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Families living in medically underserved rural areas across the United States encounter many obstacles to accessing high-quality outpatient pediatric care, including limited transportation 1 and clinician shortages. 2 Children insured by Medicaid may face particular challenges finding a primary care physician or scheduling an appointment. 3 Poor access to care can result in preventable pediatric visits to an emergency department (ED) for low-acuity illnesses and ambulatory care-sensitive conditions, such as asthma. Telehealth technology provides an opportunity to enhance access to care by connecting health care and community settings. Specifically, school-based telemedicine can facilitate the delivery of necessary, nonurgent care for children without requiring caregivers to miss work or arrange nonemergency medical transportation.In this issue of JAMA Pediatrics, the natural experiment described by Bian et al 4 contributes to our understanding of how school-based telemedicine programs perform outside of research settings. The authors analyzed more than 2 million child-months of Medicaid claims data for children ages 3 to 17 years living in rural South Carolina, comparing all-cause ED use by children from 1 county that had a school-based telemedicine program (Williamsburg county) with use by children living in 4 adjacent counties without telemedicine services. In the full sample, the authors found no association of the telemedicine program with the likelihood of all-cause ED use during the 3-year postintervention period. However, in a subsample of children with asthma they found that the program was associated with 21% relative decrease in allcause ED visits. Bian et al 4 concluded that telemedicine with a focus on chronic pediatric conditions like asthma may deliver substantial health benefits to rural and undeserved communities. This conclusion is exciting, and warrants further consideration of why children with asthma may have had better outcomes.While specific data on encounter diagnoses are not available, one might speculate that the difference in all-cause ED use between intervention and control children with asthma was driven by improvements in care, leading to a reduction in asthma-specific visits. Bian et al 4 suggest that there may have been a benefit from "timely asthma diagnosis and adherence to appropriate therapies." There is an advantage to having nurses administer daily controller medications in school, 5 and in this program, school nurses were trained to administer medications to children with asthma to ensure adherence. In fact, a recent study of urban school-based care found that daily administration of preventive asthma medications in school coupled with telemedicine assessments was associated with a 48% decrease in the odds of ED use. 6 If access to telemedicine care is specifically beneficial for reducing ED use, then it is unclear why intervention children in the full sample did not experience a similar a reduction in all-cause use. More than half of all pediatric ED visits are for low-acuity