Hi, everyone, and welcome to Nordhealth's Q1 2023 presentation. I'll start with introductions. I'm Charles MacBain. I'm the CEO of Nordhealth. Mari?
Yes. My name is Mari Orttenvuori, and I'm the CFO of Nordhealth.
Thanks. Today, we'll go through five different topics. First, we'll go through a company update. We'll go through new updates for both the veterinary BU and then the therapy BU. Mari will take us through a financial update, and then we'll finish the session with Q&A. Please reserve your questions to the end. Starting with the company update. Our mission at Nordhealth is to build and acquire software that empowers healthcare professionals, currently veterinarians and therapists, to save time, so they can focus on delivering great care and growing their business. How we're looking to do this, there's two main sort of levers, right? That we're optimizing for, right? One is profitability, and the second is growth, which is strategy. Our strategy to improve our profitability is one, is to have one product per vertical.
Second is to migrate acquired or legacy products to our flagship single product per vertical, which is Provet Cloud for veterinary and EasyPractice for therapy. Third, we're looking to reduce the customer acquisition costs as a percentage of new AR through improvements in onboarding efficiency, specifically on the veterinary side. Fourth is we've built up a sort of corporate G&A team, including finance, HR, IT, to be able to continue to scale this platform for the next few years. We don't foresee adding any additional headcount on the G&A side. Lastly, on the profitability part is that we've also, are not looking to have any significant net increase in headcounts in the BUs in order to be able to achieve our three-year plan.
On the growth side, the key is to focus. On the therapy side, that means no new markets in 2023. We're focusing on our markets in Finland, Denmark, and Norway. On the veterinary side, we're focusing on continuing our expansion in these growth markets, which are the U.K., U.S., and Spain. In addition, we're looking to continuously grow average revenue per user, or ARPU, right? By adding more and more solutions to our software suite. We started with PMS, practice management software. We've gone into payments for veterinary. We're now launching payments in therapy, and we're working on launching a booking portal for the therapy side. Then we'll do that same thing for the veterinary side.
Before starting off on the individual KPIs, I wanted to go through the new primary KPI that we are going to look at, that we had discussed originally in 2022, that we will now focus on in 2023 onwards, which is shifting from signed AR to implemented AR. Just for definitions purposes, signed AR, as we defined it before, was the total value of signed and implemented recurring revenue at the end of the quarter, multiplied by four. Implemented AR is the quarterly revenue multiplied by four. There is basically two main things which differ between both of those. One is the fact that, if a customer has not yet been implemented, for example, corporate chain has implemented 10 clinics, but not the other 90 clinics that they have, right? We would only add the revenue from those 10 that are implemented as part of the implemented AR.
The second part is that a customer which is implemented mid-quarter might only have half the revenues for that quarter accounted for in implemented AR, right? Because they only paid us recurring revenue, which are subscription fees and transaction fees for half the quarter. Those are two significant differences. This is a more conservative measure. However, it has less judgment call, right? That is included in it. This is especially important on the veterinary side, where we've got a lot of these corporate chains, right? Which it's hard to know how much to include given that they're continuously growing, and we have to make assumptions around their transaction fees and so on.
Before starting the presentation, I want to sort of bridge the gap between our Q4 2022 signed ARR and Q4 2022 implemented ARR. There's two main differences. The first is the exchange rate impact. In order to be able to analyze growth throughout the year, excluding the impact of currency which can fluctuate quite a lot, right? Does not actually have too much meaning in terms of the actual business performance of recruiting new customers at all. We fix a constant exchange rate for a lot of this analysis, but we reset it every year. The resetting of it had an impact of around EUR 900,000, and that was due to the weakening NOK and SEK relative to the EUR.
The second was we've removed EUR 1.2 million of order backlog, which means that it's the value of signed but not implemented deals. The vast majority of which are on the veterinary side, given the time, the lag time it takes to be able to implement is much longer. That impact was about EUR 1.2. Now we've got a good understanding of the differences between signed AR and implemented AR, let's dive into the KPIs. In the last 12 months, ending Q1 2023, our implemented AR grew 19%. Of which organic net retention was 110%. The third, probably the most impressive part of our business is our churn rate, which remains incredibly low at 3.5%. That is gross churn, right? Not net churn, which most. That's per annum.
Lastly, the great thing about our business is the fact that people never quit, but or very rarely quit. Also it makes it very challenging to be able to recruit new customers. You can see that on sort of our CAC to new implemented ARR ratio of 2.3. This is something we're actively working on, especially on the vet side, where we're looking to reduce some of the time and effort it takes to be able to implement the customer, which should allow us to be able to do it with a lower customer acquisition cost, but also be able to do it faster, thereby we have smaller order backlog. Looking now how things have panned out quarter-over-quarter.
We look at Q1 2023 relative to Q4 2022, we can see that implemented ARR has grown 8%. That means that at the end of Q1 2023, our implemented ARR was EUR 32 million and signed ARR was at EUR 33.4 million, which leads to an implemented ARR per share, right? Which is our best sort of proxy for future cash flow per share. If we multiply that by our expected margin of EUR 0.4 per share. Let's dive in a little bit into these metrics, specifically implemented ARR and how that has improved quarter-over-quarter. As we had mentioned in the previous slide, we sort of ended the 2022 year with a implemented ARR of EUR 29.7 million.
We grew 8% to EUR 32 million. That growth came from 24% of that growth came from new customer acquisitions and 76% from net retention, right? Which is mostly driven, as you can see, by price increases. You can also see that the Provet Cloud signed, but not implemented order backlog has increased from EUR 1.2 to EUR 1.4. Another interesting thing to note is that 45% of our AR were on cloud products, relative to 42% in Q4 2022. We're increasing the share of recurring revenues or implemented AR from cloud products. Looking at this year-over-year 'cause quarter-over-quarter there's a little bit of noise always, right?
We ended Q1 2022 implemented AR with EUR 26.9 million, and 2023 Q1 end was EUR 32 million, which means we grew 19% during that last 12 months. Looking at where that growth came from, right? 39% came from new customer acquisition, right? 61% came from net retention, including the price increase which was the largest part of the net retention. The interesting thing as well as you can see the impact of 3.5% churn, which is around EUR 900,000. Let's take a look at this in a bit more detail still, by breaking it down by veterinary cloud products, veterinary hosted products, therapy cloud and therapy hosted. A couple interesting things to note from this table. One is that the net retention of 110%, differs quite above a lot by segment.
What you can see, which is very impressive, is that the Provet Cloud net retention is 123%. Second, you can see the incredibly low churn on the veterinary side, both from the cloud side and the hosted side, which is 1.2% and 1.5% respectively. Something to note, and we put a note to that as well, is that the therapy cloud churn, which is 8.2%, right? Let's dive into that. There are two parts of that, right? Which basically one is DRM, which is a churn rate of 2.9%, and EasyPractice, which is an annual churn rate of 17.8%. That seems very high, but it's really worth understanding two things about EasyPractice makes a difference.
One is that they've got much smaller customers, and there's a very strong relationship between the size of the customer and the churn rate. What we see in EasyPractice as well is that the actual churn rates between, for example, 2020 and 2022 was between sort of 2.2% and 5% per annum, right. For customers that we charge DKK 250 per month, which is quite similar to what we're charging DRM customers or Aspit customers, right. The churn is much higher for small customers, where we charge less than DKK 250 per month. The second thing which makes it different is that it's very easy to onboard and to sign up to this service. A lot of customers try it out for a couple days and then churn, right.
It's a very different type of business than we have. The hurdles for us to be able to onboard therapy customers on Aspit or DRM or on Provet Cloud are much higher because it requires implementation and so on. The commitment is already there. With EasyPractice, they can just try it out and then churn away. The last part which is interesting to look is looking at the cloud business. At the time of our IPO, pretty much our whole business was the cloud business. You can see here that the companies that we have acquired, which are mostly the hosting companies, are growing by 12%, right? However, our sort of cloud companies are growing almost 30%, right at 28.8%, right? What I particularly like about that is that almost half of the growth comes from new customers.
It's great to have a great net retention, right, which is roughly 115% for our cloud products. However, you can only be able to increase revenue per customer, right, so much over time. It's really important to have this new customer engine continue to be successful. This is a new slide for us. We're looking more and more at profitability, and we wanted to show you the progression of profitability over time, right? What we had mentioned is that during the IPO in our story was that we wanted to be able to raise money to be able to invest more aggressively in R&D and in growth markets, to be able to grow faster in them and cement our position.
Once most of the customers have actually decided on a cloud platform, right, it'll be very hard to switch them, right? As we can see from our own churn metrics. Starting in 2021, we increased the amount of spending, and you can see our EBITDA minus CapEx went from positive to negative EUR 3.6 per quarter. However, since Q2 2022, we've actually, through a combination of growth, right, and reduced hiring or even reduced headcount in the latter parts of 2022, we've been able to continuously improve that, and we have now ended Q1 2023 with a negative EBITDA minus CapEx, negative EUR 2 for the whole business, and negative EBITDA of about EUR 0.6. Our goal is to continue improving that every single quarter.
One of the big drivers of this improvement is the fact that we've reduced our headcount from a peak of, in Q3 2022 of 404 to a headcount of 378 at the end of Q1 2023. Now, diving into the veterinary update. Just to remind everyone, our focus for the year is to migrate our Nordic legacy customers on, for example, Vetserve, Sanimalis and Novasoft over to Provet Cloud to make a good chunk and good improvement in the migrations. The second is to acquire new customers in U.K., U.S., Spain and also Italy. A bit of update on growth and profitability. On the growth side, in Q1 we signed three large enterprise deals, right? Each have over EUR 150,000 in implemented ARR a nd implementation has been done for all three clients.
The U.S. surpassed over 100 customers, which is a nice milestone for us. Now that Nordhealth Pay has been tested and is out of beta, we actually have recruited 48 customers and are processing over EUR 2 million of payment volume per month. Also, from the product perspective, Veterinary IT Services in the U.K., which is a veterinary publication, has actually chosen Provet Cloud as the number one practice management software for veterinarians in the U.K. That's a nice stamp of approval for the work that our product and engineering team have been doing. On the profitability front, which we'll see in the profitability slide later on, you can see a margin improvement, mostly driven by revenue growth, right? And also more efficient customer acquisition.
Also on the profitability side, we have made significant progress in being able to sign up or implement, migrate Legacy migrations. Over 100 Provet Legacy or Vetserve Sanimalis customers have actually decided to migrate onto Provet Cloud. How does the progression look quarter after quarter for veterinary? In Q4 2022, implemented ARR was EUR 13.6 million. Right. We grew 12.7% to EUR 15.4 million by the end of Q1 2023. The majority of the growth here can be accounted for a price increase, which happens normally in January. But we also added 200,000 new customers. What's interesting as well about this growth in terms of new customers is that all of it came from our cloud products, Provet Cloud.
We're no longer recruiting customers. We signed no long-term customers on Sanimalis, Vetserve, or Novasoft, as well as Provet Legacy. Looking year-over-year, right? Which is the way I prefer to look at it because it gets rid of the fluctuations. In Q1 2022, we ended that quarter with EUR 12.7 million of implemented ARR, and we grew 20% over the 12-month period, 20.6% actually, to 15.4 million. What you can see is that 30% of the growth came from new customer acquisitions and 70% from net retention, of which a large percentage comes from these price increases. You can see again, this EUR 1.4 million signed ARR over that period to get us to EUR 16.8 million, which is signed ARR for Q1 2023.
Looking at profitability for the veterinary business unit quarter-over-quarter. We've been every month improving EBITDA and also EBITDA minus CapEx, right, which is a proxy for free cash flow. The main drivers of that, specifically Q4 to Q1, is a headcount reduction between 233 and 225, despite having an increase in revenue during that period of time. We'll continue every quarter to see an improvement in both EBITDA and EBITDA minus CapEx. Looking at therapy. Just as a reminder of what we're focusing on this year, we're focusing on two main things for therapy. The Aspit migrations to EasyPractice, and second is launching the booking portal in Finland. From the growth perspective, we were able to migrate our first customer from Aspit to EasyPractice in February 2023, and that customer is satisfied.
We're very happy with the outcome. Since then, we've migrated quite a few more, and our aim is to have a fully automated migration. We're testing that out with a couple of beta customers, and that's working quite well. It's a dramatically different exercise to migrate therapy customers than veterinary customers. It's much easier to migrate therapy customers, given the level of complexity and integrations to physical devices is much lower. Secondly, on the growth side, EasyPractice implemented AR grew 6.8% in Q1 with no price increases. That's a very impressive growth rate that they have. There might be price increases as well for the future.
We have done price increases for all products except EasyPractice, and there is a price model change which will be happening later in the year for DRM as well, which should also have an impact. Lastly, on the growth side, we've launched a waiting list for the booking portal in Finland for therapists, which is called Nordhealth.fi. You can see the link there. You'll be able to click. It's in Finnish, right? Because it's mostly targeted for the Finnish markets. We're very excited about this new product for the market. It'll help us be able to provide a full service to therapists, not only on the managing record side, but also helping them gain customers, right? Getting customers to have improved access to therapists and visibility over pricing, services, and availability. That's a very exciting step in terms of cementing our customer relationships.
On the profitability side, we have begun migrating development and support resources from Aspit and DRM to EasyPractice. That's been quite a successful process. We're very happy with the employees that have migrated in terms of being able to shift over their knowledge of those markets to EasyPractice in order to accelerate the EasyPractice localization. DRM and Aspit are focused on two things, right? One is improving efficiency, right? By, for example, focusing developments on where the most tickets are and so on. Second is to make sure these customers remain satisfied despite the lower level of investments. It's very easy to migrate customers that are satisfied. It's much harder to migrate customers that are not satisfied. For both Aspit and for DRM, right?
We've got very satisfied customers, both in terms of NPS, which is Net Promoter Score, right? Also in terms of customer satisfaction score for the supports. Looking at how the growth happens quarter-over-quarter, we grew from EUR 16 million in Q4 2022 to EUR 16.7 million. This is a chart which actually shows the fluctuations quarter-over-quarter, because as you can see, net upsell is negative here, right? Churn is quite high. The reason why is that there's a lot of annual contracts for EasyPractice which end in the first quarter and second twice a year, which is in the beginning when you see the Q1 and you see that in Q3.
You see Aspit, customers being able to reduce the number of users that they have. There's a little bit of seasonality here. Let's take a look at how it looks year-over-year. We ended Q1 2022, implemented ARR with EUR 14.2, and we were able to increase it by 17.5%. New customer accounted for roughly half that growth, and then net retention was the other half. Churn was 5.4% here, which you can see. Higher than net retention, but still at a very good level, right? And we can also see that the growth in net upsell was quite similar to the growth in price increases.
We're still continuously increasing our sort of average revenue per user or per customer by adding users and also by upselling products. Looking at profitability for the therapy business units, you can see it has always been profitable, both on the EBITDA and EBITDA minus CapEx level. That profitability has continued to increase over the last few quarters as we have refocused our attention on migrating everything to EasyPractice. You can see here the impact of sort of the operational leverage, right? As we continue growing, we don't need more people, right? Every time we add more revenues, that will lead to much higher EBITDA minus CapEx and EBITDA.
We saw that by the end of Q1 2023, right, our EBITDA minus CapEx for the therapy business units was EUR 1.1. Our EBITDA was EUR 1.5. The reason why it's improved in Q1 2023 relative to Q4 2022 is because we've had a reduction in headcount from 140 to 127 as we wound down the Matilda project and refocused all of our attention on EasyPractice. We foresee a further improvement in profitability in every quarter of this year, right? Slight improvement, there'll be a big improvement when we shift over all the customers from first Aspit and then Diarium to EasyPractice. Mari, over to you for the financial updates.
Thank you, Charles. Looking at the reported numbers then, our first quarter reported revenues grew by 22% year-on-year, and they amounted to EUR 8.7 million. Reported recurring revenue in the first quarter also grew by 22% year-on-year, as Vetera wasn't included in the first quarter numbers in the comparative year, and therefore the growth in the reported numbers is higher than the pro forma implemented ARR numbers, as Charles just discussed. Although the net decrease in our headcount in the first quarter was 22 employees, representing a 5% decrease in our headcount since the end of the year, the number of employees still 15% higher than it was a year ago. Personal costs are significantly higher than what they were in the comparative period.
Plus, they also now include Vetera personal costs for the first quarter that were not included in the comparative period. Also our personal costs include one-off items of EUR 0.4 million that relate to mainly restructuring activities during the first quarter. Capitalized R&D expenses in the first quarter, they amounted to EUR 1.4 million or 18% of recurring revenue. Adjusted EBITDA minus CapEx was negative EUR 2.3 million. Overall, we have really succeeded in maintaining good cost control during the first quarter. Our adjusted EBITDA minus CapEx margin was - 23%, which is a clear improvement from the 31% of the comparative period. We are really starting to see a more positive trend in these margins as expected. If we move on to the balance sheet.
During the first quarter, we paid the EUR 4 million earn-out relating to EasyPractice to the sellers. Despite of that, our cash position still remains strong at EUR 32.2 million. That comprises both cash and money market funds. At the end of the first quarter, we were in the process of reinvesting our money market funds, and those were only partially reinvested at the end of the period. This has now temporarily impacted our cash and money market fund balances at the end of the reporting period. This reinvesting has now been accomplished, and we have invested approximately EUR 9 million into money market funds as of today. Our goodwill is mainly denominated in Norwegian kroner, and that has depreciated quite significantly.
There's been no write-downs of goodwill, but the change is driven by currency fluctuation and amortization. Generally, the changes in the balance sheet when comparing to the previous year are mainly been driven by the acquisitions of the previous year, or mainly the Vetera acquisition that was accomplished during the second quarter. On to the cash flow. The reported operative cash flow here has not been adjusted for one-off items, and that includes the EUR 0.4 million of restructuring costs that we incurred during the first quarter. If we take that into consideration as well, our operative cash flow has improved quite significantly from the previous year. Cash flow from investing activities include capitalized R&D expenses and the already mentioned earn-out payment that was financed through the proceeds from the money market funds.
Here the net proceeds from the money market funds amounted to EUR 10.8 million, whilst this EUR 4 million has now been used for the earn-out payment, in addition to that, approximately EUR 5 million have been paid into the money market funds now up to the end of the reporting period. No financing activities have now taken place during the first quarter. Now looking at the total cash outflow adjusted for these non-recurring items in the last 12 months ending March was EUR 24.5 million. That is for the last 12 months. That includes one-off items of EUR 0.9 million. Already those incurred during the fourth quarter of last year, and now the ones incurred during this first quarter of 2023.
Adjusted free cash outflow was EUR 12.2 million. Acquisitions amounted to EUR 11 million, and repayments of debt were EUR 1.3 million during the last 12-month period. For the time being, we are not expecting any further significant one-off payments such as earn-out payments or restructuring-related payments. In saying that, there will be fluctuation in operative cash flows between quarters also going forward due to our billing cycles as our billing cycles vary between our products quite significantly. Our second quarter results will be presented on the August 22nd . In connection with our Q4 results presentation, we mentioned that we would be holding a capital markets day later on this year. Instead of that, we will be holding an extended quarterly presentation in connection with the Q3 presentation, which will be held on the November 14th. That will be held as a physical event and with an opportunity to participate either virtually or physically. More information on that will follow.
Thanks. Mari, just to conclude, right, one is we want to confirm the guidance of 15%-20% growth in recurring revenues in 2023, right, to 2022 in constant currency for December 31st, 2022 FX rates. The second guidance we want to confirm is that we're looking at EBITDA less CapEx breakeven by Q1 2025. The second conclusion is signed ARR and implemented ARR both on targets. I think EBITDA and EBITDA less CapEx improvements have been better than expected, right? Lastly, that a key focus for the year is on migrating acquired and legacy products to Product Lab EasyPractice to be able to unlock these savings and synergies we can have from that. Now on to questions.
For questions, feel free to either raise your hand and ask the questions, or you can ask the questions in the chat. I see that Oliver has already asked a few questions. Maybe what I'll do is once you ask questions, I can repeat the question, and then I can, me or Mari can answer that question. The first question from Oliver was, "Gross margin expansion continued at good pace this quarter. What is the main driver, and what is your view on this development going forward, particularly high margins in this quarter?" I believe that this was relative to this one. The materials and services have not increased that much despite the revenue increase. Mari?
It is mainly to the sort of nature of our services. We can see now the expansion in our revenues from cloud products that do not increase sort of material services costs at the same rate. If you remember last time we also prepared more in-depth analysis on the sort of profitability of our different products on the hosted products versus non-hosted products and the cross margins are sort of quite varying there. With regards to our share of hosted product revenue increasing, that will ultimately improve our cross margin overall.
Thanks, Mari. I think if we look at it in Q1 2023, just looking at materials and services, the gross margin is around 85%, right? As Mari said, in terms of the trends, as more and more of our revenue basis shifts from our legacy products, which have quite a few licenses, Microsoft license, Citrix licenses that have to be charged to the cloud, which have none of these licenses, we should see that continuously improve.
On the flip side, there is a negative effect as well, that some of our current products are hosted by our own servers that we own, thereby when we will ship them all to the cloud, even though that's a real cost for buying and maintaining those servers are there, the cost of buying those services are CapEx usually, and so that will move from being CapEx to OpEx. However, I believe that the first effect should have a stronger impact than the second, thereby seeing a continuous improvement over time. Does that answer your question, Oliver? One second. Allow to talk. Here we go. The second question was any color on the M&A market environment and your appetite for further M&A? Yes.
Well, I think the we're seeing more and more sort of reasonable valuations relative to previous years. That's good news, and I think it's going on the right trends. On the private side, however, right, relative to the public side, they still haven't had the full brunt of it. I think that's over time, as a lot of these companies are sort of need cash in order to be able to grow, right, especially our smaller competitors, there might be a time when they're forced to be able to go to market and they'll have the full brunt. They'll realize that the valuations that they had of last year or two years ago is different valuation today.
We're always on the lookout for fairly priced acquisitions, right, in veterinary or therapy, which means other PMS, legacy PMS that we can migrate over or add-ons to our current PMS suites. Those are the two things that we're looking at. We are not as much looking at PMSs in other verticals for now. However, if something great comes up, right, we'll obviously look at it, even though it might accelerate our plan. The pace, probably, we've got a lot of legacy products which we have to integrate. Although we are still looking at acquisitions, it would obviously be a delayed migration, given that we've got a backlog of migration that we have to do for both veterinary and therapy. That's on M&A.
In terms of capital allocation, right, if I always look at when I'm thinking about should I buy a company for a certain multiple, or if my company, which has a higher percentage of cloud-based software and also a, I know everything about our company, and I know you always have unknown unknowns in acquisitions, it's hard for me to justify to pay some higher multiples of AR than we're currently trading at. In terms of use of cash, it doesn't make too much sense to invest in something that you don't know as well with probably less high quality revenues than invest in something we do know very well with higher quality revenues. That's also a trade-off we're looking at. The next one is how much of the organic AR growth was price-driven approximately.
Let's go back to this chart right here. If we look here at the growth, right, we went from excluding the churn, which would be growth when we looked at EUR 32 million minus EUR 26.9 milion, which was a total growth of EUR 5.1 million, right? It's 2.3, the impact of the price for EUR 5.1 million, which is roughly 45%. Again, price increase is not just pure price increase because we're continuously improving and adding features to our software, which are included. It's always hard to be able to see, like, how much of the price increase should actually be a net upsell because we've actually added add-ons, which they value more and thereby they're willing to pay more for it.
That's why I like to separate it out to see the difference, but still it's a bit of a gray line between what should be net upsell versus price increase. The final question that you had, Oliver, was will you stop reporting signed ARR in the months ahead? We will continue reporting in terms of implemented ARR, right, and we will, most likely continue reporting on order backlog for Provet Cloud, which is the majority of the signed ARR. We're talking about over 95%, right?
For now, how we report the order backlog might be in a range, given that it's very hard for us to know exactly how much transaction revenues a certain corporate will have of 100 locations because we have to figure out how many X-rays they do, how many SMS they will send. A lot of that, given the change in how they work, once they migrate over to our software, is really hard to predict. We'll do a range estimate for those. Implemented ARR will be a certain number. If you have any other questions, please feel free to add them to the chat or feel free to just raise your hand and I'll allow you to talk. No? All right. Well, if there's no more questions, thank you very much everyone for your time, and we will see you next quarter. Thank you.
Thank you.
Bye.