[Jon Kuniholm - Good Design by Design May 2nd, 2014[
MICHAEL WEISS-MALIK: Hi, everybody.
Hear me OK?
OK.
So I think we're going to get going.
My name's Michael Weiss-Malik.
Our guest today, Jonathan Kuniholm.
I met him in, we think, 2007 as far
as we can piece back together at a SciFoo conference.
And he had some pretty cool tech that he
was demoing on some open source robotics stuff
related to prosthetics.
And I was impressed enough that I said, hey,
you should come and give a talk at Google some time.
And he took that to heart.
And about four or five years later,
emailed me and said, hey, you offer that talk at Google.
Now would be a great time.
So we're hosting him today.
Jonathan is the president and founder of the Open Prosthetics
Project.
He's also a founder of StumpworX, a startup that
focuses on prosthetic technology.
He's also presidential appointee to the National Council
on Disability.
And the stuff he has to say is pretty cool.
So please put your hands together
and help me welcome Jon.
(Applause)
JON KUNIHOLM: Thanks very much, Michael.
Let me first just offer a disclaimer with respect
to my government job.
They encourage us to do this.
That everything that I'm going to say today
is-- are my personal views and not
reflective of any position of the government.
So what I would like to talk about today
is, how we can design good design to solve problems
that society has, for the most part, neglected.
And I came across one of those problems
personally after I lost my arm in 2005
and discovered that prosthetic arms were
an orphan medical device.
And in thinking a little bit more
about why prosthetic arms lagged so far behind other technology
that we use every day, I started to realize
that prosthetic arms and orphan medical devices
are part of a larger group of those problems
that society has tended to neglect
which can be solved by something that we're beginning
to call public interest design.
And the question that I'd really like
to talk about today-- and I would actually
like it to be the beginning of the discussion
because it's something that, by no means,
I claim to have even begun to solve.
--is, how can we marshal all of the tools at our disposal to,
trying to better solve those problems.
Because very much now I believe that most of those problems
are solved in kind of a haphazard way.
Government-funded projects, philanthropy, side
projects from industry, you name the way
that people happen upon these issues and try to solve them.
But in general, you can be sure that the resources
and attention that we devote toward solving
these underserved needs are going
to lag far behind those problems which
are very obvious from every other standpoint need solving,
very profitable things.
There was no question that cellphone technology
was going to improve over the last 10 years, for example.
So in the summer of 2005, I took leave from graduate school
at Duke University.
And I was deployed as a Marine to Iraq in Anbar Province.
And I was the platoon commander for an engineer platoon
of 50 Marines.
And we were doing mostly what everybody
was doing over there which is sustainment and stability
operations, patrolling, guarding convoys, that sort of thing.
On New Year's today of 2005, I was
on a foot patrol that was ambushed
by improvised explosive device.
And the blast took off most of my forearm.
And I found myself back in the States and learning
about prosthetic arm technology.
I managed to get myself back to school
and get involved with a research project sponsored
by DARPA called the Revolutionizing Prosthetics
2009 Project.
It was one of two that DARPA was funding which is really
the first serious prosthetic arm research effort that
at occurred in the United States since-- there was
a small one in the '70s but really since World War II.
And the goal was a really ambitious one.
The goal was to create in four years
in 2007 an arm using commercially-available
technology that could go to market in that year, in 2007.
And then, more ambitiously, to create
an arm that had more degrees of freedom,
was fully neurally integrated.
So nearly the same articulation as a native human arm
and full strength.
And an incredibly ambitious project.
What I think is important to understand,
there's been an enormous-- and this picture is up here not
too brag that I was on "60 Minutes"
but to show the kind of attention
that these projects got.
For whatever reason, prosthetic arms
tend to really capture the popular imagination.
People love robotics.
They love thinking about the barriers, the singularity
and the barriers between man and machine disappearing.
And it becomes a vehicle for all kinds of philosophical
and science fiction interest.
I think the takeaway about these projects which
is important to remember is, first of all,
that we-- despite the amazing things that both
of these research efforts accomplished,
we still have not, 10 years, more than 10 years
since the war began Afghanistan, actually pushing 15 now
--still do not have any commercially-available device
that has resulted from any of this government-funded
research.
We're still waiting for the first one.
It has remained, as always, just around the corner.
And I'm told that we're waiting on FDA approval for the DECA RP
'07 project to receive FDA approval.
And it has been in some clinical trials.
But we still haven't seen a device.
The other one is-- I think that's important to understand.
It's my belief that we have a media bias.
It's not a political conservative media bias.
But it's one towards entertainment.
And so there-- the word bionic is used a lot.
The words dexterous and manipulation
are also used a lot which have very specific meanings
in robotics.
And there are some caveats that I could give.
You could call a trigger grip, for example,
where one part of the hand is grasping
a handle of a cordless drill, and the finger
is pulling the trigger.
That tends toward a sort of manipulation.
It's at lease a compound grasp where one part of your hand
is doing one thing and one doing another.
But of course, the slide that I'm showing here right now
gives you some insight into what the human hands are capable of.
This pair of hands is doing a card trick
where four cuts of the deck are being controlled
by different parts of the two hands.
And it's a dynamic movement.
And so I guarantee you that there
isn't a robotic hand of any kind that
could do these card tricks right now.
But based on the popular press presentation of all this,
you would think that it can.
You would think that these problems are solved.
So while I think it's important to acknowledge the strides that
were made by these research projects,
it's also very important to understand
that we are not there yet.
And we do not have bionic people.
And these hands are, for most part right now,
I think that it would be fair to say, at least in terms
of prosthetic control, that even these highly articulated hands
are really only capable of grasping.
And the difference between grasping and manipulation,
you can use a Rubik's cube to illustrate.
Manipulation is a speed cuber solving
a Rubik's cube in a few minutes.
And grasping is not dropping it.
And grasping a Rubik's cube is actually something
that I can do with the hook that I
wear when I do wear a prosthetic arm, which is the Dorrance
5x named after the guy who patented it in 1912.
And you can see that since then, it's evolved a little bit.
There's some rubber grip on the fingers, a cigarette notch,
and I think it's called a pen notch now.
But this remains, despite everything that's happened,
the most used prosthetic terminal device in America.
And were you to go to the Myoelectric Conference
in New Brunswick in Canada this August,
it would be a fair bet to make that the majority of amputees
attending the conference, at least the ones who weren't paid
to be there by a prosthetic company,
would be wearing one of these devices
and not any of the robotic prosthetic hands
that are available.
The other thing that's important to note about this
is that there's another choice which actually beats
all of them which is the one that I'm wearing today
which is nothing.
And about half of all arm amputees
choose most times not to wear a prosthesis at all.
And it's mostly because of weight and comfort
in suspension.
And I'm going to talk about that a little bit later.
So now, why is all of that?
This is by no means an attack on any the folks
who were generous enough to fund that project
and try to make some progress.
The real problem is that there simply
isn't a market for these things.
The market for powered arms is just barely noise
compared to these other large markets.
And even though the government has accomplished quite a bit
in some of these research projects, what
we call the valley of death which is the bridge that one
of these products must cross in order to get from the lab
into becoming a clinical product, is really significant.
And without a market to drive further funding, that gap which
is estimated by people in the industry
to be something like 90% of the R&D remaining
on a medical product once a proof of principle device
is finished, there's just simply nowhere for those resources
to come from and make it happen.
And so correspondingly, the amount
of effort that's actually put into solving this problem is
also very small, compared to-- I cherry-picked
a few really large government-sponsored
engineering projects.
Some of which have been compared to the DARPA prosthetics
project.
This is all in 2006 dollars.
The Manhattan Project comes in at over $20 billion,
the moon race over $120 billion, and just the R&D for the Joint
Strike Fighter at over $40 billion.
And so the $100 million, well more than
anybody had spent on prosthetic arms in half a century.
The DARPA spend is basically just noise compared to this.
And I would argue that the task that they set out to solve
rivals some of these in terms of the engineering
effort required.
It's a small project instead of a large one.
But nevertheless, an enormous portion of our brains,
for example, is devoted to the control of our hands
in manipulations.
I don't know if you all have ever
seen-- I don't have a slide of it here here,
but the homunculus that neural researchers use to represent,
they take a human figure and adjust him proportionally,
based on the number of nerve endings
in some studies of the brain.
So this little figure has gigantic lips, gigantic hands,
and, depending on whether you're looking at the censored version
or not, gigantic genitalia, reflecting
how much of our brains are devoted
to control these various parts of our body.
And this is true both in terms of motor control
and sensory control.
I works both ways.
And as you can see from that slide of the card trick,
feedback, sensory feedback is certainly
a huge part of our hands being able to do what we do.
So what we have is a three-way market failure
to solve this problem- Industry, government, and academia.
All doing their parts, but all unable to solve this problem.
And so -- so
But of course, it's completely understandable.
And that's why we call a prosthetic arms
an orphan device.
The orphan drug law that was passed in 1983
defined patients in need of a drug as being medical orphans
if their patient population was less than 250,000.
So prosthetic arms in the United States
are about, a couple years ago, 43,000
so fewer than 50,000 patients in the United States.
So that's 1/6 of the maximum threshold for being an orphan.
Course, the orphan drug law covers pharmaceuticals and not
medical devices.
So we don't have a companion regulation or law or anything
that covers the creation of medical devices.
And another peculiarity, of course, of that
is, how we pay for medical devices in the United States.
And I will get to that a little bit later.
So as I mentioned before, all of these medical orphans--
and the NIH-- and this includes all
of the drug, the orphan drug patient populations and others.
The NIH lists something like 10,000 orphaned conditions
on its website.
And because I happened to be interested in prosthetic arms,
I searched for limb absence, arm absence.
And so my particular orphan condition
is actually not one of the ones that's listed on that site.
So I would say that there are probably more.
And so the question is-- and this gets back to the graphs
that I showed before.
Because there's obviously no market for it,
it doesn't necessarily make sense.
I wouldn't argue, for example, that it's a travesty that DARPA
didn't invest $100 billion into solving this prosthetic arm
problem because the same could be said
for any of these other orphans.
We simply can't afford to do that
from a public health standpoint.
It's just not an effective way to spend our resources.
So nevertheless, feeling like this
is a problem that we'd like for society to solve
and that it's not the only one, this is the question.
How can we attacked these problems
and solve some of them?
And it's clear that we probably need
to think about them a little bit different way than we are now.
My friend Chuck Messer described this
as using your geek powers for good.
The Cooper-Hewitt Design Museum, in referencing
the 90% of the world that doesn't benefit
from our consumer culture, they had a design exhibit
several years ago called Design for the Other 90% in reference
to that.
And there's another movement here in the Bay Area.
For example, you have a designer and engineer
named Ralf Hotchkiss who makes a wheelchair.
Whirlwind Wheelchair is their organization.
And they make appropriate technology wheelchairs
that have larger balloon tires on the front
to deal with uneven terrain and broken sidewalks
that you're more likely to encounter,
if there are sidewalks all, in a lot of the developing world.
And they have a cool model where they
try to set up factories as a profitable businesses,
a social enterprise, to manufacture this wheelchair
design in the area where they might be used.
And this in contrast to sometimes
what gets done in the wheelchair space, for example,
is to send a kind of rickety hospital wheelchair
over to that environment where at last,
like a lot of medical technology over there,
about 10 minutes before it breaks.
And then, somebody has trouble finding a part to fix it,
and it ends up getting junked.
So there's-- whereas I'm arguing that prosthetic arm users
in the United States are an underserved population,
they're not disadvantaged, certainly,
to the same degree that patients in the developing world are.
But all of these patients are underserved
in some way or another.
So a good phrase that's been used
to describe all of these problems and the design
that we can use to try to attack them
is public interest design, design in the public interest.
And so really what I'd like to talk
about is, what are the ways besides-- I
will start off with government-sponsored research
because that's a lot of what's happening currently.
But what is our whole quiver of tools
that we might use to try to solve some of these problems?
And-- yeah.
Sorry about that.
So what are the collection of tools
that we could use to try to better solve these problems?
And I, like lots of people do, I think
I'll probably come down on there being some combination of all
of these that are necessary.
But just to brush over them all, to begin
with government-sponsored research and commercialization,
then DIY and the maker culture, potentially an orphan device
law to service as a companion to the orphan drug law
that we've had in this country since 1983.
And then, what other regulatory or policy changes
might be made under our existing structure.
But by program managers who fund, for example, some
of this government-sponsored research, what things might
they do to try to raise the impact of the research funding
that they're currently giving out.
And then secondly, what can we do in the private sector?
Are there ways that folks in the private sector
might be able to contribute in ways
that don't impact their own bottom line?
And they can potentially even have
a win-win in serving these underserved folks.
So to start off with, these are the three--
these are icons that represent the three major engineering
research efforts that I showed the funding
levels for- the moon shot, at the atomic bomb,
and the Joint Strike Fighter.
And it's certainly clear that there are some problems
that government has to solve if they're
going to get it solved for us.
While we do have SpaceX in a commercial space effort
right now, it only exists because the government
is choosing to create that capability.
And the funding's coming from the government.
So that's an example, actually, of spreading this stuff
around a little bit.
But it was clear that sending a man to the moon
or building the bomb, however you feel about
that having done, these were certainly projects that
would never have happened had not one of the largest
and wealthiest governments in the world
decided that they were going to make it happen.
And they happen because, in at least two
in these cases, the first two that I mentioned,
the results were non-negotiable.
We were going to get to the moon,
no matter how much it costs and how dangerous it was.
And those who were in charge of the bomb
viewed it as a response to an existential threat.
And that failure was not an option.
It's probably-- the government probably
would have spent anything to achieve these ends.
Now, a lot of times, some these very programs
and the other basic science research
that the government does are cited
as having intangible benefits that spin off,
that we would be without were it not for these other efforts.
And so Tang, Teflon, and Velcro are three.
And there's actually a myth-busting page
on NASA's website that I have up there on the slide.
Says that, in fact, none of these three products
were created by NASA or NASA-funded research
although the space program did take advantage of all of those.
So while they used Tang, Teflon, and Velcro,
they did not create it.
And I would argue that even if they had, building a bomb,
sending somebody to the moon, or building a high-tech fighter
jet are not the most efficient ways to create things
like Tang, Teflon, and Velcro.
So if what you want is a prosthetic arm
or to put somebody on the moon or to build a fighter jet,
that is what you do.
And this really comes down to a difference
between engineering and basic science.
So the point is that whatever efforts there
are that are devoted to solving this problem,
it really needs to be dedicated to solving the problem.
And there needs to be some agreement on actually
what the problem is.
A significant component of at least the four year
DARPA effort was based on the creation of a neural brain
machine interface.
And it is-- well, in the long term,
it's certainly true that that represents potentially
a holy grail of prosthetic arms.
It's not clear that that is a necessary component of it,
particularly given the state of the technology that most
people are using every day.
So then-- so I was-- at the time when I met Michael in 2007,
we had a version of this hardware board
that we were showing Google SciFoo.
And this is-- Tim Hanson is now post-doc at UCSF.
And he created, when he was at the Nicolelis Lab
at Duke University, the signal processing board which
is capable of processing 16 EMG, electromyogram, signals
from the surface of the skin that
can detect muscle movements.
And we designed it to have as many interfaces as possible.
Because are our goal in this DIY space
was to try to encourage experimentation
and to try to benefit from the maker
culture and the huge video game industry in --
And hope that some of those resources and efforts
and interests could rub off and make some improvements
in prosthetic arms.
What we learned is the downside to DIY maker
and open source culture was that, these projects sometimes
require-- well first, they can't be done completely
without resources.
And then secondly, there's activation energy
to any kind of collaborative effort.
Which if you don't cross, you have
a lot of difficulty making anything happen.
So this project is still alive.
I looked.
There were commits this week.
But they're primarily-- but all of those, as far as I'm aware,
are coming from the two labs at UCSF and Duke
that are using the hardware.
So the schematics-- all this is open source and GPL
to the extent that it actually applies to all of it.
The schematics are up there, all of the masks, the firmware
for the board, everything is there.
But as far as I'm aware, nobody has actually made one of these,
except for those two labs that are using
and are active contributors.
And Tim made a pretty complicated board.
It's like six layers and has these tiny little vias and some
04 components on it.
We had some-- we made this thing in a toaster
and had some horrible moments where somebody breathed on it
or-- And then, you can't tell what any of those things
are anymore, et cetera.
So as far as I know, nobody from the larger DIY or maker culture
has participated in this project.
Now, there's also-- there's another part of the project.
We have functioning pattern recognition software in MATLAB
which is not open source.
And again, this is another barrier.
In order to use the open source software that we have up there,
you need to have access to something
like $20,000 worth of MATLAB tool boxes
which you're only going to have if you're either an industry
or you're in academia somewhere.
So these, again, are some of the barriers.
But beyond that, this hasn't really
had the impact that we really hope
that it would have when we started.
Although I'm certainly proud we tried,
and it's a pretty cool piece of hardware.
Here's another one.
We had a little project on the open prosthetics project
to recreate a prosthetic hook that
was designed in the '20s which has been out of production
for something like 35 or 40 years.
And most of the guys, and it is mostly
guys, who use this hook are now 80, 90 years old.
And I live in the Midwest.
I think there are some demographic particular areas
about where this thing was prescribed
or what people wanted to use it for.
And I still get calls from people who find-- very few,
it's a trickle.
--who find this thing on the web and want one.
And you can see here, this is a picture-- somebody,
Bre Pettis put it in the Thingiverse.
And a bunch of people-- I got bunches
of people who want to volunteer.
They were offering to print as many of these things
as they could on there first generation MakerBots, which
is where I think this printed hook came from,
to help the project.
But unfortunately, even the latest generation
MakerBot 2-- which which I have and really enjoy.
--it doesn't print in a material that's
appropriate for actual use, at least in this design.
This is made to be a metal, a metal hook.
And you can see that the resolution is really not
fantastic there.
So and what we discovered, that one in the lower right
was printed using a selective laser
centering rapid prototyping process.
And we had some tolerance problems with that
until the service bureau actually printed the thing out
on a plate and then machined off the plate.
The two jaws of the hook did not fit together.
So we had something like more than 50,000ths off on that
thing.
and.
I bring this up just to point out
the limitations of some of these things.
And you see this-- just a loop back
for a moment to the breathless enthusiasm
of the press for a lot of these things.
I can't tell you the number of stories
that I've seen in the last two years
about a high school student who has 3D printed
a prosthetic hand that is supposedly better than, you
pick the price point, of some commercially-available
prosthetic hand.
And when you-- there's really no scrutiny
at all that's applied to these claims.
Very often, there are completely externally-powered.
Like motors with strings or maybe they're not even powered.
In any case, nobody really closely examines the claim
that some kid has bested a $40,000 prosthetic
hand in his bedroom with a RepRap machine.
And while I consider myself to be a part of
and fully embrace the maker culture,
I think we also need to be very realistic about what we've
actually accomplished and try not
to run victory laps before we've actually done it.
And I think that this probably is one of those cases.
Now, the happy ending to this story
is that there actually is a prosthetic company called
ToughWare that re-engineer-- they re-engineered this
and fixed some of the problems that we had actually
identified with the original design.
I think you could actually see it
in the-- that's an original hook from many decades ago up there.
And you can see the places it has been welded.
And so this company fixed some of the problems
and where these things were breaking.
And I do believe that you can actually now
purchase a version of this hook commercially again.
So I consider that to be a success even
if we weren't the ones who did it.
So lastly-- and there is some bleed across here.
Michael did reference the company that I've started.
I also decided to back up a little bit
and solve one of the problems about prosthetic arms that
may be, in fact, the most vexing and least address,
which is how we attach them to people's bodies.
This is traditionally done with a hard carbon fiber
or fiberglass socket, a rubber liner,
and maybe a plastic socket there.
And I would liken a lot of these designs
to wearing wooden shoes and rubber socks.
And it does pretty horrible things to your skin
when there's moisture and friction involved.
And heat, moisture, weight, and perceived weight
is really related to all of these things
because people will tolerate hanging less off of your body
when it doesn't really fit well.
It feels like it's heavier if it's uncomfortable.
So we decided that the way to solve this
was to go back to what prosthetic arms used
to be like in the '40s before the VA did
all the research that created these composite sockets.
And consider making prosthetics sockets more like shoes,
like athletic shoes.
Prosthetics sockets used to be made of leather.
And I've been told by old guys who
wear leather sockets that they're
the most comfortable thing in the world.
And they'd never wear anything else.
But you can't find anybody to make one of these things
now because they're really labor intensive.
And the VA actually did a whole bunch of research
in the '40s, trying to figure out
how to make them not stink because of they're basically
like shoes.
So we now have a pending research proposal
that we should hear from the Army and DARPA
from any day now to use current athletic shoe technology to try
to make a flexible, variable compliance socket that's
stiff in some places and flexible and others,
breathable everywhere.
That basically solves all the same problems
that your running shoes do.
And this would address the number one reason
that people abandon prosthetic arms.
And that, by the way, actually includes, for example,
one of the DARPA arms that was tested in VA clinics
among transradial patients like me.
Comfort was actually one of the major reasons
that I think about half of those patients
said that they might not be interested in having
one of those new arms.
So if we solve that problem, then we
could potentially make a lot of the other technology
more effective because we'll be better
at attaching it to people's bodies.
So that's what we're up to right now.
An orphan device law.
So at the time that the orphan drug law was passed in 1983,
we had a bipartisan Congress.
And I think that to imagine in the current legislative
environment that we can get anything done,
may be over optimistic.
Although, perhaps, in an ideal world,
we would consider a law that could increase innovation
and competition in this space.
Now, for those of you who are unfamiliar with it, what
the orphan drug law does is, it extends exclusivity for a drug
company who has developed a product
but who believes that the further investment
necessary to actually bring a proven drug to market
is not worth the investment because their patent,
the exclusivity available to them on the original patent,
has expired.
Drug development is often a really long process.
And it's a race against the sundown on the patents.
Now unfortunately, I'm not convinced
that a similar model in the this even much smaller orphan device
spaces would actually do anything
because exclusivity in prosthetic arm patents
is often abandoned when people decide
to stop paying the maintenance on their process arm patents
after seven or 15 years.
So they're leaving exclusivity on the table with regard
to patents in the space already.
So would extending it actually do anything?
And I'm not convinced that it would.
So Yeah?
AUDIENCE: [INAUDIBLE].
JON KUNIHOLM: OK.
So since we're not miked in the audience,
the question is, is the approval process for medical devices,
prosthetic arm specifically, similarly long
as it is for drugs.
That's sort of a complicated question
because it depends on which class of devices
you're talking about.
The FDA it has three classes of medical devices- I, II,
and III.
The DARPA neural sensing system would be a Class III
medical device because it actually
involves an internal implant.
Most prosthetic devices right now are Class I.
And they're not only Class I, they're
Class I Exempt which means that there are exempt from-- there's
something like seven or eight requirements for Class I
devices.
And all but three of those are ignored
for this group of Class I Exempt devices.
So in fact-- and this is something actually
that there's been some-- some of the folks who've
been pursuing these new things have been assuming--
and they may be right. --that the FDA is seeking
to regulate prosthetic arm stuff more rigorously than they
have in the past.
So even though you could bring-- there
are articulated myoelectric hands
that have been brought to market in the last five years
that were brought to market.
All you have to do basically is announced to the FDA
that you're going to start selling these things and do it.
And if you're going to test it, you stamp it experimental.
And you're good to go.
But nobody wants to invest hundreds of millions of dollars
in the creation of a device unless they
are sure that they're going to get away with that.
And the FDA had been making noises
that they were going to try to bump up
the classification of some of these things.
And they also have a requirement for orthopedic devices
which is reasonable.
It's based on-- so a screw in an orthopedic implant
is a Class I device that's a component of a Class III device
which is the implant.
And there was a bad failure in the '80s because
of the changing of these Class I devices.
And so the FDA requires each Class I component
be separately recertified with the Class III system.
And if somebody did something like that, for example,
with, say, there's a bolt that can go through your skin
into the bone.
It's called osseointegration.
A titanium bolt.
And the bolt, of course, is a Class III device
because it goes inside the body.
And if they required you to separately certify
every prosthetic hand or foot that you attach
to one of these systems, it would effectively
mean that there wouldn't be any available because nobody
would bother to do it.
So the whole-- so actually, you bring up a really great point
which is that the FDA is a really important part of this.
And some orphan device law, a hypothetical orphan device law
or revisions of regulations that might really impact the space,
should try to remove some of those barriers
that actually the FDA could potentially
create in trying to better protect us.
And there are humanitarian exemptions available.
And so it's something that I think
bares further consideration.
So that leads into the next group
of things which are beyond new law.
What about the interpretation of existing laws and regulations?
The Bayh-Dole Act is the law from 1980
that governs the government-funded creation
of intellectual property.
And the part that most of us are familiar with, if you've ever
received a government grant, is that the government
has royalty-free nonexclusive license to anything
that they pay you to create.
But then, in order to encourage economic activity,
anybody who creates this stuff has the permission
to go off and license it.
Do whatever they want, exploit that intellectual property
on their own, as long as they don't charge any royalties back
to the government.
In practice, I think some of this actually goes on.
Because if they fund, particularly weapon systems
and stuff like that, it's not like they segment off
what the intellectual property component of it is.
It's not like anybody else can make some of these fighter jets
or tanks or whatever.
So the least popular provision of this law
is what are called march-in rights.
Which means that if the government-- if there are--
there are four criteria that could be met where
the government can come in and say,
you are not making use of this intellectual property the way
we intended you to.
We're going to take it from you and give it to somebody else.
And people-- it has been exercised very few times,
if ever.
And it's a very unpopular, as you can imagine,
provision with people who get a lot of government funding.
How much time do we have?
So while this law exists, it is something
that could be made use of that's on the books already.
And so people, program managers could say, OK,
so it's been 15 years.
You haven't-- you created a product where we're going
to find somebody who will because our goal is to bring
something like this to market.
And another one that I referenced earlier
is the Center for Medicare and Medicaid Services.
So all these devices, and many medical devices are like this,
are reimbursed as durable medical equipment-
canes, walkers, CPAP machines, and prosthetic devices.
And the weirdness that this creates
is that the whole cost of supporting
the device for something like five years
in between replacements has to be captured just
in the provision of the product at the beginning of its life
cycle.
All of the appointment and everything.
So a prosthetist needs to be able to function based on that.
The other thing that's weird about this
is that there's a perverse incentive, of course,
to provide more of these products.
Because if you give somebody a myoelectric arm,
it reimburses at $30,000, $35,000.
A body-powered arm may be $8,000.
And the other thing is that the way that these reimbursement
codes are created is that a company has
to demonstrate efficacy.
And then, they petition CMS.
And so that they have to basically outlay all of the R&D
ahead before they know if they're going to get
reimbursed.
Then, there have been some recent cases
where people get the wrong answer back from CMS.
And it kills the company.
A good example is the iBot wheelchair
which everybody agrees is pretty impressive technology.
That came back as being excluded to a very
few pretty serious disabilities and not
reimbursable at a rate that could sustain its manufacturer.
And the company has closed it doors.
And so it's actually up in the air
what's going to happen to that technology.
Hopefully, DEKA, which is the creator of it,
will figure something out.
So one thing that I think people might do
would be to create incentives in reimbursement codes.
You could create a code for the performance
of a particular device without knowing that it exists.
And so I could say, a 15 degree of freedom prosthetic hand
and wrist that's capable of all these performance criteria
will reimburse at this rate, $150,000, whatever it is.
And then, a company would know ahead of time
that they have a payday ahead of them
if they're capable of meeting the criteria.
And so it would be much more clear that this was possible.
Then, contract language.
There's a bunch of open source and open architectural language
that the Navy, for one, still has on kind of dead
website that's still up there.
But it's sample program manager language
to put in RFPs to ensure that you
can get what you want out of them.
And those are tools that could be used.
And then lastly, the DARPA has made really good use
of challenges and contests.
And I think this sort of thing, in partnership with industry,
might be very helpful.
So I guess in some sense, my graphic here
of somebody cutting red tape, maybe
I'm actually talking about creating
some more in some cases.
But you get the picture.
So what about industry?
And that's you guys here at Google.
I think that Google has done some really creative things
in terms of business model in creating great products that
solve problems in ways that people hadn't before
by focusing the business model in sort
of unexpected parts of it.
And so I think both Android, both the Android operating
system and Gmail are good examples of that.
In a recent acquisition of yours, the nest company that
makes these thermostats and the smoke detector,
those are examples of products where
people would have said the innovation is--
these are commodities.
You can't improve on this.
It is what it is.
Everybody has to have one.
And you're going to buy the $8.95 one instead
of the $9.95 one because it just does whatever it needs to do.
And I think the way that that company was able to really pay
attention to consumers represents creative thinking
which is the way that probably everybody needs
to attack challenging markets.
And these ones that I've talked about
are certainly some of them.
So you guys have also been in the news
recently for, by count, something like nine,
counting the drone company, robotic acquisitions
over the last year or so.
And one of these is Redwood Robotics
which I think involves a part of a Willow Garage spin-off.
And I looked a little bit-- I'd never
seen this hand picture before.
It looks to me like a rendering.
I don't know if it represents a real product.
I think that it's interesting that, in terms
of a manipulation and terminal device, a hand
acquisition that you guys chose to acquire,
Redwood and not any of the companies
that were involved in the DARPA prosthetic arms,
the-- there's an interesting companionship between robot
teleoperation and prosthetics.
Myron Diftler, who runs the robonaut program for NASA
at Johnson Space Center, said that when he thought about it,
the prosthetic problem is basically
a teleoperation problem.
You just happened to be attached to the device you're
trying to teleoperate.
So in some sense, when you take away video latency
to the moon or whatever, the prosthetic control problem
might be, in some sense, easier.
Although the way that these things are usually
performed right now is with a haptic armature.
And in the prosthetic case, obviously, you're
trying to control a limb that's absent, so you don't have
access to those fingers to tell you,
to tell those digits where to move.
Anyway, my point in bringing this up
is that there is some great companionship
to these problems.
And in fact, while it is not clear
right now who in America is ready to buy, for example,
a personal assistance robot or some other things
that one might imagine as products
that could come out of companies like these down the road.
There are prosthetic customers who
can, according to the current reimbursement
system, in some cases, pay in excess
of $100,000 for one of these devices.
So it might be possible to create a synergy of interest
where you're solving problems for the future of home
and mass-produced robotics at the same time
as you are serving prosthetic customers in the near term.
Even though they don't represent the huge revenue stream
that we all would if everybody has a Jetsons-style maid
in their home.
This is a picture of my friend Kevin
who was born without both of his legs.
I throw his picture up there because he is, in some ways,
represents an orphan of an even smaller community than my own.
Without any hip joints, when he was about 10 years old,
they tried to put prosthetic legs on him.
And they weren't really anything but another couple
of extra crutches for him to sort of haul around.
And he very quickly decided that he wanted no part of that.
And he gets around on a skateboard.
Now, that said, if you were to envision--
and that's a way to stay active, too.
But if you were to envision a robotic prosthetic device that
might help him, it could look something
like Boston Robotics, Boston Dynamics-- I forget
the name of the company. --in Cambridge.
They have the big dog, walking bot
and those others where they pretty famously kicked them
over in the video.
A pair of those walking legs, controlled like the Segway,
is by leaning, could do a pretty fair bit
towards replacing legs.
And so that's another case where one of these robotics companies
might hold, in currently available technology, the keys
to making a change in somebody's life.
And my hope in mentioning industry--
and I think, again, none of these are mutually exclusive.
I do believe that the only way that we
are going to solve these extremely vexing problems
to society is by throwing nearly everything that we have at it
and seeing what sticks.
And so really my purpose in talking to you today
is to try-- I want to start this conversation because it's
pretty clear to me that there are some things that we could
do better about how we're responding to these problems.
And I'd very much like some help in figuring out how to do it.
So I used up more time than I had intended to.
But if you all have any questions,
I'd certainly like to try and answer them.
So the question is-- I mentioned that most arm amputees still
use hooks vise the more complicated
electrical externally-powered prostheses and why.
I think cost is part of it.
The Affordable Care Act has changed some of that.
Before January, a lot of people with medical insurance
had lifetime caps of, in some cases, just more,
like $1,500 lifetime cap on prosthetics services which
isn't even enough to get a single prosthesis.
And beyond the expansion of coverage,
the removal of the lifetime caps and pre-existing conditions
are huge for the prosthetic community.
So to the extent that it is monetary,
the Affordable Care Act should change some of that.
I, anecdotally, I don't think that there's
any great data on this.
But I think that a lot of common complaints
about the myoelectric prostheses are latencies,
unintended movements, the speed with which the motors move,
the weight.
And then, I think you hit on it, function
is probably the primary reason.
The hook has been famously described in TED Talks
as a rubber band and a hook on the end of a stick.
But I believe that the bar is actually
quite a bit higher than that.
The Dorrance hook is really kind of a marvel of design.
It's got a bunch of affordances built into it.
You can pick something up, use it as a hook,
and as a split hook, you can open it up
and use the individual fingers for different things.
The little thumb that has the cable on it---
I'll put that back up.
The little thumb that has the cable on it
can be used to push things.
And is the part of the device that's
used to wedge a knife and a fork.
Actually that's a perfect example
is eating with a knife and fork.
With cosmetic coverings on the myoelectric hands,
they tend to be slippery.
And it's hard to get a knife and a fork to sit securely in them.
And this thing is designed to do exactly that.
It's got a chisel tang in the middle,
so you can stick a tool in there.
Or you can wedge either a knife or a fork
in between the fingers and over the thumb.
So I think function is a lot of it.
Any other questions?
Yeah?
AUDIENCE: [INAUDIBLE].
JON KUNIHOLM: Yeah.
So well, first of all, it's selfish of me, right?
That's my problem.
So that's what I spend a lot of time thinking about.
But there are other complications.
So there are something like 50 times more leg amputees
in America than arm amputees because of peripheral vascular
disease secondary diabetes.
And that's the major cause of leg amputation.
So there are more than two million leg amputees
in America.
And most of-- and is an easier problem to solve, too.
When you're looking at-- well, Oscar Pistorius
is a great example.
The cheetah legs make somebody capable of running close to 10
second 100.
Although knees are a problem.
And Oscar Pistorius is a below knee amputee.
But then, among the powered devices,
control engineers who work on legs
have told me that it's possible to do reasonable approximations
of gate with the individual components not even talking
to each other.
Where they just respond to the external forces,
and they're capable of doing a pretty good job walking.
And contrast that to an arm where just,
forget the manipulation stuff, just
reach to grasp with a whole arm for somebody
up to the shoulder level involves the coordination
of all of the joints together.
So I like to say that if you imagine that these are legs,
the arm problem has five of them on the end of a sixth.
And they all have to dance together in order
to do the most basic task that an arm has to do.
Yeah.
And so the economics are-- legs are a lot bigger business.
So there is a real incentive.
Although there are some new leg companies,
because of the high cost of additional degrees of freedom,
there are some leg companies that
are going to be in trouble if they don't
get the reimbursements that they want on powered ankles,
for example.
And so in that sense they share exactly the same problem.
Anything else?
Any questions from our remote rooms?
All right.
Well, listen.
Thank you very much for taking the time to check it out.
And I don't if there's a way for me to post contact information
or whatever.
But if anybody's interested in further talking about this,
please get with Michael Weiss-Malik.
And he'll put you in touch with me.
Thanks very much.
(Applause)