Telehealth poses new possibilities, problems

Ready or not, veterinarians urged to better inform themselves
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Telehealth in veterinary medicine continues to advance with greater use by corporate and private practices—and even use by the AVMA in pilot studies. This is happening both in the U.S. and abroad, with use abroad potentially having an effect on veterinarians and animal owners stateside. Still, although telehealth is a useful tool that some say has the potential to earn practices greater business and allow clients greater convenience, its success remains dependent on veterinarians' skills and willingness to adapt.

Dr. Lori Teller, District VIII representative on the AVMA Board of Directors, explained during a session on telehealth at the AVMA Veterinary Leadership Conference in January that right now, all telemedicine in the U.S. must be conducted in the context of an existing veterinarian-client-patient relationship. This means the animal has to be seen in person initially, though the AVMA policy on "Telemedicine" allows an exception for emergencies, such as calls to poison control centers. While most but not every state has a VCPR requirement, federal laws apply to all practicing veterinarians, and those laws mandate establishing a VCPR first.

Dr. Kevin Collins of Illinois asked at the session whether it was reasonable to consider a situation as qualifying as telehealth if a veterinarian is talking with a client about a problem and is considering a "generic diagnosis and treatment," such as probiotics and kaopectin to treat nausea.

"It will be at your discretion—we were purposefully vague on our part—and your judgment to treat over the phone and electronically versus when you need to see a patient in your office," Dr. Teller said about AVMA's telemedicine policy, adding, "(but remember), a VCPR can't be established through telephonic means."

Audience members also asked about enforcement and monetization. Telehealth is just another tool, Dr. Teller responded. "State boards are complaint-driven, so if (a client) complains, that's how it will be investigated," she said.

As for monetization, Dr. Michael Cavanaugh, CEO of the American Animal Hospital Association, said the main difference between consulting with colleagues or clients and telehealth is that veterinarians have been doing it for free all these years.

"The hurdle is getting over being people pleasers and bill for services we provide. The whole question about monetization is old news. Accountants and lawyers have been doing this forever," he said.

Telehealth can take many shapes (see sidebar). Some telehealth companies are looking to connect with veterinary practices and provide veterinary triage, while others are client-facing, directly interacting with animal owners. Payment models vary, whether they are for services on demand or subscription-based fees. For example, a company would have the client’s credit card on file so the person would pay upfront when using the service.

"The telehealth industry is very fluid. Some companies getting into it today might not be around (later)," said Adrian Hochstadt, deputy CEO of the AVMA. "We need to engage with those providing service, learn what they're doing, and educate them as well."

Further still, some clinics are eliminating the middleman and providing telehealth services on their own. Dr. Teller has heard of practices that charge a fee for the call and then deduct that fee from the visit and still come out ahead because of diagnostics or other services provided during the visit. "You'll be making more money that way than if someone else is charging for it," she said.

In practice

Veterinary corporations already have gotten on board with telehealth. Banfield Pet Hospital used a text service in the aftermaths of hurricanes Harvey and Irma to enable pet owners to connect directly with a veterinarian. Owners who were existing Banfield clients could submit pet health–related questions for free to a veterinarian at via text. For example, they could ask for vaccination records to enable access to a shelter. Banfield is now looking at incorporating telehealth into its wellness plan.

Petco announced in April 2017 that it had acquired PetCoach, a digital services company that connects pet owners with veterinary professionals who give "expert advice." In addition, Petco has expanded its pet services to include in-store veterinary clinics. Its first hospital, operated by Thrive Affordable Vet Care, opened in Aldine, Texas, this past October.

Even the AVMA is giving telehealth a try. Dr. Kendall Houlihan, an assistant director in the AVMA Animal Welfare Division, manages the Reaching UP program, which provides high-quality, high-volume, spay-neuter and veterinary preventive care services to underserved populations. The program is currently operating on a Native American reservation in New Mexico.

We should look at telemedicine as an adjunct and not be so scared of it. Your skill set will carry you through the profession. These things will fail without our skills.

Dr. Jennifer Bolser, consulting veterinarian, International Center for Veterinary Services, Beijing

During multiple visits that were strategically scheduled each year, volunteer AVMA member veterinarians performed up to 170 surgeries and as many wellness examinations over the course of four days. Telehealth provides a unique opportunity to further improve aftercare, as the nearest veterinary hospital is over an hour away, and many people on the reservation don't have consistent access to transportation.

To encourage and enhance access to recheck appointments, starting with the March clinic, these appointments will be scheduled seven to 10 days after surgery and use videoconferencing to follow up on patients. Rechecks can take place at the animal control/police department or at the owner's home with a Wi-Fi hot spot brought by the animal control officer. The AVMA hopes that making rechecks easy will support owner compliance and, when compliance has positive effects, increase the value of veterinary services for these owners.

This telehealth pilot program's goal is to further increase access to veterinary care within this underserved Native American community and potentially act as a model for similar populations.

Student AVMA members who participated in the Reaching UP program this past year helped care for these young canine patients. The program is conducting a telehealth pilot program starting with the March clinic. (Courtesy of Dr. Kendall Houilhan)

"We're being very deliberate about the research we're doing. We have pilot studies going on, and as we learn how to use these tools, our policies can adapt to that," Dr. Teller said.

International action

In Canada, telehealth has evolved even further. This past March, the governing Council of the College of Veterinarians of Ontario approved a new standard regarding the use of telemedicine in the delivery of veterinary medicine in Ontario so that veterinarians can establish a VCPR via telephonic means.

Doug Raven, Ontario VMA CEO, explained, "They looked at what happened in the human health care world and reasoned if you can do pediatric medicine (via telemedicine), why can't you do veterinary medicine via telemedicine? You can't prescribe or dispense; diagnosis is a gray area. You must have what you feel is reasonable and sufficient knowledge of an animal. If you think you can defend that, then away you go."

Although the Ontario VMA wasn't thrilled with the decision at first, he said, leadership figured if this were going to happen, veterinarians would best be a part of it rather than others less qualified.

"We want practice owners to have a piece of this and control it," he said.

The Ontario VMA has a pilot project underway among a dozen practices working with a veterinary telemedicine provider. They are starting with phone-only telehealth services on evenings and weekends (to augment regular business hours) and trying out methods for billing clients. One model being considered is having clinics paying a set amount per client per month for access to the service.

Raven said the vendor tracks the reason for the call and advice given. For every call that comes in, a report goes to the practice. If the advice was "see the veterinarian tomorrow," when the practice opens, the first thing the staff would do is contact the client and schedule an appointment.

One thing that the OVMA is concerned about is nonveterinary providers charging $40 per call but providing only limited service. Callers will then arrive at their veterinarian angry at having already spent money with little to show for it, he said, and seeking free service from the veterinarian.

He said, "Realistically, the best model is if you offer wellness plans, you build it into that. Client gets charged so many dollars a month to access services that we would like to offer to our members so they can offer to their clients."

He noted that even though a veterinarian in the U.S. can't establish a VCPR without seeing an animal, that doesn't stop providers based in another country from connecting with clients here. "So ultimately it will be difficult to control access to services," he said.

Legislation and regulation

Hochstadt said activity on the topic of telehealth is picking up in state legislatures and will only increase in coming years. In 2017, Virginia passed a law that covers telehealth and included veterinarians. Utah has a proposed regulation that would create conditions allowing for telehealth services.

The AVMA House of Delegates adopted a policy on telehealth July 21, 2017. Its purpose is to promote to key stakeholders the AVMA's perspective of how telehealth should be legislated and regulated. This past November, the AVMA, American Association of Veterinary State Boards, and Association of American Veterinary Medical Colleges issued a joint statement on telehealth that reads as follows:

Telehealth can provide valuable tools to augment the delivery and availability of high quality veterinary care. According to the Center for Connected Health Policy, "Telehealth encompasses a broad variety of technologies and tactics to deliver virtual medical, health, and education services. Telehealth is not a specific service, but a collection of means to enhance care and education delivery." Veterinarians need to utilize emerging technologies to enhance accessibility and client communication, while promoting the responsible provision of high-quality veterinary medical care. Both AVMA and AAVMC are committed to continue their collaboration with a wide variety of stakeholders to promote access to the convenience and benefits of telehealth, while providing information to the veterinary community about the development of applications and other technologies that help connect veterinarians with clients.

"We are collaborating so we can be on same page for what telemedicine will look like in the future," Dr. Teller said. "We're not working in a bubble."

An AAVSB task force is currently accepting comments on telehealth. In addition, the AVMA has released its Model Veterinary Practice Act for comment on proposed revisions; the deadline is March 25. It is available at

Dr. Teller encourages members to look at the policy in terms of how telehealth can be incorporated into it and what changes need to be made.

Dr. Jennifer Bolser, a consulting veterinarian at the International Center for Veterinary Services in Beijing, has already seen telehealth (without a VCPR) in practice. One business in China developed services that would allow owners to call in anytime, and she said that business "failed pretty quickly because most of the time, the recommendation was to see a veterinarian. I don't know what is happening in other industries, but in most cases, you'll need to see a veterinarian. We should look at telemedicine as an adjunct and not be so scared of it. Your skill set will carry you through the profession. These things will fail without our skills."

The term "telehealth" encompasses a broad variety of technologies and tactics to deliver virtual medical, health, and education services, according to the Center for Connected Health Policy, a project of the nonprofit Public Health Institute working to promote telehealth. Telehealth is not a specific service but a collection of means to enhance care and education delivery. "Telemedicine" is often still used when referring to traditional clinical diagnosis and monitoring that is delivered by technology. However, the term "telehealth" is now used more commonly, as it describes the wide range of diagnosis and management, education, and other related fields of health care, according to the CCHP.

Adrian Hochstadt, deputy CEO of the AVMA, said telehealth in veterinary medicine encompasses the following examples:

  • Apps connecting a pet owner to a veterinarian.
  • After-hours triage services offered to veterinary practices.
  • Pet poison control hotlines.
  • Smart collars.
  • Remote monitoring via webcams in intensive care units.
  • Videoconferencing with a specialist when one isn't available locally.

Related JAVMA content:

Advisory panel report offers guidance on telemedicine (March 1, 2017)