programs with persistently low numbers of telemedicine consultations? Might some minimum number of cases be suggested as a floor? More generally, what kind of procedures, if any, are appropriate for training and then certifying proficiency in a particular telemedicine application?

How the volume-outcome hypothesis might apply for telemedicine is largely unexplored. One possibility is that quality of care would improve if the consultations involved both high-volume consultants and services those for which high volume was linked to better outcomes. Another possibility is that specialists who had received referrals that were subsequently handled through telemedicine consultation (with a different specialist) might lose the volume of cases needed to maintain their proficiency in diagnosing or treating certain problems. Even if local specialists were reasonably available, would more complex cases be diverted to distant telemedicine consultants? These unanswered questions have implications for both quality of care and access to care. The latter topic is discussed next.

Evaluating Access

From its beginnings, one of the major promises of telemedicine has been that it would improve access to health services for people living in rural or remote areas where medical professionals and facilities were scarce or altogether absent. This promise has been the rationale behind three decades' worth of demonstration projects targeted at rural areas. More recently, the potential for telemedicine to improve access for other groups—for example, the inner-city poor and the urban and suburban homebound—has attracted interest. An emerging issue is how a restructured health care system might employ telemedicine as part of increasingly aggressive strategies to manage patient access to services, especially hospital care and referrals to specialists.

Although the emphasis in telemedicine has been on geography or distance from health care providers as a barrier to timely care, other barriers to access also need to be considered in an evaluation framework


health plans attempt to concentrate patients needing a complex procedure in a few "centers of excellence" that perform the procedure frequently, present evidence of good outcomes, and offer an attractive price.

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