An Overview of Telemedicine
Most of us, on at least a weekly basis, use telemedicine. We consult with a specialist on radiographs. We call the ASPCA on a poison case. We even receive text pictures from clients and give advice. All of this seems safe and reasonable.
But what if one of your Washington clients told you that a veterinarian in Georgia did a video chat with them and then prescribed three medications which they started two days prior. Would this be reasonable? What if a veterinarian from England was able to prescribe vaccines via video chat which a local veterinary technician could then give at a Washington pet store? Or what if you could make extra money on the side by doing video consults with pet owners in South America? Are these opportunities or recipes for disaster?
Technology is expanding in ways that allow us to better visualize and assess patients remotely in real time. Video chats and remote monitoring devices improve our ability to see a patient that is not physically present. Phone apps improve scheduling and billing, easing the ability to “see” patients remotely.
These technology changes mean that many more ways of providing care are possible. However, not everything that is possible should be done. By proactively understanding what is possible, we can better envision and plan how to best use the technology to improve the care we can provide.
Definitions and introduction
Telemedicine is broadly defined as the remote diagnosis and treatment of patients using telecommunication. Telemedicine can be either asynchronous or synchronous. Asynchronous telemedicine involves sending information out and receiving a response at a later time. Synchronous telemedicine involves real-time information exchange and communication.
In January 2017, the AVMA Practice Advisory Panel published a report on telemedicine. This document summarizes their recommendations for veterinarians in regards to telemedicine. At that time, several definitions were made in order to more completely describe this area of medicine. These definitions are described below.
Firstly, according to the AVMA document, telemedicine refers to the specific electronic communication between DVM and client with an established VCPR (veterinary-client-patient relationship) involving the delivery of information specific to a particular patient. Veterinarians can charge for these services. Under this definition, telemedicine is a tool within a practice and not a separate discipline. State laws and regulations must be followed in the state in which a DVM is licensed.
Important to note, the AVMA recommends that an exception to the VCPR requirement be made in an emergency situation until a patient can be seen by a veterinarian.
Telemonitoring is remote monitoring of a patient when the patient and health care provider are in different locations. Telemonitoring requires a current, active VCPR.
Telecommunication/telesupervision is defined as any communication between DVM and the healthcare team.
Teleconsulting is a separate category. This area refers to consultation between a general practice DVM and a DVM specialist using telehealth tools to care for a specific patient. The AVMA task force recommends that the specialist not be required to hold a license in the state of the general practice DVM or patient.
Teletriage/Teleadvice is allowed without a VCPR. In this category, health information, guidance or recommendation are made in general terms to help a client make decisions on their pet. To fit into the recommendations, the guidance can NOT include diagnosing, prognosing, or treating an individual pet. Examples might include a recommendation to see a veterinarian for an emergency exam or the recommendation to talk to a veterinarian about heartworm preventatives.
Electronic prescription is providing prescriptions via electronic communication between DVM and pharmacy or medicated feed distributor to fill a medical prescription. This takes the place of paper or faxed prescriptions. Requirements vary by state.
mHealth (Mobile Health) is a subcategory that employs mobile devices used by a DVM within an established VCPR or devices used by the client with no established VCPR.
So what is a VCPR (Veterinary-Client-Patient Relationship)?
Washington state defines a VCPR as the basis for interactions between a veterinarian, their client and patient. It is established when a veterinarian has assumed responsibility for making clinical judgements and recommendations for treatments for a patient and the client has agreed to follow the recommendations. In order for the relationship to be active, the veterinarian must have examined the pet within the last year or in farm situations, been personally acquainted with where and how the animals are kept. In addition, the veterinarian must be available for follow up or have an arrangement for continuing care. Washington regulations also state, “The veterinarian shall not establish a veterinary-client-patient relationship solely by telephonic or other electronic means. However, once established, a veterinary-client-patient relationship may be maintained between medically necessary examinations via telephone or other types of consultations.”
Forty-six states provide a definition for the VCPR. This document provides an overview of the state laws as they relate to the establishment of a VCPR.
A review of VCPR was published in the August edition of Today’s Veterinary Business. That article reports that Virginia may currently be the only state that allows for a digital VCPR.
In Canada, in 2017, the Council of the College of Veterinarians in Ontario approved a standard allowing a VCPR to be set up through telemedicine. However, the standard was clear that a physical exam was needed in order to prescribe.
Most recently, the AAVSB presented guidelines at their September 2018 meeting that opened the door to establishment of a VCPR without an in-person physical exam. In some cases, they proposed that a veterinarian could develop sufficient knowledge of an animal to treat using diagnostic results or instrumentation with results sent electronically.
What do telemedicine regulations look like in human medicine?
Telemedicine has been around for much longer on the human side. While a key regulatory component is the establishment of an active physician-patient relationship, in the majority of states, an in person physical exam is no longer required. In Washington, an in person physical examination is not required but documentation must be kept including a client consent to the relationship. Medical records must be kept by the physician providing telemedicine services and must be available to patients when requested. This paper describes the regulations.
Regulations on the human medical side do still require that you be licensed in the same state as the patient with whom you are consulting. In order to help control costs, nurse practitioners and physician assistants can be engaged in telemedicine visits, as well as physicians. One common approach is to allow nurse practitioners to do a hands-on exam, and then set up a conversation with a remote physician.
Prescriptions can be made based on a telemedicine visit in Washington but different regulations apply from the DEA. While prescribing and the telemedicine regulations vary state to state, controlled drug mandates are controlled on the federal level.
Pushing the Limit?
Several online veterinary telemedicine/teletriage services exist. As an example, LiveDVM was recently profiled in dvm360. This service allows for clients to set up a text, phone call or video call appointment for a fee. The service preferentially matches clients to doctors from their own practice when available. However, they are matched to veterinarians from another part of the country when one is not available, even if that veterinarian is not licensed in that state. “Protocols” are set up to answer questions using hypothetical scenarios in order to qualify as “telehealth,” rather than telemedicine that would require a true VCPR and applicable state license.
While LiveDVM was profiled, it is not the only business in this arena. Other companies include Kuddly, which advertises “borderless veterinarians” and Ask.Vet, which advertises online consults to avoid veterinary visits. It is unclear how each of these is meeting state guidelines for appropriate VCPR.
What is next? Petriage and other ideas
Local veterinarian, Shlomo Freiman, has worked with a team to develop Petriage. With Petriage, clients can assess the need for veterinary care and remotely engage their family veterinarian. The mobile platform consists of several core features that enable DVMs to engage their clients, and vice versa, with both Teletriage and Telemonitoring. All communications, including photos and videos, are automatically captured and available to be uploaded into the medical record.
Petriage was designed with veterinarians in mind, for the dual purpose of strengthening the traditional veterinary business model and adopting innovative technology. This approach to telemedicine is unique in that it addresses today’s client needs and is a VCPR compliant solution. The VCPR is still established with an in person physical exam but rechecks can be done remotely.
To succeed in today’s on-demand economy, Dr. Freiman believes veterinarians must expand their traditional business model, offer a personalized telemedicine solution, and evolve into “brick and click” vets.
Active4Pets is another company also providing a platform for veterinarians to be able to work online with clients.
In the August 2018 Veterinary Practice News, Dr. Rolan Tripp makes the argument that a global certified licensure for televeterinary medicine should be developed. He believes that this type of certification would improve client’s access to good advice for their pets around the world.
Other options would be to allow for a digital VCPR for discussion but require an examination for drug prescriptions. Still other proposals would be to allow for a digital VCPR but only if a veterinary technician was on site during the conversation.
Open Questions in Washington
The Telehealth Task Force’s goal is to query the Veterinary Board of Governors for guidance in 2019. The legality of providing telemedicine services to a client with an established VCPR that moves out of state is quite unclear. It is even less clear if the pet has been seen in the last year, whether their veterinarian can prescribe medication for them across state lines. It is unclear whether services such as Kuddly that have veterinarians in many states are abiding by the teletriage or VCPR current state statutes.
We’d love to hear your comments and questions to pose to the Veterinary Board of Governors. Click here to submit your comments and questions.
More information and resources can be found at avma.org/telehealth.
This article was prepared by members of the WSVMA Telehealth Task Force. Members include Drs. Maria Baker (chair), Carmen Czachor, Beth Davidow, Schlomo Frieman, John Mattoon, and Lainey Vaught.
Posted February 15, 2019