Innovation and Disruption in Digital Health Startups –

Rick Menassa: So I looked this up last night and I was shocked at the definition of a startup.

Katie Bryski: Hello and welcome to Digital Health in Canada, the Digital Health Canada podcast. My name is Katie Bryski, and I am a podcaster turned digital health professional.

Shelagh Maloney: And I’m Shelagh Maloney. I’m a digital health professional turned podcaster.

Katie Bryski: Where entrepreneurship and patient care meet, startups are driving innovation, spreading new models of care, and offering creative solutions to share challenges.

In this episode, we’ll explore startups unique role in Canada’s digital economy. digital health ecosystem, the impacts of Canadian innovators, and how we can all hone our entrepreneurial skills no matter our career path. We are so pleased to welcome two fantastic leaders in this space to join us in the conversation.

Welcome to Chenny Xia, Chief Executive Officer at Gotcare, and Rick Menassasa, Chief Executive Officer, Health Espresso, and iCare Home Health. Thank you for joining us today.

Rick Menassa: Good morning, and I’m happy to be here.

Chenny Xia: Thank you for having us.

Katie Bryski: Absolutely our pleasure. We’d like to start with some introductions. And one of the things that is always really interesting to hear is the journeys that people take on their careers.

So to start, I would love if you could tell us about yourselves, your work, your organizations. Rick, let’s start with you.

Rick Menassa: Sure. So my name is Rick Menassa and I’m the founder of iCare Home Health and later Health Espresso. And my background actually is not in health care. I do come from a business transformation and telecom technology background, where I’ve done work for a lot of Canada’s leading companies and did one gig actually in Europe for three years representing a Canadian company.

At one point, I decided that, okay, you know, I want to give back and do something with the community. And that was the beginning of my journey into home care. And eventually that evolved also into doing the startup for Health Espresso.

Katie Bryski: I’m excited to unpack some of this. And, Chenny, I know that you have also had a really interesting path to get to your organization.

Chenny Xia: Yeah. So my background is in human centered design. So prior to my company now, Gotcare, I used to run a firm where we were co designing solutions for various different industries, with customers, with different stakeholders, and we dream up the future together. And one of my last initiatives before I moved on from consulting was in community based health.

And I was just so inspired by the stories that were coming out, as well as the gaps that we were seeing that through that initiative was how I met my now co-founder, and then lo and behold, we’re where we are now.

Katie Bryski: Can you tell us a bit about the work that Gotcare does? And Rick, after, same question for iCare Home Health,

Chenny Xia: Yeah, for sure.

So at Gotcare, we are really reimagining how people receive services in the home setting. So it can be a combination of in person support, virtual support, clinicians and unregulated workers working together as a team, paired with care plan monitoring, care plan adherence, and coaching and training for patients and family caregivers.

We have a specific focus on self management and skill building so that we can support our patients in better managing their own chronic conditions. We work with a variety of different folks in the ecosystem. So we work with various different care funders, including insurance companies, public health authorities, and hospitals.

Rick Menassa: So iCare Home Health is more on a parallel stream, but different. We’re more of a boutique agency that is more focused on the customizable and individualization of the care that’s being delivered. We leverage some, um, unconventional tools to deal with the families that are, let’s say, dealing with grief because of, let’s say, cancer or a loved one having cancer.

And then, of course, that’s all in addition to our regular delivery of regular care. Using nurses and personal support workers for the three main pieces of care, which are medication management, hygiene, and nutrition. And then depending on the length of shifts, we then also focus on stimulation being physical, mental, and or social.

And everything is individualized to each specific patient. Which comes on a lot of, um, collaborative work between our agency and the family receiving care.

Katie Bryski: I find it really, really interesting that you both started outside of the health system and ended up in quite specialized niches within it. And I’m curious about what that pivot looked like.

Like, was it from an entrepreneurial mindset, seeing a need and having a passionate line with it. Can you walk us through that moment of decision making?

Chenny Xia: I think for me, it’s really, really identifying where the need is the greatest and where people are falling through the cracks, where there’s the greatest need for innovation and really where there’s a need for a knitting together of different solutions and different services.

So that we can live in a more accessible and inclusive health system. And so right now when we take a scan at everything that’s happening, I think that a lot of people fall through the cracks in the community. And so I think that’s potentially why you’re seeing a lot of startups, a lot of founders these days focused on how we can support patients in that way.

Rick Menassa: For me, it was more personal. My mom was aging and when I was still working in business transformation and telecom, she called me once and said, “Can you promise me not to put me in a home?” And my answer was, “What’s a home?” I have no idea what that stuff is. So, long story short, where we come from, we actually take care of our own families.

We don’t place them in places. And then I started to look at what services are available out there. And then I realized, you know, this does not work for us. That what I call wholesale care, it’s efficient and it’s what can be publicly funded. But when it comes tocertain families like ours, which really want to have healthy aging in place, then, you know, we need to have a different solution.

And that’s when I left what I used to do and I start to research, how can we provide healthy aging in place? And then I went back to school and I took different certifications, in aging care. And then of course, the rest is history. I should add that it doesn’t stop with the elderly. Our agency also now about 25 percent of our customers are also special needs children, which is another segment in our health care system that is not very well addressed.

So we have a lot of children with autism and delayed development. And again, this is really the kind of care that while we do have several agencies, government agencies, that provide good services during the day. But after that service and the weekends, the parents are left on their own. And that’s where we come in.

It’s kind of a journey that is kind of evolving as we go. We’ve been doing this now for 12 and a half years. But it’s not a journey that actually has, I don’t think, has an ending. Because we need to arrive to a point where healthy aging in place becomes we’re going to use the word health equity.

Available to everyone, not just from the private care side.

Shelagh Maloney: I just want to pick up on that. And Rick, I know you’ve been doing this a long time and you know, you mentioned the journey. And so I’m wondering, and, and as researching this episode, how do you define a startup? And do you still consider yourself a startup?

And when does a startup stop being a startup?

Rick Menassa: So this is an amazing question because I looked this up last night and I was shocked at the definition of a startup. Do you know what a startup definition is? So it’s called a 50, 100, 500 rule. So if you have 50 million in revenue, run rate, a hundred or more employees and or you’re worth over 500 million, that’s when you stop being a startup.

And I thought, you know what, I’m currently at the SAAS North conference in Ottawa, where there’s a lot of startups and founders, and I don’t think this applies to any, even the investors who are here, I don’t think they probably still count as a startup. I’m not sure what that is, but I think in my world, the startup probably until your revenue surpasses your costs, your running costs, that’s when you start being a startup.

Chenny Xia: I think being a startup is more of being a mentality. I see it more as like an identity that a team takes on because at the end of the day, an organization is just a team or teams of teams. I feel like there’s parts of our organization at Gotcare where part of it is a startup and part of it is a scale up.

And it’s about having both. There’s parts where you have product market fit and you want to scale that, but also as a team, you know, there is. We just have to look through the news headlines to know that there are so many challenges yet to be solved in health. And so, yeah, I think it’s more of a mindset than anything else.

Katie Bryski: How would you characterize that mindset? Because I agree, I think there’s a sort of like a metrics way to look at it, but it also feels like an ethos more so.

Chenny Xia: Yeah, I had, I actually just, I met with a hospital CEO yesterday afternoon, and she said a word that I was like, oh, yeah, that’s the thing. She said norm busting.

And I love that.

Katie Bryski: I like that too. And while there are challenges in the health system, I’m sure there must be an additional set of challenges in starting a business. So I’d love to go back again to the beginning of your business and learn about the challenges that you faced at the start and how you overcame them.

And also, whether those challenges have changed over time as your business has evolved.

Rick Menassa: So as you know, I do have actually two companies. My second one is a startup in that definition that Chenny just said as well. So Health Espresso is a technology company that evolved from iCare Home Health to track the patient journey digitally, so that basically all the participants in the circle of care can connect with each other and collaborate.

On a single platform. So more of a sandbox for the hospital, the primary care physician and the patient’s family. And of course, the community care organizations to collaborate. So in that light, when you’re developing technology, and Chenny might probably relate to this, at the early stage, you need to get, of course, funding.

So whether you’re gonna do your own funding, then eventually put in the seed funding and they always tell you what, get the friends and family first to kind of buy in and they believe in you, then you go for the larger circle, right? Well, as I shared earlier, I’m at the SAAS North conference in Ottawa, where it’s about funders and founders getting together.

And it seems to be like an ongoing thing of fundraising, because as you evolve the technology, you need more money and you need more money. Well, you need more people who buy into what you’re building and what you’re selling and had four meetings yesterday where people really look at your business in a very pragmatic way.

There’s no emotion in it. It’s really, what are you doing? What have you done? And what are you gonna do for me? Kind of thing. If I give you X amount of millions. And that’s kind of where the challenges lie.

Chenny Xia: I think for us, you know, so I would say startups can get a bad rep, especially technology startups, because there is this sort of quality of disruption that can happen.

And I think that you have to be really careful about disruption in certain services, in certain sectors, particularly in healthcare. So, very much at Gotcare, we take a more co-creative and collaboration based approach, which is the harder path. But it’s the needed path. And our origin story was that me and my co-founder, we actually tried to do what we do now within the health system.

So we were actually asked to with, by a consortium of different community providers, to come up and dream up of what Gotcare is today. And what happened was when we ended up getting patient referrals for the thing that we built for that consortium, it took those providers three weeks to service the patient.

And I think it was just a real reflection of like the status quo was just so heavy. That was very hard for an innovation to survive. So we actually got permission to exit out of that situation and we continue with the idea. And that’s when Gotcare was born. And actually a couple of executives behind that consortium ended up becoming some of our early investors.

And yeah, and because at that point we already came into this sector with or my co-founder came into the sector with a lot of relationships already in, particularly, insurance funded care. Yeah, we got to a million dollars in revenue before we needed to raise money. And so by the time we raised money, we were able to secure some venture financing.

To date, we’ve raised almost five million dollars in venture financing, as well as about three million dollars in non dilutive financing as well. And so, I would say we definitely have an unconventional startup journey, for sure, and continue to sort of scale in the startup space in an unconventional way.

Like I said, we work within the community with all the various different stakeholders. So we work with traditional home care, we work with hospitals, we work with CSS. And the biggest challenge is the change management side of things, right? Because everyone’s really used to doing things a certain way.

So when there’s a new kid on the block, so to speak, it can feel really disruptive for them. And so a lot of, a lot of our time is spent one on one building relationships, building trust and navigating. The politics that is digital health implementation.

Shelagh Maloney: One of the things that’s so true that health care has a bit of a reputation for being a very tough nut to crack.

And I think the kiss of death is, but we’ve always done it this way. And you know, Jenny, I think one of the comments you made is around building trust and progress happens at the speed of trust. Right. And, and I think change management is so important when we do these things. And so can you talk a little bit about how your company grows and what does that look like for you and how do you go from startup to scale up?

Chenny Xia: So to clarify we’re a B2B business or B2G business. We’re not a B2C or direct to consumer business. And so what that means is we collaborate with care funders to design programs and services for the patients that they serve. And so for us, as we grow, it just means that we work with different funders, and as we work with a funder, you know, it’s about expanding our presence with that funder, taking on more patients with that funder.

So to date, we work with about 41 care funders across the country. Even though you, you, you’re kind of like wiggled your way in, so to speak, right? That’s just square one. It’s truly square one. There’s so much relationship building, um, and trust building, as you mentioned, Shelagh, that’s needed in order to expand your footprint within a single care funder.

And so the way we see it is one stakeholder at a time, one conversation at a time and one patient referral at a time. And for us in terms of breaking through a lot of the noise, the best thing that we can do is story tell our impact and story tell the difference of what we’re able to do for a patient that we serve.

So I’ll give you one example. Um, we have a patient, he’s 97 years old, right? The candidate that you don’t think is a digital health user, 97 years old. We, uh, supported him in getting home after being in the hospital. And one of the things that we learned and one of the things that we were able to support him with was managing his diabetes.

Turns out he had been going to the hospital for 25 years. Every single time he needed his insulin administered for 25 years, he just had this fundamental belief that he couldn’t do it. He lived alone. He didn’t have family nearby, kind of like all the social determinants of someone who tends to fall through the cracks.

And so, when you first enrolled in our program, we were supporting him in self-administering at home. We had a, what we call a health ambassador, which is an up skilled PSW in the home, supported with a virtual nurse, an RN, who supervised through a tablet device that we installed. And that’s how he administered every day, was having someone in the home, and having a clinician virtually who was able to supervise him.

Then we transitioned from that to just him and the virtual nurse, one on one, and then we transitioned from that to just him and cues and prompts with the tablet. And I’m proud to say that after three weeks of working in that way, he’s now fully self-administering and no longer going to ED for his insulin.

And so I think it’s really just about storytelling and patients and the triumphs that they’re able to have to really get that buy in and to really get that support from those who She was like you said they’re used to doing things a certain way But also they’ve seen a lot of change right like I think a lot of our partners have witnessed so much change, good and bad, but they’re really nervous about something new and they’re nervous for the right reasons

Katie Bryski: It’s such a good point tonight I appreciate the link between storytelling and your earlier comments about relationships because I think storytelling is fundamentally about relationships.

And stories are one way that we can understand each other and understand each other’s different experiences. And, Rick, I also wonder if there is a connection to something that you mentioned to me previously, which is that Canadian innovation has quite a good reputation internationally, and can sometimes struggle to get that same buy in or traction closer to home.

I wondered if you could talk a little bit more about that, some of the reasons for it, and some of the strategies that Canadian innovators can take to mitigate that.

Rick Menassa: For sure. So it’s kind of interesting. Chenny and I had an offline conversation and, and where we, uh, did things differently in our business journey is she quickly recognized that after three weeks of not getting service from the public side, she switched more to a more private side, I believe.

Uh, we, our platform is really built for, as a certified EMR and collaborative health record, is to actually be adopted by public organizations. And that’s where the challenges lie. In the Canadian health care system, we have an amazing reputation. As you know, I travel a lot internationally and wherever I go, we are just one of the best healthcare systems looked at from the outside.

And our technology is very well regarded as well. At home, we are usually challenged in our sector where the U. S., for example, solutions that are already here or coming here will be at least looked at favorably versus, let’s say, Canadian startups. When a Canadian startup makes inroads and actually gets traction, for example, Health Espresso right now provides the technology for three out of six Ontario health regions, covering 7.2 million people in Ontario with the access to care virtually. So to get to that stage, it’s a real challenge to get the buy in, to get the adoption. Then after you get the buy in and the adoption, you need to get paid. And that’s a whole different conversation. Now you travel overseas, promote your technology, and you find the very receptive adoption is faster.

And of course, the payment is faster as well. So, so that’s just one of the challenges we have here. Certification and getting the approvals as a software is a different journey. So for example, we’re being certified as an EMR. It’s quite a long journey and quite a costly journey. I must say at the end though, it’s quite favorable because you do have the credentials.

You’re able to put your head high and see, you know, once you’ve got the security, the privacy and all the required pieces to really play in that segment. But if you’re not well funded, that can be really challenging because the cost can run really high.

Shelagh Maloney: Talking about the challenges that we face in Canada, we’re striving for a connected care system with the information flowing freely.

What role do you think startups play in that? I’m curious to know what your experience has been working with others, trying to implement the standards and the tools that you need to help with that information flow.

Rick Menassa: So number one, converting from paper to digital, so managing the document and information flow is really the Holy Grail here.

The ability to allow or have different organizations or sectors, so the hospitals have great systems, but they are within the hospital. Doctors have EMRs and they are within their clinic. And then you have a kibosh of different software that different community organizations use, or some of them are still on paper today.

Some of the challenges you have is, from a technology standpoint, is everybody’s worried about the data. And that’s obviously very valid from a security perspective, but then some others are worried about the data because they want to hold on to it so they can own it and sell it maybe later on.

And that’s the part where it becomes a hurdle. And having a proper flow of data for the betterment of the system and the patient. So if we follow the patient journey, we’ll take Betty, who is 92. Betty, for example, is a home care bound person. She experiences a couple of falls. She goes to the hospital, gets treated, sent back by ambulance to her home.

The people who spend the most time with Betty are the people who are serving her at her home. They don’t receive any information of what happened to Betty at the hospital. At the same time, if the Observe some problems at the home with Betty. Let’s say she’s regressing or digressing. Well, they have no contact with her physician to actually say, you know, we’ve observed this and this is happening and everybody can have their own technology, but nobody’s talking to anybody.

And that’s where Health Espresso comes in, right? It’s connecting the dots so that now everybody is notified with any critical health event that this happened and can act on it. Now to say connecting the dots very quickly, that is a three year project that we have. Finally finished and getting the buy in for people to say yes, I will work within that system in addition to mine. That becomes also another challenge.

Thank goodness for interoperability now so people can say, you know, what? I don’t want to change my system, but I’m willing to shake hands with yours and allow for certain pieces of data to flow. And this is what’s starting to slowly happen is to have the trickle of critical information flow, where different people touching the same patient are able to actually be more proactive.

So prevention comes into play now with the information flow, uh, where we can prevent critical health events. And of course, reduce the cost of the system and keep the quality of life of that person where they are not experiencing that stroke or that heart attack and continue to live in a healthy place.

Chenny Xia: I think for me, it’s, it’s about finding, when it comes to finding various different solutions, it’s really about what outcomes are being funded right now. How do we tie our solutions to the outcomes that are being funded? Because I think that ultimately, how you learn to earn the trust to play, really, is by meeting those outcomes.

And yeah, it means that as a startup, we have to be really flexible and creative about how solutions get funded, what patients we focus on, geographies we focus on, and just really adapt to the landscape.

Katie Bryski: You know, as I reflect on the conversation that we’ve had this morning, A few themes seem to keep coming up.

It is about this building this trust, these relationships, this finding the area of greatest need and impact within a very complex system. So looking back over the conversation we’ve had, if you had a piece of advice for someone who is either interested in stepping into startups for the first time, or even someone who just wants to employ some maybe startup mentality within their own organization, what’s a key piece of advice you’d give?

Chenny Xia: Yeah, I think the thing that is most needed in our health system is optimism. I think that we are, most of us, and I’m including people in the startup ecosystem as well, I think most of us feel a sense of overwhelm, a sense of things can’t change, like we’re just moving through the motions that kind of thing, right?

You know, I think it’s a very dangerous mindset because what that means is we end up just being really paralyzed. And we do the same things on both sides. Like we do the same things. So like, you know, a startup suite, we keep trying to approach our market in the same way. And in health organizations, we try to deliver things the same way too, right?

So it’s like, everyone is just stuck doing their way and the way that they’ve done things. And I think what’s most needed is a way of cultivating a sense of hope, a sense of optimism. And revitalizing the energy that we bring to our work. And that starts with ourselves. I know this is like super basic, but like, what are some ways I can inject more radiance and joy into my life so I can bring it to my work?

And then once I’m there, how do I do that for my teammates? How do I do that for the people I work with? So that we can create an opening, like literally just an opening in our calendar, in our minds, in our hearts, to have the energy to really try something different.

Rick Menassa: Most startups start with an idea and a passion.

Whether you’re going to be pursuing that there’s some realism that has to come into play, which is, you know, a lot of people say, follow your passion. And that’s only partially true. It’s not very true because sometimes your passion can take you downhill. So, so I think being realistic as a startup, as to, What, what’s your market and are there gonna be receptors or are you actually trying to kind be um, a disrupt?

If you’re a disruptor, you hang in there until you actually disrupt. So Chenny is a disrupt, I’m a disruptor. We’ve changed or trying to change parts of the healthcare system to the betterment of that healthcare system. And you constantly have to kind of keep re-evaluating. Am I still on the right track? Or do I need to swerve a little bit because things are also changing rapidly right now?

I was just saying yesterday that, you know, we’ve had this, um, lean curve that now is becoming like a hockey stick because all of a sudden people are waking up that we have a healthcare crisis, for example, and we’re looking now for solutions, like real solutions, and we’re ready to adopt, right? So now people are saying we’re ready and government is responding and they’re actually now funding some of the, um, organizations.

To actually start adopting some of this technology. So back to the startup, back to the, you know, what advice, you know, can you last, you know, how long will it take for you to actually take off? You know, how long is your runway and can you last on that runway? Do you have enough fuel to last on that runway?

And what happens if you don’t, what’s plan B? Are you going to have some people who are standing behind you who are saying, you know what, take your run? And if you know, you need help, I’ll step in or are you on your own? Yeah. So these are very important fundamental questions for a startup because otherwise there’s no sense just starting something that they might not make it.

So yeah, so that’s, that’s the thing. I think you should, um, I think most people fail to plan and that’s a plan to fail really.

Shelagh Maloney: Thank you both so much for coming and talking to us today. Your passion clearly comes through and picking up on a point that I heard earlier, do something that will make a difference and spread an impact.

I think that’s so important. Thank you for taking the time to speak with us. I’m sure there are a lot of people out there who have a good idea, who may be thinking about getting into this space and hopefully you’ve given them some really good food for thought. I know you’ve given them some great food for thought.

It’s not easy, but you can change the world one patient and one client at a time.

Katie Bryski: So Shelagh, I am dying to ask you a question about the conversation we just had. I know in the past you have mused about being an intrapreneur, right? So taking, like, that innovation and entrepreneurial mindset within an organization. And I’m curious, now that we’ve talked to Cheney and Rick, how does that color your lens on that?

Shelagh Maloney: Well, you know, it’s interesting because I think one of the things for me is, Aad I think it was Chenny said it earlier, a startup is a mindset and there’s so many people that you work with. And I know even just sitting around with friends over drinks someday, it’s like, what would be the perfect solution?

And we all, I think being part of any kind of, whether you’re in healthcare or law or education. When you’re on the inside, you know what the pain points are and you recognize them. You think, wow, you know, we can do something about that. And everyone has that million dollar idea, but it takes a different mindset for people to act on that.

And I think that’s, for me, was the takeaway. It’s like having a really good idea. And. And just persevere and just, you know, I think when you’re involved in something internally, it’s almost less risky just by the nature of the fact that it’s part of a larger organization and you can take these projects on, and isyou’re a startup, the stakes are much higher. And I think in healthcare, we are such a risk averse mentality that, you know, that entrepreneurial spirit and mindset is much harder to come by. So I really admire and applaud those who who take those kinds of roles on. What about you? What was your sort of take away from this conversation and perspective?

Katie Bryski: Yeah, I mean, it was definitely interesting to think about the metrics that make a startup versus the ethos that makes a startup. That is a mindset thing that I don’t know that. You ever really stop being a startup, perhaps like as Chenny was saying, it’s norm busting. Maybe it’s when the norms you have busted themselves become a new norm.

But sort of philosophy aside, I was fascinated by the fact that both of our guests started in a field other than health care. I think it’s interesting to see the way that some of the learnings and skills and experiences you’ve built in other sectors can be applied to healthcare in perhaps interesting ways.

And I may be biased, because obviously I started not in health care as well. For one of the skills that I picked up was podcasting, and here we are. So it’s always interesting to see that journey mirrored in others.

Shelagh Maloney: I love that, cause I think, it’s sort of a common theme for many of our guests, isn’t it?

That they didn’t start in health care or they started in health care and transitioned to a different area in health care. And so I wonder if that’s unique to health and for these entrepreneurs. I think, again, they had personal experiences or they saw an opportunity and recognize that they could influence.

It would be interesting to see and whether all startups are like that. And you’re right. If you have a background that is different, I think that can enhance, and again, you don’t have that, well, we just can’t do it, or this is the way we’ve always done it. You don’t know any better, and that naive say is probably really helpful.

Katie Bryski: Yeah. And I wonder too, again, just thinking about the mindset aspect, if there’s something about that entrepreneurial spirit, right? That willingness to take risks, that willingness to jump into the area where need and passion intersect. I wonder if there’s something about the mindset that just lends itself well to switching sectors.

If you were risk averse, you would probably wouldn’t leave the sector you started in.

Shelagh Maloney: Like you said before, this startup being a mindset is that, so when you do get from startup to scale up to operational, you know, you’ve, you’ve busted that nest or you’ve broken the ice and you are now a known entity.

Does that entrepreneurial spirit now automatically turn you to, “Okay, what’s the next thing I need to do?” And, and you, you know, there’s definitely that role of serial entrepreneurs and thank goodness we have them. And like I said, it’s just kind of blows my mind a little bit: the people that have that mindset and clearly I don’t have it and so I think I admire it more in people that do have it.

Katie Bryski: I was going to say, I wouldn’t count yourself out. I think being an intrapreneur still, still counts. At least that’s what I’m telling myself. I will be fascinated to see what our two guests turn their talents to next and what our listeners turn their talents to next. Hopefully this episode has provided some good inspiration.and empowerment for them to do so. And we will see you next month, right here on Digital Health in Canada, the Digital Health Canada podcast.

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