James Min is the cofounder and CEO of Cleerly which is a healthcare company whose mission is to create digital care pathways to prevent heart attacks. The company has raised $60 million from top tier investors which include New Leaf Venture Partners, LRVHealth, DigiTx Partners, and Cigna Ventures to name a few.
In this episode you will learn:
- Turning your passion into a sizeable company
- Getting your product to market
- Four major categories for building a successful company
- Staying on the mission
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About James Min:
James K. Min (born June 23, 1971) is an American physician, a former Professor of Radiology at Weill Cornell Medical College, and a former Director of the Dalio Institute of Cardiovascular Imaging at NewYork-Presbyterian Hospital/Weill-Cornell Medical Center. Prior to this, he held the title of Professor of Medicine at both Cedars Sinai Medical Center in Los Angeles, CA and David Geffen UCLA School of Medicine, Los Angeles, CA. He is an expert in Cardiovascular Imaging and has led numerous multi-center international clinical trials. He studied clinical utility and coronary artery diseases for over ten years. During his work at UCLA and NewYork-Presbyterian Hospital/Weill-Cornell Medical Center, Dr. Min published over 250 papers on Cardiac CT and Coronary Artery Disease.
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Read the Full Transcription of the Interview:
Alejandro: Alrighty. Hello everyone, and welcome to the DealMakers show. Our guest today has an incredible story. He’s definitely tackling a real problem, one of the biggest issues right now, heart disease. What he’s doing is unbelievable. We’re going to be talking about scaling, fundraising, and everything that goes into building something meaningful. So without further ado, let’s welcome our guest today. Jim Min, welcome to the show.
James Min: All right, Alejandro. It’s great to be here. Thanks so much for having me.
Alejandro: Originally, you were born in Oklahoma, but you moved quite a bit, so tell us about your upbringing.
James Min: It was humble upbringings. I was born in Norman and raised in a small town in southeastern Wisconsin. Primarily, it was about half farmers: dairy farmers, soybean farmers, and half were kids of the university faculty. There was a small university there. I had a great childhood growing up. It was definitely a protected world since it was so small-town. Then I managed to leave Wisconsin, and since then, I’ve only lived in Chicago, New York, LA, and Philadelphia. So I’m definitely attracted to larger cities.
Alejandro: At what point would you say in your life, you were exposed to making a difference in the world of medicine and being so attracted to medicine. Why did you choose that career path out of all the different paths that you had in front of you?
James Min: I was always interested by the science. I studied at the University of Chicago, and biology was my primary major. It was always that science drove me. So I’ve always been interested in the intersection of new biology, new science, and how that can affect human life. After college, I ended up in grad school. I didn’t plan on being a physician, and then I found the science to be as equally engaging as it was in my earlier years in college, but I felt that there wasn’t enough human contact and enough personal feeling of being able to help people one on one. So I ended up going to medical school after that, and that was the start of it.
Alejandro: In your case, you ended up going to Chicago. You did medical school in Temple. Then you ended up in Chicago doing the training there. Out of all the different areas in the medical field, why did you choose the whole heart and get into that space?
James Min: It’s ironic because I really like the procedural aspect of cardiology. I like the acuity of the illness and the feeling that you can really help folks. I think the field has done that quite remarkably in terms of treating patients who have come in with myocardial infarction or heart attacks. In my second-to-last-year fellowship, I was introduced to a gentleman in Milwaukee, Wisconsin, who invited us up for a conference. They were showing this image of a coronary CT angiogram. It was on a very old-generation forced ICT scanner. Now we have 640 ICT scanners. I thought to myself, “Your research interests are around coronary heart disease and prevention of heart attacks.” My plan was to go into interventional cardiology and do a lot of acute care where you’re in the cath lab or you’re in the ICU. What I ended up doing was to say, “I’m going to fundamentally change the direction of what my career is because I think that this non-invasive test will fundamentally change our understanding of coronary heart disease biology.” So I shifted to non-invasive imaging, mostly because my interest was coronary disease, and I felt like this was a brand-new tool that would allow us to study actual disease rather than sequelae disease or consequences of disease that are priorly tested. So I made the shift to non-invasive imaging and finished that up and got a great job offer to come to New York City in 2005 to head up a CT program and build that from scratch. So I came here in 2005, and I’ve been here ever since.
Alejandro: It sounds like New York has been a city that has been good to you because you went to LA, but then you wanted to come back, so what is the thing about New York City that you just keep coming back?
James Min: It’s the best city in the world. Right? For those who like urban life, you cannot beat it. You can do anything at any time, and it’s open 24/7. It’s truly the city that never sleeps. There’s so much opportunity here, too, and so many bright, bright people that you can collaborate and partner with. Yeah, there’s something about this city that I find to be infectious.
Alejandro: During your time here in New York City, you started pushing on the clinical side and more of the prevention side. What were some of the findings and things that were getting you even more excited about the problem that you had in front of you?
James Min: Yeah. It’s interesting because it sort of melded. The first six or seven years of my career, I spent a lot of time attending in the ICU. So, it was very end-stage, very sick people, and I thought, “There’s got to be a better way to do this than to wait for people to have these catastrophic events. It’s not just cardiology; it’s pervasive through medicine. We spend more than half of our healthcare dollars on the last six months of life. If we allocated those monies to prevention on the other side of that spectrum, we would prevent these catastrophic events, and we would never have to see them. In my seventh year, I started a program called Heart Health, which was a cardiovascular disease prevention program. We had the luxury of being supported by the institution, and the patients really loved it. The differentiating feature between our program and others was that we said to the patients, “We don’t care what your cholesterol level is right now. We don’t care about some of the other things that other people have focused on as important. We’re not saying that they’re unimportant; we think the primary important measure here is simply how much disease you have. And the disease turns out to be the plague buildup or the atherosclerosis within the heart arteries. That builds up silently in the vast majority of people such that the majority of folks who will have a heart attack or die from one have actually no symptoms before their event. So we started this prevention program to carefully phenotype the types of disease somebody would have and leverage that information to see how sick they are, independent of whether they had symptoms or no symptoms. Then we would prescribe therapies, whether medical therapy or lifestyle interventions to try to reduce that risk of heart attack and prove that we could halt the progression of disease. We would prove that by doing longitudinal imagining. After a few more years, we would bring them back, and we would show them what their therapies were actually doing. Did we halt the progression of disease? In parallel to that, we were doing something that informed our therapeutic decision-making. We had done a series of large-scale multi-center clinical trials to understand what is disease, and are there different types of it? It turns out that atherosclerosis is the primary disease process that causes all of the problems, but there are many different types. What we found was that some of them are very unstable and risky for the patient, and others were not. They were very stable and almost protective for patients. What we found was that the good things we would do for patients, whether it’s medical therapy or a healthier diet, or physical activity, didn’t regress the disease or regress the plaque. What they did was transform it from a very dangerous-looking phenotype into a stable phenotype. So now we had two markers that we could identify. 1) We can prove that we can stop the progression of disease, and 2) we can prove that we transformed the disease from an unstable to a more stable phenotype. It was those lessons that we learned that would help us do this precision care where we would individualize and custom-tailor therapies and custom-tailor management plans based on exactly how much disease and the type of disease that person had.
Alejandro: What was that day, Jim, that it was the most mind-blowing, like Wow-factor that you were perhaps like, back at home, on your bed, looking at the ceiling, and you’re like, “I cannot believe this,” in this journey of figuring out the whole prevention part of it?
James Min: I think that the realization came through these trials, where we realized that the most important thing, the primary disease process, has never been measured in cardiology. For seventy years, we looked at three things. We’ve looked at surrogates of disease like cholesterol or LDL cholesterol. We look at signs of disease like symptoms of chest pain or shortness of breath. And we look at sequelae disease, which is the downstream narrowing in the arteries that occur due to the plaque buildup. But for 70 years, we’ve never looked at the primary disease process. So we worked with some folks, and they were like, “Isn’t that obvious that if you want to understand the biology of a disease that you would study the actual disease? We just never had tools to be able to do that until we had the advent of coronary CT and geography. But even then, when we did the research trials, it would take us seven to eight hours to analyze the single patient’s image. So we said, “This is never going to be a clinical tool unless we can automate this somehow with high precision and accuracy. I think that was one big aha moment where “Gosh. We need to measure disease, not surrogate. I think the second aha moment was when we—when we started the company, we were approached by a couple of imaging vendors. At that point in time, they had a very strong emphasis on mammography. I don’t know why they were interested in it, but I think they saw it as a potentially large commercial market opportunity. Then they started pointing out what we were doing. Actually, somebody pointed out to me what was taught to me 20 years ago when I was training an internal medicine resident. They said, “What did you recommend for women at risk of breast cancer?” We said, “We used to recommend monthly breast exams, and we used to look for blood in the stool as an early sign of colon cancer, and we used to do chest x-rays in a limited fashion for patients at risk of lung cancer.” If you look at all of those three things, they all fell out over the last 20 years in lieu of advanced imaging to characterize and phenotype the primary disease process. So now, we use 3D digital breast tomosynthesis or mammography. We use colonoscopies. We use high-resolution lung CT scans for patients at risk of breast, colon, and lung cancer. Then when I contrasted that with the way I was taught 20 years ago as a Fellow, we don’t do that, and we haven’t changed. We use surrogates, we use science, we use sequelae, but we never actually used advanced imaging to characterize the actual disease. The rhetorical question is, do you ever wonder why we use advanced imaging to prevent the most common causes of cancer but not the most common cause of death? That’s the situation we’re in today, and that’s the purpose and the mission of the company, Cleerly, to try to identify those at risk so we can eradicate heart attacks from the face of this earth.
Alejandro: During this time, you also became a professor at Cornell, but this was all the segue into what became your baby, Cleerly. So let’s talk about Cleerly. How did you incubate? You were already in this; you were already looking into this, but what was that moment when you said, “I’ve got to start a company,” and the whole thought from incubation to bringing it to life. Tell us about that process.
James Min: We spent 15 years doing biology and large-scale clinical trials and taking care of patients, and we realized that the patients absolutely loved the clinical cardiovascular disease prevention program that we had. They raved about it. They told their friends and family members. It was such a popular program when we were at Cornell and NewYork-Presbyterian, but it was never going to scale. We had the support of the institution; we had the support of some very generous philanthropists who help support the program. But we would literally take eight hours to analyze a single person’s image, and we realized that it was never going to scale past the research because it took too long. It was never going to scale past the Cornell and NewYork-Presbyterian walls because it was too costly, and we said, “In order for us to deliver this at scale globally, we’re going to need to figure out a way to automate or semi-automate this process. At that time, we were doing a series of other research efforts, and around 2012 and 2013, that was when machine learning applied medical imaging was just becoming a thing. So we had thrown our hat in that ring too from a research standpoint, and we said, “Aha, why don’t we combine these two together. We’ll take all of the machine intelligence, and then we’ll take all of the biology that we understood, and then we’ll fuse it, and then we’ll try to create products and services that will touch each and every stakeholder of the care pathway. One other problem that we identified when we were taking care of patients and reading images was that if you’re not an imager, you don’t understand what’s on the image, so we needed translational tools to help effectively communicate to every stakeholder in the care pathway, whether it’s the clinician, the imager, the patient, and provide them and empower them with knowledge. The transition to making this company was really out of that nidus, it says like, “How do we deliver this to the world in a way that’s scalable, usable, standardized, accurate, and precise. That was the nidus of Cleerly in 2017.
Alejandro: Tell us about the early days of Cleerly.
James Min: The early days of Cleerly were like any startup. It was the antithesis of glamour, so it’s definitely not a glamourous process. Particularly for health care, as you well know, it’s a regulated industry, so there’s a lot of going through not only product development and getting the minimum viable product, but also how do you get that regulatorily approved by the FDA or other regulatory bodies. So we spent about 2.5 years doing product development on two FDA Cleerly products and then started to say, “Now that we’re here at this point, we now need to transition into the clinical community to be able to offer the services. That transition was last year, about a year ago where we transitioned into the commercial space and identified clients who would find great clinical utility in the products and services that we were offering. The first 2.5 years was a small but extremely talented team of engineers, data scientists, quality management folks, regulatory specialists. It was around, let’s get product approved and the ability to go to market. Then in this last year, it’s been about company building and thinking through all of the different verticals that you need to attack in order to successfully disseminate the product and services.
Alejandro: For the people that are listening, Jim, to really understand, what ended up becoming the business model of Cleerly?
James Min: We have a number of verticals. We’re focused on two major verticals. We engage and partner with health systems, so hospitals and IDNs, and to a lesser degree, large private practices and even some imaging centers where we have two programs. One is for that patient that we are worried about, the one who comes in with chest pain or shortness of breath that needs a comprehensive evaluation of their disease process that we haven’t been able to give them before. So we have that product. We also have another program where we identify very high-risk individuals independent of their symptoms in order to get them on good preventive medical therapy and lifestyle intervention. That’s been a very gratifying vertical to work with because you’re on the front line, and we believe that Cleerly should be the standard of clinical care. So we want to start that in the health systems. The second is to direct and use precision diagnostics to reduce healthcare wastes. The estimates are that about 40% of healthcare dollars in the U.S. are wasted. They don’t actually do any good for patients, and we believe that part of that reason is because, at least in cardiology, we have so relied on population-based estimates of things. I can take a million people over on the left and a million people over on the right, and I can say the million people on the right are much sicker than the million people on the left. But within the million people on the right, I can’t pinpoint any particular individual and say, “You specifically are the one that is sick.” That is the holy grail of personalized medicine and precision care, and that is what we offer. We offer precision diagnostics where we carefully and comprehensively phenotype the disease within every artery and its branches in a way that informs the clinician and the patient of how to deal with it and how to stop the progression of the disease. If you can couple the precision diagnostics with this goal of reducing healthcare waste, then the second vertical becomes working with pairs. How do you do this in a way that you can do judicious referral management to cardiology to stress testing to embrace angiography in a manner that improves outcomes while reducing over total costs of care? So those are the two major verticals.
Alejandro: How much capital have you guys raised to date, Jim?
James Min: We’ve raised a little under $60 million worth of capital through two financing rounds. Our first one was about an $8.5 million round, and our second one was around $45 million. We had done a small extension round right when COVID hit because we didn’t understand what the world would do, so that was for about a few million dollars.
Alejandro: Here, one of the things that is there is that when you raise money, the idea is to go fast and to go really fast. So how do you go fast? How do you scale a company like this without breaking it?
James Min: Yeah. That’s a really great question, and it’s one that I think doesn’t come to mind until you come face to face with it. Like, “We have to do hypergrowth here.” And how do you do that and articulate it without breaking the company? You see, a lot of entrepreneurs put on an Excel spreadsheet that things double every year, but at some point, you can’t double every year. It’s just not possible without breaking the company. We have made a very active attempt to make sure that we build with hypergrowth but at an extremely fast pace while maintaining the culture. When I think of company building, I think of it in four major categories. 1) I think there’s the purpose: are you doing something that’s real? And what is the total addressable market? 2) I think it’s the people, so does that team have enough muscle memory to know how to build companies without breaking them and scaling them. 3) I think of the products. Does the technology answer a meaningful question? 4) Then I think of numbers. Numbers include capital raise and revenue. Then, obviously, you’ve got to get that off the ground. Those are the four major considerations that we keep in mind. We grew from about 12 to 15 people at the beginning of this year to about 100, so we’ve hired quite a bit in this last year. It’s been very fast-moving. The COVID virtual work from home makes some things harder to communicate, but in many ways makes some things easier, so people don’t have 2.5-hour commutes and things like that, and there’s less strain on daily activities due to the work from home. We try to be very careful. We hired a chief operating officer who is exquisitely good at communication, organization, focus, and that’s been very helpful. But I think building culture, transparent communication, having everybody on the team rallied around the mission and purpose, but also having complete transparency and openness with them. That has worked for us so far, and that’s what we will continue to do.
Alejandro: You were mentioning COVID. Obviously, with COVID, it has been a time where, for the first time, we’ve seen doctors and nurses on the cover of magazines, newspapers, day-in, and day-out, and healthcare. People are definitely more conscious about themselves and taking care of themselves. Would you say that has, in a positive way, impacted you guys and also the momentum of you being able to build Cleerly in the way that you’re doing?
James Min: In some ways, yes, and in some ways, no. The ways that it is helped is to provide secular tailwinds around this need to evaluate the patients without necessarily putting them on a treadmill because our ways of doing it were to have people running on a treadmill and taking pictures of them. The COVID pandemic precluded that because there’s a lot of perspiratory droplets that are disseminated while somebody is breathing hard and things like that. So there was some shift in institutions to go to a CT-first policy because it’s a one-second or five-second picture of somebody, and then they’re out the door. So it makes it much easier to evaluate. I think the other tailwind that came by was that for the first time, about a week and a half ago, the American Heart Association and the American College of Cardiology elevated coronary CT and geography, which is the primary imaging with our data we apply our technology for the first time ever, so it was a Level 1A classification for the first test to be evaluated for patients with suspected coronary artery disease above any other test out there. Those two things have been quite good because it established coronary CT as the standard of care, which is great. Where it didn’t help the company is this focus on COVID. It was a rightful focus on COVID, but if you look back at 2020, a lot more people died of cardiovascular disease than deaths from COVID-19, so we’re trying to raise the awareness that we have a public health epidemic and the #1 public health epidemic in this world is cardiovascular disease. Somebody will die of cardiovascular disease every 1.7 seconds. The other thing that we have to educate people on is that waiting for symptoms like shortness of breath with COVID happens because it’s a silent process, and then we suddenly realize that we’re sick. We don’t have to have that for heart disease because most people who will have a heart attack don’t have any symptoms, so let’s find you before you develop too significant amounts of disease, and then let’s evaluate you comprehensively, even when you do develop symptoms. So across the continuum and spectrum of coronary disease extent and severity. I think our company has benefited from that, but we really need to raise the awareness. Still, women think that breast cancer is the #1 cause of death in women. It’s not. There are three times more deaths from cardiovascular disease in women than breast cancer deaths. Not to say we shouldn’t emphasize breast cancer prevention. Absolutely, we should, but we also need to take care of this #1 public health epidemic. I think that COVID has been good for the tailwinds, but it also raised so much awareness just about COVID that we started to forget about the #1 killer in the world.
Alejandro: Imagine you go to sleep tonight, Jim, and you wake up in a world where the vision of Cleerly is fully realized. What does that world look like?
James Min: It’s a world without heart attacks, and it’s a world where we’re doing global worldwide screening, similar to the way that we would be doing mammography, colonoscopy, and low-dose lung cancer CT screening. It’s the only one that works. If you looked at the preventive care paradigm, we had to use imaging in order to phenotype disease. Our issue as a field was, we’ve never actually looked at the actual disease. We’ve only looked at indirect markers of disease. Now that we have a non-invasive tool that has radiation doses as low as a screening mammogram, and we have this kind of precision and outcomes data, there’s no reason that we shouldn’t identify these people earlier. The total cost that would be saved to the healthcare system, and more importantly, the total lives that would be saved in the world, is just astounding. Five years ago, I think it was a mute question because we didn’t have much in the way of medical therapy. We had just statin medications. If you put everybody on a statin, then probably you don’t need to identify the people who are at risk. You can just overtreat healthy people and appropriately treat sick people with a medication that’s inexpensive and has a low percentage of side effects. In the last four years, we’ve seen the Food and Drug Administration approve at least ten new classes of medications that are block-busters for preventing heart attacks. If you do the additive exercises I’ve seen, “This one reduces heart attacks by 20%, and this one by 10%,” and you keep adding them up, it adds up to over 90%. The conclusion I make from that is our toolbox is very heavy. We have a lot of tools that we can use to prevent heart attacks that are not invasive that revolve around medical therapy and lifestyle interventions. The problem we have is not treatment. The problem we have is identification because what we are doing is, we are waiting for people to come in with end-stage chest pain. It’s like the equivalent of waiting for people to come in with end-stage metastatic cancer. It’s just not a good way to do medicine. The best way to do medicine is to prevent it, and the best way to have good outcomes from a heart attack is to never have one, so we’re here to identify the people, whether you have symptoms or no symptoms, we can identify patients with disease and leverage that to help support doctors so that they can properly treat and track the success of their therapy.
Alejandro: That’s amazing. One thing that I’d like to ask you here is, imagine I put you into a time machine, and I’m able to bring you back in time, let’s say 2017 when you were thinking about launching Cleerly. If you had the opportunity of sitting down with that younger Jim and giving that younger Jim one piece of advice before launching the business, what would that be and why, given what you know now?
James Min: That’s a great question. It’s probably a loaded question because there are multiple responses, but I think if I had to succinctly say it in one answer, it would be: solve a meaningful problem, and don’t get so wedded to technology, but solve the problem that helps mankind. I think our team has done that extremely well. We’ve kept our focus on the purpose, on the mission, on the values of the company, and if I could give one piece of advice to anybody, it would be: solve a meaningful problem.
Alejandro: Amazing. For the people that are listening, Jim, what is the best way for them to reach out and say hi?
James Min: Go to the website. It’s www.cleerlyhealth.com, with two e’s. Then there’s an email address that you can go to info and contact me at any point and time. I’d love to hear from your listeners.
Alejandro: Amazing. Well, Jim, thank you so much for being on the DealMakers show today.
James Min: It’s a pleasure to be here. Thanks so much, Alejandro.
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