In an era of social distancing, telemedicine and technology keeps us connected to our patients, clients, and community.
The global pandemic is continuously challenging veterinary professionals in all aspects of work. Curbside check-ins, checkouts, and increased mobile phone communication with clients safely facilitates care while maintaining social distancing.
Telemedicine in veterinary care experienced a boom with the COVID-19 pandemic. As the world shifts to a new normal, it’s time to examine the path ahead for telemedicine in veterinary care.
This webinar will bring together legal and medical experts to discuss legal, clinical, and operational aspects of telemedicine.
Dr. Apryle Horbal is a practicing veterinarian and President of VetNOW, a virtual care initiative seeking to perfect clinical workflows while setting and maintaining the highest of clinical standards.
Dr. Lance M. Roasa is an attorney, veterinarian, and co-founder of Drip.vet, an online learning platform for veterinarians. He specializes in veterinary law and lectures at 14 veterinary colleges on the legal and business aspects of veterinary medicine.
Dr. Horbal and Dr. Roasa will discuss the challenges of veterinary telemedicine, the regulatory environment, and how they expect telemedicine to evolve in a post-COVID world.
What’s the difference between telemedicine and telehealth?
In human medicine, telemedicine is a new way of practicing, using tech to allow the medical community to do medicine in a different way. Telehealth is the combination of all the tools, services, and associated systems that bring telemedicine to life.
In the veterinary space, however, telemedicine means the practice of medicine through remote means, while telehealth is a broad term that is used to describe giving health advice remotely.
Telemedicine could be something like prescribing medicine or diagnosing an illness, while telehealth might be giving general advice on nutrition.
Historically, we’ve been performing telehealth for a long time in the veterinary space. We give our clients advice over the phone all the time.
Telemedicine is new.
Does a conversation between a veterinary specialist and a generalist on the phone fall under telemedicine or telehealth?
This kind of conversation certainly falls under “advice”. The specialist is consulting on a case, while the generalist is actually practicing medicine.
Potentially, a new term could come into use: teleconsultation.
This creates a greater specificity and allows there to be legal differentiation between the person with the VCPR and the consultant.
What’s the historical precedent for telemedicine, and why were laws around them put into place?
The FDA was very concerned about how a few select “rogue” veterinarians were over-prescribing antimicrobials to animals that likely didn’t need them. This instigated the use of the VCPR at the federal level, and many states quickly took hold.
Simply put, the VCPR exists mostly to stop veterinarians from overprescribing pharmaceuticals at will and making a lot of money unduly.
Unfortunately, it’s often seen as stopping small animal practitioners from diagnosing real issues.
The spirit of the VCPR has always been to protect the patient and the client. It’s becoming evident that there is overreach in some of its aspects. With telemedicine and telehealth, we can loosen and change some regulations while still maintaining a totally capable system that fully protects the VCPR.
There seems to be a lack of uniformity in VCPRs throughout the 50 states. Is anything being done about this?
VCPRs vary greatly throughout the United States; 5 or 6 states don’t even have one, and so they fall back on the federal guidelines laid out in AMDUCA. There are many other state guidelines, acts, and even lawsuits that end up providing a totally patchwork, non-uniform system, leading to tons of confusion.
Today, it’s mainly up to the veterinarian. Practicing across state lines provides even more difficulty.
Human telemedicine faces the same issues.
COVID-19 has forced the medical community to be practical, to take down some barriers, and to focus on what’s important: providing and enabling access to care as quickly and effectively as possible.
What does “access to care” mean in terms of telemedicine and telehealth and their associated regulations?
There’s a lack of specialists in the US. As an example, patients can wait months to see oncologists if they have cancer. A first level of access involves connecting generalists to specialists through telehealth.
Connecting with pet owners who do not have a veterinarian is an expanding field.
Less than 20% of the pet owner market is being accessed by vets right now. In terms of the VCPR, are we really going to keep saying “you must have a physical relationship with your vet” to provide care? Telehealth can absolutely provide a new avenue for clients who might not get care for their pets otherwise.
With COVID-19, this access through telehealth is especially important.
Even afterwards, the struggling economy means telehealth, a potentially more affordable option, will create opportunities for clients where there might have been none before.
Some conditions simply lend themselves to telehealth very well. Unfortunately, some regulators often think in a very black-and-white manner (“all or nothing”) about telemedicine. A better viewpoint is that many components of veterinary medicine can be done through telemedicine, but naturally there will remain some that cannot.
What it simply comes down to: telemedicine and telehealth is better than not seeing a veterinarian at all. If it’s between a DVM on a screen or “Doctor Google,” there’s only one real choice.
Explain the legal framework surrounding telehealth and telemedicine. What’s allowed and not allowed?
An important first step is knowing whether the client is new or there’s already a VCPR. Under most state laws, new clients are separate from prior VCPRs. Some states only allow VCPRs to form in physical relationships.
The second step after creating the VCPR is to determine how long it lasts, and under what conditions. Often, states don’t provide guidance for this, and the best guidelines are “what would a reasonable and prudent veterinarian do?” Common sense reigns in most states.
Consent forms have to be in place!
Clients should be aware that telemedicine is not perfectly equal to a physical exam, and that they can request a physical exam if they’d like. Transfer of VCPR also needs to be done within this legal framework.
There’s often a lot that can be done without a VCPR to improve an animal’s quality of life if contractual and legal issues arise.
Careful language is very important. There’s a grey area that holds the difference between “advice” and “practice.” Saying something like “pets with these symptoms generally have gastritis, and here’s how’d I’d treat gastritis if it were present” is advice. In contrast, “I’m diagnosing your pet with gastritis, and here’s how to treat it” is not.
When operating outside of the VCPR, be conscious of wording.
What happens if the VCPR is violated? Does the law vary state by state?
There are two avenues that veterinarians mainly get in trouble through.
In civil lawsuits, substandard care on a telemedicine care would have to be proven. However, through a state board action, the board could take action against any violation, whether there was an adverse effect on the patient or not. Most vets are more concerned with state board issues, as even the best-intentioned vets might run up against them accidentally.
As long as veterinarians continue to uphold the same clinical standards as they always have, and remain conscious of their language and of the new technology, they’ll easily avoid trouble.
You can still uphold the VCPR and do something wrong. The practice of medicine is separate from the VCPR, which acts a gateway to this practice.
What has changed in telehealth and telemedicine from a legal perspective due to COVID-19?
A number of states have relaxed their VCPR requirements for new clients. It is now possible in much of the US to form a VCPR through remote communication. Unfortunately, it’s often temporary.
A few states (CA, NM, NC) have doubled down and reminded veterinarians they still cannot form a VCPR, except in person.
Could you support the concept of a primary DVM with a VCPR who could assign a second remote VCPR, allowing this remote specialist to talk to the client, suggest diagnostics, etc.?
This is an excellent and creative measure. There should maybe be a set of standards for not only this, but credentialed nursing, alternative facilities, or something similar.
State boards need to protect clients, and one of the ways they do that is through repercussions to a license. In this situation, there are two licenses, which gives them a greater right of retribution to the client.
What does the future hold?
We need data to show state boards whether clients and patients will successfully be served through telehealth and telemedicine.
COVID-19 has given us this data, through the widespread implementation of telemedicine by force. It’s likely that we’ll see it’s very useful and successful.
80% of vets want telemedicine to be a part of their practice even after COVID-19.
Telehealth and telemedicine is undoubtedly important for extending veterinary resources, and if it’s not used into the future, both clients and veterinarians will suffer.
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