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Telemedicine is evolving into an important tool in delivering services to emergency departments (EDs) in rural areas. However, we do not yet know what kinds of services can be effectively delivered or the degree to which these services might be useful. In this pilot study, a high-speed, high-quality video, 24-hour ATM (asynchronous transfer mode) network linked a rural ED to an ED of a major medical center. The objective was to measure the utilization of telemedical consulting services. Specifically, this one-year study examined the significance of telemedicine in changing diagnosis and treatment and the influence on patient transfers.