(IOM, 1993a,b) A more comprehensive list of barriers would include

• significant distance from primary, secondary, and tertiary medical services;
• poor transportation (e.g., lack of an automobile, limited or nonexistent bus service), even for relatively short distances;
• inadequate financial resources, particularly insurance coverage or directly subsidized services;
• family, educational, and cultural factors (e.g., illiteracy, distrust of technology);
• delivery system characteristics, including poor coordination of care, long waiting times for appointments, inadequate numbers or kinds of specialists, and bureaucratic obstacles to services; and
• gaps in our knowledge about how these factors interact to affect the use of services and what can be done to overcome or eliminate barriers to access.

Further, access involves more than an open door to personal health services provided by health professionals. Today, telecommunications and information technologies permit greater access to health information and thereby allow patients, potential patients, and families to learn more about health problems, care options, and prevention strategies. For those without computers or even telephones, however, access to these information resources is more a promise than a reality. Community clinics may be able to provide some with access to information resources, but funding for such services and for the clinics themselves is vulnerable to retrenchment in public services and budgets. Deficits in literacy and language skills may create further difficulties for disadvantaged populations. The gap in access may actually widen if information services improve only for the more affluent and educated.

The committee notes that the availability of telemedicine for clinical, educational, and other purposes may aid in the recruitment and retention of health professionals in underserved areas, although this has not yet been systematically evaluated. Telemedicine has the potential to tie rural practitioners more closely to experts and colleagues in more urban areas and, thus, to reduce isolation. To the extent that managed care networks reduce professional opportunities