Newsday - Cyber Crime Rings, Oracle's Promises, and Block Chain with Proofpoint's Ryan Witt
Episode 2131st January 2022 • This Week Health: Newsroom • This Week Health
00:00:00 00:42:55


Today on This Week in Health IT.

If I'm a listener to this podcast and I'm thinking about, Hey, am I vulnerable to a nation state sort of attack? I would think long and hard about what about my institution would be desirable from a nation state hacker. If you are aware and are promoting that you are world-class the reality is cyber criminal gangs and nation state activities because of the IP desirability of that research you're vulnerable.

📍 📍 It's Newsday. My name is bill Russell. I'm a former CIO for a 16 hospital system and creator of This Week in Health IT. 📍 A channel dedicated to keeping health IT staff current and engaged. Special thanks to CrowdStrike, Proofpoint, Clearsense, MEDITECH and Cedars-Sinai Accelerator, who are our Newsday show sponsors for investing in our mission to develop the next generation of health 📍 leaders.

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All right. It's Newsday. And today we are joined by Ryan Witt. Industry Solution and Strategy leader for Proofpoint. Ryan, welcome back to the show.

Thank you. Good to be here. Thanks a lot, Bill.

This is actually your first Newsday show. We've done a couple of things talking about various cybersecurity things and whatnot in the past.

So since this is your first Newsday, let's give people a little background. Tell us a little bit about Proofpoint and what you do there.

Sure. Proofpoint's all about protecting people from cyber attacks and how they work. It's very clear whether you want to look at our data or a whole range of third party data.

I think the World Economic Forum put a report out this morning that said almost all, when I'd say almost all like 90% plus cyber attacks are targeted on a person or member of staff or a job function. And they're trying to unwittingly get that person to spate and their cyber criminal activities.

So we're not talking about network based attacks anymore. Although those do happen or medical device attacks, those do happen. It's all about protecting people and how they work. That's what Proofpoint does essentially. My role is to try to translate that capability to healthcare has our primary focus industry.

And to make sure that we go deep into health care to understand healthcare industry use cases. So we can go build, adapt our technologies, our solutions to go better serve the industry. Is really that straightforward. That tunnel vision sort of focus on healthcare.

It continues to be a really hot space in healthcare and healthcare IT as you sort of noted. In fact one of our first stories here. We have five really good stories here. We've HHS issues the warning for healthcare ransomware threats. We're going to go into that. We're going to do the blockchain revolution story that John Halamka did on health system CIO. We're going to do the Oracle Cerner EHR.

bigger role in healthcare in:

Let's start with HHS. This is really your story. So what's HHS warning us about?

They're just warning us about the increased prevalence of ransomware sort of attacks. And they've indicated that healthcare should be on high alert for more of these attacks.

And I guess to a degree that's helpful because we want to have as much sort of promotion of this activity as possible, but also to a degree it's like, gosh, I mean, anybody in healthcare. Knows that the industry has been completely under siege from various cyber criminal gangs, mostly around ransomware.

But I mean, the reality is it's a whole range of attacks. So they're just making sure that broadly the industry is aware that this is a significant challenge and we should be on high alert for that.

As I read the newspaper, I mean, should I read anything into world events? So I read the Russia Ukraine thing. I read North Korea, firing missiles.

I read China sort of saber rattling and testing the United States. Does any of that sort of proceed anything that's going to go on in the cyber security space? Or is it less nation, state and more crime family kind of thing s .

Yeah, I think it depends. I would, if I'm a listener to this podcast and I'm thinking about, Hey, am I vulnerable to a nation state sort of attack? I would think long and hard about what about my institution would be desirable from a nation state hacker. And I remember having this conversation, not that long ago with a academic healthcare institution who had very specific research in genomics. A field, a portion of genomics that they happen to accelerate.

And they were very proud about all the work they were doing in this particular area. And I tried to make them aware like, Hey, if you are aware and are promoting that you are world-class and this one, although very, very niche, but very specific sort of endeavor. The reality is cyber criminal gangs and nation state activities because of the IP desirability of that research you're vulnerable.

And lo and behold, when we analyzed their health system or their academic health system, a significant proportion, exponentially higher of all their attacks are going into a very small portion of this institution. And it was largely into this area where they were doing this research. So back to your question for a world event and they stayed actors, if you have something about what you're doing that you think is valuable, like from an IP standpoint, clinical research standpoint the bad guys have probably figured that out. And you are a target.

Yeah. So you're painting this picture that these people are smart. They do their research. They read the same kind of journals we do. They might even listen to this show and hear somebody talk about the really great research they're doing and that kind of stuff. And that informs their their strategy as they start to attack these health systems.

ember? I think it was like in:

And it got a lot of publicity got a lot of notoriety and it made people like really, really nervous, like, wow, I can you can actually launch an attack on a person by by taking over this sort of a medical device. A lot of our medical devices too. And the reality is for Barnaby Jack to do that, a tremendous about a knowledge for him to go through the steps.

A lot of understanding about how microwave technology works, how communication technology works, how the device works, and yes, he could do it. And those devices were vulnerable then and they're vulnerable now. But that's exponentially more difficult than it is to put together a compelling email to get you to possibly, a unsuspecting recipient of an email, to interact with some malware. Right. And I can train somebody to go surf LinkedIn or Facebook or Twitter, gather some basic reconnaissance, have some basic template emails already built out and educate that person to go create a very compelling email. And I just need to be right. A couple of times. And then I'm into your health system. That is so much easier to invest. Think about it in terms of the level of expertise and attention to detail they were putting into how to go hack that infusion pump. They're still doing that, they've just shifted their priorities. Their priorities are all around social engineering.

So Ryan, let me ask you this. We're doing a webinar and we were trying to get security people to come on and do the webinars. Clients, essentially. Health system providers.

And we ran into a bunch of roadblocks. They don't want to get out there and talk about their posture or stories or those kinds of things. Do you think that's gonna be the norm? I mean, I would assume that's like the military commanders getting up there and saying, Hey, here's where all of our stuff's deployed. And here's the types of weapons we have. And that kind of stuff. I assume, consultants are telling CISOs to not really talk about security in public forums.

We're seeing more and more of that. You just go on the LinkedIn you'll see examples of that. So people who you have been connected to, or want to connect to their names or somewhat hidden. Like maybe they use on their first name and last initial or their job titles are now been removed, et cetera.

So, yeah. This is kind of like, and this is one of the things I was talking about with this academic healthcare institution. At one end of the spectrum you want to promote your activity cause you want to get more funding. You want to be desirable from a possible you know student applicant sort of standpoint, et cetera, and so you want to raise your profile.

But the moment you raise your profile, you're also putting a cyber target on your back. So yes, I think if you're in, you've got to determine like how you want to weigh that up. And if you're in cybersecurity squarely, your risk tolerance is going to be like, Hey, I'm going to weigh against doing some of these things.

Yeah. Last security question. I saw this article and I'm just hitting you up on this because this is more in your field than my field. You may not have heard this, but they're telling Olympic athletes not to bring their phones to the Olympics for fear of having their identity stolen or something to that effect. Have you heard that, have you heard that story?

I saw the headline. They didn't really get into the detail, but yeah, I mean, these are people who are they're highly, those identities are highly desirable and worth a lot of money on the black market. So these things don't surprise me at all. No w, how do you handle that? I mean, of course they're going to bring the phones, right.

If I'm an Olympic athlete, I'm thinking, okay, I'm going to go halfway around the world and you don't want me to bring my phone, I guess. I don't know. This is where we start to act like criminals and we bring burner phones with us to these places.

I don't know. I have no idea. All right. Which way do you want to go? You want to talk blockchain, Oracle, Watson? Where do you want to go next?

Let's go blockchain. We're on cybersecurity. Let's go a little bit more. We can pivot at other places.

Yeah. So the, the blockchain story's interesting. It's in health ystem CIO. It's really well researched. John Halamka and Paul Cerrato. Paul is a senior research analyst for the Mayo clinic platform. If you're not familiar with him. He co-writes a lot of stuff with John. They talk about this. We expected a blockchain revolution.

In fact, he starts to starting with simply put blockchain, holds the potential to revolutionize healthcare. And that was in Forbes magazine, which is of course to be trusted in all cases. In theory, the technology could enhance security controls around the health record access, but to understand those potential benefits, it helps to understand the basics of the technology.

And then it goes into the basics of the technology and how it works is a distributed ledger. It's not a database that collects all the data. It's a distributed ledger that stores things in blocks it's immutable. So that you can trust the transactions that are going on in, in that kind of environment.

And cryptocurrency has been running on this for a while. You see finance and that kind of stuff. In healthcare, not as many things have been done on top of this. In the UK, two hospitals used it to track the temperature sensitive COVID-19 vaccines. It is interesting. The distributed nature of it's interesting. The immutable records interesting, but it hasn't really taken off in healthcare. They go on to talk about this, but does this surprise you at all, that it hasn't taken off in healthcare?

A lot of thoughts about this one. But to your question, no this doesn't surprise me at all. And when I think about that question, I think about blockchain, I think about the promise of that capability and we should be excited by it. Okay. So as you've already alluded to, the whole cryptocurrency, I mean, I have cryptocurrencies being pummeled right now in the market. So maybe it's not, I'm not a great example.

At this, at this very minute. It's down so far. It's hard to even imagine. It's a bad day.

It's a bad day. But that being said the whole cryptocurrency as a model works. Forget about the actual whatever the coin is. The model is based around blockchain. About this idea that all parties can agree that the parameters for the transaction have been met and therefore we can proceed.

Right? That is essentially what blockchain, what got a very rudimentarylevel. That's what blockchain allows to happen. And so I understand the promise of it and the excitement of that and the applicability to healthcare and John's article is very good. However, when I see these sorts of stories and I think about the possibility, I'm also like come down to earth with a thud.

And I think about the HIMSS:

This idea that you're going to like leapfrog all of that stuff. And ll of a sudden, just pivot to blockchain at a time when you know, health is under great duress. It's harder and harder to find cybersecurity resources. I just think it's a, it's a great article. It's the kind of thing you would expect to see in Forbes, but I don't think it's the kind of thing you're going to see in your health system anytime soon.

I'd like to see the:

Exactly. I run an advisory board for Proofpoint. So we have an advisory board made up of mostly healthcare assists CISOs but there's a few, CIOs on there as well. And they advise us on a roll we're all strategy about how to go be more relevant to the industry. And so one of my advisory board members actually brought up this article yesterday and asked me about it.

And he said if we were to deploy blockchain would we need DLP? DLP being data loss prevention that stops exfiltration of data. And I said, well, you know what you're, I think what you're really saying is if you had a, if you truly trusted that your had an ability to secure all of your PHI would you need DLP, which would mitigate against removal of that PHI? And I guess the answer is you wouldn't necessarily. Okay. Because if you truly trusted that capability, whether it's blockchain or any other capability, you wouldn't then need that safe guard. But the reality is how much can you truly trust that a technology is going to solve for all of your PHI vulnerabilities? And I don't think you can. And so that's why DLP and other solutions exist to, to offer another layer of protection.

Yeah. Iit's interesting when I look at this. So again, my interaction with blockchain has not been that extensive. So my experience in a lot of different areas as a CIO for a health system was pretty extensive, but not in this area. But my understanding is there are some transaction speed issues, scalability issues, if you will around it.

There's also a lot of different databases and trust architectures that exist within health healthcare. And there's no financial incentive to move us, which is probably the biggest barrier, right. We, we rarely do anything. People are negative on meaningful use, but if we hadn't done meaningful use, we'd still have paper records in majority of the hospitals.

So we require incentives to move and even regardless of the potential that this, this displays we're not going to move there until there's a compelling use case. Unfortunately even the compelling use case may not take us there. It will probably take some sort of financial benefit.

And so it'll be a third party that creates something on top of a blockchain technology that reduces the the transaction costs within a health system, increases efficiency in some way. Reduces our cost of managing records or and when you do that at scale, you're talking about millions and millions of dollars.

That's when people will take notice. I think, regardless of how good the technology is. It's interesting. We're doing all this stuff in TEFCA and other ways to try to break open the medical record and have it shared with the with the patient and empower the patient as part of 21st century cures.

This framework, this technology, actually from where I sit, it looks like it would work pretty effectively as an underlying structure for this, but again, we're building out TEFCA. And we're using Secoya project and others to build out this framework. By the time that's all built out, it won't matter what this technology can or cannot do. I guess the square project could use blockchain in some facet of what they're doing. I have no idea.

I agree with you. I mean, there needs to be some sort of incentive or penalty. I think I prefer the incentive to allow disruption to occur. I guess my only little caveat to all that is and thinking about that word disruption, and certainly in relation to the other stories we're going to talk about.

I mean, disruption is happening to healthcare all over the place, and so they might be forrced to move more quickly than they would like to as an industry. Or we might be forced to move more quickly as we'd like to. But I suspect that disruption is going to happen and clinical care and care delivery and other areas before it kind of hits blockchain.

Let's hit one of the big tech stories. Oracle buys Cerner. Now we've talked about this on the show before just what does Oracle need to do? But my gosh, I'm reading this article in healthcare IT news. Can Oracle make Cerner's EHR Sing? CIOs and analysts chime in.

And listen to these promises. This is where big tech. Cause the other story we're going to cover is IBM Watson being sold. And it almost is like they're following the same playbook. Listen to these things. In announcing the deal larry Ellison Oracle's co-founder chairman and CTO said it would provide our overworked medical professionals with a new generation of easier to use digital tools that enable access to information via a hands-free voice interface to secure cloud applications. So that's Larry Ellison's promise. It goes on the company pledged zero unplanned downtime in the medical environment for Cerner customers said, Mike Sicilia, Oracle's Executive VP of vertical industries said it's autonomous database, low code development tools and voice digital assistant user interface will enable us to rapidly modernize Cerner systems and move them to our gen two cloud. Okay. That's number two. And it doesn't end there. Cerner CEO, David Feinberg, meanwhile said joining with Oracle would offer an unprecedented opportunity to accelerate our work modernizing electronic health records, improving the caregiver experience and enabling more connected, high quality and efficient patient care. And I make this correlation between the Oracle at these three statements, the Oracle announcement and IBM Watson, because IBM Watson came into healthcare loud and proud. We are going to solve your problems. We are here. We are we are the savior and it looks like Oracle is doing the same thing.

think relatively now in what,:

And so there will be an opportunity for those who are considering the change to look at other options. And so if you are an epic house and you want to look at what this new promise might bring, then you at least have a chance to have that a meaningful sort of discussion, okay. POC or however you want to entertain that sort of dialogue.

And so I think there will be a good opportunity for testing of these sort of promises. So I think that will be interesting. And I think if you are on the outside, looking in at how those EMRs were deployed, you saw a lot of clinical prowess and those tools or those applications, but maybe they are not, we're not as always, there were a lot of head scratching in terms of some of the underlying technology to them.

So can Oracle solve that in a way that healthcare cares about? I don't know, we'll see. So I think it's interesting. I'm also and I'm not sure that they would call themselves in the EMR marketplace, but I've kind of also keeping a little bit eye on Salesforce. Because Salesforce is they have a CRM tool.

The CRM tool is not a million miles away from what an EMR does, a customer relation management tool versus a electronic medical record. They've been rolling in much more clinical capability of that tool. They show up at HIMSS with bigger and better booths every year. And bigger and better stories every year. And bigger and better case studies.

And so I don't see them as necessarily an equivalent. But I see them as a disruptor in the same way I see Oracle as a disruptor. So I'm kind of curious when we get into this kind of full fledged EMR 2.0 Revolution, and then those health institutions are going to look at what are their options. I'm kind of curious how this will all work out.

Yeah. No I agree with you. We have to remember that these health systems that have paid billions of dollars to migrate to these EMR which just is astounding. When you come in from another industry and you look at the money that's spent on the EMR, you just sort of scratch your head and go, I've never seen anything like that. In any other industry it's just unbelievable.

A hundred percent. But they will be written down in a kind of point in time when they can go and they will have to go look at a refresh at some stage. Right. So, I mean, you were a CIO, so you know that concept better than I do, but what are these, like ten-year projects, seven year projects? When will they do the kind of the quote-unquote refresh?

Yeah. Well, I mean, yes. We had some of our hospitals running at least a decade old technology that we had no business running and we had to do that upgrade. Now, hopefully people have gotten better with tech debt and realized the danger of tech debt, especially in a cyber aware world, you can't keep this really old technology around. You got to keep it updated. And we had stuff that was end of life, that we were still running. So I agree with you. There's going to be another cycle. What they're looking for though is they're looking to Epic and saying, okay, you've got to upgrade the underlying data architecture because we want to run in the cloud.

So they go out, they do the next iteration of inner systems and they now have a new platform. They've replatformed underneath the existing Epic. So essentially they're looking to them and saying, Hey, keep our architecture as current as you possibly can. Keep it secure. Keep it performing. The question is, and I think Oracle's heading in the right direction here.

Can they fundamentally change the experience of the provider and of the patient? Because that's where all this is, why you're talking about Salesforce. Salesforce in a lot of industries changes how organizations interact with the community, interact with the consumer in ways that that changes industries. Changes I mean buying patterns and all sorts of other things.

And that's the thing that's compelling. Can we do that in healthcare? Because we're not changing buying patterns, we're changing health patterns in the community. And so we're, we're now having this discussion around public health initiatives and how much should we invest in those kinds of things? What if we actually had a way for health systems to engage the community effectively in public health and help them to make healthier decisions, as opposed to just doing what we've done for the last 20 years, which we know gets us in last place and all these character these characteristics when we get compared to other countries.

A hundred percent agree with you. You made a point that I wanted to kind of build upon. So the area where health systems want say Epic to make improvements is the exact area where Oracle and Salesforce are probably pretty strong. Right? So now is that compelling enough to have this huge rip and replace and shift to these systems? I'm not saying that. But I think it's probably interesting enough to have a conversation about what could be possible. And once you have the conversation, once you are seriously evaluating an alternative, I mean, you don't know what happens there, right? Even the most loyal car buyer will flip to a different brand or

Absolutely. We've seen that happen a lot. So if you want to check out that article, there's a bunch of CIOs do weigh in on that. They have a little skepticism like we do. But it's one of those that we don't live in a, we, we live in an environment that is very dispersed.

We have no matter if you're an Epic shop, you're still dealing with Cerner in your market, more than likely. You're still dealing with Meditech and you're dealing with a lot of different EHRS. So every deal matters regardless of what your chosen platform is. IBM sells Watson Health to Francisco Partners. Francisco Partners for those people who don't know is a private equity firm. They've bought up a bunch of other assets within healthcare. Availity, capsule, Good RX, Trellis, Z cDoc. So roughly 30 billion in assets in healthcare. So this is a company that knows healthcare invest in healthcare and understands how to do business in healthcare.

So from that perspective, very interesting acquisition for them. It's roughly valued. Nobody gave us the terms of the deal, but Bloomberg said it's probably over a billion dollars. A little bit more than a billion dollars and IBM is exiting and saying, look, the transition will be fine. We'll make sure the transition goes well, but they want to make it really clear that IBM is a, let me get the exact words.

Platform-based hybrid cloud and AI. That's what they are. That's what they want you to know. And by the way, it's repeated at least three or four times in this article. So clearly they've their messaging and branding has coalesced around we are a hybrid cloud AI company.

Watson didn't fit the brand new brand I'm guessing.

I think they just made so many mistakes with Watson that there's an opportunity here. A billion dollars to IBM, good for them. A little bit more focused in the conversations they're having with healthcare. They do take that black eye but they get to move on. Francisco could actually rebrand it. And quite frankly, the thing's worth more than a billion just in the data assets alone.

I would think so. Yeah. We all have been involved in these Watson demonstrations seeing the promise of what Watson was going to do in healthcare. I don't think have all been really excited by it and I still am excited by it to a degree, but I think what's the Gardner tune, the trough of disillusionment kind of hit that sort of a hit that sort of phase of the engagement. And I don't know, I never found that IBM or never thought IBM found a way to monetize the capability. And it's hard. It is a hard thing to monetize and AI is coming and so even though IBM's brand clearly is around AI. I mean, they mentioned it three times in the article, but in Watson kind of sounds like AI capability or at least I think it wouldn't say that capability. So they still decided to shut it anyway. And I suspect because they just could not find a way to monetize it.

I mean, that's probably true. Plus you have new leadership and I think the new leadership came in and said, he probably asked a handful of questions around this. It's like, why are we doing this? And the answer predominantly was, well, healthcare is a $3 trillion business. It's like, okay, that's great. But why are we doing this?

Well, Watson is some of the best AI technology in the world. Okay. And they just couldn't get to that, that compelling. And you're right about the monetization. They did close some deals. MD Anderson's the most I guess written about debacle in this. They went in and said, Hey, we're going to help cure cancer.

They also did that with Sloan Kettering and others. The playbook that's going to be studied for years in business school is what went wrong with IBM Watson Health. And I hope Oracle doesn't make the same mistake. I hope you're right that they're riding into a user experience curve and they see something, an opportunity and they're able to get on that. But IBM Watson just, they turned off everyone coming in.

I remember when they came in and everyone was sort of looking at them like we're going to solve the problems of you Luddite healthcare technology people. And we're finally bringing technology to this problem. They didn't understand healthcare. They didn't understand the data in healthcare.

You can't do AI without good data and so they ended up going in and saying, all right, we need all this data. And then they saw the data and they said, all right, well we have a consulting group that could come in and help clean up the data. And it's only gonna cost you 15, $20 million.

And people are looking at them. Yeah. Like I thought you were going to solve our problem. That's one of our problems. It's like, we can. Give us 20 million.

They kept trying to boil the ocean too. Right. They realized that they couldn't solve cancer. They couldn't fix healthcare and they couldn't fix cancer.

So they started to get very granular about which aspect of cancer they wanted to address. And they had to get more and more granular because the problem once they kind of peel back the layers, the problem became much more pronounced than the amount of data that had the mind became much more enormous.

And then some of it was structured for some, it was unstructured. And so yeah, you had to go through this cleanup activity. You had to establish these data lakes and matter to data lakes. And I think, yeah, I think it became too big of a task. Right. And that too big of a task that might be really interesting from a clinical capability, but I don't think it was interesting from a monetization a business that need to be monetized standpoint.

The good news is they ran through the wall, right? Somebody has to be first to go through that wall. There's a point, the famous Moneyball line where Billy Bean is talking, he's being courted by the Red Sox GM.

And he's talking about ho how hard it was for Billy Bean to implement money ball in Oakland. He goes somebody has to be first through the wall and you did it. And it's going to change the way the game is played. And that could be how this plays out. We're still reading a lot of articles about AI.

And people have realized and recognized the importance of data governance in order to enable your AI projects. And we're seeing people take that a lot more seriously and understand what that means. We're seeing people get really crazy. And they're starting from the data assets and saying, what data assets do we have that are clean to start with that we can educate these, these AI models and really get some some value out of them, almost out of the shoot.

And we've always known that images are probably the cleanest, cause it's not input by us. It's just a camera taking an exact image of what's there. And that's where we've seen. In the clinical setting. Anyway, that's where we've seen the most progress in the in the administrative setting though, we're seeing a lot, a lot of progress and a lot of different places that AI is being applied on the administrative side, the clinical side. The good news is they went through the wall. We realized what we needed to do, and we're, we're starting to put the things in place, especially around data to make more progress there.

No I agree with you. I, I used to work for a partner who provided some of the solutions into Watson and then kind of under the covers.

And so I had a little bit of exposure how that works and I, I applaud, I applaud IBM for their innovation and what they did, and they did break that wall down or broke barriers. And I think the promise of AI with a lot more realistic post Watson than it did pre Watson. So I do applaud them for what they did.

Yep. All right. So Amazon. I'm not going to go into the article, we'll have a link to it in the show notes. People can look at it and go over there. What's your take on Amazon, in healthcare? They're doing a lot of stuff.

Yeah. I'm really worried for healthcare as an industry overall. Because of Amazon, but because of everybody else, that's also, it feels like the interlopers for a long time now have been in the stadium, watching the game. They been creeping down to the sidelines and now they're entering the field of play. Right? And it's great from a patient standpoint, because we have greater choice. We have greater access or driving down some costs.

But the healthcare revenue pie is not growing that much. It's probably pretty stagnant, I would guess.

Yet there are so many more players that are trying to take a chunk of that revenue pie, and I just fear for the smaller health systems who just were reliant on these revenue streams, whether it was testing, whether it was flu shots, whether it was COVID shots, whether it was care visits, whether it was outpatient activity, this activity now going to Amazon and Walmart and Walgreens and CVS and you can list a whole lot more. I'm worried about that for the industry overall. It's a level of disruption that I think has been needed and was coming. It's happened to other industries overall. We've seen this right across every sort of segment. Healthcare has always been a little bit immuned, but it feels like those walls have been broken down.

And it's one thing now about losing a flu shot. Losing a COVID shot. Losing a COVID test. Losing a basic sort of outpatient service, but you're looking into like a second cause of effects, at what stage do new patient no longer value in the way, maybe people who are age that relationship with their care provider, because they don't have necessarily a defined care provider.

They use multiple different institutions or different, different outlets for their care. And so you have a much more transient sort of transaction, a much more transient relationship and health traditional healthcare as we know it at a time when morale is down, revenues are down operating margins were, which were already super thin or even getting hit even more. I worry about this from the industry sort of standpoint, I understand the value of it from a patient standpoint.

Agree with you. The large players have billions of dollars in investments and in the bank, and they have dominant market shares in their various markets that they serve and those kinds of things.

So as you sort of pointed out, they're insulated. It is the smaller players who rely on every piece of revenue to sort of make it. And when an Amazon Care comes in and takes away a little bit of their pharmacy. Or Amazon pharmacy takes a little of their pharmacy away and then Amazon care takes a little bit of their primary care. And they don't do this, but others are doing this. They come in and they take radiology away. They take away their profitable lines . They don't make money across the board. So when you start taking away the profit of profitable things, you're going to have closures. You're going to have closures in rural markets.

You're gonna have closures in some of the challenging areas to deliver care today. And so that I agree with you from that perspective. As I look at Amazon and others, Amazon specifically does not have a, Amazon has 15 strategies in healthcare. And I might be being kind there.

It might be 30. 30 strategies in healthcare. They don't have an overarching strategy in healthcare. If someone thinks, oh, Amazon Healthcare has somebody at the helm going, Hey, here's what we're designing and building. They're wrong. They're they're 15 entrepreneurial ventures that may talk to each other.

They may not talk to each other. There's no indication that they do talk to each other, to be honest with you. I think they, they look at the assets, they have going into a market and the needs that exist in that market. And they go, we can do that. And they spin up a company and now it happens to be a couple of billion dollar company when they spin them up.

But that, that's what they're doing. Microsoft a little bit more focused. I always call them an arms dealer. They come alongside the existing players and they'll help all of them. Even if they compete with each other, the same will give you access to our data capabilities. We give you access to our cloud.

We'll give you access to our, our tools on site. We'll give you whatever you need. We're going to, we're going to provide it to you at, at a fee. I love that analogy. Get on the sidelines and start to play. Cause Amazon got a little bit out of their swim lane with Haven. And got really close to the sideline. Microsoft never gets anywhere near that sideline. They just sit there and go, Hey, do you need more Gatorade? Here's some Gatorade. Just keep playing the game and we'll keep you energized and keep you focused.

Yeah. I don't know if you saw what Mark Cuban's doing too. Right? So he, so he's also a disruptors coming in and okay it's on the pharmaceutical delivery sort of side of the equation. But as you said, if you were these smaller health systems or these smaller providers, you are reliant on every sort of revenue stream you could possibly do, and you get someone like Cuban.

Big brand, big platform making pretty strong assertions about his ability to deliver low cost drugs to the marketplace medicine to the marketplace. That's that's gonna cause some problems.

Yeah, that was, it was interesting. Two years ago, he got up on the HLTH stage and essentially looked at everybody and said you guys are some of the worst business people I've ever seen. He's just like, he goes the cost of drug prices. He essentially broadcast I'm coming after you. He told us two years ago he was going to do this. And away, he goes, and I hope he's. I hope he's successful. The cost of drug pricing is one of those things that is hard for .. It's hard for us to even understand.

It's one of those factors kinda like gas prices. People feel that pain directly. Like if you're reliant on drugs to help you cause you have a, you need drugs in your life coz you have a chronic condition or whatever, and you can reduce the prices of those of those drugs is kind of like when you reduce the price of of your gasoline, I mean, that makes a direct impact to your bottom line. And you feel that direct impact month in, month out. So I hope he's successful as well.

It's interesting. My father-in-law who's passed away, but he was in the donut hole. Before my parents started talking about this donut hole, I just thought they were literally talking about a donut hole, but it talks about the insurance coverage and, paying their medications.

And, and it just got earlier and earlier in the year that the medications weren't being covered for some of these people that needed that coverage. Yeah, definitely. Ryan, I want to thank you for your time. This was a fun conversation. We'll do it again in about six weeks.

I'll look forward to it. Good stuff.

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