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Telemedicine nears a crossroads

Much has been accomplished to this point. Now it’s time for lawmakers and state and national organizations to step up.

Telemedicine nears a crossroads
The bottom line is we have no clear path forward, unlike human medicine, where organizations stepped up and in some cases were formed to drive reforms to increase access to health care.

It’s time for a checkup. Not for my pets, but for a certain item called veterinary telemedicine. Every reader of Today’s Veterinary Business knows that you cannot attend a local, state or national veterinary meeting without seeing telemedicine on the agenda. It’s been that way for the past 2½ years. The NAVC’s January conference, VMX, had no less than 40 exhibitors offering telemedicine services or products.

Telemedicine, it appears, finally has earned a seat at the veterinary table, right? But can we trust appearances? Hence, this checkup. Here are the categories we’ll examine:

  • The adoption of telemedicine at existing veterinary clients.
  • Telemedicine/triage services in employee benefits plans.
  • Academic telemedicine.
  • The view of trade and professional organizations regarding the formation of the veterinarian-client-patient relationship (VCPR) via telemedicine.
  • State board and legislative adoption of pro-telemedicine language and practices.

1. Veterinary Practice Adoption

We can say definitively that practices across the United States are learning about telemedicine, experimenting with it and, in many cases, adopting a fee for telemedicine services as part of their client offerings. Austin, Texas-based

ZippiVet provides a human medicine level of telemedicine services at rates embraced with enthusiasm by clients. Spend a few minutes with ZippiVet’s Audrey Wystrach, DVM, and you will see why millennials in particular love the service — advice is conveniently available when and where they want it. The service doesn’t harm in-clinic visits.

Major veterinary industry providers have geared up to support telemedicine. The outsourced service relieves clinic staff from having to become technology experts, which was a major barrier three years ago. At the time, skeptics wondered whether telemedicine could be commercialized and not be just a free after-hours consultation that added to an already long day. Experts and practitioners have worked together to figure this out, and it’s safe to say that telemedicine will soon be a standard offering of modern small animal practices, large and small.

2. Employee Benefits

WhiskerDocsWhiskerDocs shared data from teletriage services provided through Competitive Health, which offers benefit plans to employers and large member groups. Partial data from whiskerDocs founder Deb Leon, who built a successful human telemedicine business, shows the economic value to pet owners and the enhanced view they have of the benefits of the services.

3. Academic Telemedicine

It’s too early to call it a trend, but consider this: The Texas A&M College of Veterinary Medicine officially launched a clinical position in telemedicine and appointed telemedicine expert Lori Teller, DVM, as the first faculty member. Schools don’t make such appointments as a fad. They do it to provide students with the training they need to succeed in contemporary practices. And now, Texas pet owners are getting telemedicine guidance from A&M faculty and students. I doubt that A&M will be the only school to implement telemedicine in its curriculum, so stay tuned.

4. Trade and Professional Organization and the VCPR

Now we arrive at the heart of the debate over telemedicine: Should veterinarians be able to use digital tools like telemedicine to start a relationship with a client and her pet? A handful of states such as Texas flatly say “No,” and of the rest, all but Connecticut, the District of Columbia and Alaska, require an in-person examination of the animal before a VCPR may be created. (Virginia’s language suggests it might be open to an electronic VCPR.)

Most state veterinary medical associations have not adopted an official policy, but it’s safe to say a large majority aren’t pushing for reform. Does that mean most veterinarians in these states oppose reform? No, but it does suggest that most state VMA boards of directors are not yet comfortable with the idea. All states are looking at telemedicine, so the door isn’t locked shut, but it’s not exactly open and inviting.

The American Veterinary Medical Association conducted a nearly two-year review of telemedicine. While the organization endorsed the use of telemedicine with existing clients, the AVMA opposed the use of digital tools (telemedicine) to create a VCPR. The AVMA acknowledged that views might change down the road, but for now the VCPR remains where it’s been for decades: as if telemedicine didn’t exist or hasn’t been demonstrated to be a high-value tool.

The North American Veterinary Community, publisher of Today’s Veterinary Business, formed the Veterinary Innovation Council (VIC) in January 2016 with an impressive set of sponsors and board members, including:

  • Eleanor Green, dean of the Texas A&M CVM.
  • James Lloyd, dean of the University of Florida CVM.
  • Former AVMA president Dr. Doug Aspros.
  • Steve Leder of Zoetis.
  • Ken Yagi of the National Association of Veterinary Technicians in America.
  • Mars Inc. thought leader Jeannine Taaffe.
  • Idexx chief medical officer Dr. Roberta Relford.

VIC’s first order of business was to establish telemedicine as the policy topic of interest, to which VIC has devoted the past three years.

The VIC board examined all facets of telemedicine and ultimately adopted a policy that allows a licensed veterinarian to determine if he or she has adequate knowledge of the animal’s condition to start a relationship. Which means that if a veterinarian has confidence in telemedicine tools, then she can work with a client and patient remotely. This reform was grounded in human medicine’s success with telemedicine, particularly in rural areas where access to health care is limited. VIC publicized its recommendations in veterinary media and meetings throughout 2016, 2017 and 2018, and it was apparent that a growing number of veterinarians welcomed VIC’s approach.

In September 2016, the American Association of Veterinary State Boards held its annual meeting in Scottsdale, Arizona. CEO Jim Penrod and AAVSB’s board agreed to devote a half day to the then-emerging topic of telemedicine as a way for state boards to get in front of the issues. AAVSB invited the AVMA (represented by Dr. Teller) and VIC (represented by the author), plus a technology executive to address the meeting and participate in a two-hour series of table discussions. Interest was keen.

AAVSB launched a two-year review of telemedicine at the national and state levels, culminating in AAVSB’s official adoption of Model Practice Act language at its September 2018 annual meeting. Part of the Model Practice Act states:

The veterinarian must employ sound professional judgment to determine whether using telehealth is suitable each time veterinary services are provided and only furnish medical advice or treatment via telemedicine when it is medically appropriate. A veterinarian using telemedicine must take appropriate steps to establish the VCPR, obtain informed consent from the client, and conduct all necessary patient evaluations consistent with currently acceptable standards of care. Some patient presentations are appropriate for the utilization of telemedicine as a component of, or in lieu of, hands-on medical care, while others are not.

DEFINITIONS

Telemedicine is the remote delivery of health care services, such as health assessments or consultations, over the telecommunications infrastructure. It allows veterinarians to evaluate, diagnose and treat patients without the need for an in-person visit. A veterinarian-client-patient relationship (VCPR) exists when:

  • Both the veterinarian and client agree for the veterinarian to assume responsibility for making medical judgments regarding the health of the animal(s); and
  • The veterinarian has sufficient knowledge of the animal(s) to initiate at least a general or preliminary diagnosis of the medical condition of the animal(s); and
  • The practicing veterinarian is readily available for follow-up in case of adverse reactions or failure of the regimen of therapy.

5. State Boards and Lawmakers

The Colorado State Board of Veterinary Medicine issued the “Guideline for the Appropriate Use of Telehealth Technology in the Practice of Veterinary Medicine” on Oct. 18, 2018 (revised April 11, 2019). The document mirrors the AAVSB model language.

The Oklahoma Board of Veterinary Medical Examiners issued a position statement on telemedicine and telehealth. A key portion of the guidelines is this:

Telehealth is a reasonable option for patients who lack regular access to veterinary care. It also enhances opportunities to access emergency or specialty veterinary expertise in geographic areas where no other options are available.

The veterinarian accepts that he or she cannot prescribe drugs when practicing via telehealth alone, unless the veterinarian has sufficient knowledge of the animal or group of animals by virtue of a history and inquiry, and either physical examination or medically appropriate and timely visits to the premises where the animal or group of animals is kept.

That’s it so far from state boards: two sets of guidelines allowing for telemedicine based on the veterinarian’s judgment, with a restriction on prescriptions. This is progress, but 45 states still do not follow the human practice of allowing for digital creation of a VCPR. In many cases this will require legislation to amend state veterinary practice acts.

Which organizations will step up to call for these reforms? Will telemedicine become the de facto norm and state boards look the other way? Will state boards follow the lead of their national organization, AAVSB, like Colorado and Oklahoma did, and adopt guidelines allowing for formation of a VCPR remotely? We know that pet owners are not organized at local, state or national levels, so expecting them to lead the charge is not realistic. Maybe millennial veterinarians will call on state VMAs to lead the charge, but that’s probably a long shot.

The bottom line is we have no clear path forward, unlike human medicine, where organizations stepped up and in some cases were formed to drive reforms to increase access to health care. This is a challenge veterinary medicine needs to discuss as the marketplace favors the convenience of these tools in all facets of life, including pet care.

Does it make sense to ignore the great work done to date and let the AAVSB policies die on the vine?

Politics & Policy columnist Mark Cushing is founding partner of the Animal Policy Group, serving a wide range of animal health interests as well as veterinary schools on accreditation matters. He is legislative consultant to the Veterinary Nurse Initiative and is a member of the Today’s Veterinary Business editorial advisory board.

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