Veterinary telemedicine is poised to quickly expand exponentially. The question is whether the current regulatory scheme is adequate or illusory to ensure quality pet care and increase access to care. We will summarize the arguments for and against veterinary telemedicine, analyze the regulatory environment, and explore whether changes are needed. While readers can answer for themselves, we’ll provide a frame of reference.
Pros and Cons
A newly enacted California law allows veterinarians to establish a veterinarian-client-patient relationship through telemedicine. Those in favor argued that California faced a statewide shortage of veterinarians and that a virtual house call was an excellent option for improving access to veterinary care, especially in rural locations.
Opponents say the standards of acceptable veterinary care cannot possibly be met through virtual interactions because animals, unlike human patients, cannot tell a doctor what is wrong and instinctually often hide symptoms. Because telemedicine provides no direct physical contact, critics argue that the quality of care drastically falls below acceptable standards.
Decrees and Directives
The current regulatory scheme might appear more than adequate in addressing quality of care concerns. However, a critical analysis raises serious questions about the safeguards.
Veterinary telemedicine regulations vary significantly from state to state. For purposes of this article, we will consider California and New Jersey. Those two states require telemedicine services to be interactive and in real time, including a video component that allows the veterinarian to observe the patient and client, and vice versa.
Surprisingly, the regulations do not require an ability to electronically transmit static images, diagnostics, data or clinical information. However, since the virtual encounter must meet the same standard of care as an in-person visit, we question the standard if the technology doesn’t include those capabilities.
In establishing the VCPR virtually, veterinarians in California and New Jersey must introduce themselves, including any specialty or board certifications, identify the client and patient, and confirm that the client owns the animal. The veterinarian also must document the animal’s physical location in the patient record.
Before providing services, the veterinarian must review the patient’s history and clinical records. These appear to be the only specific requirements for the veterinarian to diagnose the animal’s malady.
The regulations imply but don’t specifically state that the veterinarian should try to fill in any gaps in the records and determine the patient’s “chief complaint” (the reason for the encounter) to the best extent possible from the client dialogue. In addition, the regulations require a video component. Therefore, we can infer that the veterinarian must observe the patient before proceeding to the next step.
At this point, after an evaluation, the veterinarian must determine whether they can provide services to the same standard of care as when seeing a patient in a clinic. Under the strictest regulations, the determination must be made during each telemedicine encounter.
As for writing a prescription, the telemedicine veterinarian may do so if it meets the standard of in-clinic care. The only exception, in some states, is that Schedule II controlled drugs require an in-person examination. The only other nuance, in some states, is that a veterinarian may not issue a prescription based on answers to an online questionnaire unless a virtual VCPR was previously established.
If telemedicine veterinarians conclude at any point that they cannot meet the standard of care, the regulations appear to require that the encounter be terminated and the client be told to seek in-clinic treatment. The strictest regulations mandate that a telemedicine veterinarian have a referral list if the virtual visit isn’t appropriate, the client requests a referral or the case is an emergency.
Depending on the circumstances, the standard of care might require a telemedicine veterinarian to consult with a brick-and-mortar veterinarian.
After the telemedicine encounter, these four requirements come into play:
- The client must receive the veterinarian’s contact information and be able to resume the encounter within the next 72 hours.
- Upon request, the client may receive the veterinarian’s records of the encounter.
- The veterinarian may share records with the patient’s primary care provider upon the client’s request.
- The veterinarian may refer the patient for follow-up care, presumably in a telemedicine or in-clinic format.
Are the Regulations Illusory?
Do all the regulations ensure that telemedicine is functionally equivalent to in-clinic care from the perspective of the standard of care? We won’t try to answer that question. Instead, we prefer to initiate a thoughtful and rational discussion.
The regulations are clear that the prerequisite for providing telemedicine services is a determination that they will meet the same standard of care as in-clinic services. But is that goal possible considering that the definition of “virtual,” as an adjective, is “almost or nearly as described but not completely”? In the context of our query, we can modify the definition to “almost or nearly as it appears, but not completely.”
By definition, then, a telemedicine veterinarian engages in a virtual event and uses a virtual vehicle (with an audio and video electronic presence) as a substitute for an in-clinic visit. Can those veterinarians determine whether they are meeting the in-clinic standard of care through a virtual exercise using a virtual tool?
Opponents of telemedicine say no because animals cannot speak and, consequently, the veterinarian must smell, listen to the sounds of and touch the patient to determine an ailment.
But what if, for example, the veterinarian can ask the client to talk about the pet’s gastrointestinal discomfort, direct the owner to gently press the animal’s belly at a particular spot, and describe any lump or mass felt? During all this, the veterinarian can observe the animal’s reaction.
Is such a virtual encounter the functional equivalent of how the animal would appear in the clinic? Proponents of telemedicine would undoubtedly say yes.
The final answer is probably several years away after the veterinary profession has more experience with telemedicine.
Looming Issues
Another criticism of telemedicine is that it will provide corporate-owned veterinary practices with opportunities for thousands of brief encounters with clients and patients in which the primary focus will be selling products — food, vitamins, over-the-counter medications and grooming supplies, for example.
State veterinary boards could limit retail sales in a telemedicine encounter. In human medicine, one chiropractic board allows the in-office sale of vitamins and supplements if the items are prescribed as part of a patient’s treatment. Lobbying veterinary boards for similar restrictions is a matter of consideration for veterinary professional associations.
Clearly, the corporatization of veterinary medicine and telemedicine is here to stay and will grow. Given that reality, the final issue is how to regulate telemedicine in the best interests of the veterinary profession, clients and patients.