Home telemedicine is an emerging healthcare paradigm that has the potential to transform the treatment of chronic illness. The purpose of this paper is to: (1) develop a theoretical and methodological framework for studying workflow in telemediated clinician-patient encounters drawing on a distributed cognition approach and (2) employ the framework in an in-depth analysis of workflow in the IDEATel project, a telemedicine program for older adults with diabetes. The methods employed in this research included (a) videotaped observations of 27 nurse-patient encounters and (b) semi-structured interviews with participants. The analyses were used to provide a descriptive analysis of video visits, understand the mediating role of different technologies and to characterize the ways in which artifacts and representations are used to understand the state of the patient. The study revealed barriers to productive use of telehealth technology as well as adaptations that circumvented such limitations. This research has design implications for: (a) improving the coordination of communication and (b) developing tools that better integrate and display information. Although home telemedicine programs will differ in important respects, there are invariant properties across such systems. Explicating these properties can serve as a needs requirement analysis to develop more effective systems and implementation plans. © 2009 Elsevier Inc. All rights reserved.