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This report details why health care monitoring is an irresistible change in medicine. Then it looks at health monitor segment, which has 5 known competitors: Agilent, American Telemedicine, Cyber-Care(CYBR), Kodak, and Panasonic. Finally why Cyber-Care's advantages mean that the competition can't compete.

Although I am trying to report as I see things, I am biased in this view by being long on Cyber-Care and being mainly influenced by Cyber-Care postings and posters. However, I have made every effort to verify sources. Also I refer to a transcription of a recording of the AGM conference made by a poster and not released by the company. Finally, I do not have any professional investing skills.


Broadly defined, telemedicine is the transfer of electronic medical data (i.e. high-resolution images, sounds, live video, and patient records) from one location to another. -

This post examines the telemedicine solutions supplied by home health monitoring kits. In their most basic form, the kits are just boxes that provide two way video and data exchanges. By placing boxes in patients' homes and in caregivers' offices they provide the mechanism to simulate consultations. The kits offer reduced health care costs while maintaining quality of health care. The virtual consultations target the 1% of the population who use 35% [1,2,3] of all health care costs, $367 billion in the US. This post estimates there are around 3 million candidates in the US and at least 9 million worldwide who would benefit from this service. Without health care savings the ageing population will cause tax rates to rise.

Although there are many solutions on the market, most are based on point-to-point solutions, i.e. a direct phone link between the patient and the caregiver. Cyber-Care's solution is differentiated from their competitors by offering a health network for the patient that enables: a 7 * 24 service, instant referral to an available clinician, electronic billing, and enforcement of best practice through the patent pending HELPpath system. The Internet is introducing itself to the health service.

1% of the population is responsible for 30% of health care costs

The Health Monitoring segment is targeting the 1% of US population who are responsible for 35% of all healthcare costs [1]. Chronically ill patients cost on average $70,000 to treat per year in the US.

Health monitoring saves between 1/3 and ½ of health costs

Monitoring can save between 1/3 and ½ of all health costs [3]. This means that each monitored patient saves between $23,000 and $35,000[1].

Running costs

Since a health monitor costs around $8,000 you can see why they may be popular with managed care companies and health management organizations (HMO's). Cyber-Care also charges for a network license fee of $280 a month per patient.

So Assumptions:
-- Each Internet monitoring machine costs $7,495
-- Each machine has a monthly networking fee of $280 per month or $3,360 per year.

U.S. health costs
-- A 35% minimum savings on the $70,000/yr cost per high-risk patient per year or a $24,500 savings [3].

European health costs
-- Europe's chronic patients also cost 35% of the budget – according to the conference call [6]
The US health service costs more because they use more expensive drugs and have a tendency to sue doctors who are only doing their job. Before considering the benefits of a universal health system. I will conservatively estimate that we manage to cut costs by between ½ and 2/3 (perhaps we keep ill people in boxes?). We will have a better understanding of this once the Yale study in Greece is concluded.
Benefit to cost ratio
Year1 Year2 Year3 Total Ben/Cost
Complete monitoring costs 10,645 3,360 3,360 17,575 -

US savings per patient 24,500 24,500 24,500 73,500 4:1
Europe savings per patient (1/2) 12,250 12,250 12,250 36,750 2:1
Europe savings per patient (1/3) 8,100 8,100 8,100 24,300 7:5

So in the US for every dollar spent buying and deploying an EHC machine, or similar, $4 will be saved. In Europe without better data I approximate this to be $2 to perhaps $5 used to $7 saved. However, the studies did not allow for staff reuse (see below) and we shall see that this alone will pay for the system.

How savings come from monitoring
Telemedicine offers a number of savings; these can be categorized as follows

1) Direct Time saving
2) Administration
3) Staff Reuse

1) Direct Time Savings

Savings are made because monitoring means that there are fewer home visits given by the caregivers and the support and quality of care produced by the monitoring reduces the number of times the patient enters the hospital. Telemedicine allows more doctors and nurses to treat more patients for less cost.

2) Administration

Hospital administration covers normal office tasks like payments and ordering but also includes patient progress and treatments. To save money there is more electronic filing. Monitoring boxes will collect transactions and patient progress and feed this back into the “administration” database.

3) Staff Reuse

Cyber-Care anticipated having to having to supply staff in a call center. However, what they found was that large health authorities are using their incapacitated staff. Instead of them sitting at home they are being used as primary contacts for the monitored patients. A nurse typically earns $40,000 in the US [5]. This is a saving which couldn't have possibly been anticipated by the clean cut academic Iowa health study [3] and means that in many cases the network costs are covered entirely by staff reuse. The network savings become pure profit.

Market Size

Chronically ill make up 1% in each country.

Markets will be determined by:
a) GDP - US (2nd), but note Taiwan (33rd), Greece (37th), and China (84th) are testing or have ordered.[7]
b) Health Care Development (WHO figures) - Greece (14th) US is (37th) China 144th. [8]
c) Cultural – in some cultures, such as China, you have to look after your parents.
d) Ease of transport / size/ population density – one again China and India make interesting candidates due to their size and populations with high densities allowing acceptable Internet infrastructure costs.

The Candidate Countries this post highlights have higher WHO rated health service than the US and a per capita GDP above $15,000. Note Greece and Taiwan have GDP below $15,000 but have placed orders.

Candidate Countries
Market Chronically ill (1%) Cyber-Care Sales

Europe (EU-15) 3,753,465 Greece has agreed 1,500
US 2,740,280 30,000 to US companies
Japan 1,262,810
Canada 305,610 Toronto Children's hospital
Saudi Arabia 201,810
Taiwan 220,920 See 20,500 Xender Contract
Australia 185,200
Hong Kong 66,600 See 60,000 SIIC contract
Switzerland 72,290
Israel 59,890
Norway 44,190
United Arab Emirates 23,530
Singapore 34,760
Iceland 2,760
Candidate Total 8,974,115
- Population data [9] except Europe [10] and Taiwan [11]

This post estimates 9 million candidates for EHC's even leaving China and India as wild cards.
My take on China
Wild Cards

China 12,556,980
India 9,822,230

Politicians don't want to raise taxes

Tax Savings - Current Medicare (Medical cover for the over 65's) tax rates are unsustainable and will have to double by 2030 just to keep up with the population change. It is no surprise that politicians see telemedicine as one way to reduce medical costs. Bills to encourage interstate telemedicine visits and increased access to health care for Medicare beneficiaries through telemedicine have received cross party support. This is not just a US phenomenon, SIIC Asian contract was possible because of the strong interest shown by the Chinese government for exactly the same concerns as the US government.

In summary of the prospects for telemedicine

Medical monitoring for the chronically ill benefits all sides. Patients get away from the hospital raising their quality of life. Caregivers can treat more patients while reducing administration time. Payors get to utilize staff that can't work to get a significant saving on the costly frequent flyers while reducing the strain on hospitals. The more health care managements buy the more they will save.

The Competition

The "complete" home health monitor segment has 5 competitors: Agilent, American Telemedicine, Cyber-Care, Kodak and Panasonic. This section shows why Cyber-Care will out compete the current incumbents.

Only Cyber-Care can have a consultation and transfer readings at the same time (See video patent below). So, Cyber-Care has the superior home monitoring kit. However, to compare monitoring products misses the point that Cyber-Care's real aim to create a network and get revenues from this network. The Panasonic is the first solution to even consider networking seriously. The rest have been taken by surprise and are no longer competing in the same space as Cyber-Care. As we shall see Cyber-Care are trying to make revenues from their network. They can give away the monitors and still make significant license revenues by providing services that a point-2-point solution cannot charge for.

The Competition In Complete Home Care Monitoring
Company 2-WayVideo Production Networking Name

Agilient . X X
American Telecare X X . Aviva
CyberCare X X X EHC
Kodak X X . LifeView
Panasonic X . X Active Serve


Cyber-Care was formally called Medical Industries of America (MIOA), changed it's name after the acquisition of a private company called Cyber-Care. Cyber-Care developed, with the Georgia Institute of

Technology, an Internet-based remote monitoring system, called Electronic House Call or EHC.


To look at the Cyber-Care Products

Cyber-Care has a number of divisions, however the products that are relevant to home help are.

EHC600 Care Provider Station - for the doctors and nurses
EHC500 Portable Patient Station - in home
EHC400 Desktop Patient Station - in home

Current EHC Functionality

A number of Plug and play modules can be attached to the EHC, as Cyber-Care move toward a “Doc –In-A-Box” these include blood Pressure Monitors, Blood Glucose Monitor and electronic Spirometers as well as the more pedestrian Weight Scales.

These are constantly being developed and more should be expected.

"...We have qualified a dozen (12) different devices functionalities in our clinical trials...They all work and they have been working very nicely...and I know we have a formality to go thru with the FDA...but the primary devices that we need have already been approved"... John Haines at the AGM 2000 [12]

Competitive Advantages

1) Network Advantage
2) Patents
3) Administration
4) Staff-Training
5) No connection Limitations
6) Staff Reuse

1) Network Advantages

several of our competitors require that the patient call into a call center and post a request that the talk to a nurse and then they have to wait for a call back - John Haines at Cyber-Care AGM 2000. [12]

Cyber-Care's competitors' solutions simply put the doctor and the patient at the end of a videophone and added some measurement devices. They did not think about even the first possibilities that a network can give. Consequently they are reliant on staff answering phones, finding people and all the other inefficiencies you get in busy hospitals.

In contrast Cyber-Care are linking up hospitals. If you combine this with transaction capability you have an instant worldwide referral system with transaction closure. A B-2-B network for healthcare professionals.
Cyber-Care has already demonstrated a link between Honk Kong and Mayo institute.

Cyber-Care made the shift to the Internet and will benefit from all the usual network effects. These include instantly available staff, many more patients can be supported with a small infrastructure cost, patients using the EHC for support groups so they will benefit by getting community effects.

The network “knows”
a) The doctors and nurses in your particular HMO/Insurance plan.
b) Your problems/disease states this means you will be connected with a practitioner qualified in the required area of expertise.
c) The duty roster.

And does all these items 24 Hours a day 7 Days a week. A patient presses a button, the system gets the patients records and delivers them to the best-qualified practitioner and starts the consultancy. The Cyber-Care network is described here -

Patients are allowed chat sessions, a powerful benefit for the elderly who are commonly left alone and the final network benefit.

2) Cyber-Care Patents

a) Video - Transmission of medical data in a two-way interactive voice and video session between a local and remote site. The data being sent in packets, basically using the TCP/IP protocol for telemedicine. This has been untested in law but if it holds then all telemedicine box manufactures will have to use it.

The Panasonic solution avoided patent infringement by having an automated system that only calls in the doctor when something is wrong. The data feed stops and the doctor contacts the patient. Panasonic have avoided Cyber-Cares patents but in doing so you can't hold a consultation. You're left with either a video exchange or a data exchange but not both. To read more, and also some interpretation of the legal issues StockWarrior has passed his views, follow the next link.

b) Health Management - Each EHC base station comes equipped with HELPpath a patent pending way of enforcing best practice by including clinical pathways and protocols that link assessment information with clinical interventions and outcomes. This is an outcome driven system, which improves the quality and efficiency of care by standardizing the process of home care and by providing the ability to track and control the delivery of services. Cyber-Care's EHC is the only box that has this functionality.

From the Website

c) Networking - Additional patents for the networking architecture are pending. These are vital to Cyber-Care's business model because they want to move towards mainly license revenue.

3) Administration

There is a move within health to use electronic filing. Once again the EHC offers billing and administration solutions. The EHC is a complete one-stop solution that feeds data into the administration system.

4) Self-Training

The competitive products rely on a training session given when they install the product. The EHC comes with a self-training unit. This allows anyone unfamiliar with the EHC to start using it.

5) No Connection Limitations

A beneficiary of using the TCP/IP protocols means that there are no limits to connections between the patient and the caregiver. Typically access to the network is achieved via ISDN/xDSL or cable T.V. all of which provide superior video performance; giving the EHC it's final advantage.

6) Staff Reuse

Using staff on disability to work from home allows health management companies to use the services of nurses who can't otherwise work. A nurse typically earns $40,000 the cost of 11 network licenses. In the US nurses are being hooked up to 15 patients and their pay savings are covering the costs of the network []. Although this could be a general benefit for all health monitoring I feel that the network facilitates this process.

Revenues and Income

Cyber-Care breaks down revenues into 4 divisions. However, it is the Technology Disease assisted management divisions that accounts for research costs and sales of the EHC and network.

EHC sale price is $7,495 for the patient station EHC400, with a 40% - (margin taken from management source), $2998, profit margin.
Recurring fees per month is per EHC unit is $280 gross, $200 net.

EHC Revenue net of costs
             Cyber-Care Current Sales / Revenues
2001 2002 2003 2004 2005 2006 Total
Xender Corp[14] 2,000 3,000 5,000 3,500 3,500 3,500 20,500
SIIC Medical 10,000 17,000 18,000 19,000 - - 64,000
Other US 8,000 13,000 15,000 - - - 36,000
EHC Year Ttl. 20,000 33,000 38,000 22,500 3,500 3,500
EHC Total 20,000 53,000 91,000 113,500 117,000 120,500 120,500

Revenue net of production cost (Th)
EHC Rev* 59,960 98,934 113,924 67,455 10,493 10,493 -
Networking[13] 22,000 84,300 169,000 243,150 276,250 284,650 289,200
Total Rev.## 81,960 183,234 282,924 310,605 286,743 295,143 289,200

## If you want to consider the worse Case Scenario, that SIIC sell none, whatsoever, in which case you want to half the total revenues to give $180 million in 2005.

Year net EHC revenue is found by multiplying the EHC sale price $7,495, by the profit margin, which is 40% to give $2998.

Although Cyber-Care is estimating 20,000 by the end of fiscal 2001, there is reason to be optimistic on third parties to help production and add infrastructure and for many additional orders. The revenue model gives excellent revenue visibility and we can see we will be producing EHC and collecting license revenue for the next few years.

Balance Sheet [13,14,15]

Working Capital

Working capital is vital for a growth company. The company increased cash by issuing stock. Sale of Air Ambulance will add to this.

1st QTR 2nd QTR
------------ ------------
Total current assets ....... 29,807,563 42,840,237
Total current liabilities .. 7,434,726 7,208,303
------------ ------------
Working Capital ............. 22,372,837 35,631,934
------------ ------------

Cash to Debt Ratio

The company has a manageable level of debt that will improve with the sale of the Air division. Much of the long-term debt is paying off of aircraft leases.

Cash $30 / (short term debt = $7 + long term debt = 21.5) = 1.13

Sale of Air ambulance

Sale has not gone through yet but if it does the balance sheet improves dramatically
Cash +$6million dollars / Equipment -$20Million to $2million / Total assets from $92million down to $74million.


Of the four divisions, 2 divisions make a profit while two make a loss (See Table 1 below). The air ambulance makes a loss and is being sold off within the next 2 months (providing the deal completes). Leaving just the technology management section as the only loss making division. This division is making the capital expenditures to support the EHC development. Over the last 6 months the division made an 8 million loss. Cyber-Care has $30 million in cash and equivalents that will be boosted by the Air ambulance sale. As we discussed above, they are selling the EHC's at a profit margin of 40% and recurring network licenses delivering $200 profit a month per unit at a profit margin of 71% ($200/$280). At a conservative estimate of $80 million in high margin revenues for 2001 it looks like Cyber-Care should be profitable well before the cash runs out.


At the current levels Cyber-Care has been priced to fail. If they get 5% of the monitor market they will do exceedingly well. Just one of the big 650 HMO companies and Cyber-Care's valuation will look cheap. I have attempted a more precise valuation in the Cyber-Care posting board but on this I'm going with Buffet. It is so good an opportunity that it is obviously excellent value. Mozerd [4] has many postings based around this.


The only significant fear I have is the dilution of shares many from the acquisition of private companies but also from stock options. My feeling is that with profitability this will slow. However, I am still looking at this and an investor should consider this before making their purchase.


As of March 28th, 2000 Cyber-Care employed approximately 528 people, 481 full time. None of the employees are union members and there have been no stoppages. [3]


most if not all of the other people are in the hardware business...we not in the hardware business...don't want to be in the hardware business...we are in the recurring revenue business Mike Morell at the 2000 AGM.

Cyber-Care will be happy to allow other manufactures to make EHC and just get royalties for the use of their patents. Current manufactures being used are:

Colin – for US production, 50,000 units per year
Xender - for Taiwan production
Zhuhai - for China

Partnerships and Significant Clients

Americhoice, Inc
The Americhoice program is revenue sharing. They are inviting Cyber-Care to find additionally ways to save money with their system. This is a chance to earn more revenues and an invitation to get under the skin of the hospital system.

Georgia Tech and Georgia Medical College
Georgia Tech and Georgia Medical were the original developers, and still developing the product. Grants and further assistance were obtained from the US Army Medical Center at Fort Dietrich, Maryland.

Mayo Clinic
The Mayo Clinic has run the Cyber-Care network since 1998. The Mayo clinic is one of the world's renowned medical institutes and provides a concentration of talent, exposure, and practical experience for the EHC. By networking up the Mayo clinic they are providing an immediate referral capability to the best in the world, something that other providers signing up to the network are very aware of.

Cyber-Care has announced a strategic alliance with Nursefinder. Nursefinder, who has offices in 38 states of the US, will with the aid of the Cyber-Care network, provide cover in 50 states on a 24-hour, 7-day-a-week basis.

SIIC Medical Science and Technology (Group) Limited

"SIIC is 40% owned by the Chinese by doing business with SIIC...we are doing business with the Shanghai Government" Anthony Cheung – at AGM conference 2000 [12]

SICC has agreed to market and sell approximately 64,000 EHC units over four years with a minimum of 30,000 EHC units sold to retain the exclusive license for the greater China area, not including Taiwan.

Yale's telemedicine group will complete studies with Cyber-Care product and will provide additional scientific evidence and credibility. Yale has close contact with the influential New England Journal of Medicine and Cyber-Care should expect Yale's findings appearing in that Journal.

Health System One, Inc., Cambridge Medical Centers, Inc., Americhoice Health Services, Inc., Evangelical Lutheran Good Samaritan Society of Sioux Falls, Metcare, Veteran Affairs and received other orders and commitments for over 36,000 units to be sold over the next three years. Nortel have a marketing contract.

Think about the Future

Potential future moves

1) The company wants to become a licensing company. They don't want to make EHC but they want the benefits of revenues from their innovation.

2) Third party products – if Cyber-Care does have a hold over the space. We should expect third party products that fit into their network. Value chains aid and protect the incumbent.

3) Shrinking the EHC and making it more mobile - You never know where they might end up?

4) Move away from chronic illness to monitor other illnesses, e.g. acute.

5) Current point-2-point solutions licensing and manufacturing Cyber-Care's technology.


Cyber-Care can charge for a service and still save health insurers a lot of money, allow caregivers to increase productivity, give chronically ill patients a better quality of life and provide politicians a quick way out of the burdening health budgets. It has a number of important advantages over the competition, the networking, the video over TCP/IP and integration of best health practice. While being able to undercut the competition because the network adds value through services which a point-2-point connection cannot mimic. With the cheapening of bandwidth they can use the system to offer the advice of the best consultants in the world to anyone attached to the system.

Due to the time needed to test and get various levels of approval Cyber-Care will have a year to a year and a half before another competitor is on the market. However, once Cyber-Care are fitted into a hospital it will be difficult to replace them and indeed through partnerships like AmericChoice. They are being encouraged to find new savings and thereby integrating further into the operations.

Cyber-Care has raised their product prices and increased their sales estimates; not the actions of a company having problems selling the product. Once the network is in place other third parties could become involved and opportunities may become available as they move from supporting the chronically ill to supporting other patients within the hospital system.

Standing on the shoulders of: Mozerd, ToTheHilt, jakesmith19, ShawShank, StockWarrior and t-rat and the rat board, 'cause I saw it there first. Once again I would like to thank Mozerd for the use of his DD for EHC running costs, working capital and modified revenue generation and what a network knows. Without which my appreciation of Cyber-Care would never of happened.

Table 1 Other Telemedicine Companies – many belong to ATA

Company Ortivus
Field Monitoring equipment
Projects Acute Care
Products MIDA & MobiMed

Company Vidimedix (bought by
Fields 2 way Video equip to allow Patient / doctor interaction
Products Vidimedix series 2000, Vidimedix Series 1000
Notes Private, bought by (MED)

Company IMED Link
Fields Works on telemedicine projects like teleconferencing and data
sharing between hospitals. Interested in projects to provide
information to the general public to reduce numbers of
unneeded admissions.
Notes Partnered with Yale and AT&T

Table 2 Revenue Table – in thousands

For the six months ended June 30, 2000:

------- ------- -------- ------- ------
Revenue .........$ 463 $ 6,064 $ 3,064 $10,847 $20,439
Income (loss) $(8,111) $ 680 $ 53 $ (683) $(8,061)

For the six months ended June 30, 1999:

------- ------- -------- ------- ------
Revenue ....... $ 227 $ 4,215 $ 2,215 $ 9,452 $16,109
Income (loss) $ (206) $ 836 $ 270 $ 675 $ 1,575

TECH DSASE = Technology Assisted Disease Management
REHAB = Physical and Occupational Rehabilitation
PARM = Pharmacy Services
Air Trans = International Air Ambulance Transport


[1] Cyber-Care's 10-K – 1999
[2] A list of projects evaluating telemedicine -
[3] A two year project between the University of Iowa and CyberCare using the EHC System, has resulted in 36% saving.
[4] Mozerd DD-
[5] Average Nurse Pay:
[6] VCALL -
[7] GDP statistics
[8] Health system attainment and performance in all Member States, WHO Statistical Information
System -
[9] Population in thousands for the countries of the world - United Nations Population Division,
Department of Economic and Social Affairs-
[10] Eurostat -
[11] Taiwan Statistics:
[12] AGM transcription -
[13] Network Rev. Formula = Total EHC Start of Year * Network License Costs +
EHC's Produced * Network * 0.4833 (the availability of the unit is the avg. time a produced unit is available during the year. I'm using 0.4833 but you could easily use ½. I.e. any unit produced during the year will have on average 6 months of network license revenue.
[14] The initial order was 10,000 but this has been upped to 20,500. See this update on an FAQ on their website.
[15] The American Telemedicine Association, the whose who of American Telemedicine if you dig around the site there is a lot of information here.
A list of members who were at the ATA2000 conference
[16] Current Assets on the balance sheet
[17] The Many Faces of debt
[18] Introduction to Stock Options

Further Reading

Before investigating further. You should be aware that this is still a small stock. The share price has been known to go beneath $5. A sub $5 stock means it isnot marginable. You should expect Herb Greenberg to have more negative articles; it's his hobby. You should not feel any anxiety over your decision and if you are not comfortable you should wait and see how it plays out. Now,

If you want to consider this stock further then read.

Mozerds rotating messages, he posts on RagingBull but I've stored some posts on the fool. He has spent a long time researching the stock and is more 'bullish' than my conservative report.

Read More about Class actions in General – you can't read enough on Class Actions

Government Brief of the changes needed in Medicare

White Paper on Cyber-Care's Intranet

Listen to the conference call, April 3rd, 2000

Finally, if you have questions then the Raging bull website has the most knowledgeable posters

Of note, I have seen Mozerd tirelessly answer all newbie questions

While the Motley Fool is developing a following

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