Editorials |

A Difference Is a Difference if It Makes a DifferenceDifference FREE TO VIEW

Don Eugene Detmer, MD; Karen S. Rheuban, MD
Author and Funding Information

From the Department of Public Health Sciences (Dr Detmer), School of Medicine; and the University of Virginia Center for Telehealth (Dr Rheuban), University of Virginia.

Correspondence to: Don Eugene Detmer, MD, University of Virginia, Department of Public Health Sciences, Charlottesville, VA 22908; e-mail: ded2x@eservices.virginia.edu

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Rheuban is an (unpaid) past president of the American Telemedicine Association. Dr Detmer has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

Chest. 2013;143(1):7-8. doi:10.1378/chest.12-1751
Text Size: A A A
Published online

The systematic review and analysis of critical care telemedicine programs by Kumar et al1 in this issue of CHEST (see page 19) summarizes many of the challenges facing those who seek to learn from a review of a technologic innovation in a complex health-care environment. The most obvious issues relate to total sample size (typically rather small), missing variables (universally an issue), wide variation in costs, and, as a result, questionable conclusions that may be drawn. This is not intended as a criticism of the investigators, but rather recognizes the challenges that faced them.

When one is unable to “control” for either intensivists and staffing models, the presence or absence of electronic health records, as well as their varying functionalities, the result is certain to be problematic. The lack of capability to assess an impact on throughputs, patient volumes, and outcomes left us with a model for future researchers to use for similar evaluations and some raw benchmark cost data. Other less costly models of telemedicine-supported ICU consultations were not included in the analysis.

Two specific conclusions jump out. First, this extensive review shows quite clearly that there is great interest in the use of telemedicine in critical care environments. After many decades of telemedicine applications, this is no real surprise. Telemedicine can improve access, mitigate workforce shortages, and play an important role in both acute and chronic disease management. Technology integration can help reduce variations in care. The second lesson, however, is a more serious one. With an annual expenditure estimated to range from $50,000 to $123,000 per monitored bed, we are not talking about “chump change.” Our guess is that the return on investment will be difficult to justify, particularly when the overwhelming challenge we currently face in the United States is how to efficiently and effectively manage chronic health problems outside the hospital or clinical environment, such as in the home or the workplace.

Again, from this broader perspective, it is fascinating that after all the years we have invested in creating the globe’s most expensive and, comparatively speaking, underperforming health-care system, Americans still dream of technology fixes to layer upon the in-hospital environment. Meanwhile, if we take the necessary time and effort to genuinely engage patients in understanding and clarifying their own preferences for care, we are most likely to see fewer critical care choices on the adult side and a much greater investment in telehealth aimed at wellness, disease prevention, and chronic disease management. These shifts will not be all that simple to achieve and they, too, will require rigorous evaluation. Meanwhile, there is little question that telemedicine addresses specialty shortages, can improve access to care, and can save money in selected environments.

The important point articulated by the authors is that we have yet to validate the full value proposition in critical care settings. As Thomas1 noted years ago, most medical technologies are “half-way.” Going forward, there should be increasing pressure to validate and identify the return on investment, but only in those situations in which the benefits are expected to have a good chance of being worthwhile. Knowing what works can help prevent avid cost cutters from inadvertently limiting commendable improvements in patient outcomes. These are the key differences we will need to protect as we apply more fiscal discipline to our struggling health-care system.


Kumar G, Falk DM, Bonello RS, Kahn JM, Perencevich E, Cram P. The costs of critical care telemedicine programs: a systematic review and analysis. Chest. 2013;143(1):19-29.
Thomas L. Lives of a Cell: Notes of a Biology Watcher. New York, NY: Viking; 1974.




Kumar G, Falk DM, Bonello RS, Kahn JM, Perencevich E, Cram P. The costs of critical care telemedicine programs: a systematic review and analysis. Chest. 2013;143(1):19-29.
Thomas L. Lives of a Cell: Notes of a Biology Watcher. New York, NY: Viking; 1974.
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543