Considering a Practice Sale to Corporate Volume 2 – Prospective Corporate Buyers
Veterinary Business Advisors, Inc.
1 Washington Drive
Whitehouse Station, NJ 08889
In our last article, we discussed how to prepare your veterinary practice for an acquisition by a corporate buyer. We recommended that you first gather your team of professionals and have them review your financials and practice entity documents. We explained that you will need to set aside time to devote to the process for tasks such as digging up documents and having introductory meetings with the buyers. When you have all your ducks in a row and have decided that you are ready to begin, you will then need to determine which corporate buyers would be interested in your veterinary practice.
How Corporate Buyers Choose Veterinary Practices
Many corporate consolidators base their acquisition criteria on a number of factors, starting with geographic location. While the big dogs are nationwide, there are also some smaller corporates popping up all over the country that are specific to a particular geographic region. Their pockets may not be as deep as the larger, older companies; however, they may have a strong infrastructure in your area and may be able to provide you with better support. They may also offer you a future career opportunity in their local corporate office.
Location also matters because as the smaller companies grow, they strategically pick the next market where they are potentially expanding. If your practice is located in that market, they may be willing to pay top dollar to acquire you.
Your pool of prospective buyers can vary depending on the size of your practice. A few factors that buyers take into consideration are the following:
- Number of veterinarians employed at the practice
- The practice’s gross revenue for the previous year
- The presence of year-over-year growth
The size of the hospital building can also influence buyers such as:
- Number of exam rooms
- Extra space that can be converted into additional exam rooms
- Multiple floors in the building
- Space on the property that could accommodate expansion of the building and future growth
The type of hospital will also determine who is interested in your practice. Some buyers are interested in acquiring specialty and emergency hospitals, while others only want general practices. There are corporates that are in the market for equine and mixed animal practices, but many only acquire small animal hospitals. If you are the owner of an equine facility, make sure the buyer you are entertaining has experience and is able to support your practice. It can be risky to sell to a “newbie” who is just dipping their toes in the water and wants to start with you.
How Practice Owners Choose Corporate Buyers
Once you reach out to the various corporate buyers and determine who is interested in reviewing your practice, you can then begin getting to know them while asking yourself the next question: which of these buyers would be a good fit for your veterinary practice?
Consider the type of management style you would prefer in a buyer. Some practice owners need to have more control and may want to continue running the show after the sale, while others have had enough of the business side and would prefer to step back. Would you like a company that is highly involved and takes over all of the management duties so you can just focus on medicine or would you prefer a company that is a generally hands off?
You can also ask the buyers for a list of references. They should be able to provide you with contact information for practices they have recently acquired in your region. Be sure to speak with both the former owners as well as the practice managers to get the inside scoop on what it’s like to interact with the company on a day-to-day basis. Talk to someone who closed a few years ago to see how they are doing today. Did all of their doctors quit? Is the majority of the staff happy? It’s also helpful to speak with someone who closed more recently and is still going through the transition process today.
Corporate buyers offer different types and levels of employee benefits. Some buyers say that they will keep your staff whole by making adjustments to their hourly rate/salary if their benefits are not as good as what you are currently offering your staff. You certainly don’t want your employees to have to take a pay cut or pay more for insurance after the sale. That would not be good for employee morale. You may want to ask the buyers what kind of discounts they offer the employees. You could provide the buyers with a copy of your employee manual to confirm that their company would offer similar perks and benefits.
Another aspect to consider is how you may feel about the buyer making changes after closing. Some will show up on closing day and immediately switch your practice management software over to their system. They could also change vendors including the reference laboratory or even your in-house lab equipment. It’s something to consider because your employees would then have to learn how to use all new machines. Other corporate buyers choose to continue using all of your current vendors and don’t really change a thing, or at least wait until the dust settles.
The best way to determine whether a corporate buyer would be a good match for your practice is to get to know them. Through phone calls, zoom meetings or in-person meetings, practice owners gain the opportunity to ask questions and get to know the culture of each company. Keep in mind, that most owners continue to work after the closing and their buyer becomes their future employer. Ultimately, you should ask yourself if you would want to work for this company.
In the end, the decision to choose a buyer often comes down to the purchase price. Many, if not most owners are counting on the funds from their sale to enable them to retire down the road, so the final number is important. However, it’s good to do your homework because if you have two similar offers, you will be giving the other factors some serious consideration.
If you are fortunate enough to receive multiple offers on your veterinary practice from corporate buyers, you will be faced with making one of the most important decisions of your veterinary career. In our next article, we will explore the various types of offers and sale structures.
Top 5 Veterinary Practice Information Management Software (PIMS) Products
Veterinary Business Advisors, Inc.
1 Washington Drive
Whitehouse Station, NJ 08889
The use of technology has revolutionized operations and methods of performance for businesses while simultaneously providing competitive advantages and economic opportunities.1 Using practice information management software (PIMS) has the potential to streamline processes by reducing operating costs, improving the communication process, and boosting productivity.1 Veterinary practices can use PIMS programs to make practicing medicine more convenient and efficient as well. Within the last decade, the field of PIMS options has grown exponentially. So, how do you decide which program is the best fit for your practice? This article is meant to provide veterinarians with an overview of the major PIMS options available to their practices and the benefits they potentially bring to the table.
The demand for veterinary services has skyrocketed since COVID-19.2 Increased demand for services combined with a shortage of veterinarians, wide-spread burnout, and staffing challenges, has created a near-perfect storm for the veterinary industry. At the same time, the previously mentioned variables are also partially responsible for the ongoing advancement of veterinary-specific software.3 Given the state of the industry, the need to maximize productivity and efficiency has arguably never been greater. Historically, technology has been a massive driver of transformation in the industry,4 and the future will, in all likelihood, continue this trend.
Before Cornerstone and Avimark, there was PSI, one of, if not the earliest veterinary-specific programs. It most notably offered a primitive computerized SOAP, reminder system, and receipting. Since then, the selection of veterinary programs, and now applications in addition to the features they offer, has thankfully increased. Globally, and through our own research, we would conservatively estimate there are currently over a hundred veterinary-specific programs and applications on the market. Granted, not all of these programs and applications are complete and all-inclusive platforms, and many of them exist within niche spaces to meet the associated demands of said niches. From generalists to specialists, a modern and efficient PIMS system that compliments a practice’s unique personality is an increasingly crucial tool. Through over a month of careful research, we personally test-drove (when able) the major PIMS options available on the market in North America. Join us as we compare the notable options and offer a comprehensive guide on how to pick the best product suited for your hospital’s unique needs.
Finding the Virtual Glass Slipper
Before we dive too deep into the various PIMS options, we would recommend asking the following practice-specific considerations. Is the program financially feasible? Regardless of how helpful implementing a new PIMS program would be to your day-to-day activities, it’s not going to be beneficial in the end if your practice can’t afford it. Is the program able to be integrated with any other current programs or vendors? Many PIMS programs can automatically port diagnostic results and inventory supplies in real time, so it’s important to consider whether these aspects of your practice are able to talk to each other seamlessly. While you may be enamored with one program it’s also important to compare the pros and cons with other options. The veterinary PIMS market is arguably crowded, so make sure you are taking every aspect into consideration. You will want to ask yourself whether the seller is a good fit for your practice overall. When it comes to partnering with a PIMS supplier, the program itself is, at times, just the tip of the iceberg. It will be important to make sure your practice and the seller are compatible as well. For example, if your practice is open 24/7 does the PIMS supplier offer 24/7 customer support? If not, you may want to reconsider. Lastly, you may want to contemplate whether the program is compatible with your staff’s personalities. If you have an associate that is easily intimidated by technology, opting for a program that has a more simplistic layout may be beneficial. If you are an equine practitioner and often find yourself without an internet connection, you may want to look into a cloud-based program that automatically updates when internet connectivity resumes. Now that you are prepared to ask the right questions, there are just a few more trends to consider.
- Cloud-Based programs are the future in our opinion. Often accessible anywhere, these programs mean less money invested in hardware, improved live collaboration amongst staff, improved data security (generally), automatic software updates, mobility, and scalability. In today’s fast-paced world, we highly recommend considering a cloud-based PIMS.
- Veterinary phone applications are our prediction for the next big trend. If you haven’t noticed as of late, the world is increasingly on the move, and working with a phone application has the potential to save time and make your job more convenient. Some veterinary PIMS programs currently offer mobile access and integration with practice computers.
- Telemedicine has become extremely relevant given the recent pandemic. Many of the practice management programs have telemedicine capability, providing a great way to accommodate clients and staff who would prefer to practice social distancing.
Without further ado, let’s dive into the major available options. All of the programs that we are about to discuss are capable of doing the following: appointment scheduling, billing and invoicing, confirmation/reminders, have 24/7 customer support, and are cloud-based.
We have also included a Capterra rating for each program. Capterra is a software review site openly viewable by the public where reviews are posted by real buyers and validated. Vendors cannot influence these reviews in any way.
1. DaySmart Vet (Formerly Vetter):
Pricing: Starting at $99 per month for one user and up to $399 per month for 15 users.
Capterra Rating: 4.6 stars out of 5.0
Pros: From inquiry to demonstration, DaySmart Vet stood out as an impressively intuitive and customizable product. The software was originally created for the brother of Vetter’s founder, a veterinarian. It most notably allows for live SOAP collaboration amongst users, meaning multiple people can work on one SOAP if the practice would like. The design is simple and modern. DaySmart Vet’s customer service is 24/7 and notoriously excellent across multiple practice review sources. Based on our research, the development team behind the platform is very responsive to client suggestions.
DaySmart Vet recently released their PetCare client-facing phone application which pet owners can use to schedule appointments, view medical records and invoices, and much more. The phone application is an additional $99/month for clinics. That being said, it’s the minor details about this program that excited us the most. From the automated cage card creation to the Google Maps interface for mobile practices, DaySmart Vet was clearly made with a high-level firsthand understanding of the veterinary industry. One significant highlight about this program is the lack of a contract requirement.
Cons: Some common complaints about DaySmart Vet include that its reminder system can be a bit difficult to use and that the program lacks substantial reporting capabilities.
Pricing: Starting at $140 per month for 1-2 users and up to $500 for 31+ users.
Capterra Rating: 4.3 stars out of 5.0
Pros: NaVetor’s smooth integration with diagnostics companies like IDEXX and Petlink are a favorite amongst many clinics. The program’s developers are very receptive and have been known to implement customer suggestions into the product. Pricing is extremely attractive when compared to other options. The interface is attractive, modern, and cohesive from start to finish. NaVetor is impressively easy to navigate and its list of integrations are substantial and constantly growing. The company also consistently receives praise for its customer service.
Cons: Like many other PIMS options, NaVetor is click-heavy, and many other reviews seem to agree that there are at times too many steps to a single task such as processing payment for a customer. User interface is definitely geared more towards veterinarians and not technicians or other staff.
3. Covetrus Pulse (Formerly eVetPractice):
Pricing: Pricing varies based off many variables. We would recommend calling Covetrus Pulse so that they can provide pricing based off the specifics of your practice.
Capterra Rating: 4.2 stars out of 5.0
Pros: If you are looking for a PIMS option that has a massive number of features, then look no further. Covetrus Pulse puts all applications and integrations front and center in one place, saving you time and money. The program has a great task dashboard to improve organization and boost productivity. Covetrus Pulse is generally recognized as an approachable program that is friendly towards users who do not consider themselves tech-savvy. As a result, onboarding for this program is generally short and easy.
Cons: Many people have sited issues with the program’s practice management reporting function which can be complicated and a bit nonsensical. Additional comments include the sheer number of mouse-clicks it can sometimes take to work through tasks. Lastly, many users have cited a lack of customer-suggested edits.
4. Hippo Manager:
Pricing: Starting at $119 per month for 1 user.
Capterra Rating: 4.0 stars out of 5.0
Pros: Hippo Manager is reportedly easy to learn and gets a lot of love from clinics for that reason. If you are easily overwhelmed by the other PIMS out there, this may be the software for you. Their tech support is also quite popular according to many verified reviews. If you checked out Hippo Manager sometime in the past, it may be worth revisiting as the program is constantly being updated.
Cons: Unfortunately, Hippo Manager’s team has put new subscriptions on pause for the remainder of the year as they are transitioning into Hippo 2.0. Like many others, Hippo Manager’s reporting capabilities have been frequently cited as an area that could use improvement.
Pricing: One-time fee of $300 per payment terminal and $1,000 for data migration. Then, a per transaction fee from 1.39%-2.69% depending on the payment method.
Capterra Rating: 5.0 stars out of 5.0
Pros: Rhapsody is lesser known but does have some great features, and has been recently implemented into hundreds of NVA practices. This PIMS program does not utilize tabs, making browsing much less cluttered. The program is easy to set up, and the company boasts it has gotten practices up and running in just 48 hours. Rhapsody is constantly producing updates to improve the product, so if you have an issue or suggestion there is a higher chance that it will be addressed. Rhapsody launched in 2019 but has the lowest number of negative reviews. Rhapsody also has an add-on application called Boop, which integrates with Zoom for telemedicine. Our favorite feature from rhapsody is its check-in kiosk function. Through Rhapsody’s check-in software, customers can confirm they are ready for their appointment, fill out any necessary paperwork, confirm account information, and much more. This lightens the load for your front desk team.
Cons: Their customer support team is not 24/7 yet, so if you have overnight services you may need to look elsewhere. The program also does not have a color-coding system, which can be problematic for clinics that typically like to color-code. The program also used to have notable connectivity issues, although, those have reportedly been fixed.
Return on Investment (ROI):
Almost all veterinary PIMS options have substantial features, but they are not helpful in your day-to-day service if practices do not know how to use them. It’s important to put the features you are paying for to work in order to maximize your investment. A study done in 2021 where an entire clinical staff was trained in the software proved that the right PIMS can help boost productivity through automation, and operational efficiency was boosted by 46%.5
The vast majority of veterinary PIMS programs on the market today have the same key features such as inventory tracking, electronic medical records, reporting and analytics, invoices and accounting, and appointment scheduling. The key to selecting your program is determining which product and seller are a good fit for your unique practice. Implementing a new PIMS system is a commitment, from the financial investment itself to the time spent onboarding your staff, so it’s important to partner up with the right seller-product combo. Make sure you figure out your specific priorities and then do your homework. You should also be ready to test drive every PIMS program that interests you. Demonstrations are great for a quick introduction, but familiarizing yourself through actual interaction will make a huge difference in understanding the product itself and making the best choice.
- Kiradoo, G. (2021). Analysis of Influential Role of Digital Transformation in Enhancing Effective Business Management and Operations. Turkish Journal of Physiotherapy Rehabilitation, 32(2), 557-560.
- Zhang, S. (2022, July 6). The Great Veterinary Shortage. The Atlantic. Retrieved November 12, 2022, from https://www.theatlantic.com/health/archive/2022/07/not-enough-veterinarians-animals/661497/
- (2022, August 26). The ultimate list of veterinary software with a downloadable checklist. Vetstoria. Retrieved November 12, 2022, from https://www.vetstoria.com/blog/the-ultimate-list-of-veterinary-software/
- Larkin, M. (2020, December 3). Pivot or perish: Veterinary leaders talk industry trends. American Veterinary Medical Association. Retrieved November 12, 2022, from https://www.avma.org/javma-news/2020-12-15/pivot-or-perish-veterinary-leaders-talk-industry-trends
- Veterinary Practice Management System Development. Rishabh Software. (2021, June 15). Retrieved November 14, 2022, from https://www.rishabhsoft.com/blog/veterinary-practice-management-software-development
Considering a Practice Sale to Corporate:
Helpful Tips to Prepare for the Process
Volume 1 – Are You Ready to Sell?
Veterinary Business Advisors, Inc.
Many young veterinarians have a clear vision that one day they will become a practice owner. What they may not plan for, is what will happen later in life, when they are older and in need of an exit strategy. Ownership consumes a great deal of time and energy at a level that can be difficult to maintain year after year. Many veterinarians reach a point in their career when they are ready for a change. They have been working their tail off at their practice for the past 15, 25, or even 30 years, and they are getting burned out. Some owners are ready to retire from veterinary medicine altogether. Others may want to continue working, but they are tired of the business responsibilities and just want to focus on practicing medicine.
There are also practice owners who had plans that did not pan out. Some may have intended to pass on their practice to a son or daughter, but that child grew up to live out a unique dream of their own. Others were hoping that one of their associates would be interested in buying, but not everyone wants that kind of responsibility or the burden of a business loan. Some owners work with a broker to find a private buyer and that can lead to a successful sale, but they may be leaving money on the table. An alternative that is becoming more and more commonly attainable to all of these owners is the acquisition of their business by a corporate consolidator. The purchase prices on corporate transactions tend to be much higher than many sellers ever dreamt of receiving.
Things to Consider
There are many things to consider when entertaining the sale of a business and this applies to the veterinary industry as well. For starters, you should realize how time-consuming the sale of a business can be, especially if you are bidding to multiple corporate buyers, and consider whether you have that kind of time and energy.
Consider the following questions:
- How much free time would you have over the course of a week to correspond with prospective buyers via email, phone calls, video meetings or in-person/onsite meetings?
- Are you ready to take the leap now, or will you have more free time in another 3 months when your associate returns from maternity leave or when that new hire gets onboarded?
There are numerous financial documents to be located, organized, and sent for review before a buyer is willing to show you the money! The last thing you want is to hook a buyer’s interest but then be unable to deliver and have them walk away.
Additionally, you should take a look at your numbers. If you’ve recently lost a doctor and your production reports are showing a drop in revenue, then now may not be a good time to sell. If your COGs are suddenly way up, or your payroll expense is higher than most practices, these are things that are not going to look good on paper when the financial analysts begin crunching your numbers. It may be worth consulting with a CPA or a financial advisor with veterinary expertise to find ways to make your practice more profitable and “clean up your books” before you put it on the market.
In order to sell the assets of your practice, you will also need to confirm that the business entity that owns it is in good standing. Similar to how you need a clean title in order to sell your car, the same applies to selling your veterinary practice. Many owners are not aware of their state’s corporate law requirements such as filing an annual report for an LLC entity or holding annual meetings for a corporation. If you have not been keeping records properly over the years, then you should work with a corporate attorney to bring your business entity into compliance before moving forward.
If you own your facility, the same applies for the landlord entity that owns your real estate. It should also have the required documentation on file. After the sale, that entity will become the landlord of the corporate buyer (unless you plan to sell the real estate at the same time as the practice sale).
Once you decide that you are ready to move forward with the sale, you will need to bring in a team of professionals to help you minimize your risk and get to the finish line. There are various transaction documents that will need to be reviewed. You will be making representations about your practice in those documents and you should have a legal professional explain them to you. It would be ideal to speak with a consultant who has expertise within the veterinary industry to determine if the terms of your sale are in-line with the current industry standards. This includes the purchase price, the terms of the facility lease (if owned) and the terms of your employment agreement with the buyer. The other thing to consider is whether the level of risk for you as the seller in those documents is what is typical and acceptable for a veterinary practice sale.
As mentioned earlier, your team should include a local attorney. If your practice is owned by a corporation or an LLC entity, the attorney should confirm that all of your corporate documents are in full compliance. If you own the practice facility personally, you may want to discuss the idea of transferring that ownership to an LLC entity to lower your personal risk before entering into a lease agreement with the corporate buyer. The local attorney can also review your transaction documents to confirm they are compliant with your state’s employment and real estate laws.
A tax accountant will be needed to review the financial and tax sections of the purchase agreement, to allocate the purchase price, and to pay the taxes associated with the sale. A financial advisor is also helpful to have on hand when you receive the funds from the sale to determine where you want to move the large lump sum. Additionally, if you are considering a rollover investment with the buyer, you will want to consult with a financial advisor on those documents.
Before moving forward with the corporate acquisition process, have a team of professionals ready to help you get the best sale terms possible and minimize your risk. Set aside time to devote to the process and give some thought as to what you want to do after the sale and how a non-compete could affect your future. A little preparation and organization will go a long way as you begin the next chapter of your professional (or retired) life.
This article is the first in a four part series. Next month, we will talk about the various corporate buyers and how to determine which could be interested in your veterinary practice.
Dismantling a Practice
Veterinary Business Advisors, Inc.
Current trends in veterinarian demographics, ownership rates, and corporate consolidation have left many small practices with aging owners and no viable succession plan. As a result, the frequency of veterinary practices closures is increasing. Closing a practice is a complicated endeavor and not one that should be undertaken lightly. This article is meant to serve as an introduction to many of the complex issues surrounding closing this process—including ones related to employees, clients, medical records, insurance accounts receivable, controlled substances, equipment, inventory, and facilities—and to provide guidance on steps to take while navigating those issues.
In 2021, Dr. Robert Bogan, a 74-year-old mixed animal practice veterinarian in Faribault, MN wanted to retire. Unable to sell his practice after five years of looking, Dr. Bogan resorted to something almost unheard of: he offered to give his practice away; his clinic, equipment, pickup, and even the clinic cat Annie were all part of the deal1.
Veterinary professionals are getting older, ownership rates are dropping, and many older veterinarians are retiring with no one willing/able to buy their one to two doctor practice that falls below the $1.2 million threshold set by many corporate consolidators2. As a result, Dr. Bogan’s situation is becoming more common. Either you give your practice away or close the practice.
Fortunately, Dr. Bogan found a taker, Dr. Zach Adams, a recent graduate from nearby Iowa State University, but not everyone would be as lucky. The reality is, a larger number of veterinary practices are closing their doors, but it is not as simple as locking the doors and putting up a sign. The following is a how-to guide for closing a veterinary practice, highlighting key issues to consider and ensuring that the practice is closed legally and effectively.
Making the decision to close a veterinary practice is a difficult one. Typically, plenty of blood, sweat, and tears have been put into making the practice a success, and so to retire/walk away can come with a lot of emotion. Before deciding to close a practice, we recommend meeting with an advisor or broker to explore the sale of the practice. While there are typical benchmarks that consolidators use in purchasing decisions, they may be willing to go outside of those benchmarks if the practice holds significant strategic value for them. There is no way of identifying this without exploring the market. Plus, there are still private buyers in the market who may be specifically looking for practices that corporations aren’t interested in as a way of avoiding the high premiums that corporate buyers often pay. By finding a buyer, you can provide continued employment to your staff and provide your patients with the benefits of receiving care in a familiar place with familiar staff.
If you still have no desire to sell or are unable to sell your practice, meet with legal counsel and establish the appropriate procedures and documents needed before announcing your closure, including to your staff.
We recommend telling staff, clients, and the public that the practice is closing all within a short time frame. No matter how tight-lipped your staff, word tends to get out quickly, and it is much better for word to come with the official documentation and procedures to save you and the staff time answering repeated questions, and this also saves clients from the anxiety of being uncertain of the continued care for their animals. Notify staff first and train them on how to manage questions related to the closing of the practice. Express gratitude toward the staff for helping through the transition and offer as much support as possible in finding new employment. Once everyone is trained, announce the closing to your clients and to the public.
How to manage remaining employees depends largely on what type of employee they are, whether or not they are under contract, and whether or not you want to offer severance.
Veterinarians are often under contract, and their contracts may dictate that certain notice be given to them in advance of terminating their contracts. This may limit how quickly the clinic is able to close or it may require you to keep paying the veterinarian past the closing of the practice. Other contracts may have the veterinarian locked in for a yearlong period with the company only being able to terminate for cause. In this instance, discussing the option of severance pay to waive the remainder of the contract may be reasonable.
Veterinarians may have a non-compete in place as part of their contract even if they are an at-will employee. Typically, there is not language in these non-competes that waives them in the event of termination although some may. So, read the non-compete and interpret if the remaining veterinarians are bound by the non-compete, and then decide if the closing business wants to waive the non-compete. The non-solicitation may be more complex; if there are multiple doctors remaining and they plan to go to different practices, competition for clients and remaining employees may occur, so it is recommended to keep the non-solicitation of employees and clients in place.
Non-veterinarians in the practice may have less complex contract situations, but they are an equally important part of the dismantling process. Commonly, non-veterinarians are at-will employees without contracts. Employees without contracts are not required to receive severance pay under the Fair Labor Standards Act (FLSA)3, but it is still something the company can consider when appropriate. Severance benefits may include a salary continuation based on years of service, paying COBRA health care premiums, or providing time-off flexibility for employees to search for a new job before the closing of a practice.
Clients and Pet Medical Records
Dealing with clients and the medical records are perhaps the most important part of closing a practice. Clients may have had many pets undergo a lifetime of care, and ensuring clients are taken care of throughout the closing process is one last piece of high-quality service you can provide. The medical records of their pets are equally as important. These records will be needed to ensure continued quality care of the patients and often are surrounded by many legal guidelines that must be navigated.
First, it is important to stop accepting new clients. You can decide to stop accepting new clients before announcing your closing, but the staff and clients may catch wind of what is going on before proper documentation and procedures are in place.
In the AVMA Principles of Veterinary Ethics4, it is prohibited to abandon a patient with ongoing medical issues. Under the annotated principle 2 it states, “If there is an ongoing medical or surgical condition, the patient shall be referred to another veterinarian for diagnosis, care, and treatment. The former attending veterinarian shall continue to provide care, as needed, during the transition.”
This is an important piece in dismantling any practice. Care should be taken to identify any patients with ongoing medical issues. Attempt to complete as many as possible before closing the practice. For those that are unable to be completed, they need to be referred to a veterinarian capable of overseeing the ongoing medical issue and appropriate information pertinent to the case must be provided. This can be accomplished by ensuring the client has a complete copy of the medical record prior to the closing of the clinic, and the client has a list of local veterinarians deemed capable of managing the condition.
Certain states have specific requirements about how owners are notified of a practice closing, mainly in regard to what is done with their medical records. New Jersey offers one of the more comprehensive examples, per Title 13, Chapter 44 – 4.9 (i) of the New Jersey Administrative Code.
“Whenever a veterinary practice is to be closed due to the retirement or death of the veterinarian in charge, or the practice will be closed for more than six consecutive months, the licensee or the executor or administrator of the licensee’s estate shall:
1) Establish a procedure by which patients may obtain treatment records or agree to the transfer of those records to another licensee who is assuming the responsibilities of that practice;
2) If the practice will not be attended by another licensee, publish a notice of the cessation and the established procedure for the retrieval of records in a newspaper of general circulation in the geographic location of the licensee’s practice, at least once each month for the first three months after the cessation;
3) Notify the Board, in writing, of the impending closure and the established procedure for the retrieval of records;
4) Make reasonable efforts to directly notify the owner of any patient treated during the six months preceding the cessation of the practice to provide information concerning the established procedure for retrieval of records;
5) Conspicuously post a notice on the premises of the procedure for the retrieval of records for at least one month prior to the cessation of the practice; and
6) Arrange for the storage of any records that have not been retrieved by patient owners for one year from the date the practice closes.”
Interestingly, with section 6, New Jersey’s veterinary medical records typically have to be kept for five years since the last treatment or examination, but it appears an exception has been made for retiring or closing of a practice. If your state’s regulations don’t specify, default to the standard record retention for your state (quick reference available here).
For comparison purposes, in Pennsylvania, Title 49, Chapter 31.22 subsection 10, it states that “A veterinarian shall notify clients, in writing, at least 30 days prior to the date of a planned retirement or closing of a veterinary practice. The written notice must include instructions on how to obtain copies of veterinary medical records from the veterinarian or other custodian of the records and the name, address and telephone number of the person purchasing the practice, if applicable.” The records must then be kept for three years after the date the veterinarian retires or the practice is closed. This is consistent with the state’s law of keeping the records for three years after the patient is last seen by the veterinarian.
Most states require “written notice” to clients about the closure of a veterinary practice, so it is important to explore that definition. Under most state’s laws, “written notice” generally constitutes a letter sent to each client’s address. Emails can potentially count but only if there is a way of confirming the email has been received5. This can be accomplished through a reply (by email, letter, or in-person visit) that speaks to the content of the email. Read or delivery receipts are generally not sufficient proof. A sign posted on the premises is typically not sufficient notice, either, as it is difficult to confirm receipt by the clients.
Where to Store Records
Say you live in a state where you are required to hold your records for three to five years after closing. What are you supposed to do with those medical records all that time? Paper records can take up a lot of space and, even if you have transitioned to electronic records, who is going to sort through the record every time you get a request from the patient for the next three years? If this burden is something the practice owner is unable or unwilling to take on, there are services available that offer storage and management of medical records. Most focus on human medical records but can also manage veterinary medical records. When searching for services, be sure they offer the ability for the client to retrieve records, and that they will act as the custodian of the record, including providing appropriate confidentiality and destroying the record after the appropriate time frame. Many of the services do charge a fee to the client so, in the letter detailing the process of how they can retrieve their records, it is good practice to advise them of the fee and give them a reasonable amount of time to pick up a copy of the record from the clinic before the records are transported.
If it is decided that the practice owner, manager, or other employee shall remain the custodian of the records for the appropriate amount of time after closing, it may be possible to charge a fee to cover the time and expense associated with retrieving and/or mailing the records. Check with your state board for what fees are allowed. For example, in New Jersey, a licensee may charge a fee for reproduction of records, which shall be no greater than $1.00 per page or $100.00 for the entire record, whichever is less. If the record requested is less than ten pages, the licensee may charge up to $10.00 to cover postage and the costs associated with retrieval of the record (N.J. Admin. Code § 13:44-4.9).
Every insurance plan is different and terminating the plan may involve fees or require additional steps taken by the practice owner. It is best to contact the provider of each specific plan, discuss the situation, and individually determine how to deal with each plan.
If there is any type of health plan in place for employees, it is important that steps are taken to ensure they are prepared for when the practice’s health insurance ends. The Consolidated Omnibus Budget Reconciliation Act (COBRA) requires most group health plans to provide temporary continuation of group health plans that might otherwise be terminated 6. This commonly used option applies to all group health plans for private sector employers with at least twenty employees, but many states have similar laws in place for employers with less than twenty employees (mini-COBRA). An important feature of COBRA: the health plan must continue to exist for employees to be eligible for coverage. So, if the health plan ceases to exist once the practice closes, employees cannot get COBRA. However, if the premium has been pre-paid for a period that exists past the closing date, employees would be eligible for COBRA until the end of that period. The Department of Labor has a guide for employees regarding COBRA that details when they must enroll, benefits of the coverage, alternatives to COBRA, and more.
Another option for employees would involve searching for healthcare options available through healthcare.gov. There are several options available for unemployed individuals, and they are also eligible for a special enrollment period, meaning that they can enroll in plans outside the normal enrollment time, provided they apply within sixty days of becoming unemployed7.
What if I get sued after the business is closed?
You may be concerned about what happens if a client or employee attempts to sue you after the practice has closed for something that happened before the closing. In this scenario, what type of insurance you have is important. There are claims-made policies in which the insurer only covers claims made during the policy period. In this scenario, while normally you wouldn’t be covered for a claim made after closing, you can apply for a tail policy, meaning the insurance company would still help cover the claim.
On the other hand, in occurrence-based policies, only the date of the incidence of the claim matters. If the client is suing you for something that happened when the practice was still open, because the event occurred during the coverage period, the insurance company will still help cover the claim. For example, AVMA PLIT is generally occurrence-based.
Although notifying staff and clients of the closing and helping them through the transition can be the most emotionally challenging aspect of dismantling a practice, dealing with the leftover assets remaining in the practice can be among the most time consuming and frustrating tasks. Creating a checklist and being methodical while also possibly seeking out professional help can save time, money, and stress in the long run.
Just because the doors are closing doesn’t mean the clients’ debt is washed clean. When sending out notices of closure, it may be a good idea to include an additional note to clients with any outstanding balances. Give the clients a due date (probably the closing date of the practice) and advise what will happen if they don’t pay. A collection agency could be used post-closing to follow up with unpaid clients.
It is important to contact the U.S Drug Enforcement Administration (DEA) when deciding to close a practice. If the retiring veterinarian has an active DEA number and wishes to close it, they can do so by sending written notice to the DEA asking for deletion of their number on a certain date. If the retirement will take place shortly before the renewal date, look on the renewal form for this notation: “non-renewal due to retirement” 8. The DEA must also be contacted for guidance on how to destroy or transfer remaining controlled substances in the practice.
Equipment & Inventory
There is no shortage of companies that are looking to buy used medical equipment and unused medical inventory. Using a search engine can quickly help you locate companies that would be willing to provide a quote on your equipment and/or inventory. It is also possible that the company rep that sold you the equipment or inventory may know of a company buy-back program. Certain states do have laws regarding registration of equipment, which may impact how you can sell or dispose of the equipment. For example, in New York, all x-ray machines need to be registered with the New York State Department of Health. If you are no longer using the machine for any reason (such as selling or scrapping), you must notify the department by filling out a form on their website 9.
Your equipment may or may not also be tied to a reference lab contract. Reach out to the reference lab to determine the process for ending the contract. Like other contracts, there may be an early termination clause and/or a fee associated to end the relationship early.
If the facility is leased, examine the contract to determine reasons for which early termination of a contract can occur. If there is no provision for early termination, a buyout can often be negotiated. After negotiating, the tenant and the property owner must sign a deed of surrender to formally end the lease.
When land is owned by the practice or the practice owner through a separate entity, it may be possible to rent the facility, but veterinary clinics are highly specialized facilities, so that is an unlikely outcome. More likely, the facility can be destroyed, and the land held as a real estate investment, or it can be sold. A real estate appraiser can help you to better understand the value of the land with and without the facility and possibly advise on potential courses of action. It is also important to reach out to your state’s building commission to ensure the building and land is up to code.
Regardless of the plans for the facility, it is important to notify the utility company and postal service to discontinue service and coordinate mail forwarding, respectively.
Ancillary services like boarding or grooming may have the potential to outlast the practice. Exploring the option of keeping the boarding facility open or allowing the groomer at the practice to keep the client list and move to a new facility may help ease clients in the transition and allow certain employees to maintain a revenue stream.
Outstanding Circumstances (e.g., death)
In the unfortunate event of an owner’s death, the state that the practice is located in as well as the structure of the practice (e.g., sole proprietorship, professional corporation, etc.) play a major role in what happens next. If the practice is in a state where veterinary practices are not allowed to be run by a non-veterinarian (“a regulated state”) unless the beneficiary of the estate is also a veterinarian, the estate is most likely unable to maintain ownership and operating responsibilities of the practice. Most states do allow for a transition period that will allow the estate to continue operating the practice (if possible) while they facilitate ownership transfer to a licensed party. In New York, this time frame is six months10. The mechanics of how ownership is assumed are often spelled out in any agreement created at the formation of the entity, so it is advisable to seek counsel to help interpret the agreement and any applicable laws.
- Huppert, A. B. (2022, February 22). Rural veterinarian who offered to give away his practice gets what he wanted: A successor. kare11.com. Retrieved July 25, 2022, from https://www.kare11.com/article/news/local/land-of-10000-stories/rural-veterinarian-who-offered-to-give-away-his-practice-gets-what-he-wanted-a-successor-blue-earth/89-2b4d7995-1b3f-47b9-a8a0-9d746ea0c502
- Nolen, S. (2018, November 14). The corporatization of veterinary medicine. American Veterinary Medical Association. Retrieved July 25, 2022, from https://www.avma.org/javma-news/2018-12-01/corporatization-veterinary-medicine
- Severance Pay | U.S. Department of Labor. (2019). Dol.gov. https://www.dol.gov/general/topic/wages/severancepay
- Principles of veterinary medical ethics of the AVMA. (2019). American Veterinary Medical Association. https://www.avma.org/resources-tools/avma-policies/principles-veterinary-medical-ethics-avma
- Can an Email serve as “Written Notice?” (2015, June 3). Martin|Hild, P.A. Can an Email serve as “Written Notice?” (2015, June 3). Martin|Hild, P.A. https://www.martinhild.com/can-an-email-serve-as-ldquowritten-noticerdquo.html
- (2020, September). An employees guide to benefits under COBRA. Department of Labor. https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-activities/resource-center/publications/an-employees-guide-to-health-benefits-under-cobra.pdf
- Get Marketplace health coverage outside Open Enrollment only with a Special Enrollment Period. (n.d.). HealthCare.gov. Retrieved July 25, 2022, from https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period
- Butcher, T. (2016, November 23). Closing a Medical Practice, Part 1. Total Health Law Blog. https://www.totalhealthlaw.com/closing-practice-part-1/
- Damiani, A. (2022). Disposition of X-Ray Equipment. NY Department of Health. https://www.health.ny.gov/forms/doh-2126.pdf
- Death of a Veterinarian: Implications of the Veterinary Practice. (2016). New York State Veterinary Medical Society. https://cdn.ymaws.com/www.nysvms.org/resource/collection/E45CA734-8B73-4255-B861-5BED0FCBBAC9/deathofveterinarian.pdf
Guide to Implementing Veterinary Telemedicine:
How to Create Seamless Virtual Experiences for Pet Owners
Veterinary Business Advisors, Inc.
In the face of the COVID-19 outbreak and the associated social distancing, there is a rapidly increasing demand for digital transformation to bridge service gaps. In both human and animal health care, telehealth has become a gold-standard solution to optimize the delivery of medical care to patients. This paper will discuss the impact COVID-19 has had on veterinary medicine, the current telehealth market, and the distinctions between telehealth and telemedicine. A step-by-step guide to implementing a telemedicine service into the clinical workflow is provided to help veterinary teams offer their clients a seamless virtual experience and improve patient outcomes.
Keywords: COVID-19, animal health, technology, telehealth, telemedicine, veterinarian-client-patient relationship, implementation, clinical workflow
Humans and animals are closer than ever. This is especially relevant in today’s social climate where the entire world is dealing with the impact of COVID-19. Fortunately, the pet care industry has been recession-proof since the Great Recession and it’s been proven that this pandemic is no exception.1 According to Morgan Stanley Research, it is expected that pet ownership will increase by 14%, and annual household spending per pet will nearly double by 2030. Unsurprisingly, the most rapidly growing subsegment of such expenditures is veterinary care.2 As medical knowledge advances, so do the technological developments in delivering animal healthcare.
The unique aspect of a pandemic that’s not shared by other substantial economic events like terrorist attacks, natural disasters, and financial crises is the inevitability of prolonged social isolation, hindering pet owners from visiting veterinary hospitals. Luckily, however, there was an excellent solution to overcome this issue that had been underused for many years before COVID-19 hit the U.S.—telehealth. Data from the ASPCA Pet Health Insurance programs shows a nearly 380% increase in submitted claims for telehealth services in one year, from March 2020 to February 2021, compared to the same time frame in the prior year.3 While no one knows what the future holds, it is evident that telehealth can continue to grow as long as there is a public need for remote access to veterinary care.
What is Telemedicine?
The American Veterinary Medical Association (AVMA) defines telemedicine as “the use of medical information exchanged from one site to another via electronic communications regarding a patient’s clinical health status.” This is a subset of telehealth, an umbrella term encompassing all means of remote exchange of health-related information using technologies. According to the AVMA, telehealth includes, but is not limited to, telemedicine, teleconsulting, teletriage, teleadvice, telesupervision, telecommunication, telemonitoring, electronic prescribing, and mobile health. Telehealth does not always involve patients directly. For example, teleconsulting is a tool used by general practitioners to virtually gain insights and advice from specialists to ensure appropriate care for their patients.5
In human healthcare, the application of telehealth and telemedicine have been prevalent for decades, which is much longer than in veterinary medicine. However, when telemedicine was introduced, it was used on a non-human animal. Before Yuri Gagarin became the first human ever to travel into space during the Space Race, the U.S. and the Soviet Union had to answer whether the absence of gravity would impede cardiovascular and pulmonary functions. They launched multiple test flights with animals attached to medical monitoring systems that were capable of telemetering biometric data to Earth to answer this question.4
The AVMA’s policy on telemedicine states that “veterinary telemedicine should only be conducted within an existing Veterinarian-Client-Patient Relationship (VCPR), with the exception for advice given in an emergency until that patient can be seen by a veterinarian.” Veterinarians are not allowed to diagnose, prescribe medication for, or treat an animal without an established VCPR under most state laws and Principles of Veterinary Medical Ethics by the AVMA.6 Veterinarians are, however, still allowed to engage in teletriage, which is the assessment of urgency to determine the need for immediate referral to a veterinarian, and tele-advice, which is the provision of guidance and recommendations not specific to the patient, both of which must be performed without rendering a diagnosis, prognosis, or treatment.5,7 Establishing a VCPR for each case is extremely important, especially since pets cannot verbally convey their medical issues to veterinarians. A physical examination is an essential step in understanding the patient’s condition.
In the U.S., the following conditions must be satisfied to establish a VCPR:7
- The veterinarian has assumed responsibility for making clinical judgments regarding the patient’s health, and the client has agreed to follow the veterinarians’ instructions.
- The veterinarian has sufficient knowledge of the patient to initiate a general or preliminary diagnosis of the patient’s medical condition. This means the veterinarian is personally acquainted with the keeping and care of the patient through a timely examination of the patient by the veterinarian or medically appropriate and timely visits by the veterinarian to the place where the patient’s care is managed.
- The veterinarian is readily available for follow-up evaluation or has arranged for veterinary emergency coverage and continuing care and treatment.
- The veterinarian provides oversight of treatment, compliance, and outcome.
- Patient records are maintained.
In addition, according to the U.S. Food & Drug Administration (FDA), “the federal VCPR definition cannot be met solely through telemedicine.” However, given the current situation, the FDA has suspended some of the regulations amid the COVID-19 outbreak. Veterinarians now do not require a VCPR for prescription of extra-label drugs and issuance of Veterinary Feed Directives as of January, 2022.6,8
Veterinary Telemedicine Market
According to Grand View Research, the veterinary telehealth market was valued at $119.6 million in 2021, globally. Among different telehealth types, teleconsulting held the majority of the revenue share of 29.1 % due to more general practitioners seeking consultations from the specialists, followed by telemedicine, which still accounted for more than 25% of the share. These services have successfully reduced the burdens on veterinarians, and the initiatives to promote virtual care pushed by industry players, including telehealth service providers, are expected to keep driving this trend forward. Thirty-seven percent of global revenue came from North America in 2021. This can be attributed to factors that include long-tail investment in the animal health care industry driven by retailers with scale and the burgeoning pet insurance industry in the region. The veterinary telehealth market is anticipated to expand at a compound annual growth rate of 16.8% in the U.S. and 17.6% globally from 2022 to 2030. 2,9
There are many key industry players around the world today contributing to this rapid growth in the veterinary telehealth market. They strategically collaborate with major animal health companies, corporate consolidators, and university hospitals to develop new products and services and scale their businesses. For example, Zoetis, the largest global animal health care company (that used to be a subsidiary of Pfizer), has partnered with Airvet, one of the major telehealth service providers, to promote two free months of service amid the COVID-19 pandemic.9,10 Furthermore, Televet, another primary telehealth service provider, partnered with Cornell University’s veterinary teaching hospital, Hospital for Animals, to deploy its first virtual care platform for its veterinary telehealth operations. These collaborations effectively extended the service providers’ market growth.9,11 Other market-leading veterinary telehealth service companies include PetDesk, FirstVet, Petriage, BarbelBark, and PawSquad, among others.9
The AVMA introduces different service models for telemedicine, indicating it is customizable and should be used to fulfill the specific needs of each practice to uniquely augment its clinical services. Once a VCPR is established, telemedicine can be utilized to facilitate care delivery in various ways.12
- General consultation: It has been common practice for veterinarians to give their clients general advice via a quick phone call, email, or text, free of charge. By utilizing telemedicine and systemizing such a process, they can get adequately compensated for providing the same service. Telemedicine will become a whole new revenue stream and even become an opportunity to attract new clients willing to pay extra money for convenience.
- Urgent care: Not every veterinary practice has an emergency service while every animal has the potential to become critically ill after hours. In such an urgency, 24/7 access to veterinary care would mean the world for the owner. Implementing telemedicine would enable every practice to have a system to address this issue and fulfill client expectations and patient needs while also allowing veterinarians to manage their work-life balance.
- Post-surgical recovery: Veterinarians usually just need to hope for the best when it comes to post-surgical care. However, telemedicine can enhance continuity of care by allowing access to the patients’ health status after they leave the hospital. Not only does telemedicine allow veterinarians to monitor patients to ensure seamless recovery after surgery remotely, but it also enables them to support their owners through the process and improve client compliance.
- Palliative care: Telemedicine can also aid in optimizing the quality of life of senior patients with already deteriorating health. When it comes to palliative or hospice care, there are times in which clients forsake a veterinary visit due to the additional stress that the veterinary environment may cause. This is especially the case for feline patients. Veterinarians can evaluate those patients’ conditions remotely through telemedicine and guide any change in treatment plans and whether an in-person visit would be necessary.
It may be surprising to some veterinarians to hear that they may have already been utilizing telemedicine unknowingly. Many tend to think that telemedicine always needs to involve a video component that allows for virtual face-to-face interaction; however, if they are engaging in any of the above services remotely, they are providing telemedicine. Again, telemedicine is any virtual clinical service given after VCPR has been established. Therefore, not only video- but also telephone-, text-, and email-based communication with existing clients regarding their pets’ health can be considered telemedicine. It is up to the practitioners how extensive those technologies should be integrated into their workflow.12
Since email, phone calls, and texts are already used widely to provide telemedicine and are much more straightforward when it comes to implementation, the focus in this section will be on video chat.
Here are the nine steps in implementing telemedicine into clinical workflow:13,14
- Understand the rules
Before formulating an implementation plan, it is essential to know how a VCPR can be established and to differentiate telemedicine from the other types of telehealth services, as explained earlier. In addition, there are mainly two crucial licensure considerations about telemedicine and the VCPR that have not been discussed. Those considerations are as follows:9
- When conducting telemedicine across state lines, the veterinarian must be licensed and legally authorized to practice in both states.
- While telemedicine for specialty consultation does not require the specialist to have a VCPR if s/he is working with the patient through the consultee who has established a VCPR, if the specialist starts treating the same patient independently, a separate VCPR and a license to practice in the patient’s state become mandatory.
It is also essential to review the state-specific requirements, especially regarding the veterinary practice act, pharmacy act, patient confidentiality, and record retention. Failure to follow these regulations can result in disciplinary proceedings, which involve steps that include a hearing with a board subcommittee dedicated to veterinary liability and the corresponding punishment if the veterinarian is criminally liable. In severe cases, these proceedings can lead to license restrictions and even revocation.15
- Identify needs
The first step in planning is identifying what can be addressed and improved by implementing a telemedicine program and by prioritizing issues that align with the team’s strategic goals. Problems that need to be addressed can include revenue loss, disruption in continuity of care, low compliance, veterinarian shortages, and socioeconomic barriers to in-person visits. It may be helpful to look for practices that are similar in size and client demographic—and have executed the implementation—and seek out their help. It would be beneficial to ask earlier adopters about what problems they could overcome by incorporating telemedicine and their challenges throughout the process. It is also a good idea to start considering the cost of implementation and an anticipated return on investment at this point. This will help justify the project and incentivize the team to move forward with the plan.14
- Define success
Once the issues are prioritized and the needs are identified, it is time to set specific short- and long-term goals. These goals should have measurable metrics that will guide the process and help the team track the progress. The metrics will also become helpful in the post-implementation phase when the team is ready to evaluate the success of the telemedicine program. Examples of the metrics include improved client experience, increased access for patients, and reduced no-show rates.14
Here is an example of steps taken when defining success:14
- List solutions the program can bring to the patients, clients, and practice.
- Reevaluate limitations from financial, legal, and operational standpoints.
- Identify three to five of the most important goals for the practice that dovetail with the anticipated solutions.
- Decide on success metrics that are most appropriate for assessing progress.
- Establish specific checkpoints to collect data and track progress.
Document each step of the process along the way and define baseline metrics in each success metric before implementing the telemedicine program. This will later help the team to demonstrate how the program has contributed to its long-term goals and evaluate how genuinely impactful it is from a big-picture perspective.14
- Check the liability
While implementing a telemedicine service usually does not require additional liability coverage, it is still worthwhile to double-check for any additional recommendations.13
- Evaluate options
Depending on what telemedicine service is being used, there are unique hardware, software, and back-office support requirements. Therefore, choosing the right service type to fulfill the specific needs becomes essential in achieving durable solutions. There are mainly two options:
- Using a common application: Application software like Zoom, Skype, and Microsoft Teams have become prevalent in everyday life amid the COVID-19 outbreak. Some veterinarians may feel more comfortable using familiar technologies that they have been using for communication with their family members and friends. They are accessible for the practice to implement and straightforward when it comes to client education. However, since they were not originally developed as telemedicine tools, they often lack additional functionalities that are provided by telemedicine-specific applications, such as the ability to be integrated into practice management software with secure messaging.13
- Outsourcing a telemedicine service: There are many third-party partners specializing in veterinary telemedicine as mentioned earlier. The use of vendor resources can simplify and expedite the implementation process. However, it is critical to perform thorough due diligence and know exactly what they are offering as not every service is compatible with every practice. Understanding their business model, and their ability to integrate with the information technology landscape of the practice, usability, and level of support available through customer service is the key. These are some ways to evaluate a vendor to determine if they are worthy of a long-term relationship:13
- Ask for word-of-mouth referrals from experienced practices early on and research third-party reviews.
- Discuss any value-added services, such as staff training and client engagement management.
- Ask for case studies and referrals and schedule live demos.
- Discuss how vendor resources and infrastructure can provide scaling support within an expected timeframe.
- Design the workflow
After deciding on what type of telemedicine service to implement, it is time to consider how to incorporate telehealth appointments with the least amount of workflow disruption. This is important in the seamless introduction of the new technology into the practice. This is when a clear understanding of the capacity of each team member—both clinical and non-clinical—is important to identify any barriers the team might encounter once the program is rolled out. Plus, here are some of the technological and workspace needs to consider:14,16
- Location within the practice dedicated to telemedicine services that can provide privacy to avoid distraction and background noise and has adequate lighting for quality communication with clients
- Equipment that provides the foundation for a high-quality consultation and allows for projection of a professional demeanor to clients
Appropriately furnishing and focusing on the space’s appearance is important when setting up the location to convey a professional atmosphere. If partnering with a vendor, ask about any additional equipment needed to support the service fully. Also, keep in mind that, while modern equipment with high-resolution audio and excellent video capability is preferable, it is also essential to consider how comfortable each team member is with novel technologies. 16
Visualizing workflow with the team is extremely important to streamline the process as much as possible. The workflow should be practice-specific, and every team needs to set clear expectations to avoid missteps. Some critical factors to keep in mind pre-, intra-, and post-visit are as follows:14
- Before appointments:
- Educating clients on the type of services being offered and proper appointment standards
- Identification of appropriate clinical use cases and triage questions to ask clients during an appointment scheduling, including pet insurance coverage
- Determining when telemedicine appointments will fit in the schedule and updating the calendar
- During appointments:
- Communicating with clients on how to involve patients throughout the process, depending on the clinical area and service model
- Supporting troubleshooting on both ends in case of technological difficulties
- Integration of other technologies like AI-assisted diagnostics
- After appointments:
- Referring clients to specialists (in the case of general practices) or advising them to take their pets to emergency services
- Understanding what codes are available for telemedicine visits
- Train the team
Once the workflow is determined, the next step is to provide technical training on the telemedicine platform, new workflow, triage protocols, and patient education materials. It is essential to keep in mind the existing responsibilities of each team member.14
- Consider developing a script for the team to use during client communication, especially when setting up an appointment. It would be helpful if every team member used the same professional language.
- Discuss any available training material with the vendor and ask them if they would offer any training sessions for the team.
- Formulate a standardized process for onboarding new staff in the event of turnover.
- Conduct internal test visits and demonstrate how it is supposed to be done before officially launching the program; this will also be an opportunity to identify any problems and friction in the workflow.
- Engage clients
Now it is time to create marketing materials to advertise and promote the new services to existing clients and potential clients in the area. There may be pet owners, for example, who are not visiting a practice because of long distances involved. A telemedicine program will undoubtedly help the practice attract those clients and give it an edge over competitors around the area.14
Marketing methods include in-hospital displays, email messaging, displays on the practice website or patient portal, and social media promotions. It is also good to advertise the service in person during appointments. Again, implementation is only successful when clients know what the service entails and are incentivized to utilize it. Showcasing the benefits of telemedicine, such as increased access to care and reduced cost, is a must.13,14
It is finally time to put the workflow to the test. Once a telemedicine visit is scheduled, the clients need to be educated about the process. This should be made as straightforward as possible since not every client is fluent in technology. Walk the clients through downloading the application, the check-in process, and the payment and billing process. If possible, create online guidelines with links included.14
Consider technology access and savviness. If a client does not have the technology needed to conduct a telemedicine visit, make sure to identify community-based resources and places where they might have access, such as schools and internet cafes, so they would be able to facilitate the visit. For those clients who have a more challenging time adjusting to the new service, have the team host a brief training session to help them prepare.13,14
It would also benefit the team to get feedback from the clients, especially during the first few months. If there are any issues or complaints, make sure to address them and adjust the process, as necessary. Ensure that the success metrics set during the Define Success step are being tracked so the team can evaluate success later.14
Determining the pricing model is not one-size-fits-all. To set yours, understand how the telemedicine service fits your overall workflow and the needs and interests of the clients and the practice. Ultimately, the goal is to develop a strategy specific to the practice. However, there is no need to decide on only one pricing model. You could offer multiple models, for example, to let clients decide how they want to pay. Consider how much in-person consultation would be taken away by implementing telemedicine services, whether clients would be willing to pay more for telemedicine visits than in-person visits, and whether sequential in-person visits after a telemedicine visit should be bundled.17
Here are pricing models to consider as suggested by the AVMA:17
- Pay-per-use/time: This model is for practices that consider telemedicine visits as a separate service. It may be beneficial to use this model if the practice plans to incorporate telemedicine visits for after-hours and emergencies. This is most flexible for clients and should be offered along with other plans.
- Bundled pricing: This allows for bundling a telemedicine visit with existing plans the practice already offers, such as wellness and senior plans, as a value-added service.
- Subscription pricing: If the team is dedicated enough to implementing telemedicine as an integral part of the practice, this model is a great option.
If the practice is partnering with a vendor, it is important to understand how the vendor structures the service fee in detail. In these situations, the vendor will take a percentage of the revenue earned from conducting a telemedicine visit, so know how much of the consultation fee the practice keeps and set up a pricing plan for clients accordingly. The fee arrangement with the vendor also needs to comply with state-specific laws on fee-splitting and kickbacks. Moreover, it would be good to find out how the pet insurance companies recommended by the practice are handling fees associated with virtual care.17
Veterinary telehealth and telemedicine are here to stay. COVID-19 has permanently changed the social landscape, and new digital solutions are being developed to cope with the new reality. The public has already started adapting to a much more technology-driven work culture, and there is no going back—and animal health care is no exception. With the increasing number of pets and stronger human-animal bonds, lawmakers and industry leaders recognize the strong need for reforming regulations and systems around pet care to adapt to its changing landscape. Not only is the pet care sector experiencing a significant surge in market value, but it is also affecting veterinary medicine, including the telehealth industry. Many believe telehealth and other innovative digital solutions will become indispensable in optimizing care delivery to our beloved companions. Some even think that veterinary telehealth will establish itself as its own pillar and be recognized as an individual discipline. Whether desired or not, veterinarians need to gear themselves toward the “new normal” by understanding what resources and infrastructures are required to successfully implement virtual care into the clinical workflow.
- Seidman, A. (2020, April 16). Coronavirus is a new challenge for the ‘recession-proof’ pet industry. https://www.inquirer.com. Retrieved January 15, 2022, from https://www.inquirer.com/economy/coronavirus-recession-pet-industry-20200415.html
- Pets: A long-tail investment trend? Morgan Stanley. (n.d.). Retrieved January 15, 2022, from https://www.morganstanley.com/ideas/us-pets-investing-trend
- Crum & Forster Pet Insurance Group. (2021, July 27). The ASPCA® Pet Health Insurance Program’s data shows increased telemedicine usage. The ASPCA® Pet Health Insurance Program’s Data Shows Increased Telemedicine Usage. Retrieved January 15, 2022, from https://www.prnewswire.com/news-releases/the-aspca-pet-health-insurance-programs-data-shows-increased-telemedicine-usage-301342421.html
- Baldwin, C. (2020, March 27). A brief history of NASA’s contributions to telemedicine. NASA. Retrieved January 16, 2022, from https://www.nasa.gov/content/a-brief-history-of-nasa-s-contributions-to-telemedicine/
- Veterinary telehealth: The basics. American Veterinary Medical Association. (n.d.). Retrieved January 15, 2022, from https://www.avma.org/resources-tools/practice-management/telehealth-telemedicine-veterinary-practice/veterinary-telehealth-basics
- Telemedicine. American Veterinary Medical Association. (n.d.). Retrieved January 18, 2022, from https://www.avma.org/resources-tools/avma-policies/telemedicine
- Telehealth and the VCPR. American Veterinary Medical Association. (n.d.). Retrieved January 18, 2022, from https://www.avma.org/resources-tools/practice-management/telehealth-telemedicine-veterinary-practice/telehealth-and-vcpr
- Medicine, C. for V. (n.d.). CVM guidance for Industry #269. U.S. Food and Drug Administration. Retrieved January 22, 2022, from https://www.fda.gov/regulatory-information/search-fda-guidance-documents/cvm-gfi-269-enforcement-policy-regarding-federal-vcpr-requirements-facilitate-veterinary
- Veterinary telehealth market size report, 2022-2030. Veterinary Telehealth Market Size Report, 2022-2030. (n.d.). Retrieved January 22, 2022, from https://www.grandviewresearch.com/industry-analysis/veterinary-telehealth-market
- (n.d.). Retrieved January 22, 2022, from https://www2.zoetisus.com/species/equine/covid-19
- CUHA telemedicine information. Cornell University College of Veterinary Medicine. (2021, March 22). Retrieved January 23, 2022, from https://www.vet.cornell.edu/hospitals/clients/cuha-telemedicine-information
- Service models for veterinary telemedicine. American Veterinary Medical Association. (n.d.). Retrieved January 23, 2022, https://www.avma.org/resources-tools/practice-management/telehealth-telemedicine-veterinary-practice/service-models-veterinary-telemedicine
- Steps to implement telemedicine services in your practice. American Veterinary Medical Association. (n.d.). Retrieved January 24, 2022, https://www.avma.org/resources-tools/animal-health-and-welfare/telehealth-telemedicine-veterinary-practice/steps-implement-telemedicine-services-your-practice
- AMA Telehealth Implementation Playbook. (n.d.). Retrieved January 25, 2022, from https://www.ama-assn.org/system/files/2020-04/ama-telehealth-implementation-playbook.pdf
- , A. R., & McGee. (1970, January 1). Full title name: overview of veterinary client issues. Animal Law Legal Center. Retrieved January 25, 2022, from https://www.animallaw.info/article/overview-veterinary-client-issues
- Technology and workplace needs in telemedicine. American Veterinary Medical Association. (n.d.). Retrieved January 26, 2022, https://www.avma.org/resources-tools/practice-management/technology-and-workspace-needs?check_logged_in=1
- Pricing Models for Veterinary Telemedicine. American Veterinary Medical Association. (n.d.). Retrieved January 27, 2022, https://www.avma.org/pricing-models-veterinary-telemedicine?check_logged_in=1