1.1 EP TNP PIMS Template

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

Evidence-Based Telehealth Network Program (EB TNP)
Grant:

Start Date:

End Date:

Report Date:

Organization:
Submitted Date:
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].

1. Priorities
Priorities
Only include sites that are eligible for and receive EB TNP funding in the table below.
Did you provide services to patients in any of the following categories because of any
EB funding during this reporting period?

Type of Change

Primary Care
Acute Care
Behavioral Health Care
Maternal Care
Substance Use Disorder
Chronic Care Management
1. Priorities Form Comments

Is 1. Priorities Form Complete?
1. Priorities Form File Attachment
File Name

File Type

File Size

Upload Date
OMB Number: 0906-0043
Expiration Date:

Report Period:

Printed:

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

Evidence-Based Telehealth Network Program (EB TNP)
Grant:

Start Date:

End Date:

Report Date:

Organization:
Submitted Date:

2. Originating and Distant Sites
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.
Originating and Distant Sites
List of Selected Sites (Modify the List) and List of Selected Settings (Modify the List)
Site Name

City/Town

State

ZIP Code

Originatin Rural or
g or
Urban
Distant
Site (R/U)
Site (O/D)

Number of Each Type of Site in this Reporting Period

Setting

Number

Originating
Distant
2. Originating and Distant Sites Form Comments

Is 2. Originating and Distant Sites Form Complete?
2. Originating and Distant Sites Form File Attachment
File Name

File Type

File Size

Upload Date
OMB Number: 0906-0043
Expiration Date:

Report Period:

Printed:

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

Evidence-Based Telehealth Network Program (EB TNP)
Grant:

Start Date:

End Date:

Report Date:

Organization:
Submitted Date:

3. Specialties and Services, by Site
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. Data populated in ‘Total Sites with New Access to Services’ is the total number of ‘No’ responses for the
selected specialty in the ‘Was the specialty available in your community prior to this EB TNP funding?’ category.
Specialties and Services, by Site
List of Selected Sites (Modify the List) and List of Selected Specialties (Modify the List)
Originating Site

Specialty(s) actively available at this site
through telehealth

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

Total Sites with New Access to Services

Number

Number of sites that have access to Mental/Behavioral Health Care Services where access did
not exist in your community prior to this EB TNP funding
3. Specialties and Services, by Site Form Comments

Is 3. Specialties and Services, by Site Form Complete?
3. Specialties and Services, by Site Form File Attachment
File Name

File Type

File Size

Upload Date
OMB Number: 0906-0043
Expiration Date:

Report Period:

Printed:

Page 3 of 9

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

Evidence-Based Telehealth Network Program (EB TNP)
Grant:

Start Date:

End Date:

Report Date:

Organization:
Submitted Date:

4. Volume of Services, by Site and Specialty
Volume of Services, by Site and Specialty
Complete Form 3. Specialties and Services, by Site before inputting data in this form.
Only include 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 healthcare where patients use mobile medical devices to perform a routine test and send the test data to a
healthcare professional in real-time. Enter 0 if there is no data to report.
Volume of Services, by Site and Specialty
Originating Setting
Site

Specialty

Unique
Patients

Real-Time
Encounters

Remote
Patient
Monitoring
Encounters

Store-andForward
Encounters

Total Unique Patients and Encounters

Total Encounters

Number

Total Number of Unique Patients Served because of EB TNP funding
Total Number of Encounters because of EB TNP funding

4. Volume of Services, by Site and Specialty Form Comments
Please note that direct services have not started as of the first year of this grant funding
Is 4. Volume of Services, by Site and Specialty Form Complete?

Report Period:

Printed:

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

Evidence-Based Telehealth Network Program (EB TNP)
Grant:

Start Date:

End Date:

Report Date:

Organization:
Submitted Date:
4. Volume of Services, by Site and Specialty Form File Attachment
File Name

File Type

File Size

Upload Date
OMB Number: 0906-0043
Expiration Date:

Report Period:

Printed:

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

Evidence-Based Telehealth Network Program (EB TNP)
Grant:

Start Date:

End Date:

Report Date:

Organization:
Submitted Date:

5. Patient Travel Miles Saved
Patient Travel Miles Saved
Complete Form 4. Volume of Services, by Site and Specialty before inputting data in this form.

\

Only include sites that are eligible for and receive EB TNP funding. For the table below, capture the primary service
provided, total miles saved, and the number of encounters by each service provided. If the miles are in decimals,
round to the nearest whole number.
Patient Travel Miles Saved
Primary Service Provided to
Patient / Specialty

Total Miles Saved

Total Encounters

Total Miles Saved

Number

Patient Travel Miles Saved

5. Patient Travel Miles Saved Form Comments
Please note that no direct services have been provided as of the first year of this grant funding

Is 5. Patient Travel Miles Saved Form Complete?

5. Patient Travel Miles Saved Form File Attachment
File Name

Report Period:

File Type

Printed:

File Size

Upload Date

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

Evidence-Based Telehealth Network Program (EB TNP)
Grant:

Start Date:

End Date:

Report Date:

Organization:
Submitted Date:

6. Other Uses of the Telehealth Network
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. If
information in ‘Formal and Informal Education’ is unknown, enter ‘DK’. Distance learning is the education, of a provider
or other person, through electronic communication such as video conferencing.
Other Uses of the Telehealth Network

Number

Administrative Meetings
Distance Learning
Other – Specify:
Distance Learning (Formal and Informal Education)

Total Number
of Sessions

Total Number
of People

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)
6. Other Uses of the Telehealth Network Form Comments
We use Telehealth for Technical Assistance calls with HRSA. We have not implemented trainings specific to this
project but will be using broadly this second year and forward.
Is 6. Other Uses of the Telehealth Network Form Complete?
6. Other Uses of the Telehealth Network Form File Attachment
File Name

File Type

File Size

Upload Date
OMB Number: 0906-0043
Expiration Date:

Report Period:

Printed:

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

Evidence-Based Telehealth Network Program (EB TNP)
Grant:

Start Date:

End Date:

Report Date:

Organization:
Submitted Date:

7. Diabetes
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
A1c measure of the reporting period to complete the table below. Enter 0 if there is no data to report.
Diabetes

Number

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

7. Diabetes Form Comments
Please note that this grant is not focused on diabetes.
Is 7. Diabetes Form Complete?
7. Diabetes Form File Attachment
File Name

File Type

File Size

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OMB Number: 0906-0043
Expiration Date:

Report Period:

Printed:

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

Evidence-Based Telehealth Network Program (EB TNP)
Grant:

Start Date:

End Date:

Report Date:

Organization:
Submitted Date:

8. Mental/Behavioral Health
Mental/Behavioral Health
Complete Form 7. Diabetes before inputting data in this form.
Only include sites that are eligible for and receive EB TNP funding. Enter 0 if there is no data to report.
Mental/Behavioral Health

Number

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

8. Mental/Behavioral Health Form Comments
Please note that no direct services have been performed in the first year of this grant funding.
Is 8. Mental/Behavioral Health Form Complete?
8. Mental/Behavioral Health Form File Attachment
File Name

File Type

File Size

Upload Date
OMB Number: 0906-0043
Expiration Date:

Report Period:

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