New business beginnings, challenges, hardships, success stories, surveys and studies that map the contemporary business landscape. This is Business In The Mix, our National Bank's new podcast series on the growth and efficiency of Greek entrepreneurship
Niki Lyberaki: Hello. This episode of Business In The Mix is about the story of medical technology innovation. It is about a Greek company that was founded during tough times and is doing exceptionally well. A company with a vision to improve the quality of life of thousands of people across the globe. This company is PD Neurotechnology. I have here with me its co-founder and Business Director, Nikos Moschos.
Welcome Mr Moschos. Let’s start with an introduction to your company.
Nikos Moschos: PD Neurotechnology is a new technology company founded in 2015 and its basic, primary product, concerns Parkinson’s disease. This is a certified medical device, which is already on the market and helps doctors monitoring patients with Parkinson’s disease to constantly keep track of their patients’ condition, and to know if any interventions are needed in terms of the patients’ monitoring and management, so that the patients can gain quality of life and the health system can save on resources.
Niki Lyberaki: It sounds very interesting. I assume the doctor gets all this information remotely. Is that correct?
Nikos Moschos: Absolutely. It is a telehealth medical device that allows doctors to keep track of how things are going without being present at that moment. It is of course at the doctor's discretion to request a visit or to intervene remotely.
Niki Lyberaki: I see. Remarkable. How did you decide to embark on something like this? It sounds very specialised. In Greece, unfortunately, Mr Moschos, we rarely talk about technological innovation, especially in the field of health or telemedicine. You however have made this a reality and have a product to show for it. How did you get to this point?
Nikos Moschos: The journey began in 2006, when Dimitris Fotiadis, professor of Biomedical Engineering and Informatics and Spyros Konitsiotis, professor of Neurology at the University of Ioannina, took the first steps in the direction of this research. The objective of this research was to see if we could map the symptoms of the complex Parkinson’s disease, which cause many motor problems that are very hard to detect and record. And to do this remotely, with the help of artificial intelligence as well as wearable medical devices. This came into being from 2008 to 2011 with the so-called ‘proof of concept’. Through theoretical and practical measurements on 81 patients, it was proven that it is feasible, that symptoms can be accurately measured and that a doctor can remotely keep track of how things are going. The two founders joined by a business team of which I am the main representative, we worked for three years,
and, sought business funds. That’s when the National Bank came along, with Business Seeds, becoming the primary source of help and their contribution was very significant.
Niki Lyberaki: Which year was this?
Nikos Moschos: It was in 2015-2016.
Niki Lyberaki: What makes your company even more interesting is that it was founded and managed to attract funds at a very difficult time and year for the country. That is what makes your journey incredibly interesting. I interrupted you while you were talking about the Bank’s contribution. I can imagine that financing is a very important part of a business venture.
Nikos Moschos: Especially in Greece of that time, – we were funded mainly by people who knew us and not so much by people who had a full understanding of the project. National Bank, along with the experts on its team at the time put their confidence in the business plan, in the knowledge and in the new technology, and so all these angel investors and the National Bank came together to give us our first funding, so as to move to the next day.
Niki Lyberaki: So you moved on to the next day having achieved something that is also a standard issue in Greece: linking university research and the knowledge produced by Greek universities – because our universities do indeed produce knowledge – to entrepreneurship and, by extension, the labour market. Mr Moschos, you have achieved something that we have for years been claiming should be regularised, and should become a model and a rule: universities must be linked to entrepreneurship. How easy is this in practice?
Nikos Moschos: Greece has certain universities where this is easier than elsewhere. For example: Patras, Thessaloniki, Heraklion, as well as Athens and Ioannina, by extension, have very capable scientists who have very good ideas and test them in practice. The issue is that this link to the market, the understanding that the country's investment capital has of matters pertaining to medical technology, medical devices or biosciences, is not on the same level as in other countries like, for example, England, which is currently Europe's pioneer. And this is the answer to a question you may ask me: how is it that we are based in London?
Niki Lyberaki: You did indeed beat me to that question. PD Neurotechnology moves along a triangle: Athens – London – Ioannina. I believe you have already answered as regards Ioannina, because that is the source, the very beginning of the scientific research. On the other hand, you are based in Britain. For what reason? Is it a more attractive destination for companies?
Nikos Moschos: That is one of the reasons. The second reason is that there you can find specialised lawyers and accountants who have a grasp of what it means to be a medical device company and can draw up the corresponding contracts and carry out the necessary procedures in order for this whole thing to run. Also, London is a standard destination for such funds to find high-technology companies and, later, to be bought out in order to continue on the journey towards entrepreneurship. At that time, our country had not reached this level. Some steps have been taken to date, but still it is no San Francisco, it is no Cambridge UK or Cambridge US. It is, however, a destination where investments are increasingly being made in high technology in the field of health.
Niki Lyberaki: I cannot overlook the fact that you founded your company at a time when Greece had the sword of Damocles hanging over its head in the form of Grexit in 2015. You founded your company and based it in a country that has undergone Brexit in the meantime. Does this affect you, considering that you are based in Britain?
Nikos Moschos: It is paradoxical and interesting at the same time. But it turns out that coincidences make history in many instances. Brexit did indeed make things difficult for us, and there was no clear indication of it back then. We are talking about 2015. Despite all this, England – precisely in order to cover this gap – continues to provide incentives. There is also the advantage of having what we call “the best of two worlds”, of the US and Europe. Therefore, having all our activities in Greece, as well as in other countries abroad through our distributors, distribution networks, consultants, etc....
Niki Lyberaki: Yes, we will discuss about this. Your outward-looking approach.
Nikos Moschos: But having our main activities here, we have the opportunity to stay within the European Union, while at the same time our registered office in London allows us to enjoy the facilities and benefits provided by the British state, bringing us one step closer to the US, which is closer in terms of technology, contacts, systems, etc.
Niki Lyberaki: You stated earlier that things are improving in Greece, and that in the last 6 years, from 2015 to date, you have seen a course, a trajectory of improvement. I am wondering if your company would at some point consider relocating or repatriating, so to speak.
Nikos Moschos: As regards all our activities, we are already here and we feel very Greek. In other words, there is a strong sense of national pride; a sense of striving to consolidate and pass on this model of outward-looking entrepreneurship.
We put a lot of thought into the possibility of establishing a registered office – and not just a subsidiary or branch, as we currently have – outside the United Kingdom. We are still looking into this. We will have to see if this will be in Greece or, for some reason or based on certain incentives, in Paris or Germany. Of course, it is most likely that we will remain as we are and our branch in Greece will possibly become a subsidiary.
Niki Lyberaki: Is there a “romantic” side to your efforts? In other words, a company dedicating itself – through its research, funds and efforts during difficult times – to creating a product that helps patients in the end. For a disease afflicting millions of people on the planet.
Nikos Moschos: There are indeed millions – luckily not many millions. There are approximately 13,000,000 patients across the globe.
Nikos Moschos: You must also be inspired by the effort to help people and to improve their lives in the context of a profoundly medical issue. This is a very difficult disease.
Niki Lyberaki: Of course. It isn’t curable, right? It is degenerative.
Nikos Moschos: Unfortunately it is incurable and treatment ultimately aims at managing the symptoms and, by extension, quality of life. This is precisely what the PD Monitor does. That is, it can constantly record symptoms at the regular intervals at which the doctor requires the remote monitoring to take place and therefore, by knowing when the symptoms occur, how they develop and how they are combined with the current treatment, he/she may recommend interventions and see the results immediately.
Niki Lyberaki: Is this something that a patient can “wear” throughout the night, for example? What I’m trying to say is: does it go beyond the doctor’s ability to monitor patients in the conventional way, which involves visiting their practice and having a half-hour session, during which time the patient may not experience symptoms or a flare-up? Have I understood this correctly? Is this the possibility you are providing?
Nikos Moschos: First of all, this is not in real time. So if a patient wears the device at 11 in the evening, there won’t be a doctor there monitoring the situation.
Patients can use it for 2 to 5 days, once a month, once every two months, once every six months or once a year, depending on what the doctor requires. Some patients are in the initial stage of the disease, which is known as the “honeymoon” phase, and in this phase the symptoms are manageable, the treatment is what it should be, and the patient does not experience the so-called “fluctuations”, when the medication takes effect at times and wears off at other times. This is what their future will look like. Up until that point everything is fine and one might not even notice that a patient has Parkinson’s because the medication is strong, effective and everything is OK. However, as time goes by, unfortunately the so-called “neurodegeneration” progresses, the disease develops and the patient once again has the symptoms they had before starting treatment, but not continuously. They take their medication, as prescribed by the doctor during the day, but after a while the medication is no longer effective. The doctor then proceeds to prescribe a second dose, third dose, fifth dose, on this journey through time, hand-in-hand with the disease. This is where things start getting complicated. Because patients need to have the required dose and dosage at all times. It is impossible for a doctor to have this information without having a recording device as such.
Niki Lyberaki: So you have made this possible.
Nikos Moschos: We have made this possible. This was a so-called “unmet need”. The medical community has for years been searching for a way to help doctors constantly keep track of a patient’s condition, not in real time, but whenever they decide to make an adjustment, they can see the patient’s condition.
Niki Lyberaki: I imagine this is the greatest success: finding a way to meet a need that has up until that time not found its solution. So as previously stated, your company was established in 2015, forming the London – Athens – Ioannina triangle, for the reasons explained above. You look beyond borders, beyond all borders because you are essentially an outward-looking company.
Nikos Moschos: Precisely. Look, this is a global disease. There are approximately 22,000 Parkinson’s patients in Greece and 13,000,000 across the globe. It would be unfair not to have a de facto outward-looking approach, considering that the needs are global. Unfortunately it is widespread and it is a disease that significantly affects the entire family. Due to the fact that the disease is incurable, Parkinson's patients gradually come face-to-face with a huge struggle. And their loved-ones face it as well.
Then comes depression and many problems; they miss days of work; they are no longer productive, regardless of what stage in life they are in. Therefore, an outward-looking approach was the obvious choice right from the start. Applying an outward-looking approach has a high cost and requires one to consider how they will go about it, which associates they will find, how they intend to build a network, if they will be establishing subsidiaries or if they will be working with distributors.
Niki Lyberaki: In how many countries do you operate?
Nikos Moschos: We currently operate in approximately 10 countries, most of which are in the European Union and in the United Kingdom. We are directly interested in the Middle East market, but most of all we are interested in the US market.
Niki Lyberaki: I would assume that one of the unique characteristics of your field, the field of health and medical technology, is that you also collaborate with the health systems of each country and not only with private patients or doctors.
Nikos Moschos: Health, whether it involves the provision of hospital services, medication, medical devices, physical therapy at your home or at a physiotherapy centre, ultimately entails a degree of complexity as a system.. It is very often the case that one person receives the service, another refers them to that service, they need to go elsewhere for said service, while somebody else pays for the service.
Niki Lyberaki: It sounds like it is substantially more difficult for the company to penetrate a country.
Nikos Moschos: Precisely. What you are referring to is called “market access” and unfortunately, due to differences between countries, even within the European Union, for each country you must record everything related to the plan for penetrating the country before entering it. And this may seem self-evident for any business venture.
Niki Lyberaki: I must say, it sounds rather labyrinthine to me.
Nikos Moschos: Here however, and especially in the health system, it is indeed labyrinthine, as you say. In other words, one must look into the steps that need to be taken in order for a medical device to receive compensation from the health system. For example, in the United Kingdom compensation is provided on different levels. It can be provided in a geographical region, in the corresponding CCG, which is the Clinical Commissioning Group, of Belfast for example, or it can be provided at hospital level or at the central level with a central buyer.
Niki Lyberaki: So with a great number of branches, perhaps in each market.
Nikos Moschos: With different scenarios, different branches, a compensation network, and then we have the Payors, which can also be private insurance companies. They play a different role and participate in a different way. Health professionals also play a very important role as they are the ones who will recommend the use of a medicine or device, and therefore they must know about it and receive training. There must be clinical studies proving the product’s performance or, similarly, that it improves quality of life or, similarly, that it helps the health system save on resources. So if you consider that all this is different by country – some common and some different – it creates the need for a very different mapping of each country.
Niki Lyberaki: I don’t know if I am wrong, but based on your description, there isn’t even a common European umbrella. For example, certain products coming under other categories obtain European approval, thus opening the doors to the entire single market.
Nikos Moschos: Youhave fully understood it. Take note that here we have a CE Marking, a CE Marking on a medical technology product, which is different to the CE marking on a light bulb.
Niki Lyberaki: CE, to remind you all, is that marking you see when you go to the supermarket or anywhere else on all the products of the European Market.
Nikos Moschos: Exactly. What is known as “Communauté Européenne”. That is what CE means. Medical Grade CE is far more complicated; it includes a medical file of thousands pages, which is just an order of magnitude, describing the product’s performance, the clinical studies that have been conducted, its safety, biocompatibility and a series of other things, all of which are required. This is a journey that took us 5 years to complete. A journey that usually takes up to 10 years to complete. We just had a very strong team; a team moulded within the framework of the university workand through the experience of collaboration, thus we managed to obtain CE Marking in 2019. In order to be able to sell in every European country which is supposedly under the common European umbrella of the CE mark, some countries require a special subscription in order to be included in the register of medical technology products, while others require specific ISO certification in order for you to be considered a distributor in that country; in other words, the CE mark does not suffice; you need to obtain that specific ISO certification.
Niki Lyberaki: You said in the beginning that you were helped by “Business Seeds”, which is now an institution. I’m wondering if you would be willing to take that knowledge, that know-how you have gained – because you now have many years of effort under your belt and have a roadmap of how things are done in your field, to put it simply – and share this know-how as mentors, perhaps, through a similar institution. Would you do it?
Nikos Moschos: Very gladly. We were helped from the start by many people who were by our side, whether it was the Athens Medical Group which provided help from the very beginning, and which is also the background I came from, having been the first to stand by our side during the clinical studies, or whether it was the National Bank through the appraisal it gave us as an institutional investor, which allowed us to gather the remaining investors so that we could have a common appraisal and start out. Therefore it would be unfitting for us to not provide help wherever it may be needed.
Niki Lyberaki: I see. So, the coronavirus: it has put our lives on a course that is still somewhat difficult to get used to, even two years later. Did it make things difficult for you?
Nikos Moschos: It cost us a lot. It caused us immeasurable difficulties. Consider a burn rate, i.e. the monthly operating costs of the company, of approximately 150,000 euros, during the years of the coronavirus – or rather the months, luckily, of the coronavirus – until today, until the borders reopened to some extent in May. So the first 13 months multiplied by 150,000 euros is what it cost us, because the business plan was put off for an equivalent time period. The difficulties varied from the initial supply of certain materials from China, which first closed down in November 2019, before we could even grasp what was going on in Wuhan, where we had a factory -in the wider region -,producing raw materials and batteries in particular.
Nikos Moschos: And then they extended to the clinical studies, which could not be carried out because neurologists in the United Kingdom were focused solely on Covid-19. Only to end up affecting our commercial efforts. Despite our being well-versed in video conferencing, it turns out that it is difficult to sell an original innovative product to the US via WebEx. If you cannot go there, travel, meet the people and make the sale. We did that too, penetrated via WebEx.
Niki Lyberaki: You did it.
Nikos Moschos: Yes we did. (laughter) But things would be much easier indeed if we didn’t have the coronavirus issue. Let me just add a parenthesis here: unfortunately, on the other hand, it is also an opportunity. We must view the games of fate from all aspects so that we can always be prepared, at least in business, to face all possible scenarios.
Niki Lyberaki: Do we have any collateral benefits?
Nikos Moschos: We do have one so-called “collateral benefit” in the sense that this situation has made the need for telehealth even more dire.
And our product is purely a telehealth product, making it easier for health professionals to grasp that they can more easily monitor their patients remotely, now also due to Covid.
Niki Lyberaki: For years now, whenever I hear the term “telehealth”, a term that I do not hear as much as the term “telemedicine”, which has been spoken about for years in Greece, I cannot help but think about our own geographical uniqueness, namely the island nature of Greece, and I wonder if your plans include the creation and production of other devices or systems that could, let's say, also help in such cases. As we are all aware, there are many small islands in Greece where it is difficult – especially during winter – to find the necessary medical and nursing staff. Does your future include such goals?
Nikos Moschos: Of course, you cannot move forward without goals. As regards the first part of your question, there are islands in the eastern Aegean where we have patients and, as a matter of fact, one of them received his first compensation from the Greek health system, which is yet another reason for us to be proud, because EOPYY (National Organisation for the Provision of Healthcare Services) understood us and gave us compensation, on an exceptional basis, until negotiations take place and until the entire procedure for setting an official price in the health system moves forward. It gave us, on an exceptional basis, compensation for a patient living on a frontier island, who is being monitored by a specialist in clinical disorders in Athens. Because it realised that the telehealth of people living in frontier regions serves as an additional added value.
Niki Lyberaki: Of course. Especially when it is also a matter of national policy for people to remain in their place of residence. What you have just told us is very important and I am pleased to hear that there is flexibility on the part of the State, at least when needed.
Nikos Moschos: This is therefore a very good example. From that point onwards, the company has a development plan in place involving the next steps for the same product, namely version 2 and version 3, which will include sleep, as you had asked earlier. Because we do not currently record sleep; we record activities during the course of the day.
Niki Lyberaki: Yes.
Nikos Moschos: Or other parameters of the disease which are currently not being recorded and do not relate to movement. They relate to the so-called “non-motor symptoms”, which are also very important to Parkinson’s disease. In addition to Parkinson's, we are interested in multiple sclerosis; we are interested in the rehabilitation of brain and certain other movement disorders and neurodegenerative diseases which we can monitor with similar technology, by applying different parameterisation and following the same path of certification and development.
Niki Lyberaki: I have another question for you: 6 years later, and having heard your story, the great effort it took, the mountains of bureaucracy, the series of markets and obstacles that had to be overcome in order to enter these markets; would you say it was worth it? And I am obviously not talking about your company because you have succeeded and are on track. What would you say to someone listening to us, who is at the start or thinking about embarking on such a venture? Would you tell them to go for it?
Nikos Moschos: Look, we often feel like we are living the “Greek Dream”, something like the “American Dream”. In Greece, our country with our so-called “national mark”, which we are all drawn to because we have our history, our friends, the sea, the sun and whatever else inspires each of us individually. We can do these things here, provided there is a team, provided one has the right business idea, provided the recipe will work; in this way, things can progress because everything is much easier than it was when we started out. There are many funding sources – perhaps not as specialised as we would like, but they are improving, moving forward and trying to bridge the digital divide. Here we have a technology divide, compared to London – as mentioned earlier – or to San Francisco or Boston. Efforts are being made; there are some very good universities; there are some very good funds and I believe everything is easier, and I also hope that it will get even easier in the future.
Niki Lyberaki: Avail yourselves of the opportunity. Thank you very much Mr Moschos.
Nikos Moschos: Thank you very much; take care.