between 1990 and 1995 (Allen and Perednia, 1996). The review also suggested that teleradiology installations were growing at a similar pace, although getting accurate data on these programs has not been easy, in part because vendors have been reluctant to release sales information (Franken, 1996).

Newspapers, medical newsletters, and other sources document the development of the Internet as a vehicle for the formal and informal provision of medical advice. An increasing number of health-related organizations are establishing World Wide Web pages (including a number of programs described in this report),⁴ and a variety of individuals and groups have created less formal "chat groups" and other links that respond to many consumers for greater self-determination in medical care.⁵

The diversity of telemedicine demonstration projects is suggested by the 19 projects funded by the Office of Rural Health Policy (see Appendix A). The discussion below, which includes some of these projects, further illustrates the range of clinical applications of telemedicine. It includes both common and relatively uncommon applications. Some examples focus on clinical specialties (e.g., radiology) whereas others focus on populations or sites of care (e.g., prisons). Most programs have received governmental grants or other public subsidies, but some are essentially self-sustaining. This diversity underscores the challenge of designing evaluation strategies, measures, and data collection methods to fit different settings, populations, clinical conditions, and objectives.

As indicated earlier, the most common current applications of telemedicine (other than general telephone and fax communications) appear to involve radiologic image transmission within and among