Transformational Blueprints

Ryan Macy is the CTO of 25 Madison, a venture studio in New York that builds, invests in, and operates early-stage companies across healthcare, AI, and supply chain. He’s helped launch more than a dozen companies from scratch, and before that scaled engineering at Reify Health (pharma unicorn) from 50 to 300 engineers, founded Satchel Health (post-acute telemedicine, raised millions, exited), and cut his teeth at startups in Nashville going back to the early 2010s.
We talk to Ryan about what actually needs to be figured out first when starting a health tech company from scratch, why he deliberately avoids integrations and architecture at day one, and why the number one worst thing you can do in software is build something with the intention of keeping it that you’re going to throw away.
Ryan also breaks down his ideal first five engineering hires (all the same profile: high agency, high empathy, gets mad when they don’t talk to the customer), why he doesn’t care about healthcare experience when hiring, and why he ends interview calls early out of respect rather than dragging someone through a process that isn’t working. He gets into the real risk of AI-assisted development (deploying your next bug instead of your fix), why insourcing is the competitor most SaaS CTOs aren’t talking about, and the two engineering philosophies that have kept his teams from creating unmanageable technical debt across a dozen companies.
Watch the episode on YouTube: https://www.youtube.com/@SynaxiaGroup
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Extra Stuff:
Extra Stuff:
For hiring teams
Answer five short questions about the engineer you need. You see profiles of digital health engineers who match, with a live salary guideline for the role. Pick the profiles you like and we introduce you. It takes under 60 seconds. It covers founding engineers, full-stack engineers, AI engineers, engineering leaders and CTOs.

For engineers and market watchers
Digital Health Startup Careers tracks 550+ digital health companies and their open roles. Browse the Market Overview, Companies, Live Roles, Funding Radar and Salary Guide pages. The data refreshes every Friday. Engineers register to get matched to roles, including roles not listed publicly.

Do you want a copy of our Startup Engineering Market Report?
What's in the report?
Who's hiring the most engineers in your region/industry?
Gender diversity statistics
Is demand for engineers increasing or decreasing?
What are the key trends in the startup market?

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Get in touch: https://www.linkedin.com/in/mario-michaels/
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Follow the Podcast: https://www.linkedin.com/company/transformational-blueprints-podcast/
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Follow Synaxia Group: https://www.linkedin.com/company/synaxia-group/

Most healthcare systems have no usable API. Somewhere in every clinic, hospital, and services company, a person is logging into one system, reading a screen, and retyping what's there into another screen. A thousand times a day.
David Mlcoch is co-founder and CEO of Asteroid, a YC W25 company building AI-powered computer use agents for healthcare. Asteroid's agents log into EHRs, payer portals, government registries, and legacy desktop systems, and do the workflow a trained employee would do. At scale, with guardrails, and with humans approving every high-risk action.
David's background is in AI from Edinburgh University, autonomous agents, robotics, and space tech. He co-founded Asteroid in 2024 with Joe Hewett, who previously used LLMs at Netcraft to disrupt hundreds of millions of dollars of fraud. The company is backed by Y Combinator, Entrepreneur First, and angels from OpenAI and Hugging Face.
Mario talks to David about why he pivoted from building an AI oversight layer to being the agent itself, what it's actually like to automate a portal nobody fully understands anymore, and why prior authorisation was the hardest category to crack. They also get into the self-healing experiment that went wrong, why David would rather an agent fail than produce a false positive, and what stops OpenAI and Anthropic from doing what Asteroid does.
This episode directly connects to the problems described in previous episodes. Data not moving. Systems not talking. Humans being the integration layer. David is building the infrastructure underneath all of it.
Timestamps
The problem in plain terms. Someone in every clinic is reading one screen and retyping it into another, a thousand times a day
What makes a great software engineer in 2026.
Startup engineers are different.
Advice for software engineers right now. If your company won't let you use Claude Code or Cursor, leave immediately
The connection to previous episodes. Data not moving because nothing connects. Asteroid sits underneath both problems
How Asteroid started as a supervision layer and pivoted to being the agent. Why customers kept asking "can you build the agents instead?"
"The developer who wrote the system is not even alive now." What it's actually like to automate a healthcare portal nobody fully understands. Systems from 2009, Citrix-served pixels, sessions that expire every 10 minutes
Asteroid Integrate. Hundreds of pre-built healthcare connectors. Why prior auth was the hardest category to crack: high-branching forms, no sandbox, one try per case, a thousand payers changing criteria constantly
What self-heal actually means in a HIPAA environment. Why Asteroid minimises AI during execution and requires human approval for every significant step
The hybrid approach. DOM-based parsing versus screenshot-based computer use. The 13-digit number that only read 12, and why eliminating false positives matters more than completion rate
If every EHR opens proper APIs, does Asteroid become unnecessary? Why David would love that but isn't betting on it
How EHR vendors feel about browser agents bypassing their $2-per-call APIs. Why Asteroid acts on the customer's authority to reach data they're already entitled to
What stops OpenAI and Anthropic from doing this? Why general-purpose browsing agents are features, not companies. Why OpenAI deprecated Operator
Build versus buy for Series A/B CTOs. Build when you have one or two portals. Buy when you're spending 18 months and three engineers on plumbing instead of product
What healthcare back office looks like in five years if Asteroid succeeds.
The workflow that's still too hard today but won't be in 12 months.
The self-healing experiment that went wrong. Why fully autonomous agents rewrote themselves for a temporary error and broke two days later
Advice for early-career technical founders.
Where Asteroid is investing in 2026.

Watch the episode on YouTube: https://www.youtube.com/@SynaxiaGroup
-------------------------
Extra Stuff:
Extra Stuff:
For hiring teams
Answer five short questions about the engineer you need. You see profiles of digital health engineers who match, with a live salary guideline for the role. Pick the profiles you like and we introduce you. It takes under 60 seconds. It covers founding engineers, full-stack engineers, AI engineers, engineering leaders and CTOs.

For engineers and market watchers
Digital Health Startup Careers tracks 550+ digital health companies and their open roles. Browse the Market Overview, Companies, Live Roles, Funding Radar and Salary Guide pages. The data refreshes every Friday. Engineers register to get matched to roles, including roles not listed publicly.

Do you want a copy of our Startup Engineering Market Report?
What's in the report?
Who's hiring the most engineers in your region/industry?
Gender diversity statistics
Is demand for engineers increasing or decreasing?
What are the key trends in the startup market?

-------------------------
Get in touch: https://www.linkedin.com/in/mario-michaels/
-------------------------
Follow the Podcast: https://www.linkedin.com/company/transformational-blueprints-podcast/
-------------------------
Follow Synaxia Group: https://www.linkedin.com/company/synaxia-group/

People with ADHD have twice the rate of death before age 46. Optimists live 11 to 15% longer. And poor social relationships increase your mortality risk by 50%, double the impact of high blood pressure.
Dr. Srini Pillay is a Harvard-trained psychiatrist, brain imaging researcher, executive coach, and co-founder of Reulay, an AI-powered platform delivering visual therapeutics grounded in neuroscience. He's worked with leaders at McKinsey, Harvard Business School, and Duke, and was named one of the top 20 movers and shakers in leadership development globally.
Mario talks to Srini about why the brain is the most under-invested asset in any organisation, what nine specific mindsets are scientifically linked to how long you live, and why the most pragmatic leaders are often the ones making the worst decisions under pressure.
They also get into what makes a great engineer in 2026 (hint: it's not programming), why Srini would hire for reinvention over adaptability, and the one mental shift he thinks every founder and technical leader should make today.
We cover;
Srini's path from psychiatry and brain imaging at Harvard to biotech, executive coaching, AI music, and co-founding Rulai
Why separating the brain from the body is the fundamental mistake in mental health
What Reulay builds. AI-generated visual therapeutics using nature, geometry, and fractals, with a patent and preliminary results from Mayo Clinic and Blue Shield of California
The nine mindsets scientifically linked to longevity. Focus, optimism, confidence, awe, body awareness, connection, autonomy, resilience, and empowerment
What makes a great engineer now. Why the job has shifted from programming to overseeing systems, speaking across domains, and integrating AI agents
Why emotional regulation is the hidden performance variable in technology teams. How stress hijacks the thinking brain and forces linear thinking when you need complexity
Beyond resilience: anti-fragility. The flower delivery company that pivoted during COVID, and why "psychological Halloweenism" unlocks creativity your normal self can't access
How Srini changed an insurance company's entire strategy in one day by walking their leadership team through possibility thinking before the strategy meeting
Why Reulay isn't Calm or Headspace. Higher adherence, multi-platform deployment, deeper science, and a thesis built on the mind-body connection rather than relaxation alone
Why AI won't replace an empathic brain. Human intelligence runs on the brain, the gut, the heart, and the immune system. AI is built on cognitive architecture alone
Is the market ready for psychogenic longevity? Why Srini thinks he's ahead of demand and why that might be the right place to be
The reality of selling wellbeing to enterprise. HR budget constraints, solution fatigue, and why Srini believes Reulay is fundamentally a consumer product
Digital therapeutics took serious hits after the Pear collapse. What makes Reulay different and why agility at small scale is an advantage, not a weakness
Where mental health funding is going wrong. Most investors are ignoring the mind-body connection and funding linear solutions to nonlinear problems
The biggest mistake leaders make right now. Over-focusing. Why the default mode network only activates when you stop concentrating, and why your best ideas come in the shower
How to hire for reinvention. Why Srini would favour liberal arts exposure, watch for non-verbal rigidity, and run imaginary scenarios to test cognitive flexibility
The career advice Srini wishes he'd received earlier. Distribution beats product, and intentional networking beats networking for its own sake

Watch the episode on YouTube: https://www.youtube.com/@SynaxiaGroup
-------------------------
Extra Stuff:
Extra Stuff:
For hiring teams
Answer five short questions about the engineer you need. You see profiles of digital health engineers who match, with a live salary guideline for the role. Pick the profiles you like and we introduce you. It takes under 60 seconds. It covers founding engineers, full-stack engineers, AI engineers, engineering leaders and CTOs.

For engineers and market watchers
Digital Health Startup Careers tracks 550+ digital health companies and their open roles. Browse the Market Overview, Companies, Live Roles, Funding Radar and Salary Guide pages. The data refreshes every Friday. Engineers register to get matched to roles, including roles not listed publicly.

Do you want a copy of our Startup Engineering Market Report?
What's in the report?
Who's hiring the most engineers in your region/industry?
Gender diversity statistics
Is demand for engineers increasing or decreasing?
What are the key trends in the startup market?

-------------------------
Get in touch: https://www.linkedin.com/in/mario-michaels/
-------------------------
Follow the Podcast: https://www.linkedin.com/company/transformational-blueprints-podcast/
-------------------------
Follow Synaxia Group: https://www.linkedin.com/company/synaxia-group/

Matt Solnit spent 26 years in enterprise technology before walking into healthcare knowing almost nothing about it. He's now CTO of Pearl Health, a value-based care platform supporting over 10,000 providers and a quarter of a million Medicare beneficiaries across 40+ states.
Mario talks to Matt about why US healthcare data access is shockingly poor in 2026, how Pearl uses predictive models to tell doctors which patients need attention before they end up in hospital, and what it took to get an entire engineering team to a 96% Claude Code acceptance rate. Matt also gets into why he thinks humans will stop writing code within 18 months, how Pearl built an AI on-call agent that cut analyst ramp-up time in half, and why identity remains an unsolved problem in American healthcare.
In this episode, we discuss;
Where the data comes from.
Day-to-day as CTO. Identifying where to apply technology, guiding the board, and why ChatGPT's launch five months after he joined changed everything.
What makes a great engineer in 2026.
Startup engineers versus enterprise engineers.
Why Matt chose healthcare.
The 96% Claude Code acceptance rate. How a $20,000 Anthropic credit led to company-wide standardisation, and why command-line tools converted the holdouts.
Balancing technical skill and cultural fit.
Building culture in a remote-first company.
The AI on-call agent.
Where AI stops and humans start.
The identity problem in US healthcare.
Advice for new CTOs.
What Matt would tell his 2022 self.

Watch the episode on YouTube: https://www.youtube.com/@SynaxiaGroup
-------------------------
Extra Stuff:
Extra Stuff:
For hiring teams
Answer five short questions about the engineer you need. You see profiles of digital health engineers who match, with a live salary guideline for the role. Pick the profiles you like and we introduce you. It takes under 60 seconds. It covers founding engineers, full-stack engineers, AI engineers, engineering leaders and CTOs.

For engineers and market watchers
Digital Health Startup Careers tracks 550+ digital health companies and their open roles. Browse the Market Overview, Companies, Live Roles, Funding Radar and Salary Guide pages. The data refreshes every Friday. Engineers register to get matched to roles, including roles not listed publicly.

Do you want a copy of our Startup Engineering Market Report?
What's in the report?
Who's hiring the most engineers in your region/industry?
Gender diversity statistics
Is demand for engineers increasing or decreasing?
What are the key trends in the startup market?

-------------------------
Get in touch: https://www.linkedin.com/in/mario-michaels/
-------------------------
Follow the Podcast: https://www.linkedin.com/company/transformational-blueprints-podcast/
-------------------------
Follow Synaxia Group: https://www.linkedin.com/company/synaxia-group/

Peter Csiba has spent twenty years building infrastructure that can't afford to be wrong. Web search at Google. Platform engineering at Robinhood, handling roughly a billion dollars a day in transactions. Now he's Engineering Manager at Assort Health, leading the team responsible for EHR interoperability at a company that just hit unicorn status, a $120M Series C from Menlo Ventures, $222M raised total, revenue up 20x in fifteen months.
Mario talks to Peter about what actually breaks when you try to write data back into Epic without disrupting a health system's workflow, why he moved too fast with EHR partners early on and had to rebuild that trust, and what the Robinhood outage of January 2021 taught him about engineering for systems where the cost of being wrong is high. Peter also gets into the "write-only code era," the tension between flashy AI-generated demos and real engineering rigor, and why he thinks getting your first EHR integration right is a people problem before it's a technical one.
For any CTO or VP of Engineering thinking about their first healthcare data integration, or any engineer wondering what actually predicts a good hire in a fast-scaling startup, this one's dense with specifics.
What Makes Great Engineers
EHR Interoperability with Epic
Scaling Integrations Seed to Unicorn
AI Code Output vs Healthcare Rigor
Lessons from Robinhood Outages
Risk vs Compliance Balance
Outages and Shipping Speed
EHR Interop Edge Cases
API Limits and Monetization
Voice AI Startup Lessons
Founder Stress and Volatility
First EHR Integration Advice
Finance vs Healthcare Mindset

Watch the episode on YouTube: https://www.youtube.com/@SynaxiaGroup
-------------------------
Extra Stuff:
Extra Stuff:
For hiring teams
Answer five short questions about the engineer you need. You see profiles of digital health engineers who match, with a live salary guideline for the role. Pick the profiles you like and we introduce you. It takes under 60 seconds. It covers founding engineers, full-stack engineers, AI engineers, engineering leaders and CTOs.

For engineers and market watchers
Digital Health Startup Careers tracks 550+ digital health companies and their open roles. Browse the Market Overview, Companies, Live Roles, Funding Radar and Salary Guide pages. The data refreshes every Friday. Engineers register to get matched to roles, including roles not listed publicly.

Do you want a copy of our Startup Engineering Market Report?
What's in the report?
Who's hiring the most engineers in your region/industry?
Gender diversity statistics
Is demand for engineers increasing or decreasing?
What are the key trends in the startup market?

-------------------------
Get in touch: https://www.linkedin.com/in/mario-michaels/
-------------------------
Follow the Podcast: https://www.linkedin.com/company/transformational-blueprints-podcast/
-------------------------
Follow Synaxia Group: https://www.linkedin.com/company/synaxia-group/