Hi, I am Dr. Bipinsha, I am a senior consultant radiologist, I am a director as well as a radiologist of the Eklat polyclinic and imaging center in Vileparla, West. I have special interest in musculoskeletal imaging and I am immediate past president of Indian society of musculoskeletal ultrasound. Today I am going to cover the ultrasound technique examination of the ankle joint using a systematic approach from the anterior medial lateral and posterior quadrant based on the protocol suggested by the European society of skeletal radiology. Examination of the ankle joint can be performed by asking the patient to lie down supine on the examination table or asking him to sit up with the knee being bent at about 45 degree and the sole of the foot being flushed with the top of the table. Periarticular soft tissue structures of the ankle joint being relatively superficial in location few millimeters deep to the skin surface. I prefer to evaluate these structures by using high frequency probe. You ideally using the hockey stick probe which ranges in frequency between 8 to 18 megahertz. However, if you do not have an access to this probe, one can also use a linear probe with a small footprint having a frequency range between 6 to 15 megahertz transducer. Anterior quadrant examination of the ankle joint is performed by keeping the transducer along the anterior joint line at the level of the telus and the structure which are evaluated on this quadrant includes anterior tibioteler joint space. Also we look at the extensor tendon of the ankle and also the lateral ligamentus complex. In addition, one can also look at the cartilage covering the tailored dome then these smaller ligaments like telonevicular ligament or the calcaneo cuboid ligament. Anterior telotibular joint space examined by connecting the telus with the lower end of the tibia when transducer is parked in the longitudinal in this plane one can identify anterior telotibular joint space which usually does not contain any fluid but is filled with the fat which distance the joint capsule superiorly. On the top of this structure you can see the extensor tendons by moving the transducer from the medial to lateral aspect entire extent of the joint space is evaluated for any evidence of synovitis or the synovial hypertrophy. By asking the patient to do a planter flexion additional component of the cartilage covering the tailored dome can be visualized. So by doing this examination extending your probe from medial to lateral side almost 80% of the cartilage covering the tailored dome can be visualized. However, one point of caution ultrasound is not the best examination to evaluate osteocondrol injury MRI is the modality of the choice. Once the anterior tibia telotibular joint space is evaluated the next step is to look at the extensor tendon of the ankle joint on the NTA quadrant. So by using the bony acoustic landmark of the medial malleolus which appears as a hyper equic structure one need to move the transducer laterally and the first structure the first tendon that is visualized in the transverse plane is the tibialis anterior tendon which has got a classical speckled appearance on the transverse axis. This tendon can be evaluated all the way distally to its attachment to the medial cuneiform and proximally to its to the level of the musculotendonus junction. Once the transverse examination of the tibialis anterior is complete we need to turn the transducer 90 degrees and visualize this tendon along the longitudinal axis till its insertion over the medial cuneiform bone. So like any other tendons this tendon has got typical fibrillary appearance which is due to a bright echoes coming from the collagen fibers and the dark echoes arising from the intervening connective tissue. So that is the distal attachment of the tendon to the medial cuneiform which can be very well appreciated on the longitudinal ultrasound image. After evaluation of the tibialis anterior the transducer is moved laterally and the next extensor tendon that is identified is includes the extensor helioseus longest tendon which again seen as a speckled structure along the transverse axis and it is almost half the size of the adjacent tibialis anterior tendon. One needs to examine this tendon all along its length till its inserts over the dorsum of the distal phalanx of the graded tube. Once the transverse examination of extensor helioseus tendon is over we need to turn transducer along the 90 degree to look at this tendon in a longitudinal plane and follow this tendon distally all along its way till its attachment over the dorsal aspect of the distal phalanx of the graded toe to evaluate the integrity of this tendon and make it sure that there is no injury to the distal attachment of this tendon over the distal phalanx of the graded toe. The specific examination of this tendon can be performed by doing a passive movement of the graded toe to look at the excursion of this tendon which should happen very smoothly in anterior posterior as well as superior inferior direction. After the extensor helioseus longest is examined we need to move more laterally and between the extensor helioseus longest and the extensor digitorum one can see the neurovascular structure which consists of the anterior tibial artery and the vein as well as the deep peroneal nerve. So, moving the transducer from superior to inferior aspect all these three structures can be evaluated very well. Once the evaluation of the neurovascular structure on the anterior aspect of the joint is over, move the transducer more laterally and the tendon of the extensor digitorum longest can be identified which is surrounded by the thick retinaculum and showing a multiple slips as you go distally the slips are seen diverging towards the each toe of the foot and the dynamic examination can be performed by moving this toes in the flexion and extension. Over the extensor tendon you can see a hypoequic thin structure which shows evidence of anisotropy this is nothing but the extensor retinaculum this is the superior extensor retinaculum and when you move down distally one can also appreciate the inferior extensor retinaculum the main function of this retinaculum is to prevent the bow stringing of the tendons of the ankle. Other structure that can be evaluated while you are on the dorsum of the foot or at the anterior quadrant of the ankle is the telonevicular ligament it is a very small structure which appears as a hypoequic structure connecting these two bones and one can evaluate this structure from medial to lateral aspect for any evidence of injury. Another ligament which can be seen on the lateral aspect includes the calcaneo cuboid ligament this is another small hypoequic structure which connects the calcaneum to the cuboid. Entero inferior tibiofibular ligament can be examined by connecting two bones that is the lateral myliolus on the lateral aspect and the tibia on the medial aspect this ligament appears as a bright ecogenic structure with the compact fibers connecting bone to bone the neuro vascular structures can be seen superior to this ligament. Once this ligament is identified one can move transducer more superficially and can have a look at the introsius membrane which is seen connecting the tibia with the fibula. So in high ankle injuries along with the entero inferior tibiofibular ligament the introsius membrane is also injured. In order to evaluate lower lateral ligament complex structure one need to keep a small bolster under the medial aspect of the ankle so this allows a better contact of the skin surface and patient is asked to move the ankle in a little inward position. By connecting the lateral myliolus and the talus one can easily appreciate the compact ecogenic pattern of the anterior tibiofibular ligament and this ligament can be very visualized from medial to lateral aspect by rocking the transducer. While examining this ligament one can also look at the cartilage covering the tailored dome as well as the fat in the lateral gutter of the ankle. In the patient with the lateral impingement syndrome this structure may show presence of a thick synovitis. The third ligament on the lateral aspect of the ankle that is evaluated includes the calcaneo fibular ligament. So by connecting the lateral myliolus and the calcaneum one can visualize this ligament however because of the obliquity of the ligament in the neutral position there is a significant and isotropic hence the diagnostic dilemma always persists to make it visualize more clearly there is a need to perform dorsiflexion of the ankle. Dorsiflexion of the ankle can be performed by asking the patient to lift the foot above the examination bed. So after achieving dorsiflexion and connecting two bones that is the lateral myliolus and the body of the calcaneum one can visualize very well the calcaneum fibular ligament which appears as a hyper-equic structure. One need to do a various degree of dorsiflexion to visualize this structure. When the ligament is visualized along the longitudinal plane the peroneal tendons are seen along the transverse axis overlying this ligament. By using the booni-acoustic window of the lateral myliolus and moving the transducer in the retro myliolus group two ecogenic structures of the tendon are seen. The one with the musculotendinous belly is the peroneus bravis while the tendinous structure is the peronus longus and on top of this structure you have a peroneal retinaquilum which appears as a hypoequic structure because of the anisotropy. The peroneal tendons being running an oblique course we need to have a good contact between the skin and the examination structure. So lot of amount of jelly needs to be put between the skin and the transducer to avoid any anisotropy and getting a proper isonation of the beam to the examination structure. So one can see in this retro myliolus region the ecogenic peroneal tendons and overlying the hypoequic peroneal retinaquilum. From a retro myliolus region the transducer needs to be moved in a supra myliolus region to examine these two tendons all the way till its level of the musculotendinous junction for any evidence of injury to this tendon structure. From a retro myliolus region we need to move the transducer distally to evaluate these two peroneal tendons in the transverse view distally all along its attachment at the level of the peroneal tubercle while the peronus bravis moves anteriorly, peronus longus moves posteriorly to disappear under the calcaneuquiboid. Boni projection seen at this level is the peroneal tubercle while the peronus bravis appears as a speckled ecogenic structure. Because of the anisotropy the detailed morphology of the peronus longus is not visualized. Once the peronus bravis is identified we need to move the transducer distally and follow it up till its attachment to the base of the fifth metatars. Tendon needs to examine both in the longitudinal and in a transverse plane to look at the integrity of the tendon. At the level of peroneal tubercle the peronus longus is situated posteriorly and by using a proper toggling of the transducer one can evaluate this tendon all along its short axis till it disappears in the calcaneuquiboid tunnel or one can also see sometimes osperoneus within this tendon just distal to the peroneal tubercle. This to the peroneal retinaculum can lead to instability lesions of the peroneal tendons that can manifest either in the form of the subluxation of the tendon during the dynamic examination or a dislocation of the tendon outside the peroneal groove. Dynamic examination of the peroneal tendons is performed by doing dorsiflexion and aversion of the foot to look for any evidence of subluxation or dislocation of this tendons while keeping the transducer fixed in the retromallular region. For the medial ankle examination the structure which are evaluated includes the tibialis posterior tendon, flexor digitorum longus and the flexor halusis longus. In order to visualize tendons better there is a need to put a bolster along the lateral aspect of the ankle. By using medial malleolus as a bony acoustic window the transducer is moved in a retromallular region the first tendon which is identified is the tibialis posterior tendon. This appears as a speckled structure and one need to examine this tendon both in the supramallelar region all the way till its level of the musculotendinal junction. Once that is finished that one needs to move inferiorly and look at this tendon till its attachment to the navicular bone at the distal insertion. Once the tibialis posterior tendon is examined in a transverse view one needs to transducer in 90 degree plane and look at the distal insertion of the tendon to a navicular bone which has got hyperequiprofile occasionally one can also see in os navicular within this tendon suggestive of accessory oscicle. So one need to examine all the way from distal attachment and move proximal attachment till all the level of the supramallelar region of the tendon. So adjacent to the tibialis posterior we have another flexor tendon that is the tendon of the flexor dehytorum longus and this is almost half the size of the tendon of the tibialis posterior and this also needs to be followed distally and proximally in the supramallelar region in a transverse plane. The longitudinal axis sonography views are not very important unless you find some pathology in this tendon then it is necessary to look at this tendon in a longitudinal plane. By moving the transducer more posteriorly the third tendon of the flexor group is identified and this is the tendon of the flexor heliocis longus. This tendon is situated in the groove between the medial and lateral telertivercal. If you want to confirm the presence of this tendon you can do the passive extension and flexion of the greater trove and this tendon can be seen visual seen moving backward and forward that shows the integrity of the tendon. Between the tendon of the flexor dehytorum longus and the flexor heliocis longus one can identify neurovascular structure which is made up of two veins that is the posterior tibial vein one artery that is the tibialis posterior artery and the nerve which is the posterior tibial nerve. The pneumonic which is commonly followed to identify the structure remember the structure is tom, dick and very very nervous hairy that is the order in which the structures are visualized in the posterior medial aspect of the ankle joint. The other structure that is examined on the medial aspect of the ankle includes tarsal tunnel and its contents by turning the color Doppler on one can identify the veins and the arteries in the tarsal tunnel and the posterior tibial nerve which is divided into branches which is the medial and lateral planter calcane and nerve. Components on the medial aspect of the ankle consist of the deltoid ligament which has got three components the t-beow teller component, t-beow calcaneal component and t-beow navicular component. The t-beow teller component can be identified most prominently because of its significant fat content within the fibers of the ligament by asking the patient to do a dorsiflexion and I connect and connecting two bones that is the medial malulus and the tellers you can see a fan strip structure that is the posterior t-beow teller ligament. By connecting the medial malulus and the sustenticulum teller the t-beow calcaneal component of the deltoid ligament is identified by connecting the medial malulus and the navicular bone. One can identify the anterior component of the deltoid ligament that is the t-beow navicular component. The spring ligament or the calcaneal navicular ligament is identified along the long axis lying just below the t-belly's posterior tendon which appears in a transverse view. The ecogenic pattern of this structure can be well appreciated. Keep in mind we can see only the superficial component of this ligament. The structure examined on the posterior quadrant of the ankle joint include tendo-acleus tendon, the retro-calcaneal bursa and the retro-acleus bursa. By using the hyper-echoic bony landmark of the posterior superior calcaneal tuberosity one can identify the distal insertion of the tendo-acleus over the calcaneum which is a fibrocartilaginous attachment. Once this tendon is identified in a longitudinal view move your transducer all the way proximally till the it turns into a myotendinous junction, proximally at the level of the fusion of the eponeurosis of the gastrocnemius and the soleus muscle and tendon. Once the longitudinal examination is over the probe is turned into 90 degree and the tendon is examined again in the transverse plane all the way from its attachment to proximally till it turns into myoponeurotic junction. One needs to look at the entire extent of the tendon both on the lateral aspect as well as medial aspect to look at the any lesion which may be situated at the periphery of the tendon. So, it requires that the entire extent of the tendon should be evaluated on the transverse view while on the transverse view also the AP dimension of the tendon is measured to look for any evidence of abnormal enlargement normally this tendon appears as a flat or a kidney shape structure on the transverse view. Other structures examined at this level is a retrocalcaneal bursa it is a potential space lined by the synovial membrane situated between the distal acleus tendon and the prominence of the calcaneal tuberosity. One needs to toggle the transducer from medial to lateral aspect to look for any evidence of fluid collection or evidence of synovitis. Retrocalcaneal bursa is seen just above the distal tendoacleus between the skin and the paratinon. The tendoacleus is devoid of the synovial sheath but it is covered by the loose areolar tissue which is called the paratinon which marks as a hyper-equic structure which envelops the posterior and the lateral as well as medial aspect of the tendon. This paratinon can also appreciated very well on the transverse imaging covering the tendon both on the posterior as well as on the medial and lateral aspect of the tendon. The other structure that can be evaluated on the posterior aspect is the posterior tibiotellar joint space and the flexor heliocis longus in the longitudinal plane. By moving the transducer medially from the achilles tendon one can visualize the flexor heliocis longus tendon as an ecogenic structure and anterior to that one can also see the posterior tibiotellar joint space and inferior to that one can also see posterior sub-tellar joint space very well. To visualize the tendon on dynamic examination one need to do a flexion and extension of the great toe. So smooth movement of this tendon are visualized when the movements of the toe are performed. Dynamic examination of the tendoacleus is performed by doing a planter flexion and dorsiflexion which shows the smooth excursion of the tendon as well as underlying flexor heliocis muscle belly on the dynamic examination. Planter fascia examination is performed by connecting the hyper-equic cortex of the calcaneum and it is seen as a ecogenic structure leaving the calcaneum and situated deep to the thick heel pad. The thickness of the planter fascia is measured at the level where it exits the calcaneal tuberosity. The normal thickness is approximately 4.5 millimeter. One need to examine this fascia both in the longitudinal plane as well as in the transverse plane for the identification of the pathology affecting this structure. So this concludes the quadrant-based approach of the evaluation of the periarticular soft tissue structures around the ankle and using the protocols which are proposed by the European Society of Skeletal Radiology. Thank you.


Live from Las Vegas, it's theCUBE. Covering NetApp Insight 2017, brought to you by NetApps. Back to our live coverage, it's theCUBE here in Mandalay Bay in Las Vegas, I'm John Furrier, the co-host and co-founder of SiliconANGLE Media with Keith Townsend, my co-host, CTO advisor. Our next two guests is Sheila Fitzpatrick, the Chief Privacy Officer for NetApp and Michael Archuleta, CIO, HIPPA and Information Security Officer at San Rafael Hospital. Thanks for joining us. Great topic, privacy, healthcare, ransomware, all these hacks going on, although it's not a security conversation, really is about how data is changing. Certainly the HIPPA has got history around protecting data, but is that good? So all kinds of hornet's nest of issues are going on. Michael, well, all for the good, right? I mean, everything's for the good, but at what point are things foreclosed, like role of tech, what's your update on healthcare and the role of data in kind of the state of the union? Yeah, absolutely. So data right now is one of those assets that's really critical in a healthcare organization. I mean, when you look at value-based care on improvements utilization of real-time data, it's really critical that we have the data in place. But the thing is, though, is data is also very valuable to hackers. So it is really a major problem that we're basically having in healthcare organizations, because right now healthcare organizations are one of the most-attacked sectors out there. I was basically stating that there's an actual poll out there that stated that 43% of individuals don't even know what ransomware is. And you figure, in healthcare organizations, we're really behind the curve when it comes to technology.  What's cybersecurity? What's a breach? Everyone's like, well, I don't know what it is. So it becomes an issue. And the thing is, though, is the culture has not been fully developed in organizations like healthcare because we're so behind in the curves. But what we've been focusing a lot on is employee cybersecurity awareness, kind of bringing in that culture, having individuals understand. Because as you were stating, too, I mean, healthcare information is 10 times, 20 times more valuable than a social security and a credit card on the dark net right now. I mean, if you figure, PHI contains a massive amount of data, so it is very profitable. And these individuals go in, hack these systems because, of course, healthcare organizations are so easy to hack. They place it out on the dark net.  You can go and have some good identity theft going on. And I mean, we have a massive issue here in the States with substance abuse. So if you want basically a script or you want multiple scripts with different identities, go out there and purchase those specific things. So it is a problem. And then on my standpoint is, imagine if this was your mother's, your father's, your grandma's, any family member's information. That's why data is so valuable and it's so critical that we take care of the information as securely as possible. But it starts with the people. Because I always say at the end of the day, our employees hold the keys to either letting the individuals stay out or inviting them in. So it is a problem, absolutely. Shil, I want to get your thoughts because obviously the segment here is why data privacy is always one of the top five concerns for CXOs. And obviously the tagline NetApp has for this show is change the world with data. There's a lot of societal impacts going on. We're seeing it every day in front of our eyes, certainly here in Vegas and then throughout the world with hacks, Equifax just still in memory there. And there's going to be another Equifax down the road. The hackers are out though, that's security concern. You got developers that are getting on the front lines, getting closer to business. That's a trend in the tech business. Data privacy has always been important. But this means that there's a confluence of two things happening right now that's really the collision course. Technology and policy. Privacy is a policy of things that people spend a lot of time trying to get right. And for all the right reasons, but to make some assumptions here and could foreclose and all penalize them, have a penalty on the future. How should CEO's, COO's, CDO's, chief data officers, chief everybody, they're all at CXOs, think about privacy. Well, I think it starts at the fundamental and you're absolutely right. There's a real misperception out there around privacy. And I always tell people, people that know me know that my pet peeve is when people say to me, we have world-class security, therefore we're good on privacy. I literally want to slap them because they're not the same thing. If you think about the, if you're going to move that way, if you think about the analogy of the wheel, data privacy is that full life cycle of the wheel. It's that data that you're collecting from the time you collect it to the time you destroy it. It's the legal and regulatory requirements that say what you can have, what you can do with that data, obtaining the consent of the individual to have that data. Certainly protecting that data is very important. That's one spoke on that wheel. But if you're only looking at encryption, that wheel's not going to turn because you're literally encrypting data you're not legally allowed to have. So if you think about the healthcare industry where I absolutely agree, the data that you deal with is one of the most, you know, it's the most valuable data and sensitive data individuals can have. But oftentimes, even healthcare organizations don't even know what they're collecting or they're collecting data that maybe they don't necessarily need. Or they only think about protecting that protected health information, but they don't think about the other personal data they collect. They collect information on your name, your phone number, your home address, dependent information, emergency contact. That's not protected health information. That's personal data that's covered in privacy laws. Well here's the dilemma I want to ask you guys to react to because this is kind of the reality as we see it on the queue. We go to hundreds of events a year, talk to a lot of thought leaders and experts.  Here's a dilemma. I need to innovate my business. I got to do a digital transformation. Data is the new competitive advantage. I got to surface data, not in a batch space, it's real time so I can provide the kinds of services in real time using data. At the same time, that's an innovative, organic growing, fast paced, technological advancement. At the same time I'm really nervous because the impact of ransomware and some of these backlash events caused me to go pause. So the balancing out between governance and policy which could make you go slower versus the let's go, move fast, break stuff. Let's go build some new apps. I want to go faster. I want to innovate for my business and for my customers but I want to screw myself at the same time. How do you think about that? How do you react to that? And how do you talk to customers about that when they try to figure it out? So that's something, that's an area that I spend a lot of time talking about because I'm very fortunate that I get to travel the globe and I'm meeting with our customers all over the world. And those same issues, they want to adapt to new technology. They want to invest in the cloud. They want to invest in AI, internet of things. But at the same time, I keep going back to, it's like building a house. You have to start with the ground floor. You have to build your privacy compliance program and understand what data do you need in order to drive your business? What data do you need to support your customers, your patients, your employees? Once you've determined that fundamental need and what your legal requirements are, that's when you start looking at technology. What's the right technology to invest in? You don't start that journey by deciding on technology and then fit the data in. You have to start with what the data is and what you want to do with that data, what service you're trying to provide and what the basics are, and then you build up. So foundationally, data is the initial building goal? Absolutely, you don't build a house by starting with the second floor. If you start looking at tools and technology to begin with, that house is going to collapse. So you start with the data and then you build up. Michael, you're in the front lines and the realities are realities, your thoughts. Absolutely, so you have some excellent points and the thing is, at the end of the day, I always say security at times is inconvenience. I mean, we add two factor authentication, we add all these additional fundamentals in what we basically do, but the bottom line is we're trying to secure this data. There has to be security governments to really focus on, okay, this is the information you need. We need to kind of go through legal, we need to go through compliance, we need to kind of determine that this is going to be ease of access for your group and we need to make sure that we are keeping it secure as well, too. I mean, the bottom line is innovation, of course, they want to do so much disruption, et cetera. It's absolutely amazing, you know, I love innovation, honestly, but we still have to have some governance and focus on that and keeping it secure, keeping it focused and having the right individuals really communicate. How do you tackle that as a team? With your team, it's cultural organizational behavior or project management, product planning, how do you deal with the balance? Well, at the end of the day, you know, the CEO of NetApp basically states it starts from the top down. You really have to have a data-driven CEO that basically understands at least the fundamentals of cybersecurity, information technology, innovation, have those all combined in together and having that main focus of governance so everyone has that full fundamentals of understandments, if that makes sense. So, let's talk tactical. You know, we've talked at the high level. I love it that you brought in the global conversation into this, you're taking a global view. We talked a little bit before those shows. There's a mixed mess in taxonomy. Here in the U.S., we're focused first on security, maybe, and then, secondarily, on this concept of PII, which really doesn't exist outside of the U.S., now we have GDPR. Talk to us about the gap in understanding of GDPR and what we consider as PII here in the U.S., and where U.S. companies need to get to. Okay, that's a great question. So, the minute that an individual talks about PII, you automatically go U.S. centric, understanding that you must operate in a purely domestic environment. The global term for personal data is personal data. It's not PII. There is a fundamental difference. In the U.S., there is a respect for confidentiality, but there's no real respect for privacy. When you talk about GDPR, that is the biggest overhaul in data protection laws in 25 years. It is going to have ramifications and ripple effect across the globe. It is the first extraterritorial data privacy law, and under GDPR, personal data is defined as any piece of information that is identifiable to an individual or can identify an individual either directly or indirectly. But more importantly, it has expanded that definition to include location data, IP address, biometric information, genetic information, location data. So if you have that data and you say, well, I can't really tie that back to a person, if you can go through any kind of technology process to be able to tie it back to a person, it is now covered under GDPR. So one of the concepts under GDPR is privacy by design. So it's saying that you have to think about privacy very similar to where we've always thought about security up front. When you're investing in new technology, when you're investing in a new program, you need to think about, going back to what I said earlier, what data do you need? What problem are you trying to solve? What do you absolutely have to have to make this technology work?  So I absolutely agree, security is incredibly important because you need to build a fortress around that data. But if you haven't dealt with the privacy component of GDPR and other data protection laws, security would be like me going down and robbing a bank, coming home and putting that money in the vault in my house, locking it up and going, that money's secure, no one can get to it. When the police come knocking on my door, they're not going to care that I have that locked in a vault. That's not my money. And you have to think about personal data the same way. And certainly healthcare information the same way. You need the consent of the individual and you need to articulate what you're going to do with that data, be transparent. So the laws are not trying to inhibit or prohibit technology, they're just trying to get you to think about. So Michael, as we think about this, how it impacts GDPR specifically, the healthcare industry taught the dinner about this a little bit. We're talking about medical records, doctors, medical professionals like to keep as much data as possible. Researchers want to get to as much data as possible. What are some of the ramifications or considerations at least for the medical industry? Yeah, absolutely. So, you know, on your standpoint there, as you stated, you know, at the end of the day, when we basically look and we focus on our security governance, we kind of, we go over the same fundamentals as you were going, you know. What information is basically needed to access that information for the patient? What is needed from the physician standpoint? What is needed for the nurses standpoint? Because the thing is, is, we don't just open it up to everyone, you know, like on it coming in by different specific job functionalities, you know, we kind of prioritize and put different levels of, this is the level of data this individual basically needs versus this individual. And the thing is, is the beauty about what we basically have focused on a lot too, is we develop the overall security governance committee that kind of focuses on, you know, the specific data's from HIPAA, high tech and the different laws that we're focused on in healthcare. And, you know, we really have started focusing a lot on two factor authentication with accessing information. So we're really utilizing some of those Vasco tokens, RSA tokens with algorithm changes, et cetera. But at the end of the day, the thing is, is the main focus is what information do you need? And the bottom line is too, is it has to have that specific culture of understanding that cybersecurity and data is very important. And the thing is, is on a physician standpoint, they want access to everything, literally everything. And that's understandable because these individuals are saving lives, but the thing is though, is there has to be governance in place, and they have to have that understanding that this can be an issue moving forward. These are the potential problems of a breach that could basically happen. This is the information that you need. If there's more information that is needed, it will go through the security compliance governments committee. It's a hard job. I mean, if they want the nirvana, they want the holy grail, they want everything right there. Thanks for coming on. Appreciate making it aware of the data privacy issues. Sheila, thanks so much for coming on. Michael. I'll give you guys a final word on how management teams, executives should align around this important objective. Because there's some inconvenience happening in the short term, but automations coming, machine learning, all this great stuff is being promised and looks good off the tee, as they say in golf. But the reality is, there's a lot of lip service out there. So the tagline, oh, we're strong on privacy. So walking the talk is about having a position. Not just the tagline or the talking points, having a positioning around it first and getting an executive alignment. So final point, what's your advice to folks out there who have either thinking this through hard? Is it a matter of reducing choices, evaluation? What is your thoughts on how to attack and think about and start moving the ball down the field on privacy? Well, that's a great question. I think certainly at NetApp, and as you mentioned earlier, I mean, our executive team and certainly George Curry and our CEO absolutely has a philosophical belief in that fundamental right to privacy and respects the fact that privacy is key to what we do. It has to become a competitive advantage almost in an accidental way because we take it so seriously. It's a matter of balance. Absolutely, we need to take advantage of new technology. We're a technology company. We're building technology, but we also have to respect the fact that we operate around the world and there are laws that we have to comply with and those laws dictate what data we can and cannot have and what we can do with that data. So it's that balance between data's our greatest asset, we need to protect it. It can also be our greatest detriment if we're not treating it in a respectful manner and if we're not building technology that enables our customers to protect that fundamental right to privacy. Michael, from a management team perspective, honestly, functioning with an alignment implies a well-oiled machine. Not always the case these days, but how do you get there? What's your advice? You know, my advice is speak the language. CEOs, CFOs, administration, they basically don't want to hear this tech-lingual at times, okay? Have them understand the basic fundamentals of what cybersecurity is. What it can do to the operations of an organization, what a breach can do financially to an organization, really have those kind of put in place. Bring that story to the board of directors. Have them kind of focusing on the fundamentals this is why we're protecting our information and this is why it is so critical to keep this information safe. Because the thing is, if you don't know how to tell the story and if you don't know how to sell it and really sell it to the point, you will not be successful. So it really starts from the top. That's a great point, Michael. And we hear all the time too, the trend now is IT has always been kind of a cost center. Security and data coverage around privacy should be looked at not so much as a profit center, but I'd say you could go out of business so you don't treat it as maximizing your efficiency on costs. The effectiveness of privacy is a stay in business table stake and that has an impact on revenue, so it's quasi top line. Well, absolutely. If you think about the sanctions under the new GDPR alone, you could have one day to privacy violation that could, the sanction could be equal to 4% of your annual global turnover. So it is something that- It's a revenue driver. It's a revenue driver. It's something you need to take- It's a revenue saver. It's a revenue saver. Well, for some companies it's become a revenue driver. This is the mindset. Most people think P&L, oh, the cost structure profit center, from that profit center they're doing sales. This is a new dynamic where risk management actually is a profit objective. Absolutely. Guys, great topic. We should continue this back in California. I'd love to. Michael, thanks for coming on and sharing the CIO perspective and the healthcare. Thank you very much. Great content. It's theCUBE breaking it down here, getting all the data and keeping it public. That's our job is to make all our data public and sharing it on siliconangle.com and thecube.net. More live coverage here in Las Vegas with NetApp Insight 2017 after the short break. We'll bury your breakers. Status quo measures.