Let's start at the apex of this issue with the VCPR. How do regulatory associations define the VCPR and how does that definition affect veterinary telemedicine?
[James Penrod] The definitions of a VCPR set by the American Veterinary Medical Association (AVMA) and the American Association of Veterinary State Boards (AAVSB) aren't that far apart aside from a difference in the structure of our practice act models. Both definitions have three basic components:
- The veterinarian and client both agree that the veterinarian takes responsibility for making medical judgements about that patient.
- The veterinarian has sufficient knowledge to make a preliminary diagnosis of the animal.
- Follow-up process between the veterinarian and client so the client knows what to do if something goes wrong.
The difference lies in how a VCPR can be established. The AVMA practice act model says a VCPR can't be established through telephonic or electronic means. Alternatively, the AAVSB model VCPR statute is purposefully broader, making it easier for individual state boards to define and change specific rules in response to technology developments without requiring an act of legislation.
[Lori Teller] I agree the AVMA and AAVSB are not very far apart on this issue. Though the AVMA outlines veterinarians cannot use electronic or telephonic means to establish a VCPR, we've also created some exceptions for situations like poison control or life-threatening emergencies, such as drownings and heat strokes. We also recognize in the future there may be other carve-outs needed when access to care is difficult. The AVMA monitors trends in the profession and wants to make sure we adapt our policies as needed.
[Jessica Trimble] To me, the perfect VCPR allows individual veterinarians to define whether they've established a relationship with a patient. If they feel they have sufficient information to make a qualified diagnosis without putting the patient at risk and they're willing to accept responsibility for their decisions, then the VCPR shouldn't depend on whether they laid their hands on the animal. A company in the United Kingdom that provides veterinary telemedicine did a side-by-side study with dermatologists on their ability to properly diagnose a pet through an in-person exam or through looking at photographs. Results showed there was basically no difference.1 That goes a long way in showing there are some use cases where having hands on the animal isn't necessary.
"The VCPR isn't always black and white. ... neither a hands-on VCPR nor a virtual VCPR is appropriate in all cases."
— James Penrod
[James Penrod] The VCPR isn't always black and white. The AAVSB wants our guidance document to acknowledge that neither a hands-on VCPR nor a virtual VCPR is appropriate in all cases. Veterinarians need to make a determination based on whether they can get enough information and get access to medical records. Companies are creating platforms that allow clients to own their medical records so they can easily share them with a doctor when needed. The AAVSB is trying to proactively create an area in the veterinary space where this type of evidence-based activity can occur. However, if regulation is not open enough to allow that, then others are going to dictate how the VCPR and telemedicine work for veterinarians.
[Lori Teller] That's an important point. Veterinarians need to be the leaders in how this moves forward rather than people outside the profession.
[Jessica Trimble] Non-veterinarians in my company find it hard to comprehend that we cannot help pet owners who want help because certain laws prevent it. We as a veterinary profession need to step up and make sure we guide these changes so they occur in the right way for both the profession and our patients.
- "Could a new app spark change in the veterinary market?", Veterinary Practice, March 11, 2019. Accessed July 3, 2019.
Defining terms related to telehealth is almost as important as defining parameters around the VCPR. Here are some important words to know.
Telehealth. Overarching term that encompasses all uses of technology to deliver health information, education or care remotely. Can be divided into categories based on who is involved in the communication.
Telemedicine. A subcategory of telehealth that involves using a tool to electronically exchange medical information to improve a patient's clinical health status. Examples include using Skype or a mobile app to communicate with a client and visually observe the patient for a post-operative follow-up examination and discussion. Telemedicine is a tool of practice, not a separate discipline within the profession.
Teletriage. The safe, appropriate and timely assessment and management (immediate referral to a veterinarian or not) of animal patients via electronic consultation with their owners. In assessing patient condition electronically, the assessor determines urgency and the need for immediate referral to a veterinarian, based on the owner's (or responsible party's) report of history and clinical signs, sometimes supplemented by visual (e.g., photographs, video) information. A diagnosis is not rendered.
Teleadvice or Tele-education. The use of technologies to better inform pet owners (or potential pet owners) about all aspects of animal health and welfare that are not specific to a particular patient's health, illness or injury. This general advice – for example, pets living in mosquito infested areas should receive heartworm preventatives year-round – is often provided by paraprofessional staff.