impact of certain kinds of changes. For example, an analysis of cost-effectiveness could include a sensitivity analysis that incorporates different assumptions about the timing and cost of key hardware or software upgrades or replacement (Briggs et al., 1994; Hamby, 1995).

In reviewing evaluations of telemedicine applications, the committee was often frustrated by the incomplete or casual documentation of the methods employed and the specific findings. One result was to diminish the utility and credibility of the reports. Efforts to identify weaknesses and improve documentation in research reports have been undertaken by a number of medical and health services research journals, including the Journal of the American Medical Association, Annals of Internal Medicine, Health Services Research, and Medical Care. They have developed guidelines and procedures to improve the clarity and specificity of abstracts, the processes of peer review, and the reporting of methods (including randomization procedures, sample sizes, and statistical power), data analysis and reporting, and sponsorship. (See, for example, DerSimonian et al., 1982; Pocock et al., 1987; Haynes et al., 1990; Altman and Goodman, 1994; Moher et al., 1994; Schulz et al., 1994; Sweitzer and Cullen, 1994; Taddio et al., 1994; Rennie, 1995; and Schulz, 1995.) At least one telemedicine publication, Telemedicine Journal, is attempting to follow this guidance. Although these suggestions have been aimed at journal editors, they have the important additional benefit of reinforcing basic principles of sound research and statistical analysis.

As noted at the beginning of this chapter, one objective of evaluation and applied research generally is to provide decisionmakers with information that will help them redesign and improve programs. This is particularly true for evaluations conducted in the context of a continuous quality improvement process. The tenets of continuous quality improvement, which were derived in considerable measure from industrial applications, are described in detail elsewhere (see, e.g., Deming, 1986; Batalden and Buchanan, 1989;