Form 1 PIMS Measures

OMB Number (0915-0311) Expiration date (XX/XX/202X)

Performance Measures
Telehealth Network Grant Program (TNGP)
Performance Improvement and Measurement System (PIMS)
Form 1: Priorities
Did you provide services to patients in any of the following categories because of any TNGP funding
during this reporting period?
Yes
No
Stroke
Mental Health/Behavioral Health
Substance Use Disorder

Form 2: Originating and Distant Sites

Complete Form 1. Priorities before inputting data in this form. Only sites that are
eligible for and receiving TNGP funding should be included.
List of Selected Sites (Modify the List of Sites if Needed) and Settings (Modify the List of Settings if
Needed)
Site
Street
Originating or Rural
City/Town
County
State Zip
Setting
Name
Address
Code
Distant Site
or
(O/D)
Urban
Site
(R/U)
Number of Each Type of Site in this Reporting Period
Originating Sites
Distant Sites

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OMB Number (0915-0311) Expiration date (XX/XX/202X)

Form 3: Specialties and Services, by Site

Complete Form 2. Originating and Distant Sites before inputting data in this form. Only
sites and specialties that are eligible for and receiving TNGP funding should be included.
List of Sites (Modify the List of Sites if Needed)/ List of Specialties (Modify the List of Specialties if
Needed)
Specialty(s) actively available at
Originating Site
Was specialty available in your
this site through telehealth
community prior to this TNGP
funding?
yes/no
Number of sites that have access to [specialty from configure report]
services where access did not exist in your community prior to this TNGP
funding
Number of sites that have access to [specialty from configure report]
services where access did not exist in your community prior to this TNGP
funding

Form 4: Volume of Services, by Site and Specialty

Complete Form 3. Specialties and Services, by Site before inputting data in this form.
Only unique patients seen and encounters occurring as the result of receiving TNGP funding should be
included.
Real-Time Encounters are encounters that are live, two-way interactions between a person and a
provider using audiovisual telecommunications technology. Store-and- Forward Encounters, also
called asynchronous, are the transmission of health information through digital images or prerecorded videos through electronic communication to a practitioner who uses the information to
make an evaluation.
Enter 0 if there is no data to report.
Originating
Site

Setting

Specialty

Unique
Patients

Number of
Real-Time
Encounter s

Total Number of Unique Patients Served because of TNGP funding
Total Number of Encounters because of TNGP funding

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Number of
Store-anForward
Encounter s

Total
Encounter s

OMB Number (0915-0311) Expiration date (XX/XX/202X)

Form 5: Patient Travel Miles and Time Saved

Complete Form 4: Volume of Services, by Site and Specialty before inputting data in
this form.
Only sites and specialties that are eligible for and receiving TNGP funding should be included.
Miles and time from the patient’s location to where the patient could receive health services in the
absence of telehealth.
Use Google maps or similar program to determine the shortest travel time by car one way. (If
multiple routes are possible, choose shortest travel time not shortest travel miles. Round trip will be
assumed to be twice one way travel.)
For group sessions/clinics, each patient should be counted separately, as each would have had to
travel for these sessions.
Originating
Site

Specialty

Name of
location
where patient
would have
been referred
in absence of
telehealth

Miles from
Originating
(patient) site to
location where
patient would
have been
referred in the
absence of
telehealth

Total Miles Saved
Total Time Saved

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Estimated
time for
travel in
previous
column

Total
Encounters

Miles
Saved
(Miles
X
Encoun
ters X
2)

Time
Saved
(Time X
Encoun
ters X
2)

OMB Number (0915-0311) Expiration date (XX/XX/202X)

Complete Form 5. Patient Travel Miles and Time Saved before inputting data in this form.
Form 6: Other Uses of the Telehealth Network

Provide required data in the tables below. Enter 0 if there is no data to report.
Enter ‘UNK’ if ‘Total Number of People’ is unknown.
Categories
Administrative Meetings
Distance Learning
Other

Number of Sessions

Formal and Informal Education
Formal Education (sessions are used to fulfill formal
education, licensure or certification requirements)
Informal Education (sessions used to meet
regulatory practice requirements, as well as
supervision/advice requested by remote practitioners)

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Total Number of
Sessions

Total Number of
People

OMB Number (0915-0311) Expiration date (XX/XX/202X)

Form 7: Diabetes

Complete form 6: Other Uses of the Telehealth Network before inputting data in this
form. Only patients seen and encounters occurring as a result of receiving TNGP funding should be
included.
Provide required data in the tables below. Enter 0 if there is no data to report.
Number of unduplicated patients with diabetes
served for at least three months during the
reporting period
Number of patients with diabetes (who
received services for at least three months
during the reporting period) whose most
recent Hemoglobin A1c (HbA1c) level is 7.0%
or less.
Number of patients with diabetes (who received
services for at least three months during the
reporting period) whose most recent
Hemoglobin A1c (HbA1c) level is between 7.1%
and 9.0%.
Number of patients with diabetes (who received
services for at least three months during the
reporting period) whose most recent
Hemoglobin A1c (HbA1c) level during the
measurement year was greater than 9.0% (poor
control), or if an HbA1c test was not done during
the reporting period.

Setup Forms:
Configure Sites:
Indicate the Sites in which you had activity during this reporting period. Only sites that are eligible for
and receiving TNGP funding should be included.
For the purposes of this grant program, rural is defined as all counties that are not designated as parts
of metropolitan areas (MAs) by the Office of Management and Budget (OMB). In addition, we use Rural
Urban Commuting Area Codes (RUCAs) to designate rural areas within MAs. This rural definition can be
accessed at HRSA’s Rural Health Grants Eligibility Analyzer. If the county is not entirely rural or urban,
follow the link for “Check Rural Health Grants Eligibility by Address” to determine if a specific site
qualifies as rural based on its specific census tract within an otherwise urban county.

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OMB Number (0915-0311) Expiration date (XX/XX/202X)

Originating (or spoke) sites are the sites where a patient is located and receiving care. Distant (or hub)
sites are the sites where the specialist is located and working.

Site Name:
Street Address:
City/Town:
County:
State:
Zip Code:
Originating or Distant Site (O/D):
Rural or Urban Site (R/U):
HPSA:
MUA:
HCPN:
Primary Taxonomy:
NPI (Site):
EIN (if non-profit):
Site URL:
Select Specialty Areas
Indicate the Specialties for which you had activity during this reporting period. Only Specialties that
are eligible for and receiving TNGP funding should be included.
Select Settings
Indicate the Settings for which you had activity during this reporting period. Only Settings that
are eligible for and receiving TNGP funding should be included.
Public Burden Statement: The purpose of this collection is to use a performance measurement tool to collect
data from grantees receiving funds under the Telehealth Network Grant Program. 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 information collection is 0915 -0311 and it is valid until
XX/XX/20XX. This information collection is required to obtain or retain a benefit (Section 330I of the Public
Health Service Act. The Health Care Safety Net Amendments of 2002 (Public Law 107-251) amended the Public
Health Service Act by adding Section 330I)]. Public reporting burden for this collection of information is
estimated to average 1 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 14N136B, Rockville, Maryland, 20857 or
[email protected]. 

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