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Speaker 1: Hello everyone, this is Anthony Prakashi, your host for Startups
Speaker 1: They'll Say. Here we are with another brand new episode,
Speaker 1: and I'm super excited today to bring to you a
Speaker 1: couple of my friends. We were colleagues or partners in
Speaker 1: crime a couple of years earlier, but we are all
Speaker 1: members of a flood of community right now and I'm
Speaker 1: excited to bring to you their story, their mission and
Speaker 1: vision for something super important in the healthcare world, both
Speaker 1: in the US as well as the entire world that
Speaker 1: they're trying to solve, and it is Their company is
Speaker 1: called May June. So John, doctor John Manning here is
Speaker 1: the CEO of May June and doctor Gray Fuckinberry is
Speaker 1: the CEO of May June. So if about anything, I mean,
Speaker 1: they always inspire me because both of them are doctors
Speaker 1: by day and sometimes by night, and then the rest
Speaker 1: of the twenty four hours, they are technologists and hardcore technologists.
Speaker 1: I must say so a warm welcome John, and great
Speaker 1: to startups Bills. Why don't we kick it off maybe
Speaker 1: with John. You can go first and tell a little
Speaker 1: bit more about yourself and your journey of how you
Speaker 1: started off me.
Speaker 2: Yeah, sure, and thanks for the introduction Anthony. We've gone
Speaker 2: a long time back, so it's great to have the
Speaker 2: opportunity to speak here. So I'm John Manning. I'm an
Speaker 2: emergency medicine physician by training. I teach medical students and
Speaker 2: residents how to care for patients in one of the
Speaker 2: Level one trauma centers in Charlotte, North Carolina, and have
Speaker 2: done that for almost a decade at this point, getting
Speaker 2: close to that point right before coming down here, like
Speaker 2: right around that time, I co founded May June with
Speaker 2: an interest in building technology solutions that focused on human factors,
Speaker 2: usability and just trying to make your life easier from
Speaker 2: an end user perspective, the kind of short version of it.
Speaker 2: And we can go in depth if interested. But I
Speaker 2: used to be ascribed in a medical field in DC.
Speaker 2: I hand wrote notes helping emergency positions. Was there when
Speaker 2: we transitioned from paper to electronic saw the equivalent of
Speaker 2: twenty different health systems across med school, residency, fellowship, etc.
Speaker 2: And all with different levels of medical record integration and usability.
Speaker 2: A lot of them had a lot of usability challenges,
Speaker 2: and my attempt to give back was in building tech
Speaker 2: solutions through made focus on that.
Speaker 1: Awesome. Great, why didn't you do the same? Just introduce yourself?
Speaker 3: Great and thanks again for having us. I'm excited to
Speaker 3: be here. I've been looking forward to it, even though
Speaker 3: I responded like so, I'm Gray Falconberry. I'm CTO trained
Speaker 3: in internal medicine and pediatrics. I practice as an adult hospitalist,
Speaker 3: and my other part of my day job is I'm
Speaker 3: the co chair of the Global Health Informatics Program at
Speaker 3: the Children's Hospital of Philadelphia, although I actually live in Atlanta.
Speaker 3: That's one of the joys of technology and informatics is
Speaker 3: that so much of its virtual. You know, you don't
Speaker 3: have to be in the place where you practice, which
Speaker 3: is really nice and allows flexibility. And I there's a
Speaker 3: longer story involved, but I got into this from the
Speaker 3: global health perspective actually and looking at how you can
Speaker 3: sort of leverage technology abroad to improve healthcare.
Speaker 1: That is awesome and it's a super worthy cause. And
Speaker 1: like I've heard from both of you, I mean, it's
Speaker 1: it's obviously even in a country like the US. It
Speaker 1: is informatics and the amount of manual effort that goes
Speaker 1: into the work aside from you guys, care for patients
Speaker 1: I mean is a big part of every doctor's day, right,
Speaker 1: I mean, and there's so much of others involved in
Speaker 1: it as well. So let me ask you this, I mean,
Speaker 1: where did you kind of get the h to say, Okay, man,
Speaker 1: this is a big problem. We've got to do something
Speaker 1: about it. I mean who started that? I mean, I'm
Speaker 1: sure both of you have to think about that vision
Speaker 1: and believe in it saying okay, we can do something
Speaker 1: to do it. But John, I know you started this
Speaker 1: and Gray probably joined later. So what did you tell
Speaker 1: the audience about? I mean, where is it that you
Speaker 1: noticed this? I mean, I know you said you were
Speaker 1: ascribed maybe there, but tell us more.
Speaker 2: Yeah, So it all kind of comes back full circle.
Speaker 2: And when you're just trying to think through like how
Speaker 2: you can improve and where those options are, you mentioned
Speaker 2: usability being a big issue for physicians. Christine Sinski from
Speaker 2: the American Medical Association published on that there's a thing
Speaker 2: called pajama time, which is the time you spend at
Speaker 2: home just charting and catching up on your documentation, and
Speaker 2: every specialty has it. It's not fun, it causes burnout.
Speaker 2: It leads to burnout, so it's everywhere. The specific path
Speaker 2: that led to May June, interestingly was as a resident
Speaker 2: in Emergency Medicine, I pitched an idea to the first
Speaker 2: ever Emergency Medicine hackathon at their national conference. Got the
Speaker 2: grand prize, got a bonus phase prize, and an opportunity
Speaker 2: to speak at a public health summit in part of
Speaker 2: the keynote in Illinois. So we built an app that
Speaker 2: was based on the hackathon idea. Wrote it in Java's
Speaker 2: first time that we'd ever written any sort of code.
Speaker 2: It was a Java developer friend of mine who had
Speaker 2: not written anything in Android before, neither had I. He
Speaker 2: lived a few months away or a few blocks away,
Speaker 2: and the better part of my final year of residency
Speaker 2: training was building this application. All through fellowship, got a
Speaker 2: lot of opportunities to work with other startups and do
Speaker 2: a bit of mentoring and working with a group called Matter,
Speaker 2: a health tech incubator, and time unfortunately broke a little
Speaker 2: bit of the app, and when we were trying to
Speaker 2: think through am I going to do this in Cotland?
Speaker 2: Because Cotland is new. Am I going to switch over?
Speaker 2: Am I going to just update this in Java? That
Speaker 2: was almost exactly the time that Flutter was announced, so
Speaker 2: December of twenty eighteen. The next month, I was in
Speaker 2: Boston giving a live coding session, handshaking for five minutes,
Speaker 2: showing how you can really make this because it just
Speaker 2: fell in love with Flutter. A few months later, it
Speaker 2: was a big informatics conference at their annual symposing or
Speaker 2: their clinical Informatics conference, and in two hours introduced Flutter
Speaker 2: and live coded how to create the conference's app in
Speaker 2: real time while just talking and writing code. And one
Speaker 2: of Gray's predecessors, his co fellow one year ahead of him,
Speaker 2: tap through that conference. It was like seventy eighty people
Speaker 2: in that two hour event. And when he joined Informatic
Speaker 2: like that Informatic fellowship a few months later, he was
Speaker 2: interested in global health and maybe Android or you know,
Speaker 2: trying to build and develop for this, and she looked
Speaker 2: at him, she was like, well, why don't you just
Speaker 2: look into Flutter? And he started looking into this, and
Speaker 2: there was a shared Slack channel with a lot of
Speaker 2: Informatic fellows that were going through this new training, and
Speaker 2: we started collaborating, collaborating every day or slack over years
Speaker 2: and started building these solutions that would then allow other
Speaker 2: people that are in and around the health tech space
Speaker 2: to use the standard for interoperability FIRE within Flutter applications,
Speaker 2: and much of that goes to Gray and all of
Speaker 2: the time and effort that was spent in this, I
Speaker 2: was I just make apps and Flutter and I live
Speaker 2: code and I can talk and you know, it's the
Speaker 2: emergency medicine brain. I can talk and write code at
Speaker 2: the same time, you know. And that's my thing. But
Speaker 2: a lot of that underpinning and architecture that's open source
Speaker 2: and has been used by developers a lot across the
Speaker 2: world that goes with many things to correct.
Speaker 1: That is awesome. John, So you touched on a lot there, right,
Speaker 1: I mean you talked about fire obviously informatics and great,
Speaker 1: maybe you can wear the CTO had I've always wondered.
Speaker 1: I mean, you know, you guys have very little time,
Speaker 1: yet you've found the time to learn a technology like Flutter,
Speaker 1: decide and pick on it saying Okay, this is the
Speaker 1: best choice to move forward with what we're trying to build.
Speaker 1: I mean, for I mean, obviously you don't need to
Speaker 1: be an engineer to learn flutter and use flutter anymore.
Speaker 1: I mean you are perfect examples for that, right. But
Speaker 1: how did that love for even technology come in to
Speaker 1: both of you? I mean, obviously you need a spark
Speaker 1: within you, you need that push within you to say, Okay,
Speaker 1: this is not something that I can outsource to a
Speaker 1: company and say build it. I want to do this myself, right,
Speaker 1: I mean, how did you sort of make that choice
Speaker 1: great to say okay, I mean, you guys want to
Speaker 1: be you know, getting your hands and feed wet with
Speaker 1: building this whole thing.
Speaker 3: So I my love of technology and sort of science,
Speaker 3: I think at John's two, you know, is not not
Speaker 3: a new phenomenon we liked growing up. In college, I
Speaker 3: was a physics major and I'm minored in computer science,
Speaker 3: so I had a little bit of a background, but
Speaker 3: then I didn't really use it. I went to medical
Speaker 3: school and was in medical school when EHRs really started
Speaker 3: coming around and sort of everybody switching over from paper
Speaker 3: to electronic and so I saw that transition, and at
Speaker 3: the time it was exciting. I was looking forward to
Speaker 3: it because again I like technology, and at the time
Speaker 3: it seemed mostly good you know, the not having to
Speaker 3: fight for the chart, having one chart for a patient,
Speaker 3: having eight people trying to look at it. You know,
Speaker 3: you didn't have to worry about that anymore, having to
Speaker 3: walk across or down fifteen floors and across campus to
Speaker 3: write an order and a chart. You could just put
Speaker 3: it into the computer. So there were some really nice
Speaker 3: things about it, and then there were a lot of
Speaker 3: not nice things about it. It was obvious that, as
Speaker 3: John said, the usability was not a sort of forefront
Speaker 3: in anyone's mind. You know, with the design of these
Speaker 3: and any sort of study or survey done on physicians
Speaker 3: now you'll see that. You know that there is burnout,
Speaker 3: and so you work with that long enough and it
Speaker 3: becomes a source of frustration because it really felt like
Speaker 3: the people who designed it hadn't ever seen a patient.
Speaker 3: And that was probably true, you know they and you
Speaker 3: really need to understand the workflow. You need to understand
Speaker 3: how it feels and what you need and how it
Speaker 3: should be organized to take care of, you know, a patient.
Speaker 3: And I think what drove a lot of us into
Speaker 3: informatics is the feeling that we want to be involved
Speaker 3: in this, We want to help make this better. This
Speaker 3: is something. This is a skill set that we feel
Speaker 3: like we have and we can develop and we can
Speaker 3: actually contribute and sort of change things for the better.
Speaker 3: So much of medicine is already sort of set in place,
Speaker 3: and there's there's so little opportunity to sort of change
Speaker 3: any of it. But informatics, I think is different. It
Speaker 3: is still new, it is still changing. It is a
Speaker 3: lot of it is sort of set, but a lot
Speaker 3: of it's not, I think enough of it's not that
Speaker 3: we can sort of affect that change. And I think
Speaker 3: that's what's exciting about it is the feeling that I
Speaker 3: actually have the ability to hopefully, you know, help medicine
Speaker 3: and healthcare be provided in a better way through technology,
Speaker 3: you know. And that was sort of how informatics I think,
Speaker 3: came into my life. Yeah.
Speaker 2: So if you think of like as an example in
Speaker 2: medicine of something that's never changed and it will never change.
Speaker 2: Coagulation cascade, which sure whatever, Okay, you don't have to
Speaker 2: know about it. One of there's a dozen factors. One
Speaker 2: of them is literally just calcium and it was named
Speaker 2: its own factor. Sure, and another one factor six. They
Speaker 2: found out, oh actually it was just another version of
Speaker 2: factor seven, and so there is no factor six. There
Speaker 2: isn't one. So it's labeled up to a dozen or
Speaker 2: a thirteen, but you're missing a whole number. And since
Speaker 2: we've all learned it this way, I'm sorry you have
Speaker 2: to learn it that way too, even though it makes
Speaker 2: no sense. Welcome to healthcare. Here's a chance where we
Speaker 2: can actually build things that match the workfload that's there.
Speaker 2: To Gray's point, if you don't see it, if your
Speaker 2: brain isn't literally into the weeds, and it's not there's
Speaker 2: one thing to be shadowing somebody who was doing this,
Speaker 2: there's another where you were putting all of your cognitive
Speaker 2: effort and load into the care of a person. So
Speaker 2: you don't make those mistakes, and so that you know,
Speaker 2: medicine always has mistakes, but so that you minimize that
Speaker 2: and yet you allow for the right processes and everything
Speaker 2: to help. Well, if you have a very expert, complex
Speaker 2: system that's pulling all of your attention away, you're gonna
Speaker 2: get distracted and things will happen, and it's you know,
Speaker 2: it can lead to it can lead to harm.
Speaker 1: If you.
Speaker 2: What was the the book that was talking about the
Speaker 2: digital doctor from like ten years ago or ten to
Speaker 2: fifteen years ago, talks about all the processes of how
Speaker 2: a fifteen year old child swallowed thirty eight and a
Speaker 2: half pills of a single antibiotic and seized, and all
Speaker 2: of the workfload things, as well as the medical issues
Speaker 2: that were a part of your electronic health record that
Speaker 2: was almost like a Swiss cheese effect where everything was
Speaker 2: perfectly aligned to a point of a nurse in a
Speaker 2: room with a fifteen year old by himself, with mom
Speaker 2: or dad not nearby, as he is individually swallowing almost
Speaker 2: forty pills. There's a lot to it. So any ways
Speaker 2: that we can improve that medical perspective I think is helpful.
Speaker 1: Yeah, And speaking of a medical perspective, John, I mean,
Speaker 1: I know both of you have touched on what you're
Speaker 1: trying to make better. But if there is someone who
Speaker 1: just is a layman in layman's terms, if you want
Speaker 1: to explain before May June's in an after main story
Speaker 1: of course, using fire which is fhir for those listening,
Speaker 1: how do you explain the work that you guys are
Speaker 1: doing to make this thing better?
Speaker 3: So I could take this one. So part of it,
Speaker 3: I think is something that we're all familiar with. And again,
Speaker 3: in no way as a clinician, I think it's a
Speaker 3: patient you see it. We all go to doctor's appointments
Speaker 3: or healthcare appointments or therapy appointments where you would like
Speaker 3: to be able to move records around. You know, you've
Speaker 3: seen someone else before you would like to share those
Speaker 3: records with someone else. And it's always painful. It's always
Speaker 3: extremely hard. You have to fill out release sheets and
Speaker 3: they have to often fax them over the fact that
Speaker 3: facts comes into conversation at all anymore is ridiculous, but
Speaker 3: it does in medicine all the time. You know, I
Speaker 3: regularly get two hundred pages of faxes of someone's medical
Speaker 3: record from another hospital, you know, trying to take care
Speaker 3: of it, because medical records don't share data very well.
Speaker 3: And then about not quite fifteen years ago now, there
Speaker 3: was a standard that started being developed called fire Fast
Speaker 3: Healthcare Interoperability Resources in order to share it. And again
Speaker 3: that's a big deal because just having that information is
Speaker 3: so important. So the ability to easily share healthcare data
Speaker 3: you know can is not just a convenience issue, it's
Speaker 3: it's a safety issue. If I don't know what medications
Speaker 3: someone's taking and I give them something that interacts that
Speaker 3: obviously can be incredibly dangerous. You know, I don't need
Speaker 3: to do certain tests if I know that they were
Speaker 3: just done somewhere else. And so having the ability to
Speaker 3: more easily share that data from place to place is
Speaker 3: incredibly important. And I think it helps both from sort
Speaker 3: of again a frustration and a time sort of commitment,
Speaker 3: as well as a pure safety issue. And that's something
Speaker 3: that again we've we've sort of touched on. As John
Speaker 3: pointed out, we both sort of lean slightly different directions
Speaker 3: on this, but again trying to make electronic records that
Speaker 3: work better for the people involved. So we want to
Speaker 3: be able to share data, We want it to work well,
Speaker 3: we want it to be easy to use, you know.
Speaker 3: And and so I think both the sharing of the
Speaker 3: data and the usability can't be overstated about sort of
Speaker 3: how important those aspects are.
Speaker 2: Yeah, adding to that a little bit, and when you
Speaker 2: think of fire, so FIRE is now the global standard
Speaker 2: for interoperable communication of healthcare data period adopted by the
Speaker 2: US governments. For that large electronic medical records, they have
Speaker 2: to support at least a core subset of fire data
Speaker 2: that patients can get access to. And no cost, and
Speaker 2: when you're trying to communicate this data, it is miles
Speaker 2: beyond what was there before before the Fire standard. What
Speaker 2: kind of happened through all of this sorefly Fire with
Speaker 2: Flutter Library Integration FLI, where the packages that Gray had
Speaker 2: developed over the course of his fellowship, which is about
Speaker 2: ten million lines of code total three million lines of dart.
Speaker 2: A lot of it's auto generated, but in a way
Speaker 2: that allows you to use any published version of fire
Speaker 2: that also goes through all its test cases and then
Speaker 2: directly put this into your Flutter application. And that Android
Speaker 2: equivalent of this is open heal Stack by Google for Flutter.
Speaker 2: If you're building a Flutter app, you should use the
Speaker 2: Firefly packages. So you know. To Gray's point, so he's
Speaker 2: a medicine pedes trained hospitalist, so he cares for patients
Speaker 2: when they're admitted to the hospital, adults and children. Practiced
Speaker 2: in eight countries, spend a year in Uganda, wrote the
Speaker 2: textbook on pediatric care in that setting, and has a
Speaker 2: very high global health focus of trying to help in
Speaker 2: areas that are very resource limited. My background is emergencies.
Speaker 2: I care for emergencies. I did MS things and a
Speaker 2: lot of the things that come around me as an
Speaker 2: emergencies and disasters, and how can we improve in those cares,
Speaker 2: those care settings that are unscheduled and where a lot
Speaker 2: of people are afraid, And both of them have opportunities
Speaker 2: to improve in rural areas as well as global. So
Speaker 2: to your point that you had mentioned earlier, Anthony, of
Speaker 2: what was our story, well, we both had a shared
Speaker 2: interest of building things to help in healthcare from usability
Speaker 2: perspect with a mobile first approach. Then collaborated on the
Speaker 2: Firefly packages, reached out to the Office of the National Coordinator.
Speaker 2: The actual National Coordinator at the time was Don Rucker,
Speaker 2: who we got through other members of Nyjune. They had
Speaker 2: connections and here we are in front of the ONC
Speaker 2: talking about Firefly and how cool this is, and they said,
Speaker 2: look into social help like social care areas, and so
Speaker 2: that is where we built screening tools to help with
Speaker 2: social need and multiple states and multiple languages, and we're
Speaker 2: still on the Gravity Projects. Main page is their success story,
Speaker 2: which is wonderful and cool. But you know, as clinicians,
Speaker 2: we're always trying to see how best we can apply
Speaker 2: this in a way that helps in rural, underserved and
Speaker 2: in global areas.
Speaker 1: Yeah, so you mentioned emergency medicine. One of the things
Speaker 1: that always bothered me about, you know, going to a
Speaker 1: hospital in the US, even if you go to an emergency,
Speaker 1: is it's never an emergency in an emergency, right, I
Speaker 1: mean you'd go with you know, so much pain, and
Speaker 1: you'd be like, want to be seen immediately. You're invariably
Speaker 1: waiting for sixty to ninety minutes before you've seen or
Speaker 1: at least somebody comes and asks you something, right. I
Speaker 1: mean in a lot of cases it has got to
Speaker 1: do with data collection. You know, they are validating it
Speaker 1: behind the scenes, so you know, just as a patient
Speaker 1: myself or you know somebody who I've seen, even in
Speaker 1: the children's hospitals, great, right, I mean when my daughter
Speaker 1: was young, I mean, you know, she'd be running very
Speaker 1: high temperature and you go there, they make your sit
Speaker 1: for forty five minutes, right, I mean why because you're
Speaker 1: still collecting data. So in that sort of a let's say,
Speaker 1: I mean you don't want to call it life threatening,
Speaker 1: but it's still an emergency. Is there something that you know?
Speaker 1: Using fire in May June, I mean you can simplify
Speaker 1: that process to accelerate the time to which by the
Speaker 1: time you walk in through that door, a doctor is
Speaker 1: able to see you at least within fifteen minutes or so.
Speaker 1: I mean, you know, if sixty minutes is too much,
Speaker 1: at least cut that down by yeah, you know, seventy
Speaker 1: five percent.
Speaker 2: So yes and no. So I think on the other
Speaker 2: side of the curtain. So Atrium Health is where I
Speaker 2: practice associate professor, and I care for adults and children,
Speaker 2: and it's patients are not seen in the same order
Speaker 2: that they arrive. They are seen often by the sickest
Speaker 2: ones first. So thankfully you and your family were not
Speaker 2: that sick. There's an emergency, of course, we'll address that.
Speaker 2: But trust me, the very very like near death patients
Speaker 2: and severe traumas and medical and traumatic resuscitations, they're seen
Speaker 2: really fast. It's not sixty minutes. And there are workflow
Speaker 2: tools where you can even register a patient without any
Speaker 2: information quickly, be it medical or trauma, so that you
Speaker 2: can give them medication and treat them and get do
Speaker 2: an ultrasound or get some X rays or something at
Speaker 2: the bedside to help them. All of that stuff has
Speaker 2: its own workflow in American medicine that uses the electronic
Speaker 2: medical record and the use of majune technology probably isn't
Speaker 2: as relevant there if you look in resource limited scenarios.
Speaker 2: So another example, I helped with some of the hurricane
Speaker 2: relief efforts in western North Carolina where it was multiple
Speaker 2: groups together and some of us were using paper and
Speaker 2: some of us were using another technically medical record. That
Speaker 2: will also wasn't really designed by a clinician, and it
Speaker 2: was clear that there were a lot of opportunities to
Speaker 2: improve with that. That's a place where we can inject
Speaker 2: and help and where we have the skill set and
Speaker 2: the expertise and the domain knowledge to improve in those settings.
Speaker 2: And we've had conversations with groups that were interested and
Speaker 2: our services from there. So from the over arching perspective
Speaker 2: of you know, just emergency medicine care, usually it's going
Speaker 2: to be in the low resource or disaster response or
Speaker 2: international area where we can improve rather than the traditional
Speaker 2: brick and mortar emergency department. But medicine always changes, you know,
Speaker 2: if we build something and then it expands and then
Speaker 2: it continues to expand. And that's right up both Gray
Speaker 2: and my alley of ways that we can improve in
Speaker 2: areas that also build on the background expertise that we have.
Speaker 3: That's perfect, and I'll say a slightly different sort of
Speaker 3: view of it. I again not sort of the emergent
Speaker 3: view in terms of how quick we can get you in,
Speaker 3: but I think that some of the stuff we do
Speaker 3: can make the time we spend with you more valuable.
Speaker 3: And I think that you know, most of the time,
Speaker 3: the about of time that we spend with a patient,
Speaker 3: most of it is collecting data and very little of
Speaker 3: it is actually spent talking to a patient. And so
Speaker 3: I think using technology, including some of the June you know,
Speaker 3: questionnaire data gathering, structured data capture sort of stuff, a
Speaker 3: lot of that could be done beforehand. And so if
Speaker 3: you have a fifteen or a twenty minute appointment, or
Speaker 3: you know, whatever John has available to be able to
Speaker 3: see you in the emergency room before the next trauma,
Speaker 3: you know, instead of spending all that time or the
Speaker 3: bulk of it trying to gather all your information, make
Speaker 3: sure that we have all of your medications correct, that
Speaker 3: we know all of your history. If that can all
Speaker 3: be shared or gathered more efficiently ahead of time, then
Speaker 3: we can sort of review it quickly and then we
Speaker 3: can spend more time talking to you. We can spend
Speaker 3: more time ensuring that we didn't miss anything that's important.
Speaker 3: We can ensure that you understand the plan, and so
Speaker 3: the time that we do spend with you can be
Speaker 3: actually spent with you and so sort of caring about
Speaker 3: what the problem is instead of just asking you a
Speaker 3: whole lot of questions. And so I think there are
Speaker 3: some ways, even in sort of a traditional setting where
Speaker 3: you know, we could be beneficial that. Again, I think
Speaker 3: there's lots of opportunities to sort of improve that.
Speaker 1: Yeah, thank you for that.
Speaker 2: I mean the term doctor, go ahead, John, Oh, go ahead.
Speaker 2: The term doctor comes from dose air, which means to teach.
Speaker 2: It is literally your role is to map somebody's health
Speaker 2: literacy and then help explain and work through that. And
Speaker 2: the other point from Gray is if you've ever seen
Speaker 2: there's a twenty twelve article in Jamma called the Cost
Speaker 2: of Technology by Toll and it was a drawing of
Speaker 2: a seven year old in their pediatricians clinic where you know,
Speaker 2: they're smiling, Mom's smiling, big sisters holding baby child like
Speaker 2: baby sibling. Everybody's smiling. Then the doctor is smiling but
Speaker 2: has their back turn and a staring at a computer.
Speaker 2: And this is over thirteen years years ago when that
Speaker 2: was done, and it's still relevant today.
Speaker 3: And again I think that's again to dive back into
Speaker 3: the technology. I think that's where Flutter is so nice
Speaker 3: and actually part of the reason we chose it as
Speaker 3: the health stack. Again, I was looking at sort of
Speaker 3: a global perspective and everything global it has to be mobile, right,
Speaker 3: you know, it has to be at least available, and
Speaker 3: most EHRs or not most of them were never designed
Speaker 3: to be and so you know, we're looking at what's flexible,
Speaker 3: what can be done, you know, and multiple platforms, multiple devices.
Speaker 3: And that's sort of what sold me on Flutter because,
Speaker 3: as John said, one of my colleagues said, well, she
Speaker 3: had seen this talk about Flutter. Maybe I should look
Speaker 3: into it. So I did, and I got on Slack
Speaker 3: and I started working with John. And the punchline to
Speaker 3: his story was that it was about two years later
Speaker 3: when I realized that the speech my colleague had seen
Speaker 3: was given by John that then got that, then got
Speaker 3: the end of flu. So it was yeah, it's a
Speaker 3: full circle.
Speaker 1: Yeah, full circle indeed. And I mean, thanks for sharing
Speaker 1: the procedure about how the emergency rooms work, right, I mean,
Speaker 1: I know everybody comes in there and there's nothing more
Speaker 1: frustrating than waiting, right, so all your anger levels go
Speaker 1: up and you see a lot of people walking up
Speaker 1: to the poor receptionists and saying, I've been here for
Speaker 1: ninety minutes. You know why is nobody seeing me? So
Speaker 1: that part is super helpful. So shifting years a little bit,
Speaker 1: John and Greg, obviously you started May June with a vision, right,
Speaker 1: how much of that have you achieved? And what are
Speaker 1: the next couple of years looking like for you? Guys
Speaker 1: with May June, either of you can take it.
Speaker 2: So I'll say that our vision always shifts forward. We're
Speaker 2: always working to build new things, better things. Everything we've
Speaker 2: built in May June has been contracted work for hire
Speaker 2: to satisfy a specific problem that needed some extra usability.
Speaker 2: Flare that was cross platform by design and frequently had
Speaker 2: one group or one solution that didn't match the initial expectations.
Speaker 2: So a good example of the first thing we built
Speaker 2: was for any MS agency that had protocols to help
Speaker 2: in rural areas that the initial the content was excellent,
Speaker 2: that was something they built and curated, but the delivery
Speaker 2: needed help, and so we helped and you know, we
Speaker 2: continue to help and support them for years. We're always building,
Speaker 2: and we're always doing this in a way that can
Speaker 2: scale into other solutions and can apply some of the
Speaker 2: backgrounds and experiences that we have as as practicing clinicians
Speaker 2: and informatis and we have other informatics clinicians that are
Speaker 2: a part of MADE as well, and in addition to
Speaker 2: more tech first people as well. I think for us,
Speaker 2: we're always trying to find that best opportunity where we
Speaker 2: can have the biggest impact on the broadest scale in
Speaker 2: a way that pushes things forward in a good way.
Speaker 2: And I think that's always where we've strived. And so
Speaker 2: are we there yet? I'll say no, Are we always
Speaker 2: going down that path?
Speaker 1: Yes?
Speaker 2: And you know, it's one opportunity after the next and
Speaker 2: one solution after the next as we learn and make
Speaker 2: our code better and as we provide that service of
Speaker 2: Firefly for the global community, in addition to building upon
Speaker 2: that and harnessing it with the tools that we that
Speaker 2: we then deploy got it.
Speaker 3: Yeah, Well, I think that a lot of what we've
Speaker 3: done so far was still sort of foundation building to
Speaker 3: an extent. It was sort of learning and building out
Speaker 3: our skills building out. I mean, some of it was
Speaker 3: certainly sort of technology building out, the tech stack and
Speaker 3: that sort of thing, and some of it was also
Speaker 3: sort of finding where we wanted to be. You know,
Speaker 3: We've done you know a number of different projects in
Speaker 3: a number of different places, sort of in and sort
Speaker 3: of slightly out of healthcare, always intertwined, you know, And
Speaker 3: so I think we're we've sort of found our niche
Speaker 3: and sort of where we want to be. And I
Speaker 3: think that's again it's sort of exciting, and a lot
Speaker 3: of times it's places that other you know, groups don't
Speaker 3: want to go. And again, sometimes there's a lot of
Speaker 3: times there's a monetary barrier to it, you know, whether
Speaker 3: it's sort of rural areas or low resource settings or
Speaker 3: disaster relief one of the ones that that again John
Speaker 3: brought up earlier. You know, these are all really important
Speaker 3: to have good health tack tech stacks for if you're
Speaker 3: going to actually collect data and be able to show
Speaker 3: what you're doing, you know, who you're treating. You know,
Speaker 3: it's important to be able to record all that. It's
Speaker 3: really hard, though, but I think you know a lot
Speaker 3: of that fit what our interests and what our passions
Speaker 3: are and our knowledge and our expertise, and so I
Speaker 3: think we're sort of excited and looking forward to being
Speaker 3: able to use you know, who we are and what
Speaker 3: we want to do it, you know, even more effectively
Speaker 3: as we move forward.
Speaker 1: That is great to hear, especially the part that you're
Speaker 1: always kind of looking forward, right. And I try to
Speaker 1: bring up AI in most of our conversations because I mean,
Speaker 1: it seems to be affecting everything I mean, and especially
Speaker 1: I mean, I've heard in healthcare there's a lot of
Speaker 1: use cases and John, you started off with scribing. I've
Speaker 1: heard a number of you hospitals using those livescribers sort
Speaker 1: of thing. But with your vision for me and kind
Speaker 1: of looking forward and the impact that AI can make.
Speaker 1: Or the other trend I've been hearing about is you know,
Speaker 1: taking the hospital to the home, right, I mean, if
Speaker 1: there's critically ill patients, I mean, you're moving a lot
Speaker 1: of equipment into the patient's house and still collecting data
Speaker 1: and things like that. Are there's a lot of you know,
Speaker 1: devices that the patients can carry home, but as a doctor,
Speaker 1: you still want to collect all that information. So looking
Speaker 1: at some of these new trends, I mean, what are
Speaker 1: your thoughts on you know, how May June will evolve.
Speaker 1: Obviously you would have given that thought. I mean I second,
Speaker 1: maybe a second part of the question is, I mean,
Speaker 1: how much of AI have you actually tried to bring
Speaker 1: into the whole tech stack and try to do something
Speaker 1: with it.
Speaker 2: There's a few things from that. So the first one
Speaker 2: is AI from the perspective of the clinician and the
Speaker 2: second is AI from the perspective of the developer, and
Speaker 2: they're totally different buckets. So let's take the first bucket. So,
Speaker 2: first one, I've given local talks, given talks at Amya
Speaker 2: about this, and I've tested this and I also co
Speaker 2: chair our service line Innovation and Informatics group with an Atrium,
Speaker 2: and we've tested this from the very beginning and with frequency,
Speaker 2: there is a difference between So as a scribe, you
Speaker 2: mentioned this, there's a difference between a good scribe and
Speaker 2: a bad scribe, and a good scribe speeds you up.
Speaker 2: A bad scribe has things interjected that gives you almost
Speaker 2: twice the amount of time that you would be using otherwise.
Speaker 2: Tech always changes. Even a year ago, there were a
Speaker 2: lot of bad scribe ambient dictation tools out that a
Speaker 2: lot of it's improved even in the last eight months.
Speaker 2: And if you want something to look at, there was
Speaker 2: a AI tech sprint from the VA, the Veterans Administration
Speaker 2: that was hosted at the start of this year and
Speaker 2: then announced early Q two, and if you just search
Speaker 2: for the AI tech sprint within the VA, you can
Speaker 2: see some of the companies that were well embedded in
Speaker 2: that perspective. I think ambient dictation is going to have
Speaker 2: a high opportunity to help clinicians caring for patients, albeit
Speaker 2: in limited resource settings. That's going to be a challenge still,
Speaker 2: just because all of these need a lot more cloud
Speaker 2: services of a level to them, So that's going to
Speaker 2: be your mileage made very depending on where you practice,
Speaker 2: but there's definitely opportunity. The other aspect for decision support
Speaker 2: from the clinician's perspective, I think is great. What used
Speaker 2: to be called clinical decision support is now being rebranded
Speaker 2: by the ONC as a decision support Instrument, which includes
Speaker 2: AI and also requires you to have to get past
Speaker 2: that black box of where did this algorithm come from?
Speaker 2: Is this actually a hallucination?
Speaker 1: Or am I like?
Speaker 2: Where am I getting this recommendation? And I think that
Speaker 2: guardrail is just as important as the solution itself, because
Speaker 2: medical hallucinations of artificial intelligence and machine learning programs can
Speaker 2: cause those same issues that I talked about where the
Speaker 2: fifteen year old is swallowing almost forty pills. We don't
Speaker 2: want that, and so there's that. The other perspective of
Speaker 2: building within AI tools as technology specialists and developers, using
Speaker 2: a model to help you as you're writing code is
Speaker 2: essentially your own personalized pair programmer. I think is really
Speaker 2: useful if you have at least a basic understanding of
Speaker 2: the tech that you're trying to build in. It's not
Speaker 2: going to supplant your knowledge and information, and you have
Speaker 2: to work through some of the suggestions that are high
Speaker 2: confidence and low accuracy, otherwise your code will suffer from that.
Speaker 2: But there's really a lot of opportunities as you're building
Speaker 2: to help speed that up, and time has shown us
Speaker 2: that as well as from the perspective of the clinician
Speaker 2: as you're caring for patients of the bedside.
Speaker 3: And I again, and I think there's some ways to
Speaker 3: use it that have not been are not sort of
Speaker 3: classic when you think about it, that could end up
Speaker 3: being really useful. We know, for instance, that most research
Speaker 3: has to be published in English, it has to be
Speaker 3: written in a certain form of English, and much of
Speaker 3: the world doesn't speak English as their first language. And
Speaker 3: so if you can't write a research paper in the
Speaker 3: proper pros, your research is not going to be a
Speaker 3: to it, just even if it's high quality and so,
Speaker 3: but having AI help you write a research paper, you
Speaker 3: know where your research and your methods are sound, but
Speaker 3: because you may struggle with English, you can't get it published.
Speaker 3: That's a barrier to entry that shouldn't be there, and
Speaker 3: AI might be really helpful for, you know, to help
Speaker 3: you with that. One of the ones we were actually
Speaker 3: looking at was sort of what John was talking about,
Speaker 3: where you teach people some basic data science and then
Speaker 3: use AI to help you know, analyze your data. You know,
Speaker 3: there's lots of places where they don't have people that
Speaker 3: can do it themselves, and sort of AI can help
Speaker 3: with that. And so I certainly think AI has a
Speaker 3: good role to play. I think you have to be
Speaker 3: really careful with it. I think that most AI, especially
Speaker 3: in a healthcare setting, is untested. I think implementing a technology,
Speaker 3: you should study it. We do with all the rest
Speaker 3: of the technology, and yet AI I don't think is
Speaker 3: undergoing the same sort of you know, scrutiny, which again
Speaker 3: I think is going to have some difficulty and some
Speaker 3: problems that it's going to introduce. It has to be
Speaker 3: trained on something. Lots of the old healthcare data is
Speaker 3: not great and a lot of it's biased, and I
Speaker 3: think that's the other thing to really be cautious about
Speaker 3: is that if you're going to train on it, we
Speaker 3: know AI tends to amplify sort of biases and data,
Speaker 3: and so you have to be really cautious. I think
Speaker 3: using AI for especially for decision making.
Speaker 2: The classic example for that was the likelihood of a
Speaker 2: skin lesion being cancer was increased from the AI got
Speaker 2: algorithms if you had a ruler right next to it,
Speaker 2: because the images they were trained on whenever you're measuring
Speaker 2: the malignant lesion, they all had rulers, and so the
Speaker 2: ruler was a predictive variable.
Speaker 1: That's not right. Yeah, I did AI course at Stanford
Speaker 1: this summer and that's the exact same story that professor
Speaker 1: told us about. So I do understand. I mean, you're
Speaker 1: going to be super castle, but there are some merits, right,
Speaker 1: I mean, if you test it to grace point and
Speaker 1: put it through the rigor of going through all that
Speaker 1: unbiased data and things like that. I mean, there is
Speaker 1: some benefit to it. So switching gears a little bit.
Speaker 1: How much of adoption have you seen here? And I
Speaker 1: know for a fact that, I mean, you've tried to
Speaker 1: take this outside of the Americas as well to some
Speaker 1: of the countries. Who is using whether it's Firefly or
Speaker 1: the overall stack in general, who is using it today?
Speaker 3: So last week we checked again there are certain developers
Speaker 3: that were implementing it in Brazil, Colombia, Mexico, Germany, Italy, India,
Speaker 3: and Nigeria, Unity Candidas.
Speaker 1: It's great.
Speaker 2: I'll say that's good adoption from what we've developed over
Speaker 2: the time. I always think that's.
Speaker 1: And speaking of adoption, John and Gray, I mean, I'm
Speaker 1: assuming all of this is open source as well, and
Speaker 1: everything you do, you put it out there for people
Speaker 1: to contribute or anything people should know about everything.
Speaker 2: Everything that is the baseline package that we want to
Speaker 2: help everybody is open source. So Firefly is open source.
Speaker 2: The EMS project that I talked about, that's open source.
Speaker 2: Some of the things that we've built were closed, some
Speaker 2: have different permissive licenses that allow other people to learn from,
Speaker 2: but not necessarily directly compete with, so like functional source
Speaker 2: if you've heard about those. But realistically, our goal is
Speaker 2: we always want to move the needle forward. We're not
Speaker 2: trying to train up other people that then immediately directly
Speaker 2: compete with us. But for Firefly, we want this to
Speaker 2: be useful for everyone. That is a core package that
Speaker 2: everybody needs to have and that will always be open source,
Speaker 2: you know, through the duration that we're supporting, and it
Speaker 2: needs to be like that.
Speaker 3: Just definitely, and we and again we want it to
Speaker 3: be We want Google's Open Health Stack we brought up before,
Speaker 3: and the Android SDK is used in a number of standards.
Speaker 3: Now it's actually the WHO is creating smart guidelines that
Speaker 3: it's going to be used sort of around the world,
Speaker 3: which is based on Open Health Stack and Android SDK,
Speaker 3: And again we're not competing with them where there's no
Speaker 3: reason too, there's lots of work, but we want sort
Speaker 3: of a parallel option because again we see the value
Speaker 3: in Flutter and being able to create something that could
Speaker 3: then be used and implemented again sort of based on
Speaker 3: WHO guidelines. And that's again the sort of thing where
Speaker 3: we're not We don't want to keep it to ourselves.
Speaker 3: We want to share it. We want anyone who's interested
Speaker 3: or available or wants to try it or or you know,
Speaker 3: work with it, develop, you know with it. We we
Speaker 3: want to encourage that.
Speaker 1: Perfect Thank you so much. Any anything else that I
Speaker 1: have not asked about Me June that you want to
Speaker 1: get out there in the community to not say, If.
Speaker 2: Anybody is interested for us, certainly go to Majune dot com.
Speaker 2: If you're interested in Firefly, there's Firefly dot dev. There's
Speaker 2: a slack that people can join where you can collaborate
Speaker 2: with others across the globe that are building solutions here.
Speaker 2: We're pretty easily approachable. We're always happy to collaborate with
Speaker 2: others that are deeply invested and interested in the space
Speaker 2: and hopefully making things better for patients and families and clinicians.
Speaker 2: Just as we go from you know, one month to
Speaker 2: the next, one year to the next. We're always happy
Speaker 2: to work work together and to collaborate.
Speaker 1: I agreed, well, said John, So that Gray and John
Speaker 1: always a pleasure speaking to you both. I'm always sharing
Speaker 1: for you guys and talking about me June to whom
Speaker 1: I think is relevant. So wish you guys the best.
Speaker 1: We appreciate it, and uh you know anything you know.
Speaker 1: I'll be sure to publish all the details about me
Speaker 1: j you and all your repos and your slack and
Speaker 1: everything on the YouTube channel, so I'm sure there'll be
Speaker 1: a bunch of questions I'm sure you can answer. But
Speaker 1: thanks so much for taking the time amidst your busy schedules,
Speaker 1: lovely to speak to both of you, and I learned
Speaker 1: a lot. Hopefully everyone listening in and tuning in learns
Speaker 1: a bunch as well. Thank you so much.
Speaker 3: Thank you for having us pleasure. It was fun.
Speaker 1: Thank you.