This Policy Brief expands previous research examining hospital-based use of telemedicine by 1) determining the type of use by hospitals, whether it be providing services as a hub or receiving services as a spoke; and 2) then identifying factors from the hospitals' perspective that affect use. Key informants at 36 hospitals were interviewed. The hospitals were evenly split between urban/rural and hub/spoke in 22 states, representing all four U.S. Census Regions. Respondents reported factors that initiated telemedicine use at their hospitals, such as a variety of start-up funding from federal, state, and foundation sources. They reported benefits, such as meeting hospital missions and improving patient access, as well as challenges, such as reimbursement procedures and clinician buy-in. They also discussed barriers to expansion, such as licensing and credentialing policies. While challenges and barriers are significant, both hub and spoke hospital respondents state considerable benefits for continued telemedicine use.