of program design, implementation, and redesign. Second, evaluation should be understood as a cumulative and forward-looking process for building useful knowledge and as guidance for program or policy improvement rather than as an isolated exercise in project assessment. Third, the benefits and costs of specific telemedicine applications should be compared with those of current practice or reasonable alternatives to current practice. Careful comparison is the core of evaluation.

Fourth, the potential benefits and costs of telemedicine should be broadly construed to promote the identification and measurement of unexpected and possibly unwanted effects and to encourage an assessment of overall effects on all significant parties. Fifth, in considering evaluation options and strategies, the accent should be on identifying the least costly and most practical ways of achieving desired results rather than investigating the most exciting or advanced telemedicine options. Sixth, by focusing on the clinical, financial, institutional, and social objectives and needs of those who may benefit or suffer from telemedicine, evaluations can avoid excessive preoccupation with the characteristics and demands of individual technologies.

The committee recognizes that actual evaluations face a variety of methodological, financial, political, and organizational constraints. Nonetheless, based on its review of current applications and evaluations, the committee believes that considerable improvement can be achieved in the quality and rigor of telemedicine evaluations and, thereby, in the utility of the information and guidance they provide to decisionmakers.

Before presenting the evaluation framework, the committee thought it was important to underscore the significance of systematic planning for evaluation. Evaluation is too often an afterthought, considered after the seemingly more important issues of putting a program together are settled. This approach jeopardizes the potential for the evaluation plan, the program plan, and program implementation to operate together to answer questions about the program's benefits and costs. For example, an effort to assess whether a telemedicine application is likely to be sustainable after a demonstration period will be more useful if the conditions for sustained