telehealth , or telemedicine , is the use of telecommunications and information technology to provide health care when distance separates the participants . a number of studies have shown that home telehealth interventions can improve clinical outcomes for a variety of conditions such as dermatology   and diabetes [ 24 ] . several studies have investigated its use in persons with spinal cord injury ( sci ) , in particular for the ability to detect and stage pressure ulcers ( pus ) [ 5 , 6 ] . multiple intrinsic and extrinsic factors make these ulcers common in patients with sci . for example , transfer - mobility problems , home - environment adaptive equipment issues , recreational activities , spasticity , and bowel and bladder incontinence may all contribute to the occurrence of skin compromise and pu development . telehealth appears to be a logical option for pu diagnosis and followup , particularly when the patient is not close to a local facility or transportation is difficult . however , there has been no investigation into the costs and potential savings associated with its use for persons with sci in the us department of veterans affairs ( va ) health care system . this is unfortunate because of the relatively large number of patients with sci in va facilities . the va has developed a network of major sci rehabilitation sites , which are often called hubs , and has identified smaller va facilities in the same veterans integrated service network ( visn ) , which are often called spokes . the spokes can consult with the major facilities on sci care . to support this effort , the va 's headquarters has provided a significant amount of telehealth equipment to hub and spoke sites . certain va medical centers have instituted their own telehealth programs [ 8 , 9 ] , but in general the efforts have not been coordinated . from a management perspective , there has been little guidance about its clinical impact and none with respect to cost . telehealth consultation between hospitals could improve patients well - being while saving money and increasing access to expert care . in one common situation , a veteran with sci and an apparent pu presents at a hospital that lacks an sci center . the clinicians see few patients with sci and feel that they need consultation with a specialist . this trip often takes several hours and may require an overnight inpatient stay if the return can not be made during normal hours . if a telehealth connection was available between facilities , the expert consultation could occur without the inconvenience and potential discomfort of transporting the patient . transportation can actually contribute to the pu through an extended period sitting or lying down . the va could reduce costs and , depending on his / her copayment status , the patient may also save money . standard or usual care often includes home visits in order to check for pus and/or the status of any ulcers already under treatment . the options range from simple hand - held cameras to large machines that enable live interaction with clinicians . the existence of both high - cost and low - cost telehealth technologies suggests the need for an analysis of costs and outcomes . the present study has two major objectives : ( 1 ) to develop clinical scenarios that describe common situations in the treatment or prevention of pus , and ( 2 ) to estimate the cost implications of using telehealth under each scenario by using a range of reasonable assumptions . we allow clinical outcomes to vary between scenarios with and without telehealth by varying the likelihood that patients will need inpatient and outpatient care of various kinds . the results allow for a systematic assessment of the relative costs of telehealth compared to usual care for pus among veterans with sci . in phase 1 , clinical experts in sci care developed clinical scenarios that represent common patient situations . each scenario depends on whether the patient resides within ( 100  miles or a two - hour drive ) or outside the sci homecare catchment area . the scenarios assume that the patient is in a private home residence that includes a caregiver , or in a skilled nursing facility . sci center refers to a specialized sci treatment center at a va hub facility .   for reference , the four stages of pressure ulcers stage iii pressure ulcers may be treated in an inpatient setting depending on the precise clinical situation of the patient , while stage iv ulcers always require inpatient care . the characteristics of each scenario and option are summarized in table 2 and briefly described below . the specified frequency and length of the healthcare visits are estimated based on customary recommendations ; the times may be adjusted according to patient needs . 
 within sci homecare catchment 
 usual care for patients within the homecare catchment is for a registered nurse ( rn ) from the sci homecare staff to visit the patient in his / her residence for preventative , educational , and monitoring purposes . patients typically return to the sci center for an outpatient visit and/or an inpatient stay for a 1-year annual follow - up examination . usual care for patients within the homecare catchment is for a registered nurse ( rn ) from the sci homecare staff to visit the patient in his / her residence for preventative , educational , and monitoring purposes . patients typically return to the sci center for an outpatient visit and/or an inpatient stay for a 1-year annual follow - up examination . home telehealth care option 1 involves the use of a videoconferencing unit that is attached to a land - line telephone as a complement to standard homecare visits . the telehealth unit is placed in the patient 's home or in a nursing care residential home ( which could serve more than one patient ) . the videoconferencing unit allows the sci homecare practitioners to substitute 50% of the usual care visits with home telehealth visits . outside sci homecare catchment 
 usual care for a patient who resides outside of the sci homecare catchment boundary is follow - up telephone contact at 3 and 6 months after discharge . an in - person follow - up examination at the sci center takes place at 12 months . the patient is also advised to visit a local outpatient clinic or va medical facility near his / her residence for any care , as needed . the pu itself may be treated if the patient seeks care for skin or pus at a non - sci specialty clinic or facility , but the contributing factors and intricacies of sci specialty care may not be adequately addressed . this lack of sci expert care may impact the successful treatment of existing wounds and may not be optimal for preventing additional skin compromise . usual care for a patient who resides outside of the sci homecare catchment boundary is follow - up telephone contact at 3 and 6 months after discharge . an in - person follow - up examination at the sci center takes place at 12 months . the patient is also advised to visit a local outpatient clinic or va medical facility near his / her residence for any care , as needed . the pu itself may be treated if the patient seeks care for skin or pus at a non - sci specialty clinic or facility , but the contributing factors and intricacies of sci specialty care may not be adequately addressed . this lack of sci expert care may impact the successful treatment of existing wounds and may not be optimal for preventing additional skin compromise . home telehealth care option 1 uses the same videoconferencing unit and the same schedule as option 1 for patients within the homecare catchment . the unit allows the practitioners to interact and assess the patient on a regularly scheduled basis and via home telehealth visits as needed . a patient telehealth unit is placed in the patient 's home or in a nursing home setting . home telehealth option 2 is designed to leverage the sci center expertise through the hub and spoke model of care . the patient is sent home with the same videoconferencing unit as per telehealth scenario 1 and follows the same schedule . in this scenario , the patient connects with the sci center ; this provides oversight by the sci center with appropriate clinical attention and intervention as identified via patient response . in addition , the patient has a planned visit with a local sci consultation clinic ( a local spoke va hospital or outpatient clinic ) at 1 , 3 , 6 , and 9 months after discharge . the patient and clinician are present at the spoke clinic .  
 within the sci home care catchment 
 usual care for a patient with one or more pus the nurse changes dressings and takes a digital photo for the medical record and potential physician review . usual care for a patient with one or more pus is regular home visits by a homecare rn . the nurse changes dressings and takes a digital photo for the medical record and potential physician review . the sci home care catchment 
 usual care is for a patient to be managed by a contracted private home care agency or admitted to a skilled nursing facility until the pu is healed . in the model below , we assume that an agency is used . usual care is for a patient to be managed by a contracted private home care agency or admitted to a skilled nursing facility until the pu is healed . in the model home telehealth option 3 involves store - and - forward telemedicine integrated with telehealth consultation . the patient is managed by a homecare agency or nursing facility as in usual care . a digital camera and instruction kit if it is the caregiver , we assume that he or she is willing and able to operate the digital camera . this option also assumes that secure internet access is available for transmitting the photos via e - mail . they are then forwarded to the sci center for review by a nurse and for documentation in the medical record . sci telehealth consultation with a nurse practitioner or physician at a local va spoke facility is scheduled if the wound is either getting worse or appears healed . in case of poor healing or complications , expeditious intervention and treatment plan alterations would be implemented .  
 within the sci home care catchment 
 usual care for a patient discharged after a two - month inpatient stay that included plastic surgery to repair a pu involves one return visit to the sci outpatient clinic after one month to recheck the site and follow - up visits as needed . usual care for a patient discharged after a two - month inpatient stay that included plastic surgery to repair a pu involves one return visit to the sci outpatient clinic after one month to recheck the site and follow - up visits as needed . telehealth model of care option 1 incorporates both home telehealth and store - and - forward telehealth . after discharge to home , the patient videoconferences with a nurse using the same home unit previously described . digital still photos of the surgical site are taken using the telehealth equipment ( rather than a digital camera ) during a telehealth visit . these photos are forwarded into the medical record and made available for the plastic surgeons to review , if a consultation is requested by the sci center staff . this model works for patients regardless of the distance of their residence from the sci center . telehealth model of care option 3 substitutes a digital camera for the home video telehealth unit . digital cameras provide a greater resolution ( 3.3 megapixels minimally required ) than a video still - shot and are the standard for documenting skin and plastic surgery repairs . the photo is taken and forwarded to the sci center for review and incorporation into the electronic medical record .  
 outside the sci home care catchment 
  usual care if the patient lives over 100  miles or two hours from the nearest sci clinic , care is provided by a va medical center or other facility near the patient 's home . if the patient lives over 100  miles or two hours from the nearest sci clinic , care is provided by a va medical center or other facility near the patient 's home . telehealth model of care option 1 incorporates both home telehealth and store - and - forward telehealth . in addition , digital still photos of the surgical site are taken using the telehealth equipment . these photos are forwarded for incorporation into the medical record and made available for the plastic surgeons to review , if a consultation is requested by the sci center staff . if the patient and surgical site require further assessment , a telehealth consultation can be scheduled for those patients living over 100  miles or two hours from the sci center . the telehealth consultation would take place between a patient at an sci spoke site and clinicians ( including plastic surgery specialists ) at the sci center hub site . telehealth model of care option 3 incorporates utilizing digital cameras in place of the home video telehealth unit and is the same as option 3 within the sci home catchment . if the patient and surgical site require further assessment , a telehealth consultation can be scheduled with the sci center . the telehealth consultation would take place between a patient at an sci spoke site and clinicians at a hub site . in phase 2 , we determined the cost of each scenario under usual care ( without telehealth ) and under alternative scenarios that included telehealth technology options . about 20,000 individuals are treated for sci in the va system each year . of these , about one - third ( 32% ) will be eligible for telehealth ; the remainder either lack sufficient functional independence ( 20% ) or lack a standard land - line telephone ( 48% ) . costs associated with va carecosts were extracted from the va decision support system ( dss ) national data extracts ( ndes ) . the dss allows for the estimation of costs for every inpatient and outpatient va encounter . information on costs of va - funded care for home - based health care and for care at certain non - va facilities , such as rehabilitation hospitals and community nursing homes , was extracted from the va fee basis program files . costs were extracted from the va decision support system ( dss ) national data extracts ( ndes ) . the dss allows for the estimation of costs for every inpatient and outpatient va encounter . information on costs of va - funded care for home - based health care and for care at certain non - va facilities , such as rehabilitation hospitals and community nursing homes , was extracted from the va fee basis program files . equipment costs were found in the federal supply schedule and from va staff in the acquisition and material management service . training costs were based on national - average va staff costs in a technical report from the health services research and development ( hsr&d ) health economics resource center . other supply costs , such as for telecommunication lines , were drawn from published studies [ 12 , 13 ] . 
  a second set of va costs pertained to the telehealth system . equipment costs were found in the federal supply schedule and from va staff in the acquisition and material management service . training costs were based on national - average va staff costs in a technical report from the health services research and development ( hsr&d ) health economics resource center . other supply costs , such as for telecommunication lines , were drawn from published studies [ 12 , 13 ] . miscellaneous costs there were also several non - va costs to estimate . these included travel costs under various modes of transportation and the cost of any paid home caregiver . we estimated the costs of other modes of transportation through internet research of private firms providing transportation . home caregiver costs were estimated using average national wage rates for such care , as determined by the us department of labor , bureau of labor statistics . a second source of salaries was the web site http://salary.com/. 
   there were also several non - va costs to estimate . these included travel costs under various modes of transportation and the cost of any paid home caregiver . we estimated the costs of other modes of transportation through internet research of private firms providing transportation . home caregiver costs were estimated using average national wage rates for such care , as determined by the us department of labor , bureau of labor statistics . a second source of salaries was the web site http://salary.com/.  
 cost analysis for each scenario and treatment option , we multiplied probabilities , frequencies , and costs to estimate the cost over the entire expected treatment period . we generated low- , medium- , and high - cost estimates based on reasonable ranges of costs and probabilities . for each scenario and treatment option , we multiplied probabilities , frequencies , and costs to estimate the cost over the entire expected treatment period . we generated low- , medium- , and high - cost estimates based on reasonable ranges of costs and probabilities . the prevalence of sci is relatively low , and we assumed that the availability of telehealth would not be a sufficient incentive for patients with sci to enroll in the va health care system if they had not done so earlier . consequently , demand for sci care only among current sci patients was explicitly modeled here . we assumed no change in demand for other conditions because there was no guidance for predicting such changes and because the variation in changes could be large . finally , we assumed no changes in staffing at the va as a result of telehealth use . we present costs associated with each scenario , both for standard care without telehealth and for telehealth - enhanced care . we did not conduct any statistical tests comparing the costs across scenarios because these are modeled costs rather than averages from individual observations . table 4 presents the base estimates and sensitivity ranges for prevalence rates in the model . telehealth costs digital cameras range in cost from $ 200 to $ 300 and are assumed to last three years . the home videoconference machine commonly used in the va in 2007 was the american telecare lifeview machine ( eden prairie , mn ) . its cost of $ 11,325 came from a national contract with the va and hence has no variation . telephone calls and the lifeview station both use telephone land lines . based on actual experience , we expected that 52% of individuals eligible for telehealth would have standard ( land - line ) telephones . no cost was assigned for them because this program does not purchase or repair telephones , and their use would not noticeably shorten their lifetimes . we assumed that the va clinicians initiated all calls in order to eliminate any cost to the patient . based on our assumption that transmission costs were part of the fixed overhead assigned to encounters in the sci clinic , we did not account for their costs separately . digital cameras range in cost from $ 200 to $ 300 and are assumed to last three years . the home videoconference machine commonly used in the va in 2007 was the american telecare lifeview machine ( eden prairie , mn ) . its cost of $ 11,325 came from a national contract with the va and hence has no variation . telephone calls and the lifeview station both use telephone land lines . based on actual experience , we expected that 52% of individuals eligible for telehealth would have standard ( land - line ) telephones . no cost was assigned for them because this program does not purchase or repair telephones , and their use would not noticeably shorten their lifetimes . we assumed that the va clinicians initiated all calls in order to eliminate any cost to the patient . based on our assumption that transmission costs were part of the fixed overhead assigned to encounters in the sci clinic , we did not account for their costs separately . home - based care encounters there were three types of home - based care encounters : one with a va registered nurse ( rn ) , one with a contract rn , and one with a va nurse or doctor at an sci clinic via the lifeview machine . nurse wages in the va are not unusually high , but the costs for va nurses were more than five times those for contract nurses ( table 3 ) . we conclude that the difference stems from overhead costs in the sci service of va medical centers . finally , we assumed that using a digital camera would not lengthen the time it takes to examine a patient for pus , and thus did not account separately for the cost of using a digital camera . there were three types of home - based care encounters : one with a va registered nurse ( rn ) , one with a contract rn , and one with a va nurse or doctor at an sci clinic via the lifeview machine . nurse wages in the va are not unusually high , but the costs for va nurses were more than five times those for contract nurses ( table 3 ) . we conclude that the difference stems from overhead costs in the sci service of va medical centers . finally , we assumed that using a digital camera would not lengthen the time it takes to examine a patient for pus , and thus did not account separately for the cost of using a digital camera . facility - based encounters there were five types of facility - based encounters . the first three reflect encounters at va hospitals . the fourth ( telehealth call ) includes the patient and a hospital - based staff member . va payments to office - based physicians are often similar to medicare payments for the same encounters . the relatively low cost for the contract physician visits reflects the lack of a hospital facility component in the payment . the first three reflect encounters at va hospitals . the fourth ( telehealth call ) includes the patient and a hospital - based staff member . va payments to office - based physicians are often similar to medicare payments for the same encounters . the relatively low cost for the contract physician visits reflects the lack of a hospital facility component in the payment . the first was plastic surgery and all inpatient recovery following detection of a severe pu . the second was the 30-day average cost of va payments to community skilled nursing facilities ( snfs ) . in our models , the time spent in snfs was measured in 30-day increments . although the va has its own snf units , most va convalescent patients are treated in community facilities . the first was plastic surgery and all inpatient recovery following detection of a severe pu . the second was the 30-day average cost of va payments to community skilled nursing facilities ( snfs ) . in our models , the time spent in snfs was measured in 30-day increments . although the va has its own snf units , most va convalescent patients are treated in community facilities . the low estimate reflects only mileage costs and assumes that the patient uses a private vehicle . the medium and high estimates reflect a reasonable range of costs for private transportation by a medical transportation firm . the low estimate reflects only mileage costs and assumes that the patient uses a private vehicle . the medium and high estimates reflect a reasonable range of costs for private transportation by a medical transportation firm . overall , we found that telehealth care was less expensive than standard care when patients and facilities used low - cost technology , ( e.g. , digital cameras and e - mail ) . telehealth was more expensive when high - cost , interactive devices were employed in the patient 's home . for primary prevention of pus , telehealth care using the advanced , interactive technology ( telehealth option 1 ) was slightly less expensive than usual care in the first year . telehealth support of a spoke site by a hub site ( telehealth option 2 ) was more expensive than usual care in the first year but slightly less expensive in later years .   in the scenario of conservative treatment for an existing ulcer , telehealth care is not available for persons within the va catchment area . for those outside the area , telehealth care using a digital camera ( telehealth option 3 ) was slightly less expensive than usual care under all cost assumptions .   for postsurgical care , the telehealth approach with an interactive system in the user 's home ( telehealth option 1 ) was substantially more expensive than usual care in every case except one . conversely , a telehealth method that relied only on digital cameras ( telehealth option 3 ) was notably less expensive than usual care . care within the sci homecare catchment area was generally more expensive than care outside that area because of the relative cost of the nursing staff . as noted earlier , although labor costs for va nurses are not high , the overhead assigned to nurses in the sci service of va hospitals led to a total estimated cost well above that of contract nurses . videoconferencing is a valid method for recognizing and staging pus [ 6 , 14 ] . in the present study , we analyzed costs across a range of clinical scenarios and found that low - cost telehealth strategies could reduce the cost of care for persons with sci . the models imply that patients such as rural veterans with sci may be able to obtain clinically effective and cost - effective care for pus through inexpensive telehealth technology . an increase in use of telehealth technology could reduce the incidence of stage iii and stage iv ulcers , thereby improving veterans ' health without increasing va costs .   using the model results , we calculated the yearly system - level cost implications of employing the telehealth approaches relative to usual care . table 6 presents the range of net savings ( positive numbers ) or net costs ( negative numbers ) for each scenario , within and beyond the catchment areas . to summarize , in scenario 1 ( preventive care ) telehealth approaches were cost - saving within the homecare catchment area but not always outside of it . in scenario 2 ( treatment of an existing pu ) , telehealth was cost - saving outside the homecare catchment area . note that there is no telehealth within the homecare catchment area for scenario 2 . for scenario 3 ( postsurgical care ) , telehealth approach 1 was always more expensive while approach 3 was always cost - saving . the last two rows of the table present ranges of the total net savings if the va were to adopt telehealth care for sci whenever it was feasible . if the va relied entirely on telehealth approach 1 , then it would face higher expenditures unless the highest - cost assumptions prevailed . however , using alternative , lower - cost telehealth approaches where possible would enable the va to find net savings in the millions of dollars under low- , medium- , or high - cost assumptions . we analyzed the cost of sci care through a model that used average costs and estimated probabilities of clinical outcomes and equipment failure . as with any study , actual costs and outcomes will vary by person and by va station . our results should be interpreted in light of the uncertainty that comes from using average figures and assumed probabilities . we reflected differences in clinical outcomes with and without telehealth technology by altering the probability that patients would heal within a specified timeframe , and the related probabilities of needing inpatient and outpatient care . these estimates reflect the experiences of a single va site and might not generalize to the entire va system . the use of low , medium , and high costs constitutes a simple form of multiway sensitivity analysis that indicates the direction of difference ( positive or negative ) between standard and telehealth approaches . the relative cost of sci care with and without telehealth will naturally depend , at least in part , on differences in clinical outcomes and the va 's savings or costs . topics could include tracking actual costs for use of specific telehealth technologies by a well - described population , such as persons enrolled in a clinical trial . it would also be beneficial to track the clinical and cost outcomes of particular telehealth technologies in different settings and with different types of patients . in other words , it would be useful to replicate our present scenarios with prospective studies .
home telehealth can improve clinical outcomes for conditions that are common among patients with spinal cord injury ( sci ) . 
 however , little is known about the costs and potential savings associated with its use . 
 we developed clinical scenarios that describe common situations in treatment or prevention of pressure ulcers . 
 we calculated the cost implications of using telehealth for each scenario and under a range of reasonable assumptions . 
 data were gathered primarily from us department of veterans affairs ( va ) administrative records . for each scenario and treatment method , we multiplied probabilities , frequencies , and costs to determine the expected cost over the entire treatment period . 
 we generated low- , medium- , and high - cost estimates based on reasonable ranges of costs and probabilities . 
 telehealth care was less expensive than standard care when low - cost technology was used but often more expensive when high - cost , interactive devices were installed in the patient 's home . 
 increased utilization of telehealth technology ( particularly among rural veterans with sci ) could reduce the incidence of stage iii and stage iv ulcers , thereby improving veterans ' health and quality of care without increasing costs . 
 future prospective studies of our present scenarios using patients with various healthcare challenges are recommended .