Many veterinary organizations remain in favor of a veterinarian-client-patient-relationship established in person
Malinda Larkin and R. Scott Nolen
The issue of whether to establish a veterinarian-client-patient-relationship (VCPR) through an in-person examination or solely electronic means has recently come before state legislatures and veterinary medical boards.
And while there is vast agreement that there’s a future in veterinary medicine for telehealth, what that should look like is up for debate.
Proponents of a virtual VCPR claim that being able to establish that relationship electronically would improve access to care. But many veterinarians don’t believe that is the case because, more often than not, the care most animals need is preventive care that is tailored to the animal’s specific circumstances and requires an in-person visit.
Animals that don’t regularly see a veterinarian are more likely to have issues that require a complete physical examination to diagnose and treat. That’s not possible through telemedicine. On the other hand, once a relationship has been established with a hands-on examination and engagement with the client, telemedicine can be a great tool to supplement ongoing, in-person care.
Rules and regulations
Use of telehealth in the veterinary profession, including telemedicine, increased during the COVID-19 pandemic so that veterinary professionals could see existing patients virtually as a safeguard against spreading the SARS-CoV-2 virus. Since then, use of telehealth has slowed in both human and veterinary health care after in-person visits resumed. However, some veterinarians, telemedicine companies, and their lobbyists want to expand the use of telemedicine to include patients not previously seen by the veterinarian—and they are working to change state veterinary practice acts or veterinary licensing board regulations, depending on the state.
Currently, 43 states and the District of Columbia use language that is essentially the same as the Food and Drug Administration (FDA) with respect to establishing a VCPR. The FDA has interpreted their own language to mean that a VCPR cannot be established solely through telemedicine. Federal law requires a VCPR, established with an in-person examination or medically appropriate and timely visits to the premises where the animal is kept, for tasks such as extralabel drug use, issuing veterinary feed directives, and using certain types of biologics.
Of those states that have mirrored the FDA’s VCPR language, 22 have added additional language to explicitly require an in-person examination or visits to the location where animals are kept in order to establish the VCPR.
Just this year, Kentucky and Illinois specifically confirmed or reaffirmed an in-person VCPR requirement, while Delaware added FDA’s language as it created a VCPR definition in its regulations. Additionally, Michigan changed its board rules to require an in-person examination or conduct medically appropriate and timely visits to the premises where the group of animal patients is kept prior to providing telehealth services. In 2022, West Virginia, Hawaii, and Nevada enacted laws requiring an in-person examination or medically appropriate and timely visits to the premises.
When reviewing state statutes, including the state’s veterinary practice act, the Kentucky VMA (KVMA) and the Kentucky Board of Veterinary Examiners worked together. Debra Hamelback, executive director of the KVMA, said, “When it came to VCPR, we knew it was a hot-button item because of legislation going on in other states, so we wanted to be sensitive to that.”
Ultimately, they decided to keep language preserving the in-person VCPR requirement. To get veterinarians’ input, members of the KVMA and licensing boards traveled throughout the state and held meetings to review their work.
“A question asked at every meeting was ‘How many of you would like to maintain an in-person VCPR every 12 months?’” Hamelback said. “Virtually everybody raised their hand. That was will of membership, from mixed animal to equine to small animal.”
They followed up with a membership survey, which had similar results from a significant portion of KVMA’s membership, which represents over 85% of Kentucky’s veterinarians. All licensees were encouraged to write in their comments or concerns.
“It was a large group effort by the licensing board and KVMA to have input,” Hamelback said.
On the other hand, six states have changed their veterinary practice acts or regulations to allow a VCPR to be established virtually or use telemedicine without an in-person examination.
In May, Arizona Governor Katie Hobbs signed into law a bill that allows veterinarians licensed in Arizona to establish a VCPR virtually through telemedicine starting October 30. It limits prescribing medication by a veterinarian to 14 days from the visit and one refill before an in-person examination is required. The law also excludes food-producing animals, among other stipulations.
California also passed a law, which was signed by Governor Gavin Newsom on October 8, that provides for establishment of a VCPR via electronic means. The law, which becomes effective in January, allows prescribing for up to six months based on an electronic examination, but allows further prescribing with another electronic examination. It also limits prescribing for antimicrobials, which are limited to 14 days, and may not be refilled without an in-person examination or visit to the premises. It also prohibits a VCPR from being established solely by an audio-only communication or a questionnaire and allows only California-based veterinarians to practice via telehealth on animals located in the state.
New Jersey and Virginia require an in-person examination for prescribing controlled substances while Idaho does not allow prescribing of any medication when a VCPR is established electronically. Vermont law has few restrictions and even offers a registry for out-of-state providers unlicensed in the state to provide remote veterinary care to residents’ animals.
Legislative attempts at allowing a virtual VCPR were not successful in the past year in Arkansas, Florida, and Michigan.
Only two states have no VCPR provisions: Michigan, which requires an in-person examination prior to providing telehealth services, and New York. Regarding the later, New York State Education Department policy states a VCPR exists when a veterinarian is “personally acquainted with the keeping and care of the patient by virtue of a timely examination of the patient by the veterinarian, medically appropriate and timely visits by the veterinarian to the operation where the patient is managed, or medically appropriate and timely visits by the patient to the veterinary facility where the veterinarian is working.”
Veterinary groups supporting in-person VCPR
The AVMA policy, “Telemedicine,” advocates strongly for telemedicine to be used only once an in-person VCPR has been established, stating: “With the exception of emergency teletriage, including poison control services, the AVMA opposes remote consulting, including telemedicine, offered directly to the public when the intent is to diagnose and/or treat a patient in the absence of a VCPR.”
AVMA President Rena Carlson and AVMA CEO Janet Donlin further explained the Association’s position in an October 6 letter to Gov. Newsom asking him to veto California’s bill.
“Veterinary telemedicine is most effective and safest—for patients, clients, and veterinarians and their teams—when used to maintain a Veterinarian-Client-Patient Relationship (VCPR) that has already been established via an in-person examination of the animal or animals. The physical examination is the most valuable tool the veterinarian has in their toolbox,” Drs. Carlson and Donlin wrote.
“Without a physical examination and appropriate diagnostic tests, the veterinarian must lean heavily on an owner’s interpretation of the animal’s clinical signs and, unfortunately, owners often misinterpret. That in-person encounter also tells the veterinarian about the owner/caretaker—what their relationship is with the patient, whether they can handle the animal, and what type of care they can deliver.”
Other veterinary organizations have also voiced their opposition to legalizing the establishment of VCPR virtually, rather than in person, as the issue is debated across state legislatures.
The American Association of Bovine Practitioners (AABP) board of directors, at its September meeting in Milwaukee, issued a position statement supporting the requirement for a VCPR to be established through an in-person visit.
“Veterinary oversight and regular site visits are essential components of establishing and maintaining a VCPR,” according to the AABP statement. “This relationship can be supplemented through laboratory data evaluation, records evaluation, and telephonic or electronic communication. The AABP does not support establishment of the VCPR solely through virtual door electronic methods.”
Dr. K. Fred Gingrich, executive director of the AABP, explained that the organization’s board of directors thought it important to restate its position on the VCPR in light of how some proponents of the virtual option claim it would provide relief in areas where bovine veterinary services are in short supply.
“We thought it was important for AABP to say, ‘Yes, we recognize that workforce challenges exist. However, establishing a VCPR virtually is not something our organization supports,’” Dr. Gingrich said.
That follows the American Association of Equine Practitioners (AAEP) and American Association of Swine Veterinarians (AASV), which issued similar statements in 2018 and this past April, respectively.
According to the AAEP, “Telehealth is an indispensable collaborative tool for equine veterinarians to enhance diagnostic testing, consultation with experts, patient treatment and monitoring, as well as owner communication.” However, the AAEP supports the establishment of the VCPR as defined by the AVMA and “such a relationship cannot be established solely by electronic means.”
The AASV says that telemedicine has the potential to increase veterinary access in rural areas, improve response time, and increase collaboration between generalists and specialists.
“AASV members are encouraged to embrace technologies that will improve standard of care and animal welfare, increase biosecurity, and bolster foreign animal disease preparedness,” the statement says. “Telemedicine may supplement in‐person visits and it is the swine veterinarian's responsibility to determine which cases are best suited for telemedicine.”
The AVMA and the three allied organizations are among more than 50 members of the Coalition for Connected Veterinary Care (CCVC), an alliance of veterinary and animal health organizations that want to leverage telehealth to benefit animal patients while also protecting the integrity of the VCPR.
One of the concerns held by the AVMA and others on the push to relax VCPR requirements is related to the growth of direct-to-consumer (DTC) telemedicine in the past few years; many of these companies are supporting state legislative and regulatory changes.
“Unfortunately, it seems likely that those who are pushing for a virtual VCPR are doing so to increase patient use of high-profit prescription drugs,” Drs. Carlson and Donlin wrote.
“Again, looking at human medicine, we’ve seen this happen, where pursuit of profits has helped to fuel the opioid epidemic. Over-prescribing via telemedicine has also helped contribute to human drug shortages, as online prescription seekers who don’t really need these drugs receive them at the expense of patients who do. At the AVMA, we want to avoid a similar situation of prioritizing profits over care from happening in veterinary medicine.”
A version of this story appears in the December 2023 print issue of JAVMA.