medical information through interactive audiovisual
tools. 1 Increasingly, hospitals are using telemedicine
as a quality improvement strategy in the ICU. 2 With
elemedicine is a strategy for improving the quality
of health care through the electronic transfer of
ICU telemedicine, clinicians can remotely monitor
patient vital signs, physiologic status, and laboratory
studies and assist bedside providers in interventions
when appropriate. Given the current need for addi-
tional critical care services, limitations of the existing
workforce, and access issues related to geography, the
use of telemedicine in critical care is likely to expand
in the coming years. 3,4 However, relatively little research
has been directed at understanding the clinical and
fi nancial implications of telemedicine in critical care
or potential unintended consequences. High-quality
research is needed to ensure that the potential value
of telemedicine for patients, the health-care system,
and society is achieved. 5
ICU telemedicine uses audiovisual conferencing technology to provide critical care from a remote
location. Research is needed to best defi ne the optimal use of ICU telemedicine, but efforts are
hindered by methodological challenges and the lack of an organized delivery approach. We con-
vened an interdisciplinary working group to develop a research agenda in ICU telemedicine,
addressing both methodological and knowledge gaps in the fi eld. To best inform clinical decision-
making and health policy, future research should be organized around a conceptual framework
that enables consistent descriptions of both the study setting and the telemedicine intervention.
The framework should include standardized methods for assessing the preimplementation ICU
environment and describing the telemedicine program. This framework will facilitate comparisons
across studies and improve generalizability by permitting context-specifi c interpretation. Research
based on this framework should consider the multidisciplinary nature of ICU care and describe the
specifi c program goals. Key topic areas to be addressed include the effect of ICU telemedicine on
the structure, process, and outcome of critical care delivery. Ideally, future research should attempt
to address causation instead of simply associations and elucidate the mechanism of action in order
to determine exactly how ICU telemedicine achieves its effects. ICU telemedicine has signifi cant
potential to improve critical care delivery, but high-quality research is needed to best inform its
use. We propose an agenda to advance the science of ICU telemedicine and generate research
with the greatest potential to improve patient care. CHEST 2011; 140(1):230–238
The Research Agenda in ICU Telemedicine
A Statement From the Critical Care Societies Collaborative
Jeremy M. Kahn , MD ; Nicholas S. Hill , MD , FCCP ; Craig M. Lilly , MD , FCCP ;
Derek C. Angus , MD , MPH , FCCP ; Judith Jacobi , PharmD ; Gordon D. Rubenfeld , MD ;
Jeffrey M. Rothschild , MD , MPH ; Anne E. Sales , RN , PhD ; Damon C. Scales , MD , PhD ;
and James A. L. Mathers , MD , FCCP
Manuscript received March 9, 2011; revision accepted March 15,
Affi liations: From the Department of Critical Care Medicine
(Drs Kahn and Angus), University of Pittsburgh, Pittsburgh, PA;
Pulmonary, Critical Care and Sleep Division (Dr Hill), Tufts
Medical Center, Boston, MA; Department of Medicine (Dr Lilly),
University of Massachusetts, Amherst, MA; Clarian Health
(Dr Jacobi), Indianapolis, IN; University of Toronto (Drs Rubenfeld
and Scales), Toronto, ON, Canada; Harvard Medical School
(Dr Rothschild), Boston, MA; Department of Nursing (Dr Sales),
University of Alberta, Edmonton, AB, Canada; and Pulmonary
Associates of Richmond (Dr Mathers), Richmond, VA.
Funding/support: This work was supported by the US Agency
for Healthcare Research and Quality [grant R13HS19946 ].
Correspondence to: Jeremy M. Kahn, MD, Department of
Critical Care Medicine, University of Pittsburgh, Scaife Hall 602-B,
3550 Terrace St, Pittsburgh, PA 15261; e-mail: kahnjm@
© 2011 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians ( http://www.chestpubs.org/
CHEST / 140 / 1 / JULY, 2011 231
remote interventions, such as telephone consultation,
distance-based quality improvement, or medical edu-
cation, to constitute ICU telemedicine.
The conference consisted of a series of breakout
groups followed by plenary discussions during which
group leaders summarized and reported conclusions
to the entire working group for discussion and feed-
back. Each group was assigned to discuss one of
six specifi c content areas related to the evaluation of
ICU telemedicine: clinical outcomes, process of care,
costs and cost-effectiveness, patient safety, organiza-
tional culture, and medical education. The resulting
statement is organized into a critique of the existing
literature, a methodological research agenda (ie, meth-
ods that will advance the science of ICU telemedicine
research), and a content-based research agenda
(ie, research that will address specifi c knowledge gaps).
The statement was drafted by a designated writing
committee on the basis of the conference proceed-
ings and then circulated to conference participants
for revision using an iterative process. The fi nal docu-
ment was approved by the leadership of all four
organizing specialty societies. Complete disclosure
statements for all conference participants are available
in e-Appendix 2.
Limitations of the Existing Literature
A number of published studies have attempted to
evaluate the clinical and economic impact of ICU
telemedicine. 6-12 Although these studies provide an
important foundation for our understanding of tele-
medicine in critical care, they often suffer from a
number of conceptual and methodological limita-
tions. Most studies use a before-and-after study
design and are subject to numerous biases, including
unmeasured changes in case mix, temporal trends,
coincident interventions, and random variation. 26
Additionally, ICU telemedicine often introduces multi-
ple interventions at the same time, including audiovi-
sual surveillance, staffi ng changes, decision-support
tools, and new electronic medical records. Introduc-
ing multiple different interventions simultaneously
makes it diffi cult to understand the specifi c mecha-
nism of the effect. These studies also do not consis-
tently describe the organization and management of
participating ICUs prior to introducing the telemedi-
cine program, making it diffi cult to put the research
into clinical context.
Working group participants expressed concern
about the lack of adequate interdisciplinary expertise
in prior investigations. Given that critical care is itself
interdisciplinary, ICU telemedicine research should
involve multiple clinical and scientifi c disciplines.
To provide a conceptual and practical framework
for ICU telemedicine research, we convened an inter-
disciplinary workgroup comprising experts in critical
care delivery, telemedicine delivery, organizational
science, health services research, and health-care
policy. Our goals were to examine the state of the
science underlying ICU telemedicine, identify key
methodological and knowledge gaps, and develop a
focused agenda for future research.
A statement on the research agenda in ICU tele-
medicine was developed by a working group spon-
sored by the Critical Care Societies Collaborative,
which includes the American Association of Critical-
Care Nurses, the American College of Chest Physi-
cians, the American Thoracic Society, and the Society
of Critical Care Medicine. The working group was
funded by a grant from the Agency for Health Research
and Quality. Participants were identifi ed by the work-
ing group chairs to represent stakeholders within
the fi elds of medical and surgical critical care, critical
care nursing, critical care pharmacy, health-care
economics, health services research, rural health
research, information technology, and organizational
The working group convened a 2-day conference
from March 24, 2010, to March 25, 2010, at the head-
quarters of the American College of Chest Physicians
in Northbrook, Illinois. The goals of the conference
were to review the existing research in ICU telemedi-
cine, identify key methodological and knowledge gaps,
and develop an agenda for future research. Prior to
the conference, the working group chairs developed
a literature summary for distribution to the confer-
ence participants. We searched the English-language
literature using Medline and the Google Scholar
search engine using the search terms “intensive care”
or “critical care” and “telemedicine.” Titles and
abstracts were reviewed to identify peer-reviewed
original research articles describing remote delivery
of critical care services through audiovisual technol-
ogy. Published articles meeting these criteria 6-25 were
summarized into six categories: study design, setting,
telemedicine system design, patients, time period,
and primary fi ndings (e-Appendix 1).
The working group defi ned ICU telemedicine as a
system to facilitate the remote delivery of critical care
services using interactive audio, video, and electronic
links. This defi nition could apply to services ranging
from continuous electronic surveillance by an offsite
team of clinicians providing interactive care for broad
populations of patients to intermittent assessment
and management of patients with specifi c clinical
conditions. The group did not consider more general
that may modify the uptake and effectiveness
of the ICU telemedicine intervention, helping
readers to interpret variation in effectiveness
between studies. Finally, a well-defi ned com-
parator state would help readers to understand
which quality improvement practices are in place
in the ICU prior to the introduction of telemedi-
cine. Several ICU quality improvement programs
have achieved important successes without tele-
medicine. 30,31 Indeed, the best comparator for a
comparative effectiveness study of telemedicine
may be local quality improvement initiatives
rather than no intervention at all.
• Standardized lexicon for defi ning the telemedi-
cine intervention . ICU telemedicine, even with
the working defi nitions used for this process, is a
broad term that applies to a range of widely
varying interventions. Researchers require a
standardized lexicon to report the attributes of
the ICU telemedicine intervention under
study. Various components to be addressed in
the lexicon may include the type of technologies
comprising the system, the timing of monitoring
(eg, continuous vs intermittent), the role of the
ICU telemedicine clinicians (eg, emergent care,
general consultation, comanagement), the train-
ing and composition of the ICU telemedicine
team (eg, nurses, physicians), and the goals of the
telemedicine program (eg, more timely inter-
ventions for physiologic decompensation, enhanc-
ing access to experts, increasing compliance with
best practices). The defi nition of ICU telemedi-
cine considered by the working group represents
an appropriate starting place for this lexicon.
However, the fi nal lexicon should include suffi -
cient detail about the process and structure of
the ICU telemedicine application to allow users
to exactly specify their program. This lexicon will
improve generalizability by helping research
users to understand exactly how ICU telemedi-
cine was applied.
The benefi ts of adhering to this framework are
numerous. Subsequent research will be more gener-
alizable by allowing for context-specifi c interpreta-
tion and providing insight into both mechanism of
action and causation. Ultimately, such research will
lead to better-informed decisions about the imple-
mentation and practice of ICU telemedicine. This
framework also will facilitate cross-study comparisons
and future systematic reviews because each study will
use a similar reporting structure. Finally, this frame-
work will minimize ideologic and commercial bias in
implementation and reporting because studies will
be more transparent and reporting will be standard-
ized across studies.
Important clinical stakeholders include nurses, phy-
sicians, pharmacists, respiratory therapists, and social
workers, among others. The research team should
have expertise in health services research, epide-
miology, social science, information technology, and
health economics. In particular, because ICU tele-
medicine is an organizational intervention, strong
consideration should be given to including investiga-
tors with specifi c expertise in organizational evaluation
and the ways it differs from standard pharmacologic
or epidemiologic research. Without such appropriate
scientifi c expertise, it is unlikely that research will be
able to successfully inform clinical and health policy
Improving Telemedicine Research
Recognizing these limitations, the working group
stressed the need to develop a novel standardized
framework, different from the framework described
previously, that clinicians and researchers could use
in planning, implementing, and evaluating ICU tele-
medicine interventions. The framework should be
developed by an interdisciplinary panel drawing on a
broad range of research expertise and considering the
multidimensional role of telemedicine in critical care.
The evaluation framework should consider and incor-
porate existing telemedicine evaluation frameworks
as well as frameworks for evaluating other complex
health interventions. 27,28 Previously developed frame-
works for evaluating telemedicine outside of the ICU
setting, such as the US Health Resources and Ser-
vices Administration framework for evaluating tele-
medicine in the context of rural health ( Table 1 ), may
be a useful starting point. 29 However, no current frame-
work is fully adequate.
The ICU telemedicine framework should have two
major components: a standardized approach to assess-
ing the preimplementation ICU environment and a
standardized lexicon for defi ning the ICU telemedi-
• Standardized approach to assessing the preim-
plementation ICU environment . The baseline,
or comparator state, is essential to understand-
ing the impact of telemedicine as well as the fac-
tors that might infl uence its success. Potentially
important environmental factors include a range
of patient, ICU, and hospital characteristics as
well as the organizational climate of the ICU
( Table 2 ). Such a standardized approach to the
environmental scan would allow those seeking
to interpret and apply the research results to
better understand the comparator state and, there-
fore, to infer similarities and differences between
their own clinical context and the ICU under
study. Additionally, it would elucidate factors
CHEST / 140 / 1 / JULY, 2011 233
whether telemedicine improves the care of patients
with evolving physiologic instability, whereas studying
patients with chronic critical illness may provide
insight into whether telemedicine works by improv-
ing use of evidence-based preventive and therapeutic
strategies or by early detection of evolving physiologic
Research is needed into the impact of telemedicine
on the structure and organization of the ICU itself
and its interaction with institutional critical care gov-
ernance. The working group noted that telemedicine
can transform ICU organization, affecting staffi ng
patterns, teamwork, communication, and systems-
based practice within the ICU. This transformation
could be either benefi cial or harmful, and research is
needed into the determinants of these organizational
transformations. Research is also needed into strate-
gies to optimize organizational readiness for tele-
medicine prior to implementation, including how
variations in baseline readiness can have an impact on
the effectiveness of the telemedicine intervention. 33
For example, studies should address how telemedi-
cine enhances or disrupts the traditional chain of
command and how telemedicine enhances or disrupts
the existing workfl ow patterns of the interdisciplinary
care team. Research into organizational climate is
important not only in the ICU but also in the tele-
medicine unit itself, where organization may have an
impact on effectiveness. Key domains for climate-
based research include acceptance, teamwork,
Addressing Key Knowledge Gaps
The working group identifi ed ICU telemedicine
knowledge gaps in several key topic areas. We orga-
nized these gaps around the Donabedian framework
for health-care quality in which quality is made up of
three interrelated domains: structure, process, and
outcome ( Fig 1 ). 32 Within each domain, the working
group identifi ed several high-priority questions to be
addressed by future research ( Table 3 ).
Structure: Research is needed into the optimal orga-
nizational structure of ICU telemedicine programs,
including the competing merits of various telemedi-
cine models, such as a periodic consult model vs a
continuous management model. These models may
play a different and complementary role in various
clinical settings. Research also is needed into the
optimal make-up of the telemedicine team, core com-
petencies of ICU telemedicine clinicians, and strate-
gies to train clinicians in these core competencies.
Working group participants also stressed the need for
research that deconstructs which components of the
program are most important to ensure effectiveness.
Such an approach will help to elucidate the potential
mechanisms of effect, making the research more use-
ful to clinicians and administrators. To further uncover
mechanisms, research should assess key subgroups
of patients with varying clinical needs. For example,
studying patients requiring early aggressive resuscita-
tion (ie, trauma, sepsis) may provide insight into
Table 1— Framework for Assessing Telemedicine
Clinical outcomes Does telemedicine facilitate a more rapid, accurate, and effective treatment plan?
Does telemedicine reduce morbidity and mortality?
Does telemedicine obviate or facilitate evacuation or transport of the patient?
Does telemedicine obviate or reduce the need for admissions, readmissions, or repeat visits for an
Is the quality of information acceptable for a given clinical application?
Is the system acceptable with regard to reliability, expandability, connectivity, safety, precision,
compatibility, and interoperability?
Is the system user friendly?
Are the physical environment and location conducive to the effi cient and effective delivery of health-care
How does the telemedicine system fi t into or change the existing workfl ow and communication patterns.
What new skills and staff positions are required to manage and operate the system?
Does telemedicine enable health systems to become more productive, more effi cient, or more effective?
Do the cognitive or communication skills and the information needed for telemedicine differ from those
of conventional medicine?
What is the cost of purchasing, operating, and maintaining a given system, and is this cost sustainable?
What are the costs and benefi ts associated with using telemedicine for patients, practitioners, and
organizations (including effects on travel times, market share, revenues, productivity, and transport)?
Do patients and practitioners believe that telemedicine is medically useful and adequate for patient care?
Are practitioners concerned that participating in telemedicine will interrupt their normal work patterns?
With telemedicine, do patients receive care that they would not have otherwise received?
With telemedicine, are the patients seen by a health professional sooner than if telemedicine were not
Health systems interface
Costs and benefi ts
Adapted from the Offi ce of Rural Health Policy, Health Resources and Services Administration, US Department of Health and Human Services. 29
tices, responses to alerts and alarms, guideline adher-
ence, and protocol usage. This research should focus
on ICU patients for whom evidence-based practices
exist, such as in those with acute lung injury and sep-
sis. 36 When the evidence is not strong, researchers
should attempt to identify areas in which evidence
needs to be built. Research investigating processes of
care also should address potential unintended conse-
quences of telemedicine, such as reductions in bed-
side nurse vigilance.
Additionally, process-centered research should study
the relationship between telemedicine and the pro-
cess of medical education. Research is needed into
the effect of telemedicine on undergraduate, gradu-
ate, and continuing education in the ICU and should
include strategies for developing and testing an
educational curriculum around ICU telemedicine.
Current medical training emphasizes education with
bedside care but may neglect education in distance-
based care; thus, future research should be directed
at determining the core competencies of an ICU
telemedicine clinician and strategies to provide these
competencies. Research also is needed into the capac-
ity for telemedicine to provide off-hours education
and support for nurses and physicians in training.
Outcomes: Research is needed into the effect of
telemedicine on critical care outcomes from the per-
spective of the patient, the provider, the health-care
system, and those responsible for paying for care.
The most important patient-centered outcome is
mortality, specifi cally risk-adjusted mortality tied to
discrete time periods rather than in-hospital mortal-
ity that can be biased by discharge practices. 37
Research also should consider the effect of telemedi-
cine on other patient-centered outcomes, including
discharge location, health-related quality of life, end-
of-life care, and patient and family satisfaction. From
the provider perspective, research should address
hospital operational outcomes such as length of stay,
readmission rate, case volume, patient throughput,
ICU bed availability, and interhospital transfers (both
rate and timing). Because telemedicine could either
increase or decrease transfer rates, both of which
may be benefi cial, studies of transfer rates also should
evaluate mortality. Research should address quality
of life among care providers as well, including job
satisfaction and burnout.
Patient safety is a key outcome domain from both
the patient and the provider perspective. Research
is needed into how ICU telemedicine can be used
to prevent medical errors and complications. Such
research could be directed at the safety effects of
ICU telemedicine on routine care (ie, central venous
catheter placement, medication administration), sur-
veillance for complications (ie, self-extubation), and
communication, trust, and level of engagement. 34
Acceptance research is especially important because
acceptance of new technology cannot be assumed
and yet is essential for successful adoption. 35
Process: Research is needed into the process of
ICU telemedicine, including strategies to optimize
the delivery of critical care through telemedicine.
Such research should address methods to improve the
usability and workfl ow of telemedicine applications, 23
methods to improve the quality of the telemedicine
recommendations (appropriateness, timeliness, and
effectiveness), and methods by which innovation in
ICU telemedicine occurs. Research also is needed
into the effect of ICU telemedicine on processes of
care at the bedside, including evidence-based prac-
Table 2— Potential Elements of a Standardized
Preintervention Environmental Scan
Severity of illness
Best practice adherence
Family and patient satisfaction
Quality of end-of-life care
ICU type (surgical, medical, etc)
Degree of specialization
Physician staffi ng model
Nursing staffi ng ratio
Allied health professional staffi ng
Interdisciplinary rounding model
Quality of care
Medical and nursing leadership
University affi liation
Information technology utilization
Health system affi liation/integration
Metropolitan setting (urban vs rural)
Readiness for change
Critical care governance structure
Health-care system quality and safety
Figure 1. Proposed framework for ICU telemedicine evaluation
based on the Donabedian quality framework.
CHEST / 140 / 1 / JULY, 2011 235
When evaluating outcomes, working group partici-
pants stressed that whenever possible, research should
address causation rather than just association. The
diffi culty in inferring the direct consequences of a
complex health intervention is a common limitation
of observational research but is particularly problem-
atic in the before-and-after study designs that pre-
dominate in existing telemedicine evaluations. Future
research should attempt to elucidate causality by using
stronger study designs, including cluster randomized
controlled trials and multicenter observational stud-
ies with control ICUs that do not have a telemedicine
program. These studies should control for temporal-,
patient-, organizational-, and system-level confound-
ers in a way that minimizes bias due to changes in
case mix or coincident interventions.
The use of ICU telemedicine is likely to expand in
the coming years, and further technological innova-
tions will continue to change the way we deliver criti-
cal care. Use of these innovations should not necessarily
wait until defi nitive evidence of effectiveness exists
yet neither should their adoption be uninformed by
high-quality research. In this regard, it is essential
emergency care (ie, CPR). Given the capacity for
telemedicine to introduce redundant processes into
health care, research is needed into the capacity of
such redundancy to affect safety. Investigations of
unintended consequences also are needed, including
the potential for telemedicine to introduce medical
errors, as might occur when there is ambiguity of
responsibility in a redundant system. 38
Finally, research is needed into outcomes from
the health-system perspective, particularly the cost-
effectiveness of ICU telemedicine. Such research
should consist of formal cost-effectiveness analyses
based on the recommendations of the US Panel on
Cost-Effectiveness in Health and Medicine. 39 Cost
analyses should take both the hospital and the soci-
etal perspectives and use an appropriate time hori-
zon. These analyses also should account for all relevant
cost centers, including hardware, software, staffi ng
costs, opportunity costs, education costs both for
launch and for maintenance, and audit and feedback
costs. Additionally, research is needed into the role
of different physician and hospital reimbursement
models for ICU telemedicine, including fi nancial
incentives to encourage quality improvements with-
out encouraging overuse or unnecessary expansion
of unhelpful information technology.
Table 3— Key Knowledge Gaps To Be Assessed Through Future ICU Telemedicine Research
DomainTopic Area Potential Research Questions
Structure Telemedicine unit What is the optimal telemedicine model for different clinical settings?
What individual components of telemedicine are most important to ensure effi cacy?
What is the optimal make-up of the telemedicine team?
What are the core competencies of an ICU telemedicine clinician, and how can these be taught?
How does ICU telemedicine alter physician, nurse, and ancillary staffi ng patterns at the bedside?
How can ICU organizational readiness be optimized prior to introducing a telemedicine program?
How does organizational climate, both within the ICU and within the telemedicine unit, modify
the success of the program?
In what ways does telemedicine enhance or disrupt the interdisciplinary ICU team?
What are the organizational barriers to telemedicine adoption?
What factors infl uence acceptance of ICU telemedicine by bedside clinicians?
How do we measure and improve telemedicine workfl ow and usability?
What factors infl uence the quality of the clinical recommendations by telemedicine clinicians?
How does communication effectiveness infl uence uptake of telemedicine recommendations?
What factors determine innovation in ICU telemedicine?
How can telemedicine be used to improve evidence-based practice in the ICU?
What is the role of ICU telemedicine in protocol and guideline adherence?
How can telemedicine be used in continuing education, including performance-based education
based on quality improvement?
What is the effect of ICU telemedicine on mortality, quality of life, and end-of-life care?
What is the effect of ICU telemedicine on patient and family satisfaction?
What is the effect of telemedicine on diagnostic accuracy and timeliness?
In what ways does telemedicine either prevent or facilitate medical errors?
What is the effect of ICU telemedicine on operational outcomes, such as length of stay,
throughput, and readmission rates?
What are the effects of telemedicine on the incidence, timeliness, and appropriateness of
What is the cost-effectiveness of telemedicine?
How do varying clinician and hospital reimbursement schemes affect telemedicine use and
Readiness for change
Evidence-based ICU practice
and ICU glycemic control) and owns stock or stock options in
Abbott Laboratories; Baxter Healthcare Corporation; Cardinal
Health; CareFusion Corporation; Edwards Lifesciences Corpora-
tion; Intuitive Surgical Inc; MetroHealth Solution; Merck & Co,
Inc; and Pfi zer Inc. Dr Jacobi’s employer, Methodist Hospital/
Clarian Health, uses Cerner Corporation tele-ICU monitoring.
Dr Jacobi also serves as the task force chair for the Society of
Critical Care Medicine Guidelines for IV Insulin. Dr Rubenfeld
has received grant support from nonprofi t agencies, NIH and the
Robert Wood Johnson Foundation, and from for-profi t compa-
nies, including contracted research, Advanced Lifeline Services,
Inc; Siemens Corporation; Bayer Corporation; Byk-Gulden GmbH;
AstraZeneca; Faron Pharmaceuticals Ltd; and Cerus Corpora-
tion. Dr Rubenfeld has received consulting fees/advisory board
stipends and honoraria/lecture fees from Bayer Corporation;
DHD; Eli Lilly and Company; Hospira, Inc; Cerner Corporation;
Pfi zer Inc; Kinetic Concepts Inc; American Association for Respira-
tory Care; American Thoracic Society; NIH; and the Alberta
Heritage Foundation for Medical Research. He has held a con-
sulting relationship with Cerner Corporation related to ICU
information technology. Dr Rothschild has received grant support
from McKesson Corp for research (principal investigator),
Rx Foundation for research (principal investigator), American
Society of Health Systems Pharmacists Foundation, and Shared
Health (Chattanooga, Tennessee). He has received consulting
fees from the Institute for Safe Medication Practice. Dr Sales has
received grant support from the Canadian Health Services
Research Foundation, Alberta Innovates-Health Solution (pro-
vincial public funding agency in health), and Canadian Institutes
for Health Research. She has received consulting fees/advisory
board stipends and honoraria/lecture fees from a National
Institute for Nursing Research (NIH)-funded project. Dr Sales
received an honorarium for participating in a review panel at
Michael Smith Foundation for Medical Research, a provincial
funding agency in British Columbia, Canada. Dr Scales has
received grant support from the Heart and Stroke Foundation of
Canada, the Canadian Institutes for Health Research, and the
Ontario Ministry of Health and Long Term Care AFP Innovation
Fund. He has received the New Investigator Award from the
Canadian Institutes for Health Research. Dr Scales has received
consulting fees/advisory board stipends and honoraria/lecture fees
from Baxter Healthcare. He is principal investigator, Ontario
Ministry of Health and Long-term Care ICU Clinical Best
Practices Telemedicine Network Project and Strategies for Post-
Resuscitation Care Network Project. Dr Mathers has received
consulting fees/advisory board stipends and honoraria/lecture fees
from the American College of Chest Physicians. He owns stock or
stock options in Amgen Inc and Pfi zer Inc and participated in a
tele-ICU program .
Role of sponsors: The sponsor contributed to the conception of
this project but had no role in the working group development or
activities or in the preparation of this manuscript.
Other contributions: We gratefully acknowledge the assistance
of Jennifer Nemkovich, Michael Bourisaw , and the other staff
members of the American College of Chest Physicians who par-
ticipated in the organization of the conference. Members of the
Research Agenda in ICU Telemedicine Working Group are as
follows (their disclosures are available in e-Appendix 2): Nicholas
S. Hill, MD, FCCP (co-chair); Jeremy M. Kahn, MD, (co-chair);
Craig M. Lilly, MD, FCCP (co-chair); Derek C. Angus, MD,
MPH, FCCP; Mary Pat Aust, RN, MS; Connie Barden, RN,
MS; Robert Berenson, MD; Elizabeth Cowboy, MD; Peter Cram,
MD, MBA; Clifford Deutschman, MD; Victoria A. Freeman, RN,
DrPH; Dee Ford, MD; Theodore J. Iwashyna, MD, PhD; Judith
Jacobi, PharmD, BCPS; Benjamin A. Kohl, MD; Ruth M. Kleinpell,
RN, PhD; David Longnecker, MD; James A. L. Mathers, MD,
FCCP; Justine Medina, RN, MS; Bela Patel, MD; Dena Puskin,
ScD; Kevin Reed, RN, MS; Selwyn Rogers, MD, MPH; Marta L.
Render, MD; Jeffrey M. Rothschild, MD, MPH; Gordon
D. Rubenfeld, MD; Anne E. Sales, RN, PhD; Damon C.
Scales, MD, PhD; and J. Bryan Sexton, PhD.
Additional information: The e-Appendices can be found in the
Online Supplement at http://chestjournal.chestpubs.org/content/
that expansion of telemedicine be accompanied by
critical evaluation leading to a comprehensive evi-
dence base. 40 The alternative is that the expansion be
driven by individual and commercial biases and the
technological imperative. For good or bad, ICU tele-
medicine can elicit a strong emotional response from
ICU stakeholders, especially from those with a fi nan-
cial stake in its adoption or nonadoption. Recognizing
and overcoming these biases are important challenges
to future research. ICU telemedicine provides a criti-
cal opportunity to gain insight into the aspects of adult
critical care delivery that affect outcomes. Under-
standing the mechanisms of care delivery that bring
the most value is fundamental to advancing the fi eld.
In the end, the most important research questions
surround how we use telemedicine in the care of crit-
ically ill patients. The true value of ICU telemedicine
lies not in whether the technology exists but in how it
is applied, how well it is leveraged by ICU clinicians,
and how it affects workfl ow and team integration.
The most valuable research will uncover strategies to
optimize the effectiveness of telemedicine in a way
that is clear and understandable to clinicians and
hospital administrators whose decisions are guided
by this research. The development of the method-
ological framework recommended by this workshop
will provide an essential foundation for this research.
The resulting studies should provide insight into how
to apply telemedicine in the most effective and
cost-effective manner, in the highest impact clinical
settings, and with minimal adverse consequences.
Financial/nonfi nancial disclosures: The authors have reported
to CHEST the following confl icts of interest: Dr Kahn has an
ongoing nonfi nancial relationship with Cerner Corporation, which
provides access to data for research purposes. He has received
grant support from the National Institutes of Health (NIH) and
the Society of Critical Care Medicine and lecture fees from the
American Thoracic Society. Dr Kahn’s employer (University of
Pennsylvania) contracts with VISICU to provide telemedicine
services in some of its ICUs. Dr Hill has received grant support,
including contracted research support, from Actelion Pharmaceu-
ticals Ltd, Bayer Corporation, Genzyme Corporation, Gilead,
Pfi zer Inc, Respironics Inc, and United Therapeutics Corporation
and from NIH and the Pulmonary Association. Dr Hill has
received royalties from Blackwell Publishers, UpToDate Inc, and
Humana Publishers. Dr Lilly has received grant support from the
New England Institute and honoraria/lecture fees for National
Association for Medical Direction of Respiratory Care 2009. He
reports no fi nancial confl icts or revenue from his patents. Dr Lilly
has nonfi nancial research interests in the effects of tele-ICU on
outcomes. His wife is an employee of CeQur Corporation, a
device company that focuses on outpatient diabetes products.
Dr Angus has received grant support, including contracted
research support, from Eisai, Inc, and the National Institutes of
Health. Dr Angus has received consultant fees/advisory board sti-
pends from Eisai, Inc; Eli Lilly and Company; the Journal of the
American Medical Association ; Wyeth; Novartis Pharmaceuticals
Corporation; bioMérieux SA; and Roche. Dr Jacobi has received
grant support from CareFusion Corporation (an educational grant
to the Educational Review Systems program on insulin therapy
CHEST / 140 / 1 / JULY, 2011 237
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