and employer purchasers of health benefits to implement telemedicine as they have done with other measures (e.g., discounted fees, utilization review) that are unpopular with clinicians.

Those responsible for creating, sustaining, and evaluating information and telecommunications systems and programs face a bewildering and constantly changing array of hardware and software options, many of which are not tailored to health care uses. Assessing the utility of advanced information and telecommunications technologies is difficult, particularly given the need to consider options in combination, not just individually. Although many groups are working to develop hardware and software standards, it remains frustrating and difficult to put together systems in which the components operate predictably and smoothly together, work in different settings without extensive adaptation, and accommodate replacement components.

Getting the components of the human infrastructure of telemedicine to function efficiently and predictably is also a major challenge. The limited adoption of telemedicine is due in part to a variety of what are commonly called "human factors," including a poor fit with the environment, needs, and preferences of clinicians, patients, and other decisionmakers (both individuals and organizations). Clinicians and other decisionmakers may be skeptical of telemedicine's clinical effectiveness as well as its practicality in everyday use. Thus, the scarcity of telemedicine evaluations and evidence of benefits is itself an element in the human factors equation. In addition, those advocating, adopting, or evaluating telemedicine must recognize the uncertainties and even fears that clinicians and organizations may have about how telemedicine will affect them in a period characterized by increased competition, structural realignments, and surpluses of some categories of health professionals.

This chapter has considered some elements of the technical and human infrastructures of telemedicine that evaluators may need to investigate if they are to provide assessments that help decisionmakers determine why a program succeeded or failed and whether and how it might be redesigned to work better. The next chapter considers some policy issues that evaluators may need to consider as they affect the adoption and implementation of telemedicine programs.