Chris Ingrao: Bringing Decentralized Identity to Healthcare

Today’s guest is Chris Ingrao, a co-founder of Lumedic—a company whose mission it was to transform the patient experience in the US healthcare market. Lumedic launched an IDtech product in production and was on the brink of several incredible adoption breakthroughs, but through internal reorganization, its potential unfortunately was not realized.
In this episode, Chris takes us on a journey from Lumedic’s founding, to acquisition, to innovating inside a massive health system where they truly had the ability to build an ecosystem from the ground up.
Chris shares a tremendous amount of wisdom from his three years working on thorny, multi-stakeholder problems in healthcare. He touches on the nuance of designing an economic model where all parties are aligned, and how to establish trust between a large group of stakeholders.
You’ll be fascinated to hear how close 30 millions patients were to having access to verifiable immunization records in their mobile wallets, and tens of millions of dollars of savings were on the line if they were successful. And yet, sometimes the biggest barriers are not technology barriers.
Lumedic’s story definitely needed to be told—there are so many lessons for IDtech builders in a variety of industries.
You can reach out to Chris on LinkedIn.
Reach out to Riley (@rileyphughes) and Trinsic (@trinsic_id). We’d love to hear from you.

Full Transcript

Transcript lightly edited for clarity.

Riley Hughes: Welcome to the Future of Identity podcast, where we talk to the people building the ID tech products of tomorrow. I’m Riley Hughes, co-founder and CEO of Trinsic, and we build infrastructure for launching awesome identity products. Today’s guest is Chris Ingrao, a co-founder of Lumedic, a company whose mission it was to transform the patient experience in the U.S. healthcare market. And wow, they were right on the brink of making it happen. Chris took me on his journey from founding to acquisition to innovating inside a massive health system, where they truly had the ability to build an ecosystem from the ground up. Lumedic launched an ID tech product in production and was on the brink of several incredible adoption breakthroughs. But through internal reorganization, its potential, unfortunately, was never fully realized. Chris shares a tremendous amount of wisdom from his three years working on a thorny, multi-stakeholder problem in healthcare.

Riley Hughes: We touch on the nuance of designing an economic model where all parties are aligned and how to establish trust between a large group of stakeholders. You’ll be fascinated to hear how close 30 million patients really were to having access to verifiable immunization records in their mobile wallets. And tens of millions of dollars of savings were on the line if they were successful. And yet, people problems can actually become bigger barriers than technology problems. I left my conversation with Chris so excited for the potential for innovation within the healthcare space, and so glad that Chris was able to tell Lumedic’s story. There are so many lessons for ID tech builders in a variety of industries here, and I’m so motivated by his call to action at the end to talk less and build more. I hope you’ll enjoy it too. And now on to my conversation with Chris. Riley Hughes: Chris, welcome to the podcast. Glad to chat with you. Chris

Chris Ingrao: Ingrao: Yeah, thanks for inviting me. I’m happy to be here, Riley. Riley

Riley Hughes: Hughes: We’ve known each other for a few years now, but for those who don’t know you, maybe give us a little intro on yourself, how you ended up here, and a little bit about Lumedic, which is most of what we’ll probably talk about today. Chris

Chris Ingrao: Ingrao: So I’ve been involved in a few different technology startups for the past 20 years or so, and prior to Lumedic, one of the organizations that I worked with was a medium-sized tech services organization based out of Europe where we were building a number of different solutions leveraging decentralized ledger technology. Because of that work, I had gotten exposed to a set of folks that were sort of unique in the marketplace in their understanding of the technologies. When I got introduced to decentralized identity specifically, I was running the digital transformation team at this organization, and my engineers and architects got excited. We started talking to customers about their use cases. It was not easy to get customers to transform their business or to disrupt their business operations with some of these technologies, and so we started to use that as a lens to look at other areas where we might be able to provide significant value in the marketplace. And out of that came a concept for the healthcare company that we’re talking about, which is Lumedic.

Chris Ingrao: And Lumedic really was built to help optimize U.S. healthcare in sort of two primary ways around interoperability. One was business-to-business transactions, and the other was patient-intermediated information exchange. And so what we observed was decentralized ledgers could be used very effectively in both use cases. On the business-to-business side of things, you can think about things like claims automation or prior authorizations or these kinds of functions where you have two organizations or more that already have a pre-existing trust relationship, and they enter into some sort of contract to do some work. And it is as simple as taking what is constructed in an analog and turning it into a digital formation and building those smart contracts in a way that can be automatically processed with lots of transparency and auditability and these kinds of things. And so we started to build a set of technologies to do that. And at the same time, we identified a set of use cases for patient-intermediated information exchange.

Chris Ingrao: We’re seeing now regulation for things like patient access that is requiring organizations to share patient information with the patient upon request. But we started this sort of before that regulation was even in place. And so we kind of hit it at a good time, in that once individuals get access to their information and it becomes portable in some way, shape, or form, there are a lot of questions about trust that come up. And so I, as an individual, can share with my healthcare provider some information about my health from another provider. But if that information is not in some way, shape, or form authentic, then how do I know that I can trust it? And the answer, the short answer is they’re not going to trust it. They’re going to say, Yeah, yeah, yeah, thanks for the information, but I need to now go contact your prior healthcare organizations to get the information because I don’t trust anything that you give me.

Chris Ingrao: And so there was this unique opportunity to take what we’ve learned in decentralized identity and verifiable credentials and start to use that as a new metaphor so that individuals can take their information in a truly portable way to downstream systems that don’t have pre-existing trust relationships with the other issuers. And so a canonical use case of this comes from my mother when I was trying to explain what it was that I was building years ago. She said, Ah, so when I travel internationally, if I get injured and I go to the hospital, I can share information with them and they can trust it instead of trying to contact in another country. That was sort of the genesis of Lumedic and what we were trying to build there.

Riley Hughes: So you’ve got the B2B side with maybe smart contracts and some other stuff, and— then you’ve got some consumer use cases where consumers are presenting information to providers that needs to be trusted and trustworthy. And when did you start Lumedic?

Chris Ingrao: Lumedic, I think, was about a 2018 timeline.

Riley Hughes: What happens next?

Chris Ingrao: It was very early when we had started to build some of these things, and there was a relatively new CFO at the large health system that acquired us, and he had a tech background. And because of that, he was taking a look at the things that they were doing at the health system and having an opinion that things could be done in a more modern approach. And as part of that, he understood the power of decentralized ledgers to build modern trust systems. And so he did an acquisition of us very early. It was more of an acqui-hire structure, and he pointed us to what’s called revenue cycle management operations within the health system. And so the revenue cycle management functions are about making sure that the providers and the health systems can get paid. So it’s all of the administration for getting everything from patient access, which is on the front side, making sure that the individual has insurance coverage and if they do, what are the benefits and what are its elements of coverage, and then what procedures are required.

Chris Ingrao: And then once all of that gets done, then you package all of that information up as part of your claim. You submit it back to the payer to get the payer to pay their portion, and then the remainder, you then invoice the patient for their patient liability portion, right? And so all of that administration… is what revenue cycle management is responsible for. It’s very big. It’s very complicated. And there’s lots and lots of platforms that have been built, integrated, layered on top of one another, and so on. And that was the domain that he asked us to go focus on. The first use case was prior authorization. This is in the B2B context, as I explained. Prior authorization is a bit simpler than claim adjudication. And so the way it happens today is you go in to see a provider. If they need to do a procedure for you, they have to get authorization in order to do this. You may have even experienced this situation where you’re sitting with the provider and they say, You got to come back for this. We got to schedule it. Let’s schedule it a couple of weeks out.

Chris Ingrao: And you’re thinking, But I’m here right now. Why don’t we do it right now? And the answer is that’s about the amount of time that it takes for them to submit the request to the insurance provider, for them to run the checks, to come back and say, Yes, this is an authorized procedure.

Riley Hughes: I’ve actually experienced it where I’ve gotten the procedure, and then a couple weeks later, I got a letter in the mail that said, Actually, we didn’t authorize this, so here’s the bill. And I call the doctor and they’re like, Whoops, we shouldn’t have done that without getting the authorization first. And it’s not a fun experience.

Chris Ingrao: Yeah. This is one of about a thousand use cases in healthcare that make you scratch your head. What you experienced was actually—hopefully you got it paid for—but it was a better outcome than the alternative. The alternative is lots of patients leave and don’t end up coming back for that second procedure. And so then their health suffers. And so we have these bad patient outcomes because we created a delay in the system to get authorization. Now, you and I as technologists would say, That’s kind of crazy, because there should be a pretty easy API to make a request and get a response in semi-real time to get this information. That’s what should be happening. It’s not happening. And so this was part of the context for us, is you have a set of rules, payer and provider, that you have agreed upon. Let’s digitize those things, put them in a shared space, and we can have shared data and shared logic. And then we can automatically process these things so that we don’t have these artificial delays or the mistakes like you had. So that was our first use case. We started to build that.

Chris Ingrao: That was in the B2B context. And by doing that, we got closer and closer with the revenue cycle management teams, and we started to get more experience using the EHR, which in this health systems case was Epic, which I think is the largest EHR system in the world.

Riley Hughes: EHR, of course, being electronic health records.

Chris Ingrao: Yeah. Epic has a set of unique characteristics around how to work with it and APIs and so on, and so our teams had to learn how to do that. And along the way, because of the background I had with decentralized identity, I asked the team to see if it was possible to do a little bit of a feasibility study to see if we could marry some of the Hyperledger Indy Aries work, connect it to Epic, because we were going to these conferences and people would get up on stage and talk about all these things that they were doing. None of them could demonstrate that they actually were doing it. What I said to the team is, Let’s just go do it and then see if we can do it. And so we were able to connect to Epic and connect those two systems together, which, to our knowledge, was the first anywhere in the world. I think we were the first to do it, leveraging their older APIs before all of the FHIR, access API stuff. And so once we could do it, then it was, Hey, now there’s a set of patient use cases that we can talk about. Maybe this is interesting.

Chris Ingrao: And so as we started to explore that, the first use case we landed on was an insurance registration use case. So in U.S. healthcare, most of your audience is probably familiar. You show up for your appointment and you produce two pieces of plastic. One is your driver’s license and one is your insurance card, and one of those— is a verifiable credential. It’s analog. It’s a driver’s license, right? We go through a ritual in person with our bills and a whole bunch of other things in order for somebody, the state, to issue you a driver’s license that is a credential that you can open a bank account, you can get through TSA, you can buy a gun, you can do a bunch of things. The other one is a piece of plastic with some telephone numbers and some identifiers. That’s not actually a credential. And so when you show up, you present both of these things. And what happens on the provider side is they take those and they enter both of those to create your record within the EHR, within, in our case, Epic or it could be Meditech or a number of systems.

Chris Ingrao: Once they have that information in there, then they have to use it to get the information from the insurance company about your coverage and your benefits, because we’re all different. We might have the same Blue Cross Blue Shield provider, but our specific plans are very different from one another, and we have different amounts of liability and different coverage and different copays and all of these things the payers have, but it’s not on that card. And so today the way you get that is through a third party. The API exists from the EHR, it hits a third party, it gets some of this information back, but it’s not deterministic. And so it’s usually pretty accurate, but it’s not 100% accurate. And so our theory was, well, the insurance companies are not confused about the coverage that Chris Ingrao has. So why is it that they can’t just provide that information directly?

Chris Ingrao: And hey, instead of an API, what if we take that information and we give it to the patient on their mobile device, right, so that that individual can share that information from their mobile device and it is deterministic, it’s verifiable via cryptographic means and so on. And so the provider can accept that information and doesn’t have to do all the rest of this API check. That was the use case. The value to health systems is interesting in that even if the health systems does a really good job of getting that accurate, and even if the information is not perfectly accurate, which it isn’t, in our case, we had 4,500 human beings that did this function all day, every day. And so they get it right the vast majority of the time. But when you’re talking about these volumes, you get it wrong, and then all the way downstream in the process of revenue cycle management, you have to unwind it. You send something to the insurance company and they deny it because it’s not right.

Chris Ingrao: And so then you’ve got teams of people calling, phone calls, email, trying to get somebody to get the information, then you get the information, then you resend it. And that process is very expensive. It’s in the tens of millions of dollars for the one health system we were operating, much less across the U.S. And so it made enough sense that if we could get it right, we would be saving our organization lots and lots of money. And so the juice was worth the squeeze. And it was one small use case that would require this new paradigm of patient-intermediated information exchange. So that was our use case. That’s what we started building, and we got it working, and we got payers on board to partner with us. So two of the largest payers here in Washington State said, Sure, we’ll participate with you. We will be issuers, and our health system was going to be the verifier, and we could start to roll this out. And COVID hit. You know, it was all hands on deck. We have to do everything we can in COVID.

Chris Ingrao: It was a crazy time, as we remember, and it became everything that we could do was need to be focused on COVID. And so they said, Can’t we use this same technology that you guys have built for tests and for vaccine proofs? And the answer was, Well, of course. And that became this very political COVID passport. It was both a great time and a terrible time. The COVID use case made it very easy for people to understand what it was that we were doing and why, where for the prior two years, people couldn’t get their head wrapped around why information from an individual should be cryptographically secure and why it should be trustworthy. They just didn’t get it. And then suddenly everybody understood. The problem was that it became so political, and we started to work with some global organizations to roll these things out. And then a bunch of other folks kind of rushed in to try and profit from this, and people were launching businesses to make money out of this. And we simply wanted to build a new infrastructure for patients to be able to interoperate within healthcare in a safer way.

Chris Ingrao: The long end here for Lumedic was that eventually what became clear to us is we had to make a choice to either become a commercial organization, sort of a travel and entertainment company, or kind of exit that space. And we ended up exiting that space. Lumedic itself was one of six technology organizations that had been acquired by this large health system over a number of years. They chose to combine all of those companies together last year in 2022. And so that was the formal sort of end of the Lumedic vision around building these automation technologies with decentralized ledgers.

Riley Hughes: Yeah, there’s a lot to unpack there. Thanks for breaking down that story, and I can imagine how disruptive COVID must have been. I think if there’s one area that I want to sort of unpack a little bit first, it would be the product side. I think when I talk to people, one of the key use cases that I use to illustrate the value of an ID tech product or decentralized identity as a concept is, I say, you know, imagine you walk into a brand new health clinic that you’ve never been in before, and you walk up to the front, to the receptionist or whatever. You tap your phone, and now they have the insurance information needed. They verified your identity without calling some third-party API and paying for that. They know your preferred pharmacy. They know your allergies. They know maybe your past medical history that’s relevant for their particular thing. You tap your phone, you hit I consent or share or whatever the button is on your phone. That’s it. How great would that be?

Riley Hughes: That’s the use case that I illustrate, and it sounds like that is exactly the use case that you were targeting first.

Chris Ingrao: Yeah, where you just went was something that they call longitudinal health record. And so that is this idea of all of my health information all within my control. We weren’t trying to be that ambitious at first, but yes, the idea is the same, which is this portability. I think people will naturally say, well, there are other ways to get this information, and lots of these organizations are interconnected, and we have now all these FHIR resources that we can go hit from other providers. Epic has, you know, Epic Everywhere and these kinds of things. And so more of this information is available for providers and payers to access one another and share information. That said, I think people underappreciate how valuable a disconnected but verifiable system is with an individual. And I think each of those other stories, the pattern of the last 30 years of hitting APIs across these systems. Requires a level of interoperability and maintenance, and the IT costs of these organizations continues to go up. And every new tech provider comes out and says, I’ve got a new platform.

Chris Ingrao: I’m going to layer it on top. It’s going to connect with your other 38 systems, and it’s a lot of connections to manage. And these IT organizations are getting bigger and bigger and bigger, and it’s more and more expensive to run the operations in a world where an individual can carry that information with them. As long as it’s trustworthy, as long as they can trust it, you can flatten that and simplify the systems, and I think reduce the cost associated with managing all of that information. And so I think people underappreciate that, which is why I think the portability aspect is so compelling.

Riley Hughes: Yeah, I want to unpack maybe some of the specifics about the product that you built. Sounds like you were pretty deeply embedded in the revenue cycle management component of the business, and probably the business element. There’s a lot of stuff that you were doing there, probably working with those IT departments and existing business systems to solve some of those problems internally. But then I’m interested on the consumer side. As you were preparing for this pilot with the major payers and major health system, was there like a consumer app? Was it a website?

Chris Ingrao: The entire thing was built end to end, including two mobile apps. So we had a mobile app for both iOS and Android, and they ended up both being in market in the stores for the COVID use case specifically. So towards the latter part of the journey, we simplified the user experience drastically to make it just for COVID use case so that we could get that out, and those were both out commercially available. On the insurance one, what we ended up doing was the insurance company, the payer, would need to host essentially a QR code on their side, on their portal behind the login. So one of their members would need to log into their portal as they normally do, and they do the validation of the individual. And then if they clicked a button to get their insurance card on their phone, we’d prompt the QR code and would facilitate the flow you’re used to, which is scan that with your mobile device, your camera, create the integration, and pull down the insurance credential.

Riley Hughes: And did Lumedic build a widget or whatever you want to call it and sell it or offer it to these payers that were participating, or did the payers need to go figure out the standards and kind of build their own variant of this internally?

Chris Ingrao: We never deployed at the insurance side. So it was all our code that we were going to provide to the insurance organizations and help them bootstrap it.

Riley Hughes: Yeah. So it sounds like this pilot was close, but I’m gathering that COVID hit before it could happen. Is that right?

Chris Ingrao: Yeah. We had two insurance companies here locally that were on board. The other thing we had to create is a community. It was not our intention of doing that, but at the time there was no existing community in the U.S. that was focused specifically on interoperability using these technologies. And so there’s a HIMSS blockchain task force that we were members of, and we could share information there, but there was no group that was saying, okay, I’ve got a use case, and here is my use case, here is my schema, and here’s my governance framework that goes along with that, and here’s the rules of the road and we’re going to partner in this thing. And so we felt like we needed to stand all of those things up simultaneously so that we could operationalize this. And so we ended up building a community with some partners like Mastercard and a few of the insurance companies here locally. Mastercard was providing its ID service for us at the time. That was how we were onboarding a set of folks.

Chris Ingrao: And so we had some identity providers, we had some insurance providers, we brought them into the ecosystem, we had a couple of healthcare organizations. And so that was the community that was. partnering on the use case, the specific schema, and the governance framework associated with each use case. It was called the Lumedic Exchange, and we had to host it, but longer term we didn’t want to host it. We wanted it to be more of sort of a Linux Foundation kind of effort that was a separate community, but we had to bootstrap it. So there was a community aspect of this as well where we were doing the definition of these things in a public way.

Riley Hughes: I think that’s one challenge that comes up a lot, regardless of the use case. I’m sure in a regulated industry, especially something like healthcare, where there’s so many players involved, it’s probably even more important. But it’s this notion of bringing an ecosystem together around a use case where you’ll bring in, you use the terms issuers and verifiers, right? You bring in the issuers, you bring the verifiers in, you figure out the governance, you figure out the kind of identity verification or onboarding step. You’ve got a lot of these things, and you use the term stand them all up at once. I think with a lot of these ID tech products, there’s a clear value, like I think the registration use case for a new patient, for example, is clearly valuable for everybody involved. But in order for that to be reality, you sort of need to stand all these parties up at once. And the approach you took was to kind of bring an ecosystem together in a community and get ready for a pilot. It sounds like without COVID, you know, we can assume that would have gone on to run through this pilot.

Riley Hughes: I don’t know where it would be by now, but for other people who are kind of struggling to bring an ecosystem together or who are trying to solve a big problem that requires multiple parties to work together, do you have any advice for people who are trying to do that? Or lessons that you learned in trying to make that happen in this setting.

Chris Ingrao: It’s hard. I mean, we read it all the time. It’s hard. It’s hard. I think my suggestion would be, to the extent that you’re able to find a use case where you can reduce the number of parties is important. So I think places like airlines or events, you know, like Ticketmaster or something, those to me seem like very obvious use cases where you can control both sides of it. You can be the issuer and the verifier, and you have an audience that is compelled to use your mobile app or something. Those will be easier places to go first. Short of that, the work you have to do and the work we had to do was to build some notion of an economic model that made sense for all parties. So in our registration use case, there was financial benefit to the providers in the terms of tens of millions of dollars a year. Okay. There was not that kind of value for the insurance companies. The insurance companies care a great deal about member experience. To the extent that this improves the member experience, you can get them to nod their head and say, okay, all right, fine, I’m with you.

Chris Ingrao: But we had to introduce the notion of verifier pays issuer as part of our economic model in order to really cement the deal. And I think that concept is pretty common now. At the time when we brought the ecosystem together, nobody was talking about that. So that was a moment, sort of a breakthrough for us of how to get the other side of the ecosystem. And we had to pay them a portion of the value from one side. So I guess the other piece of advice then would be, if you are working on a use case that has really significant value for one side. Just figure out how to share that value with the other side, and that might be enough to get both parties on board.

Riley Hughes: Yeah, that’s really interesting. You were operating inside of the verifier, for all intents and purposes. Do you think that that was critical? What would it have looked like differently if we imagine a world where Lumedic remained an independent company and you were attempting to bootstrap this ecosystem, you know, without that being embedded inside of the large health system where presumably some of the big payers are answering your emails, I would assume? Yeah. How do you think that would have been different?

Chris Ingrao: I think an organization that was not positioned the way we were positioned would have enormous problems getting any kind of traction in the health system. So we had CEO support, we had chief medical officer support, we had CFO support, we had CIO support. So we had the entire C-suite excited about what we were building and supporting it throughout the organization. And even with that, when you come down to operational teams, they have few resources and they have a bunch of other priorities. And so even if they want to support you, it’s, okay, fine, I hear you. I’m happy to help you. Which of the following other priorities do you not want me to do? And in a health system, if they’re care-oriented or these other things, you’re just never going to win out. And so I think it is true that innovation in large organizations is really hard for all the reasons. And I think even with that kind of support, it’s really, really hard to do it. With COVID, it accelerated our access. We were able to integrate with systems in six to 12 months that I think outside organizations, it might take them…

Chris Ingrao: Three to seven years. We were able to get through a security review in six months that I think could have taken 18 months. I mean, these are things that take a long, long time that got compressed for us. And so it would be hard for any other organization to have moved anywhere near the speed that we moved. So that was the benefit of things. Yeah. And on the payer side, they make the introductions. The introductions are like C-suite to C-suite, and then we’re in the meeting next week with the executive saying, here’s what we want to do. And so we got a lot of people nodding their head to the vision, but the execution takes a long time. If you can get the commitment like we got across the board, that’s great. I think people might not have a great understanding at the beginning of how long it’s going to take to get these things done, even if your team executes flawlessly. There are human problems that aren’t technology problems that you’re just waiting, and, you know, that delay in large organizations takes a long time.

Riley Hughes: You mentioned ticketing and airlines and some other use cases that are maybe a little bit more obvious and require maybe fewer participants. The other side of the coin there is because of those very things, I think it’s a little more crowded. There’s, you know, a hundred thousand people who’ve been to a concert in the last few weeks who thought the experience should have been better, and therefore there’s a lot more people thinking about how they could address those problems or whatever. Obviously, being deeply embedded inside the revenue cycle management part of a major health system, you’ve just, I’m sure, got a vantage point on such deep, thorny, tricky problems that are so non-obvious to the average person. That’s maybe the other side of the coin, right?

Chris Ingrao: Yeah.

Riley Hughes: There’s the easy use cases. I shouldn’t say easy, but I think you know what I mean by maybe the obvious use cases.

Chris Ingrao: Yeah.

Riley Hughes: There’s the non-obvious, but maybe more challenging ones, and I think there’s a different set of trade-offs there. Were there other things that you looked at aside from the registration use case that were interesting or non-obvious, or things that you evaluated along the journey that maybe if you would have had time, you wished you could have gotten to?

Chris Ingrao: On the patient side of things, the patient-intermediated information side, I think what you’ve landed on earlier on the longitudinal health record was in play. The other thing is payments. It’s logical to pair these things together from a member or patient experience to do payments. We talked about in-person registration. We didn’t talk about check-in. We didn’t talk about each and every time you show up. We have to check again your health background and get consent again on all the same paperwork. But there are easier, better, faster, cheaper ways to do that. And there are platforms out there now that will allow you to check in and register and do these kinds of things on your phone ahead of time and consent. But we would have just brought all of that together because I think that, as you would probably agree with me, given your background, this consent management with things like verifiable credentials becomes really powerful. And so you can turn on consent for a single use. You can turn it on for a period of time.

Chris Ingrao: You can turn it on for, you know, all kinds of things that we can’t really do today. And so today we’re pretty ham-fisted in the way that we manage consent of information. And I think that entire thing is going to be disrupted. And so we had a pretty big vision around a new patient experience that transcended all of these things. You can even imagine a world where you can use your insurance information in the context of a claims and a verified credential to do your lookup for providers. So today I’ve got to go to my insurance company site and I’ve got to search by my plan or something. But if I already have that information on my phone, then I should be able to do a pretty quick search on, I’m looking for a GI doc or something in this area, and I should be able to set a set of criteria and have it just pull that back for me. And even the next step would be to find availability and schedule the appointment and send my insurance information ahead of time and do all these kinds of things. And the technology is there to do it.

Chris Ingrao: People haven’t gone that far and they’re kind of in different silos. So I think we were planning on going that direction.

Riley Hughes: Well, shifting gears a little bit, I want to jump back to the middle part of the story around the COVID period. We talked about setting up the Medic Exchange and an ecosystem of several parties that needed to get stood up all at the same time to solve the problem that you were trying to solve. In the world of COVID, we saw maybe a similar thing with groups like the COVID Credentials Initiative, Good Health Pass, CommonPass, the Vaccine Credential Initiative, or VCI. And I know that Lumedic was a major kind of player in some of those ecosystems. I think a lot of the intention there was to tackle the cold start problem and hopefully align some players so that instead of going in different directions, they would kind of take a similar direction. If you had to do a retrospective about the experience and how the model of aligning these players together to try to tackle this market problem, I guess, what do you think the impact of those organizations was?

Chris Ingrao: I think that the long-term implications and impact from some of that work is yet to be felt. I think we’re going to start to see it in global travel in coming years as some of the interoperability challenges are being addressed between countries and jurisdictions and different kinds of regulations. So I think there was good work there. Maybe the only way you get that kind of collaboration across the globe is that kind of event to get people to put all of their metaphorical weapons down and come together in a way that’s sort of for the greater good. On that note, I will say that I think that in many of these scenarios, it’s going to take regulation in order to enforce better behavior. Interoperability is the kind of thing that me in a naive state says, well, we should all approach this in a way that we can be interoperable. And I think entrenched players want to be interoperable within their ecosystem and not necessarily with a competing ecosystem if they feel like that’s the turf they have to defend. And so.

Chris Ingrao: when you have true regulation and frameworks that say you must exchange information or it has to be available and these kinds of things, then it forces the kind of behavior that we want to see from organizations. And I think short of that, I think we’re going to just see humans being humans. So the good news for healthcare is that I think in the U.S. and other places, people recognize the importance and criticality of sharing health information with other providers for the good of people. So I don’t think that’s going to be as highly politicized as maybe some other domains.

Riley Hughes: So once the Lumedic Connect app was in the app stores and people could download it, what were the learnings that you got from having real people get real verifiable credentials in an application that they could then use in their real life? Like, I guess the other way to say this is, what did you learn taking a product to production?

Chris Ingrao: Well, maybe two questions. One question there is what did we learn from users, and the other is what we learned along the way of taking things to production. I think I’ve been involved in bringing a number of products to market over the past 20 years or something, and so I understand that flow. What the wrinkle in this particular case—I mean, things always change a bit—but the wrinkle in this particular case was that there were some either laws or guidelines set forth by the app marketplace themselves, by Google and Apple, around what could and couldn’t be launched in the app store related to COVID. And so we had to sort of work through some of those. Components. I should note that all of this that we were building, we were not monetizing. It’s a completely free app because it was intended to better the experience for patients with their providers and payers. And so we would monetize longer term with things like payments and others. But for now, just exchanging information is kind of free. We were not in it to profit. We were in it for the public good.

Chris Ingrao: But there were some unique wrinkles there. Otherwise, launching mobile apps is nicely well-trod territory now, and so your teams can build their development pipelines to do that. User experience. I’d say the other applications that I’ve been a part of in the past have been more business applications to SMEs in their particular domain.

Riley Hughes: To SMEs?

Chris Ingrao: Subject matter experts in any given area, right? Whether it’s an agriculture app or whatever it is, we’re working very closely with the users in the design of the system, and therefore there’s less variability of the feedback we get. This was different because it was a consumer app, and it was the first consumer app I’d been a part of, and it’s targeted towards the entire population of the U.S. And so the variability on the feedback surprised me a little at just the usage paths of individuals that would tap in a certain pattern that I would have never thought that somebody would tap in that pattern. And so it reinforced to me the value of user experience, user design, folks that understand information architecture to make sure that these things are as human-proof as possible, because we had lots of Paths where people would get confused, and we did not expect so many permutations of that kind of consumer confusion. That’s no slight to our team. Our team did a great job on the design of the thing. It was very clean, and even then the feedback was people get lost.

Riley Hughes: Were there places where consumers could share their credentials from a verification perspective? And you alluded to the fact that maybe we’re sort of being drug toward travel or events or entertainment or things like that. What did you learn about the ecosystem, if we go back to that narrative around the ecosystem? Any lessons or takeaways there?

Chris Ingrao: We did enable a usage here in the local Seattle market where organizations could navigate to a browser, log in, and they could do verification. And so if an individual had the credential on their mobile device, and now we’re talking about vaccines specifically, so we were getting the vaccine credential on the mobile device, then they could use it if a facility wanted to run that for proof. They could just put it up and people could scan it, and then they get the big green check mark if it’s true and a red X if not. And that went really well. That was easy for people. The problem was we never got tens of millions of users, and the reason was the health system we were a part of has about five million patients or something. They operate in seven Western states. It’s a fairly large organization. They have something like 20 billion plus in revenue, but that equates to like 5 million people, which is not a lot of people across seven states.

Chris Ingrao: And so I’ll share one piece of unique information here that doesn’t really answer your question, but that is all of that vaccine information exists in what’s called immunization information systems, IISs. And those IISs are managed by the states, the departments of health. And there’s a relationship between the IISs and the health systems so that the health system, if they give you the shot, they push the information to the IIS and it has it. And as you can imagine, the organizations that manage the IISs had been unloved for, what, 30 years or something. They don’t have a lot of budget. They didn’t have modern systems. And so suddenly everybody says, We need that information. They didn’t really have an easy way to get it out. But because we were integrated with the health system, we had access to the IISs across the seven states. One of the states is California. So we had something like 30 percent of the U.S. population. We had access to their immunization records.

Chris Ingrao: We could have— with a couple of signatures, gotten all of that information into people’s devices and have it stamped with authenticity, which is different than taking a picture of your card or whatever else it was. And that discussion was very difficult for us because we would have those discussions and everybody would nod their head, and all they have to do is sign legal paperwork. And in fact, we had our health system lawyers draft documents to the IISs that would allow the health system to share information for non-patients, because the problem is the health system cannot share the information from the other 30 or 40 million people who are not their patients. They can only share information for the 5 million patients. So with a signature authorizing us, in the context of COVID only, in this period of time, yes, you can share it. We could have had 30 or 40 million people with access to this information, which could have been a significant game changer. We could not get people at those organizations to sign.

Chris Ingrao: So when we talk about it being a human problem, even when it’s completely built, you still can’t get over that hump. They wanted to release their own technology. So that’s another wrinkle. But long story short, we didn’t have 5 million users. We had thousands of users. And so with that kind of volume, you just can’t move the needle. It wasn’t the kind of thing where it made sense for us to get more aggressive. This is why the question came up. Do you just become an event company or a travel company or whatever, and you see Clear try to do this. They were trying to do some things at Climate Pledge Arena here. They have some verification stuff. And I think that we had talked a lot about Ticketmaster and organizations like that should be using these kinds of systems, and it would get rid of the bots. Recently, I think they got in trouble for all the bots that are still all over their infrastructure. And so there are really good use cases where this should be used. Those people don’t want to disrupt their own business.

Riley Hughes: This is a really interesting conversation because I think that the patient registration use case is so compelling, and you had the technology, you had the players kind of around the table, you had the distribution, I guess we could call it, and the community. And the COVID use case is really compelling and, as you alluded to, is sort of easy to understand and feels like something that the world needed as well. And it sounds like there’s human problems, I guess is the takeaway that I’m getting from this conversation, that sort of made it challenging to actualize either of those use cases in a meaningful scale that sort of was envisioned. Is there anything that you think could be done differently if you could go back with all the knowledge you have now, or is this just how it goes in enterprise companies and with technology companies that are trying to change things, and that sometimes the biggest barriers are outside of your control?

Chris Ingrao: I think that in our case, we could have said no to leadership on the COVID thing and just kept focusing on the registration use case. The problem was that all of our partners also became overwhelmed with COVID. Use cases at the time as well. And so we would not have likely been able to make progress in that two years anyway.

Riley Hughes: Yeah.

Chris Ingrao: So if we wouldn’t have been able to make progress in that time frame, we would have had to build other capabilities into a patient app, whether that’s payments or something else, so that there would be enough time to then go back to the registration use case. We could have tried to do that. In our particular case, we were building a payment solution, and it was being implemented also at the health system. And the health system brokered a deal with another very large organization that was doing patient payments, which then they came back to us and said, Oh, sorry, we’re not going to be able to use your payment app anymore. And so it took away another roadmap item. I think in our case, we executed incredibly well, and it just wasn’t meant to be. If somebody restarted our work today, given all that we explored and determined, I think that they could do it. Maybe organizations are working on it. There are other organizations talking about these things. Their vision, when I hear the vision, it tends to be a bit different.

Chris Ingrao: They tend to want to do things like, I’m going to use quotation marks here, own the patient identity. And so instead of the old federated model, this is a new federated model, but we’re going to sort of greenwash and talk about it as though it’s kind of cell phone identity, but in reality, it’s our infrastructure. We’re the issuer. We grant you the identity credential, and now you can be portable and I don’t know that we could have had a different end given what we went through.

Riley Hughes: Yeah, and I just ask the question, in case there are others out there struggling with similar things. It was obvious that your team executed well, given the app in the marketplace with thousands of users, the integration with the EHR system, and I’m guessing that a lot of that is still there, just maybe not fully realized. But hopefully that’s on the horizon, maybe.

Chris Ingrao: Well, I mean, I would love to see somebody come along and pick up where we left off and make it a reality. I think the vision is compelling, and I think the technology that’s available today is even more capable than it was when we started. We proved that it was technically feasible. Now the EHRs are being required to open more and more up with FHIR resources and USCDI. And so it’s easier to do what we did today than it was three years ago. I still think that that’s a possibility. I think there’s a lot of entrenched organizations trying to offer alternatives so that they can still monetize some of the friction. And if there’s an underlying theme here of where some of these self-sovereign identity-type system struggle is that they’re disintermediating in a way that takes the friction out of the system, whatever the system is, and that friction is being monetized by someone somewhere. And so it’s not a zero-sum game. It is actually reducing the overall cost and therefore revenue associated with any given business function.

Chris Ingrao: And when you do that, people are going to try and defend the turf. And so these kinds of things are truly transforming, not transitioning.

Riley Hughes: I definitely hear that. I think the other side of the coin, though, is consider the example of somebody going in to get a procedure and the authorization is not complete and they go home and then they never come back for the procedure. If that friction is removed, then it’s more likely for people to go in and get the procedure and maybe then go in for their follow-ups and get their next steps as well because there’s less friction, which could conceivably lead to an increase of revenue from some other players in the space. I think the point, though, about where does the friction lie is an interesting one because I think you’re right. A more streamlined user experience is going to maybe reduce the pie in one area and increase the pie in another area. And those changing dynamics are definitely things that can be disruptive.

Chris Ingrao: We have this idea of digital transformation, and I think we’ve gotten pretty cavalier with the term because transformation is disruptive. And I think we use digital transformation in a way that is more digital transition. Like, we’ll take an analog system and we’ll move it to a digital system. That’s not really transformation. That’s just, you know, moving it to a different system. Now you might be able to fix them in better, faster, cheaper ways, but you’ve not transformed anything there. And so I think that organizations are less likely to actually disrupt themselves. It’s the same momentum problem. It’s hard to get the change happening, which is why sometimes the suddenness of the change is the thing that is required to get the ball moving and the flywheel spinning in a more positive direction. We thought that COVID might do that for us. We thought we might exit that moment with 30 million patients, or whatever it would be, along seven Western states, with the ability to transact in a different way with their personal information.

Chris Ingrao: And then other people would say, Oh, if you can do that, what else can I do with it? And then it would just grow the ecosystem from there. And it didn’t happen for us, but I think that is the kind of inflection that some of these things require.

Riley Hughes: Are there any opinions you’ve gained that may be counterintuitive or contrarian relative to the generally accepted knowledge or language that’s used, or maybe said another way, you know, if you’re advising a company tackling a similar problem, what would be the things that you’d call out maybe?

Chris Ingrao: I’ve hit on a few of these things in our conversation, so I’ll just kind of restate a couple of them. We talked about having executive-level commitment, which is great. But you also have got to have the commitment throughout the organization and the ability to prioritize your tasks above some other tasks in order to get the momentum at the pace that you need to move. I think this is one of the reasons that large organizations aren’t great places for innovation to happen in most cases, but they’re incredible in that they can move the needle in a meaningful way. So I wouldn’t tell people to stay away from large organizations as much as you have to do everything we did in terms of getting executive support, and then you have to paint a picture for them of, and here’s the rest of the commitments I need from you. I need prioritization over these kinds of tasks, and I need this kind of commitment: time, energy, resources, whatever it is, for this length of time, because these things take a while.

Chris Ingrao: A year is a long time for them to remember about the passion they had for their small innovation project, and some of these things take five plus years. So you’re asking for a very long time for them to be passionate about this. And so I think you have to be clear from the beginning. I think that if I were thinking about the big vision, I think I would try to find smaller ways to add incremental value along the way, also not a novel concept. I think we tried to do that with the registration use case that would add tens of millions of dollars of value per year to the organization, but was such a tiny sliver that when you shared with somebody, Oh, we want to fix the two-plastic-card thing, that seems, you know, not very interesting. But it’s one piece along a road. I think that’s a good strategy so that you can execute the one thing in near term. I think people should talk less and build more. There are a lot of people I feel like make their living in some kind of persona, especially in this era where we’re content creating all kinds of stuff. I think we kind of need less of that.

Chris Ingrao: Just go build the thing and demonstrate that it works, and then go from there. Because what we noticed was we were telling that story for a while and didn’t get a lot of traction. And then when we did it with Epic and I said to people, We’ve integrated with Epic and it works, all the heads in the room turned and said, Really? Tell me more about that. So suddenly it became real, and I think that that’s powerful. And I do think the ecosystems matter. You know, being a part of Trust Over IP, being a member of some of the DIF and some of these other organizations, I think it matters. And I think finding other organizations that will link arms with you on a common vision is an important thing to do because a rising tide floats all boats, especially in this nascent industry. And so I think trying to restrict what appears to be a competitor, maybe in self-sovereign identity or something, is maybe a little bit short-sighted because the world we want to live in is one in which the interoperability exists across all of these things.

Chris Ingrao: And I can take my information and share it in all kinds of ways that I don’t have to think about, that was part of this ecosystem and that was part of this ecosystem. And so in order to do that, I think we need everybody to be successful. And then the final piece is kind of work on legislation. I’ve never been an advocate for these kinds of things. I found myself participating in the Cascadia group here in Washington State with WTIA, and through that meeting some of the folks at the blockchain group in California, and they’re writing legislation. And so a few months ago, maybe six months ago, California signed a piece of legislation to allow verifiable credentials to be used for birth, death, and marriage certificates, which are not super compelling use cases, but the fact that that now is a viable alternative should get people really excited. And I happened to be a part of the team that worked on that, so it was interesting and gratifying to be a part of that and see it work through. But those kinds of things now open doors.

Chris Ingrao: And so once you get your— Birth certificate for your child or something. Now what do you do? Now you’re a parent. Now you’ve got consent stuff you can go work on on behalf of parents, and there’s a little bit of a stub there that you can build off of. So those are maybe some things that top of mind.

Riley Hughes: Yeah, that’s great. Thank you. Yeah, that’s really helpful. You know, if we had more time, I would have dug in on some of the legislative bits there because I think it’s a really interesting and less explored area. The story of Lumedic is one with an ending that’s left me a little bit unsatisfied, right? It’s like something that I’ve, like, really wanted to see in the world. I remember our daughter was born in Washington State in a hospital that was part of the health system that I knew Lumedic was working with. I remember, you know, I was, like, so excited to maybe potentially, you know, and I tried to dig around and poke around, but it was something that I was really, you know, wishing for and I think would have been really interesting to participate in. I think this future will exist. It’s just a matter of breaking through barriers to make it happen. Who will make it happen, when, where, in what order, I don’t know. But I guess tell me, what do you think the future of identity holds and why does that matter for the world in your eyes?

Chris Ingrao: I continue to be positive that this set of technologies provides a pattern that affords us the ability to traverse the world in our digital lives and still do it in a privacy-preserving way. I think that it is a when, not an if. And I think that when we live in that world, I think we will look back at the trade-offs we were forced to make. For services today, and be sort of shocked at how much of our personal information and behaviors we were willing to trade for access to a website with pictures or something on it, you know, some experience. I do think it’s coming. I think it’s coming fast. I think it’s going to be driven more and more by regulation. And we’re seeing organizations like Apple move towards providing security services and things in ways that even disrupt some of their customers. And I think that’s going to happen more and more. I think a driver of this is the realization that an inflection point has already happened.

Chris Ingrao: We don’t have the date yet, but in the future, I think we will look back and we will say, Aha, in 2020 or something, here was the moment where we now can put our finger on it. And that inflection point is the moment when customer data being valuable became customer data is toxic, and we don’t want to store it. And I think that people haven’t gotten that memo yet, and there are still organizations that think, I have to store everything I can about my customers. I have to mine it. That’s my gold mine. But that was the prior 20 or 30 years, and that gave us an incredible rise of services to connect in ways that we never could have connected. And the only way to pay for all of that implementation and all of that work and all of that thinking was to use people’s personal information in an ad-generated world to do it. We have now amazing services and things as a result of that. I think we just have grown up, and now people are saying, Okay, that’s not a good trade-off.

Chris Ingrao: I think we will move from that world to a privacy economy that, as you said, there’s going to be enormous economic value to organizations building out the privacy stack that still makes all those services viable to us. We still want Facebook.

Riley Hughes: Yeah.

Chris Ingrao: We just don’t want to have to give all of our information to them without having control over the consent of when we share and how we share and to whom we share. And so as those things evolve, I think all those services and more will happen, but we as individuals will have a new way to live in that world without being unfairly maybe exploited. And so I’m excited about that world. I think that’s the world we’re going to be living in, and I think we’re going to see it in the next couple of decades.

Riley Hughes: Awesome. Well, that’s a great vision to paint. I appreciate that. Chris, if people want to get in touch with you, where should they find you? Or do you have anything to plug, anything going on, anything you’re working on, anything that people may want to collaborate with you on or be aware of?

Chris Ingrao: Well, I’m working on a few things right now, nothing to plug. I try to hide as much as I can. If people want to reach out, I think LinkedIn is probably the best way. I’m happy to share any and all information that I’ve learned, resources, connections, and even opinions, whether they are right or wrong, with anyone. So if I can help anybody succeed, I’m happy to do that and be a part of that journey for them.

Riley Hughes: Yeah. Well, I can tell you’ve been very generous with your time and your thoughts and insights here, so appreciate that. Thank you very much for being here. And thank you, audience, for listening. You can find us on YouTube, Apple, Spotify, and wherever else you listen to podcasts. Feel free to reach out to us on Twitter at Trinsic underscore ID, and me at Riley P. Hughes, and visit Trinsic if you’re interested in building the ID tech products of the future. Subscribe to get new episodes as they drop. And with that, we can wrap up. Thanks a lot, Chris.

Chris Ingrao: Thanks, Riley. Have a great day.