2 of wait times, coupled with poor communication between primary care and specialty care providers in this setting, presents a challenge to the delivery of specialty care services to uninsured and Medicaid patients using the San Francisco public health system [4]. The challenge of access to specialty care services at the primary safety-net hospital, SFGH, is slated for an even greater strain, with a potential increase in the inﬂux of the volume of patients in the San Francisco safety net. In 2006, the City and County of San Francisco instituted a new ordinance which created Healthy San Francisco (HSF), the city’s healthcare program for uninsured resident [5, 6]. Since 2007, enrolment in HSF, based on estimates, has grown to over 43,000 uninsured San Francisco adult residents; this equates to a total of 72% of the population in the city [7]. Even though the city has expanded the provider network to include other hospitals and a national HMO (Kaiser Permanente), the strain on the system is slated to get worse with about 26% of all enrollees in the program reporting a delay in medical care or treatment since joining the program [8]. Thus, there currently exists an opportunity to unravel the eﬀects of the HSF expansion on the healthcare safety- net. With this opportunity comes the understanding that the eﬀect on access to specialty care services is an area worthy of further investigation. Furthermore, in 2006 the California policy environment took a new turn with the passage of Proposition 1D. This educational facilities bond now provides funds for capital improvements to expand and enhance medical education programs in the state [9]. In essence, with this proposition and additional funds, SFGH will be able to connect UCSF and SFGH with clinics in remote areas all over the state of California using telemedicine. The goal of the San Francisco General Hospital and Trauma Center Telemedicine Network is to develop a sustainable and robust urban telemedicine network that facilitates clinical programs to increase access for primary and specialty care patients with a wide range of chronic illnesses in diverse communities throughout the Bay Area, Northern and Central California [10]. 2.1. Study Aims AIM 1. To determine key services for telemedicine in primary care and specialty care settings of the San Francisco public health system. This proposition will provide resources for building the basic infrastructure to increase capacity for expanding broadband connections between the hospital and the nexus of outpatient clinics with healthcare providers, both special- ists and primary care providers all over the city. However, it is still unclear as to how SFGH Hospital leadership should use these resources within the context of providing valuable services to clinics in the safety net, alongside enhancing the medical education program using telemedicine Thus, it is clear that the opportunity exists to determine priorities for the use of infrastructural funds to enhance telemedicine services for uninsured and Medicaid patients in the San Francisco public health system. International Journal of Telemedicine and Applications AIM 2. To determine a framework within the safety net to prioritize institution of key services for telemedicine. 3. Hypothesis This study sought to understand and identify key services for telemedicine in primary care and specialty care settings of the San Francisco public health system. Based on a selected sample of key informant interviews with local clinical physician staﬀ, we also sought to determine a framework within the safety net to prioritize institution of key services for the use of infrastructural funds to enhance telemedicine services in primary and specialty care areas of the San Francisco public health system. 4. Study Design Key informant ethnographic qualitative interviews were conducted with a selected convenience sample of stakehold- ers in targeted roles input from whom was identiﬁed as being important to the implementation of key services for telemedicine in the safety net. 4.1. Ethnographic Research Design. The study design involves the qualitative method which employed the collection of ethnographic data’ during in-depth semi-structured inter- views with the selected convenience sample. The qualitative ethnographic approach was employed in this study to examine the nature of the technology-based interaction [11], that is, “black box” interaction with the use of telemedicine, and to identify the sociocultural challenges and barriers with its use in the safety net. 4.2. Ethnographic Method Adopted. The fundamental ethno- graphic method adopted for this study involved key infor- mant ethnographic qualitative interviews. 4.3. Ethnographic Sampling. Participants for the key infor- mant ethnographic interviews were identiﬁed and selected as a convenience sample by the Chief Medical Oﬃcer of the San Francisco General Hospital and Trauma Center. The program coordinator of the study communicated with the selected individuals to make arrangements to set up the interview in the clinic setting. In order to have been selected as a participant in this study, the following criteria had to be met, Medical Director of the aﬃliated COPC clinics, and/or the Clinical Chiefs of the UCSF medical specialty divisions. Participation required the willingness to provide written informed consent to be interviewed at the clinic of their choosing to discuss key services for telemedicine in the delivery of specialty care to uninsured and Medicaid patients in the San Francisco public health system. Copy of the recruitment script is attached in Appendix B. 4.4. Collection of Ethnographic Data. Study participants for the interviews were identiﬁed by the Chief Medical Oﬃcer of San Francisco General Hospital and Trauma Center. Once identiﬁed, the program coordinator of the study