In an early 2026 piece, I criticized the growing practice of outsourcing bedside ICU care to tele-critical care programs. I argued that replacing the in-person work of physicians, nurse practitioners (NPs), and physician assistants (PAs) with remote physicians leads to the lack of a bedside leader, shoddy exams, breaks in the continuity of care, the depersonalization of the doctor-patient relationship, and an overall degradation in the quality of ICU care. I illustrated those concerns through the case of a young woman who died of postpartum sepsis after a tele-critical care physician failed to recognize her need for emergent surgery.

It was heartbreaking, but predictable, that not long thereafter we learned of Conor Hylton, a 26-year-old dental student who died after being admitted with pancreatitis to a community hospital’s ICU in the Yale New Haven Health system in 2024. Court documents and reporting allege that Hylton was not seen by an on-site physician after his clinical status deteriorated and he was transferred to the ICU. Instead, in the hours before his death, Hylton was cared for by a tele-critical care physician. The patient’s parents are suing the hospital for wrongful death and are claiming the care their son received amounted to negligence. This case follows reporting of a public outcry from nurses worried that a move by TeamHealth, a private equity-backed medical group, to transition in-person ICU care to telemedicine in a Wisconsin health care system will endanger patients.

With nurses, patients, and physicians sounding the alarm, a response from industry was anticipated. In a June 2026 piece, Dr. Chris Gallagher, the founder and former CEO of one of the nation’s largest providers of acute specialty telemedicine, offered a defense of tele-critical care and called for its expanded use. He asserts that while the criticism of tele-critical care relies on anecdote, a careful reading of the literature supports his position. “To frame tele-critical care as the modern face of medical neglect is to misread two decades of pragmatic trials, observational cohort, and meta-analyses.”

Indeed, a more careful reading of the literature is needed.

When critically evaluating the medical literature, one question the reader should ask themselves before accepting a study’s conclusions is: “Are these findings generalizable?” In other words, are the study population and the intervention tested similar to what happens in the real world? Tele-critical care can take many forms, and not all iterations of it are equal. A useful distinction is to classify tele-critical care as an augmentation of the ICU team, where it functions as an extra set of eyes and is an addition to the existing staffing model, versus a replacement for an in-person provider. These are inherently different interventions.

In the “landmark” 2011 UMass Memorial pre/post analysis, the telemedicine executive’s claims run headfirst into a fundamental problem of generalizability. The UMass study bears little resemblance to how tele-critical care is practiced today. It was conducted at a large academic medical center where existing bedside staffing was fully preserved. Board-certified intensivists remained responsible for ICU patients, while residents, NPs, and PAs staffed the ICUs around the clock. Prior to implementation of the tele-critical care program, the study team identified best-practice guidelines for the prevention of venous thrombosis, cardiovascular complications, stress ulcers, ventilator-associated pneumonia, and managing central intravenous catheters. In addition, they created an electronic system that monitored vital signs remotely and received continuous updates designed to preemptively identify evolving physiologic instability. The off-site tele-critical care physician (who also worked in the UMass system as an intensivist) would then provide the bedside providers with real-time alerts of physiologic instability and notify the team if their medical care deviated from the best-practice guidelines in order to prompt an intervention. Moreover, the tele-critical care physician participated in the team’s morning and evening sign-out rounds. This study tested a first-in-class augmentation model of tele-critical care and was associated with a 1.8 percent reduction in adjusted hospital mortality.

The problem is that you rarely if ever see that version of tele-critical care in ICUs today. The argument for tele-critical care is not comparing like to like. Nearly every study he cites evaluates tele-critical care as an augmentation of bedside care. Yet, as health care systems are constantly looking to cut costs, the tele-critical care physician’s primary job is to outsource the in-person overnight PA, NP, or physician, not to augment the existing team.

In my experience staffing ICUs, and in conversations I’ve had with colleagues around the country, the dominant trend since the COVID pandemic is replacement. In one large health care system where I provided locums coverage, the entire system outsourced their overnight NPs and PAs to tele-intensivists. The internal medicine physicians caring for the rest of the hospital’s patients at night were then given the additional job of covering the ICU with the tele-critical care service. Because these physicians were already stretched thin, the model quickly devolved to the tele-intensivist caring for the ICU patients without a bedside physician. Admissions, consultations, and bedside care were all done remotely. The tele-intensivist functioned in a reactive manner, responding to changes in a patient’s status after it was noticed by nursing. In the models practiced in most ICUs today, there is no proactive continuous hemodynamic monitoring, I’ve never witnessed structured prompts to notify staff of deviations in best practices, and collaborative sign-out between tele-intensivists and the in-person day team is vanishingly rare.

The issues with holding up the UMass study as a justification for the version of tele-critical care practiced today don’t end there. First, the patients and interventions in a medical study are optimized. Rarely are the full effects of the studied intervention realized in clinical practice. Not infrequently, they disappear altogether. Second, the data was not randomized; it was an observational before-and-after study of data collected from 2005 to 2007. As with any observational data, it is possible unmeasured confounders not accounted for in the study design, and not the tele-critical care intervention, produced the observed results. Third, using data from the mid-aughts is dubious. I worked in medical, trauma, and surgical ICUs in the 2000s. Back then, doctors took ownership of their patients. Nobody would have dreamed of outsourcing any important medical decision to a tele-intensivist.

The UMass article is one of a series of pre/post studies that suffer from similar methodologic limitations. Another study he references in support of tele-critical care is a retrospective pre/post study using the Medicare claims data of 132 hospitals from 2001 to 2010. Like UMass, the study evaluated tele-critical care in an era where remote physicians augmented rather than replaced bedside providers. The study excluded small hospitals so it is not generalizable to many of the critical access hospitals where tele-critical care is championed today. The authors found wide heterogeneity in the effect of tele-critical care, “with most hospitals seeing no significant effect, some hospitals seeing reduced mortality, and a few hospitals seeing increased mortality.” In fact, the hospitals that did observe a reduction in mortality were the larger urban hospitals, where an in-person provider was almost certainly assured, and not the smaller rural hospitals where tele-critical care is most aggressively marketed.

He then goes on to cite two meta-analyses, the most recent from 2019. This analysis included 13 pre/post studies, one of which was published in 2018 with the remaining 12 being published from 2000 to 2014. The study examined an aggregate of 161,109 ICU patient encounters. The largest contributor of patients was the UMass study which provided 74 percent of the data. The next largest contributing study once again tested augmentation and not replacement. All preexisting staffing levels for medical residents, fellows, intensivists, and hospitalists were preserved. Moreover, that study contains a fatal methodologic flaw: The mortality data reported was not adjusted for patient illness severity. There is a saying when it comes to meta-analyses: “garbage in, garbage out.” Combining a bunch of low-quality, biased, or methodologically flawed studies gives you one larger low-quality and biased study, not the truth.

This brings us to the 2024 TELESCOPE randomized clinical trial (RCT) which provides the most methodologically robust evidence to date. In their supplement, the investigators highlight the limitations of the prior pre/post observational studies as a justification for performing the trial. TELESCOPE was conducted in 30 Brazilian ICUs struggling to meet performance targets, where the average mortality was 20 percent higher than predicted. The clustered RCT tested the effect of daily multidisciplinary rounds led by a tele-intensivist versus standard care without an intensivist. The rounds were required to be at least five minutes per patient, goal-oriented, utilized established best-practice protocols, and set the care plan for the day. The protocol excluded ICUs where multidisciplinary rounds previously existed or ICUs where an on-site full-time intensivist was available. The study tested an optimized augmentation model, as an internal medicine-trained physician continued to staff the ICUs, but it is the closest thing we have to what occurs in many U.S. hospitals today. Across more than 17,000 patients, TELESCOPE found that tele-critical care failed to improve ICU length of stay, mortality, ventilator-free days, or the incidence of central line and catheter infections. His assertion that this trial supports the expansion of tele-critical care cannot be reconciled with the study methodology or any of its findings.

The telemedicine executive then argues that the shortage of U.S. intensivists further justifies tele-critical care. He is right that there is a shortage of critical care fellowship-trained physicians; however, there is a national surplus of NPs and PAs. But from a business perspective, outsourcing an in-person ICU PA or NP is the most attractive feature of tele-critical care and not a bug to be fixed. Safeguards that he proposes: “structured, mandatory sign-out between in-person and remote intensivists; minimum bedside advanced practice provider coverage so that no remote intensivist is the sole physician presence for a unit in extremis; [and] capped patient-to-tele-intensivist ratios” sound great but don’t pass the sniff test. For example, if a tele-critical care physician covers six ICUs with an average of fifteen patients per ICU, and if that tele-intensivist were to devote one to two minutes per patient per sign-out, nightly sign-out would take over two hours. This assumes the tele-intensivist could seamlessly coordinate with six in-person physicians across six hospitals. The process would then have to be repeated in the morning for the daytime shift. In the same vein, one can call for capped patient-to-tele-intensivist ratios, but he surely must know that the real-world ratios of 100:1 (ICU patients to tele-intensivist) far exceed what anyone would consider attentive or high-quality critical care. These realities break the business model.

Ultimately, his article should be seen not as an academic argument but for what it truly is: a business pitch. There are billions of dollars at stake in telemedicine. He recently led a $400 million deal to take Access TeleCare private. In a LinkedIn post, he extols the virtues of tele-critical care by increasing a hospital’s return on investment (ROI) by perfectly matching clinical work with a remote physician’s availability. In reality, he has helped create a system where if in 2026 you are sick in a U.S. ICU, you are now more likely to be left alone without a dedicated in-person ICU MD, NP, or PA compared to a decade ago. Americans should realize that there are two conversations being had here: one is publicly facing and the other is a private discussion. “Attentive care” and “being by your side for your toughest moments” are slogans for the hospital billboards. In the back rooms, where the deals are made, misrepresenting the literature and ROI win the day.

When the lawyer for Conor Hylton’s family told a local outlet that Conor had been cared for in what amounted to “a fake ICU,” he saw through the sales pitches and misplaced enthusiasm. In three words he captured the essence of the wild-west-like expansion of tele-critical care that is being foisted on patients and physicians today. Tele-critical care can be a valuable solution in critical access hospitals and as an adjunct when it augments bedside clinicians. Sadly, we are in an era where the literature is being misrepresented as cover for the hollowing out of bedside care. Until advocates of tele-critical care stop citing evidence for augmentation to justify replacement, and acknowledge what is lost when a living physician, NP, or PA is gone from the ICU bedside, the public debate will remain fundamentally misleading.

Keith Corl is an emergency and critical care medicine physician.  

His research focuses on point-of-care ultrasound, IV fluid resuscitation, and sepsis. He shares updates on LinkedIn and X.

The views he expresses here are his own.