Medical Internet of Things (IBM): Creating and Deploying Connected Medical Devices

It was a treat to feature IBM’s Kimberly Cobb at this year’s 10x Medical Device Conference.

Kim finds manufacturers who say, “We don’t want to be a medical device company any longer, we want to be a services company. We want our services to drive the demand for our devices.”

Are you among them?

PDF Click here for a copy of the slides.
PDF Click here to download the transcript.

Kimberly Cobb: Thank you Joe. First I have to say wow! Right, this has been a great conference. And I feel a little bit like Napoleon Dynamite up here, I have no skills. I don’t know Stephen Hawkings, I’m not a physician or a doctor, haven’t done tremendous research. I haven’t even thought about curing aging. Not a wonderful investor, my 401(k) seems to always be going down and not up these days.

So it has been really wonderful to be here and to hear all the speeches that we’ve had and all the wonderful topics that have been presented. And Joe put on a little brochure that I’m going to tell you everything you need to know about connecting your devices to the cloud and I’m going to do it in half an hour or less. So maybe I’m going to be superwoman after all if I can do that in half an hour.

So I’m going to try at least to give you some context and talk about the internet of things and the intersection with medical devices, and some of the really interesting things that are happening in market space today.

So first of all the Internet of Things is incredibly simple but also incredibly complex. From my experiences with talking to many many clients around the globe that are either in the Internet of Things realm or wanting to be into an Internet of Things business approach. What I’ve come to realize is that IoT or Internet of Things or connected medical devices really means very different things to different people, and it’s all based on what their goals are and what they’re trying to accomplish.

So to vastly simplify the IoT let’s think of it as like a coin with two sides. On one side it’s all about making what we call “dumb things” smart. So taking things and technologies and products that already exist today and instrumenting and digitizing them and getting information from them into the internet in order to make it more meaningful than just the to the device or thing itself.

On the flip side it’s also about taking things that are already smart instrumented, interconnected, intelligent which many medical devices already are today and combining these things together in some manner to create new and meaningful modes of interaction.

So in my sole humble opinion the IoT is really about the ability of humans, you and I, to engage and manipulate the physical world of things around us through the combination of technology such as sensors and devices and electronics and components within devices. And take that information that comes from those sensors and the devices, the data that comes from that.

And with some real-time analysis of that data, with combination of that data from other data sources, translating that into actions in order to create and deploy new and powerful experiences.

So it’s all about leveraging the human beings in the process. Some people say, “Well isn’t it sort of like AI or Artificial Intelligence?” And I really don’t believe so. I think that the power of an Internet of Things of connected devices is really going to be exciting and beneficial to humans and it’s going to inform us in ways that we’ve never thought of before in order to use our unique capabilities to drive better care, to solve some of the challenges and disease states that are out there today. So I think it’s a very interesting and compelling technology that we can bring to bear particularly in medical device and healthcare space.

And certainly the IoT is certainly disruptive as well but as I said I hope it’s disruptive in a good way. The idea of disrupting the traditional interactions with the physical world that we may have, new business models, new definitions of what a product or a medical device is, all of this can really drive incredibly personalized engagements with the physical world around us.

It can lower cost and improve performance and safety and efficacy of devices of systems or systems, and it can do so across the globe in many areas of intersections between health and care.

We actually see IoT also transforming whole other industries like manufacturing, retail, auto insurance, infrastructure oil & gas and those types of places. But certainly in devices where sensors and data can really enhance a human experience engage in value from the things around them. That’s where we see some significant impact from the IoT.

So what about you as medical device manufacturers or servicers or investors or wherever you are in the continuum, the IoT can really impact many areas of your business. So we see that it will impact how you gather and analyze customer data, so that may be patient data, that may be data from physicians, that might be curated data in medical journals, it may be free form data that you get from many other sources.

But Internet of Things is certainly going to change the way that you gather and analyze customer generated data and other data.

And it can change how you interact with your customers and your stakeholders, so it may be patients, it may be physicians, it may be your payers, provider networks etc. And it will certainly change how your products might be marketed or how they might be purchased, or how they might be reimbursed in the end result.

And we also see Internet of Things technologies changing the way individuals are developing and manufacturing their devices. And how these devices are serviced out in the field if it’s a device that can be serviced in some manner.

And 00:06:31 really have an impact on new product development so lots of companies I’m talking to today are thinking about the future. Five to 10 years from now what will my products look like? How will they be interacting with other devices? What kind of meaningful data and insights can I take from them? And how can I change the business models that I’m currently pursuing in order to really change the way my company does business?

So IoT we talked about devices and changes to devices. It’s not only about making dumb products smarter or smarter products better, we also see it allowing companies to advance the state of practice that they have in managing their assets or managing their devices or the performance of their devices.

So what if your devices could talk to you as a manufacturer? What if they could tell you that they’re complaining about something or there’s challenges with something or there’s new things that they could do? So taking event-driven information from sensors in devices and looking at the insight that that might give you could also give you avenues to preventative maintenance for devices.

And you might be able to do that on demand versus how we see it today which is usually by calendar schedules and that can be inefficient, or you might miss challenges with the product and not be able to be timely in the way that you react to issues.

So highly connected systems can be in a way a early warning system too. What’s happening with your devices when they’re being used and operated out in the field if you will. So combining that data you may be able to get some predictive insights into what the next generation of your product should do or be but also how you service them and how you fix them and how you prevent failures before it fails so to speak.

So we see Internet of Things also driving value just not in the connection and collection and use of data, but also as a critical component in managing assets, the products that are out there into the field. In some cases it might be not applicable if it’s a disposable product or something simple that’s replaceable, but many cases we also see medical devices that are huge, very expensive, costly to repair. And there’s a lot of data that could be taken from them and be predictive in the way that they go out and service these devices across the world. So two ways to think about the IoT as well.

So this underlining chart here is from Frost & Sullivan. So when I don’t know of something I just borrow it from the smart people who do. So I borrowed the slide from them and I’m going to add two highlights here. And the reason for this is that I think in their study when they looked at the forces that are changing healthcare today as we know it and what’s going to be, healthcare is going to look like in the future, a lot of these trends really intersect with Internet of Things and connected and smart devices.

So one thing they’re talking about is the movement of information flow. More towards consumers that’s an opportunity for integrated systems and information from these systems. Move towards more of a patient-centric-based approach to care. And that’s an opportunity for what we see in wearables, analytics, mobile medical apps, provider services, personalized care. So can you take your medical devices, extracting data, and personalize information to the consumers and to the caregivers?

In a move to more of a decentralized community care, community-based care, home-based care. So we heard that in a couple of presentations today. So that’s an opportunity for taking your devices into smaller settings, home-based settings and instrumenting them so that they consumers themselves, the patients are asking for your devices and enjoying the use of your devices. And are able to do a lot more home healthcare, home diagnostics. And all that is going to be made possible through Internet of Things technologies.

And there’s also the move towards more collaborative care so less episodic care. You have a fever I’ll treat that with some aspirin, go home. Next thing you know you have a much larger challenge with your healthcare. So collaborating on your care on the whole person care that’s an opportunity for leveraging a lot of data analytics.

So if you have multiple devices that you work with or devices that you might interact with or even simple wearables that a consumer may have like their Fitbit or anything like that. If you can consume that data and leverage data, and move more towards care of that individual, whole care of that individual, that’s where we think we see a rise in connectedness in Internet of Things in order to gain that data to realize insights off of that data in customized care.

So all of these transitions that we are seeing in the healthcare market space, and this happening primarily in the US because of “Obamacare” right, the changes in the care and changes in reimbursement, but this is also across the globe. This trend more towards consumer base, towards information, towards preemptive care. And all of these transitions mean that medical devices and medical systems must become more interconnected and more personalized.

So the devices in the past that have been standalone, one size fits most not all, now really have to have communication capabilities. They have to have personalization capabilities. Quality outcomes have to be considered versus episodic care. So indicators of what’s happening within devices and the data you’re getting from them. You have to change the way you’re thinking about that data.

And so in turn this will mean that the Internet of Things and connected devices can provide opportunities for more cognitive analytics to be placed into patient care. And certainly opportunity from medical devices manufacturers to grab hold of new markets and interesting ways to market and sell devices.

So again another slide that I took from Frost & Sullivan, and they’re looking at the shifts in spending in healthcare so not just how healthcare is changing over time, but into the future how they think they see that swing in spending and reimbursement.

So let’s look a little bit further at the trends in spending to the left there, where a couple of things are highlighted. We see in their studies and I think this is representative of multiple studies. A swing towards spend and reimbursement in monitoring, in prevention, and in better diagnosis. So again a move towards connected care versus episodic treatment of single events. And this is where the money is spent in the healthcare industry but also how reimbursement is starting to change in order to reimburse for these types of things.

And at the same time as we see spend analysis and reimbursement analysis changing and the models changing over time, we see trends expand in the device fields. So miniaturization, sensorization, change in chips and devices, it’s become, all these things are becoming much more cheaper, easier to use, smaller, capable to be embedded in and on and around devices. And all of that is generating data, potential to generate data.

So more data is available from everything, from the basic things like fitness monitors and wearables right down to unique dedicated medical devices for certain capabilities. And this is really enabling devices to capitalize on some of these trends. These trends towards monitoring, towards prevention, towards earlier diagnosis. And the increase in spending on diagnosis comes about because of the increased amount of data available so it’s sort of a Catch 22, one thing is driving the other.

So with more data better diagnoses can be made providing the analytics that we can take from that data are applied and applied well. So again here is an opportunity for IoT and cognitive analytics technology to really change the way medical devices are designed, delivered and presented to market.

And if we look at the increase in spending on monitoring it’s again driven by the increase in available data so again same thing. More data more ability to do monitoring and better diagnoses can be the result of that. So with smart connected devices data can be monitored continuously in many ways. Not just oh I go into my provider’s office and, you know, they check a couple of things and I might do that once a year, once a month, if I’m having issues quarterly whatever it is.

You’re getting these slices of data and they’re not continuous and they’re not in some cases helpful in ways to really predict what might be happening with you as an individual as you interact with devices.

Or you go into a hospital setting you’re hooked up to 500 devices and you’re getting the slices of when you were there for care, what happens when you go home or go into another care environment? How do they make that connection between what has happened to you and the monitoring that occurred?

So we’re thinking and seeing that with Internet of Things and with data readily accessible and combinable there’s going to be some real changes in the way that people look at monitoring of your health. So it was very interesting when Dr. Lowe made his presentation and he asked how many people in the room had had their blood pressure monitored within the last year.

And almost everybody raised their hand. And he said how many people have had their brain monitored in the last year, and unfortunately for whatever reason I think one person raised their hand and I hope that they’re fine and they got the care that they needed and there’s a good reason for that.

But it made me think, yeah I don’t do regularly monitoring of all the things that I could do that might be indicators of what might be challenges in my future health. They could be predicted, and they could be changed, and my providers could be much more proactive with me.

So it’s very interesting to see the trends in spending and I think a lot of that is driven by the ability to access data and use data, and have data be mobile with patients as well.

And the report doesn’t really call out prevention, but again this is driven by extended monitoring and the capabilities that are involved there with healthy people as I mentioned. So there’s a lot of trending not just creating devices to treat a specific disease state or a specific medical issue but also devices that could be monitoring and contributing to greater health.

And that’s also a reimbursement opportunity for many medical device manufacturers. Changing from a device concept to more of a continuum-of-care concept. So can I leverage my device to be something that’s sort of constantly usable in a patient’s lifetime? So interesting stuff here, right?

So let me kind of go back a little bit about IoT. A lot of people say, “Is it real? Is it hype? I hear about it, I read it about, what exactly is it?” The question itself is interesting because there is a lot of hype in the marketplace. Seems like I go places and everybody is like, “Yeah I want to talk about IoT,” and then they don’t know what they’re going to do with it, or what it is, or what business value, or what ROI might come from it.

So the question is very interesting, but there is hard evidence from organizations spinning all different industries that clearly illustrate that there’s benefits and that there’s differentiation possible and there’s improved client or patient experiences possible, all enabled by an Internet of Things type of technology.

So IBM loves to do research, they do it all the time. So they go out and they ask lots of questions across all industries. So this is one study that I didn’t steal from somebody else, I just stole it from the smart people at IBM that did some research for us. And some of the surveys that they came out with let’s look at some of the top three fundamental ways that the Internet of Things is changing industries today.

And responses across industries kind of came to these top three things. And when we talk to customers that are implementing IoT strategies or wanting to, this is what they said. So the first thing is unlocking new revenue. So from existing products and services, connected products new products. So the idea is we can leverage Internet of Things to unlock new revenue; very important.

It’s going to create new practices and new processes for me as a manufacturer, as a designer. And it can vastly change my business model if I decide to do so. So one major medical manufacturer who I won’t name recently told me that, “I don’t want to be a device company anymore,” and you could have blown me over with a feather because that’s what they do and that’s what they’re good at.

They said, “We don’t want to be a medical device company any longer, we want to be a services company. We want our services to drive the demand for our devices.” So that was where I said, “Okay, now I know I’m still talking to the right people in the room not so scared.”

But they were looking at ways that they can deliver benefits from the data from their devices so how can I do things direct to consumers? How can I impact caregivers? How can I change providers’ mindset about who I am and what I do and what my products are? And ultimately can I impact reimbursement model so I can get paid more for the devices that I’m putting out to the marketplace?

So it was really interesting and they’re really on board with, “This is going to change my business model. I’m going to have services and capabilities attached to my devices that are going to really drive a change in the way I interact with the users of the devices and the consumers of my devices.

And a couple of statistics down there, in the interest of time I won’t read through all of them, but one of the most interesting statistics from the survey responses were that 62% of those that were interviewed believed that organizations that are slow to adopt IoT technologies will fall far behind their competition. So that’s a pretty good number. That’s people who are saying, “This is really going to change my industry and I have to pay attention to it so.”

So let’s talk more about devices, right, I’m in a medical device conference so let’s talk about it. Joe said, “Why is IBM here?” Right, so this is why we’re here. We see that the devices of tomorrow will look and feel very different from devices that came into existence just two to three years ago. So today’s products are more connected than was ever really thought possible or considered possible. As much as just a few years ago, right.

So products now can connect to the internet, can send data, they can connect to each other, they can connect to interconnected subsystems. You have to think about network connections and all these things. So what this means to individuals who are developing medical devices they have to consider interconnected systems, they have to consider interfaces, they have to design with connectivity in mind. And they have to think about the emerging technologies and behaviors that might be possible just a few years into the future leveraging Internet of Things.

So devices now have to be designed with data generation in mind, they have to be designed with connectivity in mind, they have to exist as part of larger ecosystems in many cases. Devices have to deployed against various different sets of platforms and protocols and APIs. And software is now no longer just something that might be embedded into the device. So this is where we see a lot of interesting things happening too. There may be companion devices with software, there may be mobile apps.

And I don’t know about you but most embedded software developers that I know are really not good at creating apps that they publish onto the app store and update on a regular basis. So it’s a whole different world. And if consumers get your apps that you may have created as a companion to your devices and they don’t like it, they’re going to rate it and they’re going to talk about it.

It’s an immediate feedback from your end users so there’s also that concept of, “I have to think about how the patients are going to be interacting with my device, the data from my device. And also how I’m giving them access to the device.”

And it’s not just the patients it’s the physicians as well. If device A gives me a whole lot better interface to the information flow from it across one patient or across all the patients in my practice will the same thing in a hospital provider, I might choose device A versus device B that doesn’t give me that kind of data.

So there’s this thought of, “I really need to change the way I think about my products and my systems and my software.” So for devices within the IoT obviously complexity rises but so does the ability to be disruptive and innovative in the space.

So how does one be successful in Internet of Things and connective medical devices? So you really need to think about delivering not a product, you are no longer a device manufacturer or a device designer, or a deliverable of devices. It’s not a product anymore, it’s an experience. An experience that various stakeholders are going to have with your devices.

So you really need to think about planning your device for instrumentation, for connection, for data use in mind, but you also need to think about the device benefits and how those will be delivered. So sensors, software, applications, human interaction, a device is no longer a standalone sort of black box.

Quite some time ago devices the important thing were really the hardware components, the electrical components, how those work together, maybe some software in there. Whole new world now. It’s not a standalone black box, there’s data access from a multiplicity of devices that might be connected. There may be mobile applications to be delivered and updated into all those various stakeholders I mentioned before.

And most importantly you have to really think about added value streams to your devices. So can I leverage data? Can I do meaningful analytics of that data and create an experience with my device? So a whole new sort of digital experience with devices now.

So the key is to deliver to all of the various stakeholders that you think of something that’s beyond just the physical in a whole new digital revolution of where your devices are going to fit and how they’re going to play and what marketplace you want to be in. So it’s really you need to think about moving beyond the physical nature of the product and all of the other ecosystem that’s going to surround it or that could surround it if you enter into that connected device market space.

So I mentioned a number of times data, and sometimes one of my colleagues sits in the back of the room counts up how many times I say data or Big Data and penalizes me because I keep talking about data. And everybody says, “Well isn’t it really about putting sensors and making my devices smarter and maybe I connect them to something?”

But it really that’s part of it, sure you have to design your devices to do that, but one of the key components of driving value or ROI from connected devices or the Internet of Things is really the data that you get. You get it from your device, you get it from other resources. And you combine that data with your device and that’s where you derive value from the Internet of Things.

So it’s really about being connected is not enough, having the data in the cloud somewhere not enough, not going to be a differentiation for you. Having a companion app, maybe it’s a bedside monitor that connects through Bluetooth and grabs that data, so that’s cool — not enough. If I have a really fantastic mobile app, still not enough. And that’s what a lot of people think about when they think about connected devices and Internet of Things is all of those components that go into that.

But it’s really about taking analytics against that data and driving yourself as a business up the analytics value chain. So you want to be able to move from the descriptive, which is on the left-hand side. What just happened? Blood pressure is high, glucose level is low, infusion pump X is infusing medicine Y, alarm is sounding, wave form is in this range or that range. Those are just, those are descriptive. That’s what is happening right now with a devices.

Meaningful data one point of data. Really what’s it’s about is moving from descriptive, what just happened to more predictive, and I hate to use this word in medical device areas but prescriptive. Only your physicians are really going to prescribe what you should do, but the data could really tell you inform you or inform the physicians what they should be thinking about and what they should be doing.

So this is really done through what we call ‘Cognitive Insights’ within IBM. So if you look at all of our commercials it’s all about cognitive, it’s all about a new level of interacting with data. So given all that we know from the data both real-time, trending over time, historical databases, consolidated data from perhaps other sources, data from connected systems, known disease states, successful care paths, let’s combine these known interactions with the devices etc.

And can we now more intelligently provide insights in order to more confidently inform the best recommended courses of action. So can we customize these insights for our patients, for the caregivers, for the physicians, for the clinics, for the hospitals, maybe for the payers so you get reimbursed well for our device.

So you really need to think about moving from just saying, “Okay I’m in the Internet of Things, I got a device, I connected it up, I got some data in the cloud.” It’s really all about, “Can I make that meaningful and can I move that into a business model that gives me some ROI?” Improves my device with this kind of insight is better than the competitor’s device with no insight. So that’s where we see some real shifts in what it means.

So let me move on a little bit to we were talking about IoT as a prominent market force, and how it’s influencing not just the nature of modern products and systems but I see it also influencing the way that manufacturers are designing and developing their systems. So more than ever clients and consumers we’re looking for products that are tailored to specific needs and customized and giving me these updates and this data all at the right time in order to make the right decisions.

So in a way we’re really looking at an industrial revolution moving from mass production of devices to more mass customization of devices. In many cases the devices will still be much the same but how we interact and work with the data is going to be vastly different. And we talked about how competitive advantage might be found in taking that data and doing a more personalized approach or user experience.

But we see the trend also in interconnected products and smart products machine and machine communication driving changes in research and development in the way you see people are designing their products. So designing and developing for the IoT really requires a shift in development focus. So I sort of made the joke nobody laughed about embedded software engineers not understanding how to put an app on Apple iStore but they really don’t. So you really have to think about how are we developing this product as a whole and what kind of capabilities do I need from a development process?

And shifting my development focus from the physical which is a focus on the hardware and the mechanics and the electrical engineering to more of an integrated product. And software and systems are going to play a much deeper role I think when we see that.

And so it’s also important to know that you can’t just develop a mobile app or like I said throw a device into, device data onto a cloud and claim you’ve got a strategy. You really need to think about how you’re designing that devices, and specifically in medical device it has to be done so that your whole system now is safe, it can be compliant if it has to be, it has effectiveness that I can prove.

So I cringe when I see somebody just develop something and say, “Okay I’m going to put my app out on the App store and it’s going to be fantastic and I’m going to make a really big change here.”

But I never wrote down the requirements, and I never did risk analysis, and I never really thought traceability or VNV 00:34:49 or systems tracking. Or what am I going to do when there’s issues with my app? Is that CAPA is that not CAPA? How do I deal with that?

So we talk a lot in IBM about something called ‘Continuous Engineering’ which is taking into account the whole system, and tracking and tracing all of that information. So people think it’s my quality management system, the tools that kind of support the quality management system. When you’re designing for IoT you can’t just throw all that out the window, it still has to come into play.

FDA is doing a lot or regulation around mobile medical apps and they’re trying to get their head around what this means and how they’re going to regulate it. It seems to change every day, so my advice too is thinking about value and thinking about changes in development process, but also think about maybe now is the time to mature my development cycle.

Ensure that I can prove that I said what I was going to do, I did it, I have traceability, I have proof, I can generate the documentation that’s necessary. If I have to go through some compliance steps for creating my device and connecting it and using that data across the Internet of Things.

So don’t throw all that out, baby out with the bath water, you still have to think about this. So combine those two things as you’re thinking about ways to change your business.

And so another thing about sort of traceability, I talked about traceability and design of the devices themselves, but this type of ecosystem also puts new demands placed on teams to think about the operation of the device once it’s out into the field, to utilize them to the best benefit. So we’re looking at also how can we take information that’s coming in through the data from user reports, from feedback, linking that into engineering data.

And more importantly can I change the outcomes of my product so we have to look at everything across the development process, ensure you’re doing the right things following the right processes and leverage IoT and this data to inform and improve your R&D and your product roadmaps.

So connect all of the sources, don’t just think about, “Connecting my device to the cloud and getting some data,” think about, “Can I take that information that might be coming and use that to better my next derivation of products? And can I inform my roadmaps based off of the data that I’m getting?”

So a lot of customers I talk to don’t really think about the whole process and how one thing should be feeding the next. So I think that’s also important to consider. Connect and use all the information you can, is what I’m saying.

So to be successful in IoT type of world, a couple of things also to consider from sort of a technology standpoint. 00:38:00 discuss this briefly. So you really need to think about how will securely connect and manage devices whether that’d be through gateways or across networks, cellular networks or BLE networks.

You must think about your data, so data that you’re generating, data from other sources. Data can be structured and unstructured in many cases. You have to think about ways that you’re going to parse, translate, store, annotate, and use that data to your advantage. So when you’re looking to move into the Internet of Things world think about those.

You must also have an analytics strategy. So what actional outcomes do you want/need from your data? And you do need to manage risk, so you need to think about anomaly detection of data that’s coming through these networks. Some customers are looking at Edge analystics, “Can I filter and source some things at the far edge of the devices giving me data versus way up into the cloud?”

You need to think about key certificate types of protection as devices connect and data is being streamed. So not only do you need to exercise good engineering practices that I just spoke about in the previous slide with tools and process, but you also need to think about is the IoT platform and capabilities that you put into place. Does it have the rigor to be secure for what you need to accomplish, particularly important in the medical device field.

Am I getting the hook over there Joe?

Joe Hage: Not quite actually no-

Kimberly Cobb: How am I doing on time?

Joe Hage: We’re getting close. When a medical device company is ready to take the leap, they recognize they need to be in the space, do they call you first or do they call their design and development firm that’s deeply embedded in medical device VNV, FDA etc.? How does that partnership work?

Kimberly Cobb: Yeah, that’s a good question. Many of them call us directly and they may already have, if they’re a larger company they already have a lot of the expertise in FDA and getting products through but they don’t have expertise in Internet of Things and connecting the devices, or necessarily a lot of the data analytics. And I didn’t even get a chance to cover some of the really cool things we’re doing with data analytics like text-to-speech, speech-to-text, natural language processing you name it.

In smaller instances we’re looking at partnership with some medical device design and manufacturers so that they can help people that don’t have huge resources go through the design process. And they’re leveraging the IBM technology and making it consumable for smaller medical device manufacturers. So it’s a little bit of both.

And we have physicians, doctors, ex-FDA people all working within IBM so we have a huge healthcare division. Sometimes people don’t even know that. So we have a lot of expertise that we can bring to bear to advice and help clients as well that want to enter into this. It’s not all just technology.

Joe Hage: I see a future of many opportunities to share your knowledge with the Medical Devices Group.

Kimberly Cobb: Thank you.

Joe Hage: Kimberly Cobb, IBM.

(Applause)