in a period of significant economic and political uncertainty. Continued support will, in large measure, depend on better evaluation and evidence of the practicality, value, acceptability, affordability, and profitability of telemedicine.

The Demand For Evidence Of Effectiveness

Although telemedicine faces some particular challenges in the realm of evaluation, it is hardly unique in facing demands for better evidence of its effectiveness and cost-effectiveness. For more than a decade, demand has been growing for better information about the effectiveness of specific health services (OTA, 1978, 1994; Eddy, 1984; Wennberg, 1984; IOM, 1985, 1990a; 1992a; Roper et al., 1988). The commonly cited sources of this demand include the sharp escalation in health care costs during the 1970s and 1980s, the documentation of wide variations in clinical practice, the proliferation of expensive medical technologies, and the publication of studies questioning the appropriateness of a variety of health care practices.

In response, a number of public and private initiatives have been launched to extend the evidence base for health care and to improve the use of such knowledge by clinicians, patients, and other decisionmakers (see, e.g., IOM, 1985, 1990a, 1992a; Ball, 1990; PPRC, 1989; OTA, 1994). These initiatives include the establishment in 1989 of the Agency for Health Care Policy and Research, a federal agency with a specific mandate to support research, guidelines development, and other activities to increase knowledge of what works and what does not work in health care. Some medical professional organizations, including the American College of Physicians, have an even longer record of efforts to assess the effectiveness of medical services and develop evidence-based guidelines for clinical practice. Elsewhere in the private sector (often with some public funding), initiatives include research-oriented ventures such as the Medical Outcomes Trust and the Cochrane Collaboration; market-oriented enterprises such as the technology assessment collaboration of the Blue Cross and Blue Shield Association and Kaiser Permanente of Southern California; and hybrid entities such as ECRI (formerly the Emergency Care Research Institute), a nonprofit technology assessment organization in Pennsylvania.

With the proliferation of advanced and even amazing new technologies,



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