#137: Adam Rakestraw (MediView)

Adam Rakestraw (Mediview) [00:00:00]:

This is the greatest effort professionally in my career. And if, at the end of the day, metaverse as an entity can make the human health needle tick forward just one tick lifetime achievement, and if we can really advance human health, that's where we're working towards land. We've been blessed along this pathway to be in Ohio, to be partnered with the Cleveland Clinic on a clinical, on a research perspective, on an investment perspective, to have the Mayo Clinic also as a partner, and be working with GE Healthcare and other strategic entities as well. Those partnerships along the way have helped us drive to that destination.

Jeffrey Stern [00:00:34]:

Let's discover what people are building in the Greater Cleveland community. We are telling the stories of Northeast Ohio's entreprenuership builders and those supporting them. Welcome to the Lay of the Land podcast, where we are exploring what people are building in Cleveland and throughout Northeast Ohio. I am your host, Jeffrey Stern. And today I had the absolute pleasure of speaking with Adam Rakestraw, the cofounder chairman, General Counsel and Chief Business Development Officer at Metaview XR, based here in Cleveland, Ohio. With approximately $29.5 million in capital raised from strategic partners like the Cleveland Clinic, Mayo Clinic, GE Healthcare, Jobs, Ohio, and many others since its founding in 2019, Mediview is a medical technology company working to advance human health through its digital augmented reality ecosystem. Metaview's AR Visualization platform aims to unlock the full potential of 3D data to transform image guided medical procedures with intuitive 3D Xray visualization seamless, remote collaboration and evidencebased data insights. And this dream to democratize healthcare by removing barriers to patient access and to address the long standing limitations of current medical imaging technologies is well underway as the company recently secured the first 510K clearance of its kind for an AR device with live imaging. Combined with three D x ray visualization by the FDA. Adam has an extensive legal and medical device background with over 20 years of experience across organizations like Merck and Medtronic. This was such an amazing conversation that feels like a genuine clairvoyant portal into the future of healthcare and how Adam and his team at Mediview are leading the charge to make it all happen. So please enjoy my conversation with Adam Rakestra after a brief message from our sponsor. Lay of the Land is brought to you by Impact Architects and by 90 as we share the stories of entrepreneurs building incredible organizations in Cleveland and throughout Northeast Ohio. Impact Architects has helped hundreds of those leaders, many of whom we have heard from as guests on this very podcast, realize their own visions and build these great organizations. I believe in Impact Architects and the people behind it so much that I have actually joined them personally in their mission to help leaders gain focus, align together, and thrive by doing what they love. If you two are trying to build great, Impact Architects is offering to sit down with you for a free consultation or provide a free trial through 90, the software platform that helps teams build great companies. If you are interested in learning more about partnering with Impact Architects or by leveraging 90 to power your own business, please go to IA layoftheland FM. The link will also be in our show. Notes. When people think about the future of healthcare, I find that they often imagine this future where clinicians are granted superpowers, kind of fully leveraging the capabilities of technology for good, able to aid patients with levels of precision and efficacy that really have never been possible before. And what I love about metavea and the work you're doing is that it feels kind of right out of this imagined Sci-Fi future. Something like X ray holographic visualization. So surgeons are able to look directly into a patient during a procedure, seeing the internal anatomy under their skin in three D, all of it the organs, the bones, the vasculature. It really feels to me like you're building something that has never been done before, that blends the physical world and the digital world in a really exciting way. And so I've just been really excited to hear more about how this came together, the work you're doing, the problem space, and your personal path to all of us. So thank you for joining us.

Adam Rakestraw (Mediview) [00:04:39]:

Excited to be here. I mean, the funny thing is, you've got these great movies out right now, like and Superman, and it's this blending of the digital capabilities that you see with Iron Man and Tony Stark, with the Superman vision of being able to look under somebody's skin, that's the crossroads we're at. And to be able to bring that to fruition in the state of Ohio, in Cleveland, for the world, is an honor, and I'm humbled to be a part of the journey.

Jeffrey Stern [00:05:11]:

so how is it that you Came to find yourself at this intersection of Superman and Iron Man and making.

Adam Rakestraw (Mediview) [00:05:16]:

That I asked myself this just last night. We've had some really good news lately for the company. Land the company is going in a tremendous direction. We are blessed with some really incredible people. But on my personal journey, I transitioned away from the practice to law, got into medical device because I wanted to be a part of healthcare. And I had a great career going there. And I got a call saying, hey, there's this amazing technology at the Cleveland Clinic. Would you come up and take a look at it? John Black, the other co founder met of you, called me, and I was blessed that he thought of me first. And I had very measured expectations came up. I had not experienced augmented reality yet. I played with a little bit of virtual reality. This was back in 2016, and came up here and put this headset on. And having been in thousands of procedures with clinicians who are trying to look at flat screens, two flat screen images to understand depth and anatomy internally, I saw how it allowed a human being, a clinician, to consume 3D data, to see 3D data. That is what augmented reality does. Extrapolating that just from being able to insert digital images in your space with depth perception to draw that line across to where you're applying it for healthcare, it just unlocks potential land capabilities that frankly hadn't existed. So it didn't take us much time to go back and say, let's start a company at that point in time. So that is how the introduction itself happened. And then we really scaled from there. And that's a longer part of the dialogue we can certainly dump into that story. But that's how that spark started for me.

Jeffrey Stern [00:06:57]:

So the potential for what you saw, the implications of this technology being were kind of there from the onset?

Adam Rakestraw (Mediview) [00:07:04]:

No, the minute I put the headset on, I saw it. The thing I would say is really true, even to this day. It's an experiential technology. No matter what words we put around it, you have to experience it to really understand the implications of it. And there's been a lot of people who've been skeptics and naysayers land. They come put the headset on and they see what we've built and they're like, oh my gosh, I thought I knew and I didn't know until I put the headset on. That's one of our biggest challenges, and it's the beauty of augmented reality at the same time.

Jeffrey Stern [00:07:36]:

Yeah, I have found that to be the case for that kind of medium, where to me, one of the most fascinating experiences when I came around to trying VR and AR stuff for the first time was that it didn't feel like I was using a technology. It felt like I was in a different place. And my memories of it were of experiencing what it was to be in that space, not looking at a screen. It is hard to describe. I don't know how you can imagine what it feels like.

Adam Rakestraw (Mediview) [00:08:07]:

Yeah. And people there's still confusion out there and knowledge to be disseminated about the difference between virtual reality where you don't see the outside world, and augmented reality, where you wear a pair of glasses kind of like what I'm wearing. They're much bulkier now, but they'll get to this form factor and you still see everything around you. It just puts digital content in your world, whether it's a floating screen and you're doing a remote collaboration, whether it's taking a CT image or MRI image or whatever it is and the making it back into a hologram. That's life size and putting it under a person's mean, it just allows you to interact with the real world Land digital content at the same time. And those nuances are different. I mean, our team had a great team building exercise this week in Cleveland. We went to and did a VR experience, and I don't do well in VR personally, because especially when you get into the really complex, uh, my balance doesn't really work right with that. But with AR, I'm fine. I love both technologies, but I really love what augmented reality is going to bring to the market.

Jeffrey Stern [00:09:16]:

At that point in time, some work had already been done to allow you to see the potential in this. Can you take us through a bit the impetus for that work and just kind of the nuts and bolts of how the technology transfer out of the Cleveland Clinic actually transpired and the vision at that point for what the company would become?

Adam Rakestraw (Mediview) [00:09:37]:

So the Cleveland Clinic innovations had a couple of different patents that related to the technology. And so John and I formed the company in 2017, and then we went about negotiating with Cleveland Clinic to license it. And so that licensure process took a little bit of time, but what we ended up getting at the end of it was a global, exclusive, worldwide license for those technologies. One is to take the imaging and register it under the skin, and the other one is to take live imaging land, fuse it with a CT or a Hologram in that space. So once we are able to get the Licensure done, then we set about bootstrapping and doing the work, initial foundational work with initial early investors with the state of Ohio, using grants and otherwise to get the technology back to up to a point of maturity where we could do a broader or bigger fundraise. And what that meant in our case was getting the technology to a form factor. We could do a series of early inhuman evaluations, what we call an IRB case. And we got five of those completed. And once we were able to get those five completed, we were able to use that to show to go out to investors and say, hey, this isn't just a theory. It has already been built in at least a prototype format and has been used in human at the Cleveland Clinic. It is viable. And now, because it's viable and we can show you it's viable, we are seeking funds to mature the technology further. That took place in October 2019, and we raised a $4.5 million seed round, and then we started hiring core team members and growing the team from there.

Jeffrey Stern [00:11:17]:

So at that point in time, I imagine the potential applications of the technology were vast. At that point, did you think about Mixed Reality's impact on healthcare on a broad scale and the potential for what it would take to bring it forward and realize its full potential and the actual specific applications you would choose to focus on?

Adam Rakestraw (Mediview) [00:11:38]:

Well, that's a really great point, because mixed reality has a breadth of applications, whether it's training and educating people and simulating, whether it's how you plan a procedure to how you deliver a procedure. There's a broad spectrum land the thing is you can't take on all of that. You can take on a focused piece of that. And our piece was we are going to go to what they considered the Holy Grail, which is where a patient and an instrument and the imaging interact for procedure, which a lot of other entities out there were already focusing on the other place, that's great, we can partner with those entities later. But we wanted to focus specifically on that Holy Grail and then within know there's so many different use cases and applications. We were fortunate enough to be connected with Dr. Chuck Martin, who's chair of interventional oncology at the Cleveland Clinic. And he goes, one of the most difficult procedures to execute and complex and that more patients need more access to is tumor ablation, where you percutaneously, take a needle or a probe, I should say. You put it into a tumor and you either heat that tumor or freeze it to kill it. Now the thing is though, doing that through the skin is highly complex. He gave the analogy of trying to hit a grape that's inside of a watermelon and trying to figure out where that grape is and there's critical structures around it and those kind of things. So we set about focusing on that application first with the technology to get it matured to a point where we can get it to a product ready state, submit it to the FDA, because that's the other complexity we're under regulatory. Get it to the FDA so that first application in use can be the foundation for a breadth of other applications moving forward. So going back to your question about the IP, the intellectual property that licenses for all applications, we still had to figure a focused one first to get it through the FDA and then beyond that we can partner and develop for really it's a platform technology from head to toe, we can expand from there. So that's how we decided that part of it was happenstance and part of it was really focused and long discussions on what we wanted to pursue and how we wanted to pursue it is.

Jeffrey Stern [00:13:48]:

Part of the thinking there. That if you can have an application that proves to facilitate one of the more practically complicated procedures, that it might be easier from there to cover a wider breadth.

Adam Rakestraw (Mediview) [00:14:02]:

Exactly. Number one, you want to show that the system functions. Number two, you want it to serve a need, clinical need and then number $3 make sense? Especially in a startup world, you've got to show that it's got an economic impact with it also. So not only just the clinical impact that you can get it through regulatory, but it can have an economic impact. And we can show all three of those with the system, with the application that we went to market with that sets the foundation. Then once you've proven those out that we're talking tumor ablation, we have people approaching us for neurosurgery, spine surgery, breast applications, prostate. I mean, you can literally go from head to toe, because that's what our breadth of ownership and our IP is. And they're requesting that at this stage of the company, still, the no's are just as important as the Yeses are. So with all these requests in front of us, we have to remain focused and deliver on the task at hand and set ourselves up for the path of where we can pursue those things moving forward. But each path is scrutinized for what's it going to do on an impact on our financial runway, what's it going to do for our investors, what's it going to do for the technology. And if it checks all those boxes, we can put it in the yes potential yes category. There's a lot of things we have to say no to, but it's being focused on that path is what will deliver the technology to market and allow us to grow it.

Jeffrey Stern [00:15:23]:

It is quite literally head to toe.

Adam Rakestraw (Mediview) [00:15:25]:

Head to the. The IP is head to the and what's really unique about Metaview is that we are the first company in the world to submit to the FDA for integration of live medical imaging into augmented reality. Our submission before the FDA is for soft tissue and bone application. So a lot of the technologies that are out there right now are bone specific. The way that we're able to, number one, take a patient's CT or MRI and turn it into a hologram, put under their skin. It's a reference image, so it's not as dynamic yet. We're not to a point where they're dynamic images, but it's reference. So what we do by taking live imaging is we can confirm the location of where the hologram should be, and we can confirm the location of where the instruments and the tracks of the instruments should be. So we have been able to pursue soft tissue, which other companies have not.

Jeffrey Stern [00:16:22]:

So you had mentioned this analogy of finding a grape in a watermelon, and I kind of hope practically, that isn't quite exactly what the status quo looks and feels like today. But I am curious, and when you go to pitch Metaview in the context of practitioners who are performing these surgeries and different procedures, is it a matter of unlocking things that they couldn't do before, or is it enhancing things that the have done historically, or is it both?

Adam Rakestraw (Mediview) [00:16:55]:

It's both. And there are clinicians with a different spectrum of capabilities and experiences. There's this thing where some clinicians have what I would refer to as a 3D mind. They can look at 2D imaging and orient their space, create a 3D picture in their mind easily. They've just done it. They're used to it. And some people are born that way. Some people that's not as intuitive. In either event, you're still taking on a cognitive load. You still are doing mental gymnastics to get that picture in your head and navigate it. Some people can do it right away, and some people it takes the a long time and it's complicated. And that's why it dissuades some people from doing that. What augmented reality does is it takes that cognitive load completely off. It gives everybody the 3D mind and it puts it right in front of you in a natural and intuitive way so that even that expert who's done a bunch, there's still times that they could benefit from more information or better information and data and better visualization. There are people that are just starting their practice that have never done a procedure that need more confidence and comfort in doing that. And what we do augmented reality does is gives them the information in an easily digestible format, reduces the cognitive load so they can focus on the more critical pieces of the procedure. So that right now specific to Ablation. About one in five candidates for Ablation actually gets it. And the alternative to an Ablation is an open surgery resection. Maybe it's chemotherapy, maybe it's radiation. Maybe it's nothing at all for some of these patients. And what giving clinicians better tools opens up access to the cancer patients for therapies that they could deserve and they could do better with. And that's part of that dignity of medaview as an entity bringing these technologies to market. But going back to your question, there's benefits to all clinicians from all different ranges of experience and confidence and comfort. And it really plays more into, I think, the adoption of it. Who do we go to first? Who's going to be an early adopter? Who wants to be a visionary or a luminary in that space, that tip of the spear and be able to iterate on it? Because there's this really rare window of opportunity for some of these clinicians to get involved with this kind of a technology, to be that pioneer and to inform it. And that's what we're looking for in this next phase as we go to market in this first year. It's not going to be necessarily broad commercialization, but it's still targeted so that we can find the right clinicians and the right partners to continue to refine it, to get it to that state where it deserves to be and to deliver it to human health. I've said several times, this is the greatest effort professionally in my career. And if at the end of the day, metaview as an entity can make the human health needle tick forward, just one tick lifetime achievement, and if we can really advance human health, that's where we're working towards land. We've been blessed along this pathway to be in Ohio, to be partnered with the Cleveland Clinic on a clinical on a research perspective, on an investment perspective, to have the Mayo Clinic also as a partner, and to be working with GE Healthcare and other strategic entities as well. Those partnerships along the way have helped us drive to that destination.

Jeffrey Stern [00:20:08]:

Right. It's fun to think about that. Even a tick at that scale is quite an enormous shift in the experience and implications for clinicians, for patients, all the practitioners involved. And I know since the onset, you've been able to raise about an additional 30 million in funding. And so obviously the picture that you're painting is quite large of the kind of impact this can have at scale. What is that vision, looking into the future that you've convinced investors of the future of medical care? And what in your mind is the path and strategy look like to achieve that?

Adam Rakestraw (Mediview) [00:20:50]:

Our vision is that really Metaverse vision is to simplify and inform and democratize healthcare delivery at a very, very high level. The way augmented reality does it is by giving tools that don't exist and capabilities that don't exist that, when delivered to the healthcare market, will make more procedures possible. Open up access and therapies to patients, create efficiencies in care delivery, make these procedures shorter, more efficient, less radiation, being able to push care out to rural areas effectively. And that's our vision now. We still pare it down. Land make it really focused. We're delivering on this specific area of it. We have the opportunity, though, because I think we do have a keystone technology where it's designed for partnerships and integration, but we have a very focused technology that when delivered to the market, will impact healthcare, number one. Number two, it will drive returns from it for our investors, because it's not just the story you tell, it's what's going to follow it. I think they see that. And then as you go through these phases of funding, it's not just the story you tell, as you well know, but it's the people you have on board. They want to see the people behind it and they want to see the proof of what you've produced to date in the direction you're going in the future. Land lining those efforts up and those elements up has really been the key to our success in fundraising.

Jeffrey Stern [00:22:17]:

So how does Metaview make money? What does the business model and sales process look like?

Adam Rakestraw (Mediview) [00:22:23]:

So Metaview has been revenue producing since 2022. Now, we are not revenue positive. We are still an investor funded organization. We produce revenue in a couple of different ways. Number one, contracted development is one of our revenue paths right now. So entities will come to Medevu and say, hey, and I'll take a step back. Metaverse as an entity has been built top to bottom internally. We don't do external contractors, so regulatory is our own. Adam Cargill on our team leads our regulatory, and we've got some really awesome team members for that. But we took that in house, so we own it. Our development is all done in house, and we've got some of the best developers from across the country that we've hired we've been very targeted and specific in that we've got really wonderful people. I cannot lay enough about this team and what they're building to move forward. So the team's phenomenal. But the underlying business model going back to that, we do contract development. So because all of our functions are in house, an entity, whether they're a medical device company, whether they're a medical imaging company, will come to Mediview and say, hey, we'd like to build this application. You're going to be more efficient than we are because we're a juggernaut of a company. You have this specific skill set. Will you build this for us? And that's part of what we've done with GE Healthcare. They wanted to build the interventional suite of the future. So in an interventional suite in a hospital where a cardiologist or radiologist or a neurosurgeon can walk into, and they've got a machine mounted in there and there's different imaging inputs, there might be an ultrasound machine in there. There's going to be fluoroscopy where they're doing X rays. What we've built and what GE has contracted with us to exclusively build for them at this point is that Tony Stark cockpit of the future for interventionalists. So starting this October is our target. Those clinicians will be able to step into that suite, put on a headset, and all their inputs, their feeds, their fluoro feed, their auto, write, their ultrasound, they can see a 3D image of what they want to see is all in front of them, and they can interact with it any way they want. So that's contracted revenue and that's a global go to market agreement with GE. On the flip side, at the same time, we are building our own organic products, and we are going to be selling our own organic products. So in 2022, we sold a handful of systems to learn not only from going out and going through that process with those customers, but also watching how the customers interacted with the system to refine it as we continue to move forward. So this year we are continuing to sell systems organically again. It's a very measured paced growth because we're still refining it. We've had these headsets on over 1000 clinicians, and even though we brought revenue in, we're not trying to scale revenue yet. We want to get to a degree of product maturity. Moving into 2024, that's going to start scaling at a different pace. It's going to increase. So we have one system that's registered with the FDA. We are refining that to add product maturity and open up its installation base. We have the full blown navigation system. We will sell those organically as well, and some partnerships. So two streams, contracted development, organic sales. And then when you dive into organic sales itself and go to market, we actually have different channel partners that we'll distribute for. So we're going to have our own sales force. We're going to have resellers that work with us, whether it's through GE or other contracted partners or distribution entities as well as we go to market.

Jeffrey Stern [00:25:57]:

So there are a few ideas there that I want to touch on, but we can only really talk about one at a time. But across the partnerships, the team, the idea of kind of the super user physician and the product maturity, I think just at this point, it would be helpful to understand, knowing to your point that it's hard to visualize what this looks like without experiencing it for yourself. But practically speaking, you put on this headset and you've alluded to some of the information that's going to be surfaced, but take us through what this experience feels like for a clinician.

Adam Rakestraw (Mediview) [00:26:34]:

So imagine this. You're a clinician. Land we've had people who are not clinicians put the headset on and say, I could do a procedure with this. It's the gamification of surgery at the end of the day, is what it is. Imagine sitting there and walking into a room, you've got a patient in front of you, and you put a pair of goggles on, and as you look into that patient, you can give voice commands and see what you want to see when you want to see it. So patient has a tumor in the liver, and you can sit there and give a voice command and say, show tumors. And the tumor is highlighted in front of you under the patient's skin, within their body. You can move around. There's no limitations on how you move or your position, but you get to see that tumor under the skin. So you can localize it. You can see right where it is and you can localize it very quickly, but you need to understand more, not just where the tumor is, but what anatomy is it within. So say it's in the liver. You can sit there and give a voice command, say show liver, and you see the patient's own liver show up under their skin. Well, what else am I worried about? I can say show vessels. I can say show me the kidneys, just for reference if I want to see those. Or say that lesions at the top of the liver which puts it under a rib cage. You can say show bone, and all these things appear. So they're all in front of you. You get full depth perception. You completely understand the anatomy very intuitively up front. So say, now you want to stern that needle, that instrument to that lesion, and you've got to get around the bone first. You start steering that needle and inserting it into the patient, steering it towards that lesion. You understand where the vessels are. You understand where the bone is. Now you're past the bone and you don't need to see the bone anymore. You can say hide bone and that part of the imaging disappears. So you focus down specifically on that location that you're trying to. Drive to. You drive your instrument, that needle, to that location, and as you're driving it, you can say, show ice ball, which sounds kind of funny. But what it is, is it will show you the zone you're going to freeze, theoretically, to kill the tumor before you even hit the button to turn it on, to start killing that tissue so you can place it. You get a model of what you think it's going to be. Then I can say float anatomy. And that floats above the patient, which was initially displayed as X ray vision under the skin, now floats above the patient. Why would you do that? Well, because now I can sit there and take a hold of that imaging and spin it and look at it from every angle to make sure that that zone is exactly where I think I want it to be. And then I can go back to say, project anatomy. It snaps back down under the patient's skin. You've got your X ray vision back again. You hit the button, and you can execute your procedure on the back end of that. As you're doing that, the system is capturing 3D coordinate data for everything that you're doing. Where was the imaging? Where was the tool? Where was the patient during the procedure? On the back end of it. Then we're going to be able to build AI. Land other data off of that. But for the first person user, that's what you would see Land experience during a case. And then to pull on that string a little bit. The next step of that is being able to collaborate like you and I are right now. So I'm in that case with that visualization, and I say to myself, you know what? I would really like Jeff's opinion on don't. I'm really concerned about this, or this is a little more complex. I could give a voice command and call you in to that procedure. Land what happens for me is the wearer. A little screen pops up, just like on this call on a teams, on a zoom call, whatever. A little screen pops up. I see you. Nobody else in the room sees you, but I see you wearing the headset. And we have voice dialogue between us. You can sit, but you get to see on the receiving end through my eyes, you get to see the surgical space, all my medical imaging, that X ray vision, the guidance, everything. And we can have a voice conversation and you can annotate. So you could sit there and say, hey, Adam, I would really watch out for this specific vessel. And if I don't get it by what we're talking about verbally, you can circle it. And that circle would show up in the space, my operative space, in front of me. And that's just the fundamental level of collaboration you can start with. But that starts taking that capability and expanding it out, expanding the experience of other clinician and users. Whether you want to teach with it, whether you want to collaborate with it, whether you want to push care to rural settings, that's where you just take just that fundamental visualization, that incredible accomplishment of that visualization and navigation land, start pushing it out and delivering it to other spaces.

Jeffrey Stern [00:31:05]:

So when you think about, I guess, a competitive concept here, is it mostly against the status quo? Are there other folks doing that? And then in that line of thinking, I imagine even from the perspective of clinicians, you're going to have those who are very excited about this are innovative, they're early adopters. And then like most markets, there's going to be people who are skeptical and lagging in that adoption and probably have concerns about how is the efficacy land accuracy of these visualizations. And obviously a lot of that is tested and ironed out in regulatory trials and things of that nature. But how are you addressing those concerns? And if anything, do you think about competition here?

Adam Rakestraw (Mediview) [00:31:52]:

Competition is good. If it was us alone in this market, yeah, you could say up front you'd think, oh, there's benefit to that and that's great, but we need other people driving the maturity of the technology. This is really a matter of partnerships and this is something we sincerely believe in. It's not just partnerships with clinicians. It's healthcare systems, it's imaging companies, device companies. Competitors out there in the space who are also driving adoption benefit us and we benefit the because it's going to take that to get mixed reality, to really a place of maturity and a place of broader adoption. Now, what I would say, there's competitors that are using mixed reality for surgery right now. Our methodology is different and it is IP protected. And it gives us capabilities that some of our competitors, most of our competitors don't have. But we want them to be successful. And we want to be successful because I think human health benefits from that. So it pushes us to be better, number one, and to deliver the product to the market, a quality product to market. On the remote collaboration side, there's competitors in that space as well. There's companies that are focused specifically on installing cameras around a room and allowing people to collaborate remotely. There are companies that are working on letting one person, one location, operate a robot in another location. That's all great. We know we are walking towards a time when 30% of clinicians are over the age of 65 and you can't train enough people to catch up and deliver care. So that idea, remote collaboration, again, these competitors are in that space that are building on that. The more it gets adopted, even in different form factors, the better. We really think that our form factor is already integrated into the system. It integrates medical imaging in a very unique way. And it's from the first person perspective of the user, which differentiates us. Now, I will say this. I have a 278 slide presentation just on IP because that's something we monitor. But competition is good for us. We're going to compete. We believe in what we've built, and we think about that every day and how we position the product.

Jeffrey Stern [00:34:06]:

And then to that idea of the innovative early adapters and those who are skeptical of what you're doing, how do you balance those?

Adam Rakestraw (Mediview) [00:34:16]:

Well, it helps you target your efforts. You got to find the early adopters who are going to be champions and help push you. And even within that, you've got to find the champions. Not the ones that just say, yes, it's great and I'm going to use it, but the ones that say it's good, but it needs to be better, and this is how you make it better. Those people that really are genuinely committed, those clinicians that are committed to the technology, to what it can serve, the practice of medicine land what it's going to do for the patients? Those are very strategic. You know, I think we've been very fortunate medaview as a company has been very fortunate to find those clinicians and partner with them, starting with Know in in Cleveland and then growing from we want ultimately to your point. We want to get to the point where we get the early adopters. They get in the market, they prove it out, grows adoption more broadly and to even to the point we're not going to sell everybody. I don't think any product has ever sold everybody. But if we can get breadth of adoption, even some of those guys that say, I'm an expert, I don't need it, and the they start seeing what it can deliver and say, you know what, I may not need it, but I'm humble enough to say I want more information in the room. Land we should have this system here. We should have X ray vision on hand, and it's more information for me to make a better decision at the end of the day.

Jeffrey Stern [00:35:36]:

And part of that adoption, I imagine, would be greatly facilitated by some of Know formidable partners that you have. You mentioned partnerships, I believe GE Healthcare, Microsoft, obviously coming out of the Cleveland Clinic, working with the Mayo Clinic. I mean, at this intersection of technology, imaging, healthcare, how have those partnerships come to know what is it like to form those as a startup? What have they brought to the table? Land what ultimately do you hope to validate through those well being?

Adam Rakestraw (Mediview) [00:36:08]:

The IP? Being born out of the Cleveland Clinic didn't hurt us at all. That was a huge help. Our offices are in the Global Cardiovascular Innovation Center here. Right on Cleveland Clinic's campus. We have the benefit of walking across the street and working with these world class clinicians every day. That's something that you just can't replace. And we were extraordinarily blessed to be born out of the Cleveland Clinic and growing out of the Cleveland Clinic and still have that weight behind us, that is an attention grabber. So you get one partner like that and people start to pay attention, then you grow it. Land we've been selective about our engagements when Mayo Clinic comes on and decides to make an investment. Land medevue was the first time that Mayo Clinic and the Cleveland Clinic have ever invested in the same company. To have the number one and two hospitals, arguably in the country for sure, and arguably in the world, invest in the same company speaks volumes. And then to get the world's number one imaging company to also invest and do partnerships with you while leaving yourself agnostic and able to work with other entities and companies, puts you in a strategic position to really accelerate into the market and draw those quality clinicians and partners moving forward. So that sounds like a simple way to state it. It took a heck of a lot of work. It's long days and endless nights and a lot of travel, meeting and networking and leveraging and communicating effectively communicating what we've built and how we've built it and who we've built it with. It leads you to these pathways to the right partners. And part of that also is your advisors along that journey. So Metaview is blessed with some really great world class advisors. So Daniel Jamil, who is a Forbes 30 under 30 guy who launched software company for education because we are software based, at the end of the day, we're a Medtech software company. He came on fossil merchant who was CFO of DreamWorks and now has worked with a multitude of global companies. Mark Griswold here in Cleveland as well, has come on, he's a busy man that works with Microsoft. Land is known as one of the founders of Milk Strategy and Healthcare. And what they're doing, choosing these critical advisors as well, is really important to us. I could Sabine Sheikh, Brad Hughes, I could go down the line of the people that were Land Patel, another clinician, and we go down this line. These people who are committed to bringing that mission forward, those are equally as important as the partners out there. But again, it's networking. It's just networking and getting that message out and finding the right people. And our board of directors has been really instrumental in that as well.

Jeffrey Stern [00:38:56]:

I'll pull on the building in Ohio thread, knowing that the company is based here in Cleveland, and obviously you've spoken highly of the support you received from local organizations and the role that the ecosystem has played in Metaview's success so far. Can kind of dovetail that with the team building part because I imagine one of the difficult pieces to me as an outsider, learning about what you're doing is how do you find people who both understand the absolute nuance of these kinds of medical procedures. Land also the software part of it. So how has that played out?

Adam Rakestraw (Mediview) [00:39:35]:

Well, I'll take on the state of Ohio question first and we can talk about building a team. The state of Ohio has been a blessing. I think a lot of people, even down this journey, I think we get a lot of East Coast, west coast people know these are really tech companies coming out of Ohio. And I think Ohio has done a lot of steps lately to really showcase and build the state as an entity and a location where tech is being developed. I mean, you have the intel factory going down around Columbus, you have battery manufacturing plants going in. We've had some great advocacy land partnerships within the state. So early on we got a Tvsf grant, which is non dilutive funding that helped us support that came from the state jobs. Ohio. The Growth Capital Fund has also been an investor in US. But there's other resources early, very early on. There's what they call ESP entrepreneurial service providers. And that was provided to us as well as some small amount of funding, some initial, really critical seed funding to get the company going. That's all here for you in Ohio. There's people here, there's tech, there's infrastructure, it's all available and it's just what you leverage to make of it. We are still Ohio born and Ohio proud, but launching global technologies, and we're Cleveland proud on top of it. So we're really excited for where we're at and where we've done the form of our funding, the Safe funding. We've launched and executed the largest Safe in Ohio's history. And it's a simple agreement for future equity. It's a vehicle. It's gained momentum as of rate lately, especially in this crazy funding environment that's typically an east coast, west coast thing. We brought it to Ohio and delivered it here and Ohio executed on it. Our investment core, one of the first groups. So we were blessed to go through an investment syndicate where these investors gathered together, formed a company specifically to fund Metaview and these mean business, thought leaders, clinicians, et cetera. There's a landscape of them, but they formed one entity called Inside View and they invest in us. That came out of Ohio, primarily northwest Ohio. I'm from Finley, where that area where it came from, but that gave us our seed funding, that reinvested in the Safe round and then doubled down even more from there. So whether it's been funding or otherwise, Ohio's got great avenues, I can't say enough about it. And the support that we've received transitioning to how do you grow talent here? So the interesting dynamic and metaBUS faced its challenges a couple of different times, and the Pandemic was one of them. So in October 2019, we raised that $4.5 million seed round and we started to hire. We hired our first four people. Mina Fahim came over as our chief technical officer from Medtronic. He lives in Minneapolis. Greg Miller they're both like employees one A and B, we hired him at the same time. Greg Miller is from Finley, Ohio. We joke that he invented the Internet. He's a MacGyver on our team and they're both leaders. But we hire these core people. We knew based upon what we were building that some elements of the company were going to be in Ohio and some of them, frankly, we weren't going to find here. We wanted the best of the best, and so we set ourselves up from day one. Greg was really great about setting the company up to work remotely. So when COVID hit and we had started to hire people, we had obviously an emergent board meeting. Like, are we okay? I'm like, we're okay. We're set up to work remotely. Well, we knew we were bringing in the talent it's allowed us because we can do the mix. And right now we've got 32 employees and 16 of them are in Cleveland and 16 are dispersed. But being set up remotely allowed us to take advantage of a national pool of the best talent that we could look at but still be based out of Ohio. So we have employees from California, you name it, across the United States. Every time zone, we've got an employee that comes in and we work with. And the being connected remotely allows that, but it also doesn't replace the work that we get done in person. We just had a town hall one of the times a year. We have the entire employee pool came in this week to work together. But we've got the best talent from across the country. They're still coming in here to work in Ohio and they're happy to do so. Being connected is what allows us to do that.

Jeffrey Stern [00:43:55]:

When you think about the team, what, to you, does it mean to build culture? What is the culture of Metaview family?

Adam Rakestraw (Mediview) [00:44:03]:

Right. That's one of our statements that hangs over the door, and it's hung over the door since day one. Actually, John Black, our co founder, said it first, and we've emulated this moving forward. It's Faith family. Metaview So, you know, you've got to have your faith land your family have to come first, but Metave is right after that. That's how we live day in and day out. We take care of one another. Our culture is supportive of one another. We work very hard. We share the challenges, and we celebrate the successes together. And we hold each other accountable to a very high standard of performance. If somebody's in a time of need or help, we help them out. If somebody's achieving, we celebrate it land. We all hold ourselves accountable to those goals going down that line. Even taking that a step further, I think we've got a pretty humble team. It's what's the best for the company, what's the best for the technology. So John, the other co founder, we both came from medical device he exited and took on the CEO role. At the early stage of the company, we had had discussions about me coming over and taking over the CEO role as the company continued to mature. And what ended up happening is that Mina Fahim, who I mentioned earlier, came over originally as CTO, and he quickly demonstrated who he was as a leader. And we knew at that point in time, John and I, as co founders, land the board, promoted Mina to president and CEO, and that was the right decision. It's been instrumental for the company, and we've had other people that have shifted positions, and it's what's right for the company at the right time being that co founder terminology only means something outside of Metaview. Within the walls of Metaview, the co founder thing is not it's who we are every day. We don't talk about that kind of stuff. We just put the right people in the right positions to do the right things.

Jeffrey Stern [00:46:03]:

When you think about the vision and where you're trying to go, kind of a two pronged question here. Fast forwarding a bit. What will have gone right if you achieve it, and what will have gone wrong if you haven't?

Adam Rakestraw (Mediview) [00:46:16]:

Wow, there's so much going on. If it goes right, we deliver X ray vision to the world right, we deliver X ray vision to surgery for an initial application. It grows from there. Our pathway is likely a scenario where as a company matures, it's either standalone and you go IPO or you get acquired. One of those scenarios happens for us as we mature. If it goes wrong, we didn't hold ourselves accountable. Something fell through the cracks that we didn't think about, we didn't anticipate. We do business continuity planning, risk planning, and that involves an evaluation and a reflection of everything. Where's our IP going, what's our development look like, all these risks that we face. But if we hold ourselves, if we really plan the way we are and execute the way we're doing and hold ourselves accountable, we shouldn't face that. But if we fall short, it makes funding harder. We don't get sales like we want to. It's a cascade of things. Not to say that those challenges haven't happened and aren't going to happen, but to really get to a point of a failure. A lot of things fell apart and we didn't hold ourselves accountable. Going back to your question about culture, the culture of accountability and delivering land performance and perseverance, that's what we pull through. Land it's how we work, but it's how we support each other and how we celebrate each other. And that culture is really important to us.

Jeffrey Stern [00:47:45]:

So one of the items of timely importance, which we haven't yet discussed, but is important to the whole journey, is that Metaview has recently received 510K clearance from the FDA for your platform. So in the broader scope of Mediview's journey, can you talk about what exactly this clearance entails, what went into achieving its approval? And what exactly are the implications of having unlocked the first clearance of this kind going forward?

Adam Rakestraw (Mediview) [00:48:16]:

So I think that's thank you for asking about it. It's the biggest milestone in Metaview's history in terms of development and regulatory submission and approval. So as a company, it matures Metaview to the point where we have successfully achieved a regulatory approval and can now go out and start marketing our technologies. And in this instance, it's the XR 90 navigation system that has that x ray vision and live integrated imaging. So for a company, it's a monumental accomplishment. Did you take it a step further into the market and you've got a broader effort going on with mixed reality that the FDA is learning from and developing their strategy? Land their approach around what metaBUS approval does is because it is the first approval that the FDA has issued that integrates live medical imaging and extends the use of the system to both soft tissue and bone. Because soft tissue moves, bone does not. And the way we integrate live imaging allows us to compensate for that movement, but it opens up the pathways for others to expand on that. And that includes both Metabue ourselves and our ability to expand upon our own technologies and then for others to look to the benchmarks and guidance now that the FDA has started to establish, it really is a tremendous accomplishment and a baseline for everything that's going to move forward. Land a lot of these other mixed reality companies trying to pursue this in the navigation and imaging space, when you ask about what level of work went into it, the amount of work land effort was incredible by this just absolutely amazing team. Adam Cargill, who leads our regulatory and the members of his team were just incredibly diligent and focused in getting this accomplished. But it wasn't without bumps along the way. And we learned from initial responses and communications with the FDA. We actually partnered with the FDA on some activities and allowed that structured communication to build forward so they had a better understanding of our technology, of some of the elements of mixed reality that we were overcoming, of the capabilities, land limitations of the headsets, et cetera. It was a moment of absolute elation for the company to receive that letter saying, you guys have approved it. So I can't really thank the company, the team enough and everybody that participated in it. But it was a monumental undertaking, to say the least.

Jeffrey Stern [00:50:44]:

Yeah. Land for those listening in, you can just see a real big smile on Adam's face as he says, awesome.

Adam Rakestraw (Mediview) [00:50:52]:

Yeah. Again, I appreciate it. The thing that for Cleveland, Ohio, to think about a world first for X ray vision, soft tissue navigation in augmented reality is really an incredible prospect and a reflection of what is being done in the state of Ohio and what can be accomplished here. And this is just the start. So we're going to continue to expand. We've positioned the technology for integration and partnerships with medical device, medical imaging, with other technology enablers that are inside Ohio, outside of Ohio, and around the world. So we're preparing for a big and broad journey that will not only be domestic here in the US. But will also be global.

Jeffrey Stern [00:51:31]:

That's incredible given the convergence of all these technologies, right? The mixed reality VR AR you layer on AI when thinking about the future of healthcare? I think, like an optimistic framing of AI and clinicians is that every doctor and healthcare practitioner will have this assistant that is infinitely patient and compassionate and knowledgeable and helpful and present through all of the things that the clinician is doing and really kind of maximizing efficacy and their outcomes, which is in some ways kind of aligned with, I think, what you're building. What is your take generally on the future of healthcare and where this is all going?

Adam Rakestraw (Mediview) [00:52:18]:

Well, the future of healthcare right now has some struggles ahead of it. Cost delivering care, et cetera. These technologies are all going to feed into that. We have to reduce cost. We have to be more capable. It has to be more efficient. Where is it going to go? I think we're going to see doctors with headsets. They're already now using augmented reality. It's going to grow. You're going to see them using augmented reality and these other technologies day in and day out to inform them to make better decisions, to deliver care. I think it's going to be if you tease out what metaview is building, you're going to have a headset on, you're going to be able to see patient anatomy. Those capabilities are going to grow. You're going to be able to collaborate in an instant across the world if you want to. You're going to have AI built into the back of the system that's informing you and making suggestions. And you'll be able to use all those tools to execute a procedure to drive better outcomes efficiently on a cost effective lay, no matter where that patient is. Hopefully that really is the ultimate goal is where I think we'll see that. And again, you're going to keep seeing all these technologies converging and blending together in these partnerships. Land it's going to take the partnerships from these different people, building different things, because the other thing you could build on is have X lay vision with a robot working in front of you as well. While remotely collaborating, the robot takes the shake of the hand out and augmented reality gives the clinician X ray vision. The more tools, the more information you present to them in an easy, intuitive way, the better the health care is going to be. At the end of the day, what I'd love to see is whether you're a nurse or whether you're the world's most advanced cardiothoracic surgeon. You've got a headset. Its form factor may be like my glasses. You're connected. You've got access to data and information. You're passing along information efficiently. The patient's coming in, they're feeling supported, they're getting the care they need in an efficient way. The system is functioning the way it needs to and all these technologies are blending together. It's a big vision. It's going to take time and it's going to take partnerships and an investment and we get to have a really unique role in that.

Jeffrey Stern [00:54:31]:

I want to ask I think it's become one of my favorite questions for the non obvious thing that we haven't talked about but you think is critical to metaview's journey.

Adam Rakestraw (Mediview) [00:54:45]:

Well, people are an obvious thing. The non obvious thing. I guess when you live immersed in it, everything seems so obvious because it's so in your face. I think on the outside looking in some things that are maybe not as obvious, the interpersonal dynamics within a team are really critical. It's not just hiring the right people, but it's the way you work together is probably one of the most critical things that I think people may not give as much thought about. Again, you made a great point about culture. The importance of that culture early, deeply seeded, lived and executed to is probably one of the things that may not be as obvious, but you have to do it land. You see that pulled out as the company grows land the number of the people that are there, the importance of that culture just multiplies. So if you haven't seeded it early on land, you can always correct and build it. But getting that direction, that vision early and then building off of it is really important. That's one of the, I think the things that is less seen but needs to be pulled through.

Jeffrey Stern [00:55:52]:

Given your background, what have you found to be the most valuable? Land transferable lessons from law to company building?

Adam Rakestraw (Mediview) [00:56:03]:

So a couple of things. I mean, the law teaches you when you go to law school, it teaches you way to think very analytically about any situation that extrapolates to. You can extrapolate that to almost every element of life. My wife will probably tell you I think too analytically even about her and my conversations sometimes. But it just teaches you to approach a decision and an action in a step by step way, be calculated, think it through. Think through what's the step going to be, what the implications are and how to do, you know, reading contracts, executing contracts, legal implications that's had huge benefits from the day we negotiated the license with Cleveland Clinic to now. When we're negotiating contracts with these parties we're working with, that legal aspect of it benefits us every day as a I mean, I don't just use it in the contractual sense or the fractional law sense. It's pulled through in how we operate as a company.

Jeffrey Stern [00:57:03]:

I like that. Any closing thoughts? Parting words before we come to our.

Adam Rakestraw (Mediview) [00:57:09]:

Traditional closing question, what I would invite people to do is experience the technology. Come see it for know, once you see it, you believe it, you understand it. It really is the future. And it's again born, growing, going to go global out of Cleveland, Ohio. And I couldn't be more humbled or proud to be in the city of Cleveland in the state of Ohio, building the technologies that we're doing, working with the people we're doing, and changing healthcare.

Jeffrey Stern [00:57:40]:

That's amazing. So we'll come to our traditional closing question here, which ties into Cleveland itself, which is for a hidden gem, something in the area that other folks may not know.

Adam Rakestraw (Mediview) [00:57:53]:

I'm being from Finley, I've been steered into just a couple of little areas because we come in, we work our butts off, and we leave. So I don't get to do the fun stuff. Ironically, on Cleveland Clinic's campus, they've got some eateries there that really make some decent food. And our team jokingly, we go in there and they make these Asian bowls on the campus and they are to die for. So you can get like a rice base or vegetable base or noodle base. And then they'll have like a Hawaiian bowl. You can get raw tuna on it. You can get Korean. They've got really some great food. Believe it or not, if you have to come to Cleveland Clinic, they have great food on campus. So I guess a plug for dietary at Cleveland Clinic is probably the most exciting thing I can come up to. Our team is we're always going to different taco places. So whether it's Barrio or some of these other ones in, really, that's one of the other nuances. And then we also always like spending time down by the river. That's kind of an area where we can get a breather and celebrate and be relaxed.

Jeffrey Stern [00:59:01]:

Well, how about a plug for in and around?

Adam Rakestraw (Mediview) [00:59:10]:

Know, I'm a big proponent of Finley, Ohio. They've got a lot of great restaurants and places downtown. One offs that you don't get anywhere else. So, like, uh, the gathering, the Bistro Finley Brewing Company, the Bourbon affair. I'm giving you all my favorite places. They've really built this wonderful downtown district. They've won awards for it's like Top Micropolitan. And there's just great food and good people. The Logan's is another one I could keep going on. There's just these little one off restaurants that are just amazing in downtown Finley. So anybody ever wants to come down and hang out, the Hancock Hotel downtown is affordable. It's great. It's brand new, and there are awesome places to eat and hang out in Finley, despite being in the middle of a bunch of cornfields, it's a great town.

Jeffrey Stern [00:59:57]:

Awesome. Well, Adam, I just want to thank you again for coming on and sharing your story. It's really cool to see what you're building at Metaverse.

Adam Rakestraw (Mediview) [01:00:07]:

Well, it's been a pleasure to be here again. If people ever want to reach out and connect land, see what we're building, we've got a website. We're in Cleveland. Come see us.

Jeffrey Stern [01:00:17]:

Awesome. Well, thank you again.

Adam Rakestraw (Mediview) [01:00:19]:

Yeah. Thank you very much.

Jeffrey Stern [01:00:22]:

That's all for this week. Thank you for listening. We'd love to hear your thoughts on today's show, so if you have any feedback, please send over an email to Jeffrey at layoftheland FM or find us on Twitter at podlayoftheland or at @sternjefe. J-E-F-E. If you or someone you know would make a good guest for our show, please reach out as well and let us know. And if you enjoy the podcast, please subscribe and leave a review on itunes or on your preferred podcast player. Your support goes a long way to help us spread the word and continue to bring the Cleveland founders and builders we love having on the show. We'll be back here next week at the same time to map more of the land.