Applicant: UrgentEMS, Inc

1. “Briefly describe the scope of the telemedicine services provided” (Telemedicine will be used a bridge to monitor member patients in the home then follow up inperson services.) UrgentEMS, Inc will be a hybrid telehealth company that will provide advanced healthcare solutions over a daily use network. Our company will see patients, both members, and nonmembers over the system. UrgentEMS will work with Employers, social groups, other healthcare organizations, and religious organizations to enroll members into our telehealth network. The telehealth network's purpose is to support the delivery of meaningful healthcare by mobile clinics, affiliated Primary health providers, or the future UrgentEMS subsidiary clinic at 401 Market St, Shreveport, LA 71101.
   1. Scenario one is UrgentEMS will recruit patients to the network by working with employers to create primary health maintenance services by sending the mobile clinics to the business. UrgentEMS will generate value to the employer by allowing employees to get their primary care and treatment of such conditions as hypertension, diabetes, asthma, and other minor diseases without missing work time. For the employee, they get the convenience of "healthcare brought to you." We believe this convenience will enhance the employee's ability to be compliant in their healthcare, which has the ability to help decrease their healthcare cost.
2. Once a relationship has been established through the mobile clinic with our healthcare network, the patient becomes a basic network member. This basic level of membership will entitle the patient the right to call into the telehealth network for a fee through their computer using the Teleray telemedicine platform UrgentEMS will be using. The cost of services will be advertising the upfront an immediate cash discount, Medicare, Medicaid, and commercial insurance prices. This price list will help the consumer make an informed choice on our services.
3. The tiered membership model will all patients to purchase in-home telehealth services at various healthcare monitoring levels and access for chronic disease or lifestyle management.
   1. For instance, a CHF patient can enroll in the monitoring program where our call center will take the daily weight, EKGs, blood pressure, pulse ox, and other parameters to keep the patient out of the clinic or hospital. If the patient shows signs of decline, we will depend on membership to send the mobile clinic, set up transportation to the physical clinic, or send traditional EMS if the patient is in an Emergent state. Ideally, we will send the mobile clinic to the patient to bring the mobile labs, ultrasound, and treatment to them, provide necessary adjustments as directed by Dr Najberg in real-time and keep the patient in their homes.
4. The second scenario would be our chronic afib patients enrolled in the network. They can effectively monitor the network using new EKG technologies and checking in on the patient from the call center regularly. If the patient asymptomatic to minimally symptomatic, we will be able to send the mobile clinic to the patient, obtain the point of care labs, 12 Lead EKGs, and provide appropriate treatment as directed by Dr. Najberg or another provider over the network. Such care could include:
   1. Rate control medications such as
      1. Cardizem drip. This will require approx. 1 to 1.5 hours of inpatient monitoring
   2. IV Beta-blockers are requiring approx. 45 min of onsite care
   3. Or PO medications
   4. A single mother is at home with one child crying ear pain but has multiple other children. She will be able to access the network if she is a member with a video otoscope. Have that image of the child's ear evaluated by our provider, or have the mobile clinic come to the residence to obtain the ear's image. Once the image is obtained by Dr. Najberg or other qualified providers, medications can be prescribed and started. For instance, if Dr. Najberg were to prescribe an IM, IV, or PO antibiotic, the first dose can be administered with remaining doses to either be delivered by local provided, amazon pharmacy, or for pick up.

These are just some real scenarios based on providing real-time meaningful healthcare solutions. At every encounter, a triage decision will be made is the patient

1. Emergent, if so, they will be sent directly to the emergency room.
2. Is the patient nonemergent? Can they be treated in the home?
   1. If nonemergent but can not be treated in the home and deemed medically stable by Dr. Najberg or another qualified provider on the network. Transportation the subsidiary clinic or other qualified providers' office will be arranged. If a patient can not drive, we will arrange transportation through UBER Healthcare. These patients must be medically stable and have no emergent condition. For example, this would be simple orthopedic injuries
3. If the patient is nonemergent but can not be treated in the home and deemed at risk for becoming unstable in any way, we will contact an ambulance to transport the patient to the subsidiary clinic. In the state of Louisiana, ambulances can now transport to licensed UrgentCare facilities.
4. If the patient is determined to be nonemergent but can be treated in the home, the paramedic on the mobile clinic will carry out the care as directed by Doct Najberg or another qualified provider on the network.

2. “Does the applicant employ or contract the physician and ancillarys and are we to provide their medical mal practice coverage? If so, please complete spreadsheet roster.”At this point Dr. Tiffany Najberg Do is our Medical Director with the title of Director of Emergency Products and Services. Additionally, Dr. Najberg will become the Medical Director of our follow-on Subsidiary Clinic to be located at 401 Market St, Shreveport location. From this location, Dr. Najberg will be responsible for directing the mobile clinics as their online medical control. Once the clinic is operational, Dr. Najber will see patients in the clinic. We will be adding paramedics to staff the mobile clinics as demand grows. In the clinic, we will staff for a minimum of 12 hours of operations.

3. When choosing a patient, we will use the following criteria:

1. All calls for services will be screened for emergent conditions.
   1. If the patient has immediate life-threatening conditions like severe shortness of breath, new onset of chest pain without a history of angina, signs or symptoms of sepsis will be sent by 911 to ER.
2. If there is an existing membership and patient monitoring relationship in place with an Urgent, NOT EMERGENT condition, a mobile clinic will go to the patient's home within 1 hour. At the patient's home, the mobile clinic will re-evaluate the patient starting at the Emergent triage screenout with Dr. Najberg over the telemedicine link.
3. If there is no existing membership but a real-time telemedicine triage with Dr. Najber or another qualified provider, if the condition is determined to be nonemergent but urgent, a mobile clinic will be dispatched nonemergent to provide care for the patient.
4. We will NOT!! To be involved in chronic pain management, we will support hospice and palliative care organization for medical comfort care. However, we will not administer opioids; the hospice or palliative care organization will have to send their pain management staff for those treatments.
5. In cases of special acute care conditions involving pain such as fractures, the UrgentEMS mobile and Subsidiary Clinic staff will have limited opioid access that must be administered per Dr. Najberg or the Other Qualified provider. Dr. Najberg has stipulated NO prescription for acute pain will be prescribed without verification against the state dispensary database, and all prescriptions for opioids will be clinically reviewed by Dr Najberg
6. In the area of controlled substances, Dr. Najberg reserves the right to prescribe:
   1. Seizure medications
7. Limited Benzodizapines for medically indicated conditions such as
   1. Valium
8. Versed
9. Our clinic will NOT be involved in ADHD care or pharmaceutical weight loss using amphetamine compounds. The clinic will refer all ADHD patients to a qualified primary care provider. Under no circumstance will amphetamines be administered by UrgentEMS owned clinics in mobile or fixed locations. There will be no financial relationship with any clinics we refer ADHD patients.

4. “Is there any physician between the service and the patient like a PCP.” UrgentEMS will encourage and cultivate a relationship with Primary Care or Specialty Care physicians to participate in our network. We are interested in providing urgent care services on demand and will inform the primary care physician assigned to the patients seen of the care provided. UrgentEMS recognizes that many patients do not have a medical home or primary care physician we will provide limited primary care services through the mobile clinics and the subsidiary urgent care clinic to be located at 401 Market St, Shreveport location. Our proposed agreement with the owners of 401 Market St, Shreveport location is to become the cornerstone clinic to bring other medical clinics and services to the building. Those services and clinics in the building will bring specialty care services that we want to participate in on the telemedicine network. We will have no ownership or financial relationship with these facilities beyond the cost of network services.

5. Our clinicians will reserve the right to prescribe medically necessary medications for:

1. Hypertension
   1. Beta-blockers
2. Diuretics
3. Calcium channel blockers
4. Chronics pain management for arthritis
   1. N saids
5. Steroids to the moderate inflammatory response
6. Toradol
7. NO OPIOIDS WILL BE PRESCRIBE FOR THESE CONDITIONS. All chronic pain patients will be referred to pain management clinics.
8. COPD
   1. Steroids
      1. Solumedrol
   2. Brocholdiators
      1. Duo neb
   3. Albuterol
   4. Infections
      1. Levaquin
   5. Rocephin
   6. Zithromax
   7. Flagyl
   8. Amoxicillin
   9. Penicillin
   10. “When do they write prescriptions and what specific drugs do they prescribe?” Any Narcotics Acute Pain Management Specifically associated with orthopedic injuries and acute dental conditions. No refills wil be provided by the Urgent care clinic. In the case of dental needs they will only be provided for two days as a bridge to going to a dentist at the lowest possible dose required. If seen at the subsidiary clinic and directly seen by Dr. Najberg or other qualified providers, medications will be given PO. If the mobile clinic sees the patient Dr. Najberg reserves the right to order administration of 1 oral dose and send in the rest to a pharmacy to fill. The mobile clinics will have a limited number of opioids secured in a computer-controlled safe with daily audits and controls. The number of opioids kept for use to by the mobile clincs will not exceed 2 doses of any one medication. Opioids for acute pain management will be:
       1. Hydrocodone/acetaminophen
   11. Percocet
   12. Fentanyl shot (in clinic only) fractures or severe acute pain
   13. NO LONG DELAYED RELEASE MEDIATION PATCH OR PO will be prescribed
   14. Codeine based cough syrup prescription sent out to pharmacy only
   15. Benzodiazepines for acute seizures, anxiety control, and medical procedures. NO REFILLS will require to follow up a referral to a specialist.
       1. Versed
   16. Valium
   17. No amphetamines for diet or ADHD will be prescribed by our clinic
   18. Other Controlled substances to be sent out to the pharmacy for filling and refill only in member patients with long term primary care relationship with the clinic
       1. Seizure medications
          1. Phenobarbitol
       2. Keppra
       3. Dilantin
       4. Both the mobile clinic and subsidiary clinic will use medications for wound closures such as Dermabond.

6. “Do they have first time face to face exam with a physician at a facility location as now required by several states?”Using the mobile clinics in person one on one onboarding process at healthcare onsite employer health fairs, we will employ midlevel providers such as NP and PAs to obtain the face to face exam where required. Reading the authorized scope of practices for paramedics in Louisiana operating a physician extenders with a real-time telemedicine link will for many conditions. Additionally, we will use our subsidiary clinic located at 401 Market St, Shreveport location. We will bring patients for annual face to face assessment as required. In select member patients willing to pay for premium services, we will our physicians go to the patient for their yearly face-to-face assessment with a mobile clinic.

7.” How do they build a Patient history?” Patient histories for members will start with the onboarding processing during health fairs. During this process, the mobile clinic staff will start with a standardized onboarding process obtaining the following baseline information.

1. Blood pressure
2. Weight
3. Pulse ox
4. Where indicated spirometry
5. Where indicated Point of Care Ultrasound
6. Where indicated mole mapping and imaging. (Future add on service)
7. Standardized measurements for BMI
8. Baseline cognitive video assessment to
   1. Verification of patient's speech
9. Verification of Range of motion
10. Verification of facial range of motion
11. Cognitive written test-optional

For patients who come in as nonmembers, a standardized triage chart will be used to start the telemedicine triage process once the determination of emergent vs nonemergent condition has been made. This process will be done prior to the arrival of the mobile clinic. We will be using the Teleray telemedicine platform with an OpenEMR EMR provided by HealthTech, including an electronic prescription system.

8. What are their diagnostic protocols? Meaning when and how do they determine if a patient should go to the ER, Urgfent Care, or their primary care physician. (as oppesed to writing the scrip themselves or just advising the the patient on what course of action to take by themselves)

The telemedicine triage center will send ALL chest pains to the ER. Patient who are not members with known medical history of COPD and CHF will be sent the ER. For member patient’s with a known history who are not in extremis will be evaluated by the MD or assigned provider if determined to be urgent our mobile clinic will be sent to patient or patient will be directed to the subsidiary urgent care clinic.

NO Chronic pain management medications will be filled patient will be directed to their primary care physician. No ADHS medications will be filled patient will be directed to their primary care physician or a specialist.

Any orthopedic injuries identified as displaced fractures, femur fractures, or probably hip fractures by the telemedicine link will be directed directly to the ER using traditional 911 services.

Mobile Protocols we will use the current Emergency Protocols from Region One in Louisiana as the basis of our Emgency Protocols, we will modify them for a Community Care Model. Additionally we are looking at severel community care paramedic protocols that we will adjust to fit our operations. I am attaching two versions of protocols one emergency and one community care paramedic protocol, along with the Louisiana Paramedic Scope of Practice protocols. Anything not enumerated as a standing order by Dr. Najberg will require online realtime telemedicine consultation with the patient and paramedic present. Where prohibited explicitly due to specific mediations or procedures UrgentEMS will employ roving RNs, Nurse Practioners, or Physicians depending on the level of care to be provided in the field.

After speaking with Dr. Najberg at this time we are not inclined to provide suturing in the field, we are however willing to provide field Dermabond and Zip stitch technologies for superficial wound closures. All would closures will require realtime evaluation by on line medical control. We will revisit suturing in the field at future point and time due the need to for specialized training for the paremedic before these procedures can be approved. Any wounds at this time that require suturing the field shall be reserved for NP, PA, and MDs at this time. Invasive procedures will be referred back to the subsidiary clinic. Invasive procedures available at the subsidiary clinic:

1. Incision and drainage of abcessess and boils
2. Mole removal PA, NP, and MD only