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  1. 1. 2012Tallinn University of Technology
  2. 2. 2The paper has been written independently and allsources of information have been referencedstudent’s code: 111650student’s e-mail: janno.nou@eesti.eestudent’s code: 104939student’s e-mail: urho@printon.eestudent’s code: 121814student’s e-mail: birgitaavik@live.comstudent’s code: 121335student’s e-mail: kim.kisenja@gmail.comstudent’s code: 122857student’s e-mail:
  3. 3. 3PITCH ........................................................................................... 4INTRODUCTION ............................................................................. 4Market and Industry .................................................................... 51.1 Industry and market description ........................................... 51.2 Key competitor’s strategy ................................................... 71.3 Hocoma Business Model ....................................................... 9HIGH GROWTH IDEA ...................................................................... 122.1 Cura Business Model ............................................................. 122.2 Product description .............................................................. 172.2.1 Technical working .............................................................. 182.3 Execution Strategy ............................................................... 202.3.1 Future ideas ....................................................................... 23CONCLUSION ................................................................................ 23SOURCES CITED ........................................................................... 24APPENDIXES ................................................................................ 26Janno NõuMechanicsBirgit AavikBusinessKim KišenjaBusinessTanel TammjärvBusinessUrho OrasmäeIT
  4. 4. 4PITCHThe main idea of Cura is to give reassurance tothe patient that one is being looked after,knowledge what to do when the patient isexercising, motivation to exercise and all that inhome enviroment - we achieve it with the sensorsthat will be placed on the body.Our solution consists three different parts:Sensors: fixed to the right place of the body withpatches during the first visit to the doctor.Therapy bracelet: gives information to the patient.Application (in tablet or smart phone):communicates with sensors and bracelet,processes the information, shows the rightmovements and sends processed data via Internetfrom where doctor can see the patient’sexercising results online.The communication between these devices isdone by Bluetooth v4. Every device has its specificrole. Sensors gather information, bracelet warnspatient if the exercise is done incorrectly andshows the number of exercises left. The applica-tion analyzes the data that gives feedback to thepatient and provides doctor with updatedinformation via Internet.Cura binds together existing technology andprovides a whole new concept of values. Cura’scustomer segment will be health-care institutionsand the end-users will be patients who need to dorehabilitative exercises. The clients who use Curawill experience the ability to take more patients,make the rehabilitation process more efficient, getdata and feedback more easily and quicker fromthe patients.Cura’s technological platform remains open forfurther developments. For example, the idea is torelease additional solution for athletes with 3Dmapping, technique analyzing feature and other.Cura’s technological platform remains open forfurther developments. The strategic goal is todevelop different products for different clientssegments. For example professional sports, wherecoaches and doctors can better measure indica-tors of a sportsman like speed and power. It allowscoaches to improve the technique and get betterperformance of sportsmen.INTRODUCTIONOne of the most dynamic industries in oursociety is health-care technology. Health-care isfast growing, impacting our very well being, whiletechnology is the engine fueling both societal andeconomic change. Pediatric physician at BostonMedical Center who has been involved withseveral health care startups has said “The morethe technology is integrated into the workflowthat a doctor is used to, the more likely it’s goingto be accepted:“This work has been done by team of five studentsfrom Tallinn University of Technology for„strategic management” course and in addition toparticipate in a business model contest „Mektory”.There are two objectives. Firstly, to give an over-view of the health-care field and to take a lookinside to our main competitors’ business modeland strategy. Secondly, to introduce our businessidea through building up a business model andstrategy.This work is divided into two sections. The firstpart describes market and industry and the sec-ond part focuses on authors high growth idea.Business Models are described through AlexanderOsterwalder’s and Yves Pigneur’s „The 9 BuildingBlocks” and Cura’s strategy is built up withassistance of InnoTools.
  5. 5. 5The first part is divided into three chapters wherein the first chapter authors give a brief overviewof the health-care industry, in last two chaptersthere are used different theories to describe oneof the competitor’s strategy and to analyzecompetitor’s business model.The aim of the second part is to introduce Cura’sbusiness model, and execution strategy. Theoriesare used to give academical proof to author’sstatements on business model and company’sstrategy. This part also contains descriptions andpictures of the author’s innovative idea.For better understanding, authors have usedacademical articles and presentations. In addition,there were interviews with experts like The NorthEstonian Medical Centre’s chief doctor SergeiNazarenko, the board member of SportMedFoundation Mihkel Mardna, and others like the CEOof the GSM Valve Hans Alter. The authors also in-terviewed patients from different age groups withvarious injuries.“The more the technology isintegrated into the workflowthat a doctor is used to, themore likely it’s going to beaccepted“MARKET AND INDUSTRY1.1. Industry and market descriptionAmericans spend approximately $7,600 a yearper person on health-care and avarage wait timeto see a doctor is 20 days. The entire system isstarting to change thanks to health-caretechnology companies. “We are about to see afundamental transformation in the way care isdelivered and the way patients are engaged withthat care,” said Frank Moss, head of the NewMedia Medicine Group at the M.I.T. Media Lab.Entrepreneurs are evolving model of health-carewhich is more focused on outcome than just aservice (Zimmerman 2012).Health-care startup numbers are increasing andthey are trying to provide better coordination ofcare. The main thing is to offer value bytechnology. According to article „A Framework toManage the Early Value Proposition ofEmerging Health-Care Technologies” it has to beproven that the new product is better than theexisting one in terms of value (Shirley 2011). Valueis the main starting point for thinking oninnovation and it leads to more integratedsolutions.The two most dynamic industries in the world arehealth-care and technology. It is necessary toprovide people with the right information at theright time. People may think that something assimple as smart phone is just a device but inhealth care, it is a gateway product. They allowyou to find the information what, when or whereever you need it (Reiss 2012). It makes life easierand more enjoyable to coordinate everything fromone product.Even those companies which are not technologicalcompanies, like health-care, have included socialnetworking or mobile technology into their busi-ness models (Debaise 2011). Everything is moving
  6. 6. 6towards integration and therefore products areeasy to use and may implement differentfunctions.Health-care industry using IT is inevitable. Theunique combination of health-care and IT may berealized in a different manner in the health careindustry than in other industries because it couldbe employed to improve the productivity benefitsof IT. It is difficult to improve patient care, reducethe cost of care or ensure patient privacy but IThelps better to seek those goals (Timur 2012).In health care technology, complicated web ofpayment and reimbursement have removed the„build it and they will come“ strategy, because itis no longer effective. Innovation has shifted froma push model to pull model. Startups need morethan just a good idea to secure capital growth.It has to be known who your customer is. Thecustomer mix varies for each company (Kurtzman2012). Customer segment depends on whatproduct or service company is providing.Regulations in this industry are often complicatedfor participators. Health care sector is the secondmost regulated sector after the nuclear powerindustry. For example, in 2010, Samer Hamadeh,who founded Zeel, which offers booking withalternative medicine practitioners, like chiroprac-tors and acupuncturists, had to comply withHIPAA (Health Insurance Portability and Account-ability Act) privacy rules. It means he had to makebooking appointments secure by providing onlyfirst names and last initials. There was also oneother problem. He wanted to add small fee fordoctors who were referring the service forpatients, but it can be considered as fee-splitting.The founder and CEO of Private HealthManagement, which offers treatment planstailored to patient needs, considers it a weirddynamic because technology is changingrapidly but everything else is stuck thirty yearsago (Moukheiber 2012).On the other hand, governments value health-carecompanies and support entrepreneurs in thissector. For example, health-care is a golden sectorfor the UK. Governments may want that health-care sector would be more transparent and moreconvenient to orient but rewriting legislation maytake some time.However, it can be more difficult to smallercompanies. Joanne Rohde, founder of health-carestartup pointed out that government policiesmake it hard for smaller companies to cope at themarket. Laws are written from the perspective ofa big company (Brussel 2012). That may be thereason why bigger companies can benefit from thesmaller ones. Smaller companies help bigger onesto cope.Venture capitalists believe there are two promis-ing areas. Companies that serve consumers di-rectly and those that help hospitals provide betterquality and cheaper services.Bigger companies want that smaller ones to dogreat, hoping to benefit from their ideas.Bigger companies often buy ambitious startupsand when the founder leaves, one starts some-thing new. In health-care case, there may behospitals, pharmaceutical companies or otherhealth-care conglomerates. It can be explainedusing capability lifecycle from resource basedview theory as health care is one of the mostdynamic industry in the world. This theory dealswith resources and capabilities over time. There isfounding, development and maturity stage. (Helfat2003) Therefore, mostly in the founding stage,resources and capabilities are influenced by othercompanies or investors.According to the Wall Street Journal, secondannual ranking of 50 companies in which venturecapitalists have invested, shows for the secondstraight year health-care companies are on thetop of the list (Debaise 2011). Although, the thirdranking is the first time when health care companydid not top the ranking (Zoran 2012).Health-care angel investor, Joanne Chang pointedout that grammatical or logic mistakes areinvestment deal breakers. Also startups which
  7. 7. 7is 3,53 in a scale of 1-5 (5 being very highconfident). It is said that 6-18 month outlook forraising funds is pessimistic, but long-term outlookfor health care companies is promising (Baum2012). Although this long-term time may not beacceptable to investors or other partnersbecause of the liquidity despite the opportuni-ties by changing the structure in the health careindustry. Lisa Suennen, who is managing memberin health care investment firm have said that thefirms that survive this special period (4-5 years)have advantageous situation. (Baum 2012)Now, general adoption of health is slow, but soon,much of this will truly matter. Also ROI will bemore apparent (Kurtzman 2012). Health care isgoing to be all about information in the future.CEO of WebMD said that it’s about being able touse information to change lives.  It’s becomingmore of a dialog between a health care providerand a patient. (Reiss 2012)There are many health care start-ups but this fieldis difficult to manage, both investments andregulations. It is a popular industry but only thebest ones will survive. Also, it takes some time forpeople to value the outcome of those companiesand their possibilities which can provide betterhealth care system.“We are about to see afundamental transformation inthe way care is delivered andthe way patients are engagedwith that care”1.2. Key Competitor’s strategyCompany introductionIn this field every company deals with someparticular customer segment. Nevertheless thereis a company that is operating in relatively samearea and it offers neurological rehabilitationmachinery. The name of the company is Hocoma.It has a Headquarter in Switzerland and twosubsidiaries in Singapore and in the USA. Thecompany has 120 employees and the require-ments for them are very high. The CEO ofHocoma AG is Gery Colombo and Hocomagenerated a turnover of more than 26 million CHF(21,5 million euros) in 2010.Company’s strategy descriptionHocoma operates internationally. The companysold products to 31 countries in 2008 (Colombo2008). With so small personnel it is hard to workin so many countries so the firm has to choosenetwork strategy. On the one hand, workingthrough networks reduces the costs but on theother hand it might be risky. Researches showthat firms usually fail half the alliances they form(Kale et al 2007). There might be some parallelswith network management and formation. Existingcomparisons show that companies have to takeinto account the need and strategies of otheractors and no company is capable acting in linewith its strategic intentions (Munksgaard et al2012). The joint product development networkscan be seen as borderless, adaptive, self –organizing systems that no single firm can director control (Ibid). Even if the network is establishedit is still difficult to extract one’s strategic goalsfrom it. In Hocoma’s case it is the only opportu-nity because usually SME’s does not have enoughfinancial resources and manpower (Pullen et al2012).have been trying to unsuccessfully raise moneyfor years or there have not been any substantiveoperations (Chang 2012).In the field of health care, before it improves, itis getting even more difficult. The Silicon ValleyCapitalist Confidence Index measured for the Q3
  8. 8. 8The company has brought out two university hos-pitals as their partners- and these two can be alsoseen as the lead users, because they are usingthe technology and at the same time they help todevelop the products. Universities are Hocoma’spartners in product development too. Hocoma re-lies strongly on four universities by developing thecompany’s products with them. Every university isinternationally recognized and the combination ofZurich University, University of Twente andUniversity of California Irvine makes good innova-tive platform (Product Development). In the com-parison with theory the universities that Hocomais working with are adding value to the company.In some theoretical articles the universities wereseen as passive wait-and-see actors. However inthis case it does not seem so.Technology labs are also one of the keydevelopers in Hocoma’s case. As it was mentionedbefore the researches show that it is hard to buildup partnerships and network even though Hocomahas managed to do it effectively in productdevelopment. The products are quite expensivefor individual users. For example robotic walkerLokomat costs $250 000 but some of the newdevelopments are aiming towards individual pa-tient, too (Langreth 2005).Also, the company has chosen not to distributethemselves but to use partners. The companyhas qualified sales partners in 35 countries (SalesPartners) into account the smallness of Hocoma itis crucial for the company to have inter-mediaries to distribute their products. Even if Ho-coma’s approach to sales is cheaper it might havesome disadvantages in theory. The use of interme-diaries can lead to resistance toward adoption ofnew products and therefore inter-mediaries can negatively affect the commercialsuccess (Aarikka-Stenroos et al 2012).Hocoma has solved this problem by building upsales system that even if the product is boughtfrom intermediaries the company sends its tech-nicians to install the product and to educate theclients (Colombo 2008). By this mean Hocomastays in touch with clients and intermediaries haveonly the representative role.In theory, the R&D network there could bedistributors, buyers, consultants, suppliers,research institutes, universities, government agen-cies, industry associations and evencompetitors (Aarikka-Stenroos et al 2012). Goodproduct development needs fairness trust,reliability trust and network position strength(Pullen et al 2012). In Hocoma’s case partners canbe divided mainly in two categories: sales-partnersand R&D partners.Three main types of development partners can bedistinguished:• Rehabilitation centers and hospitals - Hocomastays in touch with its clients who use itsproducts. Users are mainly divided into leadusers, mavens, expert opinion leaders and hubpersons (Aarikka-Stenroos, Sandberg 2012).The users can contribute by demonstratingthe use of products and may act as references(Ibid). Lead-users can also be connected withother innovative users in network and theycan shape the product to be more after theirneeds (Harrisson, Waluzewski 2007)• Universities - Public organizations andeducational institutions may support diffusionby articulating optimistic visions of the use ofthe innovation. Due to a lack of power theyoften take a wait-and-see stance. (Aarikka-Stenroos et al 2012)• Technology LabsHocoma stays in touch with its clients byoffering them full support. It means that thecompany achieves two goals by this action. Theyget feedback from users and at the same timeby offering full support the company gets goodreference. In Hocomas case it is hard to distin-guish whether the company has lead-users or notbecause Hocoma works close with every client.
  9. 9. 9In conclusion Hocoma has a very clear strategyand it has proven its use. The company has aniche product and they are developing productseven further. Also, the company stays in touchwith its clients and solves the client’s problemwith their products. It is hard for other companiesto enter this niche because Hocoma has a verystrong position in it. Although Hocoma isoperating internationally it has managed to staysmall and innovative. The product developmentand sales are done with partners. It is cheaper towork with partners because the company getsmore information and resources than it could geton its own. Hocoma has managed to build inter-national sales and product development networksand it makes the company more competitive ininternational markets.1.3. Hocoma Business ModelIn this chapter Cura’s competitor Hocoma’s busi-ness is analyzed through Alexander Osterwalderand Yves Pigneur 9 blocks. The authors choseHocoma because they are the leaders in roboticrehabilitation therapy for neurological movementdisorders. They develop innovative therapysolutions working closely with leading clinics andresearch centers focusing on rehabilitation.Table 1. Hocoma’s Business ModelSource: Made by authors
  10. 10. 10To be successful in health care field it is vital tofocus on a certain customer segment. Hocoma’ssuccess in their business is lying mostly on theirclear segment, which are end-users, who have tovisit physiotherapist to get medical aid. They arefocused on people who have neurological disorder,whether it is stroke, multiple sclerosis, spinal cordinjury or other difficult disorders. It is their goalto improve therapy for these kinds of patients(Patients). Another customer segment is healthcare institutions that buy their products and thenoffer supporting services and also rent theseproducts to their patients. Clients are also workingclosely with co-operation partners to ensure thesafety of their products (Philosophy).Health care is high profit area and clients arewilling to pay good money for quality productsand services to ensure their patients well-being.Hocoma product’s value offer is combined withmany different aspects through which customerreceive full satisfaction from the product andservices provided. Hocoma handles all the activi-ties to make sure that the product is delivered andintegrated successfully without making customersany problems. The purchased product delivery isarranged by Hocoma and it comes with specialtraining instructor who trains the client’s staff touse the product. The people that got the trainingcertificate are able to use the product and to trainother staff members when necessary. Secondly,the products are very convenient to use. All ofthem are fully automated. Hocoma products havealso self-directed functions- it means that patientcan do the exercises on their own so the role ofdoctor or a nurse is just to supervise the training(Hocoma Homepage).Hocoma is using direct marketing; they get directcontact with potential customers like hospitals.This is the most efficient way to market theirproducts because Hocoma’s products are veryspecific and they have to make clients realize thatthese products are needed for more effectiverehabilitation service. Another way Hocoma isreaching its clients through different kind offairs they get involved. They have received manyawards and it makes their products more desirableand trustable for potential customers (Awards.)Given statement is endorsed by the theory whichindicates that organizational achievements, R&Dand business relations, and reputational knowl-edge helps company to build up new relationshipswith potential customers and partners (Aarikka-Stenroos et al). If the client is purchasing onesproduct they receive well developed costumersupport as well. The product must be strictlyused according to the recommendations thereforeHocoma offers counseling services to partnersand to patients who can get direct contact withthem or with their sales partners nearby.They aim for long-term relationships and close co-operation is to avoid any errors through explaininghow some specific equipment works and how itshould be used. They also use L-Mobile applica-tion which helps customers to get immediate helpto their problems and because of that they havesales partners in 35 countries, time-zone is not anissue (Sales partners).If one of its sales partner is not available in cer-tain country, then customer has the opportunityto contact directly with Hocoma’s headquarter(Sales Partners). For example if customer havesome problems with one of the Hocoma’s productin Estonia, they firstly should get contact withthe partner in Finland. If they cannot get contactor do not find solution to the problem then theyshould get contact with Hocoma’s headquarter.Because of the products specifications the aftersale service is probably needed time to time. It isunknown whether the after sale service is includedin selling price or not. If assuming that the aftersale service is not included in the selling price,then the company gets revenues from sells andafter sale service. Despite the fact that after saleservice is needed the company probably receivesmost revenues from selling its products.Based on the fact that Hocoma’s aim is to developand produce innovative products for rehabilitationwe can assume that company’s revenue stronglyrely on their employees because innovation in their
  11. 11. 11products can only be achieved by their over 120employees that that are working at the Zurich’sheadquarter and manufacturing facility, and insubsidiaries in the United States and in Singapore.Relying on the company’s vacancies they are onlylooking for employees who are highly educated,experienced and motivated. The fact that Hocomahas succeeded shows that their employees aredoing well on company’s daily activities which areconsulting and working with R&D and with salespartners for example the Biorobotics Laboratoryat U.C. Irvine which has skills and knowledge to de-velop robotic and mechatronic devices,developing and manufacturing process, logisticsand after sales support. All these activities can-not be done without reliable partners in differentareas.The theory suggests that when the quality of aservice is harder to evaluate, this service is morelikely to be supplied by partnerships (Levin 2002).For example because of their focus on developingand manufacturing products they probably out-source logistics service because it is not economi-cally reasonable to own trucks for justdelivering their products and because of themeasures delivering products can be complicatedtherefore logistics knowledge from experts isviable. Secondly, only with their 18 partners inR&D it is possible to develop and produce innova-tive products because of the partner’s contribu-tion in projects on different fields like robotics,specialized and leading clinics, hospitals andresearch centers like Sensory-Motor Systems Lab(SMS Lab). These partners provide Hocoma withthe best knowledge and skills.Hocoma’s products are on sale all over the world,they have partners who sell rehabilitation equip-ment and provide rehabilitation services accord-ing to patient’s needs. Looking the selection ofthose 35 countries, they have gained the effectthat every continent is widely covered with theirdistributors.Unfortunately the company is very conservativeand it is hard to find any documentation on thecompany’s costs. Nevertheless few most impor-tant factors can be mentioned:• R&D- Company produces high tech productsand has 18 partners in product development.Therefore it can be assumed that this factormight be one of the most significant costs.• Logistics- Company claims that it has verycomplicated and expensive logistics. (Colombo2008)• Personnel- Nevertheless the company has only120 employees, they are all high professionalsand need to be well paid.Hocoma’s business model shows that they havewell-planned every aspect and covering company’sthe four main areas of a business: customers,offer, infrastructure, and financial viability. Theyhave clearly focused customers segment andmany awards helps to claim new customers andpartners, and are a proof that their products arevaluable. Their sales partners in 35 countries pro-vides company the opportunity to sell products allover the world and L-mobile service helpscustomers to get immediate help to their prob-lems even if they dont have partner in onescountry. For such innovative company like Hocomatheir major are R&D, logistics and personnel butfor financial viability and the fact that they havebeen successful selling products along with thesesales partner covers the cost and with normalmargin.
  12. 12. 12HIGH GROWTH IDEA2.1 Cura Business ModelIn this section we describe Cura’s businessmodel through Alexander Osterwalder’s and YvesPigneur’s „The 9 Building Blocks” parallelly usingdifferent theories. This Business Model helps toget organizations work. It describes how anorganization creates, delivers and captures value.These 9 blocks are described in the followingparagraphs.Table 2. Cura’s Business ModelSource: Made by authors
  13. 13. 13Value propositionCura defines its clients to be organizations thatare dealing with rehabilitation. The company offersits clients convenience and additional value byallowing the patients to do rehabilitation exercisesat home. Patient’s activity can be viewed onlineand the most of the rehabilitation process canbe done on distance that makes the process lessannoying for patients. They can spare on theirtransportation cost and time.Cura’s gadgets give precise information about thepatient’s workout progress and provide the dataand patients review about their situation via In-ternet to the doctor. The patients need feedbackwhen doing exercises because they fear to dosomething wrong (Appendixes Patient 1- Patient8). The doctor and therapist can view how thepatient is doing any time they want because thedata is available online. Easy feedback and datatransfer allows doctors and therapists to analyzethe effectiveness of the trainings. At the momentthe feedback data is poor because of the manypatients and lack of time to give it (Saulus 2012).Additional value for clients is created through theflexibility of the system - the system allows toprogram different exercises for different patientwho need supervised rehabilitative training (Naza-renko 2012). Therefore gadgets can increase theamount of patients the rehabilitation centre canreceive because it cuts down the time spent onpatients by the doctor. According to interviewedpatients given exercises are not difficult and it ispossible to do them at home (Appendixies Patient1 to Patient 8). Furthermore the rehabilitationprocess can be more effective when using Cura’sdevelopments (Mardna 2012). The patients’opinion is that they would definitely complete allthe exercises if they knew that doctor can viewtheir progress via internet (Ibid).Quoting S. Nazarenko: “The rehabilitation processneeds a lot of vis–a–vis contact but with thisproduct it is possible to reduce the number ofnecessary visits”. The average statistical dura-Customer segmentCuras’ customer segment is clearly defined forhealth care institutions but the end users arepeople who are required to visit physiotherapist.According to Marge Saulus from AS Medicum thereare more younger and middle-aged patients thanolder ones.However, in the long-term, the customer segmentand the whole platform, has to be let open,because according to our evaluation and inter-views with different professionals, authors believethat with this concept it is easy to link differentsolution possibilities that can be applied.According to the theory, segmentation is groupingcustomers with similar needs and buying behaviorinto segments thereby facilitating each segmentbeing targeted by a distinct product andmarketing offerings to be developed to suit therequirements of different customer segments.Segmenting customers helps a company toimprove customer’s satisfaction, customer loyaltyand customer retention (Epetimehin 2011).In the future, Cura can offer its value to differentsegments through improving today’s short-comings and requirements of different segmenta-tion. As it was mentioned before, Curas platformremains open and in addition to rehabilitation solu-tion there can be many different segmentation ofthis product, for example sports. Future plans arediscussed in the chapter “Curas’ strategy”.“The rehabilitation processneeds a lot of vis–a–viscontact but with this product itis possible to reduce thenumber of necessary visits”
  14. 14. 14tion of the cure process is about 15 days. Basedon this information one Cura makes available 72additional appointmens to new potential patients(see Appendix 1).The cost of the one set of gadgets can be around200-300€ which makes it relatively cheap for aproduct in health care business.Company also provides its client full after salessupport. The client does not have to worry aboutthe technical issues with the gadgets or repla-cing used patches with the new ones. Everythingrelated with the technical issues are solved bycompany’s helpdesk and support team.ChannelsAt least at the beginning, Cura reaches its clientsmostly through direct marketing. In addition to,both, end-users and health care institutions canget information from different journals where theproduct is exposed and acquaint with product’seffectiveness, innovativeness and convenience atdifferent fairs.Another way of marketing is word-of-mouth whichmeans that patients who use Cura are impressedand recommends it to their friends who are inneed of rehabilitation. Mihkel Mardna’s and AivoNormak’s commentaries might be good referencefor further sales of the product.More value to the product gives customer sup-port. Sales and technical agents providecustomers with full support 24/7. Along with theproduct comes lessons and manual how to useCura. After purchasing product all maintenanceactivities are provided by Cura’s support team.Customer relationshipsAuthors want customers to cooperate with themand take their opinion into account to providebetter product and service.Cura is a product, which comes together withservices. Cura uses many ways to gain and keepgood customer relationships. For a client it is veryimportant that there is always somebody to helpthem when problems occur.As in one research paper is said that customersatisfaction is considered a prerequisite of cus-tomer retention and loyalty, and can help to boostprofitability, market share and return on invest-ment, we believe it too (Sureshchandar et al2002) Therefore, for customer satisfaction, Curahas 24/7 telephone helpdesk in every market theyare active. Another solution that boosts patient’ssatisfaction is getting fast feedback from the doc-tor via mobile application that allows to exchangedata between doctor and patients in a short time.It also gives doctor the opportunity to constantlyevaluate and give feedback to patient progress.For patients there are also reviews in online forumfrom other people who may have same injuries, sothey can share their information and experiencewith each other.For health care institutions, customer relationshipis maintained by supporting also everything thatthey are in need related to this device. For exam-ple if patches need to be replaced or if technicalproblem occur. Cura keeps constant contact withcustomers to make sure that everybody are com-fortable using this product.
  15. 15. 15RevenueCura gets its revenues from renting its productkit. The company provides a technical service toits clients by fixing bracelets, tablets (or smartphone) and replacing patches. Patches providedby Cura, are in personal use which are changedmonthly or according to the needs. Also, a minorper cent of the revenues comes from the onlineforum where different banners are displayed. Thebanners are located in the tablet (smart phone)under the topic “Advertisements for you”. By thismean people watch advertisement if they want.The best tablet performance duration is about 1,5years and after that tablets should be replacedwith new ones. Depending on their amortizationthey will be sold or donated.Key resourcesAccording to the resource-based view theory afirm resources are strengths that firms can useto conceive of and implement their strategies. Forpurposes of this subject, these firm resources canbe conveniently classified into three categorieswhich are pointed out in the following paragraphs:(Barney)• Physical capital resource - Cura is developedand produced in Estonia, its headquarter andmanufacturing facilities are in Tallinn which isashore of the Baltic sea that provides theopportunity to export goods out of the Euro-pean Union. Also well built distribution networkin Finland, Sweden, Norway, Denmark and inthe United States because exporting and sell-ing its solution in those markets is making themost of the income. For quality, Cura uses thenewest high technological equipment to makesure the product is at its best quality andmeet for example International Organizationfor Standardization (ISO) standards.• Human capital resource – this is Cura’s mainresource because success in developing andmanufacturing new products depends on high-ly qualified and experienced employees. Curahas undergraduates from Tallinn Universtity ofTechnology in logistics, information technol-ogy, finance, engineering, governance andemployees who are currently studying mas-ter’s degree in economics. Employees receiveconstantly trainings and they are providedwith opportunities to take part in differentmedical fairs to generate new ideas for furtherdevelopment.• Organizational capital resource – Cura, as anorganization, is well structured. Each depart-ment has their responsibilities and work tasksbut departments are linked with each otherthrough manufacturing process and controlledby production manager. In addition to man-agement structure in company, Cura providesemployees with different sporting activities,collective trips and for employees well-beingcompany offers free beverage and snacks.Some of the tablet which are not sold aredonated to the orphanages and to children’shospitals.Cura’s resources meet its requirements tosuccessfully implement Cura as a product. Allthree: physical, human and organizationalresources are well-planned and can cover initialneed of the company. Furthermore author’s aredoing a research about patent possibilities for thissolution. Hans Alter, who is the CEO of GSM Valve(see Appendix 4) said that if there is no way forpatent possibilities, then it is more difficult, be-cause you got less time and you have no protec-tion from bigger companies. After the discussionhe added that, if you want to sell the idea to bigcompanies instead, then it does not matter.
  16. 16. 16Key activitiesEvery company which is active in their businesshas to perform certain activities that they areperforming, like developing, producing and man-aging service. Cura devices needs different kindof activities which are outlined in the followingparagraphs:• Managing information flow – information flowand integration between patches, bracelet,mobile application and server is vital for usersatisfaction. This requires mobile applicationsworking on Windows Phone, iOS, Android plat-forms, and electronic information center whereall the information is gathered and is possibleto see for both parties online.• To get customers full satisfaction, Cura offers24 hour a day client support and in any prob-lems Cura’s service department are ready tohelp.• Because Cura’s targeted market is mostlyoutside of Estonia it is important to manageand develop distribution centers and logisticsdepartment.• Another activity for Cura is product develop-ment and manufacturing. Product develop-ment and manufacturing includes productresearching, designing, manufacturing.To sum up, Cura’s key activities are product andcustomer oriented. Each activity is well organizedand works toward certain purposes.Key partners, PartnershipKey partnerships describe specific company part-ners that make the business model work. Mostly,companies create alliances to reduce risk andacquire resources, which are designed to optimizethe allocation of resources and activities.According to the needs Cura have developed sup-pliers network and partners to offer high qualityrehabilitation solution. For manufacturing processCura has direct links with premier manufacturerand innovator of hook and loop fasteners Velcro,in order to provide them with different strapswhich are used in bracelets. Another partner TexasInstruments provides Cura with Bluetooth lowenergy chip that is used in bracelet to gather andsend information to the information center. Vibra-tion alarm systems are provided by leading vibra-tion motors supplier Precision Micro drives and dif-ferent colors on LED light are displayed with E-Inkelectronic paper. For research and developmentCura has partnered with many medical institutionand rehabilitation centers like Fertilitas, East-Tallinn Central Hospital, Tartu University Hospitaland Foundation of Sport Medicine. Cooperatingwith different institutions gives Cura an opportuni-ty to get help from experts whose knowledge andexperiences needed to improve Cura and developnew solutions. In further development focusing onathletes technical issues main partners are physi-cal therapists and sports institutions.For example Aivo Normak, who is the formerAthletic Association head coach and now workingat Sport Medicine Foundation as a developmentofficer said if this platform also allows to analyzesporting techniques, then they would like to offertheir partnership.
  17. 17. 17CostThere are plenty of costs and expenses whichhave a big impact on company’s welfare. Cura’smain costs are divided in the following paragraphs:1) Research and development - expenses consistcosts for research and development of new andexisting products and services2) Sales and Marketing - expenses in customerservice, sales, and sales support functions, as wellas promotional expenditures for example participa-tion at fairs.3) General and Administrative expenses consistprimarily costs related for personnel and facilities,and include costs related to our facilities includingproduction equipment, human resources, informa-tion technology.These are the main costs may vary in time by theyare presented in every phase of the company’sdevelopment. There may also be some consider-able initial costs.2.2 Product descriptionProductOur solution is to imitate some aspects of thetherapist to give patient reassurance that he isbeing looked after, knowledge what to do whenhe is exercising, motivation to do the exercisesconsistently and all of that in home environment.We achieve it with sensors that are placed on thebody.All information about technical issues can be seenin Appendixes 17-20There are three devices that are needed: bracelet,tablet and plasters with sensorSensors can’t do anything reasonable by them-selves - they need some interpretation. Our solu-tion consists of three different parts. Firstly, asmentioned there are sensors, secondly there isa device that is with you all the time (even whenyou are sleeping) to monitor your physical activ-ity and warn you when needed. Thirdly there is adevice that will assist you when you are workingout (tablet or smartphone) - it has more specificcapabilities to help you along the way.It has been researched by Design & Engineeringstudent Janno Nõu which would be better, wheth-er a patches or straps/pants. Authors decided togo with the plaster concept, mainly so because ofthe benefits when wearing it and the fact that it isless demanding for the patientSensors are placed and held on the body with akind of plaster. This is done by a doctor to ensurecorrect placement of the sensors. The doctor willset up the devices and teach patient to use them.Plasters are thereafter changed every few weeksduring visits to the doctor. Sensors and braceletare replaced with new ones that have chargedbattery. Data stored in the bracelet is transferredover Bluetooth to tablet/smartphone that pro-cesses it and then sends the processed data overmobile network to the doctor. Doctor receivesinformation about patients’ activity between thevisits, wrong movements made by patients andmonitored limb’s movement amplitude and cangive suggestions and new workouts directly faceto face or, when needed, send information directlyto the tablet/smartphone.Usability• PatchesPatient is wearing patches all the time; these areapplied and changed during medical visit that hap-pens roughly once every month. The patches areinvisible under clothes, they withstand showeringbut bathing and swimming is not allowed duringrecovery period (this will exclude water therapy asrecovery method). Patches are made from fabric
  18. 18. 18that lets skin breathe and makes the patch moredurable. When a patch has been applied on skinfor a month it could be stuck quite toughly sosolvent can be applied to remove it.• Bracelet & TabletUsability milestones of bracelet:*uniformly understandable display data*easily manipulative grasp of the bracelet, so itis easy to put it on and take it off *antibacterialmaterial*good contrast of display colors*is applicable with one handBenefits of bracelet:*black-white and two warning colors*uses 3 different possibilities of alarm: visual,sound and vibration - they all work simultaneouslyand complement each other to give clear under-standing of the situation*it has also low battery indicator (emergency only,normally battery is replaced in hospital)*easy to put on and take off because of mate-rial of the strap and system of the clasp what isbroaded on the end so that it is impossible to pullit out of the buckleThe bracelet uses Velcro to open and close easily.The end of the strap is bigger than the buckle sothe bracelet never completely opens, and is there-fore easy to slip on the wrist.Usability of tablet:Current solution for home rehabilitation exercisesis to give a paper with exercise descriptions topatient that he must understand (Appendix 14.).Cura solution takes another path and usesportable aplication that can be run ondifferent devices to show videos of the exercisesto be made and give real-time feedback aboutyour current workout. You can see your resultsand compare it to previeous workouts. Aplicationalso points out when you make wrong movementand helps you to correct it as seen on interfacescreenshots in Appendix16. If application is run ona tablet that is used only for rehabilitation pur-poses it can be run in “one app mode” to makeinteraction easier.2.2.1. Technical workingThe figure on the next page describes the interac-tions between the patches, bracelet and tabletelectronic components.The patches capture the body movements withthe motion sensors (1) and send it to the brace-let via bluetooth (2). The collected data is thenprocessed by the bracelet microcontroller (3) tocalculate the joint angles. These angles are savedin the bracelet memory (4). The bracelet displaychanges according to the quantity of movementregistered (5). If a problem is detected by themicrocontroller, the alarms will work (6).When the user is working out, the LCD screendisplays a video of the exercise, which is stored inthe tablet memory (7-8). The data processed bythe bracelet are used by the tablet microcontrollerto command the speaker (3-7-9-10).BraceletPatchesTabletSoundalarmInterfaceMovementWiredWirelessVisualalarmVibrationalarm12345666787910Source: Made by authors
  19. 19. 19bracelets - opening closing the velcro strip,patch & suitable tablet (Lenovo IdeaTab A2107)
  20. 20. 20Third very important factor is developing speed.These companies that can develop the beta ver-sion relatively fast have a competitive advantage.As it was mentioned before medicine and medicalequipment is strongly regulated by internationaland domestic laws. High regulatory rate in medi-cine makes this factor also very important.Last but not least in medical equipment industryit is very important to find and pay attention tothe lead-users. Lead users are clients who by theproduct and at the same time they give very valu-able feedback. Having cooperative and enthusias-tic lead-users network can also be a competitiveadvantage.For better performance Cura has to focus the fol-lowing capabilities:• Product development. In medical equipmentbusiness it is crucial to have safe and efficientproducts (Nazarenko 2012)• Helpdesk performance. The clients must havefull support to be able to focus on their coreactivity. Therefore the helpdesk performanceand ability to solve quickly all emerging issuesis very important.• Logistics. Third very important capability.Logistic solutions should be able to deliver theproducts to client. In addition, the helpdesklogistics (product fixing ability and spare partsdelivery) has same importance as productdelivery.• Lead-users network. Lead-users have impor-tant knowledge in medicine. Effective lead-users network can give input for new productadjustments and develop.• Regulatory requirements. Medical equipmentdeveloper should meet all the requirements.For example: 2007/47/EC 93/42/EC ISO 13485, ISO 149712.3 Execution StrategyIn this chapter the authors describe Cura’sstrategy. First the focus would be on mappingcapabilities of the Cura’s team and plans forfurther development. After determining the mostcritical capabilities it is important to formulatenew mission and vision of the company. Lastly, theaim of this chapter is to determine the plans ofaction for company, sales, product developmentand network development.These capabilities that are difficult to replace arethe base for business growth. Having a unique anddifficult-to-imitate capabilities mean that some ac-tivities are done considerably better than compet-itors do. Organizational capability is a combinationof business processes and resources which areexecuted to deliver a particular business outcome(Kolk sine anno). Even though, the dynamic ca-pabilities consist of routines. (Helfat et al 2003).Cura is an emerging organization and it has initiallyfew capabilities that qualify as competitive advan-tage (see Cura’s SWOT in Appendix 21). However,some capabilities can be emphasized:• Team motivation and engagement- team workis very important. Small team makes the deci-sion process faster and allows more flexibility.The team knowledge is very different andthere are people with different knowledge:information technology, finance etc.In medical equipment business there are someimportant factors that influence the industry. Itseems that one of the most important factor isquality. The ability to improve patient’s healthcondition is the main goals for every medicalorganization. Therefore every product has to havesuperior quality. The ability to deliver safe and su-perior medical equipment needs much cooperationand partnerships.Therefore another important factor is productdevelopment network, which can increase the abil-ity to innovate.
  21. 21. 21The most relevant capability for the company isproduct development. It is very important to befast improvers of existing technologies and tocreate new. To have good product developmentcapability there should be good partners network,ability to finance and good IT and mechatronicsteam. Also, there should be continuous routineslike network meetings, beta versions development,testing and commercialization.Cura’s vision:“To change the understandingabout opportunities inrehabilitation throughinnovative products and to bethe leaders in new conceptsinternationally.”Cura’s mission:“To offer more convenient,efficient and independentrehabilitation solution.”Company’s main objectivesCompany’s objectives can be divided into twocategories. First category is product and marketobjectives and second one is company andexpanding objectives.In 5 years the company should have differentvariations of products, which are meant fordifferent client segments. The core platformremains the same but the capabilities of the sys-tem vary throughout the products.In 5 years there should be three main products:• Cura rehabilitation• Cura pro sports• Cura sportsCura’s main goal is to take lead role in marketsit enters. In 5 years Cura should have 50% ofthe market in rehabilitation, 70% in professionalsports and 40% of nonprofessional sports.As for company and expanding the initialobjectives are:• Establish company – All the regulations mustbe fulfilled and there should be enough financeto produce first working version.• Establish product development network- It isvery important to find lead-users.• Fix market position in Estonia- Cura shouldhave control of the market by that time.• Expand to Scandinavia and USA- Expansionplans are ambitious but if there would be awell working version with good reference fromEstonia then the expansion should be easier.• Widen product capabilities to sports- It is im-portant to develop products for new potentialclients and markets.
  22. 22. 22Company’s objectives are set as developing steps.After getting all initial activities settled, it is im-portant to fixate company’s market position. Fixat-ing market position would be the milestone forother objectives like expanding to other marketsand widening product capabilities. If the companywould have market lead innovator position thenthe expansions plans can be taken into account.But, if the company meet problem, then it is wiseto focus on these problems and to reappraise allstrategy.Strategic activitiesThe strategic activities (see Appendix 15) areplanned for 3-5 years. The time is set relativelyflexible because it is hard to foresee all issues. Inauthors opinion there should be time buffer. Thereare four phases which you can see in Appendix15. Every phase would be briefly discussed in thissector.• Preparatory phase- The tactic of the prepara-tory phase is to focus on inner capabilities.Because of lacing finance the activities shouldbe done by the team and for free.- Team work- It is vital to develop the crea tivity, communication and cooperation between team members. Some important capabilities like physics and mechatronics should be added to team. Therefore the team should look for at least two new members.- Company structure planning/licenses- The initial structure needs to be set. Also member should find potential operating place and prepare the documentation for necessary licenses.- Development of first beta-version- The milestone of this phase is ready Cura beta-version.• Market positioning phase- When the workingbeta-version is ready the tactic of the fol-lowing phase should concentrate on productdeveloping and sales in Estonia. The mostimportant activities are the following.- Seach for additional finance- Marketing plan and sales- It is important to find partners who can be lead-users. It helps to sale the product and develop it for user’s needs.- Product development network- As product development is the most im portant capability in this industry; every thing should be done to achieve the best level on product development.• Preparation for expansion phase- Initial plan isto expand company business to Scandinavia.In this phase the company starts preparingfor building sales-partners network. Workingthrough sales-partners is a good way to enterthe market with low costs. It is important tofind a partner in logistics.• Foreign market expansion phase- Sales net-work is done and it is working actively. Thecompany have found partner in logistics andhave well organized delivery of products andspare parts in Scandinavia.To sum up, there are many aspects to pay atten-tion to. Every activity is very important and tacticdecisions are very important.
  23. 23. 232.3.1 Future ideasAs it was mentioned before, Cura plans to set acore platform open. In the future the platformshould carry out different products. For exam-ple Cura pro sports is a product for professionalsportsmen and their coaches. This applicationwould allow exercise perfect techniques.According to M. Mardna in professional sports itis getting harder to achieve better results withdietary supplement and there is a big potentialin improving techniques with electronical deviceslike Cura (Mardna 2012). For example Cura can behelpful in javelin throw or high jump. Cura sportspro should be able to measure the speed, accel-eration and power of a sportsman. Sport MedicineFoundation offered it partnership to develop suchkind of application.CONCLUSIONHealth care sector is the second most regulatedsector after the nuclear power industry, despiteof that startup numbers are increasing. The mostvalue is offered by healt care technology to meetpeople’s need to the right information at the righttime.This work has been divided to two parts. In thefirst part authors made brief overview of thehealt care market and industry. Authors pointedout that healt care is very regulated area but stillreceives support from the government. Start upcompanies might meet some barriers entering themarket but if a company can handle them it oftenmeans success. Therefore authors described oneof their main competitor Hocoma’s business modeland strategy.Hocoma has very clear strategy and it has provenits use. The company has a niche product andtheir international sales and product developmentnetwork makes the company more competitive ininternational markets. Hocoma’s business modelshows that they have well-planned every aspectand covering company’s the four main areas ofa business: customers, offer, infrastructure, andfinancial viability.In second part Cura’s business model focusesmostly on customer segment and the value ofthe product. Cura’s segment is clearly defined forhealth care institutions but the end users are peo-ple who are required to visit physiotherapist andthe main idea of Cura is to offer its clients conven-ience and additional value by allowing the patientsto do rehabilitation exercises at home. For healthcare institutions it gives an opportunity to servemore patients in the same amount of time andfor end-user it helps to cut down costs and timespent on rehabilitation.Revenue for Cura is generated by renting the de-vices to the health care institutions and the costsfor Cura are mostly R&D, producing and managingcustomer support.Cura’s first strategic aim is to get decent marketshare in Estonia and find partners in R&D. The nextstep is to widen our market to Scandinavia and tothe United Sates. For further development Curaplans to widen their customer segment to sports-men. The idea is to release additional techniqueanalyzing solution for top athletes. Also to re-lease additional application solutions for amateursportsmen. The overall goal is to achieve 50%market share in rehabilitation services, 70% mar-ket share in top athlete’s technique solutions and40% market share in amateur sportsmen applica-tion market.According to the product innovativeness and goodfeedback from interviews made with health careexperts and patients the product gives additionalvalue to the health care area. Furthermore, au-thors plan to program first prototype and developsales model for Estonian market. According towork that is done by now and the interest andmotivation of the team, the work is moving frompaper towards reality.
  24. 24. 24SOURCES CITEDAarikka-Stenroos, L., Sandberg, B. (2012). Fromnew-product development to commercializationthrough networks. Journal of Business Networks.University of Turku Finland.About us. Hocoma homepage Pullen, P.C de Weerd-Nederhof, A.J. Groen,O.A.M Fissher, 2012 “OpenInnovation in Practice: Goal Complementarity andClosed NPD Networks toExplain Differences in Innovation Performance forSMEs in the Medical DevicesSector”, Product Development & Management As-sociation.Awards. Hocome Homepage, J. (1991). Firm Resources and SustainedCompetitive Advantage. Texas A&M UniversityBaum, S. (2012) Medical device/life science start-ups that survive the next 36 months „will be inthe catbird seat“. MedCity News. care-startups-that-can-survive-the-next-36-months-will-be-in-the-catbird-seat/Brussel, J., (2012) Health Care Startup Finds Suc-cess Despite Public Sector Obstacles (27.12.2012)Chang, A. (2012) This is What a health care Start-up Investor Looks Like: Meet Joannse Chang care-startup-investor-looks-like-meet-joanne-chang/(28.11.2012)Davey, S., Brennan, M., Brian, M., Rodney, M.,Girling, A., Chapman, A., Lilford, R. A Frameworkto Manage the Early Value Proposition of EmergingHealth care Technologies. Irish Journal of Manage-ment; 2011, Vol. 31 Issue 1, p59-75, 17pDebaise, C., Scott, A., (2011) The Top 50 Venture-Backed Companies., M, F. (2011).Market Segmentation: ATool for Improving Customer Satisfaction and Re-tention in Insurance Service Delivery. Joseph AyoBabalola University.Fighting Fit: Obamacare is inspiring a horde ofhopeful entrepreneurs (2012-12-05 (02.12.2012)Grey Colombo, 2008 , “Hocoma Case Study”.Helfat, C., Peteraf, M. (2003). The Dynamic Re-source Based View: Capability Lifecycles. StrategicManagement Journal. pp. 997-1010.Kolk, A. The Innotool - Capable Company & OpenGrowthKurtzman, G. (2012) The question every healthcare IT startup must answer. care-it-startup-tips/ (02.12.2012)Langreth, R., Forbes. To Walk Again. (2005).Vol.176, Issue 11Levin, J., Tadelis, S. (2002). A Theory of Partner-ships. Stanford University. Department of Econom-ics.Moukheiber, Z., (2012) Scrap Outdated Regulationsto Unleash Real Innovation in Health Care Hocoma Homepage
  25. 25. 25Product Development. Hocoma homepage Hocoma Homepage Hocome Homepage. research paper about Cura. (2012).Reiss, R., (2012) The New Health care TechnologyModel (20.11.2012) care-technology-model/9Real customer benefits start with your employees partners. Hocoma Homepage, G.S., Rajendran, C., Ananthara-man, R.N. (2002). The relationship between ser-vice quality and customer satisfaction – a factorspecific approach.- Journal of Services Marketing,Vol. 16 Iss: 4, pp.363 – 379UK’s top health care startups announced (2012) care-startups-an-nounced/3453.article (29.11.2012)Zimmerman, E., 2012. Vital Signs by Phone, Then,With a Click, a Doctor’s Appointment (25.11.2012), B., Maltby, E. (2012) Looking for the „NextBig Thing?“ Ranking the Top 50 Start-Ups. to Hocoma News. Hocoma Homepage care institutions:Alter, H. (2012). Health care industry. J. Nõu’s, B.Aavik’s, T. Tammjärv’s, K. Kišenja’s, U. Orasmäe’sinterview. Notation. Tallinn, 14. December. GSMValve.Nazarenko, S. (2012). Health care industry. B.Aavik’s, T. Tammjärv’s, K. Kišenja’s, U. Orasmäe’sinterview. Audio recording. Tallinn, 10. December.The North Estonian Medical Centre.Tammeka, M. (2012). Health care industry. B.Aavik’s, T. Tammjärv’s, K. Kišenja’s, U. Orasmäe’sinterview. Audio recording. Tallinn, 10. December.The North Estonian Medical Centre.Saulus, M. (2012). Health care industry. B. Aavik’s,T. Tammjärv’s, K. Kišenja’s. Audio recording.Tallinn, 6. December. Medicum.Mardna, M. (2012). Health care industry. B.Aavik’s, T. Tammjärv’s, K. Kišenja’s, interview.Notation. Tallinn, 4. December.The Foundation of Sport Medicine.A, Normak. (2012). Health care industry. B.Aavik’s, T. Tammjärv’s, K. Kišenja’s, interview.Notation. Tallinn, 4. December.The Foundation of Sport Medicine.
  26. 26. 26Patients:Patient 1. 23 years old, male. (2012). Patient’srehabilitation service experience. B. Aavik’s, T.Tammjärv’s, K. Kišenja’s interview. E-mail. Tallinn,1. December.Patient 2. 24 years old, female. (2012). Patient’srehabilitation service experience. B. Aavik’s, T.Tammjärv’s, K. Kišenja’s interview. E-mail. Tallinn,2. December.Patient 3. 25 years old, male. (2012). Patient’srehabilitation service experience. B. Aavik’s, T.Tammjärv’s, K. Kišenja’s interview. E-mail. Tallinn,3. December.Patient 4., 26 years old, male. (2012). Patient’srehabilitation service experience. B. Aavik’s, T.Tammjärv’s, K. Kišenja’s interview. E-mail. Tallinn,3. December.Patient 5. 31 years old, male. (2012). Patient’srehabilitation service experience. B. Aavik’s, T.Tammjärv’s, K. Kišenja’s interview. E-mail. Tallinn,7. December.Patient 6. 52 years old, female. (2012). Patient’srehabilitation service experience. B. Aavik’s, T.Tammjärv’s, K. Kišenja’s interview. E-mail. Tallinn,7. December.Patient 7. 71 years old, female. (2012). Patient’srehabilitation service experience. B. Aavik’s, T.Tammjärv’s, K. Kišenja’s interview. Notation.Tallinn, 12. December.Patient 8. 76 years old, female. (2012). Patient’srehabilitation service experience. B. Aavik’s, T.Tammjärv’s, K. Kišenja’s interview. Notation.Tallinn, 13. December.APPENDIXESAppendix 1.Interview in SportMed Foundation withMihkel Mardna and Aivo NormakMardna:Ma hakkasin mõtlema kuidas tippspordis saab ärakasutada seda, tehnilistel aladel. Tegevusraadiuspeaks olema sellisel juhul suurem. Tegevusraadiuspeaks olema 30-40meetrit. Peaks olema algusestpeale. Peate mõtlema laiemalt. Et saaks rakendusisellele asjale peale veel lisaks lasta. Sõudmine,jooksmine. See on laboriväline. Meid huvitab labo-riväline liikumisanalüüs ehk siis kinesiomaatika. Etme saaks staadionil, spordiareenil seda kasutada.Kui ta on selline, et see raadius oleks suurem, siisoleks, võiks see ka võimalik ollaNormak:Näiteks kõrgushüpe. Kas seda on võimalik niipanna, et see muutub 3D mudeliks? Me oleks isehuvitatud 3D rakenduse kaasaaitamisele.Mardna:Täna on 1 doktorant,kes tegeleb kinesionmaatikaja 3D anaalüüsiga, kus ta filmib ülesse 2-3 kaam-eraga ja märgib punktid ja kaaderhaaval kannabpunktid programmi ja tal võtab analüüsiks aega3-4h.Toidulisanditega ei ole võimailik edasi minna. Sellesmõttes, et treeningu täitustamiseks on enam-vähem kõik juba ilmselt ära kasutatud; toidulisan-did jne. Kui siuke 3D asi valmis teha, siis on naguKÕIK olemas.Bluetooth võtab 60m raadiuses infi. Näiteks mevõtame jooksuanalüüsi, mille puhul sõidame au-toga kõrval.Kas need andurid on ka kiirendustundlikud. Kasnad suudavad välja tuua ka parameetrid? See ontehniline teostus.
  27. 27. 27Kas teil on kaasatud füsioterapeut?Teoreeriliselt on see võimalik. Iga inimese ana-toomia on erinev ja igal inimesel on algne pain-duvus ja lihastoonus individuaalsed. Kui töötadavälja 1 konkreetne harjutusemudel. Siis ma kujutanette et keerukas saab olema see koht et kleepsudlähevad väga õigesse kohta. See arst või füsiokleebib need ja siis see kuvab pildi arvutisse jasiis füsioterapeut korrigeerib vajadusel andureidja paneb paika konkreetselt selle patsiendi jaokskonkreetselt tehtud selle sooritatud harjutuseja paneb arvutis need parameetrid. Mis nurga allja kui kõrgel. See annab signaali siis patsiendile,arvuti on võimeline tagasisidet andma patsiend-ile. Kui selles piirides ei tee harjutust, siis annabmärku. Kas siis ekraanil või midagi undab. Patsienton vaja ära kalibreerida.Eesmärk on pigem see, et kulutatatud ajaga. Etnäiteks 3 nädala pärast tagasi, et selle aja pealeon harjutustest rohkem kasu. Ta peab seda harju-tuse õigesti tegema. Nii kui nii kutsub füsiotera-peut 3 nädala pärast tagasi.Normak:Mulle tundub 2 variantiEsiteks. Andurid ja mehhaanika, mis mõõdavad.Üks on see, et õpetatakse selgeks õige liigutus janii on hea. See on mudel, mille lähedale peab pat-sient kodus püüdmaTeine variant. Üldised parameetrid. Kui palju kõi-kuda kõrvale. Teine on see pool.Mardna:Meil see nädal füsioterapeutiliste harjutuskavadefilmimine, mis on prementatiivsed meetmed, et en-netada vigastusi spordis. Neid on kuskil 25 videoringis, mis on mõeldud nagu.. noh..erinevad kavad.Siuke areng, aga see on teine suund. Pigem infomaterjal ja erinev spordimaterjal. Aga see haakubhästi.Kui bluetooth. Kas märku annab kell ja arvuti regabära selle et on mindud järgmise harjutuse juurde.Liigutuste kava on sisse progretud, mis koosneb3st komponendist.M. Mardna answers to questions:1. Missugune on üldine paberimajandus seotudühe patsiendiga (mida ja kuidas peab dokumen-teerima)?Protseduurid on funktsionaalsed testid. Koor-mustestid, aga mis puudutab füsioterapeutilisttegevust, on erinevad harjutuste kavad.Paberima-jandust väga palju ei ole. Kirjutame kaartidesse,teeme füsioterapeutilise hindamise, mis seisuspatsient on. Oridneeridu harjutuste kava. Tavaiselton olemas selline füsiotools, kus on palju eirne-vaid pilte. Väga palju kasutatakse seda. Kordadearvud muudetakse ära. Väga palju erinevaid ke-hapiirkondi, erinevatel otstarbetel.Aega dokumen-tatsiooni peale ca 5 minutit. Ja kui inimene äraläks, siis kokkuvõte või kui ta tuleb uuesti aatgasi,kirjutatakse amplituudid, kui palju lihastoonus onparanenud, vajalik funktsioon. Seda saab hin-nata näiteks heitjatel kui palju millise jõuga saabvisata. Meid huvitab ka see.. teie selle vidinagasaab vaadataka võimsust. Võtate kätte 4kg palli jamassi ja kiirusega on võimalus arvestada võimsust.Teil võimalik ehitada see peale. Mis on väärtuslikinfo. See on see, mida on vaja. Tippspordis on vajaselliseid asju. Ma näen siin edasirakendusi ja aren-guvõimalusi, mida on tippspordis vaja. Sinnamaanivälja, et meil on spordimed klaster ja teatud toot-earenduseks on võimalus meil isegi mingil määralrahastada.2. Kui palju 1 visiit patsiendile maksma läheb?Umbes 32eurot ja 1h. See ei ole 5 min.Joonsitatakse välja, kontrollitakse.Reeglina 1h. Võib-olla tuleb sportlane, kellel oleksvaja kinesioteip uuesti kinni panna. See OK 15 minvõib-olla. On erinevad. Aga kui on jutuks harjutusekava koostamine, hindamine jne. See võtab aegarohkem kui 1h. Hind muidugi sama.3. Mitu korda keskmiselt patsient kordusvisiidiletaastusravi perioodi jooksul? Kui palju keksmiseltühe patsendiga aega läheb?Keskmisel kordusvisiidil.. keskmiselt.. ma arvan.Tuleb ütleme 2,5 korda. 2-3 korda tuleb. Mingi ajapärast kutsub tagasi, et hinnata töö tulemuslik-kust. Vahel on võib-olla vaja midagi korrigeerida,
  28. 28. 28kuskil tesie arsti juures.. käib seal ära ja siis tagasi.Kordusvisiidid on umbes poole odavamad.4. Mis te arvate, kas elektrooniline jälgimise lahen-dus võib leevendada töökoormust ja suurendadapatsientide arvu?Ilmselt parandaks töökvaliteeti.5. Mitu arsti ühe patsiendiga tegeleb?Oleneb. Me teeme funktsionaalseid teste. Need onerinevad. Üks lihtsalt koormustest. Hapniku. Vägakeerulised võivad need olla. Tippsportlased võivastupidamisala sportlased. Mina ja doktor Hel-dur, vaatame spordivigastusi. Siis füsioterapeudid.Õed vereanalüüside jaoks. Laborisse saadetakse.Tegeletakse seal .. võib-olla tal veel mingi erialaarsti visiiti vaja. Näiteks neuroloogi, siis läheb veelkuskile suurde haigla. Ma arvan, et tippsportlasepuhul on 4-5 isikut, kes temaga lähemalt tegel-evad.6. Kui arstil oleks võimalus lisaks kliinikule ka kodustöötada, mis te arvate sellest võimalusest?Patsientidega suhtlemine oleks võimalik Internetiteel.Mulle kohe tundus, et hea asi. Ma ei soovita teilka kitsalt mõelda. Parandada harjutuse soori-tuskvaliteeti; mitte ainult seda vaadata. Vaidka need, mida me rääkisime. Et saaks mõõta kavõimsust, kiirust, kiirendust. Need on lisatavadsellised funktsioonid. Mida võimalik valemissesisse kirjutada. Aretada sinna edasi. Mis puudutabneid harjutusi, millised on? Sellest võib tulla vägakõva asi. Ja muidugi ei saa teha kõike korraga.Algselt kavandada nii, et tekiks andmetekogu, missüteemis annaks võimaluse erinevaid funktsioonepeale panna et sinna saab veel lisada ideid. Prindinteile nüüd harjutuste kava välja. A4 formaadis; sealon pildid ja tekst juures. Te võite neid kasutada.Appendix 2.Interview in Põhja-Eesti Regionaalhaigla(PERH) with Sergei Nazarenko (the boardmember and the chief doctor) and MaretTammeka (rehabilitation manager)Kim: „Palun kirjeldada protsessi, alates patsiendisaabumisest kuni patsiendi ära minekuni.“Tammeka: „Teid huvitab ilmselt ambulatoorneosa?“Kim: JahKim: Veelkord seletab toodet ja Nazarenko küsibtäpsustavaid küsimusi. A’la:Nazarenko:“ Mul on niisugune küsimus, et needkiibid paigaldatakse patsiendi nahale ja, et kiibidannavad informatsiooni iseenda asukoha kohta?“Meie: JahNazarenko: „Need on inimesele kasutamisekslubatud plaastrid, et ei ole mingeid toksilisi aindeidselles liimis, allergilisi, naha lamatisi - mida iganes.Kas need plaastrid on teil olemas juba või te otsiteveel lahendusi?“Birgit: „Me otsime hetkel otsime lahendust. Meietoote ja disaini tudeng teeb selle kohta magis-tritöö, milliseid plaastreid tuleks kasutada ja et kasplaastrite kasutamine on kõige õigem lahendus.“Kim: „Jah, ta otsib seda lahendust. Ehk on veelküsimusi?“Nazarenko: „Tähendab, enne kui edasi minna, midaminu arvates erakordselt tähtis on arvestadainimesele ohutuse aspekte. Plaastri puhul kindlastima eeldan, et siin ei teki probleeme. Aga see tee-ma tuleb ära käsitleda. Kiirgus mis lähtub, et egasee patsienti ei kahjusta. Pacemakeriga koos, kaspatsiendil või kui pacemaker on tema lähedastelvõi sugulastel - ohutusse aspekt. Ma soovitaksinteil läbi mõelda see aspekt et kui tegemist saabolema meditsiinilise seadmega siis on olemas med-itsiiniliste seadmete direktiiv. Millist sorti seadmeteliigi ohuklassi alla see võiks tulevikus kuuluda.Püüda see ära lokaliseerida ja vaadata, et vastak-sid sellisele seadme klassile kehtestatud ohuklas-sile - see oleks üldine soovitus, sest meditsiinilisteseadmete puhul on kaks olulist asja mida tulebalati tõendada kui me võtame seadme kasutusele:
  29. 29. 29ohutus ja toimivus.“Kim: „Meie aparaat suudaks parandada haiglatetööd, suudaks taastusvõimlemise protsessi tõhus-tada. Patsiendi käimise aeg lüheneb ja selle võrraoleks võimalik haiglatel rohkem kliente võtta.“Tammeka: „Ma arvan, et teatud protsendil juhtud-est oleks see väga suureks abiks, oleneb inime-sest. On selliseid, kelle juures peab olema ja se-letama korduvalt, et ta üldse aru saaks. See, et onolemas video ja et keegi teda distantsilt parandab,ei ole alati toimiv – see on individuaalne.“Nazarenko: „Me saame positiivsest küljest tõstaseda, et kui me oleme suutnud identifitseeridasellised patsiendid, kes saavad nii-öelda iseseisva-malt hakkama siis me teeme nende jaoks taastus-ravi mugavamaks. Nad saavad seda teha kodustestingimustes ilma kohale sõitmata. Mis Eesti puhulon ääretult oluline on see, et Eesti on suhteliselthõreda asustusega mistõttu taastusravi vajavadinimesed võivad elada kaugel, ollla oma taastus-ravi perioodil linnast väljas, suvilas või juba heastaastus järgus liikudes maailmas ringi ja saatameile infot selle kohta kuidas tal läheb. Teisekssee annab ka vabadust. Inimene ei pea tulema kell11:45 vaid võib seda teha natuke hiljem, või natukevarem aga info jõuab meile kohale.Tanel: „Mitu patsitenti taasturavi arst päeva jook-sul keskmiselt vastu võtab?“Nazarenko: „Taastusravi arst, kes tegeleb ra-vivõimlemisega? Kas küsimuse mõte on kui mitmeinimese võrra on võimalik vähendada koorumusttaastusraviga tegelejalt?“Tanel: „Kas see või et arst saab võtta selle võrrarohkem patsiente aga koormus jääb samaks.“Tammeka: „Teid huvitab siis ikka füsioterapeut,mitte arst.“Meie: Nõustume.Tammeka: „Füsioterapeut praegu, tööpäevaga 8tundi, suudab vastu võtta antud koormuse juures14-15 inimest, sest üks protseduur kestab 30minutit. Tegelikult kuskil 13-16 on see vahemik.“Kim: „Kas see hõlmab patsiendi kordusvisiiti?“Nazarenko: „Võibolla peaksime paari sõnaga se-letama kuidas see asi on meil korraldatud?“Tammeka: „Me juba natukene rääkisime sellest.Alguses vaatab arst, teeb raviplaani, et mida seepatsient üldse vajab ja kui ta vajab füsioterapeudinõustamist siis me planeerime talle füsioterapeudiajad. Üldiselt 2-3 korda nädalas aga kuna meielepingumaht võimaldab tal käia meie juures mak-simaalselt 4 korda siis me propageerime 2 kordanädalas käimist. Kui patsient tuleb kaugelt, tal onraske siia tulla, siis kord nädalas. Kõigepealt vaada-takse patsient üle, tehakse esmane harjutustekava mis talle võiks sobida, ta tegeleb sellegakodus. Järgmiseks, kui patsient järgmine kordtuleb siis vaadatakse üle, mida patsient on vahe-peal teinud, kas on võimalik midagi veel täiendada,lisada harjutusi. Nii et üldjuhul, kui patsient tulebsiis ta saab 2 protseduuri järjest.“Kim: „Kui oluline on patsienti näha nii-öelda näost-näkku?“Tammeka: „Üldiselt on oluline kuna meil teist või-malust ei ole olnud. Aga kui mina või füsioterapeutsaab selle info kuidagi teisel moel kätte siis maarvan, et ta teebki selle järgi otsuse. Et kas piisabsellest, et ta annab infot edasi mitte ise patsientikatsudes/kombates või ta vajab selleks patsiendikohalolekut.“Nazarenko: „Ma saan aru, et te otsite meilt sedaargumentatsiooni kuidas seda projekti arendada janäidata selle elujõulisust jne?“Meie: Nõustume.Nazarenko: „Me liigume siiski individualiseeritudmeditsiini poole, seda me vähemalt deklareerimeja püüame seda teha vähemalt nii palju kui võima-lik. See tähendab seda, et me püüame patsiendileanda võimalikult individuaalset nõu ja just sell-eks on see vis-a-vis kontakt füsiterapeudiga võitaastusravi arstiga tingimata vajalik. Aga kui seeinimene saab neid harjutusi ise kodus teha siis sel-lel hetkel ei ole seda vis-a-vis kontkati vaja ja sellevõrra saame me koormust vähendada ning arstivõi taastusravi juurdepääsu parendada.“Kim: „Me ei taodelnudki seda et patsient ei käi ül-dse, vaid seda, et see vaheperiood mil ta teeb neidharjutusi võiks nii-öelda laheneda online vestlusenäol, et mul läheb hästi, teen ära, ei valuta jne.Hiljem ikkagi fikseerida ära.“Nazarenko: „Jah, aga ta peab ikkagi käima kunaseda on raske kauge maa peale hinnata. Kui mingiliigese liikuvuse ulatust tahame suurendada - sedapeab ikkagi nägema, et kuidas tal on. Või mõõtamingisuguseid väga spetsiifilisi parameetreid, et tapeaks ikkagi tulema siia.“Tanel: „Kui patsient tuleb siis missugust doku-mentsiooni peab arst täitma ja kui palju see aeganõuab?“Tammeka: „Mina isiklikult täidan Estri kirjeldusenaja kui on väljavõtet vaja perearstile saata siis ma
  30. 30. 30saan selle välja printida, ma ei ütleks et see vägakeeruline on.“Nazarenko: „Ma ei arva, et see dokumenteerimistvähendab, tõesti selles osas, et inimene nii tihti eikäi siis need juhud kukuvad ära. Aga see, millineon lähteseis ja milline on vahepealne dünaamika,mis on mingi perioodi lõpptulemus, see jääb ikkaendisesse väärtusesse dokumenteerimise mahus.Küll ütleksin, et selline automatiseeritud doku-menteerimine mis toimub selle lahenduse puhul,on nii-öelda lisaväärtus. Ma oleks väga üllatunud,kui kukuks natukene teisiti välja kui on toimunudtegelikult kõigi niisuguste uute rakenduste näitkestelemeditsiini rakenduste puhul. Nad ei ole andnudkunagi säästu, nad ei ole kunagi vähendanud min-gisugust töö, materjalide ja muu kulu, kuid needmis on ellu jäänud, on andnud mingi lisaväärtusesee on täiesti minul tekkinud maailmavaatelinepoint. Vot nende lisaväärtuse peale tasub rõhuda.Ei maksa öelda, et see säästu ei anna, see peabniikuinii selge olema aga mingid lisaväärtused(onolulised).“Tanel: „Kui patsient tuleb oma probleemiga siia, kuipikk keskmiselt taastusravi protsess on?“Tammeka: „Sõltub juhusest/patsiendi haigusloost.Mõnel on nii kerge häda, et saab tõesti nädalavõi paariga hakkama aga on ka neid, kes käivadsiin poole aasta vältel. See ei tähenda seda, etme teda iga nädal 2 korda siia kutsume, vaid tategeleb vahepeal iseseisvalt kodus. Siis kutsumekontrolli. Kui ta teeb poole tunniseid protseduuresiis saab kuni 15 patsienti teenindada ja kui tun-niseid siis 7 patsienti. Statsionaarses ravis saabpool tundi ja ambulatoorses 2x pool tundi.“Nazarenko: „Ja no kui kaua see ravi võib kestavaadake, ma tahaksin seda rõhutada, et see võibolla tõesti madal kaar aga võtame ajakirjandusestLeokid, nad teevad aastaid oma harjutusi. Võibollapigem, kui me saaks midagi niisugust öelda, et kuipatsient peab praegu käima füsioterapeudi juuresmingisugune x arv kordi siis mitu korda vähem tapeaks käima, kui ta rakendast seda süsteemi? Äkkime saame siit kaudu tulla?“Tammeka: „Ja kordades vähem peaks Ta käima.“Nazarenkio: „Oletame, et ta peab harjutusi tegemaiga päev aga siin ta käib kord nädalas. Siis me ta-haksime teda näha ainult kord kahe nädala tagantvõi kord kuus aga harjutusi teeb iga päev.“Tammeka: „No päris iga ei tee aga..“Nazarenko: „...aga me tahame, et ta teeks igapäev. Kui ta teeks neid harjutusi siin haiglas siista käiks 5 korda nädalas siin haiglas tegemas. Misteeks 20 korda kuus aga me näeme teda ainult1 kord siin. Need suhtarvud saab ilmselt... onmõistlik anda mingisuguses vahemikus, see olenebpatsiendi haigusest. Just nimelt sellest funktsion-aalsest seisundist millest me lähtume ja kuhu metahame jõuda.“Tanel: „Kuidas teil järjekorraga on?“Tammeka: „Järjekordadega on meil hästi.“Tanel: „Mis see tähendab, järjekordi pole?“Tammeka: „Meil on selline lubatud järjekord, paar-kolm nädalat.“Nazarenko: „Teate see järjekord on meditsiinisnagu kumm, et sa võid tekitada olukorra, kus ei olejärjekordi ja samas olukorra kus on pikad järjekor-rad.Tammeka: „Meil on siin võibolla natukene erinevsüsteem teistest. Ma ei ole küll küsinud aga meilon järjekord sellistele plaanilistele tegevustele, kuion erakorraline näiteks traumaga seoses siis meei ole neid lükanud järjekorda. Me võtame nemadväljaspool järjekorda. Meil on lepingu järgi kavasvõtta 30 uut, plaanilist haiget nädalas aga tege-likult võtame 90 ja rohkem, kuna meie haigla onaktiivhaigla siis meile satuvad enamasti traumade-ga patsiendid. Meil on plaaniline ja erakorralinetegevus. Kui meil seda poleks, siis ei tea kui pikaksneed järjekorrad võivad minna.“Nazarenko: „Ma tekitan teil küsimusi ja probleemejuurde...“Meie: Meile see meeldibNazarenko: „ järjekord mistahes tervishoiu asu-tuses on asi, mis on ääretult elastne nähtus sellesmõttes, tervishoid ja taastusravi sealhulgas, et kuimeil oleks võimsust ja riigil ressurssi siis see võiksolla mitmetes kordsetes mahtudes tegelikult. Kuime piirame seda ja ütleme, et meil ei ole võimsustja võtame tõesti ainult kategooriad siis me needvõtamegi ja meil järjekord ongi lühem. Ma panek-sin siia meditsiini, ma paneksin siia samuti ka kõikneed spordisaalid jne, sest tegelikult oleks vajaharjutusi kõikidele nendele haigusrühmadele mismeil siin käib. Igasugused luu- ja liigesehaigused,südame veresoonkonnahaigused, närvihaigused,seda on tohutult palju, seda on isegi raske mõõtakui palju seda kokku on. Isegi vähi kohta öeldakse,et on andmeid, mida regulaarsemalt liigud sedaväiksem tõenäosus on haigestuda.“Kim: „Kui me kujutame ette sellise hüpoteetilise
  31. 31. 31situatsiooni, et meie selline lahendus peakskinäiteks 10% aastas patsientide voogu suuren-dama, kas lisateenused: massaažid, magnetravidsaaksid selle 10% protsendilise patsientide tõu-suga hakkama?“Tammeka: „Praegusel hetkel küll, massaazi kuisellist haigekassa praktiliselt enam ei tasusta.On ainult keskmise või raske pareesi puhul, mistähendab aga seda, et inimesed ei ole praktiliseltvõimeliselt ambulatoorselt kohale tulema. Massazkui selline peaks jääma füsioterapeudi alasse. Nadon sellise koolituse/väljaõppe saanud. Mis puudu-tab aparaatset osa siis see dendents on vähen-emise suunas.“Tanel: „Kui patsient siia tuleb, missugused kuludkaasnevad?“Tammeka: „Visiiditasu ikka.“Nazarenko: „Visiiditasu on ühekordne, see onravijuhu peale, kas ta käib 1 või 40 korda - see onüks visiiditasu. Mõtlen kuidas teie projekti toetada,on niisugune asi nagu ravisoostumus. Ma tooksuuringuid mis on tehtud ravimitega ja ravimitegaon igasuguseid trikke tehtud, eesmärgiga vaada-ta kuidas inimesed võtavad nendele kirjutatudravimeid ja tegelikult on olukord kaugel ideaalsest.Arsti tudengitele, oli mingi preemia kehtestatud janeil oli ülesanne võtta kolm korda päevas tic-tac’i.Mingist purgist vajutada, mis registreeris selle, kuitic-tac sealt välja kukkus. Ja vist kolmandik püsisselle reziimi sees, et ravisoostumise- complianceaspektist on see kohutavalt suur lisaväärtus mistuleb niisugustele süsteemidel, sest inimene ikkamõtleb, et ma lähen käin täna poes pikemalt jasee on ka harjutuse eest. Või teine häda, mõnedsatuvad sellisesse seisu, et harjutavad üle. See onka probleem, et sellist ravissoostumist, see oleksväga tugev argument, kui te paneksite selle omaprojekti kirjeldusse sisse, viidates et isegi ravimitepuhul tehtud uuringud, mis ei olnud seotud ajakuluga, muude kulutustega justkui motiveeritudseltskonnas, näitavad et need asjad tegelikultei toimi. Aga siin me räägime sellest, et see onpikaajaline, aeganõudev, mingil määral oma elusät-timist nõudev tegevus, see nagu põhjendaksseda.“Kim: „Küsiks vahepeal ühe täpsustava küsimuse,kuidas teil ajaga praegu on?“Nazarenko: „Mina saan natukene üle 12 olla, äkki12:15-ks valmis. Me küll räägime teile vahele...“Meie: Meile see meeldib.Nazarenko: „.. aga need on olulised asjad. Teieküsimused on küll väga head aga siin on asjad midameie näeme omalt poolt.“Tanel: „Seda me tulimegi otsima! Mis on kompleks-vigastus? Kas kompleksvigastus on selline, kuisul on põlv viga saanud ja samas ka hüppeliigesvigastatud?“Tammeka: „Siin on ilmselt mõeldud erinevaid süs-teeme. Ei ole seal ainult lihaskond ja liiges, vaid onka veresoonkond või siis mingi kompleks mingit-est muudest haigustest aga kompleksvigastus onerinevate organsüsteemide vigastus ma arvan.“Nazarenko: „Ja ma kaldun ka nii arvama, et näitekstrauma kompleksvigastusega me eedlame, etkuskil on näiteks neurokirurgiline probleem jakuskil on mingi jala probleem ja on mingi vasku-laarne veresoonte probleem, mingi põrnarebendvõi muud sellist.“Tanel: „Kuidas taastusravi arst, füsioterapeut raviläbi viib kui patsiendil on kompleksvigastus?“Tammeka: „Siis tulebki meeskonnatöö. Kõigepealtvõetakse kokku ja arutatakse läbi arstiga eesot-sas, mis on need esmased tegevused ja mida seepatsiendi seisund võimaldab, millele tähelpanupöörata. Kontsentreerutakse olulisemale, ei olemõtet hakata sõrmedega tegelema kui on teada,et üleval pool(õla piirkonnale osutades) on suure-mat sorti kahjustus(ed). Antud piirkonnaga tulebenne tegeleda ja siis hakata sellele piirkonnaletähelepanu pöörama(sõrmed) kui on juba teada, etsealt võiks midagi hakata tulema.“Tanel: „Kas kuidagi samal ajal saab seda ravi/prot-seduuri läbi viia?“Tammeka: „See sõltub sellest haigusest/traumast,seda on väga raske ette öelda ja sageli sealt või-vad tulla ka ravivead, et me ei hinda alguses või eioota ära kõiki uuringute tulemusi. Oluline on täpnediagnoos ja siis saame alles hakata oma järjekordija raviplaane tegema.“Tanel: „Valede liigutuste tegemine ja üle tegeminevõib tegelikult ravi tulemust negatiivsemaksmuuta?“Tammeka: „Jah.“Kim: „Kas kompleksem vigastus nõuab ka komplek-semaid harjutusi või selles ei ole olulisust?“Tammeka: „Sellisel juhul tuleb kombineerida te-gevusteraapiat ja füsioteraapiat. Füsioteraapiategutseb üldise lihsakonna, lihaskorseti parandam-ise eesmärgil ja valib oma harjutused, tegevustera-peut siis peenema motoorika osas. Üks(arst) oma
  32. 32. 32poole tunni või tunni jooksul, mis kummalgi on, eisuuda seda kõike haarata. Eerinevad spetsialistidtegelevad.“Kim: „Me kartsime seda, et kui meie lahendus su-udab ainult teatud liigutused kaardistada, võibollamingi eriti keerulise liigutuse puhul võib see prob-leemiks olla, Me ei oska hästi hinnata kas see võibtakistada harjutuste tegemist?“Tammeka: „Kui info jookseb temani siis ta peaksseda ikkagi nägema.“ Toob näite: „Väga paljuaastaid tagasi, üks Raplas elav naine kellel olikõõluse kahjustus, kuna tal oli raske käia siisesmaselt terapeut tegeles temaga. Traumatoloo-gia poolt oli saadetud. Mõne aja pärast tuli uuestiennast näitama, kui ta riidest lahti võttis siis majahmusin/ehmusin. Inimene oli väga tublilt tööta-nud, ainult et tegi kõike valesti. Trapetsi kohal oliselline „pall“. Patsient ise ei osanud hinnata, midavalesti tegi. Töö oli vales suunas ja õlg oli aboslu-utselt kinni. Oluline distantsi puhul on, et infotuleks ja vajadusel füsioterapeut saaks öelda „eiei” et tehakse valesti või siis seletada, mis tulebteha(kuidas).“Nazarenko: „Mida selle projekti juures võiksveel rõhutada. Esiteks selle koht aktiivravis jahaiglapõhise taastusravi juures, ütleme traumad.Teine asi mis võiks olla, et enne proteese võiksinimesed hakata lihased harjutama ja peale lõikustnäiteks liigesproteesimine(puusaliiges) jne. Inimeneon proteesimise järjekorras ja me tahame et tasellelel ajal hakkaks juba oma lihaseid tugevdamaselle eesmärgiga, et kui see protees tal on, et kõikfunktsioneeriks nii-öelda ennetav taastusravi.“Kim: „Selle peale me ei olekski tulnud.“Nazarenko: „Selle võite sinna kirja panna, kuiräägite milleks seda vaja on.“Tammeka: „Tegelikult ka aktiivhaiglast, trauma-haiged lähevad praegu väga kiiresti koju. Neileantakse esmased juhendid kaasa. Patsiendid last-akse juba nädalaga haiglast välja kuna seisund onnii palju paranenud, et nad on võimelised enamaks,et ta ei peaks tulema siia ja et me saame teda siiskontrollida ja juhendada edasi.Nazarenko: „Mis ka minu arvates on väga olulinevaldkond(meditsiin) kuna meil elanikkond vananeb– aktiivne vananemine. Siis kindlasti on teil sealsees juba niisugune kaitseväele, -jõududele suuna-tud aspekt, ütleme, et meil on ka siin inimesi keson kuskil missioonidel kannatada saanud.“Kim ja Birgit: „seda meil ei olnud – me olemespordi peale mõelnud.“Nazarenko: „Sport on väga hea mõte! Aga seeka(kaitseväe/-jõud), kus õnneks neid hädalisi eiole Eestis palju aga iseenesest selle aspekti väljatoomine võib kuskil anda lisaväärtust.“Tanel: Mehhatroonika vallast: „Kas tulevikus onkiibid painduvad...“Birgit: „Mõtleme seda, et kas kiibi pealt saaks mas-sazi teha, kas tohib, kas peaks vastu?“Nazarenko: „Muidugi oleks parem kui oleks sellinekiip millega saab ka saunas käia ja ujuda, mida onvõimalik nö. masseerida – parem on. Kui ei ole siisesialgu oleks see ka samm edasi.“Kim: „Tehnoloogia läheb edasi.“Nazarenko: „Ma ennustan, et mingi päev tulevadnaha alla kiibid mis on lahustuvad.“Tammeka: „Kaovad ära siis kui terveks saad...“Nazarenko: „Jah, nüüd juba on niisuguseid bio-materjalist asju, mis paigutatakse inimese sisse japroteesid. Imenduvad või asendatakse kehaomastekudedega. Pole võimatu.“Tanel: „Kas lihaspinget on kuidagi võimalik mõõta?Kas seda mõõdetakse ja kas see on tähtis?“Nazarenko: „On ikka. Lihaspinge jaoks mingisugustEesti aparaati kasutati.“(pealtnägija näide, kaalutaolekus)Kim: „Mõtlesime seda ka, et kas kui need kiibidpeaksid võimaldama harjutuse täpsust mõõta, kasnad suudavad mõõta ka venituse täpsust? Venitusosa on ka väga tähtis taastusravis.“Tammeka: „Oleks hea aga ma ei kujuta ette kui-das.“Nazarenko: „Kui ta lähtub kiipide positsioneerimis-est siis võibolla midagi on võimalik mõõta aga ekssellest peabki lähtuma.“Tammeka: „Kui panna kõõlusele, ülemineku kohalesiis see venivus seal praktiliselt puudub, see eianna meile midagi. Kui panna mahukale osale siisseal võib kasu olla, oleneb kuhu need kiibid panna.“Nazarenko: „Jah, oleneb kui täpselt me suudameneid kiipe paigutada.“Kim: „Esimese visiidi jooksul pannakse täpseltpaika. Võibolla peab paika sättima ja kohandama.Kui me käisime erataasturavis asutuses, nendeviisidtasu on 32 euri. Siin on viisiditasu 3,2 eurot,kas see ongi kogu kulu ja ülejäänud kompenseeribhaigekassa?“Nazarenko: „Ei see ei kata tegelikult midagi see3,2. See on keeruline küsimus, haigekassa hinnadei ole täpselt kulupõhised. Haigekassa arvutab