Finally, the definition deliberately omits resource constraints on the grounds that judgments of what constitutes excellent, acceptable, or unacceptable quality should be independent of constraints on resources. This does not, however, imply that decisionmakers can or should ignore resources in making decisions about what level of quality is desired and affordable.

In recent years, traditional quality assessment and assurance concepts and strategies in health care have been powerfully reshaped by proponents of continuous quality improvement or total quality management models. These models stress internal responsibility for quality rather than external regulation. As noted in Chapter 6, they also posit planning, control, assessment, and improvement activities grounded in statistical and scientific precepts and driven by data.

Conventionally, three broad types of quality problems have been differentiated. They are overuse of care (e.g., unnecessary telemedicine consultations); underuse of care (e.g., failure to refer a patient for a necessary consultation); and poor technical or interpersonal performance (e.g., incorrect interpretation of pathology specimen or inattention to patient concerns). In principle, no one of these three problems is more important than any other. Depending, however, on the setting, the clinical condition, the predominant financing mechanism, and other circumstances, one area may warrant more attention than another in a particular telemedicine evaluation. For instance, as discussed in Chapter 4, policymakers have been concerned that payment for telemedicine in a fee-for-service context might lead to excessive consultations that might, in turn, lead to overuse of diagnostic or therapeutic services for which the benefit would not be worth the risk. In capitated environments, the worry has been that financial incentives might lead to underuse of appropriate face-to-face consultations or other services and to poorer performance in the interpersonal aspects of patient care, including good communication between clinician and patient.

For purposes of this discussion and consistent with past usage in IOM reports, appropriate care is defined as care for which "the expected health benefit [exceeds] the expected negative consequences by a sufficient margin" that the care is worth providing (Park et al., 1986, p. 6). At what point is the extra margin of expected benefit such that an intervention might be "worth" any additional risk, therefore making the intervention appropriate? Answering this question

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