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									  Rescuing Rural Northern
      California ICUs:
Both Medically and Financially

           James K. Gude, MD
         Clinical Professor of Medicine
     University of California – San Francisco
              Rescuing Small and Rural
                  ICU’s and ER’s
   Rural, small ICUs and ERs are endangered species in
    California and in the World

   OffSiteCare, Inc., is trying to rescue these endangered ICUs by:
        Providing Adult Intensivist and Sub-Specialist consultations in:
             Cardiology, Infectious Diseases, Neurology, Nephrology,
              Infectious Diseases, and Pediatric Intensive Care
        Via Robotic Telemetry 24/7 anytime and anywhere:
             If Best Care cannot be provided in the rural, small ICU, patients will be
              transferred to Centers of Excellence

   Studies have demonstrated decreased ICU Mortality, LOS, and
    Costs with Robotic Telemetry Consultative Services.
        Better studies are needed and are being done by OffSiteCare

              Want more information on OffSiteCare, Inc.?
                     Descriptive Paper Available.
               Email OFFSITECARE@GMAIL.COM
     OffSiteCare: Anywhere, Anytime Care
        OffSiteCare’s vision is to provide by robotic telemetry state of the art
         specialty consultations for small, rural ICUs, ERs and Clinics
         wherever they are
                            Consulting Specialists Available include:

•   Dr. Greg Hopkins     - Cardiology               • Dr. Chris Ives           - Nephrology
•   Dr. James Gude        - Critical Care           • Dr. David Tong              - Neurology
•   Dr. Paul Kefalides   - Gastroenterology           (California Pacific Medical
•   Dr. Rick Flinders    - General Medicine           Center, San Francisco)
•   Dr. Laurel Warner - Infectious Disease          • Dr. James Hanson            - Pediatrics
                                                      (Oakland Children’s Hospital)
                     OffSiteCare Network
                  PALM DRIVE            HEALDSBURG                  HOWARD          UKIAH VALLEY
                   HOSPITAL               DISTRICT                 MEMORIAL           MEDICAL
                                         HOSPITAL                  HOSPITAL           CENTER

Location        Sebastopol, CA, 25      Healdsburg, CA,         Willits, CA, 100    Ukiah, CA, 60
                miles west of Santa     20 miles north of       miles north of      miles north of
                Rosa, CA                Santa Rosa, CA          Santa Rosa, CA      Santa Rosa, CA

Beds / ICU      37 Total / 5 in ICU     43 Total / 4 in ICU     25 Total / 3 in     78 Total / 6 in ICU

ICU status      ICU was closed,         ICU was closed,
                reopened in July        officially reopened
                2007                    in Jan. 2008

OffSiteCare     • Onsite intensivist    • Onsite intensivist    • Remote            • Remote
Service Model     8hrs / day/ 5           8hrs / day / 5          intensivist         intensivist
                  days a week             days a week             coverage 24/7 -     coverage 24/7 -
                • 24/7 remote           • 24/7 remote             100% via Robot      100% via Robot
                  intensivist on call     intensivist on call
                  via Robot               via Robot
                • Hospital bills for
                  onsite                • Hospital bills for
                  intensivist’s           onsite
                  consults and            intensivist’s
                  procedures              consults &
       Possible Additions to OffSiteCare’s
   More Small, Rural hospitals (with 3-6 beds in ICU)
    continue to be added to the OffSiteCare Network in
    Northern California:
            Mendocino Coast Hospital, Fort Bragg, CA
            Barton Hospital, South Lake Tahoe, CA
            Sonoma Valley Hospital in Sonoma, CA
            Sutter Lakeside Hospital in Lakeport, CA
            San Quentin Prison in Marin County, CA
            Sonoma Developmental Center in Eldridge, CA
            Palm Drive Medical Center Clinic in Sebastopol, CA
            Alliance Clinic in Healdsburg, CA
            Petaluma Clinic in Petaluma, CA
            Southwest Clinic in Santa Rosa, CA
      Intensivist as OffSiteCare’s
   The RTP (Robotic TelePresence) consultations will be coordinated
    by a 24 X 7 Adult Intensivist on call with the assistance of
    subspecialty consultations including:

             Cardiology               Pediatric Critical Care
             Infectious Disease       Nephrology
             Neurology                Gastroenterology

   Patients will be transferred to levels of higher care as needed by
    Intensivist triage.
   As appropriate, with initial consultations and follow-ups, patients will
    be treated in their home facility.
   The goal is the BEST CARE for every patient whether that be at the
    home facility or with transfer
   Touch can be accomplished
    through Ultrasound viewed
    through the ControlStation

   Ultrasound waves allow
    examination of the:
            Heart
            Lungs
            Carotids
            Abdomen
            Major vessels
            Peripheral vessels
        Evidence Based Protocols
   DIAGNOSIS leads to the application of Evidence
    Based Protocols
       25 Protocols for life threatening illnesses have been developed
       Protocols are applied to each set of Patient Problems/Diagnoses
            Robot facilitates sharing these protocols through discussion MD to
            Also sent via email and fax to remote hospital
   Thus, the process of examination, diagnoses, and
    therapy is completed.

   To receive copies of the protocols, send email
    requesting protocols to: OFFSITECARE@GMAIL.COM
    Multicasting – still to come…
   MULTICASTING will allow the Triage Intensivist and MULTIPLE
    Remote Specialists to have joint, live discussions while examining the
        Remains to be done by InTouch Health



               Remote                                   Remote
              Specialist                               Specialist
    Top Telemedicine Studies To Date
   Title: “Effect of a multiple-site intensive care unit telemedicine
           program on clinical and economic outcomes”, Michael
           Breslow et. al.,
           Critical Care Medicine 32 (2004), 31-38.

   Design: Before and after trial, 2 years, >2000 patients, 2 ICU wards,
            Apache III physiological assessment utilized

   Results: Addition of supplemental, telemedicine remote intensivist
             was associated with improved clinical outcomes and
             hospital financial performance
        Hospital Mortality for the ICU patients was lowered during the period of
         the remote ICU Care
             9.4% vs. 12.9%; relative risk, 0.73; 95% confidence interval (CI), 0.55-0.95
        ICU length of stay was shorter
             3.63 days (95% Cl, 3.21-4.04) vs. 4.35 days (95% Cl, 3.93-4.78)
        Lower variable costs per case and higher hospital revenues (from
         increased case volumes) generated financial benefits in excess of
         program costs.
         Top Telemedicine Studies To Date,
   Title: “Intensive care unit robotic telepresence facilitates rapid
            physician response to unstable patients and decreased cost
            in neurointensive care” P.M Vespa et. al.,
           Surgical Neurology 67, (2007), 331-337

   Design: Before and after trial, 2 years, > 1100 patients, 1 ICU

   Results: The use of RTP was associated with –

        Rapid assessment of unstable patients
        Decreased LOS (length of stay) for patients in
         ICU with SAH (2 days) and brain trauma (1 day)
        ICU cost savings (>$1.1 Million)
        Increased ICU occupancy by 11%
        Improved efficiency
     OffSiteCare Services Offered
   AM & PM Rounds, Team Rounds, Rapid Response Codes
   Red Alert Investigation, Preventative Measure Checks – DVT, Peptic Ulcer
   Nurse consults, Continuity of Care on Patients discharged to wards
   Attending, Teaching Rounds with Rotating Residents, and Disease Specific
    Informational Sessions with individual and assembled Patients
   OffSiteCare Service Models

A. Robotic Telemetry Consultations in the ICU and
   ER without the presence of an Intensivist or

B. Robotic Telemetry Consultations in the ICU and
   ER with Hospitalists

C. Daily Intensivist Coverage in the ICU with Night
   Time Robotic Telemetry Consultations and
   Hospitalist Coverage
            OffSiteCare Business Model to Set up
Annualized hospital costs of OffsiteCare services – $250K - $500K
      Startup costs                                     $20,000
      ICU/Medical Directorship/                         $5,000/month
       OffSiteCare Management Fee
      Hospital Robot Rental                             $5,600/month
                                                         (with 4-YR Rental Agreement)
      Service package
           Onsite 40hrs + 24/7 call*                   $1,000/day
        (*Hospital bills & keeps collectibles for intensivist services)
           Remote only + 24/7 call                     $ 300/day (for 2-4 bed ICU)
           Remote only + 24/7 call                     $ 500/day (for 5-6 bed ICU)
           Remote only + Specialty Consultation        No call charge
            (as requested, if available)**
        (**OffSiteCare bills & receives collectibles for Consultation & Follow-up services)
      Physicians can bill for allowable telemedicine charges for their
       services, or they can designate the hospital to bill for these services
 NOTE: The above numbers may be subject to change.
    OffSiteCare Business Model to Set
           up Coverage, contd.
   Reimbursement for allowable telemedicine
    charges for physician services rendered will have
    the following allocations –

       Billing                 10%
       OffSiteCare             10%
       Consulting Specialist   80%
OffSiteCare Reimbursement Success
Physician Reimbursement via EMMI Billing Services
As of June 2008, below payments were received for in-patient services
                         billed year-to-date

        PAYER       CPT     Count       Billed     Paid
                    99232           1     134.00     -58.57     -59

                    99233           2     400.00    -240.12    -120

                    99255           5    2040.00    -630.26    -126

                    Total           8    2574.00    -928.95    -116
                    99233       13       2600.00    -842.93     -65

                    99255           9    3672.00    -833.70     -93

                                22       6272.00   -1676.63     -76
      Insurance     99233           1     200.00    -200.00    -200

                    99255           3    1224.00    -816.00    -272

                    Total           4    1424.00   -1016.00    -254

      Grand Total               34      10270.00   -3621.58    -107
     OffSiteCare International Activities
1. Connecting 24/7 the National HIV/AIDS Clinicians' Consultation Service
   (NCCC) at the San Francisco General Hospital, University of California-
   San Francisco, CA, by Robotic Telemetry to YRGCARE's HIV/AIDS
   Center in Chennai, India –
           Dr. Ron Goldschmidt is the Director of NCCC
           Dr. Solomon Suniti is the Director of YRGCARE
           OffSiteCare is applying for a Melinda and Bill Gates Foundation Grant

2.   Connecting the Royal Prince of Wales Hospital's ICU under Dr. Yahya
     Shehabi in Sydney, Australia, with an outlying Rural ICU to provide
     HIV/AIDS and other Expert Consultations and Patient Care via Robotic
     Telemetry –
           OffSiteCare is applying for a Melinda and Bill Gates Foundation Grant

3.   Exploring ICU/ER Applications of Robotic Telemetry in Europe, New
     Zealand, and China.
                   OffSiteCare & Education
    I. Mandatory Residency Program – Sutter Medical Center/UCSF - CA
    One- month Mandatory Residency Program – This Sutter Family Practice
     Residency Program will be based at the Sutter Medical Center, Santa Rosa, CA,
     under the Division of Family and Community Medicine, UCSF
                  ICU Clinical Coordinator – Dr. James Gude
                  36 Residents will spend 1 month (in latter half of the 2nd year of their 3-yr residency)
                    in a rural OffSiteCare hospital for a mandatory combined Hospitalist/ICU Rotation
    Hospitals involved in the Residency Program – Currently, 4 hospitals are
     involved –
              1.   Palm Drive Hospital, Sebastopol, CA
              2.   Healdsburg District Hospital, Healdsburg, CA
              3.   Howard Memorial Hospital, Willits, CA
              4.   Ukiah Valley Medical Center, Ukiah, CA
    Hospital site expansions for the Residency Program - As OffSiteCare
    expands this year, so will the experiences of the Residents. Plans are to expand to –
                Mendocino Coast Hospital, Fort Bragg, CA
                Sonoma Valley Hospital, Sonoma, CA
            OffSiteCare & Education, contd.
    I. Mandatory Residency Program – Sutter Medical Center/UCSF - CA

   Robotic Telemetry & Residency Program – The Residents will learn
    Robotic Telemedicine in depth. Robotic Telemetry will be used for –
               AM Attending Rounds
               Patient Presentations to an Attending MD
               Specialty Consultations
               Teaching Conferences

    Residency Program Teacher designations & Career advancement –
               Local MDs will be designated as teachers & paid for Resident teaching and
               They will be given either Instructor or higher position at UCSF and can work
                up the academic ladder as possible.
         OffSiteCare & Education, contd.
    II. Clinical Robotic Telemetry School - Palm Drive Hospital, CA

   William Heberden School of Robotic Telemedicine
     (Palm Drive Hospital, CA)
     This clinical Robotic Telemetry School will provide 1-week course for a
     hospital Team of MDs/ RNs on the use of Telemetry in the ICU, ER, Ward &

        Curriculum Coordinator

                  •   Dr. James Gude
        Fees
                  •   All inclusive at $10, 000
        Course
                  •   Seminars
                  •   Demonstrations
                  •   Laboratory Sessions
          OffSiteCare & Education, contd.
     II. Clinical Robotic Telemetry School - Palm Drive Hospital, CA

   Robotic Telemetry School Venture Support provided by –
    1.   Director - James K. Gude, MD,
                   Clinical Professor of Medicine & of Family & Community Medicine, UCSF,
                   Medical Director, OffSiteCare, Inc. , &
                   ICU Director, Palm Drive Hospital, Sebastopol, CA
    2.   ICU-ER Nursing Director - Val Takes, RN
    3.   Director of Nursing - Karin Reese, RN
    4.   Hospitalist Medical Director and Clinic Director - Dr. Greg Rosq
    5.   Critical Care Transport Coordinator - Lori Austin, RN
    6.   Critical Care Intensivists –
                Dr. James Gude                  Dr.Tom Shaughnessy

                 Dr. Ken Lamb                   Dr. Robert Newbury
                 Dr. Tom Nuckton                Dr. Gary LeKander
Palm Drive Hospital
Palm Drive Hospital History
               Location    Sebastopol, CA, 25
                           miles west of Santa
                           Rosa, CA

               Beds / ICU 37 Total / 5 in ICU

               ICU status ICU was closed,
                          reopened in July

                   State of affairs in April 2007
                    Owed $2.7 MM, losing
                    Filed Chapter 9
       Palm Drive Hospital History

 New Team Member – Herb
 Program has enabled ~20%
  increase in patient days
 Renewed surgical activity

 Fewer ED transfers

 Expect to see continued patient
 Key strategy in getting hospital
  out of chapter 9
 Overall, attracted new doctors,
  expanded services, opened a
  new MRI facility
    Increased Revenues & Decreased
   Operating loss in the ICU due to Herb
                                To BREAKEVEN
Only 50 more patient days (=15 critical patients with > 4-day LOS) needed

                        FY 2008*            FY 2008*            Difference
                      Without Herb          With Herb
                     (>4-day Stays)
Patient Days                779                925                  146
Revenues                $ 2.36 MM           $ 4.1 MM            $ 1.74 MM

Net Revenues            $ 1.5 MM            $ 2.6 MM             $ 1.1 MM
Expenses                $ 2.5 MM            $ 2.8 MM             $ 300 K
Est. Net Gain /         - $1.0 MM            - $ 207 K            $ 800 K
Loss on Service

*10-month data annualized

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