Concerns about a virtual VCPR

Telehealth, including telemedicine, can improve continuity in patient care; strengthen relationships among practices, clients, and patients; and enhance the efficiency of veterinary practices.

• Teleadvice provides animal owners with basic answers to their questions and education around preventive care (no VCPR required).
• Teletriage is used to determine whether an animal needs to be seen by a veterinarian and with what urgency (no VCPR required).
• Once a VCPR has been established, telemedicine is used to provide patient(s)-specific recommendations and follow-up, including support for client communication and compliance with the treatment plan.

An in-person visit prior to using telemedicine protects patients and clients. During an in-person visit a veterinarian uses sight, sound, touch, smell, and specialized instruments to collect detailed information about the patient(s); collects needed diagnostic samples; and learns about the owner/caretaker (what their relationship is with the patient, whether they can comfortably and confidently handle the animal, and what type of care they are able to deliver). The result is a fully informed diagnosis and a targeted treatment plan for that patient(s) that the owner can effectively implement, setting the patient(s), client, and veterinarian on a path toward best achievable outcomes.

Eliminating the in-person visit as a requirement for establishing the VCPR poses unacceptable risks to the health and welfare of animal patients and the public. It also poses economic risks for producers. Telemedicine conducted without an in-person visit can result in delays in critical diagnoses; provision of unnecessary or inappropriate drugs and other medical products; failures to identify and consider co-existing conditions; potential drug-drug or drug-disease/condition interactions; and duplicity or conflicts in treatment due to disconnected providers. Misdiagnoses, delayed diagnoses, or missed diagnoses in the case of zoonotic diseases (e.g., rabies, leptospirosis) and/or otherwise high-consequence diseases (e.g., HPAI, FMD) create public health risks and can result in economic consequences for animal owners and the public that can range into the billions of dollars.

Federal law includes requirements for an in-person visit to establish the VCPR, and states have followed suit. The FDA requires an in-person examination or premise visit to establish the VCPR for covered activities (extralabel drug use and Veterinary Feed Directives) and allows its maintenance via telemedicine. Forty-three states mirror the FDA's definition of the VCPR, and 22 states have added language specifically prohibiting the VCPR from being established electronically. The U.S. Department of Agriculture (USDA) also applies the federal VCPR to the use of certain types of biologics, issuing Certificates of Veterinary Inspection (CVIs), and evaluating and testing for certain diseases. In addition, the FTC applies it to horses covered under the Horseracing Integrity and Safety Act (HISA).

Comparisons between requirements for human and veterinary medicine are inappropriate and misleading. Because physicians may establish a patient-physician relationship electronically, it's been suggested that veterinarians ought to be able to do the same. As support for this, comparisons are drawn between children and animals. However, the American Academy of Pediatrics (AAP) does not support the use of telemedicine for children younger than 2 years old without an in-person visit. Within its telemedicine guidance the AAP states:

"Telehealth services should not be provided to children under two years of age in their home or other non-clinical setting except when the provider or their surrogate has a previously established in-person relationship with the patient or when the Patient-Centered Medical Home¹ has referred them for subspecialty consultation."

The AAP further notes that "support for the use of telehealth within the medical home recognizes that the medical home offers continuity and the prudent use of health care resources, avoiding fragmented and episodic care delivered without such coordination."² In addition, individual states and payers (including the Centers for Medicare and Medicaid Services) have placed a variety of requirements around what is required to electronically establish a patient-physician relationship and the activities that may or may not be conducted after doing so (e.g., prescribing).

Furthermore, how drugs are regulated for use in humans is very different from how they are regulated for use in animals. For human use, the label is regulated. For veterinary use, both the label and how the veterinarian uses the drug are regulated, with direct consequences for the latter (i.e., drugs may be deemed "unsafe", "misbranded" and/or feed containing drugs "adulterated" if used in violation of federal law). In part, this is because drugs are generally prescribed for people with the intent to improve the health of the individual, while considerations for the use of drugs in animals include human exposure (e.g., residues and food safety, exposures associated with administration) and potential impacts on public health.

Veterinary patients and human patients are different. Animals instinctively hide illness and injury and cannot speak to convey what they are feeling. Behavioral cues are subtle and often require skilled observation to detect. Studies show that even well-intentioned animal owners may underestimate or incorrectly recognize or report health problems, and overreliance on them to gather and convey information may lead to misdiagnoses, delayed diagnoses, or missed diagnoses and inappropriate treatment recommendations.

A virtual VCPR is NOT the answer to access-to-care concerns. Many of the animals for which access to care is truly an issue do not receive regular care and, as a result, the issues for which veterinary help is being sought are acute, rather than preventive. Not only will the problem not be able to be resolved via telemedicine, but the client has now incurred a cost for two visits (telemedicine and in-person), rather than one, which is particularly concerning for owners with limited funds. Not surprisingly, remote areas without a veterinarian often also lack reliable internet access, making the use of telemedicine impractical. Mobile veterinary services are a better option not only in terms of access, but also quality of care.

What might a virtual VCPR deliver? Overprescribing and the emergence of "pill mills," as well as more complaints and liability. Multiple peer-reviewed publications from human health care show increased prescribing of medications via telemedicine (particularly direct-to-consumer [DTC] telemedicine) as compared with in-person visits. Of considerable concern are inappropriate prescribing or dispensing of prescription drugs, including antimicrobials and opioids. In the veterinary space, evidence of overprescribing can drive restrictions on access to drugs considered medically important for human medicine. Unfortunately, some DTC telemedicine companies appear to be "product sales-oriented" rather than "care-oriented," meaning their focus is on delivering a preferred set of drugs and/or medical products instead of comprehensively evaluating patients and their need for health care. Lax regulatory environments around the VCPR are ripe for the expansion of such "pill mills" into veterinary medicine.

Animal health and safety and public protection are of utmost importance, and it is well-known that complaints and claims lag behind activity. Not surprisingly, the AVMA PLIT is now seeing both complaints to licensing boards and professional malpractice liability litigation related to telemedicine. A virtual VCPR also presents significant enforcement challenges for state veterinary medical boards, especially when remote medical care is easily delivered by practitioners who are unlicensed in that state. In such instances, enforcement may be required through a state attorney general's office that may have other priorities. The result will be increased health and welfare risks for veterinary patients; limited recourse for clients; and the considerable personnel and fiscal impacts of trying to develop enforceable regulations, conducting investigations, and pursuing bad actors.

Relationships first, technology forward. The Coalition for Connected Veterinary Care, of which the AVMA is a lead partner, is an alliance of more than 50 major veterinary and animal health organizations across the United States working to empower veterinarians to integrate tools of telehealth into their practices in ways that best support animal patients, human clients, and veterinary teams. Coalition members are passionate about supporting the innovative and responsible adoption of technology to improve continuity of care and the efficiency and success of practices, and to meet the expectations of clients and the needs of patients, now and into the future. A foundation of the Coalition's efforts is the agreement of its members as to the importance of establishing a VCPR in-person.

¹ In human health care's Patient-Centered Medical Home each patient has a personal physician, care is physician-directed with joint decision making with the patient, care by specialists or other healthcare providers is coordinated and integrated, and information technology is utilized to centralize and ensure exchange of healthcare information among providers, so that the patient receives indicated care when and where needed by the appropriate provider. The same concept doesn't currently exist in veterinary medicine.
² Alison L. Curfman, Jesse M. Hackell, Neil E. Herendeen, Joshua J. Alexander, James P. Marcin, William B. Moskowitz, Chelsea E. F. Bodnar, Harold K. Simon, S. David McSwain, Section on Telehealth Care, Committee on Practice and Ambulatory Medicine, Committee on Pediatric Workforce; Telehealth: Improving Access to and Quality of Pediatric Health Care. Pediatrics September 2021; 148 (3): e2021053129. 10.1542/peds.2021-053129