Butterfly Network, Inc. (BFLY) Earnings Call Transcript & Summary

Hello, everyone, and thank you for joining the Butterfly Network's Q3 2022 Earnings Call. My name is Darius, and I'll be the operator for today. [Operator Instructions] I now have the pleasure of handing you over to your host, Heather Getz. Please go ahead.

Good morning, and thank you for joining us today. Earlier this morning, Butterfly released financial results for the third quarter ended September 30, 2022, and provided a business update. The release and earnings presentation, which include a reconciliation of management's use of non-GAAP financial measures compared to the most applicable GAAP measures are currently available on the Investors Section of the company's website at ir.butterflynetwork.com. I, Heather Getz, Executive Vice President and Chief Financial Officer of Butterfly, alongside Dr. Todd Fruchterman, Butterfly's President and Chief Executive Officer, will host this morning's call. During today's call, we will be making certain forward-looking statements. These statements may include, among other things, expectations with respect to the financial results, future performance, development and commercialization of products and services, potential regulatory approval, the size and potential growth of current or future markets for our products and services and the impact of the COVID-19 pandemic on our business. These forward-looking statements are based on current information, assumptions and expectations that are subject to change and involve a number of known and unknown risks, uncertainties and other factors that may cause actual results to differ materially from those contained in the forward-looking statements. These and other risks are described in our filings made with the Securities and Exchange Commission. You are cautioned not to place undue reliance on these forward-looking statements and the company disclaims any obligation to update such statements. As a reminder, this call is being webcast live and recorded and we will be referencing a slide presentation in conjunction with our remarks. There may be a short delay between the live telephone audio and the presentation being shared. To access the webcast, please visit the Events Section in the Investors Section of our website and replay of the event will be available following the call. I would now like to turn the call over to Dr. Fruchterman. Todd?

Thank you, Heather and good morning. I'd like to start the call off today a little bit differently than I have in the past. I thought it would be worth taking a step back and reminding everyone of the path we're on here at Butterfly and what makes us fundamentally different, so you can better understand why Butterfly. This context will be important as we get further into our discussion because it will help you better understand how we view the results of this quarter, our growth in the near-term and how we are taking our learnings from the market to drive our future growth and care transformation with ultrasound information at scale. Many of you will remember that we entered the market as a truly remarkable and transformative device. By putting ultrasound on a semiconductor chip, we became a disrupter in the industry based on our innovation and the hardware alone. We are proud to say we are leading in the handheld ultrasound segment today, and we continue to invest in this area to maintain our edge. Our technology works and it keeps getting better. Some of our initial learnings in the market, however, made us recognize that we were not where we needed to be in order to realize the full value of our technology and the impact to healthcare. So we went to work on our enterprise level software and workflow solutions. We have spent the last year investing heavily in the development of our software solutions Blueprint and Compass. Significant progress and software development has created best-in-class image management and workflow software across ultrasound platforms, both internal and external to Butterfly. As a result, we have gone from software that was objectively lagging to software that is now highly valued and we continue to innovate and push it beyond the status quo. Based on what we're learning from our customers, we know that software is the enterprise enabler. We are proud that enterprise level software development has now become a positive differentiator for Butterfly. Our platform for our solution and the catalyst for providers to begin their journey of care transformation, but given the significant strains on practitioners throughout the healthcare system we've learn that they need specialty applications that are highly focused streamlined, easy to learn and easy to use. The burden of learning ultrasound cannot be put on them while practitioners don't want to learn nor do they have time to become experts in ultrasound, so we have reorganized our product clinical and commercial teams around the coordinated pursued of specialty applications that only Butterfly can enable. Providers want to quickly learn the applications that are most relevant to their practice and that will dramatically improve their ability to care for their patients and streamline their workflow. And now Butterfly, we are committed to delivering our technology in a way that accomplishes this. We are developing clinical partnerships that will provide clear evidence to support application specific adoption and usage that is relevant and impactful. Our backlog of applications, are deep proprietary and unique to Butterfly. Our strategy and roadmap are confidential for obvious reasons and will be revealed as we launch them. We realize this challenging for the outside world to monitor our progress, but we believe long-term value is maximized by hitting the market with tailored solutions that are unique to Butterfly without competitive distractions. With the hardware and software now working complementary to one another Butterfly has truly become the practical application of ultrasound information into the workflow. The experience with the Butterfly is fundamentally different than any other ultrasound device that has come before us. With Butterfly providers now have the ability to use ultrasound to guide their assessment instead of doing an ultrasound to confirm their decision. This is what separates us from the pack. This is what Butterfly and semiconductor base ultrasound makes possible and it's this distinction that we believe will lead to a major shift in how medicine is practiced and how care is delivered across all settings. We expected this shift to take time because leading people through behavior change takes time both in practice and implementation, but just as others are experiencing within the industry, the budgeting and workforce pressures have intensified resulting an implementation delays. Some of our future partners are simply delaying implementation and commitments until they can catch up on people. We are prioritizing the appropriate coordination for successful launches and rollout over the speed of short-term revenue generation that doesn't meet our long-term objective. With that said, the signals we are receiving and the conversations we are having in the market reassert that Butterfly message is clearly resonating and that we have the ability to fundamentally change the care experience for providers and patients alike with how care is delivered across all settings. And with that context, I'd like to discuss our business performance and briefly comment on the third quarter high level financials. From a revenue perspective, we ended Q3 with $19.6 million in quarterly revenues a 34% increase versus the third quarter of 2021, while this was our highest quarterly revenue to-date and an acceleration in our revenue growth over first half levels. It is lower than our internal expectations due to increased challenges at the macro level. Heather will speak to this more, but the broader macro environment is waging a toll on health systems. The environment has placed additional demand on frontline healthcare workers and management that has pushed out their inevitable innovation in the very near-term. The impact of this environment, it's causing a delay in our growth and as a result, we are adjusting our guidance to $73 million to $76 million because we have proactively and fully offset this lower revenue with expense reductions. There is no change to our adjusted EBITDA loss. While our top line revenues reflect the market dynamics, we have discussed, we are also acutely aware of the opportunities it creates for Butterfly, because we have a tool that quickly becomes part of the solution for hospitals and clinicians. We are confident that our business is foundationally strong and growing based upon these 5 things. First the texture of our revenue shows that we are growing where it matters and health systems and software and services. Hospitals realizing that they need to have the right infrastructure in place to manage and use our technology want oversight device management credentialing and QA solutions. As critical first steps to technology, leading to care transformation Butterfly delivers here. Second, there is improved customer and client experience that is driving increase in usage and validity to our vision. Third, we are meeting our customers where they are with our Blueprint and Compass enterprise software, as well as building a pipeline of applications and product introductions that fit the needs of enterprise customers, individual practitioners and patients. Fourth, we have a building pipeline of leading institutions whom we have engaged with to drive specific applications with accelerating adoption in the coming periods. While we are not going to project large client deals in the near-term, our backlog has clearly built in quality. And fifth, we are giving institutions and providers, the foundation upon which they can build transformational programs, they use ultrasound information to change the way care is delivered across the continuum. Everywhere we evaluate the needs of patients and providers can only be best satisfied with Butterfly. To help address these market dynamics, and further ensure Butterfly remains well-positioned to capture this value as we head into 2023 and beyond. Today, I'd like to announce some changes to the executive leadership team to start, Stacey Pugh, our Chief Commercial Officer, has chosen to pursue another opportunity outside of the company and will leave Butterfly as of November 24. I'd like to personally thank, Stacey for the contributions to Butterfly and her commitment to this organization. She has helped lead Butterfly through this time of transformation and has expanded our reach and healthcare institutions around the globe. We wish her the best in her future endeavors. As Butterfly, continues to grow and evolve. It is important that we continue to look at the business to make sure it is structured optimally. With Stacey's departure we took an opportunity to assess the needs of our organization to ensure we have the right structure and leadership. As of November 1, our commercial function is now broken up into 2 entities commercial operations, and commercial development. The commercial operations function will include all commercial operations and activities for North America in our core markets. The commercial development function will be responsible for all marketing operations, the veterinary business, and the international business and expansion. This new structure is intended to drive focus and tighter execution for our sales and marketing teams. With that said, I'm excited to announce 2 new additions to the executive leadership team to lead these respective functions. On November 1 [ Mike DelVacchio ] joined Butterfly as Senior Vice President, Commercial Operations and [ Nicky Montgomery ] joined as Senior Vice President, Commercial Development. Mike and Nicky are 2 highly accomplished leaders with deep relevant experience and track records of success with specific challenges Butterfly is facing right now. I look forward to their partnership and expertise to help us achieve our revenue goals and market adoption. As I've said before, we are making steady progress in the market and I would like to discuss some of our achievements in Q3. This past quarter, we introduced Butterfly Cloud 2.0 software a launch that included several new product features and the proficiency management solution for our blueprint platform that makes it even easier to manage your workflows and analysis across an institution. After implementation Dr. Ryan Gibbons, Director of Ultrasound Education at the Temple University School of Medicine said the Butterfly proficiency management system will lead to more recognition of the value that Butterfly brings to clinical assessment at the bedside. We know the power that ultrasound information can bring when it is unlocked at scale. Our job is to make it as easy as possible for people to acquire that information. Our proficiency management tool does that system-wide. And we believe this will help institutions accelerate adoption and utilization of ultrasound information in patient assessment diagnoses and treatment. We continue to see milestone achievements in each of our 4 pillars that are built on our foundational principles of easy everywhere and economical. If we take a look at hospitals and health systems for example the Butterfly solution is showcasing its relevancy across the country, irrespective of geography. We've closed deals in major health systems, large IDNs and rural healthcare institutions like Monument Health a community-based healthcare system in South Dakota that will now have blueprint system-wide coupled with a probe deployment. We are now providing blueprint at Yale New Haven Health and signed a new contract with Stanford that includes an expanded system footprint of our enterprise software and probes. And we continue to make progress embedding our overarching solution and major academic medical institutions across the U.S. This includes UC Irvine who for the fourth year in a row is utilizing Butterfly for the next generation of doctors. Each new student gets his or her own Butterfly a one-to-one model we are replicating across med schools. Because of this, the students are learning Butterfly powered assessment from the beginning of their training and they will now have this skill set as they become physicians and the ability to practice medicine differently. These are significant milestones in their own right and we're just getting started. With that said, let's move on to our international pillar, this past quarter Butterfly officially deployed 500 Butterfly iQ+ devices to healthcare practitioners in Kenya at an event at Kenyatta University. This deployment is supported by a $5 million grant from the Bill and Melinda Gates Foundation announced earlier this year that will provide 1,000 healthcare workers predominantly midwives in Sub-Saharan Africa, with the world's only handheld whole-body ultrasound probe to advance maternal and fetal health. According to the World Health Organization regional office for Africa, about 830 women die from pregnancy or childbirth related complications around the world every day with more than half of these deaths occurring in sub-Saharan Africa. The total of 500 practitioners will be trained by the end of the year in partnership with the Global Ultrasound Institute bringing ultrasound capabilities to over 50 facilities in rural underserved communities, facing maternal health challenges. This is just Phase 1 of this deployment. Another 500 probes will be deployed to South Africa early next year. From a global health context, this is the largest deployment of medical imaging in history and we are already hearing about the life saving impact it is having in this region from mothers and their unborn infants receiving ultrasound exams, for the very first time. Moving onto our third pillar home-based care, you've heard me say, as a digital health company, we are focused on unlocking information and helping make more informed medical decisions, no matter where they take place, especially as care is moving outside of the hospital. By facilitating more advanced assessment in non-traditional settings butterfly is key to advancing care outside the hospital where we see enormous potential for Butterfly to be an invaluable tool to help monitor and manage the health of those living with chronic conditions. This past quarter, we kicked off a clinical study for heart failure patients with the John Muir Cardiovascular Institution Research Department. This is a first of its kind feasibility study that will evaluate a novel tool developed by Butterfly and is designed to provide novice clinicians and patients with the ability to assess pulmonary congestion themselves, the most common reason for morbidity and mortality in congestive heart failure patients against an established implanted device. The value of Butterfly a noninvasive technology providing similar data to an implanted device could be a tremendous opportunity for managing the care of a rapidly growing population of CHF patients. This type of work that is demonstrating the capabilities of Butterfly to transcend the lens of traditional ultrasound and its current market is what makes us confident in our strategy and confident in our ability to reach a non-consumption user as an advanced clinical assessment tool. A tool that is far more valuable to a lot more people and allows us to take advantage of our core semiconductor technology, because it's about using information from ultrasound technology to guide care decisions and improve the lives of people, it's not about ultrasound machines or doing ultrasound. And finally, let's discuss our work in adjacent markets. As many of you know, we continue to find value in markets adjacent to healthcare such as veterinary medicine. This past quarter, Purdue University of College Veterinary Medicine announced that it will integrate Butterfly iQ+ Vet into the first year of their veterinary medicine programs. We're also excited to share that Texas Tech University we'll be expanding their partnership with us. The School of Veterinary Medicine has acquired additional Butterfly iQ+ Vet probes to assign every incoming student with the device for the duration of their education. We also added 10 Vet as a new distributor. They are regional distributor for the Eastern United States, which is the largest market in terms of volume for both vets and vet hospitals in the country. Lastly, as we help veterinarians along their journey of care transformation through the use of ultrasound information, we announced the collaboration with We See You Solutions, which will provide real-time one-to-one veterinary ultrasound education and care support services for hospitals. We believe as strongly today as we ever have, that Butterfly has the power to be as ubiquitous as the stethoscope and its utility in patient assessment across all specialties, species, and care settings. Providers using Butterfly now have access to valuable information when and where they've never had it before. They now have the ability to use the information that ultrasound provides much earlier in the care of a patient and in care settings where it's never existed. Only Butterfly can make that possible because our hardware enables the acquisition of information and our software makes that information usable and valuable to provide us of all skill sets in any setting across the entire continuum of care. Our path to transformation at scale is on the right track. And we are a young and agile company with fiscal discipline organizational optimization and learnings from end market experiences working to create every opportunity to accelerate growth and adoption. Heather will speak to this further and also take a deeper dive into the financials to give you a clearer picture of the results we are seeing.

Thank you, Todd and good morning again. Revenue for the third quarter of 2022 was $19.6 million a 34% increase versus the prior year period and our highest quarterly revenue to-date. Once accelerated on first half 2022 levels albeit at less than our internal expectations. Product revenue was $13.2 million, an increase of 21% versus Q3, 2021. This increase was driven by higher average selling prices in both our U.S. and international markets. In addition, total volume was up 3% with health systems volume up significantly and global health volumes more than quadrupling due to our launch with the Gates Foundation in Africa. Partially offsetting these increases was a reduction in e-commerce this trend of higher health system sales, partially offset by lower e-commerce is consistent with our strategy of driving adoption in health systems and de-emphasizing our individual probe sales through e-commerce. Software and services revenue was $6.5 million in the third quarter growing by approximately 71% over the prior year period. Software and services mix was 33% of revenue and increased by approximately 7 percentage points versus Q3, 2021. This increase was due to implementations that occurred in the quarter as well as a higher installed base of products with accompanying subscription software and increased renewals. We are encouraged by this momentum as we diversify our revenue from the aforementioned e-commerce channel to providing software and services to health system that enable more informed clinical decisions. Overall, we believe our Q3 revenue was negatively impacted by quarterly softness, as well as some intensifying macro trends, where we are seeing hospitals constrained not just budgetarily but also by the resources needed to implement. Internationally revenue was also impacted by the weakening of the euro, which made our products more expensive. I will touch more on these factors later when I discuss the full year guidance. Turning now to adjusted gross profit, adjusted gross profit was $12 million in Q3, 2022 compared to $7.2 million in the prior year period. Adjusted gross profit margin was 61% for the third quarter, which compares to 49% in Q3, 2021. This increase was primarily due to product mix, reflecting a higher proportion of subscription revenues in addition to higher device prices. Also contributing to the increased margin was higher manufacturing productivity partially offset by the increased cost of manufacturing materials. We expect our gross margin percentage will fluctuate quarterly along with the change in mix between product and subscription sales. We believe the fourth quarter we'll have a slightly higher percentage of product revenue. And as such, we anticipate a reverse margin percentage by a few 100 basis points. We do however expect that both our subscription sales as a percentage of revenue and gross margin percentage will increase for the full year 2022 versus 2021. For the third quarter of 2022 adjusted EBITDA was a loss of $32.9 million compared with a loss of $33.5 million for the same period in 2021. The improvement in adjusted EBITDA loss was driven by increased adjusted gross margin dollars due to the aforementioned positive product mix and ASPs. Partially offsetting these benefits were investments in our commercial and R&D functions as we build out our commercial operations and products. Moving to our capital resources as of September 30, 2022, cash and cash equivalents including restricted cash were $273 million. Our monthly operating use of cash was $15 million in the third quarter, down from over $18 million in the first half. In addition to our year-to-date operating expenses, our September 30, cash position was impacted by fiscal '21, annual bonus payouts capital expenditures for the build out of our headquarters, the annual renewal of insurance premium and inventory purchase obligations. In Q3, we implemented the previously announced plan to reduce cash expenses by approximately $36 million annualized when fully implemented by year-end. In addition to this plan, we continue to evaluate all spending to ensure it aligns to the strategic vision of Butterfly. Looking at our 2022 guidance interest in Butterfly is strong and the long-term opportunity and available market for our products is clear. As many in our industry have noted intensified labor constraints in the third quarter and associated budget pressures from temporary labor costs have limited client side implementation capabilities and cause deferrals in adoption of medical technology more broadly. As we do not have a good faith basis to assume that it will immediately reverse in the fourth quarter and as Todd discussed along with our change in sales leadership, we believe it is prudent to revise our full-year guidance to $73 million to $76 million. However, due to the actions taken in Q3 and additional control measures, we are able to reiterate our adjusted EBITDA guidance in the range of a loss of $155 million to $145 million. We need to be realistic about the macro and micro environment, where it is at its burden on health systems and how it affects our ability to grow quickly. As we are changing the way healthcare is delivered, having a strong go-to-market strategy that we can build on and optimize against is essential, but also having an environment where hospitals are able to invest in resources and grow their budgets is also important. Until then, we will remain laser focused on extending our leadership position that clearly differentiates Butterfly while working against the headwinds of a difficult macro environment. To close, in addition to seeing continued top-line growth in the third quarter we tightly managed expenses and reduced cash consumption. Our plan will allow us to navigate the headwinds from the macro environment, while still realizing the vision and mission of Butterfly. We have a solid cash position, and we plan to continue to invest in a targeted manner to maintain our momentum and continue to capitalize on this attractive market opportunity. With that I will turn the call back over to Todd for closing remarks, Todd?

Thank you Heather. Butterfly is a game changing technology solution to the current state of healthcare. Our technology works and our value is real. It is my hope that you walk away from this call. Having a better understanding of our path and appreciation for how we are navigating the market with our innovative technology and our ability to manage the foundational elements of the business to weather external factors. We understand the elements needed for the success of the Butterfly solution, hardware, software and connectivity and we are meeting our customers where they are and providing a blueprint to using ultrasound information to catalyze care transformation, fundamental to all of these achievements is our people. I'd like to thank them for their incredible hard work and commitment to this organization and to each other. Our employees are dedicated to our mission. I want to help realize our vision to impact the lives of people all around the globe. Our leadership and organization changes will help to ensure their success. In the challenging time for healthcare with increasing demand and a workforce that is stretch thin Butterfly is ultimately a solution that efficiently delivers better more informed lower cost care and while we continue to evolve our go-to-market and investment strategy to provide accelerated revenue growth and adoption, the achievements this past quarter still demonstrate that Butterfly's message is resonating broadly. As we finish out this year and move into 2023, our charge is to continue to walk this journey with physicians and care providers to get them to think about Butterfly technology and solutions differently. To get them to understand that Butterfly is the evolution of what they have previously known or been exposed to about ultrasound and Butterfly's accessibility, ease of use and broad utility, is the only solution out there that makes the evolution possible in all settings and geography. It's why Butterfly. And with that, we'll open it up to questions.

[Operator Instructions] Our first question comes from Josh Jennings from Cowen.

I was hoping to just start, Todd and Heather, just to ask about the sales funnel. If anything you can share quantitatively or qualitatively about how that's building out? It sounds like you are getting in front of more and more high-profile accounts and that maybe there's just with the macro environment, just some delays in finalizing contracts. But wanted to just better understand how the sales funnel has been developing and what sort of visibility you have within that pipeline?

So absolutely we see, we see our pipeline building. We also see the recapturing the revenue. So if you look at where revenue is coming from as it looks from hardware, software and our services, we see positive momentum in each of those aspects. We are lining up implementation and we see continuing build in sales funnels. So I don't know Heather, if you want to comment.

Yes sure, I'd also like to just emphasize on Todd in his script that the kind of delays that we're seeing are causing a push out in our funnel not people opting out of our products. So I think that's an important item to note as well.

And I wanted to just think about 2023. I mean I know entering 2022 Butterfly's foundation had evolved very nicely behind the scenes, but then you guys would be on everything that was happening in 2021 just in terms of building out the blueprint platform adding new compass and continuing to add to the technology, but as we're entering 2023 and a couple of months. How would you have us think about Butterfly's positioning relative to the start of 2022 in any kind of drivers that we should be considering as we model our forecast out in our models?

So Josh, I think when you look at 2023 the items that are impacting us this year with the budgetary constraints and the macro environment, we believe are mainly transitory. So we do expect to be able to enter 2023 strong and as the year progresses see improvement be the focus for next year and driving our product will be medical education, a continuation of the build of our software as well as global health. And I think we're well positioned to take advantage of those areas and Todd, you want to add anything.

Yes, Josh. I would just say that I think every minute, every day that we're in the market. We made progress in our customers understanding into where they can benefit and use the technology makes progress. I think as we look at the headwinds. I mean, everybody is seen that, I think as you look at the headwinds, at the end of the day, hospitals have to figure out how to take care of patients. As care continues to evolve itself as to what the next evolution of care is always going back to where it was. But as it continues to evolve, they're going to be looking into technologies that help them do that better Butterfly clearly comes out as part of the solution. As you start looking into more cost effective efficient care, that helps drive better quality. So we see very positive trends moving into 2003 and if you look at our fundamental elements of our technology, we continue to advance it and its performance. We continue to understand how it's being absorbed by our customers and helping them get on the journey faster, we're looking and segmenting as we get to the areas that we're making the greatest impact. I think Heather mentioned, we'll focus on med ed, global health, software enablement of the workflow and the adoption and utilization of the technology. So I think with the activities we're seeing in the market as we finish 2002 with where we see the macro evolving in '23. We're optimistic continued progress in 2020 moving forward.

Understood. And just one last question on the sales leadership change can you help us better understand, just how the sales strategy. The commercial strategy has evolved over the past 6 to 12 months and how do you think the new leaders could, what type of direction. We're going to take it from here. I know the WB, TBD as they're just getting on board, but any high-level thoughts would be appreciated?

Sure, absolutely. Look, if you think about what we're trying to do, if you just take a step back, right. We didn't invent ultrasound, right. Our technology is enabling others to re-imagine how they use ultrasound and what that means in the healthcare environment. So we have elements of our solution that make it a complex multi-level cell. So we've understood as we've been out in the marketplace. What we need to do with our customers in order to get them on the journey is complex part of what we're doing here is bringing in a leadership that understands how to work through these complex conversations in the market, reduce that simplicity and help our organization to be successful. We're doing that, both with our leadership and with our organizational structure to help our people and help our customers drive -- efficiency and effectiveness more rapidly and more efficiently and more enjoyably. So we are breaking that forward. So the commercial operations is really getting around the ultimate solution in helping our customers to implement that and realize the value of its you know across the entire continuum of care with a heavy focus on North America. We also understand that we need to continue to develop our technology to take more of the burden onto our solutions that we need to understand how to deliver that through our technology across hardware and software and across geographies. So our commercial development organization will have a greater focus on how we do that, how we support our commercial and selling activities and how we incorporate new and novel things into our platforms to help people get on their journeys faster. So this is comments from. And this is what I talked about with us being out in the market. This comes from a lot of learning by not just talking about it by being out there and we're really trying to learn be nimble and agile and help enable success of the company and our customers. And part of that is through the organizational change and the leadership change.

The next question comes from Neil Chatterji from B. Riley.

Great I guess, first off just wondering if you could maybe just talk more about the Yale and Stanford blueprint deals. And then just more broadly, with the sales funnel, I guess how much of the mix of opportunities more software based to start versus, say a hardware deployment and software?

I think, I would take a step back and say, if you think about how we are, how we need to and where the market is, we've talked about meeting our customers where they are and if you think about where our customers are, right. There people and institutions that are charged with managing and key chain and disseminating point of care ultrasound, right. And when they think about how do you do that. It's kind of been put on them because they have some expertise and then people realize there's value of that what we're doing with our software is helping experts both the expert huge and be able to help monitor the progress of how they disseminate that technology. And then help institutions, architect how they want to use the technology to deliver better care and then to help novices, utilize elements of that information into delivering better care. So if you -- so fundamentally in order to bring this to life you need a backbone to make that happen. That's what we learned, that's what we're implementing so our software really helps institutions experts and users go down there journey. And that comes back to fundamentally that our technology is revolutionary, because it allows you to use ultrasound -- information and acquire it differently, but our hardware requires the information, our software makes it user usable. Both in the device and in the application, and then we have an element of the connectivity that makes, that makes the information valuable in the context that you have it, which allows the information to travel across the continuum which then brings it into your ability to deliver care transformation. So it's a really important that we're not selling a widget and a device right, like this isn't like you back it up and sell ultrasound machine and let people use it. We are giving people the opportunity to re-imagine and benefit from ultrasound information, in order to do that our end-market learnings have helped us to see how we need to create some of the lines across the dots. To help our customers cross these things to think about how they can imagine care differently. So it's important for us to put the software and partner with them, help them understand how they are currently using ultrasound. How that they can evolve in the future to use ultrasound and how Butterfly can help them use ultrasound information differently. So it's a software, hardware enterprise solution sell. And so that's what's happening at Stanford, that's what's happening that Yale and that's our approach to helping people move forward with the journey.

[Operator Instructions] It appears we have no questions at this stage. So I am just going to -- oh there is one question from Neil again. I'm just going to open his line up again.

Sorry I had some follow-ups. Yes, just in terms of the healthcare spending environment just curious from -- at the customer level. Are you seeing any nuances there say are those labor and budget pressures more is it widely spread or are you seeing it more on the community health systems side versus say the academic medical center side, have you seen any kind of new mitigation strategies?

It's really hospital to hospital. Some folks have managed their finances as well through the pandemic and post pandemic and others have not. And then I think it's a pretty consistent theme across most of the health systems with the burn out of the clinicians and hospital staff. So, even the folks who have the budgets often don't have the resources, because they're not going to put another burden on their staff. So we are seeing it fairly widespread. Obviously, we still did have nice revenue in Q3. So it's not everywhere, but it's definitely more prevalent and became more prevalent in Q3.

No, I think we see it -- it's definitely a macro trend right, but I think in general healthcare is institution-by-institution difference the conversations that we're in. And I think that's obviously we meet our customers where they are both with their economic challenges are with their workflow challenges are, what their technology challenges are, we see it as an opportunity because there's a lot of flexibility in the Butterfly solution. It really can help you solve the problem that you want to solve and you know that's a blessing and a curse for us in the sense that we're getting people to understand that, it also brings some complexity to self. At the end of the day, it's far more an opportunity than it is a challenge and we just we're early in the journey we see positive signs across every aspect of the journey. And we definitely believe that at the end of the day, regardless of where you are as health institution Butterfly will be part of your solution moving forward.

Got it. And then just 1 more follow-up in terms of the adjusted top line guidance so is that reflective mostly of the macro environment or are you expecting some disruptive impact that commercial lead should changeover and organizational restructuring?

Look, I think it's just a combination of all, I think we're trying to, I think we're trying to be good partners. We're trying to be prudent about how we go about doing this. We're really optimistic. We have lots of good signals. And I think we're early, right. So when we look at some, it every action kind of has an opposite reaction, right? We're building. We're growing. And so we want to be prudent about the impact of the macro environment, the complexity of the cell, the changes that we're making organizationally and we just want to be cautious, moving forward. We're very optimistic about how things are going. We're getting very positive signals. But we also want to be realistic and good partners in the marketplace.

All right. That's it from me.

Thanks, Neil.

Thanks, Neil.