or use. The computer-based patient record is becoming a reality in many institutions. Nonetheless, for telemedicine and other services and technologies, the health system is still some distance from an integrated, longitudinal record that would allow patient outcomes to be compared and tracked across different settings, providers (including different managed care plans), time periods, and episodes of illness.

The committee found, in sum, that telemedicine is similar in most respects to other technologies for which better evidence of effectiveness is also being demanded. Telemedicine, however, has some special characteristics—shared with information technologies generally—that warrant particular notice from evaluators and decisionmakers. Most notably, telemedicine is not a single technology or a discrete set of related technologies; it is, rather, a large and very heterogeneous collection of clinical practices, technologies, and organizational arrangements. In addition, widespread adoption of effective telemedicine applications depends on a complex, broadly distributed technical and human infrastructure that is only partly in place and is being profoundly affected by rapid changes in health care, information, and communications systems. The difficulties encountered during more than two decades of work to implement integrated information systems suggests the importance of persistence and realism for those working to demonstrate telemedicine's promise.

Special challenges notwithstanding, more rigorous and systematic evaluation is as necessary for telemedicine as it is for other technologies. Decisionmakers still do not have good enough information comparing the effects of telemedicine applications to those of alternative health care strategies for quality, access, cost, and acceptability. Decisionmakers also lack good analyses of the infrastructure implications and requirements for sustaining telemedicine past an initial "test of concept" period. The evaluation and implementation of telemedicine projects will benefit from a careful project and evaluation plan and, when appropriate, a business plan that pays close attention to this infrastructure, to project management fundamentals, and to the relationship between the project/business plan and the mission and strategic plan of the parent institution. Although