Form 1 RTRC Data Element Dictionary

OMB # 0906-0043 Expiration Date: XX/XX/202X

RTRC Data Element Dictionary for EB TNP

Data Dictionary for a Uniform Set of Data Elements to be Collected by EB TNP Grantees for a Data Pooling Study
The ultimate objective of this study is to enhance the evidence base for telehealth in rural settings by pooling data
collected across EB TNP grantees on the services they offer through telehealth and in-person care related to
primary care, urgent care, behavioral health, maternal care, substance use disorder, and/or chronic care
management services. Pooling data will be possible by using a standardized set of data elements. Based on
grantee feedback about data collection feasibility, RTRC selected the 27 data elements described in this
document. The first set includes 13 data elements that will be collected at the patient level once, the second set
includes 7 data elements that will be collected at each encounter, and the third set includes 7 data elements
representing clinical outcomes that will be collected at least quarterly on patients receiving relevant services. A
data collection tool will be used to assemble the data. This document is a resource for using that tool.

Instructions

Data elements that are collected at the PATIENT LEVEL ONCE
NOTE that this part of the document is specific to patient-level data elements that are collected
once at enrollment for each patient who received any health services as part of the EB TNP,
either through telehealth or in-person treatment. See protocol for clarification.

Data element number:
Variable name:
Variable definition:
Valid (allowable) values:
Notes for abstraction:

Data element number:
Variable name:
Variable definition:
Valid (allowable) values:
Notes for abstraction:

Patient – 1
Patient Identification
An ID assigned to each patient that is automatically converted to a non-linkable ID
when data are submitted to protect the patients’ confidentiality
Any alphanumeric character
• This field will only be used for internal (i.e. grantee/treatment facility) purposes
to help grantees link data elements from disparate data sources for the same
patient.
• As your internal identifier, the patient ID could be the patient’s full name or any
other unique identifier.
• The patient ID must remain consistent over the duration of the project.
• To protect the patients’ confidentiality, an anonymous (non-linkable) case ID will
be automatically assigned to the record before it is transmitted to RTRC. The
patient ID will never be uploaded or saved in the RTRC study database and is for
your own reference only. See protocol for clarification.
Patient – 2
Treatment site ID
An ID assigned to each treatment site
Any alphanumeric character
• The site will usually be the clinic/organization where the patient receives inperson services or where the provider/clinician providing telehealth is affiliated.

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• This is not literally where the patient is located receiving telehealth services, but
instead is the clinic where the patient is affiliated for ID purposes. This serves as
a tracking mechanism for data management activities. See protocol for
clarification.
• The name of the site should remain consistent for the duration of the study.
Data element number:
Variable name:
Variable definition:
Valid (allowable) values:
Notes for abstraction:

Patient – 3
EB TNP enrollment date
The date when patient enrolled in EB TNP
Date in the form of MM-DD-YYYY
• Enter the date when the patient was enrolled in the EB TNP and is ready to begin
receiving EB TNP services.
• This EB TNP enrollment date should precede any encounter dates that are
considered part of the EB TNP. See protocol for clarification.

Data element number:
Variable name:
Variable definition:

Patient – 4
Assigned treatment group
Indicates whether the patient is in the telehealth treatment group or the in-person
treatment group
Check only one of the following. Options for response are:
□ Telehealth Treatment Group: Indicates that the patient was assigned to the
telehealth treatment group
□ In-person Treatment Group: Indicates that the patient was assigned to the inperson comparison group
• This should indicate the patient’s initial assigned group. The patient is assigned to
the Telehealth Treatment Group if telehealth is intended to be the primary
treatment modality. The patient is assigned to the In-person Treatment Group if
the patient’s intended primary treatment modality is in-person. Note that
patients may occasionally “crossover” (i.e., receive treatment via the opposite
modality) during the course of the study. Regardless, the treatment group would
remain as originally assigned. See protocol for clarification.
EB TNP Notice of Funding Opportunity (NOFO)

Valid (allowable) values:

Notes for abstraction:

Source for definitions:
Data element number:
Variable name:
Variable definition:
Valid (allowable) values:
Notes for abstraction:

Patient – 5
Age at intake
The patient's age at EB TNP enrollment date
Any number
• Patient age (in years) should be determined at the EB TNP enrollment date.
• Do not round up. If the patient is X years and 11 months, then enter X years.
• If the patient is over 90 years old, then enter 90.
• Enter -1 if patient’s age is unknown.

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Data element number:
Variable name:
Variable definition:
Valid (allowable) values:

Notes for abstraction:
Data element number:
Variable name:
Variable definition:
Valid (allowable) values:

Notes for abstraction:

Patient – 6
Gender
The patient's gender
Check only one of the following. Options for response are:
□ Male
□ Female
□ Other: Can be used when/if patient is intersex or transitioning or nonbinary
□ Unknown: Unable to determine the patient’s gender or not stated (e.g., not
documented, conflicting documentation, or patient unwilling to provide)
• This can reflect the patient’s identified sex.
Patient – 7
Race
The patient's racial group
Check only one of the following. Options for response are:
□ White
□ Black or African American
□ Asian
□ Native Hawaiian or other Pacific Islander
□ American Indian or Alaska Native
□ More than one race: Patient’s race is composed of or representing more than one
racial group
□ Unknown: Unable to determine the patient’s race or not stated (e.g., not
documented, conflicting documentation, or patient unwilling to provide)
• White: A person having origins in any of the original peoples of Europe, the
Middle East, or North Africa (e.g., Caucasian, Iranian, White).
• Black or African American: A person having origins in any of the black racial
groups of Africa.
• Asian: A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian subcontinent including, for example, Cambodia,
China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, or
Vietnam.
• Native Hawaiian or other Pacific Islander: A person having origins in any of the
original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
• American Indian or Alaska Native: A person having origins in any of the original
peoples of North and South America (including Central America) and who
maintains tribal affiliation or community attachment (e.g., any recognized tribal
entity in North and South America [including Central America], Native American).
• If documentation indicates the patient has more than one race (e.g., BlackWhite, Indian-White), select “More than one race.”
• Although the terms “Hispanic” and “Latino” are actually descriptions of the
patient’s ethnicity, it is not uncommon to find them referenced as race. If the
patient’s race is documented only as Hispanic/Latino, select “Unknown.” If the
race is documented as mixed Hispanic/Latino with another race, use whatever
race is given (e.g., Black-Hispanic – select “Black”). Other terms for
Hispanic/Latino include Chicano, Cuban, H (for Hispanic), Latin American, Latina,

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Source for definitions:
Data element number:
Variable name:
Variable definition:
Valid (allowable) values:

Notes for abstraction:

Source for definitions:

Mexican, Mexican-American, Puerto Rican, South or Central American, and
Spanish.
US Census Bureau: https://www.census.gov/topics/population/race/about.html
Patient – 8
Ethnicity
The patient’s ethnic group
Check only one of the following. Options for response are:
□ Hispanic ethnicity or Latino/Latina
□ Not Hispanic or Not Latino/Latina
□ Unknown: Unable to determine the patient’s ethnicity or not stated (e.g., not
documented, conflicting documentation, or patient unwilling to provide)
• Hispanic ethnicity and Latino/Latina signifies a person of Cuban, Mexican, Puerto
Rican, South or Central American, or other Spanish culture or origin, regardless of
race. The term “Spanish origin” can be used in addition to “Hispanic or Latino.”
• Other terms for Hispanic/Latino include Chicano, Cuban, H (for Hispanic), Latin
American, Latina, Mexican, Mexican-American, Puerto Rican, South or Central
American, and Spanish.
US Census Bureau: https://www.census.gov/topics/population/hispanicorigin/about.html

Data element number:
Variable name:
Variable definition:
Valid (allowable) values:

Patient – 9
Language that the patient is best served in
Whether or not the patient is best served in English
Check only one of the following. Options for response are:
□ English: Patient is best served in English
□ Not English: Patient is best served in a language other than English
□ Unknown: Unable to determine the patient’s best language or not stated (e.g.,
not documented, conflicting documentation, or patient unwilling to provide)

Data element number:
Variable name:
Variable definition:
Valid (allowable) values:

Patient – 10
Patient’s insurance status
The primary type of insurance that the patient has at time of study enrollment.
Check only one of the following. Options for response are:
□ Medicare: Select this option if Medicare is listed as the primary payment source
□ Medicaid: Select this option if Medicaid is listed as the primary payment source
□ Dually Eligible Medicare/Medicaid: Select this option if both Medicare and
Medicaid are listed as payers
□ Private Insurance: Select this option if the primary payment source is worker’s
compensation or private insurance
□ Self-pay/uninsured: Select this option if the patient has no insurance coverage
and/or is paying out of pocket

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Notes for abstraction:

Source for definitions:

Data element number:
Variable name:
Variable definition:
Skip logic:
Valid (allowable) values:

Notes for abstraction:

Source for definitions:
Data element number:
Data element name:
Data element definition:
Valid (allowable) values:
Notes for abstraction:

□ Other, please specify:_____________________________________________
Select this option if the payment source does not coincide with one of the above
options (e.g. Veterans Administration, TRICARE/CHAMPUS)
□ Unknown: Unable to determine
• Medicare includes Fee-For-Service (DRG or PPS) and Medicare Advantage
(HMO/Medicare+ Choice).
• Although a patient’s insurance status may change over the course of their
participation in the study, this should reflect their status at the time of study
enrollment.
• If you select “Other, please specify:” an additional field will automatically display
for you to specify the patient’s insurance status.
National Center for Health Statistics, National Health Interview Survey:
ftp://ftp.cdc.gov/pub/Health_ Statistics/NCHS/Dataset_Documentation/
NHIS/2020/Adult-codebook.pdf
Patient – 11
EB TNP primary service provided to patient
Indicates the principal service to be provided to the patient through the EB TNP
NOTE that the checked box will be used in skip logic to open up relevant questions
in the third section of this data element dictionary.
Check only one of the following. Options for response are:
□ Primary care
□ Acute care
□ Behavioral health care
□ Maternal care without remote patient monitoring
□ Maternal care with remote patient monitoring
□ Substance use disorder
□ Chronic care management without remote patient monitoring
□ Chronic care management with remote patient monitoring
• Indicate the principal type of service specified in the EB TNP Notice of Funding
Opportunity (NOFO) the patient will be receiving at the time of enrollment.
• Patients may receive multiple services if more than one is available through the EB
TNP, however only one service much be chosen as the principal service that the
patient will receive. This choice will be made at the time of enrollment. See
protocol for clarification.
EB TNP Notice of Funding Opportunity (NOFO)
Patient – 12
Patient residence ZIP code
5-digit ZIP code for the location where the patient resides at time of study
enrollment.
Enter the ZIP code where the patient resides.
A valid 5-digit ZIP code in the form of #####
• Although a patient’s residence may change over the course of their participation
in the study, this should reflect their status at the time of study enrollment.

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• If the patient does not have a residence, enter the ZIP code where they most
frequently spend the night.
Data element number:
Variable name:
Variable definition:
Valid (allowable) values:
Notes for abstraction:

Instructions

Patient – 13
Patient travel miles to the planned place of health services
Miles from the patient’s residence to where the patient plans to receive health
services as part of the EB TNP
Any number
• See notes for item 12 (above) for instructions on definition of patient’s
residence.
• For patients in the telehealth treatment group, enter the miles from the patient’s
residence to where they would have to travel to receive in-person health
services comparable to what they will be receiving through telehealth.
• For patients in the in-person treatment group, enter the miles from the patient’s
residence to where they will travel to receive the primary planned in-person
health services.
• Use Google maps to determine the shortest travel miles by car one way.
• If the place of health services is sensitive, then enter the distance to a nearby
proxy location (e.g., nearly school or grocery).

Data elements that are collected at EACH SCHEDULED ENCOUNTER
NOTE that this part of the document pertains to data to be collected at each encounter for each
patient who receives either telehealth or in-person services through the EB TNP. Once the
patient is enrolled, all encounters that are scheduled to be delivered during the 12-month
follow-up period should be entered, with the exception of remote patient monitoring data
transmissions/monitoring/interpretation, which will only be entered once per month. See
protocol for clarification.

Data element number:
Variable name:
Variable definition:
Valid (allowable) values:
Notes for abstraction:

Encounter – 1
Scheduled encounter date
The date when an encounter was scheduled
Date in the form of MM-DD-YYYY
• This includes encounters that were completed and encounters that were
scheduled but not completed.
• If there were multiple scheduled encounters on the same day, then enter
information about each in a separate entry.

Data element number:
Variable name:
Variable definition:

Encounter – 2
Encounter modality
The modality intended for the encounter

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Valid (allowable) values:

Notes for abstraction:

Data element number:
Variable name:
Variable definition:
Skip logic:

Valid (allowable) values:

Notes for abstraction:

Check only one of the following. Options for response are:
□ Video telehealth service
□ Phone telehealth service
□ Remote patient monitoring service
□ Non-telehealth (in-person) service
□ Other, please specify: ____________________________________________
• Select the option that is most representative of the modality used during the
encounter if it is a telehealth service. For example, if there is an encounter for a
patient receiving remote patient monitoring services that occurs by phone, select
the second response option (encounter by phone telehealth service) and input the
associated CPT code in data field Encounter - 4.
• If you select “Other, please specify:” an additional field will automatically display
for you to specify the type of service provided.
• Patients in the Telehealth Treatment Group may, at times, be seen in an in-person
encounter. Likewise, patients in the In-person Treatment Group may, at times, be
seen in a telehealth encounter. See protocol for clarification.
Encounter – 3
Encounter status
Whether the scheduled session was completed, or reason if it was not completed
NOTE that if any box is checked other than the first (indicating that the scheduled
encounter was completed) then data collection for this encounter will be stopped
(no need to proceed) at this point and skip logic will be employed so that the
remaining data elements are not visible in the data collection tool.
Check only one of the following. Options for response are:
□ Completed: Scheduled encounter was completed
□ Technology failed: Scheduled encounter was NOT successfully completed because
TECHNOLOGY or electronic communication failed
□ Patient did not appear: Scheduled encounter did not occur because the PATIENT
failed to appear or refused service
□ Patient cancelled and/or rescheduled: Scheduled encounter did not occur because
the PATIENT cancelled the appointment and notified the clinician or provider or
rescheduled the appointment
□ Clinician did not appear: Scheduled encounter did not occur because the
CLINICIAN failed to appear
□ Clinician cancelled and/or rescheduled: Scheduled encounter did not occur
because the CLINICIAN cancelled the appointment and notified the patient or
rescheduled the appointment
□ Unknown: It is impossible to determine from EMR, log, or patient visit record why
a scheduled encounter did not occur
□ Other, please specify:__________________________________________
• Successful completion means that both the patient and provider attended the
encounter as scheduled, and that the encounter was normally concluded.
• If either the patient or the clinician failed to attend the encounter as scheduled,
then check the appropriate box indicating the reason.

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• If unable to determine whether the encounter was completed as scheduled,
select “Unknown.”
• If you select “Other, please specify:” an additional field will automatically display
for you to specify the status of the encounter.
• The encounter status MUST be “Completed” in order for the rest of the encounter
information to be recorded.
Data element number:
Variable name:
Variable definition:
Valid (allowable) values:

Notes for abstraction:

Data element number:
Variable name:
Variable definition:
Skip logic:

Valid (allowable) values:

Encounter – 4
Treatment service type
HCPCS (Healthcare Common Procedure Coding System) or CPT (Current Procedural
Terminology) code(s) for each encounter.
Any valid HCPCS or CPT code assigned to this encounter (i.e., the billed code). CPT
codes take the form of #####. HCPCS codes take the form of $#### (where ‘$’ is a
letter). Enter up to 5 codes.
• The primary HCPCS or CPT code is required.
• Additional HCPCS or CPT codes may be entered (up to 5 total).
• If a HCPCS or CPT code was not generated because the encounter was not billed
due to nonreimbursable provider, enter ‘99999’ in either the HCPCS or CPT field.
• Only enter a HCPCS or a CPT code for a given treatment service, do not enter
both. However, you may enter a HCPCS code for one treatment service and a
CPT code for a different treatment service in the same encounter.
• If no HCPCS or CPT code is generated because no service was provided (such as a
call from a patient to make an appointment), then this does not count as an
encounter and no encounter record should be generated.
Encounter – 5
Clinician type
Type of clinician seen for services during this encounter
For maternal care with remote patient monitoring or chronic care management with
remote patient monitoring that are entered once per month, record a separate
remote patient monitoring encounter for each billing clinician.
Check only one of the following. Options for response are:
□ Advanced Practice RN or Nurse Practitioner (APRN or NP)
□ Clinical Psychologist (PhD or PsyD)
□ Clinical Social Worker (MSW or LCSW)
□ LPCA/LPCC
□ Nurse or Nurse Educator or Nurse Therapist (RN or BSN or DPN)
□ Pharmacist (PharmD)
□ Physician Assistant (PA)
□ Primary Care Physician, Family Practice Physician, Internal Medicine (MD or DO)
□ Psychiatrist
□ Registered Dietitian (RD)
□ Specialist Physician (e.g., cardiologist, pulmonologist, OB/GYN)
□ Other, please specify:__________________________________________
□ Unknown: Unable to determine from EMR, log, or patient visit record

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Notes for abstraction:

• The word “clinician” is meant to include any type of health care professional
acting as a provider or clinician for the encounter.
• If more than one clinician was involved in an encounter then check the box
indicating the most essential clinician (i.e., the clinician for whom the encounter
CPT or HCPCS code was assigned).
• Check the appropriate box most closely aligning with the clinicians’ professional
credentials. If none of the options seem appropriate, check the “Other” box and
provide the clinician type.
• If you select “Other, please specify:” an additional field will automatically display
for you to specify the type of clinician.

Data element number:
Variable name:
Variable definition:

Encounter – 6
Patient’s diagnoses (ICD-10)
The International Classification of Diseases, Tenth Revision (ICD-10) code(s)
associated with the diagnosis established to be chiefly responsible for the services
during this encounter
_______ Any valid ICD-10 code listed as the primary diagnosis in the form of
XXXX.XX
_______ Any valid ICD-10 code listed as the secondary diagnosis in the form of
XXXX.XX. Check the ”N/A” box if no secondary diagnosis listed ICD-10 is
available
_______ Any valid ICD-10 code listed as the tertiary diagnosis in the form of
XXXX.XX. Check the ”N/A” box if no tertiary diagnosis listed ICD-10 is
available
• The primary ICD-10 code is required.

Valid (allowable) values:

Notes for abstraction:

Data element number:
Variable name:
Variable definition:
Valid (allowable) values:

Notes for abstraction:

Encounter – 7
Prescribed medications
Medication drug code (NDDF or RxNorm or NDCs) for each prescription medication
that was prescribed, modified, renewed, or discontinued during this encounter
Enter the prescription medication drug code and action type affected during this
encounter.
Check only one of the following for action type. Options for response are:
□ renewed: Medication was previously prescribed and renewed at this encounter
□ newly prescribed: Medication was newly prescribed at this encounter
□ increased admin. frequency or dose: Medication was previously prescribed at a
different dosage or frequency and increased at this encounter (either the dosage
or frequency or both were increased
□ decreased admin. frequency or dose: Medication was previously prescribed at a
different dosage or frequency and decreased at this encounter (either the dosage
or frequency or both were decreased)
□ discontinued: Medication was discontinued and no longer prescribed
□ other (please specify)
• Only enter drug codes for medications that are newly prescribed, modified,
renewed, or discontinued during this encounter.

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Source for definitions:

Instructions

• Do NOT enter any over-the-counter (OTC) medications, drugs, or supplements.
• Only enter one form of drug code (either NDDF or RxNorm or NDC) for each
prescribed medication.
• National Drug Codes (NDCs) are a 10- or 11-digit number in the form of 4-4-2 or
5-3-2 or 5-4-1.
• RxNorm Drug Codes are 11-digit numbers with no hyphens.
• NDDF (National Drug Data File) are typically a 6-digit number.
• Check the appropriate box for whether the medication was renewed, newly
prescribed, previously prescribed and increased, previously prescribed and
decreased, discontinued, or other (specify).
• If there was a previously prescribed medication that was modified at this
encounter, for example a prescription written in which there was a dosage
change made (e.g., going from 20 mg to 40 mg of fluoxetine) but the same drug
was prescribed, then indicate that this is a modified prescription.
• Use as many data fields in the data collection tool as necessary to enter all
medications when action was taken during this encounter.
• If you select “Other, please specify:” an additional field will automatically display
for you to specify the type of action.
https://www.fda.gov/drugs/drug-approvals-and-databases/national-drug-codedirectory

Data elements that are collected on PATIENTS RECEIVING RELATED SERVICES
NOTE that this part of the document pertains to data elements to be collected repeatedly during
the 12-month follow-up period as appropriate to the services the patient is receiving.
Generally, repeatedly means as often as clinically relevant, but quarterly at a minimum. See
protocol for clarification. Note that skip logic will be implemented in the data collection tool
such that only those data elements matching the patient’s service type will be visible.

Data element number:
Variable name:
Variable definition:
Skip logic:
Valid (allowable) values:
Notes for abstraction:

Encounter – 8
PHQ-9 depression symptoms score
Use the Patient Health Questionnaire – 9 (PHQ-9) to assess depression symptoms
NOTE that this item will appear only for patients receiving behavioral health or
substance use disorder services.
Numeric value between 0 and 27 or “N/A” if not applicable to this patient or
encounter
• Patients who receive behavioral health services during the measurement period
and whose primary complaint is depression or who have an ICD-10 code indicative
of depression should be administered the PHQ-9 periodically.
• Periodically means at enrollment (baseline at the beginning of treatment) and at
least quarterly for 12 months.

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Source for definitions:

Data element number:
Variable name:
Variable definition:
Skip logic:
Valid (allowable) values:
Notes for abstraction:

Source for definitions:

Data element number:
Variable name:
Variable definition:
Skip logic:

Valid (allowable) values:

Notes for abstraction:
Source for definitions:

• Check the “N/A” box if the patient did not have a primary complaint of depression
or did not have an ICD-10 code indicative of depression or if the PHQ-9 was not
administered during this encounter.
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: validity of a brief
depression severity measure. Journal of General Internal Medicine, 16(9), 606-13.
Encounter – 9
GAD-7 generalized anxiety symptoms score
Use the Generalized Anxiety Disorder Scale – 7 (GAD-7) to assess anxiety symptoms
NOTE that this item will appear only for patients receiving behavioral health care or
substance use disorder services.
Numeric value between 0 and 21 or “N/A” if not applicable to this patient or
encounter
• Patients who received behavioral health services during the measurement period
and whose primary complaint is anxiety or who have an ICD-10 code indicative of
anxiety should be administered the GAD-7 periodically.
• Periodically means at enrollment (baseline at the beginning of treatment) and at
least quarterly for 12 months.
• Check the “N/A” box if the patient did not have a primary complaint of anxiety or
did not have an ICD-10 code indicative of anxiety or if the GAD-7 was not
administered during this encounter.
Spitzer, R. L., Kroenke, K., Williams, J. B., & Lowe, B. (2006). A brief measure for
assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine,
166(10), 1092-1097. doi:10.1001/archinte.166.10.1092
Encounter – 10
Smoking status
The patient’s smoking status
NOTE that this item will appear for patients receiving primary care, acute care,
behavioral health care, substance use disorder, maternal care services, or chronic
care management.
Check only one of the following. Options for response are:
□ Patient is a current every day smoker
□ Patient is a current some day smoker
□ Patient is a smoker, current status unknown
□ Patient is a former smoker
□ Patient is a never smoker
□ N/A – not applicable for this patient
□ Unknown if ever smoked
• Smoking includes cigarettes, pipes, etc. but does not include chewing or vaping.
Centers for Disease Control and Prevention https://www.cdc.gov/nchs/nhis/tobacco/tobacco_recodes.htm

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Data element number:
Variable name:
Variable definition:
Skip logic:

Valid (allowable) values:

Notes for abstraction:

Source for definitions:

Data element number:
Variable name:
Variable definition:
Skip logic:
Valid (allowable) values:
Notes for abstraction:

Data element number:
Variable name:
Variable definition:
Skip logic:
Valid (allowable) values:
Notes for abstraction:

Encounter – 11
Vaping status
The patient’s vaping status
NOTE that this item will appear for patients receiving primary care, acute care,
behavioral health care, substance use disorder, maternal care services, or chronic
care management.
Check only one of the following. Options for response are:
□ Patient is a current every day vaper
□ Patient is a current some day vaper
□ Patient is a vaper, current status unknown
□ Patient is a former vaper
□ Patient is a never vaper
□ N/A – not applicable for this patient
□ Unknown if ever vaped
• Electronic cigarettes (e-cigarettes) and other electronic vaping products include
JUULs, vape pens, e-cigars, and others. These products are battery-powered and
usually contain nicotine and flavors such as fruit, mint, or candy. Vaping does not
include smoking cigarettes, pipes, etc. or chewing.
Centers for Disease Control and Prevention https://www.cdc.gov/nchs/nhis/tobacco/tobacco_recodes.htm
Encounter – 12
Blood pressure
The patient’s systolic and diastolic blood pressure
NOTE that this item will appear only for patients receiving primary care, acute care,
maternal care services, or chronic care management.
___ / ___ Blood pressure should be in the form of ###/### representing systolic
blood pressure followed by diastolic blood pressure in mmHg
• Blood pressure may be taken manually or by an electronic device.
• If blood pressure was taken multiple times during an encounter (that does not
involve remote patient monitoring), then enter the last reading.
• If blood pressure readings are assessed as part of remote patient monitoring, only
enter the value closest in time preceding the monthly review date.
• Check the “N/A” box when measurement is not available during this encounter.
Encounter – 13
HbA1c
The patient’s hemoglobin A1c value
NOTE that this item will appear only for patients receiving primary care, acute care,
maternal care services, or chronic care management.
HbA1c should be in the form of #.#%
• Check the “N/A” box when measurement is not available during this encounter.

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OMB # 0906-0043 Expiration Date: XX/XX/202X

Data element number:
Variable name:
Variable definition:
Skip logic:
Valid (allowable) values:

Notes for abstraction:

Encounter – 14
Height/weight/BMI
The patient’s height, weight, and/or BMI value
NOTE that this item will appear only for patients receiving primary care, acute care,
maternal care services, or chronic care management.
____ feet ____ inches height in feet and inches
____ centimeters
height in centimeters
____ pounds
weight in pounds
____ kilograms
weight in kilograms
____ BMI
body mass index
• There are multiple options for recording patient height / weight / BMI. Height can
be recorded in a combination of two fields – feet and inches – or in a single field –
inches or centimeters. Similarly, weight can be recorded either in the pounds filed
or the kilograms field. If both complete height and weight information is provided
(regardless of the options used), it is not necessary to report BMI. Otherwise, BMI
can be reported either as the index measure or as an age-adjusted percentile (for
those 20 years of age or younger).
• It is not necessary to enter data in all fields. Just enter the data available in the
documentation. For example, if height and weight are recorded in the
documentation, it is not necessary to calculate BMI separately to fill in that field.
• Check the “N/A” box when measurement is not available during this encounter.

Public Burden Statement: The purpose of the Evidence-Based Telehealth Network Program is to fund evidence-based
projects that utilize telehealth technologies through telehealth networks to improve access to, and the quality of,
health care services. This program will work to help HRSA assess the effectiveness of evidence-based practices with
the use of telehealth for patients, providers, and payers. 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 0906-0043 and it is valid until XX/XX/202X. This information collection is required to
obtain or retain a benefit [section 330I of the Public Health Service Act (42 U.S.C. 254c-14), as amended]. Public
reporting burden for this collection of information is estimated to average 36 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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