many of them in abstract form, this study did not focus on application-specific measures and criteria.

Instead, to guide the selection of evaluation criteria or measures for particular evaluation projects, it proposed broadly relevant questions about the quality, accessibility, cost, and acceptability of telemedicine services. Quality is the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Access refers to the timely receipt of appropriate care (or, more informally, the right care at the right time without undue burden). The cost of care is the economic value of resource use associated with the pursuit of defined objectives or outcomes. Acceptability refers to the degree to which patients, clinicians, or others are satisfied with a service or willing to use it. In some telemedicine evaluations, patient satisfaction data appear to be the only patient-level data collected, a focus that the committee considers too limiting.

Box S.2 presents the basic categories of evaluation questions identified by the committee, and the appendix to this summary lists more specific questions in each category. Although the questions present the concepts of quality, access, cost, and acceptability in sequence, their interactions and interrelationships also warrant evaluation. More generally, the questions should be considered in the context of the overall evaluation framework. That is, relevant patient and organizational characteristics should be identified and considered as they might affect results. The actual as well as the planned technical and clinical processes should be recorded. The fit between the project objectives and results and the sponsoring organization's purposes or strategic plan also needs to be factored into the plan for analysis and the interpretation of results.

For some evaluation results, the findings will strongly suggest certain decisions. For example, if a telemedicine application is more costly than the alternative and performs less well (e.g., produces fewer health benefits), it should not be adopted. Likewise, if the application is more costly and performs as well, it should not be adopted. In contrast, if the telemedicine application is less costly but performs better than the alternative or if it is less costly and performs as well, it should be considered. Results are sometimes more equivocal and decisions more difficult. For example, if a telemedicine



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