have not been subjected to systematic comparative studies that assess their effects on the quality, accessibility, or cost of health care. Although telemedicine is hardly unique among health care services in lacking evidence of its effectiveness, the increasing demand for such evidence by health plans, patients, clinicians, and policymakers challenges advocates of clinical telemedicine to undertake more and better evaluations of its practicality, value, and affordability.

In response to the scarcity of sound evaluations, the National Library of Medicine (NLM) asked the Institute of Medicine (IOM) to develop a broad framework for evaluating clinical telemedicine. This report, developed by a 15-member committee of the IOM, presents that framework, which focuses on telemedicine's effects on the quality, accessibility, cost, and acceptability of health care. The objective is to encourage evaluations that will guide policymakers, reassure patients and clinicians, inform health plan managers, and help those who have invested in telemedicine to identify shortcomings and improve their programs. This report is aimed primarily at these policymakers, clinicians, patients, and managers, but it is also intended to provide context and support for researchers with an interest in evaluating information and communications technologies.

Telemedicine Past And Present

Historically, access concerns have driven much of the work to develop clinical telemedicine. Early applications often focused on remote populations scattered across mountainous areas, islands, open plains, and arctic regions where medical specialists and sometimes primary care practitioners were not easily reached. Most of the telemedicine projects from the 1960s through the early 1980s failed, however, to survive the end of grant funding or trial financing. Telecommunications costs tended to be high, and the technologies were awkward to use. Few projects appeared to be guided by a business plan or an appreciation of the project features and results necessary for a sustainable program.

Recently, another wave of interest in telemedicine has prompted a range of new activities. Costs have dropped for many of the information and communications technologies supporting telemedicine, and the developing National Information Infrastructure (NII) is making these technologies more commonplace and more easily used.

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