Form 1 CORRECTED PDF - FORM Evidence Based Telehealth Network P

OMB # 0906-XXXX-NEW. Expiration Date: (XX/XX/20XX)
Federal Office of Rural Health Policy (FORHP)
Office for the Advancement of Telehealth (OAT)
Evidence Based Tele-behavioral Health Network Program (EB THNP)
Substance Abuse Treatment Telehealth Network Grant Program (SAT TNGP)
RTRC Data Elements

Brief description of Data Elements to be reported during measurement period. The tables are
separated according to the Level column.
Domain
Access

Data Elements for Measure
1. Treatment group

ID

2. Treatment Site ID

ID

3. Patient ID

Demographics
Demographics

4. Age
5. Sex

Description of Data Element
Indicates whether the patient
was in the telehealth group or
the non-telehealth comparison
group
An ID assigned to each treatment
site
An ID assigned to each patient
that is converted to a nonlinkable ID when data are
submitted
The patient's age at intake
The patient's sex

Demographics

6. Race

The patient’s racial group

Patient

Demographics

7. Ethnicity

The patient’s ethnic group

Patient

Cost savings/
effectiveness
Cost savings/
effectiveness

8. Patient’s insurance status

The type of insurance that the
Patient
patient has at intake
Miles from the patient’s location Patient
to where the patient plans to
receive behavioral health services

Cost savings/
effectiveness

Cost savings/
effectiveness

Cost savings/
effectiveness

9. Patient travel miles to the
initial planned place of
behavioral health
services
10. Patient travel time to the
initial planned place of
behavioral health
services
11. Patient travel miles to
next likely source of
behavioral health
services
12. Patient travel time to
next likely source of

Level
Patient

Value
Check
one

Patient

#

Patient

#

Patient
Patient

#
Check
one
Check
one
Check
one
Check
one
#

Travel time from the patient’s
Patient
location to where the patient
plans to receive behavioral
health services
Miles from the patient’s location Patient
to the next likely source of
behavioral health services if the
planned place of services was not
available
Travel time from the patient’s
Patient
location to the next likely source

Rural Telehealth Research Center – Data Elements for EB THNP/SAT TNGP Grantees – 2019-5-16

#

#

#

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OMB # 0906-XXXX-NEW. Expiration Date: (XX/XX/20XX)
behavioral health
services
Cost savings/
effectiveness

13. Patient likelihood of using
next source of behavioral
health services

Domain
Clinical
outcomes

Data Elements for Measure
14. Assessment instrument
administration timing

Clinical
outcomes

15. Patient-Reported
Outcomes Measurement
Information System
(PROMIS) Global Health –
Mental Health score
(component)
16. PROMIS Global Health –
Physical Health score
(component)
17. PROMIS Global Health
score (total)

Clinical
outcomes
Clinical
outcomes
Clinical
outcomes

Clinical
outcomes

Clinical
outcomes

18. Patient Health
Questionnaire 9-item
(PHQ-9) depression
symptoms score
19. Generalized Anxiety
Disorder 7-item (GAD-7)
generalized anxiety
symptoms score
20. Drug Use Disorders
Identification Test –
Clinical utility (DUDIT-C)
substance use severity
score

Domain
Access

Data Elements for Measure
21. Treatment type

Access

22. Timing of encounter

of behavioral health services if
the planned place of services was
not available
The patient’s likelihood of using
next source of care for type of
service delivered

Patient

Check
one

Description of Data Element
The number of weeks since the
initiation of the treatment when
the assessment instrument(s)
were re-administered
Use the PROMIS to track patient
functioning scores (mental health
component)

Level
Intake
+
Repeat

Value
#

Intake
+
Repeat

Scale
score

Use the PROMIS to track patient
functioning scores (physical
health component)
Use the PROMIS to track patient
functioning scores (total global
health score)
Use the PHQ-9 to assess
depression symptoms

Intake
+
Repeat
Intake
+
Repeat
Intake
+
Repeat

Scale
score

Use the GAD-7 to assess anxiety
symptoms

Intake
+
Repeat

Scale
score

Use the DUDIT-C to assess
substance use severity

Intake
+
Repeat

Scale
score

Description of Data Element
Whether encounter was planned
for telehealth or non-telehealth
services
Number of days since first
treatment encounter

Level
Value
Encoun Check
ter
one

Rural Telehealth Research Center – Data Elements for EB THNP/SAT TNGP Grantees – 2019-5-16

Scale
score
Scale
score

Encoun #
ter

2

Commented [MKAS1]: Likelihood will be determined as one of
the following: Minimal; Some; Moderate; Great.

OMB # 0906-XXXX-NEW. Expiration Date: (XX/XX/20XX)
Access
Access

23. Therapy scheduling
success
24. Provider type

Clinical
outcomes

25. Patient’s behavioral
health diagnosis

Access & Cost
savings/
effectiveness
Clinical
outcomes

26. Treatment service type

Cost savings/
effectiveness

28. Treatment billing

27. Disposition
recommendation

Whether or not scheduled
session was completed
Type of provider/clinician seen
for behavioral health services
during this encounter
The ICD-10 code(s) associated
with the diagnosis established to
be chiefly responsible for the
behavioral health services
CPT code for each encounter

Encoun
ter
Encounter

Check
one
Check
one

Indicates the provider’s
recommended disposition for the
patient at the end of the
encounter
Indicates whether or not the
behavioral health services
encounter was billed to insurance

EnCheck
counter one

En#
counter

EnCheck
counter one

EnCheck
counter one

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 0906-XXXX-NEW. Public reporting burden for this collection of
information is estimated to average 14 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

Rural Telehealth Research Center – Data Elements for EB THNP/SAT TNGP Grantees – 2019-5-16

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OMB # 0906-XXXX-NEW. Expiration Date: (XX/XX/20XX)
suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room
14N136B, Rockville, Maryland, 20857.

Rural Telehealth Research Center – Data Elements for EB THNP/SAT TNGP Grantees – 2019-5-16

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