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Key developments in telecommunications essential to meeting the demand generated by health care activities include the availability of high-speed communication networks in sparsely populated areas. The economic and cultural aspects of the telemedicine applications can then be identified, demonstrated, and evaluated. Technology related to high-density storage and retrieval of medical images and related patient data is immature. Much work remains to be done to achieve reliable and cost-effective systems that will support patient care, medical research and education, and health care administration. The proliferation of personal computers and the increase in computer literacy are major factors in user acceptance of telemedicine and related technology.

Interaction Between Technical and Nontechnical Factors

The regulatory authority of federal, state, and local agencies to set tariffs has resulted in barriers to the economic reality of telemedicine. If the quality of health care is to be maintained in a cost-effective manner using the NII, clinical data must be transmitted promptly within cost constraints.

Other legal and regulatory issues that must be addressed include the privacy of patients and health care providers, and the security of data against unauthorized access. Many questions need to be answered regarding the "ownership" of medical information and the responsibility for retention of medical records. The differing state medical licensure requirements must be rationalized to permit access, when needed, to specialists across state boundaries, and malpractice regulations need to be modified to eliminate unnecessary medical procedures that are performed solely to reduce the threat of litigation. In the area of administration, the adoption of a uniform claims data set would substantially reduce current processing activities related to reimbursement.

Though health care costs in the United States amount to approximately 15 percent of the gross domestic product, health care information requirements alone cannot support the development and deployment of the NII. However, health care is an important contributor to the information community and is one of many large economic segments that must be included in the utilization of the NII. If the cost of the NII is shared among a large number of major segments of the economy, the application of telecommunications will be facilitated. Further advances in storage and retrieval technology are largely dependent on government agencies and sectors of the economy other than health care. The special requirements of health care can then be met by modifying the basic developments designed to meet other needs.

The current trend of health care reform emphasizes the restructuring of the delivery system toward managed care corporations. The driving force behind this restructuring is the recognized need for cost containment. Today, the decisions to adopt new technology for use in health care are predominantly made by corporate managers rather than by individual practitioners. Since health care is a labor intensive activity, in this new climate technology that increases efficiency is more favorably received.

Increased access to quality care by patients regardless of situation or geography is the primary justification for telemedicine and for health care reform. To some extent, this implies "patient acceptance" of the NII and related technology; however, health care provider acceptance is pivotal to adoption of telemedicine in practice. The acceptance of new technology requires many cultural and procedural changes by physicians, nurses, and allied health care workers. These changes have already occurred in health care financial activities such as billing and reimbursement and in medical research but are lagging in patient care delivery functions.

Contingencies and Uncertainties

The investment in and deployment of new technologies applicable to health care are partly dependent on the success of health care reform. "Many of the political imperatives driving telemedicine derive from the anticipated use of managed care incentives to provide accessible low-cost health care to all Americans."1 It is expected that the information infrastructure will be deployed because of impetus by government agencies and industries other than health care. The implementation of the NII for the delivery of health care is dependent on the cost-effectiveness of the technology as perceived by the decision makers within health care reform.

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