NURSEKOL SERVICES INC.

I. Introduction
NURSEKOL SERVICES, INC. (NSI) is a telehealth service company that seeks to deliver
health-related services and information through telecommunications technology. Telehealth
currently enhances access to health care not only in developed countries like United States,
Britain, Australia and Canada but also in developing countries such as India, Mexico,
Bangladesh, Pakistan and now in the Philippines. At present, telehealth services are available
to an estimated 150 million people in developed countries alone.1

Today, telehealth is accepted as a term to describe the practice of care over distance that may
be as simple as a medical discussion over telephone to as complex as the application of robotic
technology.2 Telehealth dates back as early as the late 1900’s but used technologies with
limited capability such as radio communications available in Antarctica. In the 1950’s interactive
video communications was first used by the Nebraska Psychiatric Institute for a psychiatry
consultation with a hospital 112 miles away.3 Its first generation in the 1970’s was paved by the
expansion of low cost telecommunication networks giving opportunity for a radical change in the
health care system especially for remote communities. However, such changes hardly survived
due to limitations of technology, time, skills and clinician’s and patients’ familiarity on the
system. It was revived in 1990’s in Norway with further developments in technology and lower
costs to put up systems and programs thus helping provide health care needs of populations in
far flung areas. Its popularity in the United States in 1995, wherein millions of dollars were
allocated for telehealth projects, surpassed that of Norway shifting the focus of telehealth
activities from Europe to North America.4

Different types of organizations have shown interest in the advantages that telehealth can bring.
One of them is the National Aeronautics and Space Agency (NASA) which developed its own
technology to monitor, maintain and ensure good health conditions of astronauts at zero gravity.
From then on, more telehealth companies have emerged worldwide making available services
such as telephone-based nurse triage and primary care among others to millions of people.

In Asia, NSI seeks to be one of the health hotlines connecting callers in need of medical advice
or information to health professionals such as doctors and nurses usually guided by standard
protocols. Other health hotlines include Healthline in Bangladesh, Tele-doctor in Pakistan, and
Health Management and Research Institute (HMRI) in India. These health hotlines continue to
serve and bring basic health information and care reaching people even in areas with limited
healthcare facilities and health workers. Telehealth breaks geographical, social and cultural
barriers, thus, transforming the future of today’s health care systems.

Defining Telehealth, Health Hotline and Triage

Telemedicine and Telehealth

Telehealth and telemedicine are terms that are often confusing as both have overlapping
definitions that sometimes readers are unable to grasp the line of distinction between the two.
The term telemedicine which become popular in the early 1990’s defined telemedicine as the
use of advanced telecommunications technology to facilitate information exchange and deliver
or provide health services at a distance crossing geographical, time and other barriers.

1
Moore, Jesse and Alison Bloch. A Doctor in Your Pocket/; Health Hotlines in Developing Countries. GSMA
Development Fund
2
Telehealth, Wikipedia The Free Encyclopedia, http://en.wikipedia.org/wiki/Telehealth, 15 September 2009
3
Maheu , Marlene M., Pamela Whitten, and Ace Allen. E-health, Telehealth and Telemedicine: A guide to start-up
and success. http://books.google.com.ph/books?
id=T8gwu1okBW4C&pg=PA3&lpg=PA3&dq=telehealth+world+health+organization&source=bl&ots=fJ0Qw5gRti
&sig=dNNAsUHkRwAIyWkTLvAMpXSMEPk&hl=tl&ei=GDavSozaA4f66QOWndDpDA&sa=X&oi=book_resul
t&ct=result&resnum=8#v=onepage&q=telehealth%20world%20health%20organization&f=false., 15 September
2009
4
Telehealth Literature Review, Royal College of Nursing, www.rcn.org .uk, 01September 2009
In 1997, the World Health Organization (WHO) defined Telehealth as “the integration of
telecommunications system into the practice of protecting and promoting health” making a
distinction from telemedicine that they defined as “the incorporation of these systems into
curative medicine.”5

Telehealth then is viewed as more encompassing than telemedicine which is suggested to be

limited to patient-physician remote interactions with the aid of technology for curative medical
treatment. Recent trends also show the prominence of the use of the term telehealth to
generally refer to the delivery of health related services through telecommunications technology
over distance that not only includes clinical but also non-clinical uses of technology such as but
not limited to distance education, research, online information and health data management,
and healthcare system integration6.

Telehealth modes include two types. First is the store-and-forward mode which involves
gathering and transmission of medical data such as digital images and videos at a convenient
time to a physician in another location for examination. The second type is real-time mode that
requires the presence of both parties at the same time and a telecommunications technology
that serves as a link allowing instantaneous interaction between the two. Examples include a
simple telephone call and video conferencing.

Health Hotline

The GSM Association Development Fund defines a health hotline as a medical call center
providing health-related information, advice, referrals and sometimes prescriptions to callers
over the telephone. These hotlines provide a link between the caller and health professionals
such as physicians and nurses who are usually equipped and guided by software of standard
protocols.

Basically, a health hotline is characterized by the following: a) primarily gives information to

individual callers; b) mainly uses voice calls to deliver information; c) primarily conducts inbound
calls; and d) callers may be anywhere. Information and services offered by health hotlines
include medical information, triage, consultation, diagnosis, referrals, treatment, counseling and
even prescriptions.7

Tele-Triage

The increased awareness on health issues brought about by discoveries and progress in
modern medical equipment, methods and technology in general builds up further pressure to
health care providers in creating products and services that are more effective, efficient, timely,
and affordable. Tele-triage has become one of the outcomes of such pressure and is now
widely accepted as a unique tool to address the need of primary health care.

Nowadays, health hotlines include triage as one of the services they offer with doctors or nurses
as the front liners who respond to callers in need of medical advice. With the aid of standard
protocols, these health professionals are able to assess the health situation of the caller thereby
arriving at a safe disposition or course of action based on the symptoms presented.

Tele-triage is defined as the interaction of a caller patient and a health professional (usually a
physician or a registered nurse) mainly through a phone line that involves the management of
the caller’s health concerns by assessing the symptoms using protocols or guidelines and
providing safe, timely, effective and appropriate disposition. A diagnosis is not performed by a
triage nurse but rather a collection and matching of sufficient and relevant data to the protocol
that aids in determining the level of urgency and care needed by the patient at the right place

5
E-Health, Telehealth and Telemedicine: A Guide to Start Up and Success, http://books.google.com.ph/books?
id=T8gwu1okBW4C&pg=PA3&lpg=PA3&dq=telehealth+world+health+organization&source=bl&ots=fJ0Qw5gRti&sig=dNNA
sUHkRwAIyWkTLvAMpXSMEPk&hl=tl&ei=GDavSozaA4f66QOWndDpDA&sa=X&oi=book_result&ct=result&resnum=8#v
=onepage&q=telehealth%20world%20health%20organization&f=false, 15 September 2009
6
Telehealth, Wikipedia The Free Encyclopedia, http://en.wikipedia.org/wiki/Telehealth, 15 September 2009

7
Moore, Jesse and Alison Bloch. A Doctor in Your Pocket/; Health Hotlines in Developing Countries. GSMA Development
Fund
and time.8 Tele-triage can range from simple advice on treatment for common illnesses at
home, to direction for follow-up with the family physician or instructions to proceed to the closest
hospital emergency department.

Protocols
Protocols or guidelines are rules, in paper or electronic format, to be followed by a triage nurse
that serves as a tool that aid in the decision-making process during the assessment of
symptoms of the presented health problem.

The following are four basic functions of protocols: a) serves as a structure in organizing
information in the process of identifying the relevant ones; b) guides the triage nurse throughout
the problem solving process that involves interviewing, assessing, and decision making; c)
serves as a risk management safeguard as it considers all possible options; and d) aids in the
reconstruction of the decision making process to guarantee the aptness of the disposition
given.9

These protocols are the essential components of tele-triage. An up-to-date set of protocols must
go hand in hand with excellent judgment skills and training on the process/system of the health
professional responding to callers as they are just as significant as these guidelines in ensuring
the aptness and safety of the practice.

Rationale for Health Hotline in the Philippines

The Philippine National Health Care Situation

Developing countries such as the Philippines continue to face challenges in their health care
systems due to a number of linked problems they have been experiencing in recent years.

Our country is increasingly challenged to sustain its health care delivery system as its fight
against poverty is still far from its end. In the 2006 Official Poverty Statistics presented by
NEDA Secretary General Romulo Virola in March 2008, poverty incidence rate has worsened
increasing to 26.9% from 24.4% in 2003 translating to a total number of 27.6 million poor
Filipinos who cannot afford to meet their basic needs and therefore even health care as well10.

This is further aggravated by disparities between rural and urban areas as the current 88.57
million total population maintains its massive growth with an average annual growth rate of
2.04%.11 The Philippines is still predominantly rural and people who live in these areas often
have no adequate access to education and healthcare as all these facilities are concentrated in
highly urbanized cities thereby affecting their general quality of life. An example of this is the
statistics reported in the 2007 Annual Report of the Field Health Service Information System
(FHSIS) on birth deliveries by attendant. In the National Capital Region (NCR), the traditional
“hilot” is sought by only 8% of the total number of pregnant mothers who gave birth while
statistics in Autonomous Region of Muslim Mindanao (ARMM) show that 47% of the total
deliveries were attended by a “hilot”12.

Moreover, shortage of healthcare facilities and healthcare workers highly contribute to this
problem of inequitable access to healthcare. In 2006, the National Statistics Coordination Board
(NSCB) reported only a total of 1,921 public and private hospitals in the country and 2,955

8
Wheeler, Sheila, MSN RN. Telephone Triage. Wild Iris Medical Education, Inc.
http://wildirismedical.com/courses/218/index_nceu.html. 16 September 2009.
9
Lafferty, Sandi and Marijo Baird. Telenurse: Telephone Triage Protocols. http://books.google.com.ph/books?
id=AQCvelMHCBkC&pg=PA10&lpg=PA10&dq=Tele-nurse:+telephone+triage+protocols++By+Sandi+Lafferty,
+Marijo+Baird&source=bl&ots=Y9iDUjyydL&sig=upvWDzHglKR-0wCYSB-
haJ5KEDg&hl=tl&ei=zmuwSv3DDpuWkAWMgdGVBg&sa=X&oi=book_result&ct=result&resnum=1#v=onepage&q=&f=fals
e. 16 September 2009
10
2006 Official Poverty Statistics. A presentation by Dr. Romulo A. Virola in a Press Conference in March
2009.www.nscb.gov.ph. 17 September 2009
11
2007 Official Population Count. Date released 16 April 2008.
http://www.census.gov.ph/data/pressrelease/2008/pr0830tx.html.19 September 2009.
12
2007 Annual Field Health Service Information System. Department of Health
government doctors13. Government physicians minimally increased to 3,047 the following year;
however, this did not improve the alarming ratio of .3 doctors for every 10,000 population.

In the global labor market, the Philippines has become a source of a great number of professional
workers especially for the first world countries; health workers are not left behind by this migration
trend. Nurses comprise the largest number of health workers leaving the country followed by
midwives and doctors. In 2006, the Philippine Overseas Employment Agency (POEA) reported a
total number of 13,525 nurses, 367 midwives and 171 medical doctors deployed to other
countries14. Next to India, the Philippines is already the largest source of doctors in hospitals
abroad. The country also supplies 25 percent of all overseas nurses worldwide. Not surprisingly,
about 10 percent of Philippine hospitals have closed down in the past three years because of the
loss of doctors and nurses to jobs overseas15. This loss of skilled manpower in the health sector
is attributed to the country’s deeper issues on employment opportunities and inadequate wages to
sustain a decent living. Our professionals continue to leave our country to seek more
opportunities for career development and higher living standards.

In a speech delivered on Oct. 7, 2007 by Department of Health Secretary Francisco Duque III
he states, “The health care delivery system in the Philippines has gone critical, almost
desperate. Seven out of every 10 Filipino doctors are already enrolled, or have completed the
nursing course or are now licensed medics. Worse, 85 of every 100 nursing professionals have
left the home front for better paying jobs across the globe.”

A National Institute of Health (NIH) study warns that because the migrating nurses are usually the
ones with training, experience and skill, patients in hospitals and other health institutions in the
Philippines can expect a higher incidence of cross-infections, adverse events after surgery,
accidents, injuries and even increased violence against the staff.

With the best among nursing students often leaving as soon as they graduate, the less skilled are
taking the place of senior or relatively more experienced nurses who have also left for other
shores. In a year or two, they too would be gone. The void would be filled once more by fresh
graduates who would repeat the same cycle: get a few years experience in a local hospital, apply
for work abroad and then leave. It is the way for many health professionals, a cycle that leaves
local hospitals in a state of perpetual displacement—and patients in constant danger.

The Honorable Secretary of Health continues, “As a result, only one government doctor is
available for every 28,000 Filipinos. By any meter stick, the ratio could only mean the under-
delivery of medical services to many of our countrymen. If we further look at the distribution of
doctors by area, we are bound to come to the conclusion that the best are concentrated in Metro
Manila and other urban centers where medical practice is more lucrative. “ “These bare facts, plus
a recent phenomenon of less and less medical graduates passing the licensure examinations
while the monthly pay of new doctors joining the government remains low, make a potentially
disastrous brew that could lead to the potential collapse of public health care delivery in the
Philippines.”

An addition to the continuing decline in the number of experienced medical professionals in the
country is the burgeoning cost of emergency healthcare. A survey of hospitals within the NCR
shows an average minimum Emergency Room cost of PhP 1,000 per visit. Add to that some
peripheral expenses such as the cost of taking a cab or the gas and parking fee if you bring your
own vehicle.

The data worsens. Disappointingly in 2009, the health budget was a mere 2% of the national
budget which translates to merely 74 centavos per Filipino per day.

Telehealth in the Philippines

13
Statistics: Vital, Health and Nutrition. www.nscb.gov.ph. 01 September 2009
14
POEA: OFW Deployment Per Skill and Country for the Period 01 January- 30 December 2006.
http://www.poea.gov.ph/stNURSEKOL SERVICES/Skills/Skill_Sex/rptPerSkill%202006.pdf
15
Chit Estella: Nurses lack hurts healthcare system, The Manila Times, 21 March 2005.
http://www.pcij.org/stories/print/2005/nurses.html
e-Health

According to the World Health Organization (WHO), e-Health is a cost-effective and secure use
of information and communications technologies in support of health and health-related fields,
including health-care services, health surveillance, health literature and health education,
knowledge and research. The European Commission defines e-Health as the application of
Information and Communications Technology (ICT) across the whole range of functions that
affect the health sector. e-Health tools or solutions include products, systems and services that
go beyond simply internet-based applications. They include tools for both health authorities and
professionals as well as personalized health systems for patients and citizens.

Health Informatics

Health informatics is the intersection of information science, computer science and healthcare. It
deals with the resources, devices and methods required to optimize the acquisition. Storage,
retrieval and use of information in health and biomedicine. Tools include not only computers but
also clinical guidelines, formal medical terminologies and information and communication
systems. These are applied to the areas of nursing, clinical care, dentistry, pharmacy public
health and (bio)medical research. 16

Historical Perspective

In the years 1980 thru 1995, the Filipino medical community started to use Word processors to
store patient information. The Department of Health epidemiologists use the Epi-info software.
The Philippine Association of Medical Informatics (PAMI) was established and represented our
country in the Asia Pacific Association of Medical Informatics. By the late 1990’s, the Philippine
Medical Informatics Society was incorporated and the Medical Informatics Unit (MIU) of the UP
College of Medicine and the UP Manila-National Telehealth Center were established.

PAMIS

The Philippine Medical Informatics Society (PMIS) was founded and incorporated in 1996 with the
mission of promoting the use if information technology in medicine. It was the official
representative of the Philippines in the Asia Pacific Association of Medical Informatics (APAMI)
and the International Medical Informatics Association (IMIA). PMIS advocates the use of Open
Source in development of health applications.

Medical Informatics Unit (MIU)

The Medical Informatics Unit advocates the use of information technology to support the vision
and mission of the UP College of Medicine. It has developed the Community Health Information
Tracking System (CHITS) which is a software that will computerize the medical records of Rural
Health Units of the DOH, It also formulated the Master of Science in Health Informatics in 2004.

UPM-NThC

In 1998, the UP Board of Regents created the UP Manila National Telehealth Center with a
mandate to improve the health of Filipinos (especially the under-served) using information and
communications technology. It is the forerunner of eHealth and Telemedicine in the country. It is
the Center of Excellence for Free and/or Open Source Software in ASEAN+3 (International Open
Source Network+3). It has three components namely, eRecords, eLearning and eMedicine.

Other Philippine Initiatives

• Molave Development Foundation, Inc.

• Ateneo de Zamboanga University
16
2007 Annual Field Health Service Information System. Department of Health 7Gavino, AI, 2nd Seminar on Health Informatics, UP
Manila, May 21, 2010
• Segworks

Benefits of ICT in Health

ICT can bring numerous benefits into the healthcare industry. One of these is the portability of
records. Patients need not repeat procedures when transferring health facilities. Computerized
systems can track down who access electronic records as compared to paper records that
cannot. In statistics, electronic data lends to easier data consolidation and analysis than paper.
Last but not the least, ICT can provide health information and services to remote and
underserved areas of the country through telehealth. 17

II. Quality Healthcare

A. FONEMED North America

FONEMED has been considered as the leader in Personal Health Management since its
establishment in 1996 by linking the individual to healthcare information, products and services
through the use of telephone and the computer. FONEMED is committed to the innovative use
of technology, creating access to appropriate health care.

A group of leading physicians and business leaders formed FONEMED in 1996 to improve the
delivery of health care worldwide. Its first medical call center was situated in Denver, Colorado.
FONEMED began its international expansion because of the great demand for fully integrated
medical call systems. It first established FONEMED de Valenzuela and FONEMED Columbia in
September of 2007 and FONEMED Mexico in November of the same year. In 1999, FONEMED
opened the world’s most advanced call center in Canada to serve all of North America.

In September 1999, FONEMED opened a Medical Call Center in Athens, Greece in conjunction
with Total Care Network and also opened another center in the Dominican Republic in
December of the same year. In 2002, FONEMED partnered with Telemedicine Reference
Center Ltd in extending family healthcare to rural communities in Bangladesh.

FONEMED operates in the rapidly growing Health Care Information Systems Industry. It
currently provides nurse triage and health information services to more than 1,800 client groups
throughout North America, the Caribbean and Asia. In North America, FONEMED operates an
accredited Health Information Center (Medical Call Center) in St. John’s, Newfoundland,
Canada. It also operates remote sites in Oregon, Virginia, Texas, and Puerto Rico.

All of these FONEMED call centers have gathered positive results over the years. Through
FONEMED, callers can now afford reliable medical advice whenever and wherever required.
The market for health information services has grown exponentially in the United States in the
past few years and had similar growth patterns in other FONEMED serviced countries as well.
Our combination of highly skilled professionals and the most advanced packages and medical
protocols means we provide the least expensive, most flexible and most reliable service
available today.

FONEMED Endorsements

1. The World Health Organization and Pan American Health Organization and FONEMED
organized an orientation program in Canada to acquaint Malaysian Health Ministry leaders
with the advanced capabilities of Health Information Centers. The program covered: the role
of telephone nurse advice in improving public health; coordination of emergency referrals
and remote health care; accreditation and quality control standards; and the intricacies of
operating medical call centers across multiple jurisdictions and languages. After two weeks
of observation, Deputy Minister of Health, Dr. Mohd Khalid advised:
17
Gavino, AI, 2nd Seminar on Health Informatics, UP Manila, May 21, 2010
 “WHO made an excellent choice in FONEMED. They have all the things we needed to learn
about health information call centres. We are learning greater details on the establishment,
management, operation and functions of medical call centers and about the Canadian
experience.”

2. The Community Clinics division of Health Labrador Corporation and the Rural Health
Academic Centre initiated a pilot project arrangement with FONEMED as a solution to
helping health care professionals manage after hours care in the community of Churchill
Falls, Labrador. Regional Director, Andrea White RN, reported that:
“The evaluation revealed that the call center service not only offers clients an accessible
and viable option to get trusted and reliable advice on what to do, it also provides a practical
and positive adjunct for the Health Labrador Board in delivering health care to remote and
isolated communities.”

3. The FioPrev health plan of FioCruz, a large public foundation linked to the Ministry of
Health of Brazil identified FONEMED as an appropriate solution for its beneficiaries. The
objective of the contract with FONEMED is the provision of healthcare orientation,
assistance, and counseling by telephone. The FioPrev Executive Directory reported that:
“FONEMED brings together the convenience of medical orientation and counseling to the
beneficiaries of the Fio-Saúde health plan and is also advantageous to the plan operator.”

3. Utilization Review Accreditation Commission (URAC), North America’s leading

accreditation body for managed care organizations, issued its first accreditation under
URAC’s Health Call Center Standards to an international health information center to
FONEMED North America Inc. At the time Garry Carneal, URAC President and CEO, said:
“Between 1996 and 2005 when I was President of URAC, I oversaw the accreditation audits
of more than 500 health care organizations and about 50 major health information centers.
Based upon my collective experiences at URAC, no company is as committed to quality-
based operations, implementing reliable technology and maintaining a high level of
customer service as FONEMED. Simply put, FONEMED is a remarkable company.”

4. The GSM Association (a global trade association representing more than 700 GSM mobile
phone operators across 217 territories and countries of the world) presented
Grameenphone Ltd. with its 2007 Global Mobile Award for ‘Best use of Mobile for Social
and Economic Development' for its HealthLine Service installed by FONEMED in
Bangladesh. During the GSMA's Annual Leadership Summit, in front of an audience of
industry leaders and government Ministers from around the world GSMA Chief Executive,
Rob Conway said
“We received more than 60 entries from operators, manufacturers, NGOs, charities and
businesses and our independent judging panel had a real challenge on their hands to select
a winner. HealthLine is a lifeline, particularly for mobile users in remote areas.””

Tele-Triage and Medical Protocols by Dr’s Schmitt and Thompson

NSI’s tele-triage service is available 24 hours a day, 7 days a week. By simply calling NSI’s
hotline, a health care advice can be accessed through a registered nurse or a general physician
who responds and assesses the health situation of the caller using NSI’s reliable protocols.

NSI’s software is based on the Schmitt and Thompson Clinical Content which is the gold
standard in the Nurse Tele-triage industry, with 686,000 licensed and fully integrated
medical protocols covering over 99%+ of symptom calls.

NSI uses the computerized pediatric protocols of Dr. Barton Schmitt, and the adult protocols of
Dr. David Thompson. These protocols have become standards of care for telephone triage in
the United States and internationally and are well known and respected by medical
practitioners.

Each protocol is put through an exhaustive testing and review process, involving repeated draft
alterations and detailed written reviews by members of a Committee that includes call center
medical directors, telephone triage nurses, emergency physicians, primary care physicians,
physician sub-specialists, and behavioral health experts.
The standing Review Committee for pediatric protocols includes 11 members, and for adult
protocols includes 26. Each triage guideline is referenced to current literature. Decision-making
is evidence-based whenever possible, and all guidelines are updated yearly. For local use, the
software was extensively reviewed and customized to adapt to existing medical practice.

As a result, FONEMED’s clients now benefit from the most flexible and scalable software of its
kind. FONEMED uses the fully-integrated protocols of Dr. Barton Schmitt and the adult
protocols of Dr. David Thompson. These are the most widely used protocols in the triage
industry and have been used in pediatric triage literally millions of calls without adverse
outcomes.

Clients

NSI’s partner FONEMED LLC currently provides nurse triage and health information services to
more than 1,800 client groups throughout North America and the Caribbean. These clients
represent physician practices, benefits providers, hospitals, universities, third party
administrators (TPAs), job corps centers, assistance hotlines, distributors/resellers, case
management organizations and home healthcare monitoring organizations. Approximately 5.1
million people currently have access to FONEMED’s triage and another 10 million plus through
FONEMED’s worldwide partners.

NSI Mission

To deal with the health situation that we encounter on a day-to-day basis and ensure
appropriate remedial action is available to as many Filipinos as possible.

Moreover, we at NSI are committed to ensuring competent, innovative and accessible telehealth
service. NSI operates an extraordinary nurse center utilizing the world’s best healthcare advice
technology that is available. NSI utilizes both existing and developed technology platform that
can make the delivery of this service more convenient.

Vision

A healthy population who are able to receive, as needed, appropriate medical advice at a very
reasonable cost.

III. Workforce:
NSI boasts of its front-liners. Our telehealth nurses are Registered Nurses (RNs) with clinical
experience carrying academic and clinical credentials commensurate to the needs of the Tele-
triage industry. They have undergone rigorous training using the most efficient, flexible,
customizable and scalable software of its kind.

The medical staff is ably supported by I.T. and Quality Assurance personnel who each have at
least 2 years call center experience in their respective fields

IV. NurseKol Service Process

A. Activation of Card Prior to Use

To Activate the Card the subscriber shall text ACT and PIN.

<ACT><space<PIN> to 0918-8911-911 for Smart/TNT/Red, 0917-567-8-911 for

Globe/TM and 0922-8-911-911 for Suncellular subscribers.

For example:
 ACT 1234567812345
SEND TO
0918-8911-911/ 0917-1-911-911/ 0922-8-911-911

The subscriber shall receive an SMS message stating a successful registration that the
card is ready for after 24 hours, and the access to the service is valid within one year
upon the activation date.

B. Access to NSI Service

The NSI Telehealth Card is valid for one year from the activation and shall be for a one-
time use only.

To use the card and avail of the telephone-based nurse healthcare advice, the subscriber
must text NSI and PIN. (NURSEKOL SERVICES<space><PIN>) to 0918-8-911-911 for
Smart/TNT/Red, 0917-1-911-911 for Globe/TM and 0922-8-911-911 for Suncellular
Subscribers.

For example: NSI1234567891224

SEND TO
0918-8-911-911/ 0917-567-8-911/ 0922-8-911-911

An SMS message prompt will then confirm that the request is successful and that a call
will be received within 5 minutes.

NSI shall, if the Tele-triage warrants, endorse callers to the nearest E.R or specialist.
Each transaction is recorded in customized Encounter Reports which are stored electronically
for the next 2 years for audio recording, and 10 years for PDF reports.

CALL FORMAT (Mobile Subscribers)

1. A subscriber sends an SMS message to NURSEKOL SERVICES’s access number

using his prepaid or postpaid phone.
2. A message will be sent to the subscriber confirming the receipt of the SMS message,
and that the subscriber should expect a callback within 5 minutes. The subscriber will
also be warned that the NSI service is not for life threatening emergency cases but is
limited to healthcare advice and information. The information shall be sent to the NSI
server.
3. NSI Nurse receives the caller information and shall make a call back within 5 minutes.
4. The telehealth nurse assesses the caller’s condition and advises the caller, where
applicable, to initiate home care, to go to the doctor within a specified amount of hours,
or to immediately proceed to an E.R.
5. The telehealth nurse asks the caller if the advice given is clear, and if the caller will
follow the recommended medical advice.
6. The telehealth nurse documents the call.

VIII. Disaster Recovery

NSI is connected to the hosted system of FONEMED LLC. FONEMED’s on-site redundant
systems are available for hardware failures. FONEMED’s new VOIP system enables it to route
calls to any agent, independent of site location, in the system using the redundant capabilities of
the Internet. Since FONEMED operates in the US, Canada and the Caribbean, its network is
positioned to recover from virtually any magnitude of disaster. All data is backed up daily and
stored off-site. PDF files are stored for 10 years and audio recordings are stored for two years.

NSI has 2 leased lines. It likewise maintains on-site redundant systems such as a 24 hour
generator back-up with a service level recovery time of 10 to 15 seconds
IX. NSI Products and Services

• Nurse Tele-triage: Specially trained telehealth Registered Nurses use FONEMED’s

software and 686,000 licensed medical protocols to guide callers through a series of
questions and arrive at an outcome that is appropriate to the particular situation. Each
transaction is recorded and documented in customized Encounter Reports which are
stored electronically for the next six months.

• Basic Medical Information and Health Information Library: Nurses answer inquiries
regarding the nature of diseases, its duration, signs and symptoms, and other questions
related to caller’s health. NurseKol Services’s Health Information Library is a
comprehensive library of recorded health information available for nurses to retrieve as
needed. When callers need basic health information, they can always talk with one of
our triage nurses and the Health Information Library will serve as a tool for nurses to
give specific and accurate answers to the callers.

Status: Information on Health Diseases and Laboratory Tests have already been
encoded. Drug Information from letters A to E is also done but encoding of Drug
Information under letters H to Z is on-hold because of unavailability of servers.

• Referral to E.R: NSI nurses shall, if the tele-triage warrants, endorse callers to the
nearest Emergency Room.