in urban and suburban communities and drive physicians and others to consider practice in underserved areas, clinical and educational uses of telemedicine could provide social and intellectual support that would ease such relocations.

Definitions and Concepts

Access was defined in Chapter 1 as the timely receipt of appropriate health care. More informally, access might be described as the availability of the right care at the right time without undue burden. The latter conceptualization maintains the notions of timeliness and appropriateness but adds two elements to the understanding of access: availability and burden.

One element, availability, incorporates the notion of services that stand ready for use if and when needed. Residents of an area may be considered to have access to available services (e.g., a nearby emergency department) even if most people never need or use them. The other element in the informal definition, undue burden, suggests that the difficulty of actually obtaining appropriate services should be considered in evaluating access. For example, if a telepsychiatry consultation saves a patient and others a risky trip over bad winter roads, then it has affected access. Similarly, if telemedicine helps ventilator-dependent patients avoid the burden of transport from the home to a physician's office, then access is affected. What constitutes an undue burden will clearly vary across individuals with differing incomes, insurance coverage, transportation resources, physical limitations, employment situations, and other characteristics. Whether a reduced burden for a patient is worth the cost involved is an important but separate question.

Both formal and informal conceptualizations of access imply that the evaluative focus ought to be on people's ability to get appropriate care rather than on their ability to get any service, whether appropriate or not. Although this point is easy to make, it is more difficult to translate into operational measures, in part because of disagreement about what constitutes appropriate care for specific problems and in part because of the difficulty of data collection or interpretation. As a result, resources (e.g., hospital beds or physicians per 1,000 population) are often used as indicators and may be acceptable for some evaluations. Nonetheless, the use of such measures



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