The mountains are calling, using a technology that still is deciding on what to call itself — whether telemedicine or telehealth. “Some say there’s no difference” between one term and the other, says Dr. Steve North, clinical director for Mission Virtual Care. But no matter what you call it, North and many other health care professionals in the mountains agree that there is a real need for the service in the area and beyond.
“Telemedicine is the act of providing care to a patient with videoconferencing technology,” while “telehealth includes remote home monitoring,” such as cardiac monitoring from home, North explains. “Virtual care is all-encompassing,” he says. That means that telemedicine includes real-time as well as asynchronous telecommunication, like email.
“There is tremendous need,” says North, noting the broad shortage of health professionals in the region. He has seen telehealth help meet this need in many forms for years, including school-based health care. North started out as a teacher in North Carolina, where he saw “kids come to school without great access to health care, and that limited their ability to learn.” North decided to go to medical school at UNC Chapel Hill so he could provide “school-based health care in a rural community.”
North, who is also the founder and medical director of the Center for Rural Health Innovation in Spruce Pine, has seen patients since 2011 through the Health-e-Schools program he developed, which is now in 33 schools in four counties. “Due to the program, all students in McDowell, Mitchell and Yancey counties have access to school-based health care. We see all students regardless of their ability to pay.”
The fourth county, Burke, does not have all students in school-based health care yet, he notes. Because of the program, “85 percent of students return to class as opposed to going home or missing a day of school entirely,” says North.
Telehealth can be beneficial in Western North Carolina for other types of patients as well, North explains. Virtual care in the mountains has been especially helpful for stroke patients and psychiatric clients, but “in most specialties in the region, we have the capacity to care for acutely ill patients. The challenge is [that] routine referrals result in extended wait times.”
Sharon Wilkening, a nurse practitioner for Carolina Partners in Mental Health, has been working with telehealth since September. In her 14 years of practice, she has seen “the need for behavioral health services continue to rise as waiting lists increase and crisis services decrease. People who are in need of mental health care are not getting the services that they need in a timely fashion, if at all.” Telehealth allows providers “to access those individuals that we would not have otherwise been able to reach.”
Wilkening says the goal of her organization is “to make behavioral health services accessible to all those in need.”
Stan Monroe, CEO of CPMH, has witnessed an overall health care shortage in the region as well. Referencing an article called “The Impact of Telemedicine” by Kristen Shrader, Monroe says, “Telemedicine helps bridge the health care gap by providing individuals with better access to care, convenience and reduced medical spending.”
While some practitioners may work with most of their patients in person, some WNC practitioners have expanded their care to clients in other areas of the world with telehealth.
Miriam Nelson, a physical therapist and owner of The Runner’s Mechanic in Asheville, specializes in manual physical therapy and biomechanics — “the study of the human body’s movement and how it relates to forces throughout the system,” she explains.
For several years Nelson has worked locally with elite athletes, such as ultrarunners, Iron Man athletes and Olympic athletes. But starting last year, she began to provide telemedicine services for people in other parts of the country. “I do video analysis for clients across the country [after they] send video of their running gait. I break down the kinematics with software I have, give them useful information about their movement patterns that have been shown to be injurious or inefficient in the research, and strength and stretching tips,” says Nelson. “I also advise them how to follow up with local practitioners for the hands-on treatment they may need.”
Marisol Tomás, a licensed clinical social worker who specializes in somatic experiencing and Organic Intelligence in her Asheville-based private practice Sol Reflection, does most of her work locally. But Tomás has provided services remotely across the U.S. since 2014 and in other countries since 2015. Her international teletherapy came about when a local Facebook counseling site indicated that a United Nations humanitarian worker wanted therapy in English, she says. Tomás began offering therapy to that client, who has since referred her to humanitarian workers in other countries. Tomás has provided therapy by videoconferencing with clients in Iraq, Kenya, Somalia and Nepal.
There are many such advantages to telehealth, says North. He notes that school-based telemedicine is convenient for parents because they don’t have to “leave work to take their child to the doctor.” Telehealth also allows school nurses and counselors to be at the school during the appointment, if needed. They “send records of all visits to the primary care physician,” which encourages follow-up visits, North says.
“The chance that a patient no-shows to a follow-up visit decreases” the closer the patient is to a health practitioner, he adds. Citing the N.C. Statewide Telepsychiatry Program, North also notes that “telepsychiatry reduces length of ER visits,” so virtual care can save time and money as well. And, he continues, telehealth also improves medical care and saves lives, especially with telestroke programs, where “the key to improving stroke care is getting the patient treated within three hours of the onset of symptoms.”
Wilkening mentions several additional telehealth benefits: “Transportation and time constraints can hinder some from being able to receive the services they need to improve their quality of life,” she says. “There are numerous reasons why patients cannot attend office visits, and this service bridges that gap. Patients are able to access services from the comfort of their home or office. To date, most patients requesting appointments for verbal therapy have been seen the day of the request and within a day for medication evaluation appointments. This is practically unheard of for behavioral health appointments.”
Nelson says she enjoys providing physical therapy for patients in person as well as remotely. “I really appreciate the chance to meet people from all walks of life,” she says. “I love treating these clients that are nonathletes — people of different ages, demographics and occupations.” Although Nelson specializes in working with elite athletes and runners, she remarks, “The truth is I love working with everyone.”
Tomás says, “I really love the accessibility of [telemedicine]. I can see [clients] wherever I am in the world,” she says. “Just check the time difference and set the appointment.”
Tomás is able to provide therapy to “people who want the specific type of therapy” she offers, no matter how far away they live. Telehealth is “good for someone who wants to create their own schedule” as well.
Wilkening was initially skeptical about telehealth for purposes of evaluation and treatment. “I was initially concerned that the videoconferencing platform would decrease my ability to evaluate essential therapeutic factors such as body language, posture, eye contact and facial expression,” she says. “These cues are extremely useful tools for a provider in regard to assessment and treatment. I believe very little of the nonverbal cues are lost when utilizing telemedicine,” says Wilkening. “I have yet to find drawbacks with telemedicine.”
But there are potential disadvantages. “Across the country, one of the challenges is being able to connect patients back with primary care” after a patient has been seen through telemedicine, says North. “Big, for-profit companies are providing telehealth services and not informing primary care physicians what they’ve done.”
Nelson says she informs patients about the potential limitations of virtual care. “I’ve actually cautioned the people that attend my courses — I teach a two-day course for North American Seminars on running rehabilitation and biomechanics across the country — that comprehensive treatment can’t just be done via online with the gait analysis. But there is a very valuable part of treating a runner by this service, sometimes greater than 50 percent for most clients, and a few at 100 percent, if that is their main issue.”
Tomás relates very few disadvantages to telehealth. While providing therapy, she is “watching the entire body for patterns and movement and flow and constriction and ease, so you would think it would be hard to see all of that” with virtual care, but it has still worked well, she says. One limitation occurs, however, when the country she is accessing does not have a good internet connection. Tomás also acknowledges that when she’s providing therapy to people remotely, they should have some connection to a therapist locally in case they need direct support. In her initial contact, she makes sure the client is appropriate for teletherapy, noting, “They need to be stable.”
Wilkening predicts that with advantages far exceeding the disadvantages, telehealth will continue to expand as a much-needed service in the future. “Prior to launching our telemedicine program, we completed extensive research on other national telemedicine providers. After completing research, it became apparent that this is the direction many practices are heading, and patients are influencing the dramatic growth of telemedicine,” she says. “We are in an age of technology, and as providers we need to keep up with the technology.”
Dr. Steve North
Sharon Wilkening and Stan Monroe