Four case studies were conducted in Georgia, Pennsylvania, Ohio, and Wisconsin to uncover factors that played key roles in state telemedicine initiatives. Factors that affect the success of state telemedicine initiatives include telecommunications infrastructure, correctional facilities, need for a champion, user buy-in, competition in the healthcare market, timing of the government's action, and financial support for the initiatives. How these factors affect state telemedicine networks, the level of importance of the various factors, and potential state actions to leverage or dampen the effects of the various factors are reviewed.