Handheld Ultrasound by Butterfly Network: Faster, Cheaper, Better

The Harry Glorikian Show

For August 15, 2023

Full Transcript

Harry Glorikian: Joe, welcome to the show.

Joe DeVivo: Thank you, Harry. It’s a pleasure to be here.

Harry Glorikian: Yeah, I’m so glad to have you on the show. I mean, as we were just talking about it, I was like. I talk about all these handheld ultrasounds when I’m giving my talk and how I am going to sort of, you know, bring the level up. And I thought, you know, but, you know, it’d be great to have. Great to have you guys on the show and actually talk about the technology live so that everybody, you know, can really understand what these technologies are, how they’re being used, where they’re being used and why they’re so critical. But I guess before we jump into that, there may be a lot of listeners who aren’t even familiar with ultrasounds except for, you know, with your pregnant spouse. But I know that these technologies can be used. Way beyond what I just described that most people may be familiar with. So can you tell us a little bit about why someone would use an ultrasound scan. What parts of the body they might scan and what sort of problems people are looking for when they’re utilizing this technology.

What is an ultrasound scanner?

Joe DeVivo: Absolutely. Absolutely. So and again, Harry, thank you so much for having me. Ultrasound is used in the hospital for many different clinical use cases. It’s used in cardiology to track the ejection fraction of the heart. It’s used, as you had said, in labor and delivery to identify the health, the sex of a child. It’s used in the abdomen to you, in the chest to see the lungs or to identify bowel obstructions that appendicitis or in peripheral vascular for DVT. And there’s all different types of carts and all different types of machines that sit in a hospital. And if you have an appointment, you can go in the hospital and you can be diagnosed by any one of these specialists. And so ultrasound is a safe technology. It doesn’t have any radiation or any artifact that lives beyond in the body. And so you’re not really limited to the number of ultrasounds. But of course, you want to limit anything that’s not necessary. So I think that’s yeah, that’s about it.

Harry Glorikian: So but I mean all these people are trained, I mean when I go in, you know, an appointment is made, I go in, they take this cold gel and, and they rub it on you. Right. And they, they’re, they’re sort of moving the probe around. Why is it so tricky? I mean, I’m thinking of the fact that. They really need to understand how to get a precise image right. And of course, depending on what they’re trying to image. They might have to understand the organ or what they’re trying to do and then be able to see if they’re pulling the right image from this.

Joe DeVivo: Yeah, exactly. So, you know, ultrasonographers are incredibly well trained technicians who understand how to operate the device, who understand anatomy, understand how to identify the anatomy, where to place the probe in order to get an image from the anatomy. And then pretty incredibly, after they see the image, they’re also skilled enough to make, to a certain extent, a diagnosis. Now, obviously, if they acquire that image, they also give it to a subspecialist who’s caring for that patient. And that makes the ultimate clinical diagnosis. But, you know, it’s really challenging. And so over the last ten years, interestingly, ultrasound makers in the market have created what’s called a handheld ultrasound. And those handheld ultrasounds now are no longer tethered to those radiology departments where those ultrasound machines are. And it allows clinicians to have them to be mobile and to be able to use them much earlier in their clinical diagnosis. You know, at a time, you know, when something may present itself. And so instead of scheduling a scan, if something is more emergent, someone with a handheld can actually start doing the image themselves. And so the first, the first, you know, the thesis of handheld ultrasound is what’s called point of care. And the market is actually called, you know, Point of Care ultrasound or the abbreviation would be pokus. And for pokus or point of care, you’re empowering doctors to have these handheld ultrasounds, to be able to take an image right. When they’re engaging the patient, not, hey, your abdomen feels a little hard, let me go send you in for an MRI or whatnot and you wait whatever time and you go into a very high cost setting. And handheld ultrasound is designed specifically to give clinicians the ability to make a diagnosis, you know, right at the point of care.

Harry Glorikian: Yeah, I’m you’re making me think of things like workflow and, you know, are they receptive to this and stuff like that. But I’ll try to get to that a little bit later. I mean, right now I want to sort of get people to understand like, what is the butterfly IQ? What does it look like and how does it work in the simplest terms?

What is Butterfly IQ by Butterfly Network?

Joe DeVivo: So it is a handheld ultrasound. It looks like a standard ultrasound probe. It is a handheld long device with a cord coming out the back that allows for an image to be extracted in a very simple way. You can actually go run down the hall and grab one and show you if you want, you can pause this and I’ll go get it. But it’s basically a handheld probe that looks like an ultrasound probe. And it has all the technology inside to be able to acquire an image. What Butterfly does differently than other handheld probes is all the other handheld probes on the market are analog. They have a fixed type of energy frequency, battery, battery crystals, and they take a pre-programmed image. Butterfly is the first on the market to actually use a semiconductor chip with a Mems wafer technology. And the chip kind of directs energy to the wafer. The wafer vibrates or the Mems, vibrates its sensors and sends the energy out and it is completely programmable and controlled. And so, first of all, a butterfly is very durable. We can drop tests from four feet. And so it’s something that can travel with you. It’s not fragile and it’s very robust. And second of all, because it has semiconductor chip technology, you can use one probe for every part of the body. You just plug it into your iPhone and the app opens up, you scan through the app, you identify which organ it sets a preset, and then and then you go and it’s connected to the cloud and has all kinds of software that makes it easy to capture the image.

Harry Glorikian: So were there any challenges, I mean, in building this or, you know, what kind of were there any technical hurdles you had to overcome?

Joe DeVivo: Oh, absolutely. So, you know, the marrying of the Mems technology with the semiconductor is the only chip in the world that has been able to create a has been able to marry the two together and produce this type of energy at scale. So everything is about chip optimization, which is energy, heat and the ability to drive as much energy for imaging as possible. And you know, very much you can look at Butterfly to all the other companies like a digital camera and everyone is a film camera. And so in the very beginning, you know, it’s all about processor speed and it’s all about how many pixels you can acquire with. That initial image. And so your first image is a one megapixel image. And then as your technology gets better, it’s a three megapixel image. And people start saying, oh, well, you know, your image isn’t as good as film. Yeah, okay. But we’re also, you know, that’s we’re also doing it in a in a very cost effective and also very high tech way. And then all of a sudden you come out with a five megapixel chip and then you come out with a seven megapixel chip and now your imaging is better than film and you have all the other benefits of miniaturization, of low energy, etcetera, etcetera. So, so much of our development is all about microprocessors and all about semiconductors. And we are launching our newest chip next year. And for us, you know, we have Moore’s Law on our side. So every 18 months, compute power doubles. You know, there’s a fixed limitation to a piezo crystal. It’s unlimited with chip technology that we’ve seen over the last 30 years manifest. So it’s no different for us. And we’re going to continue to push the boundaries of technology.

Harry Glorikian: Well, and for those of you that are old enough to remember Kodak and for those of you that are young and don’t don’t know anything about Kodak, go look it up on Wikipedia. But what happened to them? But so now the company’s founder is, you know, Jonathan Rothberg. Right. I mean he’s got I’ve been hearing his name, I feel like forever. But, you know, genomic sequencing, proteomics imaging I. What’s the backstory on Butterfly? I mean, I think you guys started, if I remember correctly. 2011 ish. How did Jonathan, like, come up with this idea? Although I have a feeling like there’s more ideas in his head than can be realized most of the time.

Joe DeVivo: Well, I’ve been here for months, and so I’m not the historian that I should be. But he tells a story about a time in a lecture where he had this idea at MIT and then was able to bring it to life by studying the interaction between the semiconductor and a Mems chip and the ability to create the vibrations and the ability to modulate the energy. And so he’s created many companies based upon similar types of technology and I think has done an amazing job in taking technology into a way where it can democratize health care. Jonathan’s a beautiful man. He is a very caring man, and he cares more about helping people through his technology than anything. And even after all of his success, when I’m with him, he has his lab that he is constantly in, you know, seeing where technology can push the boundaries. But I think time will tell that his impact on health care and humanity will be massive.

Harry Glorikian: It’s always good to get up every morning and have purpose. So. Yes, now. Okay, So you said the handheld ultrasound is connected to, let’s say, an iPhone or I’m assuming an iPad right in and it’s displaying in real time like I can think of all of this. But, you know, what are the advantages of using the iPhone this way? Like a display? I mean, is any of the processing or, say, interpretation happening on the phone? And how does all that contrast with sort of traditional ultrasound systems?

Joe DeVivo: Well, we are seeing so the ability to to project an image into a device like a phone or a tablet is something many other handhelds like our handheld ultrasound do that we do as well. What we do that’s unique is, if we first of all, you would go to the App store and you would download the butterfly app. You’d have the app now on your phone or for that matter, Android users can go to Google Play and do the same thing. And then you open your app and now your app is ready for you to plug your butterfly into. When you plug your butterfly into it, recognize it, you put in your credentials so it knows who you are. But then it’s using the energy creation inside of the handheld. It’s using the computer power of the phone to present the clearest image. And then it’s also connecting it to a cloud where there are algorithms in the cloud that are directing and communicating to the phone. And then the entire ecosystem is creating a level of intelligence that just makes it so easy for the user. All the So again, it’s like driving. It’s like driving a Tesla, You know, you have your hardware, but then you have your software that’s controlling everything and then you have your connectivity into the cloud to make sure that everything is up to date. Everything is new. That’s learning going on and the algorithms are just simply making it as easy as possible for that end user to just focus on the image acquisition. It’s very Apple-esque where it’s just incredibly simple. You open the app, you plug it in, you choose the organ, you go and you’ll get wonderful images. And if you want to have different presets, it has all the capabilities for you to tune it to your liking, but it has all the automated presets, so you just go and you don’t have to be, you know, too confused by it.

Harry Glorikian: Yeah. I got to imagine though, like with all the AI that Apple is, you know, has on its chip in the phone, I’m assuming at some point you guys are going to want to take advantage of that edge computing capability. Sure.

Joe DeVivo: Yeah. No, we use every resource that is made available to us, whether it’s in the cloud or whether it’s in the computer power of the phone. So it’s not just the tablet being used to present the image but, but the app has a certain level of capabilities that the phone is allowing it to have because of the compute power of the device. So we rely on that. And even as we’re developing new AI, you know, we can push after regulatory approval, new AI algorithms actually into the phone and into the app and update the app. And so then you are continuing to have those new capabilities. Instead of having to have an analog device where you have to now go upload software or, you know, this is a dynamic, it’s again, very Apple-esque where you can push new updates, you can push new algorithms, you can create greater capabilities all networked into into a single, very powerful cloud.

Harry Glorikian: So I keep thinking of technology as a deflationary force, right? Because we get to build more powerful systems. They become less expensive. It makes them more accessible. They do more things. How does the pricing of your handheld ultrasound system compare with a traditional ultrasound? I mean, I’m assuming this really changes the world of the developing world and technology being available. You know, can you talk a little bit about that?

How much do handheld ultrasounds cost?

Joe DeVivo: You’re exactly correct. So handheld ultrasounds are around, you know, $10,000 an ultrasound. You know, some get as low as maybe 5500, but then that’s one probe for one use. And then when you have to get the three probes for the whole body plus everything in it, you know, it’s $10 to $15,000. Butterfly sells for 2699. And so we have dramatically taken the cost down. And then we have a just about a $500 annual subscription that allows for the cloud power of the cloud and the software, you know, to be connected to it. So we have dramatically reduced the overall cost and that has led to, you know, tens of thousands of clinicians even just buying it out of their own pocket. Because even through Covid, we know we had a respiratory disease and and and our device is the best device for pulmonary imaging. And because we can modulate images dynamically that you need for the lung and also our eye to be able to assess those aliens and lines or specifically lines. So yes you know, and as you mentioned earlier, on one side, we’re democratizing the access to ultrasound for health care providers. And we’ve caught the attention of the Bill and Melinda Gates Foundation.

Joe DeVivo: And they recently gave a grant to bring 1000 handheld ultrasound probes to Kenya. And so we have a two phased approach. And we already completed the first phase where 500 midwives were trained over a two week period on how to understand fetal positioning, fetal distress, gestational age through a bunch of different algorithms. And we taught all of these midwives how to do ultrasound. And interestingly, we just recently saw a one month survey data that 377 of the 500 are using it 82% of the time, 80% of the time, or 80% of them responded that they’ve identified a high risk issue that was resolved. And we’re changing the lives and the care of people who don’t have access to ten, 15 or 50 or $100,000 handheld ultrasound carts in the hospital. And so the desire is to democratize health care. The desire is to replace the stethoscope with a device that’s cost effective and can be used dynamically everywhere in the body. And with wonderful charities like Bill Melinda Gates. And we have a new one that we’re working with that will be announced shortly to do a very large deployment in a country of need that makes this accessible, making it easy is just simply good for health care and good for mankind.

Harry Glorikian: Yeah. I mean, it’s funny. I’m trying to think. I’m. I’m almost imagining that you could use this. If you use this in place of a stethoscope. I’m trying to think of the electronic stethoscopes that are available now and how you would build these two things into one unit. But I’m always thinking about different ideas like that. But there you go. Let let’s jump into things like, you know, how does the AI you’re using? You know, move the needle or play a role in in in what you’re doing. I mean, I know that it does image acquisition. It helps with image interpretation. Um, what else does it do and, and how and why does it help automate, you know, what’s going on here.

Joe DeVivo: Right. So, um, you know, when you go get an MRI, you go into an MRI suite, there’s a technician, they put you on a table, technician leaves, presses a button, and then a standard protocol of image acquisition occurs. And those images are just a bunch of slices that go through the body. And the same thing happens for CT. Um, but when you get to a non-handheld ultrasound, it’s just so hard, right? So here we are now, you know, for 26 $2,700, making a handheld ultrasound available to everyone and making it easy. But it’s not easy to acquire the image. I mean, you know, I mean, we’ve you know, as a father, I’ve had five children, five births. I’ve gone in and seen the handheld ultrasound. And before that, the ultrasonographer actually gets to, you know, finding the child. I don’t know what he or she is looking at. I mean, it is just so it is just, you know, you just get carsick looking at it. And that’s the challenge with a non-handheld ultrasound, is where do you put the probe? And then how do you find exactly what you’re looking for? And I always assimilate it to, you know, having a flashlight and a really dark cave. You know, you have to kind of know in directionally what you’re looking for and then and then you have to find it. And then when you find it, you have to have the intelligence to know what it is that you found and what it means and where it’s at. So it’s incredibly complicated. So the iQ is designed to make it easier.

Joe DeVivo: So there’s one aspect of the eye that’s on the image acquisition side. So it’s okay, you’re putting it, you’re putting it someplace, but it’s telling you to move the probe because as it sees the image, it kind of knows where you are in the body. It’s trained to look. Even that gobbled image that is not recognizable. The eye, because it’s trained on so much data in our cloud, is able to identify what that particular anatomy is and then tell you how to move the probe in order to get a better and better and better image until your spotlight is now dead on it. And so one part of one part of the eye is simply making it easier to contort the probe, to be able to extract the right image. Another part of the eye is to kind of identify structures, is to tell people actually what they’re looking at. And we actually have some AI right now that’s waiting for our conversation with the FDA. But you literally can place the probe anywhere, you know, on the body or anywhere in the chest and abdomen. And based upon what the algorithm sees, it actually tells you this is the kidney, this is the lung, This is the liver. Right. So and then and because it can actually label the anatomy and we’re and for us, it would be an incredible education tool. So allow new users to simply without fear, put the probe on the body and start exploring. And then it’ll start telling you just like a map or a map.

Joe DeVivo: Okay. This is, you know, this is this, this is that and identifies certain pieces of the anatomy and the key component. The first key component to democratizing ultrasounds is making the probe easy and cost effective. The next set is to make the acquisition easy and automated. And then, of course, the third set is to make the interpretation something that’s easy and automated. And so the tools that we have are all trained on our data and allow us to be able to acquire and help those people acquire those images. We have a new probe coming out that is very much like a Dr. Spock type probe. Remember when he would grab that thing and put it toward the body and it would just scan through the body and said, oh, you know, you have this diagnosis. Well, it’s not that not that significant or sophisticated yet, but kind of. So our transducer for the handheld ultrasound is like an LCD screen and we have all these different Mems, Mems devices sitting on top of the chip and we can direct all those devices to work in concert to deliver energy. And so normally if you put a device on an abdomen, you get a fan, you get a single line fan, and anywhere you turn, that probe is kind of the fan of the image that you have. But now we can place the probe on top of the chest or the abdomen, and it can automatically take images at different angles.

Joe DeVivo: And so in essence, it’s creating that fan like approach or creating a series of images. So instead of having to hunt and peck for something, you can just simply place it over the kidney. Press the button, take all the images of a kidney, very similar to how an MRI would take it. You’re taking all these slices or how a CT scan always slices. And then now you can instead of while you’re trying to find something, you now have a file and you have a file of 30 or 40 images and you just choose which image just like they do in like you see the tumor get bigger and then smaller as they’re going through the slices. Well, you now can do the same thing with a handheld ultrasound and that can only be done with butterfly. And so the next probe that we have come out has this auto scan feature that will allow for a less skilled health care professional to be able to acquire an image in a in a very easy manner and then be able to send the image because butterfly has something called tele guidance, which is very telemedicine like that will allow you to send images and collaborate through a virtual medium like what we’re what we’re on right now. So, the image or the future for what we’re doing is very bright because we’ve we’ve we’ve attacked the cost issue and now we’re dealing with education, with Butterfly Academy and certification and tools that make that image acquisition easier and easier to acquire.

Harry Glorikian: Yeah. You know, it’s funny because whenever you’re talking about this, I’m like, God, I want one of these at home, right? People are like, You’re you’re nuts. I’m like, no, I mean, this is going to be, you know, I think at some point some of these technologies are just going to be available to patients and. You know, depending on their condition and their I just can’t see how the cost isn’t going to continually come down and just it’s going to be cheaper and easier to either have it near the patient or the clinic down the street will have it. And you don’t have to go into the ivory tower.

Joe DeVivo: Mhm. No, I think that’s right. I think you’re dead on and that and that’s what that is actually what’s happening. You know we, I think I mentioned to you earlier but we, I’ve been here for months and I’ve, I’ve been in digital for a while and, and health care and devices for a while. And what fascinated me by butterfly is the capabilities of the chip. And I kind of feel like the first phase of butterfly has been butterfly taking hits, unique technology and putting it in kind of an old form factor. And that old form factor is this handheld ultrasound, and I kind of assimilate it to strapping a combustion engine on the back of a horse. So we have this engine and the engine can move the legs of the horse faster and that’s really great. So now we have a faster horse, but it’s, you know, it’s a bumpy ride. I’m out in the weather and I can only have one person on the horse. We didn’t create a vehicle. I think Butterfly can create an entirely new market with benefits that are well beyond the analog handhelds. And so the chip doesn’t need that big a form factor. It doesn’t need this big handheld probe. We just have it because that’s what the market is, that’s what the current market has. But imagine having a device that’s, you know, the size of my airpod case or just the size of a computer mouse. And imagine that is now given to a chronic care patient who’s been discharged, say, a cardiac patient. And if you look, 82% of hospitals through the United States last year. Um, we’re penalized due to remission rates. And so and the biggest culprit are cardiac readmissions. And the thing that you monitor for congestive heart failure readmission rates is the amount of fluid in the lungs.

Joe DeVivo: And one of the best modalities to test fluid in the lungs is actually using a handheld ultrasound and using an eye counter that we have called. It’s a beeline counter. So now imagine you send a patient home and you put a little temporary tattoo on them and you say every day, place this device and put this on top of that temporary tattoo, but put it there and press a button. You know, the patient is not looking at that seasick image that’s trying to you know, they’re just simply placing it here and it’s scanning the body and sending an image to a caregiver very similar to other remote patient monitoring technology that you know very well that allow patients to take things to the home and then things stream into a centralized area. And if data presents itself outside of preset bands, it alarms and a caregiver then intervenes. And managing fluids in the in the chest and in the lungs is something you do with a diuretic. And so you can you can remotely, you know, help that patient manage the fluid. But if they’re not managed and the fluid becomes excess, then they’re readmitted. So I see now the ability to truly democratize ultrasound by placing these wearables on or placing a device and having a patient be able to acquire an image in an incredibly easy way. Now, this will probably take, you know, although we’re launching it next year, it’ll probably take time. We’re launching the algorithm next year and our standard probe and a year later we’ll have something like this. But that’s where butterfly changes the game and that’s where ultrasound and the market will be changed forever with handheld ultrasounds.

Harry Glorikian: Yeah, I mean, you know, I always tell people the biggest problem in moving things in healthcare is, well, the people, they’re they’re, they’re not easy to move. Right? Because they have their workflows and they don’t want to change their workflows. The EMR, Right. Trying to get information in and out of there. Right. And so that somebody has to deal with insurance. Right. So those three things make the system just, oh, my God, sclerotic and and impossible to sort of move forward because everybody’s got their entrenched area that they’re trying to defend or figure out how they’re going to make money, which is why it doesn’t move as quickly as everybody would like.

[musical interlude]

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And one more thing. If you like the interviews we do here on the show I know you’ll like my new book, The Future You: How Artificial Intelligence Can Help You Get Healthier, Stress Less, and Live Longer.

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And now, back to the show.

Harry Glorikian: If I wanted to be a sonographer right now, I mean, it would take some level of training. And I know that there’s a shortage of these people. And I think that’s one of the reasons why ultrasound may not be more widely available because there’s nobody actually to do the scan. But I think about your handheld ultrasound system. How much training do you need to use butterfly? How much do I need to interpret the image? Is it any less than a traditional? And if so, why?

Joe DeVivo: I think the key is, first of all, the images are similar to the in-hospital images. And so image acquisition still requires training. Aside from the AI algorithms that we’ve talked about previously, the handheld ultrasound is the same as the standard ultrasound. The difference is the focus. If you try to become a master at every organ around the body, it’s going to take a really long time. But if you just say, I want to build pulmonary ultrasound into my practice and even start, you know, just reduce the amount of chest x-rays I’m sending for, there are ways where you can very quickly get acclimated to probe placement and the and where the initial image is. And there’s training that within, you know, several days to several weeks worth of training, you can get up to speed. And actually Butterfly has a proficiency software that helps institute surgeons manage the level of proficiency of each of their clinicians because as they are taking scans, those scans are uploaded into a module where a reviewer can look at those scans and then the reviewer can can evaluate the quality of the scan and the diagnosis and then ultimately move that person up a learning curve because there is a very big learning curve. And butterfly as an individual probe, acquiring an individual image is the same as any ultrasound device. It’s an image that you have to deal with. It’s like driving a car that, you know, it’s very standard. But the ability to now acquire that image, use tools and then use education and proficiency tools, we’ve made that a part of the offering that we have because we know that we look at usage data because everything is connected to the cloud.

Joe DeVivo: We can see, Hey, there’s a bunch of, you know, these types of people who aren’t comfortable yet, that they’re not scanning as much. And then we see these over here who are scanning a ton. And, you know, there’s a phenomenon in the United States called ghost imaging. And what it basically is, is, you know, someone will do a scan, but they won’t document it and they won’t try to get paid for it. They use the scan because they’re curious and they want to see, but they haven’t gotten themselves to a level of comfort where they’re willing to actually render the final diagnosis based on that scan, document the diagnosis and then ask for reimbursement. And that’s what a big part of our software is doing, is helping manage the proficiency. And then when people are at the right proficiency, having them and they have the confidence, then they can document and then push it into their epic system or and then ask for reimbursement. And so the more people we train, the more we get onto a certain platform, the more revenue the hospital is making because it’s institutionalizing the program. Many doctors have just bought Butterfly and they’ve used it and the hospital, they bring it into the hospital and go, Hey, what is that? That’s not in our workflow. That’s not our procedure or standards. And then when enough of them have them, we go to the hospital and we work with them on our software to institutionalize it. And and that’s the whole process of evolution. I mean, ultimately we do have to use AI and other tools to make the scans easier to acquire, and that is what’s going to significantly grow this market.

Harry Glorikian: But if I use the Tesla analogy though. Right. So, you know, you guys have now electrified the car, right. Which now doesn’t make it a car. It makes it way more. Flexible and adaptable, and it can do things that the car could never do. I mean, I’m assuming that we’re moving from. Yeah, I’m driving it myself now to you’re making this at some point the software is going to get more. Automated driving capable where I’m assuming the training can get less over time or the interpretation of the images gets easier over time because the software adds capabilities to be able to see things and. Identify things that someone may want to sort of focus on.

Joe DeVivo: Yeah, you know, I think that’s dead on. And I think we spoke earlier. I was listening to a podcast and it was Jim Farley, the CEO of Ford, and he was saying he was very transparent and self-effacing for the industry to say, you know, he was telling the listeners, you know, do you know how many different companies we have to deal with that have their own software, whether it’s for the chairs, whether it’s for the transmission, whether it’s for sensors in the engine carburetor, or that these are all different companies with different pieces of software. And it’s just such a challenge for them because they don’t have access to the code and they can’t get the code to speak to each other. And they just have to be able to find ways to pull data in and out of the software. And he and he actually then turned around and said, Do you know how powerful it is that Tesla has its own that has a single software platform and that single software platform drives all of those sensors and all those components and can and can be able to work in concert. And then it’s connected into a cloud environment where that data is then streamed into the cloud. And so it’s acquired an AI that is then used to be able to interpret that data and create intelligence, and it pushes that data back into the vehicle. And the next and the ability to get self-driving can’t even be contemplated without this single software type ecosystem.

Joe DeVivo: And he just said, Do you know how hard it is? And he was making the case to why they needed to separate their business out and their business to be different? And, you know, Elon Musk was Jim Farley was making the point and Elon Musk would tell you that, you know, Tesla is a software company. Everyone thinks it’s an auto company. But without the cloud and without the ability to have that processing, without the ability to have all the componentry in the hardware work together, you know, then you can’t deliver those newer applications. It’s exactly how butterfly is architected. We have a device, but that device is architected through a semiconductor chip that is completely electronic, completely digital. We can tune the frequencies. We can tune them after we’ve validated them and gone through the right protocols. But we know that a device is just like a phone is not just a device that can do what it does. When you take it out of the package, it gets better and better and better. And we push our software updates and we learn and we create this ecosystem to make the device easier and easier to use, to make it smarter and allow for a bunch of different applications. So that’s, that’s it’s a perfect analogy when I heard it. And I think it’s exactly what we are aspiring to do.

Harry Glorikian: Yeah. I mean and if you think about it I can imagine Musk saying I’m not letting any other crappy software into my system that I can’t manage. Right?

Joe DeVivo: So so but, you know, one of the things just to, you know, that that kind of triggered something, you know, we just launched something called the Butterfly Garden. And what the butterfly garden is, is an is basically an AI marketplace where we publish a public SDK. And so if you’re an AI software developer, you have a big task ahead, right? Because you’re going to develop your software and come up with all this intelligence for you to now have to develop a probe and to redevelop everything that we’ve had is just unnecessary. So we are allowing developers now to take our SDK and then develop a new app that they would put into the App Store. It would be their software, and when it’s in the App store, they would then, you know, the user would open up their app, plug in a butterfly, and then the butterfly image that we extract goes into their application and their application then runs all of their scripts and whatnot that, that they wish to provide that additional value. So Butterfly is not just creating algorithms that we create, but we are making our platform available for developers to be able to bring more and more solutions. So for our customers, they’ll have all of butterfly’s capabilities and then they’ll have capabilities. If they own a butterfly probe of all these incredible companies, too.

Harry Glorikian: Interesting. That’s a.

Harry Glorikian: We could. We could have a whiteboarding discussion about the pros and cons of that. So. What’s been the impact of. The democratization of this. I mean, you know, opening up access to imaging. Do you have any? Let’s say data or anecdotes to illustrate how the IQ ultrasound has made a difference in places where doctors and patients previously had no access to ultrasound.

Joe DeVivo: Yeah, it’s really the essence of point of care. And every month we share with our employees a story of, you know, a child who received a diagnosis from point of care ultrasound or someone who’s coming to the emergency room and had a quick diagnosis, or especially the work that we’re doing in Kenya and in other developing countries where, you know, the the accessibility of ultrasound is now allowing for, you know, there’s, I think, you know, 200,000 women a year die in childbirth and 28 out of 1000 out of 1000 children die in childbirth. In Kenya alone and or in Africa alone. And we’re and through the Gates Foundation, we’re really tackling the ability of, you know, there’s one side where you’re simply bringing ultrasound to a market that doesn’t have it right. And so in that environment, all the benefits are self-evident. But in developed countries where ultrasound exists in facility, the benefits are all now being derived based upon having the immediacy of diagnosis. You know, like if someone you know a lot of what a general practitioner has to do is you have abdominal pain, well, what’s the what’s the root cause of that? Is it appendicitis? Is it a bowel obstruction? Is it a triple A? And, you know, and so giving more tools. And every day we’re hearing examples of those who have ultrasound at their fingertips finding, you know, those those those morbidities much sooner.

Harry Glorikian: What’s the biggest barrier to expanding handheld ultrasound sort of even more widely than it has been.

Joe DeVivo: Well. So, you know, first of all, there are technology barriers and then there are health care, structural barriers. And those, you know, the health care structural barriers are are you know, there there is a current workflow to bring imaging into radiology. Right? And there’s a reimbursement for the imaging and radiology. And then there’s an ownership of imaging within radiology. And so you have to kind of change the thought process of the hospital and of radiology and of the workflow to realize that, first of all, hospitals have a fixed throughput of imaging, right? So there’s only so many machines they have and so many ultra sonographers and so many images they can take. And so a by adding in point of care ultrasound, it increases the bandwidth. And it from a radiology perspective, it allows radiology to focus on the higher end, the more complex scans than just doing the routine, everyday scans that are not as necessary. And so there’s so you have to work through health care. You have to change behaviors. Because right now for a general practitioner, it’s just so easy to order a chest x ray. And they don’t they don’t have the liability, they don’t have to do the work, etcetera. But, you know, the difference between a $50 X-ray that’s done with a handheld or a $500 x ray that’s sent in, you know, it’s are we interested in health care economics? Are we interested in ease and and reimbursement? So having to change the pathways and getting to economic models, you know, you have to show people a a whole new way that it’s not 52 to 500. It’s you’re going to be at capacity through radiology no matter what. And you can increase your capacity by having more scans done at the point of care.

Joe DeVivo: And then, of course, that by catching something earlier instead of having someone in the emergency room waiting three hours for a chest x ray to be sent and whatever come back, you can just take the image and have them go home. It’s you have to build all the new models and show them how this new workflow can benefit. On the technology side, it’s it’s simply, you know, it’s I would have to say the biggest barrier is what you started off the conversation with. It’s education. It’s how do you get someone to be comfortable and have the proficiency to be able to to rely on their diagnosis earlier in and and you know, a fascinating fact is 60% of medical schools in the United States today have ultrasound and point of care ultrasound in their curriculum. So every year, kids that are now graduating and going into their residency have learned how to do point of care ultrasound. Today, 42% of all residences in the United States have point of care ultrasound in their curriculum. So we know that in five years, you know, most medical students that are graduating are all going to have this new ultrasound stethoscope mindset and they’re going to have the and they’re going to they’ve broken through the fear of someone for the first time doing the imaging and then someone who’s very busy and just doesn’t want to learn something new. So this is happening and the next generation of clinicians coming through the education system will have this capability. And I think in a decade or two the ultrasound will be the stethoscope of the future.

Harry Glorikian: I mean, it’s interesting, right, that you say 42%. And in my mind, I’m like, it should be 100% right. It’s like, how many hours of genomics does anyone, you know, learn about? And I mean, it’s just it’s it’s I mean, the last time I checked, it was like maybe a couple of days. Right? And it’s so fundamental to practicing medicine these days. I you know, if I had my way, I’d love to figure out how to. Whiteboard and build the the system from the ground up again, because the way that it’s designed is I feel just it’s an impediment to we’ve got so many of these new tools like you guys are working on that can really, really move the needle for patients and significantly bring down cost because of the capabilities that it brings to the table. And it kills me when the system is just so sclerotic on how it adopts these things. It’s it’s not designed for change, which is the part that kills me so. Well, the.

Joe DeVivo: Other part is, is that, you know, a lot of the companies who have, you know, the the all of the large companies that that are out there have MRI imaging in the hospital. And these are, you know, million and a half, $2 million magnets or CT machines, half 1 million to $1 million machine. And then all of these different, you know, probes and all these different, you know, 150,000, $200,000 cardiac echo machines, there’s not as much incentive for these large companies. They’ll have handheld ultrasound because people will ask for it. But the incentive is really to keep selling more expensive machines, not bringing care out of the hospital into these low cost settings. And so, you know, we’re fighting against, you know, existing workflows and we’re fighting against big behemoths that are not really that incentive to to disrupt their own business. And it does take time. But, you know, people point of care ultrasound has a lot of momentum and it’s here to stay. And the training and the ability to, you know, think it all starts at the bottoms up. And while we’re fighting all the current barriers over time, as all these new kids get into practice, our things will change for the better. I have a lot of faith and, you know, we have sold more handheld ultrasound than any other company in the world. And there’s a reason for that because we’ve done things that are new and unique and cost effective and we’re going to continue to disrupt. And I think it’s going to meet in the middle while we’re trying to build the market. The market is also getting developed organically. And, you know, I wouldn’t be too dour. I’m actually pretty excited about the future And, you know, health care, there’s also a lot of technologies that can hurt people. And you want to evolve in a way where data supports the technology and you want it to evolve. And I think I think the genie is out of the bottle and it’s not going back in.

Harry Glorikian: Yeah, I mean, I have a lot of faith in technology and software, especially with everything that I see coming. You know, either the system is going to change or, you know, there’s going to be disruptive change because of business models that allow this technology to get to people that need it. So, Joe, I wish you guys incredible success. You know, I’d love to see one of Jonathan’s companies again be successful as, as you know, many of them have had in the past. But it’s been great having you on the show, and I look forward to seeing how, you know, things evolve over time.

Joe DeVivo: Well, I look forward to coming back and giving you an update, and I very much appreciate your time, Harry. So thank you.

Harry Glorikian: Thank you.

Disclaimer: This podcast includes forward-looking statements regarding Butterfly Network’s third generation iQ portable ultrasound that is still under FDA review.