How to raise money as a first time founder: Joshua Liu - SeamlessMD

0:00 Hey everyone, I'm really excited to bring you this conversation with Josh. I had so much fun talking to Josh. Josh is the founder and CEO of SeamlessMD. SeamlessMD is a patient engagement platform which is used by numerous hospitals, including Stanford Health. It reduces the patient length of stay, reduces readmission rate and costs. They have raised over $7.5 million in funding so far. Josh has won numerous awards, including the Digital Health Executive of the Year by Digital Health Canada, Forbes 30 under 30 in science and healthcare, the Canadian Top 20 under 20, TD Canada Trust Scholar, the Creative Destruction Lab alum, and he's also an alum from the Next Canada.

0:46 He was the chair of the Canadian Medical Association's Innovation Council, and he was also on the advisory group to the Office of the Chief Health Innovation Strategist for the Ontario Ministry of Health. He has also served on the board of directors at Chad Valley and a startup advisor to Northeastern University. Josh is intelligent, humble, and possesses incredible grit and perseverance. We talk about his childhood, his journey from an interest in coding to medical school and then in being a founder. We discussed Chad's GPT, AI and healthcare, the future of private healthcare in Canada, raising money for his startup, and how 90% of the VCs he met initially said no.

1:31 We also get into his end goal in life and with a startup. I hope you guys enjoy the conversation as much as I did. Before we get started, I do have one simple ask. If you enjoy this podcast and this channel, please subscribe and it will help support the channel even more. Thanks so much for listening and watching everyone. Hey Josh, thanks so much for being here today. I've been really looking forward to this. I think let's go back in time and start at your childhood. Our childhood defines who we are to a fairly big extent. Talk me through your childhood and what are some learnings you took from your childhood to now and what are some things you had to unlearn from it?

2:14 Yeah, I would say for me a couple of things. So one is I've always been very much a builder. Like I won't say I've always been an entrepreneur per se, but I've always been very much a builder. So for me, when I was 11, the internet was still kind of new, but I had a friend in school who got really into building websites. So then I started learning how to use, and I'm going to date myself, Microsoft front page to build a website. And then from there, I started learning how to do basic coding with HTML. And so by the time I was in high school, and my teachers had no idea what it took to build a website, I was building websites for school projects.

2:56 Back then that was amazing. So I did that. And then when I got to high school, up until then, I had been very much academic oriented. So I was very much focused on grades in school and all that. But it was in high school when I really started to, I think, break out of my shelf from a social skills, interpersonal skills point of view. And so I think going again back to being very much a builder, I started really getting not only involved in my community, but in building stuff. So I started school clubs and nonprofit groups and things like that. And that really got me exposed to leadership and teamwork and communication and public speaking.

3:41 And so I think I went into school being very academically inclined and then graduated still, I mean, caring about academics, but becoming much more well rounded person. And then, and then going from there. Interesting. I'm trying to put you in a box and maybe I shouldn't because I'm finding it incredibly difficult. As you said, you're a builder. You look at things as a builder from first principles of breaking things down, but you're also getting to public speaking, which, and trying to fit socially. Those are two different people in most people's eyes.

4:21 How did you go about marrying the two, and which one do you enjoy the most? Do you enjoy the socializing public speaking part of your life, or do you enjoy the solo work building part of your life? It's funny, I enjoyed both for different reasons. So I think, you know, I very much like the, let's call it the zero to one phase of building things and I think, you know, building websites was going from zero to one as a solo, you know, individual creator, let's say. And I would say where things like public speaking and teamwork and leadership come in is, how do you go from zero to one as an organization, right. So when I started getting into like, hey, let's build a school club to solve this problem or this nonprofit group.

5:08 Well, it's not about just me anymore, right, you have to interact with teammates, you have to sell other people on a vision for why you're starting this club, you have to start, you know, convincing other people in the ecosystem to support your vision. And so then to go from zero to one and build a team or organization, then you have to develop all those other skills. And certainly today like building a company, I would say I'm spending a lot more time building in a social interpersonal point of view and not so much from an individual point of view, but actually even then we'll get to this later but when we started my company CMSMD with a very small team of you know, three, you know founders initially, a lot of going from zero to one was individual work and then now that you know we're at almost 40 people a lot of my work now is interpersonal communication teamwork etc.

5:58 Yeah, I completely agree I was surprised how much of building a startup and my startup was fairly small 10 people is managing people and how much time that took. Let's talk about hiring. And let's look at it from a frame of structured decision making versus intuition. Tell me your, your weightage for each structure and intuition when hiring. And how do you go about selecting a co founders, and then be your first tires. Yeah, so I mean, selecting co founders. I actually can't give you great advice on that because I went through a unique process where I didn't completely select my co founder so just for context.

6:47 When we started seamless and the we did it through an incubator called the next 36. And the way that worked was individuals across Canada, who were interested in getting involved in entrepreneurship could apply. And then they would pick 36 people across the country to this program. And then at the time at least, they would decide based on your prior interest and skill sets. What group of three should be in to start this journey together. Now you can imagine that because chemistry is so important. Many of these groups of three did not work out. And I would say that my two co founders, we were one of the few that actually survived as a team and went on to build a venture that's still around today you know about 10 years later.

7:34 So unfortunately I am not great at telling you the right ways like co founders, I will say one thing I learned though. Because actually, the year before we started seamless MD and before I did this business incubator. I tried starting and I failed at building a completely different healthcare technology venture. And in that one, I had started it with two friends from med school. And I think one of the reasons why we weren't successful is because we were all clinical people so our skill sets overlapped. None of us were technology people or could build a product. And I think one of the reasons why I did the business incubator was I wanted to find people who had skill sets that I didn't have around engineering, technical and otherwise.

8:15 And so for me the big learning was okay you got to have complementary skill sets you can't have too much overlapping effort or else you just can't move quickly enough. I completely agree. And that's advice I got an ignored from some mentors in my startup as well. Let's go back to high school. So you're a coder. Your speech your public speaker as well. It seems like the two paths I would see based on that would be software engineer or politician. But you end up into medical school talk to me about the journey to med school was that always in the cards. Or how did you reach that decision.

8:56 Yeah, I would say it was the cards for a while I mean I grew up, you know, really interested in, in medicine, I think, to be fair, like I grew up in a, you know, I think a traditional Chinese household where like medicine was one of the career opportunities that you know was like recognized and admired and all that I was certainly influenced by some of those, those ideas. But I'll tell you even when I was doing undergrad and I was preparing for medical school do my MCATs and my pre recs and all that kind of stuff. I still wasn't really sure if I wanted to do medicine. But I wasn't sure what else I wanted to do so I applied and say hey I don't have a better plan so I did and I was lucky to get into medical school.

9:39 But you know even in in medical school. I wasn't really sure what I wanted to do you know some folks know they want to go into family medicine or surgery or cardiology. I thought I wanted to do neurology and then I shadowed some neurologists and realize I wasn't as excited about as I thought I would be. And where I got lucky was I had some great mentors who got me more interested in quality safety and patient experience, they took me under wing. And so, at UHN, I ended up doing some research in med school on preventing readmissions after hospital discharge. And I became from very passionate about that topic and quality and safety and ultimately trying to solve the readmissions problem that led to me, you know, starting SeamlessMD which we can get to later. And so it's funny because I never planned to go into healthcare tech entrepreneurship, but if I hadn't done medical school there's no I would have kind of gone on this path in the first place.

10:41 What advice do you have to medical students who want to follow in your footsteps? Yeah, I was fine there are a lot more medical students nowadays who are very interested in this atypical career path. The advice I always give folks in med school is like number one. It's totally normal if you don't know what you want. You don't know what specialty you want in fact you might change your mind after you start it so there's no there's no sure thing. I always tell people, the important thing is to follow your curiosity and see where that leads you. And that means, if you get curious about something, read more about it, shadow, do research on it, go to a conference, work on a project there, and either you'll find out that you actually are curious about it and you'll keep doing more in it, or you'll realize you don't like it and you can cross off your list, but just keep following your curiosity and that's what I did right like I was curious about readmissions and then I was curious about startups and then, you know, like by chance, and by the way, didn't always work out like I had a failed startup.

11:42 Yeah, and then another one that that's still around today and so if you follow curiosity I feel like you get to a good place. And did you do a residency Josh. I did not so I actually had gotten into family medicine residency in Toronto. And what happened was that normally starts, you know, July 1 right. The incubator that I had started doing in my last year of med school for seamless MD that incubator ran until the end of August. So originally, my residency program said okay well like just start September 1 I said great. And then when we got to the end of August. They said well Josh like, what do you want to do do you want to do like 5050 time between residency and seamless do you want to do 9010 time they were incredibly supportive.

12:31 But I decided was that I didn't think I could do two things really well, and then I didn't want to do two things, you know, with it with that you know half effort. And so I said hey you know what I want to see where the seamless MD thing goes. How about we talk again in the year. And then, you know, maybe, maybe we'd be dead by that maybe didn't work out or maybe I'll do something else. And then basically, every year for several years I would come back and they would say well Josh are you coming back to residency now and say, well no because I'm still, I still want to see where this is going it's still growing. And then at that point, you know, they were so generous like after five years, like, they were like hey Josh, we can't keep this annual thing going anymore you're going to come back or not.

13:13 And I was like, I'm so grateful for all the opportunities you gave me but I'm just so all in on this there's no way I could, you know, do this part time or anything. So, there you go. That is a fascinating answer and a very brave decision from my perspective. What do you have to yourself as a med student if you were to go back in time. Yeah, I don't know there's too much I would change that I think one of the things I've come to believe is that my situation now is a result of all these compounding experiences right and so even if I think I can go back in time and optimize something that actually has to come in a way that may not have been necessarily a good thing for me. I do think that being said though I do wish I'd spent more time probably learning other skill sets that would be relevant from doing now so for example, you know, I, I know enough technology stuff I can speak to seamless MD, but I kind of wish I was more technical in some ways I wish I had a better technical mind. And so I think going back, given that like I always believe that as you get older your your schedule gets to do things gets smaller in terms of like your daily time window.

14:27 I feel like I had more time back then to explore stuff so I wish I had spent more time, like learning more basic technical skills around like coding and development or just technical architectures because now I'm just like either too lazy or just too busy to have more technical foundation, but I wish I spent more time learning about technology back then. Do you think with the rise of Chad GPT writing code to an extent, poor code from what I know is, are the new coders people who are using no code tools or AI to write their code? Or what is the market like for software engineers of the future you think. Yeah, I mean it was out of the green and so because I'm making I'm not technical, so I don't really live in that world from a software development point of view.

15:14 I don't. I think it's likely I think people have used this phrase already words like, you know, chat GPT or a in general is not going to I think replace a lot of what humans do, but I think those who use it will have an advantage so you might as well learn how it could could benefit you so I think to your point there may be a lot of repetitive tasks that similar AI tools could use to streamline development. And I think probably one of the lower hanging fruits is if you're learning the fact that you can use something like chat GPT to understand you know how should I code something, or how should I troubleshoot this issue and the fact that it can scan a lot of, you know, past data and language and actually help generate well here's, here's a framework or here's code that others have used to solve this problem.

16:02 And the fact that you can like learn faster and improve your skills faster I think that's probably the lower hanging fruit that people are already taking advantage of. And then some ways your point, some of these tools and like no code tools, make producing software more accessible to the average person so you know in the future, will people, how much code people have to know or what formal coding take could be very very different. And I think people who have a sound technical understanding and mine will always have an advantage so I think the best people in the development space will always have incredibly strong fundamentals that they can design the technical world with as much detail as possible and those who don't have that technical foundation will probably have some limitations at the end of the day.

16:47 So I think it's still important but I think you're right I think it will make development more accessible to more people. Whether you know, code or not. Yeah, I agree with that. I'll ask another question about chat GPT. For those who don't know, it recently passed the USMLEs or our board exam in the states, and also a test by a Wharton MBA professor. Were you surprised by that. Yeah, the second part of the question is, there is a decline in the value of expertise in general. And then by default a decline in the value of physician expertise. You think chat GPT will exacerbate that decline.

17:28 So I'll take a step back first and then I'll get into the specific GPT example the USMLEs so I mean if you think about decades ago right we had schools and the big focus on school was, we had to teach students knowledge, right, because knowledge was what was powerful at the time. And now, knowledge that your fingertips so now it's not as important that students go to schools universities to learn facts because you can search for answers so clinically. I don't have to know everything and up to date. I can look up to date to find clinical information whereas maybe 200 years ago I had to memorize all this information because it was not my fingertips so we've democratized access to knowledge. And so being able to make good judgment and clinical assessments and decision making is far more valuable than just having knowledge. And so, you know, and then when I think about something like chat GPT, and it's able to synthesize this information, and, you know, do more than just without knowledge, maybe in some ways to the size, you know good insight with that knowledge, but even like the USMLE or some of these clinical exams.

18:31 They're very often very straight, I would guess I haven't read the assembly but a lot of very straightforward scenarios, or very clear like solutions to questions. Whereas, in the real clinical world, when you're making judgments where there's often imperfect information, you have to incorporate way more context than what's in a, you know, five sentence, then yet. You know, I think you're too like chat GPT are going to be helpful for us to maybe pull insight from the evidence or from data more quickly, but I think very often you still need that great clinical judgment that so far only human can do.

19:13 I do think there's quite some point in the future where AI will be good enough that you can reach that like I don't know if you've ever seen Star Trek, but in Star Trek they have this like AI hologram doctor who's human like, and, and it looks and feels like a human physician, and they basically act as the doctor for people for humans. Um, can we get to that point I think that's totally possible but I don't I think that's quite far away but in the meantime I don't think something like chat GPT could replace that clinical judgment, that's that can understand the complexity needed for real clinical care, but when you're talking about like these vignettes in a written exam yeah I'm not that shocked that it could score pretty well.

19:59 So, from what I'm getting at is there's a knowledge is not as valuable anymore because of the democratizing of access, but the application of knowledge and decision making is as valuable as ever. That being said, our testing in medical school, law school, different schools is still based on knowledge. It's based on recollection memorizing facts. So we should move away from that testing, and if so should be moved more towards an OSCE based scenario of testing. So, I do think it's hard for me to say like how much knowledge is sufficient necessary but you do need some foundational clinical medical knowledge, so that you even can be resourceful and looking up more information as needed.

20:52 So we probably debate how much of the detail currently be taught in medical school is necessary but I do think some foundational, a significant amount of initial knowledge is needed so that you can actually interpret data well and and and use it properly and you're not starting from scratch with every clinical encounter. But I do think that in the future. Whoever the clinical encounter changes like let's say in the future, the clinical counters a situation where maybe you do have an AI assistant who is, you're able to have your fingertips to access information or access predictive analytics about a patient or anything like that. So, whatever the encounter looks like that should probably be at some point what the OSCE is like the OSCE shouldn't match the real clinical encounter and if in the future we're relying on AI assistants to treat patients, then the OSCE at some point should evolve to match that.

21:47 So as long as that I think is similar enough I think you know we'll be doing medical education in the right way. It's kind of like I think about like let's say, it's funny I mean think about like let's call it like cars and autonomous driving and all that right so you can argue at some point, maybe drivers licenses are obsolete because no one's driving anymore and at that point, the only people with drivers licenses are professional race car drivers because that's still a sport or something like that. So let's say in the meantime, we have a lot of AI assistant driving, then probably when you're doing like a driver's license right now like they should actually expect and appreciate that you may be using an assistant driving and that might be the right thing to do like can use the AI properly if not you should get your license maybe at some point. I don't know.

22:36 But I think I think the real world should mimic the educational world, or vice versa. Yeah, this is an interesting debate where as AI does more and more of our work. At what some point we solely exist to offload liability from the eye and the patient. When do you see that transitioning. And say we have the Star Trek version of this AI physician, and no human is involved no human physician is involved. What is the liability rest on the AI on the patient, or is there a shared liability model. It's a great question so I think the analogy I tend to think about is like let's let's take medical imaging because that's probably the lowest one of the lowest hanging fruits when it comes to AI and medicine.

23:22 So, you know, there's a question of well like, on the one hand, if everything was purely a human assessment by radiologists and let's say there was a radiologist error who is making countless errors in their reports. Well then someone could say well, this one human radiologist had a massively high error rate. If we have radiologists from the system. Then we've gotten rid of the error or if we retrain them or they fix their problems, but no one else is affected like all the radiologists are fine. Whereas if you had an algorithm, an AI model for radiology that had errors, then every image is read incorrectly, and the massive scale that impacted is bad until you fix that problem.

24:04 I think that's where people get worried about AI thinking that, yes, benefits get scaled but so do errors. So the way I look at it is, is like what is the total error rate or the total benefit and so for example, you know, even if an AI model and imaging does have errors. But if it in aggregate has fewer errors, first of all, the error would never be zero. Right, so I think people keep thinking that as we perfect well humans are imperfect the human radiology error rate is not 0%. I hope it's small but it's not 0%. So in the same way to think that AI would be 0% is flawed thinking the first place it's even humans can get to 0%. But if the total error rate from an AI is lower than the human error rate and aggregate as close as 0% as possible. I think that's actually a good thing and we should strive to get closer to 0% and if it gets us closer that's better.

24:56 So if it's a reliability question then the question I have is like well, at the end of the day, the software is an assist. But in the day like the, the healthcare system should own the outcome. Right. So for example, if we're the system has to the healthcare system has to decide is the AI good enough or so much better than us that we shouldn't have humans looking at it at all. So I think that's your point should AI be an assist that just lets us do more at scale. And at the end of the day it's like, and I don't know the legal stuff so it's probably something in law that decides when when liability passes off from a provider to technology there's probably some precedent set in law, and probably the end of the day both parties get gets get sued or in trouble to be honest that's probably what really happens and then they end up negotiating, who takes all the more blame than the other.

25:50 But I think ultimately like the provider has to decide the level of risk they're comfortable with and how much confidence they have in, in the AI. But yeah, there's probably legal precedent so that's a good question. Yeah, generally from what I've seen it falls on the standard of care, determined by what your peers would do, which is good and bad because it sets a baseline for not practicing aggressive or risky medicine. But it also curves innovation, because any deviation from the standard of care by default is opening yourself up to malpractice. Okay, so that basically of none of your peers are innovative or using AI and medical imaging than the standard of care was not using.

26:35 Which is, it sounds silly when you say it but I don't think that law will change anytime soon. For better or worse, mostly for worse I'd say. So my whole thing is that like, people should focus more I mean, I think maybe you're getting this anyways but like our healthcare system needs to focus more on like what are the goals, what are the outcomes, and having clear accountability tied with outcomes. And then based on that the right innovation the right tools, AI or not, what we pulled into the system to achieve those goals right so if there were certain targets that in the healthcare system where it was like, hey, like, I'm making this up but like let's say there's a huge backlog in medical imaging, we need to need to get more imaging done faster. And the healthcare system said okay well the only way we could do that would be to invest more heavily in AI to accelerate reading images.

27:26 Well, now you have an aligned incentive to actually innovate. Otherwise, if, if the incentive was not to be more efficient, then, like, why are we expecting people to change. You know everyone's, you know, everyone's pretty rational about their motivations. Yeah, I don't know if I want to get started on our healthcare system. I'll ask you one question. If you could change one thing about, and by our I mean Ontario's healthcare system. What would it be. Oh, it would be exactly that it would be about. We talked for decades about shifting to a more performance based healthcare system where reimbursement and funding is tied to outcomes but it's been mostly talk very little, very little progress. You know as much as I think in in Ontario in Canada. We like to think sometimes that we are, you know, it's kind of some ways better than our American counterparts in the healthcare system because we're you know completely for the most part, completely most are publicly funded and they're more of a mixed system.

28:32 We both have our own challenges and one of the things the US healthcare system has done I think better than us even a lot more progressive on different reimbursement models and value based care arrangements and at least trying to see what works and what doesn't. They've succeeded and failed in different ways and those models, but we've made very very limited progress. And so we've been mostly talk not very much action. And my concern is that, you know, you know our population is living longer, our elderly population is growing. There's also in general, you know, probably going to be population decline happening around the world in, and, and so our healthcare workforce is going to get smaller and coven that's caused all this burnout and poor, even worse, working in the workplace, and so what you're having is you have a growing elderly population with complex you know medical diseases, and then you have a shrinking healthcare workforce exacerbated by by coven now.

29:34 And this shrinking healthcare workforce is not going to be able to care for this massively elderly growing population in Ontario can around the world. And if you think we're in a crisis today. It's going to get far far worse in the coming decades. And unless we act now to not only do payment reform but re engineer how we do healthcare delivery, get more people back into healthcare. It's, I'm deeply concerned about the future of healthcare delivery in this country. And I think there's not enough action being taken to try and change how we deliver care and pay for it. And if that doesn't happen like I just fear for like 1020 years from now what's going to happen. Why do you think that is, why is not enough action being taken what is the is.

30:20 What is the missing piece of the puzzle here. So I think that the reality for us especially since healthcare is primarily publicly funded is it does start from the top of policy and government that sets. You know, the performance expectations, the metrics that matter how the reimbursement is done. And it takes a lot of courage and conviction to do things very differently. I mean, I think to be honest like if you did a lot of payment reform, you're probably going to upset a lot of physicians, in particular, who you know let's be honest when you're paid on a fee for service basis, where performance doesn't really matter besides volume. So kind of a pretty good situation to be in. Right. I mean in any other industry.

31:04 Let's say like let's say business or anything else. If you don't perform if you don't if your organization can't hit targets. You could go out of business right and healthcare we we tolerate so much and in fact, we are frankly I think are, I think your highest performing providers and organizations that are delivering the best care at the lowest cost. You should probably be paying them better and the ones who aren't you should be paying them less and create incentive structure where it's better and the performance is rewarded. But we don't have that here it's there's, there's a lot less of meritocracy and healthcare delivery. And, and I frankly like for most people that's probably a pretty good thing maybe like who wants the added pressure of having to achieve better health outcomes.

31:49 I think, as this idea gets confused sometimes about democracy and meritocracy, and there are different things the best ideas are not often the most popular ones are the most democratic ones. The one thing I will add to the value based care and I'll, I'll go based on Adam Grant's framework. I'll add him to my defensive corner is the way we measure value should be the process, not solely the outcomes, because poor processes can create good outcomes, and if we solely focus on the outcomes be incentivize perverse processes and weight loss is a good example where if you incentivize just restrict BMI, people will starve themselves, you know incentivize exercise healthy eating.

32:38 So I'll just I'll just leave that as a statement. This is a good point to get into is medicine a calling for a job. And if it's a calling, how do you know. This is probably one where I probably disagree with some folks and you have to be fair I'm actually not practicing so take what I say with the grain of salt this point maybe, maybe if I was practicing I have a very different opinion, I think, I think when most people go into a health care profession medicine or otherwise. It very much starts off for a lot of people as a calling. Right, you go in because you're trying to make a difference you're trying to take, make an impact on patient care or the health care system or something else.

33:19 And I think what unfortunately happens is the reality of healthcare medicine is that, man, is it. Is it frustrating is it stressful. So, working conditions have gotten worse, especially the last few years. And so I think it's very easy for folks and in healthcare medicine to, and understandably so get jaded get unhappy, satisfied, sometimes more recently want to leave. And so I think there's a lot of work that has to be done and important work has been done to turn it back into a calling and make it stay a calling. Once you're in it. And because I think it's, it's such an important part of society that we can afford to, not only can we not afford to lose such great people from the healthcare profession because we need it.

34:10 We have to find a way to recruit more people like I actually think the government for example and healthcare organizations need to do more to actually like recruit, like we should be recruiting our best and brightest to go into healthcare more than we do now, like we need it. But to your point, we have to fix the culture, we have to make it a calling again and keep it a calling. And part of that has to do with like improving working conditions. Some of them I have to do with like improving the way we, we do like reimbursement and do it well. Part of them, you know, might be maybe there's more training that we could do that we're not doing. I mean, I don't have all the solutions but I think the problem I believe exists the fact that there's a culture issue that has to be improved and fixed so that way it is a calling again and it stays a calling.

35:00 Okay. I'm not sure if I 100% agree with that but I get your point and I think we need more people in medicine that's as clear as ever. Let's talk about seamless MD. Talk to me, and feel free to go in as much detail as you'd like to about how you went from idea to landing your first client. Hopefully so, just to give it more background context to it so the initial idea of seamless MD was, what if we could build a technology platform to monitor a patient after they left hospital, you know, monitor their symptoms how they're doing, and then allow care team to catch those issues earlier and prevent something like a read mission.

35:44 Now when I first started working on this my team. My initial interest was in preventing read missions for patients with complex chronic diseases so think heart failure COPD because that's actually what my research was in so that's the world that I knew. So then when I started talking to people in internal medicine like my mentors, my mentors colleagues and all that. None of them were interested in the idea. They were like I know this isn't going to work or like, you know, it's not that interesting to me personally, taking a lot of rejections. And then one day, one of those individuals said to me, you know, Josh, you should go talk to surgeons, they are more tech savvy they they're more innovative they like this kind of stuff you just make it more traction there said, okay I'm kind of disappointed here that but I got nothing to lose at this point everyone just rejected us. And so I started talking to surgeons.

36:33 And they started saying, Oh yeah Josh come work with us like we have read mission problems too and yeah we are more innovative. And I said okay that's kind of interesting. And actually, you know when we first started finding surgeons. One of the things I did was I would go on PubMed, and I would type in surgery read missions. And I would find papers about it and I would look up who wrote those papers. And I remember one of the first three people that I that I called emailed one first three his name was Dr. David burger. At the time he was the vice chair of surgery at Bayer College of Medicine in Houston, Texas, and he had written a paper on preventing re admissions. And in that paper he had he, they had they came up with a framework for like these are the symptoms that we'd want to monitor after a colorectal surgery and potentially prevent read missions.

37:29 And I emailed him said hey you know like I'm working on this idea for an app, you know, and your paper got me thinking well what if we just use an app to, you know, check in on those symptoms with the patient, you know, could that be a cool idea. And he responded to me. And then we just started talking and eventually bear college of medicine ended up becoming our very first pilot site and they actually did a study with us with the very first horrible version of seamless MD so you can imagine the results of that study were not at all. Fantastic. But it was a great first step, and a great first partner to get something going. Did you move from there to your second, third, fourth client was it more word of mouth, more cold emailing. And what advice do you have to founders trying to sell into health systems.

38:16 Great question. The first the first handful were all cold outreach and networking so as a mixture of cold emailing hospitals, going through our networks like me ask my mentors hey do you know, like, who do you know, let's say, what surgeons, do you do you know what you think this might be up their alley, then everyone that you meet, asking them again, asking those people hey who else do you think might be interested in the idea about we still use those approaches today to try and like build out awareness and networks but especially back then when we have like zero proof points zero clout, or anything for us, no one's looking for us. So we're always having to reach out and look for people ourselves.

39:00 And how did you monetize your service. One thing I look for in my angel investing is a clinical ROI and a financial ROI, and a lot of founders. I find they have a very clear clinical ROI, but their financial ROI needs some work. So you've found conservative success, and I was just wondering, you know, how are your conversations with your first customers or buyers and what financial ROI did you demonstrate. I'll answer your question with the story that I'll get more specific so it's a great point and I think one of the things that I've learned is that ROI is viewed differently by different stakeholders in the system, and oftentimes I think people in the same system have miscommunication internally but what actually matters I'll give you an example so you know we had a partner in Ontario years ago where they said hey Josh, come bring seamless here and do like a pilot, you know, study with us, and we guarantee you that if you can help us like physicians, reduce readmission significantly for sure the hospital CEO would buy into this and we can turn this into like a real commercial contract and of course like you believe these things right.

40:09 So we go we implement it. We reduce readmission by over 50%. We presented contract before you implemented or was it more of a verbal contract. We still have because we're we you know we're a software platform we're managing PHI, etc. We have to be secure and we have to be contract with the hospital, but it was more that I think from their point of view, like, hey, once we prove it, like we can go to the hospital leadership to sustain and grow this even further beyond the initial scope. And so, they knew they were using it they were using it, but it was confined to like a very like defined group or department in the hospital. So then we measure the results we cut remissions by over 50%. And then together we co present the results to the CEO of the hospital.

40:55 And the CEO says like wow like these are amazing results. But, but given how you know global funding at the time worked in Ontario with hospitals. I said actually Josh you know, if you reduce these readmissions, and you save me costs and the readmissions, you know the government will actually think I don't need as much money in following years budgets. So actually, it doesn't doesn't really save me money. It just means the government thinks I need less and so there's not a real financial incentive for me to scale this out, even though he's like yes this clearly would reduce readmissions further. And then the above moment being like wait so hold on like this whole time we assumed, you know, based on what we were told by the physicians that we just improved this outcome metric.

41:42 The CEO will see the value. What we really should have been doing was talking to everyone, not just the physicians but also the CEO and the other executives to understand well like what ROI do you need to see, because because frankly, the executive is the one paying for this. And I think, and then what you guys over time is that there can be a disconnect in what they actually want to see results on and what what a clinical person. And so now we have to satisfy multiple parties like we have to improve. I'll put this way I'll give you an example. Quality and clinical people love seeing how seeing this can reduce hospital like the stay. And then some of the folks in like the finance side view that as an opportunity to increase throughput and bed capacity for the hospital.

42:29 You know, related, related topics, but kind of different still. Yeah. Who do you find. First of all, that must have been incredibly frustrating. Yeah. I think the ROI from your point person's perspective is so vastly different from the CEOs perspective so I'm, I'm sorry you had that experience because I can't imagine being, especially early on and you're you're writing on this contract you and extend emotionally. I'm sorry you went through that. Okay, well, the biggest question I have is what happens is you have all these frontline clinicians and staff who put their own bloods volunteers into this. And despite it being successful from a clinical outcomes point of view, the fact that wasn't valued by the system.

43:17 And then that means they're they're like demotivated to maybe improve quality in the future, or perhaps now they don't believe in digital health, because they had this one experience where they put all this effort into it it worked, did what was intended and still didn't matter. That's where I get more concerned for the system. Yeah. And this is different than the states where readmissions are not paid for within 30 days is that an accurate statement I made there. It's, it's, it's been more complicated than that so it's that for certain. Depending on the pair so for Medicare or CMS the pair, which is the government in the US, and that covers folks who are over 65 years old, they have certain conditions like heart failure COPD, etc where if you if the hospital exceeds a certain expected readmission rate, then they get poundies for it, but technically not not every readmission in the US is being penalized so it does matter, but I'll tell you, even the US part of the challenge is that there are some executives and hospitals who are kind of gaming the system right so I've had conversations with hospitals where they might say you know Josh, you know, I want you to help us bring our readmission rate from like 15% to let's say 10%.

44:34 But we don't want you going lower than that, because at some point if it's lower than that, then the then our financial model shows that we actually started losing money. So, there are some strange complexities in even in the US where they have these incentives where like because there are some reverse, like reverse incentives. They actually want you to only improve it to a certain extent sometimes. What are your thoughts on the pay wider model, and recent recent paper, where the insurance company is the provider. So the incentives are clear, where they want to reduce costs to increase their profits. Now, I know their profits are capped currently in the states.

45:17 Is that the same in Canada, and then what are your thoughts on the pay wider model. Yeah, so I don't know too much about the details of that and how it relates to how things are in Canada because you have to think in some ways. The public health care system here is, I guess not quite prepared so it's on the public provider model and I'm wrong because I'm not as technically sound on this but I assume in the provider model usually the payer also as a care delivery right so if I'm a provider, I'm the payer I'm the insurance provider, but I also own the hospitals, the physician practices and the whole care delivery so it's fully integrated. Whereas, let's say in Ontario, the government publicly funds healthcare, but technically a lot of the care providers here like the hospitals are not technically you don't typically work for the government as a family practice your your own entity so I guess you don't really have that that here.

46:13 It sounds very good in theory, right, I'm guessing there are some clear limitations that I haven't really dug into or just yet. But I think it comes down to like, if you have the right leadership in the organization I think if you have great leadership that's doing things right. It can work very well. I suspect if you have bad leadership. It may not be so great it may not lead to great outcomes for patients. Are they and here's the other thing too like are they going to serve every patient in the region are they going to hand select patients, right part of the benefit of the Ontario healthcare system is that like everyone gets served. Right, no one's cherry picking their patients you know no one's excluding patients, you know from insurance coverage or anything.

46:56 So in the ideal world, great leadership, fully integrated care delivery and funding model, and you serve every patient in the region, so that you have to deliver good care to everyone. Sounds good in theory. Yeah, I think it could work in certain verticals and pockets. I wonder if primary care should be more direct primary care with direct private pay and oncology surgery, more expensive procedures should be covered through a government insurance plan. It seems like the opposite will happen to be frank with you where more expensive services will become privatized and primary care will remain public.

47:40 I know whatever went bankrupt from $50, but they did from $100,000 surgery was kind of my rebuttal there. What are your thoughts on private care in Canada. Is it needed. Should it exist will help alleviate our backlog and improve access and by private care I mean true private care where patients are paying for care, not the independent surgical centers, which is a whole other conversation. Yeah, so I mean, it's great questions a lot of debate online right now and I think, you know, the trying to alleviate the surgery backlog with more private surgical facilities is a really hot topic lately.

48:21 My perspective on this tends to be that I think, I think it's been an oversimplification in the dialogue on social media to say that either private is always bad or to say, public, public is always good. I think the right answer ends up being somewhere between. For me, the important thing is you know do we have clarity on what the goals are for the healthcare system, right, which for me, right, if I were, you know, in charge to be like how do we get better access better quality lower cost right big picture details need to be worked out. And for me like if certain providers or provider groups can deliver better care to lower cost.

49:11 There's a way to do that better with some aspect of like privately, you know paid for health care, then I think the province should be open minded to what what what would that look like and what's the impact, but I do think it's an oversimplification to say, well in every possible situation the world private healthcare is no place, or, or to argue like the opposite that we need to know this should always be the case for everything everything should be private like I think both are both extremes are probably the wrong answer. And so I think people just need to be open minded and actually have a dialogue. Because I think we need to focus on what the goal is. And everything else in between is just different tools or mechanisms to hit the goal, but being closed minded to tools I think is just is is missing an opportunity to improve the healthcare system.

50:01 I agree, it's too bad that mentioning private healthcare is political kryptonite in Canada. But it seems like it could help definitely in some ways. And there is nuance and complexity here which are hard to find in today's world often. Yeah, and I think that if you are a very key stakeholder in how health care is delivered and organized. You have a duty to explore all the reasonable options to improve healthcare here, whether it's public or private or something else like you may not end up deciding to go down that route, but to ignore the options.

50:41 That does not seem like you're, you're being responsible to like patients and the healthcare system. One thing I hear from founders. Often is it's really hard to raise money from Canadian VCs. That's much easier from American VCs. Talk to me a bit about your experience raising money for your startup and did you find that to be true. So when it comes to raising money, like, I think what I've learned is that raising money is like selling a product except the product is your company shares so it's very much a sales process. And in the same way that like I tell like founders. Hey, if you can get one customer you can get like five you can get five you can get 10 you get 10 you get 100. The same with like raising capital if you can get like one investor to believe in you and assuming they're not crazy. You can get five, you can get five you can get 10 and so forth. You know when we raised our seed round back in I think it was 2015 we raised 1.1 million.

51:42 It was tough I actually had this whole spreadsheet of every investor I talked to. And most most that I invite a lot of ideas was just cold outreach. I mean that's a whole other topic we can get into if you want, but like I did not have a bunch of investors that I got intros to, or a bunch of in mount interest most of my investors I got through just cold outbound contacting, you know going down LinkedIn going down angel list Google. What was the message you're sending them. I was saying that I had to look it up but it was probably something like, like, something like hey like I'm a physician turned digital entrepreneur, a few lines on like traction raising capital like I thought this might be up your alley because you did X like you invested this company or, etc.

52:32 And I shall tell you there were two profiles work out really well for us one was physicians who had angel invest in other companies. The second profile that was good was actually people who were part of hospital foundation boards, because clearly like they you know we're very successful financially and donated a lot to hospitals and. Therefore like that's why they're heavily involved in the foundation, but they clearly care about health care. And so, we had a number of like physician investors or, and some hospital foundation board member investors who were both excited about the company from a mission point of view.

53:15 And so I think part of it is figuring out what what is the right ideal investor profile for a company and it varies this is just what works for us. But I can tell you like more than 90% of the investors who actually met with me so a lot of them even meet with me of like the, you know, who knows how many over 100 probably that I met more than 90% rejected us after meeting me. And so, people don't realize like, at least for companies like ours like how many investors I had to speak to, to get to us. And why did they say no. Oh my gosh, back then I mean price so many good reasons to say no back then. You know we had limited traction right, I mean, I mean you think digital health is like, do you have this so I think relatively early now, right, it's gotten a lot better in last year's but start rolling now.

54:05 Like 2015 I can tell you like it was tiny, like there weren't weren't a lot of, like, besides the epics as far as in medics the world there were no other major healthcare, like it success stories not many at the time. We had for a limited traction. Right, we didn't have, you know, all that many probably case days or anything so even back then most people were investing in the vision, the team and the mission. People don't want to invest in that. They want traction they want data, you know, what made you successful, because the idea to me isn't particularly novel which means it's the team, the execution, the grid the perseverance that made it a success.

54:52 Do you think that's an accurate representation, and why do you think others failed at doing this or why did your biggest competitors fail. I think there's a couple things and I think part of it is how we've chosen to differentiate so when people ask me well like what makes seamless and be different. You know, investors want to hear about companies that have some unique note, maybe a network effect or something else like that. And so the differentiation for the companies is the same as what I as well as investors and customers which is, we choose to differentiate in ways that minimize friction to adoption, because as you know very well in healthcare. It's easy to build the technology, it's very hard to get adoption new technology. And so for example for us it was investing early on and things like integrations with the major EHRs.

55:41 It was like helping our customer partners, continue to build out the largest data set of evidence in the industry to give confidence to clinicians that this can work in the healthcare setting. It's finding better and better best practices to train the staff on and how do you get patients and families adopting this novel technology. And none of that is like the sexy network effects remotes that an investor cares about. It was all about how do we get better adoption and success with our clinical partners. That's what our customers value, they don't care about network effects, they want stuff that works that patients use that drive outcomes. And so I think that we really focus on how do we deliver results and minimize friction to adoption. That's what stood out where a lot of our competitors are focused on like, oh I'm going to integrate with like our platform with like Uber, or we're going to do some fancy AI that doesn't really improve something for like the patient outcome but we want to say that we have AI like, who cares about, like I don't care about that stuff I want to actually drive value and make adoption easier.

56:44 And that makes a big difference. And so our focus is very clear. And I think that shows in our team construction, so about a quarter of our team actually comes from a clinical background some sort from pharmacy or they're from a dietitian or health communication specialist. You look at all of our typical competitors historically, it was mostly like engineers, business people like very little clinical people involved. That shows and how they interact with customers and providers. There's a disconnect there. That is an invaluable tip, and I completely agree with that. Josh, would you rather have a life full of many successes or chase outrageous goals with massive failures.

57:30 You know I think for me, those two are not really mutually exclusive. So for example, I think a lot of the goals we have for building CMSMD are in some ways outrageous or maybe back then, like even some things that we've done now back then felt outrageous. But along the way we've had a lot of both many successes and many failures throughout our journey. And so I think for me now it's about like let's go for really ambitious goals. But we have to celebrate like the many successes along the way. Yeah, that's what's worked out well for us. What's the end goal for you, Josh, are you, are you living life in the now, being mindful of everything.

58:16 Are you still chasing your next goal. And what is what is 90 year old Josh want to have accomplished in this life. This topic reminds me of a great talk that I saw from a gentleman named Jordan banks Jordan banks used to be the the managing director of Facebook Canada. And he had this great slide in one of his talks about career journeys. And he talked about how, you know, when he looked back like 10 years ago at the time. And you had asked him 10 years before like hey like, what do you think you'd be doing 10 years from now. It was I think it was something like oh I'm going to be like a lawyer or something and a deferment all that.

58:58 What happened in reality he zigzagged from like I think was law then he went to like work for like it was like eBay or something about like Facebook Canada like it no plans to go into like technology right. But he kept himself open minded and curious and, you know, accidentally found his way into a career that he absolutely loved. And so his whole point which I agree with is that humans are very bad at predicting the future for ourselves. And so I think for me, I stopped trying to think about like five or 10 year goals and horizons, and I tried to focus more on like, what am I curious about what excites me and living in that moment, knowing that as long as I'm open minded to great opportunities, I'm going to end up in a great place, even though I have no idea today what that's going to look like. So for example when we, when I, when I got into medical school like, do we plan to start CMS MD.

59:47 No. Right. I thought maybe I do something entrepreneurial 1020 years on the line but this was never planned. And so when I think about like success in the future like I don't know what that holds. I do know what matters to me is impact. And so I think about seamless and be for example, you know, our biggest goals around like how do we get this into more clinical areas to more health systems into the hands of more patients and how do we support, not only, you know, acute care, but how do we support at some point primary care and community care the whole continuum and so for us, our goals are really centered around how do we accelerate impact.

1:00:28 And so I think those things I think a lot of great outcomes will come along the way whether it's financial or clinical or otherwise. But yeah, I don't I don't plan in tenure horizons I can't see that long to the future, you just, I'm not that good. So, I think that's a good answer. And too many of us get caught up in creating goals, and then trying to chase them for the wrong reasons. And what we do is even as a company, I think sometimes, you know, we, we set goals, and then we realized it wasn't really a good goal to set. It's okay to reset, you know, or a perspective on it and change the goal.

1:01:09 I mean you don't want to extend bag and like, you know, change the goal because you didn't perform well but it's more like the big picture goals. Sometimes they're wrong, and we should change them. Do you think healthcare is a good fit for the traditional venture model where they're looking for an exit, maximum 10 years. Or do you think venture should extend their timeline or fund horizon to 20 years to fit healthcare. Yeah, so I think the way I look at it now is, we'll back up so, first of all, like most companies should not be venture back in the healthcare or not like, I think, I think we've seen the last like several years now that there are probably too many companies that got venture funding that frankly, probably should never be in venture back in the first place and I think now that we're seeing the great reset and venture capital which which is, which is probably healthy and it was important that we we end up doing that.

1:02:02 And I think probably that is emphasized even more in healthcare when given how healthcare works, there's probably even fewer companies that should be ventured back to the healthcare compared to to like the general like technology market let's say. I mean if you look at the biggest financial successes as companies, right, like the biggest companies by far for the most part or not like, let's call it healthcare technology companies right like your biggest health technology company, you know, maybe or let's say in software you could say is let's say it's epic or something. Right. And if you compare that to the size of like a Microsoft or Google or an apple like a Simon close right it's never going to be as big as those right so you think about it. If you were going to try and go into venture healthcare in general is probably not the industry you want to be in.

1:02:54 But there's clearly some investors who just like, are wanting to have an impact in healthcare because they love the industry they love the impact in the same way like I tell founders like, hey, I get my goal was to build to get the best financial outcome for myself. No one should ever go in healthcare, like you, you're more likely to build a much bigger financial success for company outside healthcare than in healthcare. So, whether you're investing in healthcare, or trying to build a company in healthcare. If your primary goal is to get the best financial return. You just shouldn't be in healthcare it makes no sense as an investor or an entrepreneur. Part of the reason you're doing is because you care about the industry or passionate about it and whatnot. And so then you just have to incorporate that thinking into your decision making.

1:03:40 That's not to say there aren't venture backable things in healthcare is just there's probably a lot fewer of them or even like the potential exercises will never be as great as, you know, consumer markets or something else. Yeah, I completely agree. The reason I stick to healthcare for investing is, I have industry expertise. Be I can actively help my founders with contract sales and give them whatever experience I have. And see I want to make an impact. I'll plug a book here psychology of money by Morgan House. So I think it's a book everyone should read. And it talks about how your financial decisions are not completely based on maximizing returns and being rational and emotion has a big part of them for better or worse.

1:04:25 It's not worth fighting that part of it. It's better to embrace it and then realize that we make emotional decisions and accept that. This has been a great pleasure Josh I thoroughly enjoyed this conversation. And I hope we can have a party someday. You got it. Rashad Thank you so much. I had a great time on your show. Thank you for the opportunity. Where can people find you, Josh. Yeah, you can find me on Twitter at Joshua PL you. Awesome. Thank you.