A small number of studies have examined the feasibility of conducting videofluoroscopic swallow studies (VFSS) via telepractice. While the results have confirmed this potential, the systems tested to date have either reported issues that impacted the ability to analyze/interpret the VFSS recordings in real time, or they were not designed to enable real-time interpretation. Further system design is needed to establish a telepractice model that enables the VFSS assessment to be both guided and interpreted live in real time. The aim of this study was to test the feasibility and reliability of using a telepractice system to enable live VFSS assessment. Twenty adult patients underwent a VFSS assessment directed by a telepractice SLP with competency in VFSS located in another room of the hospital. The telepractice clinician led the sessions using a C20 Cisco TelePresence System. This was linked in real time via a secure telehealth network (at 4 megabits per second (Mbit/s)) to a C60 Cisco TelePresence System located in a fluoroscopy suite, connected to the digital fluoroscopy system. Levels of agreement were calculated between the telepractice clinician and a face-to-face clinician who simultaneously rated the VFSS in real time. High levels of agreement for swallowing parameters (range = 75–100 %; k  = −0.34 to 1.0) and management decisions (range = 70–100 %, k  = 0.64–1.0) were found. A post-session questionnaire revealed clinicians agreed that the telepractice system enabled successful remote assessment of VFSS. The findings support the potential to conduct live VFSS assessment via a telepractice model.