interesting target. That when we started in procedure development, the first prostatectomies were were done locally, in, in the East Bay, California, by a little known urologist who was in private practice, that thought it was a good idea to try and use the robot to do one of the procedures he was doing in an open format. And he got extraordinarily excited about it. But he, he was a, you know, a guy in local practice that had no ability to communicate what he'd done, why was a good one, why it was a reasonable thing to do, and how he did the procedure. So in other words, there was no ability to export the knowledge that he had gained as to what's possible with the robot. And so I think, what is so powerful, and instead what happened is, we signed up many men in at at Henry Ford Hospital, who had an resident group, and decided, I'm going to make a procedure out of this, and I'm going to tell the world, it took some time because telling, how do you tell the world? Well, you can write a paper and wait for it to be published, or you can talk about it society meetings, but what you can't do is instantly communicate a technique real time to another clinician. And so it did take some time, and he was dedicated to developing a procedure that could that could be exported, and sort of the rest is history. But it I think it goes directly to what are the possibilities with a system like Avail? And what's possible in communication now, and how does that drive new technique and propagate it throughout the surgical community?
Daniel Hawkins 19:15
And, you know, Henry, he asked me about, in some respects, technology catalysts, there was actually an industry catalyst, right? So I'm gonna unpack that for just a minute. Those who have been involved in in the digitally enabled surgical tools fully recognize that technology runs faster than our ability to adopt the technology and the or full stop, and it's getting worse. And that being true, there's pockets of expertise within commercial implementation capability that doesn't match the geography of where you want to physically be. Right. So you asked me about the technology and consumer wise the technology is already there. It's less about the technology capability itself and more about how it's packaged, and how it turns into something that's scalable, because one of the things I recognized and I'd love for you, Fred to comment on this with respect to implementation and robotics, but one of the things I recognized was, fundamentally, there are limitations inside of the med tech organizations that are launching these products to be able to scale because you don't have access to the people there mismatch, the geography, and very often, you need some folks in the room that are able to run the equipment. And separately, you need reps in the room to be able to sell whatever widget it is, if it's an implant or what have you. And that turns out to be a scalability problem and an economic problem that, you know, we sought to solve. That's why I left Shockwave to start this.
Fred Moll 20:46
Yeah, and I think a great example of that is I was on the board of Mako from the beginning of that creation of it till to come through commercialization. And the reason why Mako is owned by Stryker today is Mako, although we were having great success clinically, when it got down to how do we make money on the on this robotic technique and these procedures, we could never get around a the fact that the procedure itself and the technology required a rep in the operating room for ever, for every procedure. And, you know, the assessment of, of the of the team was, we're not getting around that anytime soon, there is no way out there. And with that need to have a very skilled individual in every procedure, in every or that had had a Mako system, there was no path to profitability. And, you know, it was a board meeting, I'll never forget where everybody looked at each other, and we're gonna go, we need to sell the company, because we don't have a pathway to to making money here. And so I think it's, it's a one very good example of the cost associated with trying to bring new technology complex technology into the operating room and make it stick and make it safe and make it effective. And in propagate and build, build a business, something had to give there. And, you know, I think, you know, an Avail type platform gives the ability to solve that, that problem differently. And, you know, in the solution was give it to a large organization that can better afford and be more efficient about rep deployment in very technical procedures.
Daniel Hawkins 23:10
So, you know, that issue that Fred described around commercialization, you can characterize it in some respects as technology runs faster than our ability to implement and adopt. But it really highlights a problem that that I think, is pervasive outside of digitally enabled procedures, when you really consider what has happened in the last my career three decades here. You know, those who have been in angioplasty a while or been in the business a while might remember a $600 angioplasty catheter? Anybody remember that? Okay, well, that's no longer right there about $100. Now. So what do you do with that? Well, you still need to salespeople out there to be able to handle it. stents were 2500 bucks. Now they're $400. But you still need to handle it. There used to be 5500 hospitals, and 250 ASCs, or something in the beginning of my career. Now there's about 5500 hospitals and 12,000 ASCs by some counts, how do you commercially scale and how do you operate in that environment? When HSPs are going down procedure volumes are barely going up. The middle of your income statement is stackable, a whole bunch of non movable assets called people and the number of places they need to go sell just tripled or near tripled. It's an impossibility now add technology on top of all of that everything Fred was just describing have a need to be in the room to digitally enabled those procedures. And it's a mess. It's an absolute mess. So one of the things that I concern myself with and candidly it's why I left Shockwave to start at Avail is one the industry ailing if you will across that that description, regardless of technology enablement or not. And then you add technology enablement, there's no way we can possibly benefit clinically as as a community as as as a medical device industry. How do we enable clinical benefit of the technology were created, if we can't actually scale it.
Fred Moll 25:07
Yeah, I think this, you know, if you look for, you know, every technology and every procedure, ever, in every specialty is a little different with regard to need. And so if you look for a poster child for the digital OR I think you tumbled pretty quickly to, to the example of the treatment of stroke, because it is one procedure that we all know, you know, time is brain, right? And so, the communication associated with what that patient needs, how is that patient going to get appropriate treatment? And how are you going to do it in a timeframe that, that makes it relevant, because if you wait too long, doesn't matter, which do you know, it, it puts a spotlight on what better communication and better transmission of technique, however you do it from one place to another is going to really, you know, revolutionize the treatment of stroke. You know, it's it is being revolutionized, as everyone knows, by thrombectomy, which has been an enormous success, it still has the problem of who's going to do it. And, and how you're going to get appropriate capability to that patient as in time to really do the best job you can, this is a really, I mean, this, the revolution is going to happen. But it is demands, you know, I believe not only, you know, the the right technique, which has been developed, but the right communication capability, the right, the right technology, to enable a remote capability that the world is comfortable with. And then, you know, I think it's going to involve robotics, it's going to involve communication we don't have today, but it very much puts, again, puts a spotlight on sort of the need in that particular procedure. But the opportunity to broaden this sort of capability outside of something as acute as as stroke treatment.
Henry Peck 27:58
With this with this idea of you talking about different procedure spaces that saw the Innovation and Opportunities for that collaboration to be be impactful in in improving, you know, improving the way that clinicians operate and improving the way that commercial teams at strategic companies operated. Talk a little bit about that, about the future that you're envisioning now, with platforms like Avail with the robotic systems that existed will exist in the future, what is this digital connected OR look like in 5 10 15 years? What capabilities exist today that are going to be expanded and continued to be developed? And what capabilities are we missing that need innovation and new technologies to help bridge the gaps and really realize that vision that you set out decades ago?
Fred Moll 28:45
Yeah, so, so look, I think it comes back to you know, their technology will play an increasing role in the OR how do you connect clinicians and in in many ways, really merge that connection with digital information, and the use of AI and the capability of a combined decision making and planning, decision making and learning site are a cycle that, you know, that really begins in the collection of information that you know, that are data that's turned into, to turn it into information that's turned into knowledge that's turned into wisdom, and that cycle of, of gathering the information and recycling it to the, to effect, the patient journey is kind of, you know, an obvious pathway. And, you know, it's AI is, you know, everybody wants to talk about AI, as I said earlier, but I do think it is one of the keys to unlock that merging of individual knowledge, communication, and betterment of technique, and procedural learning, that is, you know, that is going to continue for forever, but is at an inflection point. That is, you know, very exciting and, but also going to take a lot of discipline as to how it evolves and how it's used, and how it truly benefits patients.
Daniel Hawkins 31:03
You know, one of the things that I think about with that, and Ray is, I've had some opportunity in the past probably six months, maybe eight months, to hear the full vision of mega cap versions of what the digital OR looks like. Okay, now let's let's unpack the digital or for a second and talk about the digital patient journey, pre OR in the OR, post OR what's that whole cycle look like? I'm sure we're all familiar with digitally enabled knee implants. Wait a minute, hold on a second. How did that happen? Right. So now you're you're watching what happens in the patient afterwards? Well, let's take that data. And let's bring it back through the cycle. So the next time you do it, it's better, right? So we have opportunity to advance logarithmically from a digital enablement capability, some of the things that I've been exposed to I look at and say, Wow, what we can do clinically is going to be 1000 times better in a call it a decade than we can today, I get back to how are we actually going to implement it? How's the industry itself going to enable that technology to be commercializable? And then commercialized and integrated into workflow? How are we going to pay for it? How are hospitals going to be able to absorb all of that expense? All of that goes to as an industry, can we solve the implementation problems, that brings out some of the cost structures so that we can actually bring those technologies all the way forward? Ultimately, it becomes an integrated, connected kind of a world, I think we all know that. And clinically, you know, what we can do will Dizzy us in a handful of years, compared to where we are today. But in the middle of all of that we need to put in the business realities of how the heck are we actually going to get all of that done? And I think we need to be very responsible as an industry. Fred alluded to this a little bit earlier. Were does the line of what the machine does, and the clinical team to do, where's that line drawn? And it'll keep on going closer and closer to the machine. But at some point, there's a question. Can you go all the way over? Well, just because we can, should we?
Fred Moll 33:14
Yeah, and I sometimes use the analogy, it's not perfect one, but the analogy to the progression in technology of autonomous vehicles. So you know, where else do you see man and machine making decisions together? The the driver taking input from, you know, what are now smart cars, to a progression to autonomous driving? You know, and I think everyone thought at the beginning of the journey of how do we how do we take the driver out of driving, that, you know, there was sort of a linear pathway to the technology gets better and better, and, you know, it's, it's, it's going to be sort of a no brainer to, to put the passengers in the back seat and let the car drive itself? Well, you know, I think the learning now is the last 10% of that journey is really hard. Because, again, it gets down to judgment in situations that are not predictable. And quite frankly, you know, you kind of can't plan for so you know, does that make autonomous vehicles going to stop that technology in its tracks? I don't think so. But I think it is analogous to you get to a certain point, yes, you can do a colonoscopy with a Um, you know, with your eyes closed or with a physician's assistant or somebody calling in to check up on how it went, and maybe what else might be done for that patient. But you start progressing into more complex capability. And it does get to the point where judgment and wisdom are at a premium to make sure that, that you have the appropriate balance between technology and human input.
Henry Peck 35:35
I think maybe just a closing question for you guys that the story you paint from the conversations you had in 98, the operationalization of that vision in 2017. And where we are now, I think about where you guys were in 2017. In 2017, I'm in a lab doing research with a DVRK, the old refurbished version of that first system. And conversations, like the ones that you were having in 98 are happening now in those research labs with a new crop of people thinking about the future of digital surgery, the digital OR coming from the benefit in the standpoint of having platforms like Avail and the robotics innovations that exists today as a foundation. So what do you say kind of as a closing to that next generation of conversations happening, and what people can be thinking about to build the future and take the vision that you set out and run with it?
Fred Moll 36:29
Yeah, so, you know, what I would say is, I think the future of using information to change a clinicians technique is, is going to accelerate and the idea of doing the same thing in the same way, without having some, you know, very strong ability to, to progress and learn, as, as the information becomes more and more valuable in order to, you know, to progress in patient care, that one has to put oneself in a situation that, you know, I think so it's really important, obviously, for surgeons to continue to be, you know, classically trained in in a in a way that makes them the best clinicians and technicians that they can be in this period of time. But I don't think it is. You know, they're no, they no longer have the luxury of saying, I've learned enough, I'm going to keep doing what I'm doing. They need to be technically enabled, they need to be robotically enabled, and familiar with how to keep up with what I think will be accelerating, need to understand, you know, what's new, what's next?
Daniel Hawkins 38:12
You know, there's, in my view, there's, there's more technology that we know how to deal with right now. A lot of really smart folks in this room are figuring out ways to implement that into clinically enabled tools. Right? I think of a technology as simple as as machine vision, and you know, AI, algorithm cinelike. What can you do with those, of course, there's a company that figured out a way to look at a sponge and see how much blood is in it using a camera. That's pretty amazing. When you think about that's a decision point of Can I can I avoid a transfusion? Or do I need a transfusion? That is a huge clinical issue. Right? So you got to be able to make that choice. Technology was properly applied to get that done. But it was at first resistant? I mean, how does that work? I don't know that I can trust that. Well, clinical studies proved now you can go ahead and trust it. You ask a question of where are we today? And what's happening in those lab conversations? And where are we going to end up? You know, for me, this is really a challenge of deploying technology in the right way to solve the right problem. Right. One of the things we resisted back in the early days of Intuitive and I would encourage thought process around now is just because we can doesn't mean we should just because we can do a long distance surgery doesn't mean we should because we're not ready for it. I'd also get to going back to what I described before, the technologies need to be adoptable. Right? So technology for technology's sake. Yeah, it's cool. Sounds great. You really need engineering project. But unless you're going to be able to actually change clinical practice with it, how are you actually going to do anything with it and how are you going to get the benefit that you're looking for? I actually concern myself more with our ability as an industry, to bring technology to market, and move medicine with those technologies, it's the last part that I worry most about, right? Because we can create really, really, really cool stuff. But until we can actually bring it into daily practice and watch it scale from there, what do you suppose to do with that?
Fred Moll 40:21
Yeah, and I think, you know, what's really important for this audience is, you know, I think what we've learned, at least from the, the Intuitive story is, there's got to be a business around changing technique. And, you know, I'm suspicious that, you know, software by itself added to hardware, you know, is or is not a, an interesting business. And if it's not an interesting business, in certain situations, it can't progress. So, so it, you know, there's a, there's a business model, or there are a variety of business models, some of which aren't going to be viable enough to create the opportunity to make money, and, you know, it, they will be found as the wrong route to innovation, cuz it just didn't work. And, you know, my example of, of Mako is a fabulous innovation, it got to a certain point where it needed a bit different business model. And, you know, I think we all have to be aware that there are going to be some challenges and finding in a in the digital or it's fabulous technique, it can change, patient care. But how do you accelerate it and give it the legs to get to where it needs to go to benefit patients? And the answer is, it's got to be economically interesting for developers to develop and sell and there's got to be a way to sell it in a way that you know, turns a profit.
Henry Peck 42:10
Well, Fred, Dan, thank you guys so much for this conversation. If anybody has questions, we'll step off stage here. Thank you again for joining us this morning, everyone for being here and round of applause for our for our speakers. You guys are fantastic.
Daniel Hawkins 42:23