may erroneously imply to some that more physical resources automatically equate to more health benefit.

One additional distinction may need to be considered. That is, does a telemedicine application affect access only when it directly involves the patient (e.g., as does an interactive video consultation for a psychiatric problem) or does it also affect access when mediated through a clinician (e.g., as in the typical teleradiology consultation)? If telemedicine allows a clinician quicker access to important information that would support a decision to treat locally rather than transfer or refer, then the patient could be said to have more timely access to appropriate care and, thus, better access to care.

Clearly, access as defined here involves multiple dimensions, some of which (e.g., appropriate care) overlap with quality and cost evaluations. Moreover, the committee recognizes that transforming concepts such as "timely," "appropriate," and "undue burden" into operational measures and evaluating results may involve considerable subjective judgment.

Questions about Access to Care

Table 7.3 lists the questions related to access proposed by the committee. Again, the choice, formulation, and interpretation of specific questions will depend on the type of application, the context in which it is employed, the research design, and the resources available for evaluation. Some questions may overlap with those used in evaluating other outcomes, such as patient satisfaction.

In principle, access may be measured at the individual, group, or the population level. Because access questions are often raised in the context of concerns about disadvantaged groups, the policy and evaluation focus is, in fact, often on populations or population subgroups. A 1993 IOM report on indicators of access to health care identified several population-based utilization and outcomes measures that could be employed to monitor national access objectives (often with a focus on identified problem groups such as rural or minority populations). For example, one proposed indicator of the lack of access to timely and appropriate treatment was avoidable hospitalization for chronic diseases. The suggested measures for this indicator included admission rates for selected ambulatory-care-sensitive conditions (e.g., asthma, diabetes) as determined from hospital discharge abstracts for groups defined by income (based on zip code

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