to expand beyond institutional boundaries. Multi-institutional teleradiology networks are emerging. Telequest, for example, is a teleradiology venture recently created by five academic medical centers (Bowman Gray, the Brigham and Women's Hospital, Emory University, the University of California at San Francisco, and the University of Pennsylvania) (Gore, 1996). Some of the individual and multi-institutional teleradiology ventures are probably outgrowths, in part, of excess medical center capacity in the United States (see Pew Health Professions Commission, 1995; IOM, 1996). They illustrate how academic medical centers may look to telemedicine as a way to expand markets nationally and internationally and to offset revenue losses in a changing health care and government environment. As two experienced academic teleradiology experts have described it, "to be digitally aware is to realize the new era of competition" in a cost-constrained environment (Mun and Freedman, 1996).

One additional argument for teleradiology is that it has the potential to improve the quality and reduce the variability of image interpretation. This long-standing concern in the field arises because general radiologists may spend only a small portion of their time on certain tasks such as mammogram interpretation and may lack the knowledge and volume of experience of subspecialists (Beam et al., 1996). On the other hand, debate continues about the diagnostic accuracy of teleradiology, quality assurance requirements, and the appropriate trade-offs between accuracy and more timely consultation in some areas (Forsberg, 1995; Franken, 1996). A number of studies have compared digital or digitized images and film (see Chapter 5), but the broader quality implications of teleradiology have yet to be evaluated.

Care in the Home and Other Nonclinical Sites

The use of telemedicine in home and other nonclinical settings illustrates the significance of nonvideo means for providing information and advice and for monitoring patient status. The most familiar nonvideo telemedicine option is the use of the telephone. Physicians, nurses, and other personnel routinely talk with patients and families—providing information, checking their status, and offering reassurance—without the expense or inconvenience of an office visit for the patient or a home visit for the clinician. To reduce avoidable



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