Telemedicine: Looking for the Sweet Spot

The veterinary community struggles to find the perfect fit for virtual care.

Few people question the value of telephonic communication in veterinary care, be it tele-triage, tele-advice or telemedicine … until it’s time to iron out the details. What kind of safeguards – if any – should be placed around telehealth? What types of diagnoses can or should be made virtually? How about prescriptions? Can a veterinarian-client-patient relationship (VCPR) be established on the basis of a phone call or Zoom? How can the veterinary practice make telemedicine profitable?

It’s no surprise that questions such as these are being raised today. “I think the pandemic threw into sharp relief on some of the advantages of virtual care,” said Hannah Lau, DVM, associate director of virtual medicine at New York City-based Bond Vet and a board member of the Veterinary Virtual Care Association. “It might be tempting to go back to the way things were, but the best solution is to implement new technologies and workflows in order to increase efficiency, quality of patient care and revenue.”

Interest in telemedicine has also grown given concerns about an impending shortage of veterinarians in the U.S. In April 2023, the American Society for the Prevention of Cruelty to Animals released data from a national survey in which one quarter of pet owners said there was a time in the prior two years when they wanted or needed veterinary care but were unable to get it. More than two-thirds of respondents reported an interest in using veterinary telemedicine if it were available.

There’s a third reason behind the heightened interest in telemedicine: The veterinary community has watched their human-medicine counterparts step up their usage, and many wonder why they shouldn’t do the same.

VCPR

Differences in state laws regarding the veterinarian-client-patient relationship are a key stumbling block for widespread expansion of telemedicine. That said, this year saw a couple of major developments. In May, Arizona Governor Katie Hobbs signed into law Senate Bill 1053, which says that veterinarians licensed to practice in Arizona no longer need to meet with patients in the flesh to establish a VCPR. Though, the law stipulates:

• The veterinarian must obtain informed consent from the client, including an acknowledgement that the standards of care apply to in-person visits and visits through electronic means.
• The veterinarian must provide the client with the veterinarian’s name and contact information and secure an alternate means of contacting the client if electronic means are interrupted.
• The veterinarian is prohibited by federal law from prescribing some drugs or medications based only on an electronic examination.
• Prescriptions based only on an electronic examination may be initially issued for up to 14 days and renewed
  one time only for up to 14 days with an additional electronic examination.
• The veterinarian may not order, prescribe or make available a controlled substance unless the veterinarian has performed an in-person physical examination of the patient or made medically appropriate and timely visits to the premises where the patient is kept.

Four months later, in September, California lawmakers passed a similar measure, bringing to six the number of states eliminating the in-person requirement for establishment of a VCPR (the others being Arizona, Idaho, New Jersey, Vermont and Virginia).

The case for telemedicine

“Accepting change is the usual struggle when it comes to revising previous standards of care and evolving with technology,” said Dr. Lau. “The evidence is strong that it is a strong component of high-quality medicine that promotes good patient welfare and delivers high client satisfaction. Human medicine has used telemedicine successfully for years, with fewer complications than expected.”

Other countries such as Canada have been early adopters of veterinary virtual care, and feedback has been extremely positive, she said. “Virtual medicine is not inherently of lower quality than in-person medicine, and has been used by hospice, holistic, large animal and specialty veterinarians appropriately for years. Even with all this aside, I strongly believe that medical decision-making and the mode of delivery of veterinary care should be entrusted to the veterinarian, who is the most closely acquainted with her client and patient, and not restricted by the state.”

But Dr. Lau said that state restrictions aren’t the only roadblock to more widespread implementation of telemedicine in veterinary care. “I believe a lot of clinics struggle to make changes to their workflow while simultaneously dealing with all the challenges of the industry. It’s easy to feel overwhelmed and unsure of where to start. I do feel that the clinics who embrace change bravely and with open minds are generally the most successful, not only in telemedicine but in all aspects of medicine and business. Regardless of how your team handled the 2020 lockdown, it is never too late to implement virtual care techniques.”

Dr. Lau believes virtual care serves one more essential function – providing a broad spectrum of care to underserved pets and clients. “I speak to clients every day who desperately want to

provide quality and compassionate care for their pet, but have difficulty getting into a traditional veterinary exam due to physical ability, illness, lack of transportation, pet anxiety or aggression, work or travel schedules, cost, caretaking of children or family members, etc. It’s important to meet our clients halfway, even if most of what we are providing is education and decision support. “

Caution ahead

Rena Carlson, DVM, president of the American Veterinary Medical Association, calls for caution in the implementation of telemedicine. “The human healthcare space has seen some real problems related to the virtual establishment of patient-provider relationships,” she said. They include delays in critical diagnoses, provision of unnecessary or inappropriate drugs and other medical products, failures to identify and consider co-existing conditions, avoidable adverse drug-drug or drug-disease/condition interactions, duplicity in treatment due to disconnected providers, and fraud.

The Arizona law “is not a model we would support,” she adds, referring to Senate Bill 1053. “The veterinary profession has been implementing telemedicine successfully for a very long time, largely because it has been done within a veterinarian-client-patient relationship that has been established with an in-person exam or, for larger groups of animals, a visit to the premises where the animals are kept. We believe skipping this critical step is dangerous for animals’ health and welfare, as well as the safety of animal-derived food products and public health. Animal owners are not always able to accurately interpret and describe their animal’s clinical signs.”

The AVMA does not oppose telemedicine, said Dr. Carlson. In fact, in 2017, the association rolled out tools to support its use and updates them continuously. In 2022, the AVMA and other professional and industry organizations formed the Coalition for Connected Veterinary Care with the intention of fostering collaboration across the veterinary and animal health industry to enhance and expand veterinary care by leveraging technology, i.e., telehealth.

“Telehealth, including but not limited to telemedicine, has arisen as one of the greatest opportunities and challenges facing medicine in this digital age,” said Dr. Carlson. “Using telemedicine to support the delivery of veterinary medical services in the context of a previously established in-person VCPR offers benefits for patients, animal owners and the profession, and can enhance animal care by facilitating communication, compliance with treatment plans, continuity of care, client education and scheduling.

“Those AVMA members who are actively using veterinary telehealth in their practices tell us they are using it to support case triage, compliance with treatment plans, continuity of care, and client education. It’s an adjunct to in-person care, not a replacement for it.

“However, all veterinary services must be provided with professionalism and adhering to the same standard of care, whether delivered in person or through electronic means. The VCPR is fundamental to veterinary practice, and an in-person VCPR is essential for the responsible provision of high-quality veterinary care.”

Said Dr. Lau, “I see a lot of incredible and innovative veterinarians employing intentional telemedicine to great effect, but I would love to see more engagement. Strengthening our ability to provide virtual care does not weaken the importance of the physical exam or in-person care, but it does allow us to build trust, improve client compliance, and care for more pets.”

Phone-a-vet

Telehealth delivered by a trusted local veterinarian is one thing, but what about direct-to-consumer “tele-advice services,” which offer pet owners quick access to a veterinarian for advice and suggestions on how they can help their pets at home?

“I believe these services exist to fulfill a need,” said Hannah Lau, DVM, associate director of virtual medicine at New York City-based Bond Vet and a board member of the Veterinary Virtual Care Association. “Clients have made it very clear that they value convenient virtual care for their pets and are willing to pay for these services.” That said, some DTC companies appear to be sales-oriented rather than care-oriented, she said. “The focus is on delivering their preferred set of drugs and medical products instead of comprehensively evaluating patients and delivering best-suited care – which may or may not involve a prescription.

“I also feel that clients naturally prefer to strengthen relationships with veterinarians they personally know and trust,” she continued. “Brick-and-mortar veterinary practices should work to expand their virtual offerings to compete with online-only services, thus reclaiming revenue. This often requires some changes with communication protocols and minor schedule rearrangement but doesn’t necessarily require more hours or staffing. In fact, I strongly believe it increases efficiency and therefore the likelihood of vet staff heading home on time. Ultimately, as is true for all aspects of medicine, it is essential for brick-and-mortar practices to evolve to meet the current needs of our clients and patients.”

Rena Carlson, DVM, president of the American Veterinary Medical Association, said, “We are concerned about the impacts that direct-to-consumer tele-medicine providers will have on patient care, client confidence in the value of veterinary services, and animal health more broadly. Many of the service models of these DTC providers revolve around dispensing drugs and other product sales, rather than a comprehensive assessment of patient needs and the delivery of appropriate and safe patient care.

“The in-person encounter with the animal and the client is the most valuable and cost-effective tool in the veterinarian’s toolbox,” she says. “It provides veterinarians with information about the patient and the client and allows them to deliver a timely and accurate diagnosis and an effective treatment plan that considers the owner’s resources and capabilities and that the owner is able to follow. A wrong diagnosis and/or a treatment plan that the owner cannot reasonably follow does not improve access to care. Instead, the resulting delay in diagnosis and effective treatment results in prolonged illness and suffering for the animal and costs the owner more.

“When most people talk about ‘access to care,’ they are referring to basic care,” says Dr. Carlson. “The basic care that most animals need is preventive care that is tailored to the animals’ specific circumstances, and that requires an in-person visit. And, unfortunately, animals that don’t regularly see a veterinarian are highly likely to need care that requires a complete physical examination to diagnose and treat. Such care cannot be delivered by telemedicine.”

Image credit: istockphoto.com/Su Arslanoglu

Image credit: istockphoto.com/ridvan_celik