Veterinarians find limits, benefits in distance care

Telehealth expands but state, federal rules bar some types of distance care
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Dr. Shea Cox talks by video with people who are trying to keep their dying pets comfortable at home.

Through, she and her employees provide pet owners 90-minute consultations on end-of-life decisions and how to prepare for the loss of a pet. Many of those clients have decided their frail pets are done with the stress of clinic visits.

However, state and federal rules prevent her from prescribing drugs for these pets without seeing the animals in person, and referring veterinarians often want to recheck the animals at their clinics before agreeing to her prescription recommendations. Many times, therefore, the animals go without medications as part of their palliative care, she said.

"There are a lot of benign things that we can offer to patients to really improve comfort when we're just managing the clinical signs," she said.

She wants more flexibility in the rules governing how to establish the veterinarian-client-patient-relationship required for medical care.

"We're talking end of life," Dr. Cox said. "The alternative is euthanasia."

During a meeting in April with three dozen selected health care providers and others involved in telemedicine, including Dr. Cox, AVMA's deputy CEO Adrian Hochstadt said the AVMA has supported the traditional view that the VCPR must be established through an in-person visit to maintain standards of care. But he noted that policies change, and the AVMA wants to know what opportunities veterinarians see for telemedicine.

Summit attendees
Attendees at the AVMA Veterinary Virtual Care Summit April 10 at AVMA headquarters in Schaumburg, Illinois (Photos by R. Scott Nolen)

Dr. Gail Golab, AVMA chief veterinary officer, said during the meeting that the Association also wants to ensure regulations don't unnecessarily stand in the way of innovation. Telemedicine has opportunities to increase access to patients that are underserved because of their owners' socioeconomic status, geographic location, disabilities, or language barriers, as well as allow remote monitoring of patient progress and compliance with treatment directions, she said.

The AVMA Veterinary Virtual Care Summit convened April 10. Attendees discussed VCPR rules and the need to set image file type and quality standards, decide who has liability and record-keeping responsibilities, measure success for telehealth consultations, set best practices that include ethical guidelines for data collection, and study how telemedicine affects animals in the homes of clients rich or poor.

Demand and potential

Dr. Teller
Dr. Lori Teller delivers a presentation at the summit.

Dr. Lori Teller is clinical associate professor of telehealth at Texas A&M University College of Veterinary Medicine & Biomedical Sciences and a member of the AVMA Board of Directors. She said telehealth can improve access to primary and specialty care, let veterinarians work from home during parental leave from office duties, reduce stress to patients, reassure clients, and reinforce bonds with those clients and patients.

Clients who want to receive services via telemedicine also want those services to come from the practices they call home, Dr. Teller said. Human health care has shown people want to receive telemedicine services.

Use of telehealth services in human medicine rose 53% from 2016-17, according to a health insurance claim analysis published earlier in April by the nonprofit FAIR Health.

A separate analysis published in a November 2018 research letter in JAMA: The Journal of the American Medical Association indicates that, for private insurance and Medicare Advantage claims included in one database, annual telemedicine visits rose from 206 in 2005 to more than 202,000 in 2017. About half were for mental health visits and 40% for primary care examinations.

In veterinary medicine, Dr. Teller said data from Fuzzy Pet Health, which provides house call care and remote consultations, indicate about 30% of its telemedicine cases are for dermatology, 30% for vomiting or diarrhea, 10% for limping or other signs of pain, and 8% for behavioral issues.

Dr. Teller said in a later interview that, with new technologies, veterinarians will need to consider exceptions to the VCPR in addition to existing emergency provisions such as poison control. The U.S. doesn't have enough behaviorists, for example, and she thinks that specialty is conducive to telemedicine.

There are a lot of benign things that we can offer to patients to really improve comfort when we're just managing the clinical signs."

Dr. Shea Cox, hospice and palliative care veterinarian in Berkeley, California

Dr. Sally J. Foote is a general practitioner in Illinois who gives video consultations on pet behavior. She thinks the best evaluations happen in a home, where she can see via Skype or FaceTime the door that swings too close to a dog's food dish, the ceramic tile floor that is causing slips and repeated injuries, or the open-plan house where an elderly dog can't escape from a toddler.

Some pets that need help also are less likely to travel well or be predictable in a clinic, she said.

Dr. Foote wants not only flexibility in what she can do to help those clients, but also clarity on what rules apply.

She receives many of her patients through referrals, and she talks with clients' primary veterinarians about, say, pain medication or radiographs that might be needed. But not all clients have access to a veterinarian.

When she sees a client with an anxious and aggressive dog, she is unable to prescribe a drug that could calm the dog enough to bring it to a clinic. A house call may be too expensive, and a veterinarian who specializes in behavior may be too far away, she said.

A mix of federal and state laws and regulations govern when veterinarians can use telemedicine. Some have vague VCPR definitions, without prohibitions on establishing that relationship at a distance, Dr. Teller said.

Connecticut doesn't define the VCPR in its laws and regulations, she said. Texas modeled its provisions on the AVMA Model Veterinary Practice Act, requiring an in-person visit to see an animal or, for groups of animals, their premises.

The Food and Drug Administration requires an in-person visit to establish the VCPR needed for an extralabel prescription, and most controlled substances used in veterinary medicine are prescribed extralabel, Dr. Teller said.

She noted that the American Association of Veterinary State Boards recommends in its Practice Act Model—most recently adopted in September 2018—that veterinarians be allowed to use their own judgment to determine whether an in-person examination is needed.

Dr. Golab
Dr. Gail Golab, AVMA chief veterinary officer

In October 2018, the Oklahoma State Board of Veterinary Medical Examiners cited AAVSB policy when issuing a position statement that says: "A veterinarian using telehealth technologies must take appropriate steps to establish the VCPR and conduct all appropriate evaluations and history of the patient consistent with traditional standards of care for the particular patient presentation. As such, some situations and patient presentations are appropriate for the utilization of telehealth technologies as a component of, or in lieu of, hands-on medical care, while others are not."

James Penrod, executive director of the AAVSB, said during the April meeting that the veterinary profession needs to be able to prove that services can change, rather than becoming the victim of outside organizations that see that potential. He thinks regulations should change with technology.

Patient evaluations should be consistent with care standards, which also will evolve, Penrod said. He suggested that, if peers on a veterinary medical board find a veterinarian's actions reasonable, they should be allowed.

Dr. Foote also has heard an argument from two behaviorists that, under current regulations, a veterinarian could not suggest so much as installing a baby gate to separate a toddler from a dog without first performing an in-person examination. That change, the argument goes, would alter the dog's mental state and amount to practice without a VCPR.

But such advice is freely available from nonveterinarians, and Dr. Foote sees a risk that veterinarians who try too hard to control services instead will cede them to trainers and other competitors.

Dr. Foote is a member of an Illinois State VMA group that is examining the state's veterinary practice act, including use of telehealth, how the VCPR is defined and applied, and what technologies can be used to improve care. She sees a chance to improve health care, welfare, public safety, and use of veterinarians and veterinary technicians by embracing the tools available.

Adding services today

Dr. Aaron Smiley, who manages two clinics in central Indiana, had relied on clients to bring in their pets after treatments or describe the change over the phone. Rechecks are valuable, he said, but clients often felt even the scheduled phone calls were too inconvenient.

"Most owners would just shrug their shoulders and accept less than 100% improvement because contacting the veterinarian again would be difficult," he said.

In the seven months before he attended the virtual care meeting, Dr. Smiley offered 1,000 remote consultations. The owner of a dog with dermatitis, for example, could send a text message with a photo or video of the treated area, and Dr. Smiley could decide whether more or new treatment was needed.

Dr. Smiley charges for those follow-up checks during a patient's visit. Clients seem to be more bonded to the clinic because they have access to their doctor without taking time off work, hauling pets, or arranging child care.

"I think that we can operate inside the VCPR in a very effective way to provide better veterinary medicine to more people," he said.

Summit attendees
Telemedicine providers listen during a presentation portion of the summit.

Making pricing models—and becoming comfortable with charging clients for the services—are among the difficult tasks, Dr. Teller said. Veterinarians need to convince clients remote work has value, she said.

Dr. Apryle Horbal is president of VetNow, a company she co-founded in summer 2017 to connect veterinarians with specialists. She had started a small equine specialty hospital near Pittsburgh in July 2016, and her hospital had 1,500 patients a month at the outset. She needed to hire additional specialists to expand but could attract few.

"We had a very hard time attracting even an internal medicine specialist," she said.

She needed cardiology, neurology, and dermatology specialists. She was able to hire a surgeon after searching.

With a partner from human health care—Matthew Rumbaugh, founder of the chronic care and patient monitoring service TeleHealth Suite—Dr. Horbal co-founded VetNow, which started as a tool to connect her clinic with consulting specialists. It has since expanded to become a service for other veterinarians, now with 50 specialists in 10 fields.

Dr. Horbal, who also attended the AVMA meeting, said her experiences through TeleHealth Suite indicate veterinary medicine will follow human medicine's lead into using wearable devices to monitor patients and encourage behavior changes. Doctors also are redistributing expertise, giving more people the highest-quality advice and life available, she said.

An oncologist thousands of miles away can read bloodwork results with a veterinarian who has hands on a patient.

Dr. Horbal thinks veterinarians who want to offer remote services should focus less on the limits placed by VCPR rules and more on what they are allowed to offer.

The rules need to change to reflect modern medical relationships, some of which can be established through telemedicine, Dr. Horbal said. But that change will take time, and she sees a chance to expand services and improve care now.

The AVMA has created an online Telehealth Resource Center with a suite of educational and practical tools for practitioners and their staff. Specifically, the pages serve to help AVMA members understand, evaluate, customize, and implement telehealth options in their practice. The resources are available exclusively to AVMA members.

Related JAVMA content:

Veterinarians encouraged to take telehealth for a spin (Sept. 15, 2018)

Telehealth poses new possibilities, problems (March 1, 2018

AVMA creates tools, resources on telehealth (March 1, 2018)

Defining relationships (June 1, 2017)

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