and problems in evaluating telemedicine. It is aimed primarily at policymakers, clinicians, patients, and managers, but it should also provide context and support for researchers and evaluators with an interest in assessing information and telecommunications technologies.

Telemedicine In Context

Concerns about access to health care have propelled much of the interest in clinical applications of telemedicine. Applications have often concentrated on remote locales in the hope that they could make needed services more available to mountain families, tribal members on Indian reservations in the Southwest and the Dakotas, military personnel on tiny Pacific islands, and ranchers and others scattered across the country's open spaces. The promise has been that telemedicine could be more practical, affordable, and sustainable than traditional programs, including those intended to sustain or expand rural health care facilities and to attract physicians, nurses, and other personnel to remote areas on a short- or long-term basis. That this potential needs to be demonstrated is the thesis of this report.

Today, with the nation's health care system undergoing profound changes, telemedicine is attracting attention beyond rural areas. To the extent that telemedicine offers mechanisms for centralizing specialists, reducing costs for specialty care, and supporting primary care clinicians, managed care plans may find certain applications attractive in the urban and suburban areas they typically serve. Some academic medical centers, faced with reduced revenues and exclusion from local managed care networks, are exploring telemedicine options as they seek to develop new regional, national, and international markets for their highly specialized clinicians. Freestanding specialty groups, multiorganization medical consortia, and other entities likewise are investigating telemedicine as they seek far-flung clients for their services.

The prospect of a physician surplus coupled with declining personal income has become a real concern for many physicians, particularly specialists (Pew Health Professions Commission, 1995; IOM, 1996). Nurses likewise are facing pressures from decreasing hospital utilization and a reordering of nursing practices in managed care, although these may be offset to some degree by more options in

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