>>Good morning and welcome back to Detroit, Michigan. My name is Savannah Peterson and I'm here on set of the cube, my co-host John Farer. How you doing this morning, John? >>Doing great. Feeling fresh. Day two of three days of coverage, feeling >>Fresh. That is that for being in the heat of the conference. I love that attitude. It's gonna >>Be a great day today. We'll see you at the end of the day. Yeah, >>Well, we'll hold him to it. All right, everyone hold 'em accountable. Very excited to start the day off with an internet, a legend as well as a cube og. We are joined this morning by Matt Klein. Matt, welcome to the show. >>Thanks for having me. Good to see you. Yep. >>It's so, what's the vibe? Day two, Everyone's buzzing. What's got you excited at the show? You've been here before, but it's been three years you >>Mentioned. I, I was saying it's been three years since I've been to a conference, so it's been interesting for me to see what is, what is the same and what is different pre and post covid. But just really great to see everyone here again and nice to not be sitting in my home by myself. >>You know, Savannah said you're an OG and we were referring before we came on camera that you were your first came on the Cub in 2017, second Cuban event. But you were, I think, on the first wave of what I call the contributor momentum, where CNCF really got the traction. Yeah. You were at Lift, Envoy was contributed and that was really hyped up and I remember that vividly. It was day zero they called it back then. Yeah. And you got so much traction. People are totally into it. Yeah. Now we've got a lot of that going on now. Right. A lot of, lot of day Zero events. They call 'em co, co-located events. You got web assembly, a lot of other hype out there. What do you see out there that you like? How would you look at some of these other Sure. Communities that are developing, What's the landscape look like as you look out? Because Envoy set the table, what is now a standard >>Practice. Yeah. What's been so interesting for me just to come here to the conference is, you know, we open source Envoy in 2016. We donated in 2017. And as you mentioned at that time, Envoy was, you know, everyone wanted to talk about Envoy. And you know, much to my amazement, Envoy is now pervasive. I mean, it's used everywhere around the world. It's like, never in my wildest dreams would I have imagined that it would be so widely used. And it's almost gotten to the point where it's become boring. You know, It's just assumed that Envoy is, is everywhere. And now we're hearing a lot about Eeb p f and Web assembly and GI ops and you know, AI and a bunch of other things. So it's, it's actually great. It's made me very happy that it's become so pervasive, but it's also fun. Yeah. We mention to, to look around all other stuff >>Like congratulate. It's just a huge accomplishment really. I think it's gonna be historic, historical moment for the industry too. But I like how it progressed. I mean, I don't mind hype cycles as long as it's some vetting. Sure. Of course. You know, use cases that are clearly defined, but you gotta get that momentum in the community, but then you start gotta get down to, to business. Yep. So, so to speak and get it deployed, get traction. Yep. What should projects look like? And, and give us the update on Envoy. Cause you guys have a, a great use case of how you got traction. Right. Take us through some of the early days of what made Envoy successful in your opinion. Great question. >>Yeah. You know, I, I think Envoy is fairly unique around this conference in the sense that Envoy was developed by Lyft, which is an end user company. And many of the projects in this ecosystem, you know, no judgment, for better or worse, they are vendor backed. And I think that's a different delivery mechanism when it's coming from an end user where you're solving a, a particular business case. So Envoy was really developed for Lyft in a, you know, very early scaling days and just, you know, trying to help Lyft solve its business problems. So I think when Envoy was developed, we were, you know, scaling, we were falling over and actually many other companies were having similar problems. So I think Envoy became very widely deployed because many companies were having similar issues. So Envoy just became pervasive among lift peer companies. And then we saw a lot of vendor uptake in the service mesh space in the API gateway space among large internet providers. So, I I I, I think it's just, it's an interesting case because I think when you're solving real problems on the ground, in some ways it's easier to actually get adoption than if you're trying to develop it from a commercial backing. >>And that's the class, I mean, almost, It's almost like open source product market fit. It is in its own way. Cause you have a problem. Absolutely. Other people have the same problem finding >>Too. I mean, it's, it's designed thinking from >>A different, When, when I talk to people about open source, I like to tell people that I do not think it's any different than starting a company. I actually think it's all the same problems finding pro product, market fit, hiring, like finding contributors and maintainers, like doing PR and marketing. Yeah. Getting team together, traction, getting, getting funding. I mean, you have to have money to do all these things. Yeah. So I think a lot of people think of open source as I, I don't know, you know, this fantastic collaborative effort and, and it is that, but there's a lot more to it. Yeah. And it is much more akin to starting a >>Company. Let's, let's just look at that for a second. Cause I think that's a good point. And I was having a conversation in the hallway two nights ago on this exact point. If the power dynamics of a startup in the open source, as you point out, is just different, it's community based. So there are things you just gotta be mindful of. It's not top down. >>Exactly. It's not like, >>Right. You know, go take that hill. It's really consensus based, but it is a startup. All those elements are in place. Absolutely. You need leadership, you gotta have debates, alignment, commit, You gotta commit to a vision. Yep. You gotta make adjustments. Build the trajectory. So based on that, I mean, do you see more end user traction? Cause I was, we were talking also about Intuit, they donated some of their tow code R goes out there. Yep. R go see the CDR goes a service. Where's the end user contributions to these days? Do you feel like it's good, still healthy? >>I, I mean, I, I'm, I'm biased. I would like to see more. I think backstage outta Spotify is absolutely fantastic. That's an area just in terms of developer portals and developer efficiency that I think has been very underserved. So seeing Backstage come outta Spotify where they've used it for years, and I think we've already seen they had a huge date, you know, day one event. And I, I think we're gonna see a lot more out of that >>Coming from, I'm an end user, pretend I'm an end user, so pretend I have some code. I want to, Oh man, I'm scared. I don't am I'm gonna lose my competitive edge. What's the, how do you talk to the enterprise out there that might be thinking about putting their project out there for whether it's the benefit of the community, developing talent, developing the product? >>Sure. Yeah. I would say that I, I would ask everyone to think through all of the pros and cons of doing that because it's not for free. I mean, doing open source is costly. It takes developer time, you know, it takes management time, it takes budgeting dollars. But the benefits if successful can be huge, right? I mean, it can be just in terms of, you know, getting people into your company, getting users, getting more features, all of that. So I would always encourage everyone to take a very pragmatic and realistic view of, of what is required to make that happen. >>What was that decision like at Lyft >>When you I I'm gonna be honest, it was very naive. I I think we've, of that we think we need to know. No, just didn't know. Yeah. I think a lot of us, myself included, had very minimal open source experience. And had we known, or had I known what would've happened, I, I still would've done it. But I, I'm gonna be honest, the last seven years have aged me what I feel like is like 70 or a hundred. It's been a >>But you say you look out in the landscape, you gotta take pride, look at what's happened. Oh, it's, I mean, it's like you said, it >>Matured fantastic. I would not trade it for anything, but it has, it has been a journey. What >>Was the biggest surprise? What was the most eye opening thing about the journey for you? >>I, I think actually just the recognition of all of the non-technical things that go into making these things a success. I think at a conference like this, people think a lot about technology. It is a technology conference, but open source is business. It really is. I mean, it, it takes money to keep it going. It takes people to keep >>It going. You gotta sell people on the concepts. >>It takes leadership to keep it going. It takes internal, it takes marketing. Yeah. So for me, what was most eyeopening is over the last five to seven years, I feel like I actually have not developed very many, if any technical skills. But my general leadership skills, you know, that would be applicable again, to running a business have applied so well to, to >>Growing off, Hey, you put it out there, you hear driving the ship. It's good to do that. They need that. It really needs it. And the results speak for itself and congratulations. Yeah. Thank you. What's the update on the project? Give us an update because you're seeing, seeing a lot of infrastructure people having the same problem. Sure. But it's also, the environments are a little bit different. Some people have different architectures. Absolutely different, more cloud, less cloud edges exploding. Yeah. Where does Envoy fit into the landscape they've seen and what's the updates? You've got some new things going on. Give the updates on what's going on with the project Sure. And then how it sits in the ecosystem vis-a-vis what people may use it for. >>Yeah. So I'm, from a core project perspective, honestly, things have matured. Things have stabilized a bit. So a lot of what we focus on now are less Big bang features, but more table stakes. We spend a lot of time on security. We spend a lot of time on software supply chain. A topic that you're probably hearing a lot about at this conference. We have a lot of software supply chain issues. We have shipped Quicken HTB three over the last year. That's generally available. That's a new internet protocol still work happening on web assembly where ha doing a lot of work on our build and release pipeline. Again, you would think that's boring. Yeah. But a lot of people want, you know, packages for their fedora or their ADU or their Docker images. And that takes a lot of effort. So a lot of what we're doing now is more table stakes, just realizing that the project is used around the world very widely. >>Yeah. The thing that I'm most interested in is, we announced in the last six months a project called Envoy Gateway, which is layered on top of Envoy. And the goal of Envoy Gateway is to make it easier for people to run Envoy within Kubernetes. So essentially as an, as an ingress controller. And Envoy is a project historically, it is a very sophisticated piece of software, very complicated piece of software. It's not for everyone. And we want to provide Envoy Gateway as a way of onboarding more users into the Envoy ecosystem and making Envoy the, the default API gateway or edge proxy within Kubernetes. But in terms of use cases, we see Envoy pervasively with service mesh, API gateway, other types of low balancing cases. I mean, honestly, it's, it's all over the place at >>This point. I'm curious because you mentioned it's expanded beyond your wildest dreams. Yeah. And how could you have even imagined what Envoy was gonna do? Is there a use case or an application that really surprised you? >>You know, I've been asked that before and I, it's hard for me to answer that. It's, it's more that, I mean, for example, Envoy is used by basically every major internet company in China. I mean, like, wow. Everyone in China uses Envoy, like TikTok, like Alibaba. I mean like everyone, all >>The large sale, >>Everyone. You know, and it's used, it's used in the, I'm just, it's not just even the us. So I, I think the thing that has surprised me more than individual use cases is just the, the worldwide adoption. You know, that something could be be everywhere. And that I think, you know, when I open my phone and I'm opening all of these apps on my phone, 80 or 90% of them are going through Envoy in some form. Yeah. You know, it's, it's just that pervasive, I blow your mind a little bit sometimes >>That does, that's why you say plumber on your Twitter handle as your title. Cause you're working on all these things that are like really important substrate issues, Right. For scale, stability, growth. >>And, you know, to, I, I guess the only thing that I would add is, my goal for Envoy has always been that it is that boring, transparent piece of technology. Kind of similar to Linux. Linux is everywhere. Right? But no one really knows that they're using Linux. It's, it's justs like Intel inside, we're not paying attention. It's just there, there's >>A core group working on, if they have pride, they understand the mission, the importance of it, and they make their job is to make it invisible. >>Right. Exactly. >>And that's really ease of use. What's some of the ease of use sways and, and simplicity that you're working on, if you can talk about that. Because to be boring, you gotta be simpler and easier. All boring complex is unique is not boring. Complex is stressful. No, >>I I think we approach it in a couple different ways. One of them is that because we view Envoy as a, as a base technology in the ecosystem, we're starting to see, you know, not only vendors, but other open source projects that are being built on top of Envoy. So things like API Gateway, sorry, Envoy Gateway or you know, projects like Istio or all the other projects that are out there. They use Envoy as a component, but in some sense Envoy is a, as a transparent piece of that system. Yeah. So I'm a big believer in the ecosystem that we need to continue to make cloud native easier for, for end users. I still think it's too complicated. And so I think we're there, we're, we're pushing up the stack a bit. >>Yeah. And that brings up a good point. When you start seeing people building on top of things, right? That's enabling. So as you look at the enablement of Envoy, what are some of the things you see out on the horizon if you got the 20 mile stare out as you check these boring boxes, make it more plumbing, Right? Stable. You'll have a disruptive enabling platform. Yeah. What do you see out there? >>I am, you know, I, again, I'm not a big buzzword person, but, so some people call it serverless functions as a service, whatever. I'm a big believer in platforms in the sense that I really believe in the next 10 to 15 years, developers, they want to provide code. You know, they want to call APIs, they want to use pub subsystems, they want to use cas and databases. And honestly, they don't care about container scheduling or networking or load balancing or any of >>These things. It's handled in the os >>They just want it to be part of the operating system. Yeah, exactly. So I, I really believe that whether it's an open source or in cloud provider, you know, package solutions, that we're going to be just moving increasingly towards systems likes Lambda and Fargate and Google Cloud Run and Azure functions and all those kinds of things. And I think that when you do that much of the functionality that has historically powered this conference like Kubernetes and Onvoy, these become critical but transparent components that people don't, they're not really aware of >>At that point. Yeah. And I think that's a great call out because one of the things we're seeing is the market forces of, of this evolution, what you just said is what has to happen Yep. For digital transformation to, to get to its conclusion. Yep. Which means that everything doesn't have to serve the business, it is the business. Right. You know it in the old days. Yep. Engineers, they serve the business. Like what does that even mean? Yep. Now, right. Developers are the business, so they need that coding environment. So for your statement to happen, that simplicity in visibility calling is invisible os has to happen. So it brings up the question in open source, the trend is things always work itself out on the wash, as we say. So when you start having these debates and the alignment has to come at some point, you can't get to those that stay without some sort of defacto or consensus. Yep. And even standards, I'm not a big be around hardcore standards, but we can all agree and have consensus Sure. That will align behind, say Kubernetes, It's Kubernetes a standard. It's not like an i e you know, but this next, what, what's your reaction to this? Because this alignment has to come after debate. So all the process contending for I am the this of that. >>Yeah. I'm a look, I mean, I totally see the value in like i e e standards and, and there's a place for that. At the same time, for me personally as a technologist, as an engineer, I prefer to let the, the market as it were sort out what are the defacto standards. So for example, at least with Envoy, Envoy has an API that we call Xds. Xds is now used beyond Envoy. It's used by gc, it's used by proprietary systems. And I'm a big believer that actually Envoy in its form is probably gonna go away before Xds goes away. So in some ways Xds has become a defacto standard. It's not an i e e standard. Yeah. We, we, we have been asked about whether we should do that. Yeah. But I just, I I think the >>It becomes a component. >>It becomes a component. Yeah. And then I think people gravitate towards these things that become de facto standards. And I guess I would rather let the people on the show floor decide what are the standards than have, you know, 10 people sitting in a room figure out >>The community define standards versus organizational institutional defined standards. >>And they both have places a >>Hundred percent. Yeah, sure. And, and there's social proof in both of them. Yep. >>Frankly, >>And we were saying on the cube that we believe that the developers will decide the standard. Sure. Because that's what you're basically saying. They're deciding what they do with their code. Right. And over time, as people realize the trade of, hey, if everyone's coding this right. And makes my life easier to get to that state of nirvana and enlightenment, as we would say. Yeah. Yeah. >>Starting strong this morning. John, I I love this. I'm curious, you mentioned Backstage by Spotify wonderful example. Do you think that this is a trend we're gonna see with more end users >>Creating open source projects? Like I, you know, I hope so. The flip side of that, and as we all know, we're entering an uncertain economic time and it can be hard to justify the effort that it takes to do it well. And what I typically counsel people when they are about to open source something is don't do it unless you're ready to commit the resources. Because opensourcing something and not supporting it. Yeah. I actually can be think, I think it'd be worse. >>It's an, it's insult that people, you're asking to commit to something. Exactly. Needs of time, need the money investment, you gotta go all in and push. >>So I, so I very much want to see it and, and I want to encourage that here, but it's hard for me to look into the crystal ball and know, you know, whether it's gonna happen more >>Or less at what point there were, are there too many projects? You know, I mean, but I'm not, I mean this in, in a, in a negative way. I mean it more in the way of, you know, you mentioned supply chain. We were riffing on the cube about at some point there's gonna be so much code open source continuing thundering away with, with the value that you're just gluing things. Right. I don't need the code, this code there. Okay. What's in the code? Okay. Maybe automation can help out on supply chain. Yeah. But ultimately composability is the new >>Right? It is. Yeah. And, and I think that's always going to be the case. Case. Good thing. It is good thing. And I, I think that's just, that's just the way of things for sure. >>So no code will be, >>I think, I think we're seeing a lot of no code situations that are working great for people. And, and, but this is actually really no different than my, than my serverless arguing from before. Just as a, as a, a slight digression. I'm building something new right now and you know, we're using cloud native technologies and all this stuff and it's still, >>What are you building? >>Even as a I'm, I'm gonna keep that, I'm gonna keep that secret. I know I'm, but >>We'll find out on Twitter. We're gonna find out now that we know it. Okay. Keep on mystery. You open that door. We're going down see in a couple weeks. >>Front >>Page is still an angle. >>But I, I was just gonna say that, you know, and I consider myself, you know, you're building something, I'm, I see myself an expert in the cloud native space. It's still difficult, It's difficult to, to pull together these technologies and I think that we will continue to make it easier for people. >>What's the biggest difficulties? Can you give us some examples? >>Well, just, I mean, we still live in a big mess of yammel, right? Is a, there's a, there's a lot of yaml out there. And I think just wrangling all of that in these systems, there's still a lot of cobbling together where I think that there can be unified platforms that make it easier for us to focus on our application logic. >>Yeah. I gotta ask you a question cuz I've talked to college kids all the time. My son's a junior in CS and he's, you know, he's coding away. What would you, how does a student or someone who's learning figure out where, who they are? Because there's now, you know, you're either into the infrastructure under the hood Yeah. Or you're, cuz that's coding there option now coding the way your infrastructure people are working on say the boring stuff so everyone else can have ease of use. And then what is just, I wanna just code, there's two types of personas. How does someone know who they are? >>My, when I give people career advice, my biggest piece of advice to them is in the first five to seven to 10 years of their career, I encourage people to do different things like every say one to two to three years. And that doesn't mean like quitting companies and changing companies, it could mean, you know, within a company that they join doing different teams, you know, working on front end versus back end. Because honestly I think people don't know. I think it's actually very, Yeah. Our industry is so broad. Yeah. That I think it's almost impossible to >>Know. You gotta get your hands dirty to jump >>In order to know what you like. And for me, in my career, you know, I've dabbled in different areas, but I've always come back to infrastructure, you know, that that's what I enjoy >>The most. Okay. You gotta, you gotta taste everything. See what you, what >>You like. Exactly. >>Right. Last question for you, Matt. It's been three years since you were here. Yep. What do you hope that we're able to say next year? That we can't say this year? Hmm. Beyond the secrets of your project, which hopefully we will definitely be discussing then. >>You know, I I, I don't have anything in particular. I would just say that I would like to see more movement towards projects that are synthesizing and making it easier to use a lot of the existing projects that we have today. So for example, I'm, I'm very bullish on backstage. Like I, I've, I've always said that we need better developer UIs that are not CLIs. Like I know it's a general perception among many people. Totally agree with you. Frankly, you're not a real systems engineer unless you type on the command line. I, I think better user interfaces are better for humans. Yep. So just for a project like Backstage to be more integrated with the rest of the projects, whether that be Envo or Kubernete or Argo or Flagger. I, I just, I think there's tremendous potential for further integration of some >>Of these projects. It just composability That makes total sense. Yep. Yep. You're, you're op you're operating and composing. >>Yep. And there's no reason that user experience can't be better. And then more people can create and build. So I think it's awesome. Matt, thank you so much. Thank you. Yeah, this has been fantastic. Be sure and check out Matt on Twitter to find out what that next secret project is. John, thank you for joining me this morning. My name is Savannah Peterson and we'll be here all day live from the cube. We hope you'll be joining us throughout the evening until a happy hour today. Thanks for coming. Thanks for coming. Thanks for watching.

>> Welcome to this IBM Watson Health client conversation. And we're probing the dynamics of the relationship between IBM and it's clients. We're going to look back at some of the challenges of 2020 and look forward to, you know, present year's priorities. We'll also touch on the future state of healthcare. My name is Dave Vellante. I'll be your host and I'm from theCUBE. And with me are Doctor Alex Towbin, who's Associate Chief Clinical Operations and Informatics at Cincinnati ChilDoctoren's Hospital and John Chrisman of course from IBM Watson health. Welcome gentlemen, Good to see you. Thanks for coming on. >> Thanks for having us. >> Yeah, thanks for having me. >> Yeah I know from talking to many clients around the world, of course virtually this past year, 11 months or so that relationships with technology partners they've been critical over during the pandemic to really help folks get through that. Not that we're through it yet but, we're still through the year now, there's I'm talking professionally and personally and Doctor Towbin, I wonder if you could please talk about 2020 and what role the IBM partnership played in helping Cincinnati children's, you know press on in the face of incredible challenges? >> Yeah, I think our story of 2020 really starts before the pandemic and we were fortunate to be able to plan a disaster and do disaster drill scenarios. And so, as we were going through those disaster drill scenarios, we were trying to build a solution that would enable us to be able to work if all of our systems were down and we worked with IBM Watson Health to design that solution to implement it, it involves using other solutions from our primary one. And we performed that disaster drill in the late January, early February timeframe of 2020. And while that drill had nothing to do with COVID it got us thinking about how to deal with a disaster, how to prepare for a disaster. And so we've just completed that and COVID was coming on the horizon. I'm starting to hear about it coming into the U.S for the first time. And we took that very seriously on our department. And so, because we had prepared for this this disaster drill had gone through the entire exercise and we built out different scenarios for what could happen with COVID what would be our worst case scenarios and how we would deal with them. And so we were able to then bring that to quickly down to two options on how our department and our hospital would handle COVID and deal with that within the radiology department and like many other sites that becomes options of working from home or working in a isolated way and an and an office scenario like where I'm sitting now and we planned out both scenarios and eventually made the decision. Our decision at that point was to work in our offices. We're fortunate to have private offices where we can retreat to and something like that. And so then our relationship with IBM was helpful and that we needed to secure more pieces of hardware. And so even though IBM is our PACS vendor and our enterprise imaging vendor, they also help us to secure the high resolution monitors that are needed. And we needed a large influx of those during the pandemic and IBM was able to help us to get those. >> Wow! So yeah you were able to sort of test your organization resilience before the pandemic. I mean, John, that's quite an accomplishment for last year. I'm sure there are many others. I wonder if one of you could pick it up from here and bring your perspectives into it and, you know maybe ask any questions that you would like to ask them. >> Yeah, sure, Doctor Towbin, that's great that we were able to help you with the hardware and procure things. So I'm just curious before the pandemic how many of the radiologists ever got to read from home, was that a luxury back then? And then post pandemic, are you guys going to shift to how many are on-site versus remote? >> Yeah, so we have a couple of scenarios. We've had talk about it both from our PACS perspective as well as from our VNA enterprise imaging perspective from PACS perspective we always designed our solution to be able to work from a home machine. Our machines, people would access that through a hospital-based VPN. So they would log in directly to VPN and then access the PACS that way. And that worked well. And many of our radiologists do that particularly when they're on call works best for our neuroradiologist who are on call a little bit more frequently. And so they do read from home in that scenario. With enterprise imaging and are used to the enterprise viewer and iConnect access. We always wanted that solution to work over the internet. And so it's set up securely through the internet but not through the VPN. And we have radiologists use that as a way to view studies from home, even not from home, so it can be over one of their mobile devices, such as an iPad and could be at least reviewing studies then. We, for the most part for our radiologist in the hospital that's why we made the decision to stay in the hospital. At COVID time, we have such a strong teaching mission in our department in such a commitment to the education of our trainees. We think that hospital being in the hospital is our best way to do that, it's so hard. We find to do it over something like zoom or other sharing screen-sharing technology. So we've stayed in and I think we'll continue to stay in. There will be some of those needs from a call perspective for example, reading from home, and that will continue. >> And then what's your success been with this with the technology and the efficiency of reading from home? Do you feel like you're just as efficient when you're at home versus onsite? >> The technology is okay. The, our challenges when we're reading from the PACS which is the preferred way to do it rather than the enterprise archive, the challenge is we have to use the PACS So we have to be connected through VPN which limits our bandwidth and that makes it a little bit slower to read. And also the dictation software is a little bit slower when we're doing it. So moving study to study that rapid turnover doesn't happen but we have other ways to make, to accelerate the workflow. We cashed studies through the worklist. So they're on the machine, they load a little bit more rapidly and that works pretty well. So not quite as fast, but not terrible. >> We appreciate your partnership. I know it's been going on 10 years. I think you guys have a policy that you have to look at the market again every 10 years. So what do you think of how the market's changed and how we've evolved with the VNA and with the zero footprint viewers? A lot of that wasn't available when you initially signed up with Amicas years ago, so. >> Yeah, we signed up so we've been on this platform and then, you know now the IBM family starting in 2010, so it's now now 11 years that we're, we've been on as this version of the PACS and about eight, seven or eight years from the iConnect platform. And through that, we've seen quite an evolution. We were one of the first Amicas clients to be on version six and one of the largest enterprises. And that went from, we had trouble at the launch of that product. We've worked very closely with Amicas then to merge. And now IBM from the development side, as well as the support side to have really what we think is a great product that works very well for us and drives our entire workflow all the operations of our department. And so we've really relished that relationship with now IBM. And it's been a very good one, and it's allowed us to do the things like having disaster drill planning that we talked about earlier as far as where I see the market I think PACS in particular is on the verge of the 3.0 version as a marketplace. So PACSS 1 one was about building the packs, I think, and and having electronic imaging digital imaging, PACS 2.0 is more of web-based technology, getting it out of those private networks within a radiology department. And so giving a little bit more to the masses and 3.0 is going to be more about incorporating machine learning. I really see that as the way the market's going to go and to where I think we're at the infancy of that part of the market now about how do you bring books in for machine learning algorithms to help to drive workflow or to drive some image interpretation or analysis, as far as enterprise imaging, we're on the cusp of a lot there as well. So we've been really driving deep with enterprise imaging leading nationally enterprise imaging and I have a role in the MSAM Enterprise Imaging Community. And through all of that work we've been trying to tackle works well from enterprise imaging point of view the challenges are outside of radiology, outside of cardiology and the places where we're trying to deal with medical photos, the photographs taken with a smart device or a digital camera of another type, and trying to have workflow that makes sense for providers not in those specialty to that don't have tools like a DICOM modality workloads store these giant million-dollar MRI scanners that do all the work for you, but dealing with off the shelf, consumer electronics. So making sure the workflow works for them, trying to tie reports in trying to standardize the language around it, so how do we tag photos correctly so that we can identify relevancy all of those things we're working through and are not yet standard within our, within the industry. And so we're doing a lot there and trying and seeing the products in the marketplace continuing to evolve around that on the viewer side, there's really been a big emergence as you mentioned about the zero footprint viewers or the enterprise viewer, allowing easy access easy viewing of images throughout the enterprise of all types of imaging through obtained in the enterprise and will eventually incorporate video pathology. The market is also trying to figure out if there can be one type of viewer that does them all that and so that type of universal viewer, a viewer that cardiologists can use the same as a radiologist the same as a dermatologist, same as a pathologist we're all I think a long way away from that. But that's the Marcus trying to figure those two things out. >> Yeah, I agree with you. I agree with your assessment. You talked about the non DICOM areas, and I know you've you've partnered with us, with ImageMover and you've got some mobile device capture taking place. And you're looking to expand that more to the enterprise. Are you also starting to use the XDS registry? That's part of the iConnect enterprise archive, or as well as wrapping things in DICOM, or are you going to stick with just wrapping things in DICOM? >> Yeah, so far we've been very bunched pro DICOM and using that throughout the enterprise. And we've always thought, or maybe we've evolved to think that there is going to be a role for XDS are I think our early concerns with XDS are the lack of other institutions using it. And so, even though it's designed for portability if no one else reads it, it's not portable. If no one else is using that. But as we move more and more into other specialties things like dermatology, ophthalmology, some of the labeling that's needed in those images and the uses, the secondary uses of those images for education, for publication, for dermatology workflow or ophthalmology workflow, needs to get back to that native file and the DICOM wrap may not make sense for them. And so we've been actively talking about switching towards XDS for some of the non DICOM, such as dermatology. We've not yet done that though. >> Given the era children's hospital has the impact on your patient load, then similar to what regular adult hospitals are, or have you guys had a pretty steady number of studies over the last year? >> In relay through the pandemic, we've had, it has been decreased, but children fortunately have not been as severely affected as adults. There is definitely disease in children and we see a fair amount of that. There are some unique things that happen in kids but that fortunately rare. So there's this severe inflammatory response that kids can get and can cause them to get very sick but it is quite rare. Our volumes are, I think I'm not I think our volumes are stable and our advanced imaging things like CT, MRI, nuclear medicine, they're really most decreased in radiography. And we see some weird patterns, inpatient volumes are relatively stable. So our single view chest x-rays, for example, have been stable. ER, visits are way down because people are either wearing masks, isolating or not wanting to come to the ER. So they're not getting sick with things like the flu or or even common colds or pneumonias. And so they're not coming into the ER as much. So our two view x-rays have dropped by like 30%. And so we were looking at this just yesterday. If you follow the graphs for the two we saw a dip of both around March, but essentially the one view chest were a straight line and the two view chest were a straight line and in March dropped 30 to 50% and then stayed at that lower level. Other x-rays are on the, stay at that low level side. >> Thanks, I know in 2021 we've got a big upgrade coming with you guys soon and you're going to stay in our standalone mode. I understand what the PACSS and not integrate deeply to the VNA. And so you'll have a couple more layers of storage there but can you talk about your excitement about going to 8.1 and what you're looking forward to based on your testimony. >> Yeah we're actually in, we're upgrading as we're talking which is interesting, but it's a good time for talking. I'm not doing that part of the work. And so our testing has worked well. I think we're, we are excited. We, you know, we've been on the product as I mentioned for over 10 years now. And for many of those years we were among the first, at each version. Now we're way behind. And we want to get back up to the latest and greatest and we want to stay cutting edge. There've been a lot of reasons why we haven't moved up to that level, but we do. We're very careful in our testing and we needed a version that would work for us. And there were things about previous versions that just didn't and as you mentioned, we're staying in that standalone mode. We very much want to be on the integrated mode in our future because enterprise imaging is so important and understanding how the comparisons fit in with the comparison in dermatology or chest wall deformity clinic, or other areas how those fit into the radiology story is important and it helped me as a radiologist be a better radiologist to see all those other pictures. So I want them there but we have to have the workflow, right. And so that's the part that we're still working towards and making sure that that fits so we will get there. It'll probably be in the next year or two to get to that immigrating mode. >> As you, look at the number of vendors you have I think you guys prefer to have less vendor partners than than more I know in the cardiology area you guys do some cardiology work. What has been the history or any, any look to the future of that related to enterprise imaging? Do you look to incorporate more of that into a singular solution? >> Cardiology is entirely part of our enterprise imaging solution. We all the cardiology amendments go to our vendor neutral archive on the iConnect platform. All of them are viewed across the enterprise using our enterprise viewer. They have their unique specialty viewer which is, you know, fine. I'm a believer that specialty, different specialties, deserve to have their specialty viewers to do theirs specialty reads. And at this point I don't think the universal viewer works or makes sense until we have that. And so all the cardiology images are there. They're all of our historical cardiology images are migrated and part of our enterprise solution. So they're part of the entire reference the challenge is they're just not all in PACSS. And so that's where, you know, an example, great example, why we need to get to this to the integrated mode to be able to see those. And the reason we didn't do that is the cardiology archive is so large to add a storage to the PACS archive. Didn't make sense if we knew we were going to be in an integrated mode eventually, and we didn't want to double our PACS storage and then get rid of it a couple of years later. >> So once you're on a new version of merge PACS and you're beyond this, what are your other goals in 2021? Are you looking to bring AI in? Are you using anybody else's AI currently? >> Yeah, we do have AI clinical it's phone age, so it's not not a ton of things but we've been using it clinically, fully integrated, it launches. When I open a study, when I opened a bone age study impacts it launches we have a bone age calculator as well that we've been using for almost two decades now. And so that we have to use that still but launching that automatically includes the patient's sex and birth date, which are keys for determining bone age, and all that information is there automatically. But at the same time, the images are sent to the machine learning algorithm. And in the background the machine determines a bone age that in the background it sends it straight to our dictation system and it's there when we opened the study. And so if I agree with that I signed the report and we're done. If I disagree, I copy it from my calculator and put it in until it takes just a couple of clicks. We are working on expanding. We've done a lot of research in artificial intelligence and the department. And so we've been things are sort of in the middle of translation of moving it from the research pure research realm to the clinical realm, something we're actively working on trying to get them in. Others are a little bit more difficult. >> That's the question on that John, Doctor, when you talk about injecting, you know machine intelligence into the equation. >> Yeah. >> What, how do you sort of value that? Does that give you automation? Does it improve your quality? Does it speed the outcome and maybe it's all of those but how do you sort of evaluate the impact to your organisation? >> I there's a lot of ways you can do it. And you touched on one of my favorite one of my favorite talking points, in a lot of what we've been doing and early machine learning is around image interpretation helping me as a radiologist to see a finding. Unfortunately, most of the things are fairly simple tasks that it's asking us to do. Like, is there a broken bone? Yes or no, I'm not trying to sound self-congratulatory or anything, but I'm really good at finding broken bones. I get, I've been doing it for a long time and, and radio, you know so machines doing that, they're going to perform as well as I can perform, you know, and that's the goal. Maybe they'll perform a little bit better maybe a little bit worse but we're talking tiny increments there they're really to me, not much value of that it's not something I would want. I don't value that at a time where I think machine learning can have real value around more on some of the things that you mentioned. So can it make me more efficient? Can it do the things that are so annoying that and they'd take, they're so tedious that they make me unhappy. A lot of little measurements for example are like that an example. So in a patient with cancer, we measure a little tumors everywhere and that's really important for their care, but it's tedious and so if a machine could do that in an automated way and I checked it that, you know, patient when because he or she can get that good quality care and I have a, you know, a workflow efficiency game. So that one's important. Another one that would be important is if the machine can see things I can't see. So I'm really good at finding fractures. I'm not really good at understanding what all the pixels mean and, you know in that same patient with cancer, oh what do all the pixels mean in that tumor? I know it's a tumor. I can see the tumor, I can say it's a tumor but sometimes those pixels have a lot of information in them and may give us prognosis, you know, say that this patient may, maybe this patient will do well with this specific type of chemotherapy or a specific or has a better prognosis with one with one drug compared to another. Those are things that we can't usually pick out. You know, it's beyond the level of that are I can perceive that one is really the cutting edge of machine learning. We're not there yet and then the other thing are things that, you know just the behind the scenes stuff that I don't necessarily need to be doing, or, you know so it's the non interpretive artificial intelligence. >> Dave: Right. >> And that's what I've been also trying to push. So an example of when the algorithms that we've been developing here we check airways. And this is a little bit historical in our department, but we want to make sure we're not missing a severe airway infection. That can be deadly, it's incredibly rare. Vaccines have made it go away completely but we still check airways. And so what happens is the technologist takes the x-ray. They come in to ask us if it's okay, we are interrupted from what we're doing. We open up the study, say yes or no. Okay, not okay, if it's not okay they go back, take another study. Then come back to us again and say, is it okay or not? And we repeat this a couple of times it takes them time that they don't need to spend and takes us time. And so we have, we've built an algorithm where the machine can check that and their machine is as good or a little bit worse than us, but give can give that feedback. >> Dave: Got it. >> The challenge is getting that feedback to the technologist quickly. And so that's, that's I think part for us to work on stuff. >> Thank you for that. So, John, we've probably got three or four minutes left. I'll let you bring it home and appreciate that Doctor Towbin >> I think one of the biggest impacts probably I knew this last year with the pandemic, Doctor Towbin is this, I know you're a big foodie. So having been to some good restaurants and dinners with the hot nurse in a house how's the pandemic affected you personally. And some of the things you like to do outside of work. >> Everything is shut down. And everything has changed. I have not left the house since March besides come to work and my family hasn't either. And so we're hardcore quarantining and staying you know, staying out and keeping it home. So we've not gone out to dinner or done much else. >> So its DoorDash and Uber Eats or just learned to cook at home. >> It's all cooking at home. We're fortunate, my wife loves to cook. My kids love to cook. I enjoy cooking, but I don't have the time as often. So we've done a lot of different are on our own experimenting. Maybe when the silver lining one of the things I've really relished about all this is all this time I get to spend with my family. And that closeness that we've been able to achieve because of being confined in our house the whole time. And so I've played get to play video games with my kids every night. We'd been on a big Fortnite Keck lately since it's been down making. So we've been playing that every night since we've watched movies a lot. And so as a family, we've, I it's something I'll look back fondly even though it's been a very difficult time but it's been an enjoyable time. >> I agree, I've enjoyed more family time this year as well, but final question is in 2021, beyond the PACS upgrade what are the top other two projects that you want to accomplish with us this year? And how can we help you? >> I think our big one is are the big projects are unexpanded enterprise imaging. And so we want to continue rolling out to other areas that will include eventually incorporating scopes, all the images from the operating room. We need to be able to get into pathology. I think the pathology is really going to be a long game. Unfortunately, I've been saying that already for 10 years and it's still probably another 10 years ago but we need to go. We can start with the gross pathology images all the pictures that we take for tumor boards and get those in before we start talking about whole slide scanning and getting in more of the more of the photographs in the institution. So we have a route ambulatory but we need inpatient and ER. >> All right one last question. What can IBM do to be a better partner for you guys? >> I think it's keep listening keep listening and keep innovating. And don't be afraid to be that innovative partner sort of thinking as the small company that startup, rather than the giant bohemoth that can sometimes happen with large companies, it's harder. It is fear to turn quickly, but being a nimble company and making quick decisions, quick innovations. >> Great, quick question. How would you grade IBM, your a tough grader? >> It depends on what I am a tough grader but it depends on what, you know as the overall corporate partnership? >> Yeah the relationship. >> I'd say it's A minus. >> Its pretty good. >> I think, I mean, I, we get a lot of love from IBM. I'm talking specifically in the imaging space. I not, maybe not, I don't know as much on the hardware side but we, yeah, we have a really good relationship. We feel like we're listened to and we're valued. >> All right, well guys, thanks so much. >> So even if it's not an A plus- >> Go ahead. >> I think there's some more to, you know, from the to keep innovating side there's little things that we just let you know we've been asking for that we don't always get but understand the company has to make business decisions not decisions on what's best for me. >> Of course got to hold that carrot out too. Well thanks guys, really appreciate your time. Great conversation. >> Yeah, thank you. >> All right and thank you for spending some time with us. You're watching client conversations with IBM Watson Health.