factors that need to be tracked and understood as part of an evaluation of quality, access, cost, and acceptability outcomes.

Broader community effects may also be considered in an evaluation. Policymakers may, for example, be interested in the effects of telemedicine on the survival of rural health care providers and the implications of such effects for the overall economic health of rural areas, including their ability to attract or maintain business, educational, and other resources (OTA, 1991; Council on Competitiveness, 1994; GAO, 1996). For any specific evaluation, the selection of measures and criteria will depend on the telemedicine application, the alternatives to which it is compared, the target clinical problems and populations, the setting, and similar factors.

Evaluation Criteria And Questions

As defined in Chapter 1, an evaluation criterion is a measure, indicator, standard, or similar basis for describing outcomes or making judgments. Because clinical telemedicine varies so much, the committee broadly interpreted its charge to propose a set of evaluation criteria related to its evaluation framework. Applications differ in the medical problems addressed, the evidence base for decisionmaking, and the diagnostic, therapeutic, and other strategies employed. It would have been far beyond the resources for this project to develop operational measures or standards of care specific to the array of teleradiology, teledermatology, telepsychiatry, home health, emergency care, and other applications described in this report.

Rather, the committee started with the set of basic questions about quality, access, and cost that guide much health services research, particularly in the interrelated fields of clinical evaluation and technology assessment (IOM, 1993b, 1995a). Although patient satisfaction measures may be incorporated into assessments of quality of care, particularly in managed care plans (Cleary and McNeil, 1988; Gold and Wooldridge, 1995), more specific questions about patient and clinician satisfaction and other perceptions are presented separately in this chapter. Questions about health outcomes are largely subsumed in the discussion of quality but also enter into assessments of cost-effectiveness.

Table 7.1 lists the broad categories of questions proposed by the committee. The importance of comparing telemedicine to an alternative



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