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The resurgence of telemedicine can be attributed to its potential for addressing intransigent problems in health care, including limited accessibility, cost inflation, and uneven quality. After discussing definitions and the genesis of telemedicine, this review focuses on conceptual issues and an assessment of past research. The scope and methodological rigor necessary for sustained development and policy making have been limited in this area of research, owing to the nature of extant telemedicine projects and the lack of a comprehensive research strategy that specifies the objectives of telemedicine research regarding accessibility, cost, and quality. Research strategies and a framework for analysis are discussed. Without a commitment to the types of research objectives, framework, and strategy presented here, the considerable promise of telemedicine, as an innovative system of care, may not be fully realized.

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This Workshop was designed to assist in the ongoing development and application of telemedicine and medical informatics to support extended space flight. Participants included specialists in telemedicine and medical/health informatics (terrestrial and space) medicine from NASA, federal agencies, academic centers, and research and development institutions located in the United States and several other countries. The participants in the working groups developed vision statements, requirements, approaches, and recommendations pertaining to developing and implementing a strategy pertaining to telemedicine and medical informatics. Although some of the conclusions and recommendations reflect ongoing work at NASA, others provided new insight and direction that may require a reprioritization of current NASA efforts in telemedicine and medical informatics. This, however, was the goal of the Workshop. NASA is seeking other perspectives and views from leading practitioners in the fields of telemedicine and medical informatics to invigorate an essential and high-priority component of the International Space Station and future extended exploration missions. Subsequent workshops will further define and refine the general findings and recommendations achieved here. NASA's ultimate aim is to build a sound telemedicine and medical informatics operational system to provide the best medical care available for astronauts going to Mars and beyond.

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Understanding the full financial effects of telemedicine systems on payers, providers, and patients has been hampered by the lack of data from full-fidelity systems operating at a steady state. The vast majority of telemedicine systems in the United States have yet to achieve their full potential in serving their target populations and are operating well below capacity. The purposes of this research are two-fold: (1) to develop a methodology that compensates for the limited availability of empirical data on the financial effects of telemedicine; and (2) to test this methodology in a comprehensive telemedicine system in West Virginia. The proposed methodology utilizes simulation modeling techniques for evaluating the financial performance of a mature telemedicine system. It is particularly suitable for analyzing large, complex systems that have not yet achieved steady-state operation. Although complex, the methodology can be described simply as consisting of two major steps. The first is the identification of all of the relevant variables and parameters for modeling. The second consists of simulating "real world" decision situations involving all relevant variables and parameters. The relation among the variables and parameters are described in terms of mathematical equations. The ability of the researcher to estimate the financial effects of a given telemedicine system is a function of the extent to which the resulting model approximates conditions of the real world; i.e., the fit between model and reality.

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Critical issues facing the development of telemedicine today are described and analyzed as dilemmas or paradoxes. The technological dilemma involves the difficult choice between using the latest technology regardless of how well it fits specific needs on the one hand, and the reluctance to capitalize on the available technological capability to create efficient and effective organizations for expanding the reach of health care on the other hand. The evaluation paradox points to the disjuncture between policy making requirements and the scientific enterprise. This engenders the difficulty of producing scientifically valid and policy relevant results from programs that have not achieved maturity or a steady state of operation. The contextual hazards of limiting the scope of telemedicine to rural areas are discussed, as well as the potential for creating a second tier of care for the remote and isolated populations. Finally, professional maturation is addressed as it underscores the importance of self regulation and control.

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OBJECTIVE: It is doubtful that any new health care delivery system that requires as much adjustment as telemedicine does will be sustained if its users do not fully support it. We sought to determine the familiarity with, perceptions of, and attitudes toward telemedicine among rural adults in West Virginia. METHODS: Data were collected in a statewide telephone survey of 461 non-institutionalized rural adults. The survey contained questions about familiarity with telemedicine, perceptions about its attributes and benefits, and willingness to use it for routine, specialty, and emergency care. Responses were examined in relation to the subjects' age, sex, socioeconomic status, access to care, and insurance coverage. RESULTS: Despite mass media coverage of the subject, only one third of the respondents had heard of telemedicine. Nearly two thirds thought patients would find it less satisfactory than seeing a physician in person. Male subjects, younger subjects, and those with higher incomes were more likely to think telemedicine would be as satisfactory as a face-to-face meeting. There was a general consensus on the benefits of telemedicine, such as greater convenience and easier contact with specialists. For chronic conditions, 47% of the respondents would use telemedicine if no physician was available locally, whereas 27% would go out of town to see another physician in person, and 25% would wait for their own physician. For emergency care, these figures were 41%, 58%, and 0. Three fourths of the respondents were somewhat or very willing to use telemedicine for routine or specialist care. CONCLUSION: More work needs to be done to demonstrate the efficacy of telemedicine and disseminate this knowledge to the public.

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The new federalism is now taking hold in Washington, with far-reaching implications for the role of the federal government in health, education, and welfare programs; financial support for such programs; and the shift of control to the states. For telemedicine, the implications of these changes include having to make do with less external financial support and a need to establish partnerships between state and local governments, public sector developers and vendors, third-party payers, and community-based telemedicine programs. The long-term challenge for telemedicine programs, particularly in rural, medically underserved areas, is likely to be their sustainability in an adverse financial environment. The problem is further compounded by the lack of reimbursement for teleconsultations.

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In the United States, we are witnessing a renewed emphasis on the potential role of telemedicine in redressing issues of accessibility, cost, and quality of medical care. This paper describes several major problems confronting the current generation of telemedicine projects as they move toward maturity. In fact, it is argued here, the future development of telemedicine as an integral component of the health care system depends on the successful resolution of these concerns. Included for discussion are issues related to physicians, institutions, patients, and the general public. On the basis of the tenets of telemedicine and its capacity to transcend traditional boundaries of medical care via telecommunications, informed speculations are presented that are intended to stimulate discussion and provide direction for addressing a number of potential problems. Included are suggestions pertaining to restructuring the medical licensure system to accommodate telemedicine and the virtual regionalization of health care; implications for provider liability and reimbursement; patient privacy; system design; and diffusion of information.

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Recent Congressional budget recissions are likely to reduce the development of telemedicine in the United States, yet federal support is considered essential for such development. Both the executive and the legislative branches continue to show interest in the field. Pressure is mounting for research data documenting the effects of telemedicine on health care cost, quality, and access. Other policy issues arise from the recent revolution in the telecommunications industry and changes in health care delivery.

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Following a brief review of lessons learned from first generation telemedicine projects, an analytical framework for assessing the potential effects of telemedicine on cost, quality, and accessibility of health care is provided. It is proposed that the effects of telemedicine on cost, quality, and accessibility are interconnected, and a comprehensive assessment should incorporate all three aspects, each considered from the perspectives of clients, providers, and society.

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Issues related to the definition and evaluation of telemedicine are articulated as a basis for conducting theoretically based, empirically sound, and policy-relevant evaluation. This paper includes a proposed operational definition of telemedicine, a discussion of the role of telemedicine in the healthcare system and economic analysis of telemedicine, an analysis of the basic approaches and requirements for telemedicine evaluation, and an identification of basic issues for evaluation. Telemedicine is conceived of as an integrated system of health-care delivery that employs telecommunications and computer technology as a substitute for face-to-face contact between provider and client. It has the potential for ameliorating seemingly intractable problems in healthcare such as limited access to care among segments in the population--especially the geographically disadvantaged--uneven quality of care, and cost inflation. Its true merit has yet to be determined by systematic empirical study. Such study should include a clear and precise identification of inputs and output and the nature of the relations between them, an assessment of the changes that might occur in the process of care as a consequence to telemedicine, and, ultimately, an evaluation of the effects of telemedicine on the healthcare system in terms of cost, quality, and accessibility. Several basic questions regarding the effects of telemedicine are posed as potential hypotheses for future research.

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This paper investigates the difficulties that people encounter in their attempt to obtain needed health services, other than their third-party coverage or lack of it. These problems can be temporal, geographic, attitudinal, or financial (even with insurance). A state-wide sample survey conducted in 1989 revealed that about 17% of Michigan's population experienced one or more of these kinds of difficulties in their attempts to receive medical care. Those at greater risk included persons with public insurance coverage (mostly Medicaid), persons with low incomes, persons in poor health, women, and members of some ethnic minority groups. The findings suggest that addressing the problem of access to care through an exclusive focus on the uninsured, especially through public programs, could leave significant residual problems for several segments in American society.

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The inverse relationship between distance from mental health services and their use has been noted over many decades and on several continents. Although many factors--diagnostic, socioeconomic, and nosocomial--may modify this correlation, its persistence is remarkable. As other barriers to use are diminished, distance remains a mutable variable for planning more effective use of many health care services.

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Federal health and medical care programs recently mandated for American Indians living in cities are predicated upon information pertaining to their unmet health needs and assessments of their accessibility to medical care. Based upon a household survey conducted among a representative Indian population living in a large metropolitan area, an evaluation is made of the accessibility experience of this population as it pertains to primary medical care. Using measures of accessibility including travel time, appointment delay time, and waiting room time, the experiences of Indian residents of major residential sections of the area are illustrated. Comparative assessments are made on the basis of the individual convenience factors as well as on the basis of an aggregate index of accessibility that has been proposed for health planning and evaluation. Significant differences in accessibility to primary care between residents in certain residential areas are demonstrated and suggestions for revision of the accessibility standards are offered.

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We present the results of a survey to determine how physicians prescribe fluoride supplements for their child patients. A questionnaire was mailed to a representative nationwide sample of 2,604 physicians who treat children. The response rate of completed returns was 49.4%. Results showed that while most respondents prescribed fluoride appropriately, there was some inappropriate prescribing for children receiving fluoridated water. Some physicians also neglected to prescribe for children who were not receiving fluoridated water. Previous differences in recommended schedules of administration between the American Academy of Pediatrics and the American Dental Association may have led to some of these problems. However, these two organizations have now standardized their recommendations.

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Results are presented of a study of the medical care-seeking behavior of black adult residents of lower and middle socioeconomic status in two predominantly black, yet geographically and socioeconomically distinct communities within the District of Columbia. Against a varied distribution of primary medical care opportunities within the District, substantial differences are demonstrated in their use by lower- and middle-status residents of a lower-class community. These differences are not, however, manifested among lower- and middle-status residents of an essentially middle-class neighborhood. The patterns of medical care-seeking behavior are observed within a framework of an almost total avoidance of the available medical care personnel and facilities in the proximate suburbs.

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