VHA's Rural category is very large and broadly dispersed; policy makers should supplement analyses of Rural veterans' health care needs with more detailed breakdowns. Most of VHA's Highly Rural enrollees live in the western United States where distances to care are great and alternative delivery systems may be needed.

Tele-emergency services provide immediate and synchronous audio/video connections, most commonly between rural low-volume hospitals and an urban "hub" emergency department. We performed a systematic literature review to identify tele-emergency models and outcomes. We then studied a large tele-emergency service in the upper Midwest. We sent a user survey to all seventy-one hospitals that used the service and received 292 replies. We also conducted telephone interviews and site visits with ninety clinicians and administrators at twenty-nine of these hospitals. Participants reported that tele-emergency improves clinical quality, expands the care team, increases resources during critical events, shortens time to care, improves care coordination, promotes patient-centered care, improves the recruitment of family physicians, and stabilizes the rural hospital patient base. However, inconsistent reimbursement policy, cross-state licensing barriers, and other regulations hinder tele-emergency implementation. New value-based payment systems have the potential to reduce these barriers and accelerate tele-emergency expansion.

Telemedicine as a technology has been available for nearly 50 years, but its diffusion has been slower than many had anticipated. Even efforts to reimburse providers for interactive video (IAV) telemedicine services have had a limited effect on rates of participation. The resulting low volume of services provided (and consequent paucity of research subjects) makes the phenomenon difficult to study. This paper, part of a larger study that also explores telemedicine utilization from the perspectives of referring primary care physicians and telemedicine system administrators, reports the results of a survey of specialist and subspecialist physicians who are users and nonusers of telemedicine. The survey examined self-assessed knowledge and beliefs about telemedicine among users and nonusers, examining also the demographic characteristics of both groups. Statistically significant differences were found in attitudes toward telemedicine between users and nonusers, but in many respects the views of the two groups were rather similar. Physicians who used telemedicine were aware of the limitations of the technology, but also recognized its potential as a means of providing consultation. Demographic differences did not explain the differences in the knowledge and beliefs of user and nonuser consultant physicians, although some of the differences may be explained by other aspects of the professional environment.

Although only used in 3.5% of ED encounters on average, our findings provide evidence that tele-emergency activation is well reasoned and related to those situations when extra expert assistance is particularly beneficial.