Form 1 Asthma

0915-XXXX XX/XX/20XX

Federal Office of Rural Health Policy (FORHP)

Office for the Advancement of Telehealth (OAT)

Telehealth Network Grant Program (TNGP)

ASTHMA MODULE

This module will be used if the SB-TNGP offers asthma services.

The information in this section is collected for each student receiving asthma services via telehealth during the measurement period.

Data Element Dictionary

The data element dictionary documents definitions, allowable values, sources for information, and instructions for abstraction.

The data elements are designed to provide the necessary data to calculate the measures. A data collection tool will be used for data entry.

Throughout this document there are references to “the measurement period.” There will be two measurement periods, each six months in duration. These will be January 1 – June 30 and July 1 – December 31.

Public Burden Statement:  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0915-XXXX.  Public reporting burden for this collection of information is estimated to average XX hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857

Data element number:	Asthma - 1
Variable name:	Referral source
Variable definition:	Indicates the referral source for this student receiving telehealth asthma services as part of the SB-TNGP
Data collection level:	Student
Criteria:	Students who received telehealth asthma services through the SB-TNGP during the measurement period
Valid (allowable) values:	Check only one of the following. Options for response are: □ Student self-referred □ Student was referred by their parent/guardian □ Student was referred by a teacher at the school □ Student was referred by a guidance counselor at the school □ Student was referred by an administrator at the school □ Student was referred by SBHC staff or the school nurse □ Student was part of a registry indicating services were needed □ Other – please specify:__________________________________________ □ Unknown: Unable to determine from telehealth log or student visit record
Note for abstractions:	If student had multiple encounters or multiple referral sources, indicate the first referral source for this student for telehealth asthma services.
Source for definitions:	Rural Telehealth Research Center

Data element number:	Asthma - 2
Variable name:	Asthma severity classification was assessed
Variable definition:	Indicates whether or not the student’s asthma severity classification was assessed
Data collection level:	Student
Criteria:	Students who received telehealth asthma services through the SB-TNGP during the measurement period
Valid (allowable) values:	Check only one of the following. Options for response are: □ Yes: Indicates that asthma severity classification was assessed □ No: Indicates that asthma severity classification was NOT assessed
Note for abstractions:	To be assessed, a diagnosis or severity classification must be from a health provider. This measure does not ask for the severity classification to be indicated here, just that such a severity classification was assessed. Guidelines specifically developed for managing asthma in children by an expert panel of the National Asthma Education and Prevention Program at the National Heart, Lung, and Blood Institute (NHLBI) provide scientifically based information on classifying and assessing asthma severity and control as well as key components to achieve and maintain asthma control. Developed initially in 1997 and called the Expert Panel Report (EPR) 2, the guidelines have undergone 2 updates with the most recent update in 2007 called the EPR3. The guidelines categorize disease severity as intermittent or persistent based on symptoms, use of rescue medications, frequency of exacerbations, and pulmonary function tests. Persistent disease is further categorized as mild, moderate, or severe.
Source for definitions:	http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/content/tags/asthma/pediatricians-ready-reference-guide-managing-asthma-chil?page=full

Data element number:	Asthma - 3
Variable name:	Asthma action plan exists
Variable definition:	Indicates whether or not there is an asthma action plan
Data collection level:	Student
Criteria:	Students who received telehealth asthma services through the SB-TNGP during the measurement period
Valid (allowable) values:	Check only one of the following. Options for response are: □ Yes: Indicates that there is an asthma action plan □ No: Indicates that there is NO asthma action plan
Note for abstractions:	An asthma action plan is a written, individualized care plan that includes annual medication monitoring, regardless of asthma severity The asthma action plan must be dated within the past 12 months to be current
Source for definitions:	CDC. https://www.cdc.gov/asthma/actionplan.html; Two examples are: http://www.lung.org/assets/documents/asthma/asthma-action-plan-for-home.pdf http://www.aafa.org/media/asthma-action-plan-aafa.pdf

Data element number:	Asthma - 4
Variable name:	Current asthma medication was assessed for appropriateness
Variable definition:	Indicates whether or not current medications(s) for asthma was assessed by a health provider
Data collection level:	Student
Criteria:	Students who received telehealth asthma services through the SB-TNGP during the measurement period
Valid (allowable) values:	Check only one of the following. Options for response are: □ Yes: Indicates that current medication(s) for asthma was assessed for appropriateness by a health provider □ No: Indicates that current medication(s) for asthma was NOT assessed for appropriateness by a health provider
Note for abstractions:	To be assessed, there must be a notice from a health provider that the current asthma medication is appropriate for the student. Medication assessment should be done at every follow-up visit. Applies only to students who were identified with persistent asthma. Exclude patients who had any diagnosis of Emphysema (Emphysema Value Set, Other Emphysema Value Set), COPD (COPD Value Set), Chronic Bronchitis (Obstructive Chronic Bronchitis Value Set, Chronic Respiratory Conditions Due To Fumes/Vapors Value Set), Cystic Fibrosis (Cystic Fibrosis Value Set) or Acute Respiratory Failure (Acute Respiratory Failure Value Set) any time during the patient’s history through the end of the measurement year (e.g., December 31).
Source for definitions:	NIH, National Heart, Lung and Blood. https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf National Committee for Quality Assurance. [email protected]

Data element number:	Asthma - 5
Variable name:	Asthma rescue medication on file
Variable definition:	Indicates whether or not a rescue medication has been prescribed
Data collection level:	Student
Criteria:	Students who received telehealth asthma services as part of the SB-TNGP during this measurement period
Valid (allowable) values:	Check only one of the following. Options for response are: □ Yes: Indicates that a rescue medication has been prescribed □ No: Indicates that a rescue medication has NOT been prescribed
Note for abstractions:	An asthma rescue medication is prescribed by a health provider for use in an emergency situation. It is also referred to as quick-relief medication. Types include: short-acting beta agonists in the form of inhaled bronchodilators such as albuterol (eg. Ventolin, Proventil, Pro-Air, ProAir RespiClick) and levalbuterol (Xopenex); ipratropium in the form of inhaled bronchodilators such as atrovent HFA; and oral corticosteroids such as prednisone and methylprednisolone.
Source for definitions:	https://www.mayoclinic.org/diseases-conditions/childhood-asthma/diagnosis-treatment/drc-20351513

Data element number:	Asthma - 6
Variable name:	Number of telehealth encounters that the student received for asthma
Variable definition:	Indicates how many encounters for asthma services that the student received that involved telehealth
Data collection level:	Student
Criteria:	Students who received telehealth asthma services as part of the SB-TNGP during this measurement period
Skip logic:	NOTE that the response to this question will be used to determine the extent of ENCOUNTER level data collection. In particular, a high number of asthma visits will trigger instructions to only complete ENCOUNTER level data collection for the first visit each month.
Valid (allowable) values:	Any numeric character
Note for abstractions:	An encounter can be of any duration, and it can be scheduled or impromptu.
Source for definitions:	SB TNGP FOA

Data element number:	Asthma - 7
Variable name:	Number of non-telehealth encounters that the student received for asthma in the school setting
Variable definition:	Indicates how many encounters for asthma services that the student received in the school setting that did not involve telehealth
Data collection level:	Student
Criteria:	Students who received telehealth asthma services as part of the SB-TNGP during this measurement period
Valid (allowable) values:	Any numeric character or NA indicating that the data are “Not Available”
Note for abstractions:	We understand that this information will not be available in many schools, in which case enter NA. An encounter can be of any duration, and it can be scheduled or impromptu. Complete only for students who had telehealth asthma services. The school setting means the setting where the SB-TNGP operates.
Source for definitions:	Rural Telehealth Research Center

Data elements that are collected at the ENCOUNTER level

The information in this section will be collected for SB-TNGP telehealth asthma encounters.

Instructions

NOTE the following questions are to be answered for each telehealth asthma ENCOUNTER if the number of telehealth asthma encounters for the student during the measurement period is less than 6. If the number of telehealth asthma encounters during the measurement period is more than 6, then answer the following questions for each ENCOUNTER that was the first encounter of the month.

Data element number:	Asthma - 8
Variable name:	Type of asthma provider seen via telehealth
Variable definition:	Indicates the type of licensed provider the student saw for telehealth asthma services during this encounter
Data collection level:	Encounter
Criteria:	Students who received asthma services via telehealth as part of the SB-TNGP during this measurement period
Valid (allowable) values:	Check ALL that apply. Options for response are: □ Primary care provider □ Asthma specialist □ Other – please specify:__________________________________________ □ Unknown: Unable to determine from telehealth log or student visit record
Note for abstractions:
Source for definitions:	Rural Telehealth Research Center

Data element number:	Asthma - 9
Variable name:	Type of asthma service provided via telehealth
Variable definition:	Indicates the type of telehealth asthma services the student received during this encounter
Data collection level:	Encounter
Criteria:	Students who received asthma services via telehealth as part of the SB-TNGP during this measurement period
Valid (allowable) values:	Check ALL that apply. Options for response are: □ Assessment □ Medication management □ Service or assessment for crisis or emergent asthma need □ Other – please specify:__________________________________________ □ Unknown: Unable to determine from telehealth log or student visit record
Note for abstractions:
Source for definitions:	Rural Telehealth Research Center

Data element number:	Asthma - 10
Variable name:	Telehealth technical success
Variable definition:	Indicates whether or not telehealth technology was administered successfully
Data collection level:	Encounter
Criteria:	Students who received asthma services via telehealth as part of the SB-TNGP during this measurement period
Valid (allowable) values:	Check only one of the following. Options for response are: □ Successful: The telehealth encounter was technologically successful □ Unsuccessful: The telehealth encounter was technologically NOT successful □ NA: Not Applicable □ Unknown: Unable to determine from telehealth log or student visit record
Note for abstractions:	Successful administration means that voice and video quality were sufficient to complete the consultation. Technical drop-outs of the telemedicine system did not occur. Unsuccessful administration means that the voice and/or video quality were not of sufficient quality to complete the consultation (e.g. unreachable network, poor image quality, poor audio signal quality). If unable to determine whether the telehealth consultation was technically successful, select ‘Unknown.’
Source for definitions:	Modified PIMS; Rural Telehealth Research Center

Data element number:	Asthma - 11
Variable name:	Immediate disposition
Variable definition:	Indicates the student’s immediate disposition at the conclusion of this encounter
Data collection level:	Encounter
Criteria:	Students who received asthma services as part of the SB-TNGP during this measurement period
Valid (allowable) values:	Check only one of the following. Options for response are: □ Student was released to resume regular school schedule □ Student was released from school to parent/guardian’s care □ Student was transferred to other health care □ Other – please specify:__________________________________________ □ Unknown: Unable to determine from telehealth log or student visit record
Note for abstractions:
Source for definitions:	Rural Telehealth Research Center

Data element number:	Asthma - 12
Variable name:	Follow-up referral
Variable definition:	Indicates whether or not the student was referred for follow-up care at the end of the encounter
Data collection level:	Encounter
Criteria:	Students who received asthma services as part of the SB-TNGP during this measurement period
Valid (allowable) values:	Check only one of the following. Options for response are: □ Student was determined to NOT need referral for follow-up care □ Student was referred for follow-up return visit to SB-TNGP WITH telehealth □ Student was referred for follow-up return visit to SB-TNGP WITHOUT telehealth □ Student was referred to primary care provider outside of school □ Student was referred to specialty care outside of school □ Student was referred for other care outside of school □ Other – please specify:__________________________________________ □ Unknown: Unable to determine from telehealth log or student visit record
Note for abstractions:
Source for definitions:	Rural Telehealth Research Center

Data element number:	Asthma - 13
Variable name:	Avoided travel
Variable definition:	Indicates whether or not the student avoided travel for care because of this encounter
Data collection level:	Encounter
Criteria:	Students who received asthma services as part of the SB-TNGP during this measurement period
Skip logic:	NOTE the response to this question will be used for skip logic for the next two questions.
Valid (allowable) values:	Check only one of the following. Options for response are: □ Avoided travel for this encounter: The student received services through the SB-TNGP and if they had not received those services during this visit then the student would have had to see a provider elsewhere □ Did not avoid travel for this encounter: The student received services through the SB-TNGP but if they had not received those services during this visit then the student would NOT have had to see and travel to a provider elsewhere □ NA: Not Applicable □ Unknown: Unable to determine from telehealth log or student visit record
Note for abstractions:
Source for definitions:	Rural Telehealth Research Center

Data element number:	Asthma - 14
Variable name:	Provider if travel was avoided
Variable definition:	Indicates the type of provider the student would have seen if travel was avoided because of this encounter
Data collection level:	Encounter
Criteria:	Students who received asthma services as part of the SB-TNGP during this measurement period where travel was avoided
Skip logic:	NOTE that if the response to the previous question indicates that travel was avoided then this question will follow.
Valid (allowable) values:	Check only one of the following. Options for response are: □ Physician □ Asthma specialist □ Emergency Department or Urgent Care □ Other – please specify:__________________________________________ □ Unknown: Unable to determine from telehealth log or student visit record □ NA: Not Applicable
Note for abstractions:
Source for definitions:	Rural Telehealth Research Center

Data element number:	Asthma - 15
Variable name:	Patient travel miles to likely source of care
Variable definition:	Indicates the number of miles from the school to the type of provider the student would have likely seen if travel was avoided because of this encounter
Data collection level:	Encounter
Criteria:	Students who received asthma services as part of the SB-TNGP during this measurement period
Skip logic:	NOTE that if the response to the previous question indicates that travel was avoided then this question will follow.
Valid (allowable) values:	Any numeric character
Note for abstractions:	Enter miles from the School to student’s likely provider as specified in the previous question. Use Google maps or similar program to determine travel miles by car one way.
Source for definitions:	Modified PIMS

SB TNGP Data Element Dictionary – Version 0.4	Page 0