and societal. Somewhat different evaluation strategies may be appropriate for various levels of decisionmaking.

At the clinical level, the evaluative focus is on the benefits, risks, and costs of alternative approaches to a health problem. For example, does digital teleradiology provide clinically acceptable images for breast cancer screening? What are the benefits and harms of telepsychiatry compared to the alternatives? Clinical evaluations provide critical guidance for decisions about individual patient care. An institutional decision to adopt a technology will, however, ordinarily require additional evidence of its feasibility and value.

At the institutional level, the focus includes not only the application but also its organizational context including administrative structures and practices, clients or customers, clinical and other personnel, and clinical protocols. An institution-level evaluation might ask the following kinds of questions: Has a teleradiology link between a rural hospital and an urban radiology center affected referrals or revenues for each institution? Does a telemedicine link for troops in remote locations reduce medical evacuations? Are clinicians and patients at each site satisfied with a teledermatology link between a university medical center and a capitated medical group? How do the costs compare to the alternatives (e.g., physically referring patients, adding another dermatologist to the group)? What factors (e.g., equipment location or ease of use) appear to underlie the results (positive or negative)? Positive results at this stage of evaluation may encourage diffusion of a technology on an institution-by-institution basis.

At the system or societal level, the focus expands to incorporate broader health care delivery and financing issues, particularly those involving the allocation of public resources. For example, does telemedicine have a role to play in state policies to support rural medical services? Or, more specifically, how do particular telemedicine applications compare to other policy options, such as area health education centers, direct subsidies for rural hospitals, and educational loan programs linked to practice in underserved areas? If the evaluation results look positive at this level, decisionmakers may support broad adoption and diffusion of the technology.

In developing an evaluative framework and related criteria, this committee has attempted to keep in mind evaluation issues at each of these levels. The distinctions are particularly relevant in the areas of

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