BoneChat call #17 - Lawrence Binder - "VSURGIC, startup with a secure live connection into the OR"

Okay, Bone Chatters, we are live with, uh, Lawrence Binder. Lawrence joined Bone Chat last month. Um, we've been friends for a long time, uh, at a distance. Lawrence has a knack for seeing the future in orthopedics, I think. Um, he was one of the co-founders of Globus Medical. In 2003 that is in the news right now because obviously Globus is eating the spine world. And anytime Lawrence starts something new, it kind of garners attention. So today Lawrence is going to share his new startup called vSurgeon that's bringing a live secure connection into the operating room. So I'm handing the mic over to Lawrence. Welcome.

Great. Well, thank you, Tiger. I appreciate it, um, and everyone for joining. Appreciate giving me the opportunity to talk through what we're doing here. And, you know, I said it's, uh, this is sort of a, an open forum. As Tiger mentioned, this is my first one live, and so I figured I guess it's appropriate that I'm presenting. Um, so I will, uh, again be presenting slides through my deck, but also Again, if there's questions or you need clarification on anything, I think we'll just— I'll kind of jump around and be able to answer whatever you guys can think of. What I'd like to do is really provide sort of an overview of, you know, why we're doing this and the problem that we're solving. And then, you know, we can get into a lot of the details of how we're doing it and some specifics. So really, when we talk about, you know, what is the goal It's really an education and collaboration tool, and what we're doing is just connecting the dots. So we're providing that conduit between, um, industry really and the surgeons. So another way to describe that would be to say, well, we're empowering just healthcare professionals in general. So really what we want to do is optimize the transmission of the information coming into the operating room and the information coming out of the operating room. And I know that's a very broad thing to say, but like I said, I can get into kind of the details as to how we're accomplishing that. It's kind of good to, again, just let you understand who the team is and how we're accomplishing this and the people that are doing it. But myself, as Tiger Buford mentioned, you know, my background has really been in spine and device development. So kind of selfishly, you know, developed this company as a way to help engineers get access to information more readily. And same with my co-founders, Andrew Lee and Ryan Durgan, both Globus guys as well. Andrew Lee was number 2, you know, him and David were, you know, basically he was in David's basement, um, you know, when Globus first started. So he really obviously understands that, you know, the process of how that company went from, you know, zero to you know, where it is now. And Ryan Durgan is a distributor for Globus, and that's where I met Ryan. So he has a very unique perspective on how access to the operating room, you know, is valuable and helpful to distributors and to the salespeople, whether it's for education and training purposes. But one of the things that we really try to be clear on with what we're doing is this is not a get rid of the rep type thing. And I know a lot of people, when they hear like, oh, access the OR, that means you're covering cases, you know, and the rep's no longer needed to be there. And if you've ever been in the OR and you've seen what the reps do, I mean, they're opening packages and moving stuff, you know, physically around the room. And so for that sort of revolution to happen, which people talk about, um, someone's got to still do those physical things, right? So I think, you know, we've never thought of this as a tool to replace salespeople. It was just a tool to to make sure the information is getting relayed between all the parties. And, you know, one of the things that we focused on as a company was really in the beginning focusing on one area— specialty. And so our area that we focused on in the beginning was sports medicine. It was kind of fortuitous. I was working on another project with a surgeon, and there just became some really strong introductions. And the surgeons that we were speaking with were KOLs, for Arthrex, and they really got the value of being able to have the access to their ORs and be able to document their surgeries. So this is kind of really our pilot team, and these are also our advisors. And then we have Tom Lendvay, who— he was the founder of a company called CSATS, C-S-A-T-S, that basically developed a, a training tool for urology and scope-type procedures where they were using AI and, um, humans to sort of train the models on identifying different pathologies in urology, um, surgery. And his company ended up being sold to J&J again as some, you know, training tool, and they really wanted a platform that they could do training on. So he's really providing a very interesting perspective on what we're doing and how it can sort of relate to, you know, his experience with, you know, integrating artificial intelligence and efficiencies and identifying things within the operating room. So that's sort of where, you know, his big value to the, to the team is. So as we talk about what the problems are, like, is there a problem, right? What are you guys trying to do? Um, basically what we're doing is, um, identifying that medical device companies they need to have access to the OR. And I experienced this firsthand as an engineer, knowing that getting to the OR really made the information so much more real when you were trying to develop a product. And so having that access was really valuable, but being out of the office was inefficient. And a lot of times you may get to the OR and you're standing in the corner or you're not really actually able to see what's happening. So, or you were relying on information coming from the salesperson to you on what needed to happen, or you were having dinner with the surgeon and they were trying to explain to you, here's what my problem is. And so none of those are really efficient ways to develop product, but that access was necessary and valuable. And then, you know, if you look at today how surgeons are using video to really market themselves, they want to showcase their skills, they want that collaboration with the device companies, whether it's for consulting or They've got product ideas. Um, they want that content to be able to build their, you know, public reputation on, hey, I'm an expert in this field. Um, but also for training other surgeons, right? I mean, this isn't necessarily a, you know, proctoring tool, but there is, um, you know, many surgeons that have surgeons come and shadow them. They fly in from other countries or they, you know, fly in from other, um, parts of the United States. And so there is value to those surgeons as well, being able to, you know, have people get access to their procedures. You know, this process of getting information secondhand in any industry is not the best. So I think what we wanted to create is a tool that lets that information get back to the engineers and to the surgeons firsthand. So we're just, you know, connecting those dots that we think everybody is looking for a good solution to that problem. Um, so that's what we do, you know, we connect the ORs to the medical industry through our network. So it's our servers, it's our, um, backend, it's our, you know, HIPAA compliance, our controlling, um, you know, who has access to what. And the operating room ultimately is making that decision on who can access their particular procedure. Um, now the surgeons have the ability to do all these things that we were just talking about, educate, archive procedures, share them with other surgeons. So we designed this from the ground up to specifically work for the operating room. And we've seen, especially through COVID, a lot of people were trying to come up with how do we get this information out of the OR and how do we get people into the OR. And in a lot of ways they were saying, well, let's just take Zoom or let's take an iPhone or let's take something else and try to patch something together. And they kind of worked and they kind of solved some of the problems, but they didn't really solve all the problems because they weren't really designed for that purpose. And so what we did is said, let's start from scratch and build something that solves all those problems in a compliant way.

And by the way, ask questions, guys. So he wants—

yeah, yeah, if you jump in, if I'm, you know, if I glossed over something or if there's anything that's not clear, I'm happy to to spend more time on any of the slides. So what we came up with is a system that's hardwired into the operating room. So it's, it's a part of the operating room. It's not an actual separate thing that has to be brought in. Um, it's a touchscreen, it's a console, everything's mounted on the wall, so there's no wires, there's nothing to charge. It's there, part of that OR. We install industrial HD cameras on the ceiling of the operating room. We're not really limited by the camera. I mean, it could be an 8K camera, it could be a 4K camera. It doesn't matter what the camera is. We're sort of agnostic when it comes to the, the tool that's capturing the content. Really, our focus is on the console, which like routes all the information through the Veeam Synergic Network. So again, it could be scopes, it could be an X-ray. Any aux input basically can be fed into the system from within that operating room. We also have mobile apps, so a mobile way of accessing that content as well and creating that content. And then we also have, um, the ability for the surgeons to capture that information and then share it in a compliant way. Um, and then one of the things that I think is really valuable about this is value, I guess, is a good word, is that this is very low cost to the facility and it's available to all vendors. So the idea would be, if some people say, well, you know, what if Medtronic wants to do this? Or what if, you know, Globus wants to do this? They can do that. They can, you know, there's nothing that stops them from creating their own network, but I think the value to the facility then becomes less. So I think us being sort of this independent company, it's a better argument to a facility to do a permanent installation when they know that this is available to all of your vendors. So any vendor can, you know, have access to the system. And again, they're paying a very low cost to have the system in their facility. And then for us, from a business model standpoint, you know, we look to make the majority of our money from the OEMs. And the vendors. So it's really, you know, very low cost to the facility, but then we focus more heavily on the OEMs for the access. This is just a couple pictures to show you. I just grabbed these, one of our recent installs that we just did in Miami. So you could see on the left-hand side, the vSurgeon console at the bottom, you know, has a little shelf where I think that's normally where we keep the headset. And then on the side, there's a bunch of auxiliary inputs for different things within the room. And then at the top, there's the touchscreen where the control access to whoever's requesting access to that particular procedure, that's where that control is acknowledged. And then you also have the top part of that screen, which would be the two-way communication. So you could see the user on the other end. If it's an engineer or a salesperson or whoever it is, you could visually see that person as well. And then on the right-hand side is just an example of the coverage that we really want to capture in the room. This has— you're only seeing 4 of the cameras. I think this does have 6 cameras in this OR, but what it does is it allows for overlap where you may not be using all 6 cameras at the same time, but especially when ORs get crowded and there's people moving around, um, we found that having at least 4 right over the bed not only allows you to find at least one or two that have a nice view of what's happening, but also you can turn the cameras around and point them at the back tables so that other people can have access to those, um, things as well. Um, and that brings up another value, um, proposition that we provide to the facility is that from the user perspective, the user is making the decision on what they want to see. So there could be multiple people accessing a single procedure for different purposes. So you may have somebody looking at the back table, you know, an engineer in training or a salesperson in training, watching how they're prepping an instrument set. You could also have somebody, you know, a nurse, watching, um, you know, how they're preparing, um, you know, preparing the room or even turning over the rooms. There's, there's a lot of things that are happening at the same time that The system just allows the user to choose their own perspective, their own view, their own audio source, all during the procedure. So I think that's the really big value proposition.

So you said the OR controls the access to the device companies. So who in the operating room, is it the circulating nurse? Is it the surgeon? I mean, who makes the decision?

It's usually, yeah, it's usually the circulating nurse sort of at the direction of the surgeon. 'Cause normally the surgeon's gonna know like, hey, you know, turn the system on for this procedure. Let in, you know, whoever, let in the person from Zimmer or let in the person from whatever. And it's not like you're getting, at least at this stage, you know, they're not getting, we're not getting requests for a bunch of people that aren't supposed to be there. But the reality is we wanted to provide that ultimate decision to the operating room. So they're always making that decision. And it's a very simple, like, The picture of the person pops up, there's a green button, you know, yes or no. And we also have it set up to where you can pre-configure it so that certain people just automatically could be let in. So we're really— we really tried to minimize the decisions that have to happen, and we didn't want to give the circulating nurse, you know, another job to do. So we tried to set it up so that it's really start it and kind of forget it unless there's some special situation. And then turn it off when you're done. So sort of the workflow is once the patient's fully draped and the surgeon enters the room, turn the system on, let in whoever you think needs to be there. And then when the surgeon leaves the room, turn the system off. And that's kind of the workflow that we've asked of the facilities. Hi, Lawrence. This is Vinay. I have a two-part question. One is who installs those 4 or 6 cameras in the OR? And instead of those cameras, is it possible to use this system like using something like GoPro that each of the person in the OR is wearing around the procedure table? Yes. Yeah, that's a great question. So we install the hardware ourselves in the facility. And what we do is depending on the city, wherever it is, we contract with a local electrician to be there with us. So, you know, we obviously know our stuff really well, but we're not, you know, licensed electricians in every state, in every city. So we basically find a local electrician, we coordinate with them, we're installing cameras in an OR facility. Usually it's an electrician that's already been recommended by the facility that they've worked with for other things. And we say, great, we'll pay them. So we pay them directly. And just contract with them to work with us to do the install. And it usually takes 2 days. It can be 1 day, but it usually is the first day of getting everything installed in place. And then the second day— to your second question, we accept, again, any sort of feed that's in the system. We have cameras from facilities that they said, hey, you know, we have this camera over here that was installed by something. Years ago, and we were like, great, we could pump it right into our system. The guy in Miami that we were working with, the surgeon there, he uses the Swiss system, the, um, you know, see what I see head-mounted thing. And so he was like, can we put that into the system? We're like, great. It's basically just an HDMI signal out, it goes right into our system, and then that's one of the choices available for the users on the other end. So they can say, oh, I want to see what the head I want to see the view from, you know, above the table, or I want to see the back table. So they still choose. It's really just, you know, as many sources as they want. I think we just did an install in San Diego that has 9 different inputs. It's, you know, there's multiple cameras, there's multiple pieces of equipment in that facility. There's an X-ray machine, there's, you know, CRM, there's all kinds of stuff, and they wanted aux inputs for everything to make them all available. So It's really whatever the facility wants.

Thank you. Mark's got a question.

Yeah. Thanks very much. I've got actually 3 questions. First of all, since I own a compliance company, I'm curious how you're handling the privacy and security aspect. That's one question. The other 2 just kind of bookends. What's the benefit pitch to the OR and what's the benefit pitch to the vendor?

Sure. So to the compliance, let's start with the compliance side of it. So for users to be on the system in the first place, they have to sign an agreement that says that they will comply with HIPAA and comply with the rules, um, you know, for their state regarding the information that they're getting. Um, we don't— we vet the users before they're allowed on the network, so it's not just an open network where everybody can just create an account and you're immediately in like we've we physically check and make sure each person is signing up as they say they are and call them and talk to them before their account's activated. We also, when we install with the facility, we're not their legal department, right? We're just a, we're basically utility. We do, they have asked us for, hey, what language should we have in our, you know, waivers or information about observation or recording? And so we can provide some general language that helps them there to make sure that they're, that what they're getting signed is, you know, covers what, what's happening. Um, so, uh, so that's kind of the, again, the front end of it. And the back end of it, as far as security is concerned, I mean, everything is encrypted in transit, encrypted at rest. Um, it's fully, um, everything is in an AWS environment. So, um, you know, it's the same. AWS is basically what, um, Epic uses for, you know, for patient health records. So, you know, we're on the same level of security as an EMR. Does that answer that question?

And the other question was, what's the— so what's the pitch to the OR? Why should they let you in?

Well, usually because the surgeon wants it. That's usually the first— that's usually the first reason why they would do it. Because the surgeon is like, hey, I really want to use this and I think it'll help, you know. I think ultimately there's— when they see that it can help reduce foot traffic and like, hey, we don't have 20 engineers visiting throughout the year, those, you know, now we've got 5 visiting instead of 10. So I think there's going to be— there's things that we can try to tell them about that they're going to see, but it's really hard to make that case to a facility purely on its merit, like, hey, we can reduce foot traffic. They're like, well, prove it, right? Um, we think we can. I think it's logical that if you've got a way for people to access a room, um, the OR remotely, they don't have to physically be there. You could conclude, like we're doing right now, we didn't have to all meet at a facility, right, to talk about this. So, um, but making that case to a hospital and then getting them to buy into it and paying for that value alone, I don't think is— that's not really our pitch to them. It's really been focused on ASCs where the surgeon sort of says, hey, I'm, I'm a part owner of this ASC and I, I want this tool, um, and I think it's going to help me, and I also think it can help us recruit other surgeons to come and perform surgery at this ASC. So I think that's, that's been sort of the angle for the facility, is focusing on the value to the individual surgeon by having these tools, um, and then they kind of push it from a facility standpoint. Thank you. And then, yeah, and then was the other— was it on the— were you also asking about the surgeon? I kind of maybe—

no, the vendor. I said I was going to ask you what the pitch was to the vendor, but yeah.

So to— I mean, to vendors, it's also a little bit of a different sell, right? It's more about saving money on travel. It's— you're, you're engaging with your KOLs, like you know, every day if you want to. So we know that that relationship is really valuable to the device company. We understand the dynamic there. We know, and because we've experienced it, that the ability to have a high level of efficiency in engaging with your KOLs or your design team members throughout a project as it's being developed is really valuable. So I think if, you know, as a device company, I would say Yeah, what— why, why would I not want to do this? Why would I not want to have this access to my surgeons on a regular basis? Um, so yeah, I think there's— and then we, we have products that we've sort of tailored towards the different parties, and I can— I think that's probably the next slide where I talk more about how we position the different product offerings to the different parties. But this slide is sort of— I'm not— I don't need to go into the details of these percentages, but The point of this was more about, I mean, everyone generally agrees that like video is now very important and powerful in healthcare, not only for the surgeons to promote themselves, but for the device companies to train and educate people. And it's just in every industry it's growing, but healthcare, I think we're just, we're seeing a lot of it more recently over the last several years.

Hey Elizabeth, jump in.

Hey, thanks.

Hi, I'm Elizabeth Hoffine, the ortho writer for about 20 years. I wanted to say, I would imagine you're going to have a lot of success with this because through the years I've seen in the literature many articles on potential infection from folks coming in and out of the OR. I remember one, I covered a story a few years ago, or was research actually showing that when one door was open at once, there was no loss of positive pressure in the OR. But if two doors were open at the same time, there was a loss of— was that pressure— and a whole influx of contaminated air from the hallway. So, um, I guess I— a follow-up to that would be, do you envision studying this, you know, the effect of this, uh, at some point, uh, you know, before and after?

Yeah, absolutely. That's, that's been on our, our list of, you know, we need a good paper, um, about the value of reducing foot traffic. I mean, you can— we've definitely found some that have been, you know, not done using this technology, but just restricting access. And they've shown that they've, you know, been able to reduce infections on particular types of surgeries. There's one paper that came to mind early on when we were doing this about total joints and how the number of door openings correlated to the increase in infection rates. It was like, you know, pretty eye-opening when we, when we saw that. So yeah, I think you just, you have to, you could say that, right? And I can point to a paper, but until we can prove that this technology reduces the foot traffic, that, you know, it's hard for them to make that connection. I mean, it seems pretty obvious to both of us, I guess, as we sit here, but I think it's again, to tell the hospital, look, if we could reduce your infections by 1 next year, this pays for itself, right? I mean, I think that's, that's a pretty easy, um, you know, easy sell. So, um, yeah, I think it's definitely an angle, and we just got to get more information to really say that solidly.

And the— can the, uh, video— can you attach an algorithm to the videos that tells you how many people go in and out or how many people are in the room?

Yeah, yeah, that's a— the people counting is really, you know, that's pretty readily available too. So, you know, the problem is sort of correlating it with infections or not. So what we've tried to do with our system is kind of stay out of the EMR world. Like, we're not really connecting with EMR. We don't have to integrate with any of that. So we don't really get, you know, follow-up on how this patient did based on, okay, this, you know, we've reduced the foot traffic and then this, these patients did better and we didn't reduce the foot traffic here and they, you know, didn't. We'd have to set that study up somehow. But right now we're just sort of like, yeah, we can count the number of people and then correlate that to other things, even efficiency. And, you know, there's optimization that I think long-term we think about of like, look, we've got— I mean, right now we've got, I don't know, 400 shoulder, you know, surgeries archived from multiple perspectives. Like, we could find that to say, okay, this is sort of the optimal number of people, um, in for this type of procedure. And, you know, this is why, you know, here's the reasons we've identified. So there's, there is some visual things we could do with positioning of equipment and people in the room and flow of people in the room that was definitely, definitely on our radar.

Hey Lawrence, got a question here. Stephen Fluty.

Yeah.

Have you guys thought about going down just kind of like the marketing med ed route as well? You know, someone wants to do a, you know how there's live surgeries that are done and you can kind of broadcast that via Teams? You guys can essentially partner with them and see if you can go down that route.

Yeah, yeah, absolutely. I mean, we've got a full system set up for, you know, paywall for access to facilities and access to procedures. And that's kind of how it— the way we've structured it is that, you know, users basically buy access to a facility by the day, by the month, or by the year. So it's a flat fee for the user. So yeah, we've talked about, you know, some of the special event surgeries that we could coordinate. You know, we've got a portable system also that could do that, but for our main installs, especially if they're at a teaching hospital or they're at a place where they're doing very unique cases, special events, yeah, we're set up to do that. So we can have, you know, a device company that says, look, we want to do a special broadcast to 400 of our sales reps or to whoever wants to buy access, we, we can manage all of the, you know, getting the people access and letting them buy passes and all that. So that is built into the, the system now. But yeah, I think it's definitely a, there's a big opportunity there for sure.

On the content consumption side, have you ever heard of CoLearning Pathways? It's essentially a platform that allows for CME credits. So say you've got, you know, an archived case that you've done, there can be CME given after someone has watched the video and then actually engaged with it. So I think there's an interesting partnership opportunity with both companies. I'll put that link in the webinar chat right now.

Yeah, yeah, no, I appreciate that. We did— so we did talk with, um, a couple companies about doing CMEs, and I think one of the things we realized after, you know, going down a couple paths is that the companies that do the accreditation, a lot of times they want to charge you for every time the users there's a new user getting the accreditation. And what I'd like to find out is like, can we just have this video archive be accredited? And then again, they get a percentage of it or something, or we find a way to get accredited ourselves. I think this is where we went back to our advisors and we talked to them about, you know, how do you get your CMEs now? Would this be a way to do it? And, you know, a lot of them are like, they're not hard to get. So like, if it's a big investment on the company's side to to set that up. Probably not a huge, you know, source of revenue for us long term. Um, and then I also talked to some other companies, um, that, you know, had done it, and they said, well, you know, it was valuable, but when we were acquired, it didn't make much of a difference that we had CME. So, I mean, I, I personally think it would be easy to just take one of our surgeries from multiple perspectives, package that, and say, this, this procedure is a very good example of this type of procedure. And, you know, you should be able to get CMEs for that if you watch that and you go through it and you interact with it from multiple perspectives and listen to the surgeon talk through the procedure. I think that's really valuable. I can't see why you wouldn't be able to get a CME for that. So I think that makes sense.

I love what you guys are doing.

Awesome work.

Thank you. Good, great suggestion. Uh, Mike Donahue.

Yeah, thanks, Lawrence. This is super cool. On the CME thing, I'm a little bit involved in that too. You just get a grant, a large grant from a, from a med device company to fund your CME. They'll do the accreditation and take care of everything. But, um, that was not my question. You mentioned very quickly in passing a portable system. I can really see a very useful tool, uh, and you alluded to this earlier as well, as an R&D, uh, process to, for in the early stage to take, to, to have video of surgery that's going on so that the engineers are learning about workflow and learning how things are done now to try to identify the problems. And then down the road when they go into clinicals to be able to see, okay, how did I solve that problem? It might be very difficult, particularly for a startup, to fund, you know, the installation of one of these, you know, in an operating room. And some of the sites may not be interested in that. But the— but you mentioned a portable option in That— is that a use case for that?

Yeah, so that kind of leads right into this slide here. So the way we sort of divided up our product offerings is we've got things that we create content with, or the surgeons creating content with, and then we've got ways that that content's getting consumed. And so if you look on the left side, we've got vSurgeon Cuts, um, vSurgeon Rapid Connect, and vSurgeon Core, we call it. And those are basically So this is kind of things that are content creation that's happening in the OR is sort of the way we're describing our content creation, um, tools. So vSurgeon Cuts is basically a mobile app that again is not recording anything to the, the surgeon's phone. It's, it's uploading that procedure directly to our, the vSurgeon cloud archive, but also making that available to users in real time. So the surgeon's, you know, rep or the nurse or somebody, if they had an interesting thing that they wanted to capture quickly and share with an engineer or ask a question, they could capture that content compliantly. So it's never getting recorded to their device. And we've all seen, you know, when you're talking to a surgeon and they're like, let me show you this case I did. And they're like scrolling through, you know, family photos and their dog. And then they're like, here's this case, you know, that I did.

So.

We're trying to give them a way to separate their, their content that they're creating from the OR and have it in an archive that's accessible from anywhere in the world, and also at the same time make that content available to the users on the other end. So that's the, that's the mobile app. So that's sort of the lowest level of access, the easiest, quickest way to start, you know, compliantly capturing content in the OR. And then the second is that Rapid Connect, so which is a portable unit, sort of like a Pelican case type thing that you, we, you know, ship to the facility. We've got multiple USB cameras, so there's two USB cameras that can clip on to like an IV pole or something within the OR, and then we've got, um, an auxiliary input so you could run a scope into it, and then, um, there's also a camera on development stages, and frankly, there's no time to really go through the logistics of an install, right? So we also see that—

uh-oh, uh-oh.

Did I lose you?

Yeah, you, you, uh, you kind of went, uh, on and off and then you disappeared for a second. We can see faces but we can't see your slides.

All right, hold on, let me, uh, let me share again. I— and I'm not sure exactly where— share screen window.

All right, he's in the mountains with, uh, Starlink.

I was just talking about how great it was and then it happened. Um, okay, so let me, uh, take a step back here.

Yep.

All right, so I forget where I dropped out. Maybe if you can remind me where I—

the last—

this is, this is the slide. Yeah, you're talking about the, uh, the portable, the portable unit.

The portable unit. Gotcha. So, um, yeah, so the portable unit is really that, you know, quick access sort of where We're trying to, we'd like to do a full install, but really we're not there yet, or the logistics of the facility is gonna take 6 months for that to happen, which is not uncommon, you know, for especially a hospital facility. So that's, yeah, so that's a great solution for getting that content quickly. Again, it's all, it's still all archived in the same location as a regular full surgery would be. And it's also live, real-time available to the engineers. So it's just sort of a slightly pared-down version of the full-on installation. And then we've got our core system, which is again where we come in, we install the cameras permanently, you know, we go through all of the logistics with IT and, you know, compliance and all that to make sure the system, you know, is on the right network and all that. So those are sort of the 3 products that we offer. And again, this is all ways to capture content that all goes to the same location. So the surgeon could technically be using all 3 of them in a week. If one facility, they don't have anything and they use their phone and another facility, look, we've got the portable unit and then we've got a permanent install here. We, it's not in our other facility yet or something. So we really wanted to, to lower the, the lead time on engaging with the surgeons quickly. And that's kind of what we learned in this past year is that, yeah, the, the permanent installs are great, but you know, they take a lot of time. So that really just needs to be a long sort of steady play for us, which is like coordinate, just have a nice pipeline of them coming. And in the meantime, we've got these other ways that we could, you know, quickly engage with the med device companies, which again, that's where that Rapid Connect is really targeted towards is the med device company, 'cause they're the ones that are gonna probably benefit from that the most in the short term is getting that quick access. And then the portable, or I mean, and then the COTS mobile unit, Again, that's more targeted to the individual surgeon that just is like, I wanna be able to capture this content for me directly. And instead of, you know, recording it to my phone, I'm gonna upload, upload it to the cloud, the vSurgeon cloud, so I could log in from my desktop later. You know, I can export it, I can make little segment clips from that information. So there's other tools that we have once the surgeon has uploaded their information to the, the vSurgeon cloud. They can go in there and see all the different camera views and angles and create little segmented clips from those, um, procedural files. All right, he looks—

are you frozen? Okay, good.

No. Okay, um, and then from the other side, we talk about the content consumption side of things, is where we've got the access the user passes. So again, this is all the different people that could consume that content on the other end—med students, residents, sales trainees, other surgeons, engineers—but there's a lot of use cases for this consumption side of things. But really, break it down by, are you accessing it as a, you know, a day pass, a monthly pass, or an annual pass for that particular facility? And I think the advantage of that is if there's multiple surgeons at a facility operating we don't charge more. It's just you've bought access to that facility. So installing these and putting them in places where there's multiple surgeons doing surgery that you're working with is— you get even a lot more value out of that as a device company. And then we've got what we're calling our showcase events, where if we've got a permanent install and a device company wants to actually have that footage, right, we can make that available again in, in in compliance with the surgeon, in compliance with the facility, like we could say, great, just like as if you would hire a video crew to come in and record a procedure, we can make that available to the device company. So say, look, you really want to capture your new thing you just launched and you want to make some promotional things with it, we basically act as a camera crew that's already permanently installed in that OR. And so again, we're providing that to the facility on a, you know, really on a moment's notice. So it's also helps with coordinating and, you know, scheduling and timing and surgeries getting canceled or moved. Once you've got this system installed permanently, it's ready to go. I mean, you could just turn it on, like I said, at a moment's notice. And then the same with the Rapid Connect. That's part of the Rapid Connect system, that the portable unit, that when the device company pays to have that shipped, they also get that footage from that procedure. So they can use that to, again, to rewatch or to look at, you know, different angles, like you said, and analyze things that they may not have caught if they were physically standing in that OR. So I think that's another advantage to the portable unit. And then obviously there's always this, this idea of data and analytics. And, you know, we're not really there yet, but we know that that's, you know, in the future that can have value for us.

Yeah, go ahead, Barry.

Get myself off mute. Lawrence, this is great. One quick question. Does it connect to all the other equipment in the OR, CTs, laparoscopes, and endoscopes? And do you get a multi-view of all that as well as the room cameras? And then kind of who can control those cameras? Is it fixed or, you know, if you have competing people, how do they manage? You know, you were talking about someone wants to see the equipment table. How was that all kind of managed?

Yeah, um, so let me start with, um, well, I'll start with that one. I think the way we've, the way we structured it is that we've kind of have one of the users, as they request access, could be designated as the moderator. So it could be any user from anywhere. So as people come in and they're requesting access to that procedure, you could have 5 people all request, and then from that, again, from that Circulator control panel they are letting people in, or they also have a choice of who do I want to moderate this procedure, and that's the person that they could select. What that also empowers that moderator to control the, the pan, tilt, and zoom of the individual cameras. So they would be able to change, you know, one camera over here and zoom in on something or zoom out. You don't have, you know, all the users don't have that ability to, you know, be pointing cameras around. However, all of the users individually have the ability to select individual views, right? So if one of the users wants to see— if one of the users wants to see the scope, they could be watching the scope full screen if they want. If they want to— if somebody else wants to be watching something else. So the moderator is not really the— I'm trying to think of the best way to describe it, like the director. They're sort of just making sure that the pan tilt zoom cameras are pointing where they want to go, and they're the one communicating with the surgeon two-way. So the moderator is sort of just looking at things that are coming in on the chat, talking to the surgeon. They can hear the surgeon. Everybody could hear the surgeon's responses, but the surgeon only hears one person, and that's the moderator. And that person can be changed. So you could say, well, this person will be the moderator for, you know, this period of the procedure, and then we're actually going to change the moderator to somebody else. And I'm going to take questions from a different person. So that flexibility is sort of all built into there. And, you know, again, the user has the individual choice of which audio source they want to be listening to and also which video source they want to be watching during the procedure. I'll follow up with a second question.

So it seems like Avail system was more geared towards a virtual surgeon, you know, scrubbing for surgery in terms of collaboration between surgical teams. They did also kind of, you know, sell it as part of, you know, being able to have, you know, virtual salespeople, etc. It seems like you're promoting this more as an R&D tool as well as a sales tool for OEMs. How do you guys compare to Avail, who I think, you know, is sitting on the sidelines these days from what I've—

No, I mean, we've, we've known about them, you know, kind of from early on when we started this company, um, and sort of watched what they did. And, you know, I don't really— I don't know anybody in that company personally. I don't know anything more than what I've just seen publicly. But along the way, we've always disagreed with some of the ways they were going about things. We would find out, like, okay, they're charging the hospital by the minute. Or they're charging the other person by the minute. And I'm like, I, I can't do that. I know that that's how we're being charged by the way the servers are running and all that, but like, I don't think people are going to want to pay that. It's gonna, it's gonna disincentivize more usage, and we want more usage. So we want people to pay a flat fee and then want to use it to get all their value out of it, right? Um, yeah, we also felt that like bringing another thing into the OR was Nobody wants to bring another thing in. Like, obviously we've got our mobile system, but that's sort of a stopgap to a full install. I think ultimately having an installation is the ideal solution because you don't have to manage it. Nobody's got to wheel it in. It could be, you know, it could be going at, you know, a permanent install could be going in 2 ORs at the same time because they're not, you know, it's not one machine at that facility. So, um, yeah, there's a lot of things that we just work In all honesty, like, we're trying to solve, I think, a lot of the same problems as a company. So when we look at that and when we read some of the things they put out there, like, this is a great collaboration tool, we're like, yes, we agree with all that messaging. It's like, that's what we're doing too. Um, I just think the way we're going about it is just different. Um, and I, you know, again, selfishly, I think because, you know, coming from an engineering perspective, that's probably why we're slightly biased towards that, you know, use case, um, because we've really, you know, firsthand could see the value in, in having access to that sort of information.

Yeah, I mean, their capital equipment costs were huge in terms of the amount of portable systems they had to transport, which was, you know, again, to your point, I think is prohibitive.

Yeah, you talk about reducing foot traffic, like, I think, again, from my understanding, was like there had to be a rep there for the, for the Avail system, I think. I mean, I don't, maybe I'm wrong, but like, I think they had to have a person operating it. Yeah. So here, let me pipe in.

So I interviewed, uh, Daniel Hawkins, um, I don't know, 4 years ago on the, on my podcast Inside Orthopedics when they were just getting started. And, um, I, my opinion, so they, they basically, uh, wanted to control the OR and sell access to the device companies. That was their MO. And, and they, they took off during COVID because everybody was interested in repless support. Um, but my opinion is they failed because they tried to boil the ocean. They tried to do— they, they had huge costs, like Barry said, and they tried to install it all over the world and every procedure possible, and it, you know, and the financial conditions changed and they just shut it down, you know, a few months ago. Focus. I think focus was their problem, not, not, and cost was their problem.

Yeah. No, and, and, you know, I think there's a lot of things that we do, we're doing in this company that are maybe more measured just from where we've been and what we've done as, you know, founders of device companies that we kind of we didn't want to just blast this out to as many places as possible. We've really been sort of measured, and you'll sort of see, like, we don't have a ton of installation sites, but we've really been monitoring, monitoring them very closely and building up the software and the reliability and the scalability and all that before we really push to more of a national launch and rollout. So again, I don't know, I don't know, Vale, and I don't know Daniel or any of those people personally. I just, when I would see, I liked that they were promoting the same message in a lot of ways, that like, hey, access to the OR is valuable, it's hard, and there needs to be a solution, and we have a solution. And we were like, yeah, we do too, you know, we, we agree that there's a, it's, it's, there's good—

oh, he's waiting for a look. You're frozen, Lawrence. We lost you. Well, while he's frozen, anybody have a question we can tee up? We haven't really gotten into the business model piece yet, but I think business model is important.

Did I lose my signal again?

Am I back? Yeah, you lost your signal. You lost— and we lost your slides, but we can see everybody. And Mike's got it. Mike Donahue's got another question.

Yeah, I was, I was curious.

Yeah, yeah, I'll keep, I'll keep bringing it back.

Yeah, I was curious on your, uh, permanent installs, are— is there an opportunity for the facility to monetize their content with the device company? Do they charge a fee if Medtronic wants to, you know, have a run a, uh, a case or something and beam it out to their customers or to their sales reps or whatever? Does the You know, does the facility stand to monetize or gain from that, or is it just for, uh, B-Surgic?

The answer is it depends. The answer is it depends. Um, you know, we've got, we've got the ability to do that, and we've actually had those conversations with some facilities, and we're open to it. I think it really comes down to, um, if the facility can understand the value of that and know that they're that the device companies are willing to pay for that, then sure, we can get them to pay more for an install. But a lot of them may say, well, we're not sure how much demand there'll be for that, so we'll pay less, right? So, but, you know, we're as a company, yeah, I mean, we're, we're not looking to be the only one that wins. And maybe to your point, if we align our interests with the facilities that we're putting them in, obviously that might make it a little easier pill to swallow if the facilities know that there's, there's something in it for them too. And so, yeah, I guess what we'd call it is sort of like a revenue share related to their, to their facility. And so, yeah, we definitely have, we definitely have some of those in place. Thanks. Sure.

So we're kind of coming up with the last few slides here.

Yeah, yeah, I'm thinking 4 more. Okay, go fast. So, um, you know, this is just really the only quote here that I think matters. So these are sort of, you know, a little bit of fluff, but like we get a lot of questions about, um, compliance from a legality standpoint. You know, some people will say, oh my goodness, like you're recording surgery, that's a legal, you know, problem. Usually not from lawyers, it's usually for people who just don't really understand it. And, you know, we've got actually one of our investors is a retired judge, and so, um, you know, his position was, you know, if you have video, it's so powerful in defending the surgeon. And I would always feel that, like, thank God I had the video, otherwise it's a he said, she said what happened in that operating room. So I think that's an interesting point for us to, to make, is that there's value, um, in having, um, you know, access to the operating room, but also knowing that documenting these procedures can be, um, valuable and a way to defend the surgeon, not just, you know, incriminate a surgeon doing surgery. We talked about the competitive stuff a little bit. There's, you know, places that are just— you go to watch surgery, there are presentations about surgery. That's sort of like the ViewMedis and the OrthoBullets and that sort of thing. So not really a competitor, but you know, it's video, and so it, it is sort of related. I think we can be sort of a content creator for those places, so not necessarily a competitor. Then you've got the systems that are brought in, again, not permanently installed. And then we also look at these like very large complex systems. I think our Miami install told us that— I think it was Striker, one of the companies— was like, well, we wanted cameras in our OR, and they told us it would be like $100,000 to like outfit the OR with cameras. And he's like, there was no way I could make that argument to my facility to pay $100,000 just for some cameras. So, you know, when we came along and we had this very reasonable low-cost solution, he was like, it was a no-brainer. So, I mean, although it's a competitor, just a very different proposition to the facility on, you know, the cost versus the benefit of having cameras. This is just a general view of our active pilot locations. So we're sort of spread out around the country. We've got 3 installs in Texas that were actually— 2 of them were our initial pilots, and then the other ones that we have now are sort of more refined installations that are running. So, but, and then this is sort of my final slide, which is, you know, our focus in the beginning was really on this, doing the installations. Making sure our product features were better, really having this customer self-service experience, making sure the system was reliable and scalable. And now we're heading into this area where we really, we're going to push heavily on more access more quickly. So getting more surgeons engaged using our products more quickly, and the idea is they lead to permanent installs ultimately. But the idea of doing, you know, specialty expansions where instead of just being, you know, shoulder surgery, You know, there's, you know, 14 other specialties we want to target very specifically to make sure, but again, that's sort of a slow rollout for us. And then, you know, partnerships with OEMs and device companies, so giving them a tool to really get access to that information quickly and stay engaged with their KOLs. And I think that's where the portable system is the first way to do that. So yeah, that's really it.

Mark, go ahead. Great, thanks. Um, I really like it. I've always operated under the precept that more information makes better decisions. How are you handling patient consent?

So, um, when we don't really control how the facility does that, again, we're sort of more like a utility for them. Um, just like as if the recording, uh, company came in and set up, like, the facility has to make sure they're getting the patient consent because they're the ones that are paying for the device. We actually, I think I may have mentioned this earlier, but we do sort of help guide them on some language that would make sure is encompassing. And a lot of times the language on their consent forms does cover video, it covers recording, some of them cover streaming, education purposes. So the idea that, you know, the only people on this system are, you know, They're signing the HIPAA compliance, they're vetted. It falls— it still falls under that educational side of things. So again, we're not getting the consent form. It's still the facility's job to do that, but we can help guide them on some of the language that should be in there.

I've been doing a lot of research into AI-enabled documentation visualization systems for EMRs, EHRs, and patient consent has been a big issue. Pretty easy to get in an urban area, a lot more difficult to get in rural areas. And I was just, just curious if that was something that you guys had to consider. Doesn't sound like it. Thanks.

Well, I mean, I think it's, it is something that's come up because I know there's a few companies out there now doing video patient consent. I was, I think I was just reading something about it today where they get the patient to actually, they, they on a screen and they hand sign and they watch a little video and they're recording the patient saying that they consent. And so, yeah, I think there's elements of that which could play into, you know, making sure it's more clear what the consent covers. So, yeah, I think that's definitely an interesting aspect. Thanks. Okay.

As we're wrapping up here, I want to ask the question that Laurence asked me at the beginning. He wanted, he wanted really critical feedback. So why not? Why don't— why not?

I don't do this.

Yeah, why not to do this? What can go wrong? What are the challenges? Throw out what do you guys think is the biggest friction?

I think some of the biggest frictions you'll get are from the OR staff just being— they don't want to do any additional work. That's something I've always realized when every time I've been in the OR, it's the circulating nurse not wanting to do more than she has to do already, or he has to do. I do think it's an amazing, amazing platform though. That's kind of some pushback I would— I could see.

Yeah, no, it's an interesting point. We have in one of our facilities, they were like, hey, this camera that's above this, you know, our, our table over here where we work, can you black out where we sit? So, you know, I was like, you know, again, I'm trying to like make them you know, get them ingratiated in this. And I was like, absolutely. So we've got a little, you know, a square, black square where the nurses are sitting at their little table because, you know, we don't really care about that. So, you know, just to make them feel good, yeah, we're doing everything we can to try to not make it this, you know, intrusive thing that bothers them.

Well, every deal I've ever been involved in involves everybody asking, what's in it for me? And I think the surgeons and the companies are going to say a lot. Yeah, but every time I ask the attorneys or IT if I could do something, they always say no.

Yeah, well, it's easier to say no. Yeah, you don't get— you don't get patted on the back when things go well as an attorney. You just get told when you messed up. So I totally understand where they're coming from. Oh yeah, thanks.

Hey, David K, can you hear us? Can you— do you have a— you have feedback? David, Dr. K is in the background. He's a hospital owner, so I thought he would maybe give a little perspective. All right, he's probably, he's probably doing 3 things at once. Um, all right. Well, thanks. Thanks, guys. This is fascinating. This is, uh, yeah, this is— I would be really interested to see how this is used in the future. There's so many ways it can go, and there's so many people that could value from it. So, uh, yeah, great stuff. So Lawrence is a BoneChat member, so you can, uh, you know, talk to him on Slack, send him notes, files, anything you want. So, uh, Thanks everybody.

This is—

this has been really good.

No, thank you everyone for your time. I really appreciate it. And like Tiger said, just if you have any questions, just, you know, reach out to me directly. I'm happy to jump on a call or send you more info. Thanks. Good luck. Thank you. Thank you.

Thank you. Future is now. Thanks. Thanks, Tiger.

Appreciate it.