Search

Interview with Dr. Joshua Liu


📷 York University

Journalist: Haleema Ahmed


Haleema Ahmed

Hello everyone and welcome back to SciSection. I am Haleema, your journalist for this week, and today we are delighted to have Dr. Joshua Liu. Dr. Liu is a physician and the CEO of SeamlessMD, a health tech company, which we will learn a lot more about today. He has received many honors, including Forbes 30 under 30 in Science and Health Care and Canada's Top 20 under 20 Award. Thank you so much for joining us today.


Dr. Joshua Liu

Thanks, Haleema. I appreciate you having me.


Haleema Ahmed

Since we will be talking a lot about tech today, what is one app that you cannot live without?


Dr. Joshua Liu

I have to say it is Twitter. It is one of the first apps that I check in the morning and before I go to bed. It is my way of understanding views in the world.


Haleema Ahmed

Yes! I think every physician out there uses Twitter and expresses their opinions on it. What is one travel destination that you are most dreaming of in a post-COVID world?


Dr. Joshua Liu

I am actually not craving travel in particular, but I would say being able to catch up with friends or family who I would normally be seeing in person once every couple of weeks. Being able to connect with those people again is what I am looking forward to.


Haleema Ahmed

The same as well. 2020 was definitely a time for Netflix so what was one show that you binged?


Dr. Joshua Liu

I am going to cheat and say something that is more recent that I have gotten into. The Mandalorian. It is one of those Star Wars ones I really enjoyed, even though I am not a typical Star Wars fan. They have been a lot of fun.


Haleema Ahmed

I think I have heard of that as well. Now talking a little bit more about yourself before you ventured into medical school at UofT (University of Toronto), did you expect yourself to go down this health care and business route?


Dr. Joshua Liu

Growing up, I always enjoyed building things, whether it was projects or school clubs or eventually some small businesses. I always knew that I would probably start a health care business at some point, but I did not think it would start so soon. I ended up going through this incubator program called The Next 36 during my last year of medical school. That is where I started SeamlessMD. It ended up just being the right time for me to go ahead and go after that opportunity. I did not expect it, but I just went with it when it happened.


Haleema Ahmed

If you were interested in business in general, why did you decide to pursue being a physician in comparison to a traditional business route?


Dr. Joshua Liu

I had an interest in health care for a long time ever since I was in high school. When I got into undergrad, I was still interested in health care and I was still planning on doing medicine. I just never thought I would combine business with medicine that soon. When I went into medical school, I did not fall in love with a certain specialty. I had some really great mentors at UHN (University Health Network) who got me more interested in broader challenges in the health care system around quality, patient safety and cost. In particular, my mentors got me really interested in preventing readmissions back to hospital. Understanding that problem led to starting SeamlessMD actually.


Haleema Ahmed

SeamlessMD is a company that you started in your last year med school, as you mentioned, and now it has become this massive company that has helped many hospitals in Canada and elsewhere. Were you inspired to start SeamlessMD from your interactions with physicians in the hospital system and the issues that they faced? What was it that really got you to go one step forward more than other people who may have seen the issue, but not necessarily decided to do something about it?


Dr. Joshua Liu

I was certainly inspired by my experience working on that readmissions problem with those mentors at UHN. During my last year of medical school, I still had the edge to explore building something, whether it was a project but not necessarily a business. I ended up learning about The Next 36 incubator and applying for it on a whim during my last year of medical school and got in. During that program, I met two individuals, Willie and Phil, who became my SeamlessMD co-founders. They came from the engineering and computer science world. I came from the medical world. We teamed up to start SeamlessMD and our first day working together, we were asked to pitch within twenty four hours a business idea, and no one expects that to be the idea you end up doing. I pitched the readmissions problem to Willy and Phil. We ended up pitching SeamlessMD and we just stuck to that same problem over the years. The idea has certainly evolved since then because we do more than prevent readmissions, but a lot of what we envisioned ended up becoming true over the years.


Haleema Ahmed

That is quite amazing that you had this idea and it has grown from this small idea you developed at this convention. What is it that SeamlessMD does for patients beyond dealing with the readmission issue?


Dr. Joshua Liu

Just to give it more context, when a patient goes through a health care journey, whether it is a surgery or a chronic condition, we tend to give patients lots of paper and verbal instructions. Patients often will tell us that they can forget these instructions and lose them. There is no day-to-day reinforcement. These instructions are not personalized. Ultimately, it is hard for patients to be compliant with their instructions from their health care team. On the health care provider side, they will tell us that there is no easy way to monitor a patient and catch a problem earlier. Ultimately, if patients cannot follow their instructions and your health care team does not know what is going on with you, particularly outside the hospital or clinical setting, since ninety five percent of the patient journeys is at home by themselves, this can lead to avoidable problems, whether that is higher recovery times, avoidable visits back to the E.R. or the hospital, and ultimately higher cost for the health care system. The way SeamlessMD works is to provide a platform on smartphones, tablets and computers that hospitals use to better engage, monitor and stay connected with patients throughout a health care journey such as surgery. Let us say a patient was going through a heart surgery. They would be guided through all of their preparations and all of the recoveries through SeamlessMD on their phone, tablet or computer. They are guided with very interactive elements. That would include reminders of what to do at the right time, interactive education, such as exercise, rehab videos, but probably the most important thing we do is we empower patients to track their progress and track data. Patients are tracking pain scores, symptoms, and photos of their surgical incision. Back at the hospital, front line staff such as nurses can get alerts and dashboards to monitor patients and catch problems earlier. Ultimately, that leads to better patient experience and better health outcomes.


Haleema Ahmed

Speaking about how patients are able to take control of their care, a lot of the time, people may feel like physicians are this authoritative figure that is dealing with their health, whereas I feel like your company provides patients with some of that autonomy. Speaking specifically of how patients are able to inform their physicians and their health care team from home, have you seen that being especially beneficial during COVID?


Dr. Joshua Liu

What is interesting is that when the pandemic first hit North America around March 2020, we were initially naive in thinking that all of a sudden, organizations would want to adopt SeamlessMD to monitor patients at home. What happened first was that hospitals adopted the low hanging technology, like telemedicine video visits, which have been around much longer than digital platforms like SeamlessMD, but had limited uptake. When COVID hit, that is where they spend most of their time, driving adoption of technology and getting more video visits in place. I would say, in late summer, early fall 2020, organizations started saying, “Hey, we figured out the telemedicine thing”. The world is not going to go back to the way it was before. So what the next step in our digital strategy is digital patient engagement and monitoring platforms like SeamlessMD. Since late summer, early fall, that is when we started seeing a rapid adoption of SeamlessMD beyond what we were expecting initially going into 2020. I think in many ways, digital patient engagement has been brought 10 years forward because of COVID. As terrible as the pandemic has been, we try to be optimistic. One of the silver linings is that healthcare is going digital faster. I think ultimately, that is going to be better for patients in the long term.


Haleema Ahmed:

Definitely. I think a lot of industries are becoming increasingly technological and medicine definitely has new innovations but in terms of, in comparison to other industries, it does seem to be lagging behind. I think companies like yours are helping to revolutionize this space and as any startup, you and your founders must have encountered a variety of barriers. If you could talk to us a little bit about what that was like, and how your team was able to overcome it and help build this really successful company?


Dr. Joshua Liu:

The truth is that there are always barriers and it actually never gets easier building a business. The only difference is that the challenge changes over time. Every time you learn how to overcome that first barrier, if you are lucky enough to survive to the next stage, you have to learn how to solve and overcome a new barrier. But I also see that as a great opportunity to keep learning and keep improving as a person. For example, early on our initial barriers were how do we actually convince our first hospital to work with us, even though we have nothing, no proof points, and no product? Once we actually get a product in place, besides the fact that it looks and feels nice, how do we actually generate improved outcomes such as preventing a readmission? Once we got the product working with effective validations and studies, the next was how do we actually integrate with an electronic health record, and then at some point, we did that, and so forth. The barriers never really go away. But it is about persistence and discipline, and frankly being excited about the fact that we have the opportunity to keep learning and overcoming new barriers and growing as people and as a business.


Haleema Ahmed:

A lot of your colleagues from medical school must have embarked on the traditional route, so what was it for you in deciding to take this leap that you were definitely very passionate about? Seeing your colleagues go and do something that tends to be more stable long term (residency), whereas with the business, even if the idea is obviously amazing, instability is still a concern. What was that like for you?


Dr. Joshua Liu:

Ultimately, it came down to where would I be able to have the biggest impact on healthcare and where would I be the most excited personally. When I graduated medical school, my residency program was very supportive. They said whether you want to do residency 50% and Seamless 50% or residency 90% and Seamless 10%, we will support you. Ultimately, I decided that I could not do two things well and I could only do one thing really, really well. I decided either I was gonna do residency full time or SeamlessMD and be full time. Ultimately, I chose SeamlessMD and a big reason was impact. One of the exciting things about building a business and organization is that if we are successful with a team, we can impact not just hundreds of patients a year as a clinician, but tens of hundreds of thousands or millions of patients over time. We exist in the healthcare system, but in partnership with it as a business. For me the opportunity to have in some ways more impact through business is what got me most excited about going this route.


Haleema Ahmed:

I think perspective is really important because it is very true. A single doctor can only impact so many patients but when it comes to something like technology, it is infinite in how it can impact people. Pertaining more towards the type of issues that you and your company are trying to tackle, how can healthcare startups like yours help alleviate patient accessibility, especially pertaining to patient noncompliance, for those who may come from different cultures or have language barriers when encountering a Western medical system?


Dr. Joshua Liu

One of the things that I have learned through working on SeamlessMD is that you have to reach patients where they are. I can tell you over the years, we have realized that if a patient cannot access the platform, they cannot engage and if they cannot engage, you cannot drive a better health outcome for a patient. We have invested a lot over the years to achieve better and better accessibility in many different ways. Just some common ones we have uncovered are being on many different platforms. This means being available not only on your phone or your tablet but also in the web browser as well. I can tell you when we first started the company, we would sit down next to patients who were elderly, and watch how they would interact with the platform. Early on, we noticed that there were a lot of elderly patients who had iPads, for example. But when you look closer, you realize that a lot of these folks did not even know their Apple App Store password. Even though they had an iPad and they could use it, they could not download a lot of apps, but they loved the browser version of Seamless and they loved getting email reminders. We have learned that we have to be multilateral to reach patients where they expect to be reached. We have also invested heavily in meeting accessibility guidelines for digital platforms. We meet guidelines around the platform being colorblind tested and contrast tested. The platform is designed at a grade six reading levels so it meets health literacy guidelines. Then to your point earlier, we have also realized that we have to support different languages. We have partners now, in terms of hospitals, who are using SeamlessMD in many languages beyond English such as French, Chinese, Punjabi, and a number of other languages. We have certainly learned to invest in accessibility, so that way we can reach every patient.


Haleema Ahmed:

That is awesome! You have given a few TED talks in your career which everyone listening should check out. In one of these, you mentioned the evolution of health care from caring for sick patients, which was the focus of hospitals for a long time, to preventing people from getting sick due to health policy changes in Canada and the USA. How do you see healthcare evolving with technology, not only with your own company, but in general?


Dr. Joshua Liu

Yeah, it is funny. Whenever I talk to folks, particularly the government, they ask me how can we get faster adoption of new healthcare, technology, and innovation? Healthcare will move based on how the incentives work so the further adoption of innovation will continue to be relatively slow unless we change the reimbursement models. Reimbursement for health care in Canada is primarily fee-for-service, meaning that doctors and hospitals get paid for every test, every surgery, and every patient seen, but not based on how well patients do with their care or how healthy they are. If you want to get better adoption of good technology that helps improve care, you have to reimburse physicians, providers, and health systems based on getting a better outcome (also known as value-based care funding.) In terms of COVID, physicians would not talk to patients on the telephone and it is not because they do not know how to use telephones. It is because the way billing codes were set up in Ontario is that physicians could not bill for talking to a patient on a telephone for the most part. When COVID hit and the government said we need to do more virtual care, they had to come up with new billing codes. All of a sudden, providers and physicians would talk to patients on the phone and not require you a five-minute visit to the clinic. The point I am trying to make is that there are lots of new technologies that I am sure will evolve and make healthcare better, but if we keep relying on very archaic fees for service models in health care, it is going to keep slowing down adoption of technologies that could be helpful. If we move towards more value-based care funding and less fee-for-service, physicians and hospitals are going to naturally adopt better technologies to improve care because no longer will archaic funding models be a barrier. If you have improved the reimbursement model, the right technologies will be adopted faster, which will help patients.


Haleema Ahmed:

What you are saying is by incentivizing doctors to provide better care for their patients and prevent bad outcomes, healthcare can improve. Alongside that, technology can evolve and become more immersed in medicine as well. Do you think that technology can ultimately replace physicians? Do you think that the doctor role will last forever?


Dr. Joshua Liu:

It is one of those topics where people then discuss AI (Artificial Intelligence) and machine learning and how that will impact healthcare. I think anything that can be automated eventually will be. We have seen electronic reminders have replaced telephone call reminders and more recently, and this is still early stages, machine learning and AI are starting to read imaging scans and not too poorly. Just not well enough to replace physicians just yet. In many ways, it is inevitable to a certain extent. I do not think technology will ever replace doctors, and nurses, and the provider-patient relationship completely. But I do think technology will continue to allow providers to operate at the peak of their skill set. Technology will keep allowing less trained or less skilled providers to do things that traditionally required more of an expert to do. In the past, only trained specialists could operate ultrasounds and now, bedside ultrasound can be utilized and read by family physicians. That was not the case many decades ago. I do not think it is crazy that in the future, a lot of imaging ECGs can be read by non-specialists because of machine learning usage. But there will still be many complex cases or relationship-based cases that a physician or provider will always have to do. It is important we realize that in the same way a few years ago, we did not have washing machines and humans washed everything. We were worried that we would lose out on jobs if we got washing machines but humans just moved on to more complex tasks. The same thing will happen in medicine. It is about leveraging technology sensibly but by being open-minded to the fact that if we could actually automate a lot of things intelligently and let our providers operate at the peak of their care, that is ultimately going to be better for patients as well.


Haleema Ahmed:

On that note, thank you so much, Dr. Liu, for joining us today and having this really awesome and enlightening conversation on healthcare and technology, and your company SeamlessMD. For all those listening, if you want to learn more about Dr. Joshua Liu, then check out his website joshualiu.ca and be sure to check out those TED Talks as well! Thank you for joining us.