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Synonyms: intensive care unit telemedicine; virtual ICU; eICU; Tele-critical care

What is tele-ICU?

Tele-ICU is critical care services provided to patient or bedside health care professionals from a different location, using telecommunication and telemonitoring technologies.

Tele-ICU is usually provided by a team of critical care nurses (CCRNs) and ICU providers. The team usually has access to patients' electronic medical records and real-time monitoring data. Most tele-ICU set up allows checking on patients and bedside life support machines remotely via cameras. Tele-ICU team can also communicate with bedside ICU team, patients and their family in real-time.

According to the 2018 American Hospital Association Annual Survey, in US, 17.9% (788) hospitals have adopted tele-ICU, most of which were nonprofit or public hospitals. Rural critical access hospitals had lower odds of implementing tele-ICU[1].

Types of tele-ICU services

Monitoring and responding

This type of tele-ICU service provides first call support to ICU when local intensivist is not available. The tele-ICU team is actively involved in patient care, identifying patients' need and responding to alerts.


In this mode, the tele-ICU team only evaluate patients based on a set time schedule or bedside request. There is always an ICU provider available to patients locally, who is primarily responsible for patient care.

Structures of Tele-ICU[2]

There has been no peer-reviewed article comparing different Tele-ICU structures.

Centralized Hub-and-Spoke structure

The tele-ICU team is located in a single remote center (hub), where reliable connection can be provided to allow continuous monitoring and responding. This is the predominant tele-ICU structure. Most large academic or flagship hospitals use this structure to cover ICUs in smaller hospitals.

Here is an example of centralized hub-and-spoke structure:

Decentralized structure

In this structure, providers can connect and provide service from their convenient locations, such as office or home. The structure is mostly suitable for consultation mode of practice.

Hybrid structure

Some tele-ICU centers have started using both structures for different patient care tasks.


Patient outcome

Tele-ICU can involve intensivists in a more timely manner, increase ICU best practice adherence rate, and reduce alert response time[3]. Many studies have showed that Tele-ICU could lower ICU mortality and decrease ICU length of stay, while conflicting results have also been reported. Despite attempts of meta-analysis trying to summarize data, due to the variations in data quality and tele-ICU configurations of different studies, there has not been any definite proof for the patient outcome benefits of tele-ICU[4].


Implementing tele-ICU can cost approximately $50,000 to $100,000 per bed for the first year[4]. The financial benefits of tele-ICU mostly come from increased case volume and acuity compared with traditional staffing models[5]. Two community hospitals reported an average of 44% increase in case volume, and increased average acuity for each of the diagnosis-related groups after adopting tele-ICU service[6]. However, in hospitals where tele-ICU failed to shorten length of stay or prevent mortality, tele-ICU programs can be poorly cost effective. Implementing telemedicine is more likely to be cost effective in sicker ICU patients, such as those with Simplified Acute Physiology Score II score of >50[7].


The global tele-ICU market size is expected to grow from USD 3.351 billion in 2020 to USD 9.058 billion by 2026, mostly driven by the rising geriatric population[8]. The major vendors in virtual ICU market includes Advanced ICU Care, Banner Health, InTouchhealth, Philips, iMDsoft, UPMC Italy, INTELEICU, TeleICU, etc.

Laws and Policies

United States

During the COVID-19 pandemic, the Centers for Medicare & Medicaid Services has temporarily agreed to pay for critical care offered via telemedicine[9]. Under this new rule, providers can care for established or even new patients regardless of geographic location. Most state medical board also temporarily lifted the requirement for a local state medical license[10]. It is unclear how policy will change surrounding tele-ICU after the COVID-19 pandemic.

In US, conflicting federal and state laws and policies remain to be a major limiting factor for the development of Tele-ICU[2].

Legal actions:

  • In February 2021, RemoteICU, a telemedicine provider group, sued US Department of Health and Human Services and the Centers for Medicare and Medicaid Services for not reimbursing telehealth servies provided by physicians who are located outside the United States. In August 2021, the motion for a preliminary injunction was denied and the case was dismissed for lack of jurisdiction by a D.C. judge[11]. In September, RemoteICU appealed and filed a motion for expedited consideration. The case is ongoing.


In Europe, a physician needs to be licensed only in the nation from which he is rendering medical care, not in the nation where the service is received by patient. EU patients have a right to receive medical treatment in member nations, and be reimbursed under given circumstances. Member nations can require prior authorization for reimbursement of telemedicine services[12].

New technologies

Evolving technologies in telecommunication, especially those that can provide secure, reliable, and rapidly responsive connections can be a major driver for future development[2].

Telerobotic sonography will enable ICU providers to perform ultrasound examinations remotely[13]. A study on a robot-assisted teleultrasound diagnostic system MGIUS-R3 showed that the robot-obtained image and bedside provider-obtained image were of similar quality[14].

Since all patient care data and information are being transmitted digitally, Tele-ICU could generate enormous amount of health care data, which could turn into powerful artificial intelligence algorithms[15]. The eICU collaborative research database is a large shared tele-ICU dataset of more than 200 hospitals across the United States[16].

International perspectives

  • Syria: During the conflict in Syria, a group of Arabic-speaking intensivists in North America and Europe set up a tele-ICU service in Syrian hospitals. The service used off-the-shelf video cameras and free social media applications as telecommunication tools[17].

Other resources

Webinar by European Society of Intensive Care Medicine (ESICM) on Tele-ICU during Covid-19:


  1. Ofoma UR, Maddox TM, Perera C, et al. Characteristics of U.S. Acute Care Hospitals That Have Implemented Telemedicine Critical Care. Crit Care Explor 2021;3(7):e0468.
  2. 2.0 2.1 2.2 Subramanian S, Pamplin JC, Hravnak M, et al. Tele-Critical Care: An Update From the Society of Critical Care Medicine Tele-ICU Committee*. Critical Care Medicine 2020;48(4):553-61
  3. Lilly CM, McLaughlin JM, Zhao H, Baker SP, Cody S, Irwin RS. A multicenter study of ICU telemedicine reengineering of adult critical care. Chest 2014;145(3):500-07
  4. Chen J, Sun D, Yang W, et al. Clinical and Economic Outcomes of Telemedicine Programs in the Intensive Care Unit: A Systematic Review and Meta-Analysis. J Intensive Care Med 2018;33(7):383-93
  5. Fuhrman SA, Lilly CM. ICU Telemedicine Solutions. Clin Chest Med 2015;36(3):401-7
  6. Fifer S. Critical care, critical choices: the case for tele-ICUs in intensive care: New England Healthcare Institute; Massachusetts Technology Collaborative, 2010.
  7. Franzini L, Sail KR, Thomas EJ, Wueste L. Costs and cost-effectiveness of a telemedicine intensive care unit program in 6 intensive care units in a large health care system. J Crit Care 2011;26(3):329.e1-29.e3296
  8. Global Virtual ICU Market Size - Forecast to 2026. Brooklyn, New York: Global Market Estimates, 2021.
  9. CMS. List of Telehealth Services. Secondary List of Telehealth Services 08/17/2021 2021.
  10. Piyush Mathur DC, David Jury. Critical Care Documentation and Billing Update: COVID-19 Pandemic: Society of Critical Care Medicine, 2020.
  11. RICU LLC v. UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES et al (1:2021cv00452). US District Court for the District of Columbia; 2021.
  12. Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the application of patients’ rights in cross-border healthcare. Available at Accessed on 10/20/2021
  13. Adams SJ, Burbridge B, Obaid H, Stoneham G, Babyn P, Mendez I. Telerobotic Sonography for Remote Diagnostic Imaging: Narrative Review of Current Developments and Clinical Applications. J Ultrasound Med. 2021;40(7):1287-306.
  14. Duan S, Liu L, Chen Y, Yang L, Zhang Y, Wang S, et al. A 5G-powered robot-assisted teleultrasound diagnostic system in an intensive care unit. Crit Care. 2021;25(1):134.
  15. Kindle RD, Badawi O, Celi LA, Sturland S. Intensive Care Unit Telemedicine in the Era of Big Data, Artificial Intelligence, and Computer Clinical Decision Support Systems. Crit Care Clin 2019;35(3):483-95
  16. Pollard TJ, Johnson AEW, Raffa JD, Celi LA, Mark RG, Badawi O. The eICU Collaborative Research Database, a freely available multi-center database for critical care research. Sci Data 2018;5:180178
  17. Moughrabieh A, Weinert C. Rapid Deployment of International Tele-Intensive Care Unit Services in War-Torn Syria. Ann Am Thorac Soc. 2016;13(2):165-72.

Submitted by Chengda Zhang