CoNurse

A large proportion of patients are on their own or cared for by their family members at home following acute treatment. The information provided to them on further care is often superficial and easily forgotten. This can prompt deviations from the post-discharge care plans, leading to potential complications. Gathering information on the patients’ living and working environments for planning more effective treatment and rehabilitation activities is unorganised. Moreover, patients’ progress after discharge is often not monitored. To facilitate recovery, ensure the continuity of care, decrease complications and reduce readmissions, comprehensive solutions providing personalised guidelines and surveys are needed.

CoNurse is a voice-guided protocol adherence technology that improves care quality and standardisation, increasing patient safety. CoNurse app runs on smartphones and is controlled via Bluetooth, ensuring hands-free user experience. CoNurse CMS is a web-based platform that enables institutions to create and manage content for their users. CoNurse allows healthcare professionals to compile personalised treatment plans for the patients. CoNurse mobile app effectively includes patients and their informal caregivers into the care continuum and provides a personalized treatment plan with step-by-step video and audio guidelines for rehabilitation procedures at home. CoNurse web-based platform enables institutions to create and manage their content. 

Our aim is to extend CoNurse to include a simple app-based survey instrument integrated within the platform for collecting Electronic Patient-Reported Outcomes. This will improve healthcare professionals' knowledge by providing statistics on post-discharge care plan adherence and results of ePROs, supporting smarter systemic resource planning. Through providing a holistic overview of the patient’s condition, it helps to personalise post-discharge patient treatment plans.  

CoNurse can meet different conditions, age groups, physical and cognitive requirements and ensure better clinical outcomes. Making our application easy to manage for both patients and their family members we can make post-discharge treatment plans 100% adhered to and deliver the subsequent benefits, e.g. improvement in outcomes, as well as care efficiency and cost. CoNurse improves patients’ experience by empowering them with more ownership of their treatment.

The problem mentioned above affects various stakeholders in the care continuum:

• Patients - lack  of access to rehabilitation and post-discharge care can compromise health outcomes, extend inpatient stays, and result in  preventable hospital admissions due to health complications. Informal caregivers - family members providing home care are not trained, they cannot rely on coordination mechanisms of professional settings, and they require knowledge as well as skills that they did not have prior to the patient's condition. 

• Healthcare institutions - readmission of patients causes inefficient use of clinician’s time, longer waiting times, increased costs.

• Local governments - people unable to work cannot contribute to economic activities and, due to an aging society, additional resources are needed to cope with them.

CoNurse addresses the continuity of post-discharge patient care by: 

• Improving healthcare professionals' knowledge of patient’s progress by providing patient’s treatment plan history, supporting smarter systemic resource planning and patient stratification.

• Enabling a risk-based approach to post-discharge follow-up visits, moderating face-to-face demand.

• Providing a holistic overview of the patient’s condition, experience and environment, and developing post-discharge personalised patient treatment plans.

• Capturing novel forms of post-discharge patient ecosystem and lived experience, helping advance understanding of all interactions and services of diverse ecosystem actors.

Cognuse has been developing innovative digital solutions for health and social care since 2011.  The team has a long history of initiating, managing and delivering digital health domain projects. The projects are ranging from successful participation in pre-commercial purchasing project in the EU (Nightingale, Appian, STARTS, LiveIncite and others), lead and partner-level engagements in 3 EIT Health funded projects in 2016, 2018-2019 (Bridgehead Pilot Programme for UK and Germany) as well as an ongoing innovation project “Little NIRVANA”, 2020-2022, working with large partners such as KU Leuven, Maastricht UMC, RISE and Philips. We are currently  carrying out two studies in Estonia  - a study in collaboration with Ida-Viru Keskhaigla (IVKH) and with North Estonia Medical Centre (NEMC). We are also collaborating with Philips to propose a joint value proposition for a population health project in Poland. Our project and financial reporting has always been on time, without inconsistencies and no failures in any and all auditing processes.

Andres Mellik is the founder and CEO of Cognuse. Andres has 20 years of experience in e-learning applications, embedded systems design and test and serious/educational games. He founded Juku Lab LLC, an e-learning company at the age of 24 and worked with the earliest standards in e-learning extensively (SCORM 1.2/2004, xAPI) while putting a lot of focus in exhaustive testing of those standards for highly scalable learning management systems. Those experiences have proven invaluable in introducing more consumable and accessible clinical information to hospitals. He holds BSc/MSc from Tallinn University of Technology in Estonia and M.Eng. from the University of Lugano in Switzerland. Additionally, he has completed research terms at UEC, Tokyo, Japan and UC San Diego in California, USA. Andres is a long-term member of the IEEE as well as the founding member of the Sleep Technology Council under the National Sleep Foundation in the USA. 

Jürgen Järvik leads the content development for CoNurse. He is responsible for the language and the logic of the procedures. Standing at the junction between the developers, the content experts and the end users, he makes sure that the content grows out naturally from the technical logic of the application, follows pedagogic requirements as well as reflects in detail the practical conditions in which it is going to be used. He has been a co-author of a number of e-learning courses for several international organizations, including the NATO CCD COE, OSCE, Frontex and many others. His mission is to make learning easy, effective and appealing. 

Karmen Markov works on core research, analysis, UX/UI and overall product development. She has also been in charge of writing several project proposals, valuation  and impact  study  protocols. Currently, she is leading an ongoing project for developing a model for dynamic protocols (link) and a study at North Estonia Medical Centre.  She received her BSc degree in Neuroscience from King’s College London (UK) and is currently a Health Sciences and Technology Master’s student at ETH Zürich (Switzerland).  During her studies in London, she  gained research experience at the Neurodegeneration Imaging Group, London Neurodegenerative Diseases Brain Bank and Neuro-Insight, a neuromarketing company. 

Birgit Krieger is the project and Product Coordinator for CoNurse’ distribution and partnership endeavours as well as the Product Manager for Kõneravi.ee digital speech therapy service and it’s internationalization branding efforts – SpeakTX. Birgit graduated from Tallinn Healthcare College as an optometrist and received a MSc in Health Care Technology from Tallinn University of Technology graduating with cum laude and publishing an original research article. 

Importantly, the core team tightly collaborates with end users - we have incorporated a nursing task force consisting of junior and senior nurses as well as nursing students across various hospitals in Estonia, USA and Spain. Additionally, 3 developers have been subcontracted to help with technical developments.

One of our core aims is to democratise access to quality healthcare by increasing patient safety. For this purpose, we are closely following the UN SDGs to cater for impact measures that are relevant for today’s development roadblocks. Hence, we would greatly benefit from the impact-centred mentorship offered by Solve.

We feel that we have built a great and impactful product but it is hard to enter the healthcare market and expand. We mostly need support with product distribution as well as public relation to increase our visibility.

The use of checklists is inconsistent and their implementation in hospital settings have not led to noticeable improvements. Their implementation focuses on improving the content of guidelines, rather than their delivery, hence making them inaccessible at the point-of-care. Other competitors' product disadvantages include inability to tailor guidelines to specific institutions. By focusing on making CoNurse actionable and accessible at the point of care, we deliver guideline adherence, improving patient care outcomes and safety, as well as care efficiency and cost. 

CoNurse also differentiates from other solutions through providing a comprehensive support and safety net tool for the whole care continuum. Stand-alone apps for managing medical conditions exist, but there are no holistic platform solutions. Existing products focus on physiological measurables rather than taking a comprehensive experience approach. Our solution brings in other factors from the ecosystem to build a comprehensive understanding of the patient’s whole experience and possible causes behind the changes in variables. Rather than being our competitors, CoNurse provides excellent opportunities for integration.  

CoNurse makes post-discharge care plans 100% adhered to. Wider education and understanding of post-discharge care progress enables earlier and safer discharge from the hospitals, hence reducing the number of preventable complications (e.g. pressure ulcers, pneumonia), the use of emergency medical services and the rate of patient’s readmissions in the post-acute treatment period, all reducing costs for the healthcare system. CoNurse enables a risk-based approach to post-discharge follow-up visits, moderating face-to-face demand. 

The innovative elements of CoNurse  are:

• Integrated understanding of elements contributing to post-discharge patient lived experience and relation with their condition.

• Focus on patient self-learning, self-management and capability development.

Adaptive personalised post-discharge patient management support.

As CoNurse is not only a tool for empowering informal caregivers, our impact goals go beyond that use case.

Impact goals for the next year:

1. Improved patient safety through 100% adherence to clinical guidelines and improved standard of care. 

• Developing CoNurse mobile Application for healthcare providers, informal caregivers and patients. 
• On-demand access to clinical guidance. Procedural guidelines compliant with the latest standards are followed by CoNurse users.
• Provide an information support platform for caregivers
• Nurses use CoNurse to ensure improved patient safety

2. Reduced cost for the healthcare system

• Publishing scientific articles on the effect of a digital support tool in clinical and home settings in collaboration with hospitals
• Data-driven insights on app usage, procedures carried out, burnout levels and equipment status through CoNurse CMS
• Institutions use CoNurse for improving the standard of care
• Easy way for the healthcare institutions to create and manage institution-specific content for their users and ensure the quality of the protocols.
• Developing CoNurse mobile Application for healthcare providers, informal caregivers and patients.
• Developing web-based Content Management System for content creation and overviewing user statistics

3. More efficient onboarding of new staff 

• Providing a support platform and safety net tool for the users.
• Validating CoNurse in clinical settings
• Efficient learning tool for nursing students and junior nurses.
• Encouraging using CoNurse in novel situations (e.g. COVID-19) or during night shifts, when performing difficult or infrequent procedures, when setting up medical devices. 
• Supporting students and junior nurses in learning and training. 
• Conducting clinical evaluations.

4. Integration of informal caregivers into the care loop

• Earlier safe discharge for patients as informal caregivers and patients are provided with a CoNurse to follow post-discharge treatment plans.
• Provide an information support platform for caregivers
• Encouraging using CoNurse through testing, evaluations and implementations in home settings in collaboration with hospitals.

Impact goals for the next five years:

The goal is to scale up the goals we have for the following year and work on reaching our economic impact goals.

The economic impact of the project

CoNurse helps to reduce avoidable healthcare systems’ costs and redirect resources to value-based healthcare, mainly through reducing costs related to preventable adverse events and onboarding new staff.

Adverse events (AEs) cause prolonged hospital stays, permanent harm, life sustaining intervention, and administrative burdens, leading to added costs to hospitals. AEs are the main cost drivers for hospitals, expected to cost the European and US healthcare systems €383.7 billion by 2022. Considering preventable AEs account for ~45% of total AEs, CoNurse could save the European and US healthcare system up to €176 billion. Moreover, AEs negatively impact staff morale, contributing to the high staff turnover. This is a critical concern as the number of medical staff is not adequate to meet the current and future needs. CoNurse addresses these problems through enforcing protocol adherence which in turn will reduce the occurrence of AEs and make the patient care pathway more efficient.

CoNurse makes training and onboarding of new staff more time and cost-efficient. According to independent calculations from Clínica Nueva, CoNurse can potentially reduce the induction process length from 15 days to 3 days and reduce the annual induction cost by 80% (from 6387 COP to 1266 COP).

Moreover, CoNurse allows the effective inclusion of informal caregivers and patients self-management. Wider education and understanding of post-discharge care progress enables earlier and safer discharge from the hospitals, hence reducing hospitalisations duration, the number of preventable complications (e.g. pressure ulcers, pneumonia), the use of emergency medical services and the rate of patient’s readmissions in the post-acute treatment period, all reducing costs for the healthcare system.

Informal caregivers do not receive adequate support for caring for post-discharge patients.

Earlier safe discharge for patients as informal caregivers and patients are provided with a CoNurse to follow post-discharge treatment plans.

•  decrease in time to discharge
• decrease in hospitalisation cost per patient
• decrease in post-discharge complications and re-hospitalisations
• decrease of the use of emergency medical services related to post-discharge complications

Improved standard of care

• % decrease in preventable AEs among institutions using CoNurse

Reduced cost for the healthcare system

• %decrease in hospitalisation cost per patient 
• % decrease emergency medical services use related to post-discharge complications

Integration of informal caregivers into the care loop

• # caregivers using CoNurse 

• Patient satisfaction measures (through questionnaires)

Failure to adhere to clinical guidelines  across the care continuum (e.g. in-hospital, post-discharge) as instructional guidance for nurses is not accessible nor actionable at the point of care. 

Data-driven insights on app usage, procedures carried out, burnout levels and equipment status through CoNurse CMS

• % increase  in hospital management knowledge on staff’s wellbeing measured through surveys

Publishing scientific articles on the effect of a digital support tool in clinical and home settings in collaboration with hospitals

• Increased credibility as a result of scientific validation -> increased interest in using CoNurse amongst institutions

Improved standard of care

• % decrease in preventable AEs among institutions using CoNurse

Reduced cost for the healthcare system

• % decrease in costs related to avoidable adverse events
• % decrease in hospitalisation cost per patient 
• % decrease  emergency medical services use related to post-discharge complications

Improved wellbeing

• % decrease in burnout and stress levels (measured via psychological assessments and cognitive tests implemented in the mobile app)

Theory of change from impact perspective:

We impact various cross-cutting themes, specifically those specified by the United Nations Social Development Goals 3 (Good Health and Well-Being), 4 (Quality Education), 5 (Gender equality) and 10 (Reduced Inequalities). 

We contribute to SDG 3.4 (by 2030 reduce by one third premature mortality from non-communicable diseases through prevention and treatment; promote mental health and well-being).  CoNurse empowers nurses by providing them with a comprehensive support and safety net tool that allows them to be more confident in their work and  benefits their wellbeing. Indeed, CoNurse has shown to significantly decrease stress and fatigue among its users. This has a direct impact on patient safety and outcomes as tiredness and burnout are strongly correlated with reduced patient safety. We also contribute to SDG 3.c (substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries [...]). CoNurse supports junior medical staff training, providing junior nurses with a platform for enhancing learning and remembering procedures and creates an extra layer of support when performing procedures. CoNurse facilitates onboarding of new nurses, in parallel with an increase of their demand as a result of COVID-19.

We contribute to SDG 4.4 (By 2030, substantially increase the number of youth and adults who have relevant skills, including technical and vocational skills, for employment, decent jobs and entrepreneurship) as we provide nursing students and junior nurses with an effective learning tool ensuring that they are up-to-date with the latest clinical protocols and standards, enhancing their skills and overall employability. It is our mission to make CoNurse available for all nursing students regardless of their background and economic status. 

We contribute to SDG 5.b (Enhance the use of enabling technology [...] to promote empowerment of women) as we provide nurses (who make up 70% of workers in health and social sector) with an accessible easy-to-use digital solution, CoNurse, to support them in health and care endeavours. Regarding SDG 5.4 (Recognize and value unpaid care [...]), we support family members/informal caregivers via clear clinical and physiotherapy protocols that they can  perform at home unsupervised by a qualified nurse.

We contribute to 10.a (Implement the principle of special and differential treatment for developing countries, in particular least developed countries, in accordance with World Trade Organization agreements.) as currently we provide CoNurse free of charge in the developing countries we are working with e.g. Kenya, thanks to publicly funded pilot programmes. In the future we will provide our platform at a discounted price according to the specific country's economic development status.

Our Technological approach is Software-as-a-Service, where Cognuse is responsible for all continuous updates and iteratively integrating all feedback from end users. 

From the hardware standpoint we are using commercial-off-the-shelf (COTS) technologies for the front line staff, family members and patients, namely smartphones. The CoNurse end-user front end app is a secure native mobile app for iOS and Android, ensuring the app contents and functionalities will always be available (online and offline). We use Android technology based on Java (Android phones) and iOS operating system technology based on Objective-C (iOS phones). CoNurse is equipped with a voice interface - it can be controlled through a Bluetooth headset - ensuring its seamless integration into the clinical workflow and a hands-free user-experience aligned to hospital hygiene policies. This allows a fluent flow so that end-users can carry out different procedures and exercises without disruptions. CoNurse captures objective information about carrying out the protocols including mobility metrics, protocol and intra-protocol step duration. Analytics and usage statistics are displayed in the web-based Content Management System (CMS). The platform also allows for anonymous usage, important in clinical study contexts. The proprietary aspects of the CoNurse mobile application are developed from 3 years of testing CoNurse in hospital settings, including highly stressful and often noisy, alarm-ridden acute or emergency care units.  

The technical output and data exchange format of CoNurse is generally JSON which can be made available for machine and/or human readable purposes. To integrate with EHR, we will use FHIR as a modern interoperability standard, enabling the interface between EHRs and mobile apps. Due to the widespread use of FHIR, as well as a regulatory push in the US for its adoption, using FHIR will allow us to become more scalable abroad. Furthermore, this will allow us to operate in conjunction with resources from the Harvard Library of Evidence, a public repository of evidence for clinical decision support, which allows download recommendations conform to industry standards as Clinical Decision Support (CDS) knowledge artifacts in FHIR specification (xml).

CoNurse app includes an audit trail secured with Guardtime Keyless Signature Infrastructure blockchain comprehending action log validity, liability control and versioning integrity. This provides a security and timestamping feature to preserve the integrity of the actions within CoNurse. This is particularly useful for when CoNurse is used in hospital settings - the AT provides a safety layer for all stakeholders including patients, family members, medical staff, hospitals, and healthcare systems. ATs can be retroactively referred to by providing the chain of events on the protocol and care pathway levels. ATs keep the patient anonymous and do not include any patient data.

The CMS responsible for the authoring, performance tracking and communications is a web-based application. The backend-level CMS is hosted in the cloud, with local/regional databases where required. The CMS allows hospitals to create and manage their own content as well as importing existing content from various onsite cloud sources, custom repositories and similar, the adaptation of existing protocols, post-discharge treatment plans and associated materials, and their integration into the CoNurse mobile app. Access to the CMS will enable the institutions to get an overview of the overall user activity and  engagement, user performance statistics and other relevant metrics that depend on the use cases. The technical innovation of our CMS is built from our 20 years’ experience with e-learning standards, learning and content management systems as well as hospital CMSs. 

We will primarily be selling B2B to healthcare systems, hospitals, universities, and nursing schools using license and reimbursement pricing options. We will also be selling B2C where applicable e.g. to nursing students, patients and informal caregivers. The pricings of competing and similar products are described under point 7.

B2B to hospitals - CoNurse for medical staff (e.g. nurses). CoNurse is sold as Software as a Service with an annual subscription which equals to 1% of annual salary/user x the nr of active users. For a large European medical centre with 1000 medical staff, the total annual contract will be in the range of €144,000 per year. 

B2B to hospitals - CoNurse for post-discharge patients. Annual tiered subscription priced according to a monthly per user fee. The starting price per user depends on the market GDP and the PPU decreases 5% by tier.

B2B to nursing schools and universities - CoNurse for nursing students. Annual tiered subscription is priced according to a monthly per student fee where the starting price per user depends on the market GDP and the PPU decreases by 5% by tier. For example, in Estonia the pricing would be the following: 50  students - 2€ per student; 50-100 students - 1.9€ per student; 100-250 students - 1.8 € per student; 250-500 students - 1.7€ per student; 500+ students - 1.6€ per student.

B2C to end users - monthly subscription model. 14-days free trial, then  5€ - monthly subscription; 20€ - 6 months subscription; 35€ - yearly subscription. 

We aim to become financially sustainable through sales, partnerships, funded projects as well as through raising investment capital. 

We calculate our market size based on the number of nurses present in our target countries and on their yearly average salary. Total addressable market (TAM) = total number of nurses in our target market * average yearly salary of nurses. Total TAM for current target countries (Austria, Estonia, Germany, Italy, Spain, Switzerland, UK, US, Japan, Georgia, Colombia, Chile, Perú) is 5.5 Billion €

We aim to be present in 80% of hospitals in Estonia. Globally, we calculate our market share as annual revenue as % of TAM): 2022: 0.027%. 2023: 0.057%. 2024: 0.2. 2025: 0.496%. 2026: 0.782%. 2027: 0.985%. 2028: 1.137%. 2029: 1.29%.

The financial capacity of Cognuse OÜ has been consistently good for the last 10 years, the company has no tax debts and the owners of the company are able to increase their working capital on an ongoing basis, if necessary.

In the past, for example, bridge funding has been used effectively for EU-funded projects.

The sales turnover of Cognuse OÜ has grown steadily in 2019-2021 due to the increase in sales of new markets and main products.

In 2014-2016, the company also included its first venture capital circle (~ € 800k) and the interest of both strategic and venture capital investors in our activities has been consistently good. In addition, existing investors are also willing to invest if there is a real need. If necessary, we can also submit the corresponding confirmation letters from both Estonia and the USA (incl. Jumpstart Foundry, DreamIt Fund II and 500 Startups funds).

Cognuse has raised €703,978 in venture funding from early-stage healthtech funds in the US, MedTech Angels in Estonia and other investors (e.g. DreamIt Health Baltimore, 500 Startups, Jumpstart Foundry). Additionally Cognuse has received various non-dilutive grant fundings (€135,000 from EIT Health, €120,000 from INNOVE SA, €195,000 from EMFA). Additional revenue streams to use for self-funding the project include using revenue from current product base, including, but not limited to Kõneravi.ee (international brand SpeakTX), and revenue from CoNurse paying clients and collaborations. We are currently actively fundraising from various sources and strategic partners with strong interest from both EU and US based institutions.

We recently received funding of ~600k € for a more risk-heavy R&D development project (link).