Teleradiology appears to be the most common application, in part because Medicare and other payers reimburse for radiology consultations without demanding the face-to-face relationship required for most other consultations.

With the nation's health care system undergoing profound changes and experiencing relentless financial pressures, telemedicine is being investigated for its utility in urban as well as rural settings. To the extent that telemedicine offers a mechanism for centralizing specialists and supporting primary care clinicians, managed care plans may find certain applications efficient and attractive in the cities and suburbs where their patients are concentrated. Some academic medical centers and other organizations, faced with reduced revenues and even exclusion from local managed care networks, are exploring telemedicine as they seek to develop new regional, national, and international markets for their highly specialized clinicians. In these contexts, telemedicine has the potential to radically reshape health care in both positive and negative ways and to fundamentally alter the personal face-to-face relationship that has been the model for medical care for generations.

Despite recent growth, obstacles to widespread use of clinical telemedicine persist. For example, although many groups are working to develop hardware and software standards, it remains frustrating and difficult to put together systems in which the components operate predictably and smoothly together, work in different settings without extensive adaptation, and accommodate replacement components. Technical systems still may be poorly adapted to the human infrastructure of health care, that is, the work environment, needs, and preferences of clinicians, patients, and other decisionmakers. Moreover, sustainable telemedicine programs require attention to organizational business objectives and strategic plans that is not always evident in current applications.

In a period characterized by increased competition, structural realignments, and surpluses of some categories of health professionals, clinicians may see telemedicine as an economic threat. Even though interstate telemedicine is not a priority for many users or potential users, jurisdictional issues relating to professional licensure and medical liability are generating considerable controversy. As computer-based patient information systems and databases have proliferated, the relative weakness of state and federal policies to protect

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