Form 1 Evidence-Based Telehealth Network Program_Data Dictionar

Evidence-Based Telehealth Network
Program
(EB TNP)
Performance Improvement
Measurement System
(PIMS)

Data Dictionary
May 17, 2023

TABLE OF CONTENTS
Introduction ..................................................................................................................................... 3
Configure Sites for this Reporting Period ........................................................................................ 3
Select Specialty Areas for this Reporting Period ............................................................................. 5
Select Settings for this Reporting Period ....................................................................................... 11
Configure this Reporting Period .................................................................................................... 13
Form 1: Priorities ........................................................................................................................... 13
Form 2: Originating and Distant Sites............................................................................................ 14
Form 3: Specialties and Services, by Site ....................................................................................... 16
Form 4: Volume of Services, by Site and Specialty ........................................................................ 17
Form 5: Patient Travel Miles Saved ............................................................................................... 18
Form 6: Other Uses of the Telehealth Network ............................................................................ 20
Form 7: Diabetes............................................................................................................................ 22
Form 8: Mental/Behavioral Health ................................................................................................ 23

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Introduction
The following document provides an overview of the Performance Improvement Measurement
Systems (PIMS) data and forms required for reporting for the 2021-2026 Evidence-Based
Telehealth Network Program (EB TNP). It includes each form required for PIMS reporting,
including an overview of that form, additional information or guidance on the data to be
reported, and includes screenshots as well as tables to show examples of the data fields.

Configure Sites for this Reporting Period
In this form, you will see listed all the sites that were active during your previous reporting
period for the EB TNP grant. Simply specify which of the sites remained active during the
current reporting period and add any new sites. If this is your first reporting period, you will
need to list all active sites.
Indicate the sites in which you had activity during this reporting period. Only sites that are
eligible for and receiving EB TNP 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
https://datawarehouse.hrsa.gov/tools/analyzers/geo/Rural.aspx. 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.
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.
When you are finished entering in data, click "Add" to add it to the table. Then click the "Save"
button to move to the next screen. See screenshots and table below for data fields requested
for each site.

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Data fields for EB TNP sites
Site Name:
Street Address:
City/Town:
County:
State:
Zip Code:
Originating or Distant Site (O/D):
Rural or Urban Site (R/U):
HPSA:

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MUA:
HCPN:
Primary Taxonomy:
NPI (Site):
EIN (if non-profit):
Site URL:

Select Specialty Areas for this Reporting Period
In this form, you will indicate the medical specialties and services provided via telehealth via
your EB TNP program. Indicate the specialties for which you had activity during this reporting
period. Only specialties that are eligible for and receiving EB TNP funding should be included.
You will see all the specialties listed, with those from your last reporting period checked; you
can remove checks to inactivate specialties you no longer offer or add checks beside new
specialties you have recently begun to offer. Please try to use the existing categories if possible,
using the catch-all ‘other’ category for small numbers in other specialties that don’t fit into
existing categories. If you require a Specialty which is not available on this list, please contact
the HRSA Project Officer for your grant.
Check the box in the left-most column to indicate each of the specialties/services in which you
had activity during this reporting period. If you leave this box unchecked, it will be recorded as
inactive and that specialty will not appear on any subsequent forms. When you are done, click
“Save” and you will be navigated to the Select Settings page. See screenshot along with a list of
selection options and definitions below.

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Specialties: Selection Menu & Definitions
The following is a list of medical specialties and services provided through telehealth:
• Acute Care Services – Health care services for patients who are suffering from serious
injuries, illnesses, or medical conditions, or who are recovering from major surgery. Acute
care is short-term, and services are designed and implemented with the goal of discharging
patients once they have rehabilitated to the point of stability. Acute care is the opposite of

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chronic care, which involves ongoing treatment for long-term illnesses and conditions. While
acute care may involve intensive treatment, this pattern of care is usually short in duration.
Allergy/Rheumatology/Immunology – Rheumatology: A subspecialty of internal
medicine concerned with the study of inflammatory or degenerative processes and
metabolic derangement of connective tissue structures which pertain to a variety of
musculoskeletal disorders, such as arthritis.1 Immunology: A medical specialty
concerned with the hypersensitivity of the individual to foreign substances and
protection from the resultant infection or disorder.2
Cardiology (includes CHF) – A branch of medicine that specializes in diagnosing and
treating diseases of the heart, blood vessels, and circulatory system. These diseases
include coronary artery disease, heart rhythm problems, and heart failure. 3
Cardiovascular Surgery - Surgery performed on the heart or blood vessels.4
Chronic Care Management – Provision of education, counseling, and other resources to
support improved outcomes for individuals with chronic conditions and/or recovery
post-procedure or treatment.
Clinical Pharmacology - The branch of pharmacology that deals directly with the
effectiveness and safety of drugs in humans.5
Dentistry - The profession concerned with the teeth, oral cavity, and associated
structures, and the diagnosis and treatment of their diseases including prevention and
the restoration of defective and missing tissue.6
Dermatology - A medical specialty concerned with the skin, its structure, functions,
diseases, and treatment.7
Diabetes Clinical Services – Diabetes care and support provided in a clinic setting. May
include insulin therapy; diabetes management education; support from a registered
dietitian and diabetes educator; and access to eye, kidney, and foot specialists.8
Emergency Medicine - The branch of medicine concerned with the evaluation and initial
treatment of urgent and emergent medical problems, such as those caused by accidents,
trauma, sudden illness, poisoning, or disasters. Emergency medical care can be provided
at the hospital or at sites outside the medical facility.9
Endocrinology Clinical Services - A branch of medicine that specializes in diagnosing and
treating disorders of the endocrine system, which includes the glands and organs that
make hormones. These disorders include diabetes, infertility, and thyroid, adrenal, and
pituitary gland problems.10
ENT (including surgery) – ENT (or otolaryngology) is a medical specialty which is focused
on the ears, nose, and throat. Medical and surgical procedures focus on the ear (ear

1

https://www.online-medical-dictionary.org/definitions-r/rheumatology.html
https://www.online-medical-dictionary.org/definitions-a/allergy-and-immunology.html
3
https://www.cancer.gov/publications/dictionaries/cancer-terms/def/cardiology
4
https://www.online-medical-dictionary.org/definitions-c/cardiovascular-surgical-procedures.html
5
https://www.online-medical-dictionary.org/definitions-p/pharmacology-clinical.html
6
https://www.online-medical-dictionary.org/definitions-d/dentistry.html
7
https://www.online-medical-dictionary.org/definitions-d/dermatology.html
8
https://www.mayoclinic.org/diseases-conditions/diabetes/care-at-mayo-clinic/mac-20371457
9
https://www.online-medical-dictionary.org/definitions-e/emergency-medicine.html
10
https://www.cancer.gov/publications/dictionaries/cancer-terms/def/endocrinology
2

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infections, balance disorders, ear noise (tinnitus), nerve pain, and facial and cranial
nerve disorders); nose (diagnose, manage and treat allergies, sinusitis, smell disorders,
polyps, and nasal obstruction); throat (managing diseases of the larynx (voice box) and
the upper aero-digestive tract or esophagus); and head and neck (treat infectious
diseases, both benign and malignant (cancerous) tumors, facial trauma, and
deformities).11
Gastroenterology - A subspecialty of internal medicine concerned with the study of the
physiology and diseases of the digestive system and related structures (esophagus, liver,
gallbladder, and pancreas).12
General Surgery - The branch of surgery that covers the main areas of surgical
treatment. General surgeons treat diseases of the abdomen, breast, head and neck,
blood vessels, and digestive tract. They also manage care of patients who have been
injured or who have deformities or other conditions that need surgery.13
Genetics - The study of genes and heredity. Heredity is the passing of genetic
information and traits (such as eye color and an increased chance of getting a certain
disease) from parents to offspring.14
Geriatrics - The branch of medicine concerned with the physiological and pathological
aspects of the aged, including the clinical problems of senescence and senility.15
Hematology - A subspecialty of internal medicine concerned with morphology,
physiology, and pathology of the blood and blood-forming tissues.16
Home Health - Home health care is a wide range of health care services that can be
given in your home for an illness or injury. Home health care is usually less expensive,
more convenient, and just as effective as care you get in a hospital or skilled nursing
facility (SNF).17 o Examples of skilled home health services include: o Wound care for
pressure sores or a surgical wound o Patient and caregiver education o Intravenous or
nutrition therapy o Injections o Monitoring serious illness and unstable health status
Hospice Services - A special way of caring for people who are terminally ill. Hospice care
involves a team-oriented approach that addresses the medical, physical, social,
emotional, and spiritual needs of the patient.
Infectious Disease - An illness caused by an infectious agent or its toxins that occurs
through the direct or indirect transmission of the infectious agent or its products from
an infected individual or via an animal, vector or the inanimate environment to a
susceptible animal or human host.18 Examples of infectious diseases include COVID-19,
influenza, HIV/AIDS, hepatitis, measles, meningococcal disease, and diphtheria.
Intensive Care Unit Services - An intensive care unit (ICU) provides the critical care and
life support for acutely ill and injured patients. ICU teams are multi-disciplinary, made

11

https://www.entcolumbia.org/about-us/what-otolaryngology
https://www.online-medical-dictionary.org/definitions-g/gastroenterology.html
13
https://www.cancer.gov/publications/dictionaries/cancer-terms/def/general-surgery
14
https://www.cancer.gov/publications/dictionaries/cancer-terms/def/genetics
15
https://www.online-medical-dictionary.org/definitions-g/geriatrics.html
16
https://www.online-medical-dictionary.org/definitions-h/hematology.html
17
https://www.medicare.gov/what-medicare-covers/whats-home-health-care
18
https://www.online-medical-dictionary.org/definitions-c/communicable-diseases.html
12

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up of highly skilled intensive care nurses, doctors and specialists trained in providing
critical care for patients with a variety of medical, surgical and trauma conditions. Some
hospital ICUs specialize in providing care for particular health conditions or injuries
including: major trauma, severe burns, respiratory failure, organ transplants, complex
spinal surgery, and cardiothoracic surgery. 19
Maternal Care Services – Organized services to provide health care to expectant,
nursing and postpartum mothers.
Mental/Behavioral Health Care Services – Mental/Behavioral Health Care Services are a
distinct profession with national standards for education, training, and clinical practice.
Clinical behavioral/mental health counselors are highly skilled professionals who provide
flexible, consumer-oriented therapy. They combine traditional psychotherapy with a
practical, problem-solving approach that creates a dynamic and efficient path for change
and problem resolution. Services may include assessment and diagnosis, psychotherapy,
treatment planning and utilization review, brief and solution-focused therapy,
alcoholism and substance use disorder treatment, psychoeducational and prevention
programs, and crisis management.20
Neonatology - A subspecialty of Pediatrics concerned with the newborn infant.21
Nephrology - A subspecialty of internal medicine concerned with the anatomy,
physiology, and pathology of the kidney.22
Neurology - A medical specialty concerned with the study of the structures, functions,
and diseases of the nervous system.23
Obstetrics/Gynecology – Obstetrics: A medical-surgical specialty concerned with
management and care of women during pregnancy, parturition, and the puerperium.24
Gynecology: A medical-surgical specialty concerned with the physiology and disorders
primarily of the female genital tract, as well as female endocrinology and reproductive
physiology.25
Oncology - A branch of medicine that specializes in the diagnosis and treatment of
cancer. It includes medical oncology (the use of chemotherapy, hormone therapy, and
other drugs to treat cancer), radiation oncology (the use of radiation therapy to treat
cancer), and surgical oncology (the use of surgery and other procedures to treat
cancer).26
Orthopedics (including surgery) - A surgical specialty which utilizes medical, surgical,
and physical methods to treat and correct deformities, diseases, and injuries to the
skeletal system, its articulations, and associated structures.27
Other
Pathology - A specialty concerned with the nature and cause of disease as expressed by

19

https://healthywa.wa.gov.au/Articles/F_I/Intensive-care-units-ICUs
https://amhca.site-ym.com/page/facts
21
https://www.online-medical-dictionary.org/definitions-n/neonatology.html
22
https://www.online-medical-dictionary.org/definitions-n/nephrology.htmlneur
23
https://www.online-medical-dictionary.org/definitions-n/neurology.html
24
https://www.online-medical-dictionary.org/definitions-o/obstetrics.html
25
https://www.online-medical-dictionary.org/definitions-g/gynecology.html
26
https://www.cancer.gov/publications/dictionaries/cancer-terms/search/oncology/?searchMode=Begins
27
https://www.online-medical-dictionary.org/definitions-o/orthopedics.html
20

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changes in cellular or tissue structure and function caused by the disease process.28
Pediatrics - Pediatrics is the specialty of medical science concerned with the physical,
mental, and social health of children from birth to young adulthood. Pediatric care
encompasses a broad spectrum of health services ranging from preventive health care
to the diagnosis and treatment of acute and chronic diseases.29
Physiatry/Physical Medicine - Physical medicine and rehabilitation (PM&R), also known
as physiatry or rehabilitation medicine, aims to enhance and restore functional ability
and quality of life to those with physical impairments or disabilities affecting the brain,
spinal cord, nerves, bones, joints, ligaments, muscles, and tendons.30
Physical Therapy - A branch of rehabilitative health that uses specially designed
exercises and equipment to help patients regain or improve their physical abilities.
Abbreviated PT. PT is appropriate for many types of patients, from infants born with
musculoskeletal birth defects, to adults suffering from sciatica or the after effects of
injury or surgery, to elderly post-stroke patients.31
Plastic Surgery - The branch of surgery concerned with restoration, reconstruction, or
improvement of defective, damaged, or missing structures.32
Primary Care Services - Primary health care is a whole-of-society approach to health and
well-being centered on the needs and preferences of individuals, families, and
communities. It addresses the broader determinants of health and focuses on the
comprehensive and interrelated aspects of physical, mental and social health and
wellbeing. It provides whole-person care for health needs throughout the lifespan, not
just for a set of specific diseases. Primary health care ensures people receive
comprehensive care - ranging from promotion and prevention to treatment,
rehabilitation and palliative care - as close as feasible to people’s everyday
environment.33
Psychiatry - Psychiatry is the branch of medicine focused on the diagnosis, treatment,
and prevention of mental, emotional and behavioral disorders.34
Pulmonology - A branch of medicine that specializes in diagnosing and treating diseases
of the lungs and other parts of the respiratory system. These diseases include asthma,
emphysema, tuberculosis, and pneumonia.35
Radiology - The use of radiation (such as x-rays) or other imaging technologies (such as
ultrasound and magnetic resonance imaging) to diagnose or treat disease.36
Rehabilitation - Restoration of human functions to the maximum degree possible in a
person or persons suffering from disease or injury.37

28

https://www.online-medical-dictionary.org/definitions-p/pathology.html
https://pediatrics.aappublications.org/content/135/4/780physiatry
30
https://www.aapmr.org/about-physiatry/about-physical-medicine-rehabilitation
31
https://www.medicinenet.com/script/main/art.asp?articlekey=11885
32
https://www.online-medical-dictionary.org/definitions-s/surgery-plastic.html
33
https://www.who.int/news-room/fact-sheets/detail/primary-health-care
34
https://www.psychiatry.org/patients-families/what-is-psychiatry-menu
35
https://www.cancer.gov/publications/dictionaries/cancer-terms/def/pulmonology
36
https://www.cancer.gov/publications/dictionaries/cancer-terms/def/radiology
37
https://www.online-medical-dictionary.org/definitions-r/rehabilitation.html
29

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Speech Therapy - Treatment for individuals with speech defects and disorders that
involves counseling and use of various exercises and aids to help the development of
new speech habits.38
Substance Use Disorder Services – Services provided to address the impacts of
substance use. They might include inpatient treatment, residential programs, partial
hospitalization or day treatment, outpatient and intensive outpatient programs, and
methadone clinics (also called opioid treatment programs).39
Surgical Specialties (other)

Select Settings for this Reporting Period
In this form, you will define the settings where patients received telehealth care via your EB
TNP program. Indicate the Settings for which you had activity during this reporting period.
Only settings that are eligible for and receiving EB TNP funding should be included. If you
require a setting which is not available on this list, please contact the HRSA Project Officer for
your grant.
Check the box in the left-most column to indicate all the patient settings in which you had
activity during this reporting period. If you leave the box unchecked, that setting will be
recorded as inactive and will not appear in subsequent forms. When you are done, click ‘Save’
and you will be navigated to the Configure report period page. See screenshot along with a
list of selection options and definitions below.

Settings: Selection Menu & Definitions

38
39

https://www.online-medical-dictionary.org/definitions-s/speech-therapy.html
https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4126.pdf

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Clinic (including RHC): A clinic means a building or portion of a building
containing offices or facilities for providing medical, dental, or behavioral
health services for outpatients.40
Community Health Center (including FQHCs): community-based and patientdirected organizations that deliver comprehensive, culturally competent, highquality primary health care services. Health centers also often integrate access
to pharmacy, mental health, substance use disorder, and oral health services
in areas where economic, geographic, or cultural barriers limit access to
affordable health care services. Health centers deliver care to the Nation’s
most vulnerable individuals and families, including people experiencing
homelessness, agricultural workers, residents of public housing, and the
Nation’s veterans.41
Health Care Provider in Private Practice: A professional business (such as that
of a doctor) that is not controlled or paid for by the government or a larger
company (such as a hospital).42
Higher Education Institution: Higher-educational institutions include not only
universities and colleges but also various professional schools that provide
preparation in such fields as law, theology, medicine, business, music, and art.
Higher education also includes teacher-training schools, junior colleges, and
institutes of technology.43
Home Health Service Provider: Home health care is a wide range of health
care services that can be given in your home for an illness or injury.44
Hospital (including CAH): An institution where the sick or injured are given
medical or surgical care.45
Local Health Department: The National Association of County and City Health
Officials (NACCHO), in collaboration with the Centers for Disease Control and
Prevention (CDC), defines a local health department as "an administrative or
service unit of local or state government, concerned with health, and carrying
some responsibility for the health of a jurisdiction smaller than the state." 46
Local or Regional Emergency Health Care Provider: An emergency medical
technician, paramedic, or first responder authorized under 16 Del.C. Ch 97. 47
Long Term Care Provider: Long-term care involves a variety of services
designed to meet a person's health or personal care needs during a short or
long period of time. These services help people live as independently and

40

https://www.lawinsider.com/dictionary/medical-clinic
https://bphc.hrsa.gov/about/what-is-a-health-center/index.html
42
https://www.merriam-webster.com/dictionary/private%20practice
43
https://www.britannica.com/topic/higher-education
44
https://www.medicare.gov/what-medicare-covers/whats-home-health-care
45
https://www.merriam-webster.com/dictionary/hospital
46
https://www.encyclopedia.com/education/encyclopedias-almanacs-transcripts-and-maps/state-and-localhealthdepartments
47
https://www.lawinsider.com/dictionary/emergencycareprovider#:~:text=Emergency%20care%20provider%20means%20an,responder%20authorized%20under%2016
%20D el.
41

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safely as possible when they can no longer perform everyday activities on their
own.48
Oral Health Provider: Providers that focus on the health of the teeth, gums,
and the entire oral-facial system that allows us to smile, speak, and chew. This
includes dentists, dental assistants, dental hygienists, and dental specialists.
Other
Other Publicly Funded Health or Social Service Agency: Examples include Area
Agencies on Aging, county mental health departments, community-based
youth programs, homeless shelters, job training agencies, etc.
Outpatient Mental Health Service Provider/Facility: Outpatient mental health
facility: A facility that primarily provides ambulatory clients/patients with less
than 24-hour outpatient mental health services for generally less than 3 hours
at a single visit. Services are provided on an individual, group or family basis,
usually in a clinic or similar facility.49
School Based Health Center: School-based health centers (SBHCs) provide
elementary, middle, and high school students a variety of health care services
on school premises or at offsite centers linked to schools. Teams of nurses,
nurse practitioners, and physicians often provide primary and preventive care
along with mental health care; reproductive health services may be offered in
middle and high schools, as allowed by district policy and state law.50

Configure this Reporting Period
This form contains ‘Are all Setup Options listed on the left menu complete?’ question. 'Save'
this form by selecting 'Yes' for 'Are all Setup Options listed on the left menu complete?'
question to display all the forms under Grantee Data Entry on the left menu. The forms under
the Grantee Data Entry will not be displayed when selected 'No' for this question.

Form 1: Priorities
Complete form below. Only include sites that are eligible for and receive EB TNP funding.

48

https://www.nia.nih.gov/health/what-long-term-care

49

https://info.nmhss.org/Definitions/index.asp#:~:text=Outpatient%20mental%20health%20facility%3A%20A,a%20c
linic%20or%20similar%20facility.
50
https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-forhealth/strategies/schoolbased-health-centers

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Services provided during reporting period
Did you provide services to patients in any of the following categories as a result of any EB
TNP funding during this reporting period?
Yes

No

Primary Care
Acute Care
Behavioral Health Care
Maternal Care
Substance Abuse Disorder
Chronic Care Management

Form 2: Originating and Distant Sites
Complete Form 1: Priorities before inputting data in this form. Only include sites that are eligible
for and receive EB TNP funding.
For EB TNP, the originating and distant sites are defined as:
• Originating Site: Location of the patient at the time the service is provided via a
telecommunications system.
• Distant Site: Site at which the physician or other licensed practitioner delivering the
service is located at the time the service is provided via telecommunications.

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List of Selected Sites and Settings (Modify the list of sites and/or settings if needed)
Site Name

City/Town

State

Zip
Code

Originating or
Distant Site
(O/D)

Rural or
Urban
Site
(R/U)

Setting

[grantee
generated
list]

[choose from
menu]

[grantee
generated
list]

[choose from
menu]

Number of Each Type of Site in this Reporting Period
Originating Sites

[#] auto-populate

Distant Sites

[#] auto-populate

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Form 3: Specialties and Services, by Site
Complete Form 2: Originating and Distant Sites before inputting data in this form. Only
include current active sites and specialties that are eligible for and receive EB TNP
funding during this reporting period.

List of Sites/List of Specialties (Modify the list of sites and/or specialties if needed)
Originating Site

Specialty(s) actively available at this
site through telehealth

Was the specialty available in your
community prior to this EB TNP
funding?

[grantee generated
site]

[choose from menu]

[Yes/No]

[choose from menu]

[Yes/No]

[grantee generated
site]

[choose from menu]

[Yes/No]

[choose from menu]

[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 EB TNP funding*

[#] autopopulate

*For each specialty listed in the configure report, it will total the number of sites that now have
access to that specialty as a result of EB TNP funding where that access did not previously exist.

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Form 4: Volume of Services, by Site and Specialty
Complete Form 3. Specialties and Services, by Site before inputting data in this form. Only
include the number of unique patients seen and encounters occurring as the result of EB TNP
funding.
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
pre-recorded videos through electronic communication to a practitioner who uses the
information to make an evaluation. Remote Patient Monitoring (RPM) Encounters are a type of
ambulatory health care where patients use mobile medical devices to perform a routine test and
send the test data to a health care professional in real-time.
Enter ‘0’ if there is no data to report.

Originating Site

Setting

Specialty

[grantee
generated list]

[grantee [grantee
generated generated
list]
list]

Unique Real-Time Remote Patient Store-and- Total
Patients Encounters Monitoring
Forward
Encounters
Encounters
Encounters

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[grantee
generated list]

[grantee [grantee
generated generated
list]
list]

Total Number of Unique Patients Served because of EB TNP funding

[#] auto- populate

Total Number of Encounters because of EB TNP funding

[#] auto-populate

Definitions
Unique Patient: If a patient is seen by an eligible provider more than once during the
reporting period, then for purposes of measurement that patient is only counted once for
the measure.51
Real-time encounters: Encounters that are live, two-way interactions between a person
and a provider using audiovisual telecommunications technology.
Store-and-forward encounters (i.e., asynchronous): The transmission of health information
through digital images or pre-recorded videos through electronic communication to a
practitioner who uses the information to make an evaluation.

Form 5: Patient Travel Miles Saved
Complete Form 4: Volume of Services, by Site and Specialty before inputting data in this form.
Only include sites and specialties that are eligible for and receive EB TNP funding.
For group sessions/clinics, each patient should be counted separately, as each would have had
to travel for these sessions.

51

https://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/Downloads/2013DefinitionEP_9_Record_Smoking_Status.pdf

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Primary service provided to patient /
Specialty

Total Miles Saved

Total Encounters

[grantee generated list]

[input total miles]

[input total encounters]

[grantee generated list]

[input total miles]

[input total encounters]

[grantee generated list]

[input total miles]

[input total encounters]

[grantee generated list]

[input total miles]

[input total encounters]

Total Miles Saved

[total miles]

Definitions
Distance: Grantees might use a standard, online mapping application such as Google Maps or
Mapquest to calculate the distance between the originating site at which patients receive
services through EB TNP and the locations where they would have been referred for each
specialty in the absence of EB TNP.
Total Encounters: The total number of patient encounters for that originating site and specialty.
Miles Saved: The number of total patient encounters multiplied by distance in miles between
sites (X 2) between the originating site and referral location for each specialty service.
• Calculation: Miles X Encounters X 2 = Miles Saved

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Example:
Primary service provided to patient
/ Specialty

Total Miles Saved Total
Encounters

Total Miles Saved Total
Encounters

Clinic A

Diabetes

567

Clinic B

Diabetes

1,325

Clinic A
Clinic C

Total Miles Saved

Behavioral Health

1,838

Behavioral Health

542
4,272

Form 6: Other Uses of the Telehealth Network
Complete Form 5: Patient Travel Miles Saved before inputting data in this form. Only include
sessions that are eligible for and receive EB TNP funding.
Enter ‘0’ if there is no data to report. Enter ‘DK’ if ‘Total Number of People’ is unknown.

Categories

Number of Sessions

Administrative Meetings
Distance Learning
Other – Specify:
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Definitions
Administrative Meetings: Administrative meetings might include meetings conducted to
operate the care site that might otherwise have required staff to travel to a “home office.”
Distance Learning: The incorporation of video and audio technologies, allowing students to
"attend" classes and training sessions that are being presented at a remote location. Distance
learning systems are usually interactive and are a tool in the delivery of training and education
to widely dispersed students, or in instances in which the instructor cannot travel to the
student's site.52

Formal and Informal Education

Total Number
of Sessions

Total Number of
People

Formal Education
Informal Education
Definitions
Formal Education: Sessions that are used to fulfill formal education, licensure, or certification
requirements. Typical characteristics of formal education may include well defined learning
goals/objectives, structured curriculum, and/or established assessment criteria.
Informal Education: Sessions that are used to meet regulatory practice requirements, as well as
supervision/advice requested by remote practitioners.

52

FORHP/OAT 2020 TNGP Notice of Funding Opportunity, p.47

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Form 7: Diabetes
Complete Form 6: Other Uses of the Telehealth Network before inputting data in this form.
Only include patients seen and encounters that occurred as a result of receiving EB TNP funding.
Use the most recent HbA1c measure of the reporting period for the table below.
Enter ‘0’ if there is no data to report.

Number of unduplicated patients with diabetes
served during the reporting period
Number of patients with diabetes (who
received services during the reporting period)
whose most recent Hemoglobin A1c (HbA1c)
level is 7.0% or less.
Number of patients with diabetes (who received
services 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 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.
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Form 8: Mental/Behavioral Health
Complete Form 7: Diabetes before inputting data in this form. Only include sites and patient
numbers that are eligible for and occurred as a result of receiving EB TNP funding. Provide
required data in the tables below.
Enter ‘0’ if there is no data to report.

Total number of adults who received
Mental/Behavioral Health services where access
did not exist prior to the EB TNP
grant
Total number of pediatric and adolescent
patients who received Mental/Behavioral Health
services where access did
not exist prior to the EB TNP grant

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