Form 1 TRC Performance Indicatator Data Collection Tool

OMB # 0915-XXXX

Expiration XX/XX/201X

TRC Performance Indicator Data Collection Tool

The Telehealth Resource Center (TRC) Performance Indicator Data Collection Tool is intended to collect data elements that are required for reporting to the Office for the Advancement of Telehealth (OAT) on TRC performance measures. The performance measures and associated data elements are designed to assess how the TRC program is meeting its goals to:

1. Expand the availability of telehealth services in underserved communities

2. Improve the quality, efficiency, and effectiveness of telehealth services

3. Promote knowledge exchange and dissemination about efficient and effective telehealth practices and technology

4. Establish sustainable technical assistance (TA) centers providing quality, unbiased TA for the development and expansion of effective and efficient telehealth services in underserved communities

OAT will require all TRC grantees to complete this tool every six months based on TRC activity for the preceding six-month reporting period. The TRC Performance Indicator Data Collection Tool collects telehealth service data at the telehealth program/network level, the originating site level, and also collects data on TRC activities, client service assessments and the impact of TRC activities. Please respond to all questions based on the current reporting period.

COMPLETE QUESTIONS 1-5 FOR ALL TELEHEALTH PROGRAM/NETWORKS IN THE TRC SERVICE AREA (only updates and new programs/networks will be entered in reporting periods after baseline data is entered).

Program-Level Distant Sites (Where Provider is Located)

1. Telehealth Program/Network Name

2. Telehealth Program/Network Status (Check one)

New

Existing and expanded

Existing and not expanded

Existing and reduced services/specialties offered

Existing but discontinued

OMB # 0915-XXXX

Expiration XX/XX/201X

3. Number of New Telehealth Services/Specialties Offered by the Telehealth Program/Network (for new and expanded programs)

­­­­­­­­­­­­­­­

4. Educational Services Delivered by the Telehealth Program/Network (Check all that apply)

Patient/community education

Provider education (Continuing education (CE) and non CE credit)

Support personnel education

No educational services delivered

5. Total Number of Originating Sites Served by the Telehealth Program/Network ________

QUESTIONS #1-5 will be repeated for each Network/Program in the TRC Service Area.

Originating Site Level (Where Patient is Located)

Please enter the following data elements in the table provided below for all originating sites in the TRC Service Area (only updates and new originating sites will be entered in reporting periods after baseline data is entered). If the originating site is the patient’s home, only enter the zipcode.

6. Program or Network Serving Originating Site

7. Setting Type of Originating Site

• Assisted Living Facility

• Community Health Center

• Health Department and Mental Health Agency

• Hospital ER

• Hospital In-Patient

• Hospital Outpatient

• Indian Health Clinic

• Licensed Nursing Home

OMB # 0915-XXXX

• Expiration XX/XX/201X

• Mobile Unit

• Non-Hospital Clinic (e.g. rural health clinic, migrant health clinic)

• Patient's Home

• Prison

• Private Medical Practice or Physician's Office

• School

• Other (specify)________________

8.1, 8.2 Originating Sites Names and Addresses- Using the originating sites’ names and addresses, PIMS will be able to automatically cross-map each site to the county where the site is located and will determine whether the site is in a MUA and/or a HPSA.

OMB # 0915-XXXX

Expiration XX/XX/201X

Originating Sites (Where Patient is Located)

For data elements 6, 7 and 8, it has been verified that it is possible for PIMS to upload a .csv file (created by an access database or an Excel document) as a way to ease TRC data entry burden.

6	7	8.1	8.2
Program/Network	Originating Site Type	Originating Site	Originating Site Address	City	State	Zip	County	Medical HPSA	Mental Health HPSA	Dental HPSA	MUA
(drop-down list of already entered programs from Data Element 1)	Values: (drop-down menu)	Enter Originating Site Name	This information will be used to look up County, MUA and Medical/Dental/Mental Health HPSA status via a web-based look up system				This data will be displayed for future updates but will be automatically generated by the PIMS system interfacing with a HPSA Finder Database.
Example:
University System A	Rural Hospital	Alpha Hospital	1234 Rural Rd	Ruraltown	CO	80002	Jefferson	Yes	Yes	Yes
University System A	FQHC	Beta FQHC	11 Main St.	Mill	CO	80003	Jefferson	Yes	Yes	Yes

OMB # 0915-XXXX

Expiration XX/XX/201X

Activities and Initiatives to Reduce Barriers to Telehealth

9. # of collaborative activities the TRC participated in to reduce barriers to telehealth during the current reporting period _________

10. Provide a brief narrative description of any specific major initiatives undertaken to reduce barriers to telehealth during the current reporting period.

Training/Technical Assistance

# of trainings/TA geared towards skill development in telehealth conducted by the TRC during the performance period. This could include project-specific TA and/or training around telehealth research, services, or operations.

11a. One-to-One trainings/TA___ 13a. # of hours spent on trainings/TA___

11b. Peer-to-Peer trainings/TA__12b.total # of attendees __13b. # of hours spent on trainings/TA__

11c. One-to-Many trainings/TA__12c. total # of attendees __13c. # of hours spent on trainings/TA__

14. Innovations Developed to Increase Telehealth Resources

Provide a narrative description of any significant innovations or training and technical assistance that the TRC may have developed/conducted in the reporting period that had a significant or great impact.

Educational Materials

14. # of educational materials (tools, templates etc.) developed or adapted by the TRC during performance period_______

14. # of educational materials provided/supplied by the TRC during performance period _______

TRC Operating Costs

14. TRC operating costs covered by non-federal sources/revenue-generating activities during the performance period $_____

OMB # 0915-XXXX

Expiration XX/XX/201X

14. Total TRC operating cost during the performance period $_____

19. 20. Client Service Assessment

Standard client service assessment questions	# of clients responding with a 4 or 5 (agree/strongly agree) on a 1-5 point Likert scale	# of clients answering question­
The TRC service was effective
The TRC service was valuable for your operations
The TRC guidance will/has help(ed) you with starting, expanding and/or operating your telehealth service
You would recommend the TRC to others
You are satisfied with the TRC consultation you received
Standard client service assessment questions	# of clients responding “yes”	# of clients answering question­
Do you perceive an improvement and/or enhancement in your telehealth services as a result of consulting with the TRC?

OMB # 0915-XXXX

Expiration XX/XX/201X

Requests for TRC Services

14. # of unique requests made for TRC services around developing and/or implementing telehealth _______

Please describe any challenges you experienced capturing data elements required for reporting in the TRC Performance Indicator Data Collection Tool.

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 0915-XXXX.  Public reporting burden for this collection of information is estimated to average .07 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 10-29, Rockville, Maryland, 20857.