The Twitch co-founder is betting big on the blockchain that’s challenging Ethereum for his NFT gaming marketplace.
Kan thinks Solana is a better option for NFT-based gaming, where players often need multiple NFTs for a game and conduct many transactions in the course of ordinary play.
Solana is trying to break out into the mainstream. It needs a killer app. Could NFT gaming make it happen?
Justin Kan, who co-founded game-streaming startup Twitch and sold it to Amazon for $970 million, could help. He now runs Fractal, a curated NFT gaming marketplace for gamers to buy and sell items for these games. He’s betting on Solana, an up-and-coming blockchain protocol that claims faster transactions and lower costs than Ethereum.
In NFT-based gaming, players often need multiple NFTs for a game and conduct many transactions in the course of ordinary play, so Solana is a better option, Kan said.
Getting more users is a challenge for Solana as it seeks to take on larger blockchains. Solana has been touted for its fast transaction speed, which has drawn investment firms such as Jump Capital into building projects like Pyth. But it has also faced challenges with usability and downtime. Gaming is a consumer-friendly application that could help.
If NFT gaming on an upstart blockchain sounds wild, Kan is known for taking a zany idea and turning it into a big business. In 2007, he co-founded Y Combinator startup Justin.tv, his self-named livestreaming site, which eventually turned into Twitch.
Despite the issues with bridges and other obstacles, it’s gotten easier for consumers to use Solana through tools like the Phantom wallet, Kan said.
Fractal, which launched in late December and has raised $35 million in seed funding led by Paradigm and Multicoin Capital, vets the games and then partners with games that agree to have their NFTs trade on Fractal by marketing games to gamers, through its Discord (100,000 members), Twitter, podcasts and giveaways. Fractal takes a 2% transaction fee on secondary sales on its marketplace. Fractal’s CEO is David Wurtz, who Kan knew because they were both early Y Combinator participants, and is credited as a co-creator of Google Drive.
The game developers are a mix of crypto-natives trying to figure out gaming and gaming industry people with startups, as well as some existing larger gaming companies jumping into crypto. One game, Tiny Colony, raised $2 million from its NFT sale in less than 24 hours. Another game, Cinder, is made by gaming veterans who made Animal Jam and also sold its NFTs. “It’s kind of a race of: Will crypto-native people figure out how to make games first or will game people figure out how to do crypto first?” Kan said.
Kan envisions gaming as just one of a broader set of vertical markets for NFTs across a range of sectors, such as music, tickets, events. “NFTs are now digital items across not just gaming,” he said. “People are doing events and ticketing, membership clubs, obviously, digital art, music and eventually the space will evolve where OpenSea’s like eBay, but eventually they’re all these different stores.”
But will gamers move to NFT-based games? Kan believes that just as free-to-play games were dismissed at first then took over, NFT-based games will be the future of gaming, because users will feel more confident investing their time and money in a game than in other types of games.
“If you buy a bunch of skins in a [traditional] game, then the game goes away or you stop playing or get bored, you lose all that money in your investment,” he said. “Whereas if it’s a game where you know you’re gonna own this thing, and you can sell it over time, you can borrow against it. Maybe you can use them in different experiences. That’s something that gives you more confidence to invest in that game.”
Fractal is working on a kind of digital passport or wallet that users could take with them to show their in-game achievements across various games.
While he believes in NFT games, Kan is not a fan of play-to-earn games in which users play games just to make income. “More and more games are pivoting away from that to where it’s more about a fun experience and then incidentally, you might get something of value inside the game,” he said. “Because otherwise it requires this continual flow of new capital, of people coming in and putting capital in to play the game and usually that happens when there’s higher speculation of assets.”
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Tomio Geron ( @tomiogeron) is a San Francisco-based reporter covering fintech. He was previously a reporter and editor at The Wall Street Journal, covering venture capital and startups. Before that, he worked as a staff writer at Forbes, covering social media and venture capital, and also edited the Midas List of top tech investors. He has also worked at newspapers covering crime, courts, health and other topics. He can be reached at [email protected] or [email protected].
These eight people are tasked with making some of the biggest tech companies on Earth more sustainable. How successful they are depends on factors outside of their control.
In some cases, CSOs have real power to bring companies in line with their climate ambitions. But in others, they are window dressing.
Michelle Ma (@himichellema) is a reporter at Protocol, where she writes about management, leadership and workplace issues in tech. Previously, she was a news editor of live journalism and special coverage for The Wall Street Journal. Prior to that, she worked as a staff writer at Wirecutter. She can be reached at [email protected].
Chief sustainability officers are all the rage. Tech companies are hiring them left and right and holding them up as the human talismans of their commitment to fighting climate change, one (sometimes dubious) net zero goal at a time.
In some cases, CSOs have real power to bring companies in line with their climate ambitions. But in others, they are window dressing. To get at where CSOs are able to exact real change, we looked at eight major tech companies’ reporting structures and whether or not executive compensation is tied to meeting sustainability goals.
Giving a CSO a direct line to the CEO not only empowers them to actually make real changes to the way a business operates, it also sends a clear signal to the rest of the company that sustainability is a central part of the business plan and not an afterthought. According to a survey of CSOs by Deloitte and the Institute of International Finance, 32% report directly to the CEO, and 13% report to the head of marketing.
“If you’re reporting to the head of marketing and you’re trying to influence someone in risk, you’re pushing a boulder uphill. They’re going to perceive what you do as a marketing campaign, when really you’re aiming for strategic transformation,” one of the surveyed CSOs told Deloitte.
In Tim Mohin’s view, the role of the CSO is “changing rapidly.” In the past, corporate sustainability used to be much more of a marketing issue, and now it sits more in the financial risk and business strategy side of things, according to Mohin, the CSO at carbon management startup Persefoni who has literally written the book on corporate sustainability. For a company to have a true commitment to sustainability, its CSO needs to understand how the business operates from a corporate risk and finance perspective, so that they can have the authority and credibility to make real change. Mohin believes it’s better for a CSO to start off with a solid background in business or product area expertise, then build in the ESG knowledge rather than working the other way around.
Kentaro Kawamori, Persefoni’s CEO, agrees with his CSO’s assessment. Questions to ask of companies to really ascertain the strength of their commitments include whether or not they’re linking executive pay to decarbonization, if they’re hiring people with the right sustainability credentials or if, in Kawamori’s words, they’re “just putting a PR person into the job.”
Here are the chief sustainability officers at some of the biggest tech companies we’re watching here at Protocol.
Who: Kate Brandt, chief sustainability officer
Background and responsibilities: Brandt leads sustainability across Google’s worldwide operations, products and supply chain. According to a Google blog post, that means she coordinates with data centers, real estate and product teams “to ensure the company capitalizes on opportunities to strategically advance sustainability.” Before starting at Google in 2015, she was appointed by former President Barack Obama as the Federal Environmental Executive and was the U.S.’s first Federal Chief Sustainability Officer, responsible for promoting sustainability across the federal government.
Reporting structure: Brandt reports to Ellen West, Google’s vice president of Engagement within the office of the CFO, who in turn reports to CFO Ruth Porat. Brandt also reports in a dotted line to Urs Hölzle, Google’s senior vice president for Technical Infrastructure.
Compensation: Google announced in a public disclosure that it is introducing a bonus program for members of its senior executive team that will be determined in part by performance supporting the company’s ESG goals beginning this year.
Who: Lucas Joppa, chief environmental officer
Background and responsibilities: Joppa leads the development and execution of Microsoft’s sustainability strategy across its worldwide business. He has a Ph.D. in ecology and is a highly cited researcher. (He has an h-index of 45 for those of you academic nerds keeping count.) Before this position, he was Microsoft’s first chief environmental scientist, founding the AI for Earth program.
Reporting structure: Joppa reports to Brad Smith, president and vice chair of Microsoft.
Compensation: Microsoft announced in 2021 that progress on sustainability goals is part of executive compensation. This is adding onto the practice the company’s had since 2016 to tie a portion of executive pay to ESG measures, starting with diversity representation gains. This applies to members of the senior leadership team, including CEO Satya Nadella.
Who: Edward Palmieri, director of Global Sustainability
Background and responsibilities: Palmieri leads Meta’s global sustainability team of more than 30 professionals, who are responsible for developing and executing the company’s strategy on environmental and responsible supply chain issues, according to his LinkedIn. Prior to this role, he was Meta’s associate general counsel focused on privacy issues. Prior to that, he was the deputy chief privacy officer at Sprint.
Reporting structure: Palmieri reports to Rachel Peterson, Meta’s vice president of Infrastructure.
Compensation: Executive compensation at Meta is not tied to sustainability goals, according to a Meta spokesperson.
Who: Kara Hurst, vice president and head of Worldwide Sustainability
Background and responsibilities: Hurst is responsible for executing the work of the Climate Pledge, sustainable operations and responsible supply chain management, among other things. Prior to Amazon, she was the CEO of the Sustainability Consortium, a nonprofit focused on making the consumer goods industry more sustainable. Before that, she was a vice president at BSR, a sustainable consulting firm.
Reporting structure: Hurst reports to Alicia Boler Davis, Amazon’s senior vice president of global customer fulfillment.
Compensation: Amazon does not explicitly link senior executive compensation to sustainability goals. In a 2021 proxy statement, the company explained that it does not tie cash or equity compensation to performance goals, stating, “A performance goal assumes some level of success by a prescribed measure. But to have a culture that relentlessly pursues invention and is focused on building shareholder value, not just for the current year, but five, ten, or even twenty years from now, we must encourage experimentation and long-term thinking, which, by definition, means we do not know in advance what will work. We do not want employees to focus solely on short-term returns at the expense of long-term growth and innovation.” That doesn’t mean that shareholders haven’t tried to make the company tie compensation to climate targets. They just haven’t been successful.
Who: Emma Stewart, sustainability officer
Background and responsibilities: Stewart, who holds a Ph.D. in Environmental Science and Management, is Netflix’s first sustainability officer and is responsible for the company’s climate and environmental strategy and execution. She oversees decarbonization efforts across Netflix’s corporate and film and TV production operations, the latter which account for the majority of the company’s direct emissions. Content and its data centers account for 55% of the company’s carbon footprint, while corporate emissions stand at 45%, according to its 2020 ESG report. (Other parts of Netflix’s Scope 3 emissions tied to energy used by its viewers dwarf these other sources.) Prior to Netflix, Stewart led World Resources Institute’s work on urban efficiency, climate and finance.
Reporting structure: Stewart reports to Netflix’s CFO Spencer Neumann.
Compensation: Stewart’s compensation is not tied to sustainability goals, according to a spokesperson, and executive pay at Netflix in general is designed to attract and retain “outstanding performers,” according to a company proxy statement.
Who: Lisa Jackson, vice president of Environment, Policy and Social Initiatives
Background and responsibilities: Jackson oversees the company’s efforts to minimize its impact on the environment “through renewable energy and energy efficiency, using greener materials, and inventing new ways to conserve precious resources,” according to Apple. She also leads its $100 million Racial Equity and Justice initiative and is responsible for Apple’s education policy programs, product accessibility work and worldwide government affairs. Prior to Apple, she was the administrator of the Environmental Protection Agency.
Reporting structure: Jackson reports to Apple CEO Tim Cook.
Compensation: Apple’s 2021 proxy statement confirmed that annual bonus payments for execs will increase or decrease by up to 10% depending on whether they meet so-called “Apple Values.” One of those values is a commitment to environmental protection.
Who: Suzanne DiBianca, chief impact officer and executive vice president of Corporate Relations
Background and responsibilities: DiBianca leads Salesforce’s “stakeholder capitalism strategy,” which includes the company’s sustainability efforts, ESG strategy and reporting. She’s been at Salesforce for more than 20 years and was previously the co-founder and president of the Salesforce Foundation and Salesforce.org, which provides free or discounted licenses to Salesforce software for nonprofits, educational institutions and philanthropies.
Reporting structure: DiBianca reports to Salesforce co-CEO Marc Benioff.
Compensation: Salesforce recently announced that a portion of executive variable pay for executive vice presidents and above will be determined by four ESG measures, which for this fiscal year will focus on equality and sustainability. The sustainability measures are tied to reducing air travel emissions, as well as increasing spend with suppliers that have signed the company’s Sustainability Exhibit, a procurement contract that aims to reduce its suppliers’ carbon emissions and align them with the 1.5-degree-Celsius target.
Who: Todd Brady, vice president of Global Public Affairs and chief sustainability officer
Background and responsibilities: The company created the CSO role within the past year. Brady sits within the manufacturing and supply chain organization of Intel. He’s an Intel lifer and has held a variety of leadership roles at the company, including environmental health and safety and product ecology and stewardship, as well as public affairs.
Reporting structure: Brady reports to Keyvan Esfarjani, the Executive Vice President and Chief Global Operations Officer at Intel.
Michelle Ma (@himichellema) is a reporter at Protocol, where she writes about management, leadership and workplace issues in tech. Previously, she was a news editor of live journalism and special coverage for The Wall Street Journal. Prior to that, she worked as a staff writer at Wirecutter. She can be reached at [email protected].
The world of work is undergoing a revolution – but workplace communication tools help businesses adapt.
Chris Stokel-Walker is a freelance technology and culture journalist and author of «YouTubers: How YouTube Shook Up TV and Created a New Generation of Stars.» His work has been published in The New York Times, The Guardian and Wired.
This is part one of a three-part series exploring the experience of frontline workers and new workplace tools being deployed to support them.
The last two years have seen deep, significant changes to the world of work. The COVID-19 pandemic has shifted business leaders’ focus from maintaining their bottom line to the front line. Employee experience has become more important than ever to keep good workers happy – and to keep them within a business.
Frontline workers have borne some of the heaviest burdens during the course of the pandemic, asked to work in person while many others work from home. They’ve kept our economy running, grocery stores stocked, and water and power pumping to our homes. Yet that’s come at a price. Frontline workers are leaving the workforce in increasing numbers – testament to the stresses and strains they’ve faced in recent years.
“Expectations of what people are looking for within their workplace has changed,” says Abby Guthkelch, Head of Global Executive Solutions at Workplace from Meta. “People have had a lot of time to reflect during the pandemic about their situations. They want to get more out of work.”
Seven in 10 frontline workers have suffered burnout because of the burden that’s been placed on them during the pandemic — or feel at risk of burning out. Nearly half of those surveyed by Workplace said the stress was so bad they’d have switched jobs by 2022. In the United States, 2.9% of the workforce resigned from their jobs in what was called ‘the Great Resignation’, says Guthkelch. And two-thirds of executives expect high rates of employee attrition — or are waiting for the wave of resignations to wash over them.
It’s all a mortal threat to the future of work and to plenty of big businesses that have seen too many people walking out the door in the last two years. But there is a way to support and empower frontline workers while improving collaboration with colleagues. It’s asynchronous communication, keeping people in the loop in a non-intrusive way — the kind of contact enabled by Workplace from Meta, the tech giant’s workplace communications platform.
“What asynchronous communication and products actually allow you to do is actually get frontline employees up to speed on information at a time that works for them on a device that works for them,” says Guthkelch. Investing in a quality communications platform pays dividends in the long run, she adds. “If you start with your people, investing in your people, they will, in return, turn up to work. They will perform better, which will in turn enable customer success and customer experiences, which will in turn drive business growth. And that really comes from communication.”
Businesses big and small are using tools like Workplace from Meta to try and foster those closer connections with employees that stop the rot and revolutionize the way workers can communicate while on the frontline. Millions of employees at businesses around the world were not able to work at all during the COVID-19 crisis. They were furloughed and sent home for a year and a half. But bosses bringing back their workers are utilizing workplace tools to reorient employees who haven’t been working for prolonged periods.
Businesses are placing more priority on ensuring there are clear lines of communication for frontline workers to raise issues — something that’s vital given 43% of employees told McKinsey one of their fears about remote work was a reduction in collaboration with colleagues.
Such consistent, constant communication acts as a pulse check for the health of an organization, enabling bosses to step in and fix issues before they fester and grow. It’s also a real-time pressure valve for frontline workers — who are often placed in the most stressful customer-facing situations — to let off steam, raising issues and feeding back opportunities for improvements in operational efficiency as they see them. Beyond that, asynchronous communication platforms allow employees to feel more valued and part of a community. Rather than being left out on a limb to face the general public, constant communication means people feel like they’re a member of a bigger team pulling in the same direction — giving workers a sense of purpose they so desperately crave in uncertain times. In a survey of workers by Workplace, 57% of frontline workers felt their ability to keep in touch with colleagues through communication tools helps improve their mental health.
For businesses looking to face 2022 on the front foot, rather than reacting to a wave of disquiet, it’s vital to take steps now to improve workplace tech to enable happier, healthier, more efficient workers.
Forward-thinking firms are putting their money where their mouth is, supporting workers and enabling them to feel empowered about the future direction of the company — shaping its future from the front line. They’re doing so by taking steps to drastically improve frontline teams’ experience, reviewing internal communications strategy, processes and the accompanying tech stack and addressing the importance of mental health and factors that can contribute to burnout.
Read the series:
Chris Stokel-Walker is a freelance technology and culture journalist and author of «YouTubers: How YouTube Shook Up TV and Created a New Generation of Stars.» His work has been published in The New York Times, The Guardian and Wired.
It’s never been this hard — or expensive — to hire, and executive search firms are loving it.
Much of recruiting can now be done without long car or plane trips to meet clients and candidates.
It’s a tough time to hire — but it’s never been a better time to be a recruiter.
With record levels of investment and M&A activity in the tech industry, fast-growing tech companies can’t hire executives fast enough. That means recruiting firms are juggling more searches than ever, and companies have to wait in line to even start a search.
“It’s really unlike anything I’ve seen in the last 20 years,” said Mike Foley, regional managing partner of Heidrick & Struggles’ Technology and Services practice in the Americas. “It’s definitely booming.”
Another placement firm, Daversa Partners, performed over 750 searches last year, partner Frank Cumella estimated. The firm hired 90 staff members of its own over the same period to pick up the slack, but “it wasn’t enough to support the demand and market,” said Cumella, who recruits executives for enterprise software and consumer internet companies.
Not even the switch to remote work in the past two years, which allowed recruiting firms to pack in more meetings in less time, has helped with the backlog of searches. Much of recruiting can now be done without long car or plane trips to meet clients and candidates.
That’s a big change from before the pandemic. Foley is based in Boston, but before 2020 he spent almost 70% of his time on the road. Kelly Kinnard, Khosla Ventures’ head of Talent, said that when she was a recruiter a decade ago, she would drive to meet every candidate: “Look them in the eye, assess their gravitas, get a sense of who they are.”
Some of the nuance is lost over Zoom, Kinnard said, “but busy executives are busy, and recruiters are now able to get away with doing eight Zoom calls a day instead of driving to Mountain View, and then Cupertino, and then Sunnyvale.”
Foley said that while recruiting remotely, it’s been harder to accurately gauge a candidate’s level of interest in a new role. More executives are willing to hop on a call than meet for an in-person lunch, after all.
Travel and in-person meetings are starting to come back: Both Foley and Cumella are back at the office and holding in-person meetings, they said.
All these searches mean big bucks for recruiters. Executive searches typically cost $100,000 or more — the going rate is 28% to 33% of the executive’s first-year pay, according to Kinnard.
And these fees are going up. One VC talent partner reported seeing searches go from the $80,000-to-$100,000 range up to $150,000. Kinnard referenced a go-to-market search firm that she said had doubled its retained search fee and now won’t do a search for less than $225,000.
“The fees have just gotten unbelievable. They’re higher than I’ve ever seen,” Kinnard said. “Every time I think they can’t go up, they go up.”
That particular firm limits its recruiters to five searches at a time, which was the norm when Kinnard worked as a recruiter. Cumella said it’s hard to focus on more than five or six searches at a time, so Daversa has been hiring aggressively to avoid overwhelming its recruiters.
Some others are juggling more work. Kinnard said she knows one recruiter — a specialist in recruiting VPs of HR — who now takes on 16 searches at a time.
“There’s just no way you can do a good job [juggling that many searches],” Kinnard said. “But they have so much business and they all feel like, ‘Now’s the time I can make a ton of money.’”
Reputable recruiting partners can easily make over $1 million or $1.5 million per year right now without doing any proactive business development, Kinnard said. Two other VC talent heads, including Holly Rose Faith of Greylock Partners, agreed that top recruiters are likely making more than $1 million per year.
(Foley demurred when asked about this range, while Cumella said that Daversa’s search partners hadn’t seen a windfall because the firm has been staffing up rather than having partners take on more searches.)
When Kinnard worked as a recruiter, she wouldn’t have let an hour go by before answering a client inquiry.
Now that she’s on the client side, her emails to search firms sometimes go unanswered for days. When she does hear back, recruiters often say they don’t have time to start a new search for a few weeks or even a few months. When Kinnard is looking for a search partner to work with one of her portfolio companies, she now takes timing into account: Which firm even has time to take on another search right now?
Foley said that Heidrick recruiters are “more open than ever” with clients on when they can start a project. “The last thing both sides want to do is get into a situation where we can’t tackle what they’re asking us to do, and that spoils our reputation or ends up with a bad outcome,” Foley said.
Faith, of Greylock, agreed. For search clients, it’s better to wait to start a search than to hire a recruiter who doesn’t have time to do a good job.
As a result, recruiters are increasingly picky about which searches they’ll take on. It can be so competitive to get in with a recruiter, founders of top-tier VC-backed businesses are “kind of just feeling fortunate to have the opportunity to partner with a top executive search firm,” Cumella said.
Recruiters have the luxury of deciding whether they want to work with a particular company or team, or whether the company seems motivated to get the search done quickly.
“Often, they’re doing calls with companies, and they’re like, ‘This CEO seems too difficult to work with. I’m going to pass,’” Kinnard said. “The tables have really turned, in the sense that the recruiters are really in the position of power right now.”
Amid pandemic burnout and increased demand for documentation, doctors are recording patient conversations and giving note-writing work to an AI-based tool, even if that risks privacy or medical errors.
The DAX system uses an app installed on a doctor’s personal or work-issued mobile device to record audio from visits with patients.
Kate Kaye is an award-winning multimedia reporter digging deep and telling print, digital and audio stories. She covers AI and data for Protocol. Her reporting on AI and tech ethics issues has been published in OneZero, Fast Company, MIT Technology Review, CityLab, Ad Age and Digiday and heard on NPR. Kate is the creator of RedTailMedia.org and is the author of «Campaign ’08: A Turning Point for Digital Media,» a book about how the 2008 presidential campaigns used digital media and data.
“Pajama time.” To most of us, that term connotes bedtime for kids, or cozying up on the couch. To doctors, pajama time means homework. In fact, it’s a common phrase describing the nighttime ritual of finishing up clinical notes about the patients they saw earlier that day.
As demands for notes and data to chronicle patient interactions from hospital administration and insurance industry payers have increased, the amount of time physicians spend on the computer has squeezed their already tight schedules. A 2017 study published in Annals of Family Medicine found that primary care physicians spend nearly six hours a day interacting with their electronic health records systems during and after clinic hours.
Amid pandemic burnout, the stress is enough for doctors to hand over the work of writing clinical notes to an AI-based tool, even if it could create patient data privacy risks and medical errors.
“Nobody went into medicine to write notes or fill out insurance authorization forms,” said J. Scott Smitherman, chief medical information officer at Providence St. Joseph Health, a national not-for-profit health system. But he said medical payers now require so much documentation related to patients that “it’s almost an arms race.”
It’s no wonder some physicians he works with have been eager to test software that, with a simple press of a button on their phones during a patient visit, automatically writes the clinical notes they are responsible for entering into the hospital group’s electronic health records system.
The software, called Dragon Ambient eXperience — or DAX — requires that a patient’s visit with their doctor be recorded, whether in real life or virtually. It’s made by Nuance, recently acquired by Microsoft, and is available today through integrations with two of the top electronic health records software providers, EPIC and Cerner. DAX is also plugged into Microsoft’s virtual meeting software, Teams, for use in telehealth settings.
Oracle, a Microsoft competitor in the health care cloud and AI arena, is in the process of acquiring Cerner, making for some potentially strange bedfellows.
Around 100 Providence primary care physicians in California, Montana, Oregon and Washington have tested the Nuance technology — only in in-person settings — for the past year through the EPIC health records platform they use, said Smitherman. “It’s taking the burden of the documenting off the clinician,” he said.
The DAX system uses an app installed on a doctor’s personal or work-issued mobile device to record audio from visits with patients. Nuance incorporates AI such as speech recognition and natural-language processing, or NLP, to transcribe that patient appointment audio recording then transform it into a formatted clinical note including information about the patient’s symptoms, their chief complaints that brought them to visit their physician and their treatment plan, such as suggested procedures or prescribed medications. Some physicians also access the DAX system through hardware installed in their offices.
Several other hospitals and health care groups also use DAX through direct partnerships with Nuance, including Augusta University Health, Boston Children’s Hospital, University of Michigan Health West, Monument Health and WellSpan Health, according to Nuance. SouthEast Alaska Regional uses the DAX system through its relationship with Cerner, according to Nuance and Cerner.
But the technology is far from perfect. Right now, it is not fully integrated with either EPIC’s or Cerner’s patient-records-management platforms. That means the automatically generated clinical notes have to be pasted manually into the proper places in those records systems.
And there are more significant problems.
Nobody went into medicine to write notes or fill out insurance authorization forms.
“The NLP that creates that note, it isn’t perfect,” said Kenneth Harper, vice president and general manager for DAX at Nuance. “It’s such a hard task, it will make mistakes. Sometimes it might omit clinical facts; sometimes it may even hallucinate something.” Hallucination is a term commonly used to reflect when an NLP model conjures up information.
The system also has trouble parsing conversations in which multiple languages or a variety of voices — from people like nurse practitioners or family members — are involved. Writing the note in the format preferred by each individual doctor can trip it up, too.
Plus, doctors don’t always vocalize every important piece of information they are detecting about a patient, like if their heart sounds good.
“We don’t really want the technology to infer something, and if it wasn’t spoken, that can definitely lead to a medical error,” Harper said. “So there are some behavioral things we have to work with providers on.»
But even without AI, doctors sometimes wait until the end of the day to write their clinical notes manually, when their memories might be fuzzy. “That inherently is a high-error-rate process,” said Will Manidis, CEO and co-founder of ScienceIO, which builds large-scale machine-learning systems that read medical documents and has provided technology to automatically generate clinical notes for customers. “I don’t think it’s inherently worse to have that automatically encoded than to have a physician do it,” Manidis said.
“The major concerns I would have here is I’m not sure the computer would be smart enough to know what is important [enough] to pull out into the note,” said Dr. Shravani Durbhakula, a pain physician and anesthesiologist at the Johns Hopkins School of Medicine, who said the hospital does not use tools like DAX to automate clinical notes. “You could miss critical information.»
For instance, she said the system might reflect the fact that a patient experienced endocrine dysfunction, but only code it as the result of a testosterone deficiency rather than an opioid-induced deficiency, a piece of information critical to understanding the person’s condition. As that information gets passed into health care records and from specialist to specialist, “that could continue to get missed in other portions of the evaluation process,” she said.
For now, until DAX improves, the process has a safety net: real-life human reviewers. After the system generates a clinical note — but before it is uploaded into the health record platform — reviewers in the U.S. and overseas, some of whom are Nuance employees and some contractors, step in to edit. They have access to the notes themselves and the audio of the conversation. Harper emphasized that the people editing the notes work in “a highly secure environment” that does not allow the data or the clinical notes to leave their work interface.
Other NLP systems also vet the outputs of their models through a human review process. Though the company does not use a time-consuming and expensive human review process all the time, Deepgram, which builds voice AI products using speech recognition and deep learning, does use it selectively to help improve language models used for things like bank customer service or closed captioning, said Scott Stephenson, the company’s CEO and co-founder. He said Deepgram might select a small portion of outputs the company was not confident were accurate, have those assessed by a person, then feed the information back into the system to keep training the model.
But there’s an obvious patient privacy factor sometimes glossed over when discussing these systems. Physicians using DAX are supposed to notify or ask their patients about recording their health care visit and obtain verbal consent, though it is unclear whether everyone using DAX does that.
“When we’ve talked to physicians, it wasn’t an issue that came up,” said Boyd Stewart, vice president of Payer/Provider Collaboration at health care industry research firm KLAS. “There are patients from time to time that say no,” he said.
A simulation of Nuance’s Dax technology capturing a conversation between a doctor and patient.Photo: Nuance
Smitherman said Providence vetted the consent process with legal teams in states where it has used DAX. He said doctors have not expressed concern about patient data privacy. They have worried about lawsuits, though.
“‘Could this be used against me in a malpractice case’ is the concern that comes up most commonly,” Smitherman said.
Harper said once a patient meeting is recorded, it does not remain on the doctor’s mobile device; rather, it is encrypted and sent to the cloud using a secure streaming process. “All patient data is fully encrypted and running in HIPAA-compliant environments,” a Nuance spokesperson said. DAX is built on top of Microsoft’s Azure cloud.
As for its partner Cerner, the company does not send or store audio recordings used to generate clinical notes, although it does store transcripts of those recordings for up to 10 days, after which time they are destroyed, said Stephanie Greenwood, Cerner’s media relations manager.
Sometimes it might omit clinical facts, sometimes it may even hallucinate something.
But there’s another way the patient data and clinical notes are used by Nuance: to continue teaching Nuance’s system to improve. The company feeds the patient data in its original form into its models, and depending on its contractual agreements with customers, de-identifies or deletes the data after a contracted period of time.
“That gives us a data source of: What did the note get right from the conversation, and what did the note miss or get wrong? And we can go back and keep re-teaching the summarization model to get smarter based on those changes,” Harper said.
Providence pays around $8,000 to $10,000 per year, per doctor, to license the use of DAX, Smitherman said.
But for EPIC, Cerner, Microsoft and Oracle, a service like DAX isn’t just about revenue. It carves out a new route toward capturing valuable real-world clinical data.
When Cerner bought Kantar Health for $375 million in April 2021, Cerner said the acquisition would enhance its pool of real-world clinical evidence data — the sort of information used by pharmaceutical clients such as Pfizer and Novartis.
“Real-world data is essentially data that’s coming from electronic medical records and commercial claims, and when you combine that data together in an anonymized and compliant way, you have an enormous asset for understanding the real-world utility of a device or a drug or a molecule, as well as the health-economic aspects of that,” said Todd Greenwood, senior director of Outcomes at ZS Associates, a tech consultancy.
Technologies like DAX also open a window on actual doctor-patient conversational interactions, Greenwood added. For instance, he said, “What these kinds of much-more-ethnographic approaches allow is for us to understand how often there is a directive conversation versus a collaborative conversation” between doctor and patient.
Data from patient interaction transcripts and clinical notes could be used for analysis companies might pass on to their own customers, helping pharmaceutical manufacturers learn how often their drugs are mentioned by name at the doctor’s office, for instance.
Their approaches to serving the health care market do not directly mirror one another, but Microsoft’s and Oracle’s goals are strikingly similar. When they have discussed their respective acquisitions, both have emphasized the use of speech recognition and NLP to detach overworked medical professionals from their computer keyboards.
“We will make Cerner’s systems much easier to learn and use by making Oracle’s hands-free Voice Digital Assistant the primary interface to Cerner’s clinical systems. This will allow medical professionals to spend less time typing on computer keyboards and more time caring for patients,” said Mike Sicilia, EVP of Vertical Industries at Oracle, in a December press release where the proposed Cerner acquisition was announced.
Microsoft touts the combination of its cloud services with Nuance’s speech recognition technology, which it refers to as “ambient” rather than “hands-free.”
For now, Harper said Microsoft’s acquisition of Nuance doesn’t change much about the company’s relationship with Cerner. In fact, he said the combination of Microsoft’s computing resources and neural networks is helping improve its technology for customers like Cerner.
“The idea of using [Microsoft’s] scale, using their compute to further advance what our technology can do within these enterprise and health care verticals, that’s where we think the most synergy is going to come about. What it means is for DAX, getting higher accuracy faster, getting to automation faster, feeding into Cerner high-quality information from the conversation.”
In the end, if systems like DAX improve, the promise of less “pajama time” could compel more physicians and hospitals to find ways to access them. Preliminary research by KLAS evaluating the effect that DAX is having on doctors’ attitudes toward their oft-maligned electronic health record platforms indicates interest could grow, despite the risks. Compared to KLAS survey participants who do not use DAX, those who do use the system said the burden of digital documentation was reduced as a result.
“They’re getting more time with the patients — more connection, more meaningful time,” said Stewart.
But Durbhakula is skeptical. “Until we get the inputs right and the systems are smart enough to encode those inputs accurately, then we’re going to have issues with bias and inaccuracies and those could negatively impact clinical outcomes,” she said.
Kate Kaye is an award-winning multimedia reporter digging deep and telling print, digital and audio stories. She covers AI and data for Protocol. Her reporting on AI and tech ethics issues has been published in OneZero, Fast Company, MIT Technology Review, CityLab, Ad Age and Digiday and heard on NPR. Kate is the creator of RedTailMedia.org and is the author of «Campaign ’08: A Turning Point for Digital Media,» a book about how the 2008 presidential campaigns used digital media and data.
Coinbase, Gemini and other companies denounced the EU’s anti-money-laundering requirements.
The European Parliament has voted to require all crypto transactions to include information on the parties involved, essentially outlawing anonymous crypto transactions.
Benjamin Pimentel ( @benpimentel) covers crypto and fintech from San Francisco. He has reported on many of the biggest tech stories over the past 20 years for the San Francisco Chronicle, Dow Jones MarketWatch and Business Insider, from the dot-com crash, the rise of cloud computing, social networking and AI to the impact of the Great Recession and the COVID crisis on Silicon Valley and beyond. He can be reached at [email protected] or via Signal at (510)731-8429.
Europe’s stringent new approach to crypto KYC is upsetting the blockchain world.
The European Parliament has voted to require all crypto transactions to include information on the parties involved, essentially outlawing anonymous crypto transactions. The new know-your-customer rules, which would also cover transactions involving unhosted wallets, are aimed at curbing money laundering in Europe.
The EU vote underlines growing concern over the use of crypto for money laundering and other illicit activity, and the push to make crypto companies more accountable for the digital assets that flow through their platforms.
“Illicit flows in crypto assets move largely undetected across Europe and the world, which makes them an ideal instrument for ensuring anonymity,” Ernest Urtasun, co-rapporteur for the EU’s Committee on Economic and Monetary Affairs, said in a statement. Following the vote, the rules still have to be negotiated with EU governments through the EU Council before they take effect.
Crypto industry leaders quickly denounced the EU vote as harmful to innovation and counterproductive.
“This regulation harms crypto innovation without a commensurate anti-money-laundering benefit,” Cameron Winklevoss, co-founder and president of Gemini, said in a statement emailed to Protocol.
Shortly before the vote, Coinbase CEO Brian Armstrong denounced the proposal in a tweet, calling it “anti-innovation, anti-privacy, and anti-law enforcement.”
The company’s chief policy officer, Faryar Shirzad, warned that “if you transact with or through a self-hosted wallet, every one of your transactions could be recorded and stored somewhere — and larger transactions will be automatically reported to authorities — even if there is no reason to suspect wrongdoing.”
On Thursday, the SEC issued a new recommendation that crypto exchanges record the digital assets of customers on their balance sheets as assets and liabilities. Crypto companies should also disclose the “nature and amount of crypto assets” they are holding for customers, the staff accounting bulletin suggested.
SEC Commissioner Hester Peirce, who has been critical of the regulator’s stance on the crypto market, said the decision underscored the regulator’s “scattershot and inefficient approach to crypto.” She argued that the regulatory uncertainty over crypto which prompted the accounting guidance was largely the agency’s own fault.
Major crypto companies have recently unveiled initiatives aimed at improving the industry’s KYC and anti-money-laundering practices. Coinbase and Circle introduced a digital protocol that would enable companies to verify the identities of customers while allowing those customers to retain control over their personal information.
Benjamin Pimentel ( @benpimentel) covers crypto and fintech from San Francisco. He has reported on many of the biggest tech stories over the past 20 years for the San Francisco Chronicle, Dow Jones MarketWatch and Business Insider, from the dot-com crash, the rise of cloud computing, social networking and AI to the impact of the Great Recession and the COVID crisis on Silicon Valley and beyond. He can be reached at [email protected] or via Signal at (510)731-8429.
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