TTAC Telemedicine Questionnaire April 2020

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Last chance DEADLINE: Wednesday, April 29, 2020 by noon PST

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Full Name: *

Title: *

Company/Organization: *

Street Address: *

City: *

State: *

Zip Code: *

Phone: *

E-mail: *

Please provide a brief overview of your company, include products and services: *

What platform do you use? *

Is this your platform? *

Yes

No

Name of third party platform: Name of third party platform:

Is it video-based? *

Yes

No

Can it be either video or audio? *

Yes

No

Can it be asynchronous? *

Yes

No

What is the video platform? *

What is the audio platform? *

Does the platform integrate with electronic medical records? *

Yes

No

What EMRs are you integrated with now? *

Do you offer different “levels” of service dependent upon the purchaser? Please describe. *

Yes

No No

Does your solution provide for... *

	Yes	No
Scheduling for clinic to clinic?	Yes	No
Scheduling across the organization?	Yes	No
Scheduling direct to consumer?	Yes	No
Call routing (cascade routing)?	Yes	No

Ease of use for providers- *

	Answers
Describe why providers find your solution easy to use	Answers
How long does it take to set up your solution?	Answers
Does the provider need special equipment? If yes, how do they get it?	Answers
Does the provider need special software/Apps? If yes, how do they get it?	Answers

Ease of use for consumers/patients- *

	Answers
Describe why consumers/patients find your solution easy to use	Answers
How long does it take to set up your solution?	Answers
Does the consumer/patient need special equipment? If yes, how do they get it?	Answers
Does the consumer/patient need special software/Apps? If yes, how do they get it?	Answers

Connectivity requirements- *

	Yes	No
Cellular	Yes	No
WiFi/Internet	Yes	No

Connectivity (bandwidth) requirements? *

How much space does your APP take on a mobile device? *

Does your solution allow medical peripherals to be used? Please list peripherals. *

Yes

No No

Who reimburses the provider for the service? *

Please list private payers that pay for services under your solution: *

Provider Panels and Mixed Use Options- *

	Yes	No
Do you provide a provider panel?	Yes	No
Can the customer use their own providers?	Yes	No
Do you offer a mixed service (customer uses own providers and your providers)?	Yes	No

If you offer a mixed use solution, please explain options available: *

How many customers use your solution? *

0-10

11-25

26-50

51+

List types of customers who use your solution (ie. health care systems, employers, medical groups, government agencies): *

Home many consumer calls has your solution answered in the past 12 months? *

Please indicate any charges for the items below. Provide a basic estimate of the standard costs in procuring your services for any of those that apply. If the item does not apply then write n/a. *

	Please answer all questions that apply
Set-up costs	Please answer all questions that apply
Software licensing (what does that include)	Please answer all questions that apply
Cost per patient (or per number of patients)	Please answer all questions that apply
Charges for additional specialties	Please answer all questions that apply
Cost per call (call charge)	Please answer all questions that apply
Cost for provider (provider charge)	Please answer all questions that apply
Annual fees	Please answer all questions that apply
Maintenance/updates	Please answer all questions that apply
Support	Please answer all questions that apply
Other	Please answer all questions that apply

Please send any supporting documentation to telehealthconsultant@gmail.com

Thank you for your time and input!