Background: Telemedicine, the provision of healthcare at a distance via telecommunication technology, has been used to address a wide range of health concerns in a variety of settings. Given the challenges schools face in keeping students healthy, telemedicine could be viewed as a mechanism to provide healthcare services directly to students in schools. This research focuses on a school-based telemedicine project in Kansas, a project of the Kansas University Medical Center (KUMC) called TeleKidcare. TeleKidcare makes use of interactive television systems located in the school health office to let school nurses interact with KUMC physicians to provide consultations for sick children. Methods: A case study of the TeleKidcare system was conducted to investigate critical factors of success in the project; data was collected primarily through personal interviews (N = 23), with project documentation serving to corroborate the interview data. Results: Results point to factors to success both in the planning and operational phases of TeleKidcare. Examples of such factors include: (a) recognizing, and accounting for, the fact that different sites in a multisite telemedicine system might adopt the system in different ways; (b) the importance of involving actual users in the planning of the system, to ensure it could be built into the everyday work of school nurses; and (c) the importance of unintended appropriation of the technology by school nurses, using the system in ways that were completely unplanned. Conclusion: The lessons learned from TeleKidcare's success can help researchers and practitioners considering similar systems in other schools.