Implementing Veterinary Telemedicine

Abstract

In face of COVID-19 outbreak, there is a rapidly increasing demand for digital transformation to bridge that gap on social distancing. In both human and animal health care, telehealth has become a gold-standard solution to optimize delivery of medical care to patients. In this paper, the impact COVID-19 has had on veterinary medicine, the current telehealth market, and distinctions between telehealth and telemedicine will be discussed. A step-by-step guide to implementing a telemedicine service into the clinical workflow is also provided through this paper to help veterinary teams provide their clients with seamless virtual experience and improve patient outcomes.

Introduction

Humans and animals are closer than ever. This is, especially relevant in today’s social climate where the entire world is worried that the effect of COVID-19 would mar our future prospects. Fortunately, the pet care industry has been known to be recession proof since the Great Recession and 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 spending is veterinary care.2 In addition to advances in medical knowledge, technological development in animal healthcare, such as, use of artificial intelligence (AI) in interpretation of diagnostic data and emergence of Internet of Things (IoT), contributed to such a growth trend.

The unique aspect of a pandemic not shared by other substantial economic events like terrorist attacks, natural disasters, and financial crises is the inevitability of prolonged social isolation, hindered pet owners from visiting veterinary hospitals. Luckily, however, there was a perfect solution to overcome this issue that had been overlooked for many years prior to COVID-19 hitting the U.S.—telehealth. Data from the ASPCA Pet Health Insurance programs shows that there was a nearly 380% increase in submitted claims for telehealth services in a one-year period, 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 will continue to grow as long as there is the public need for remote access to veterinary care.

Veterinary Telehealth

What is Telemedicine?

In human healthcare, common application of telehealth and telemedicine have been prevalent for decades, much longer than that in veterinary medicine. However, in fact, when telemedicine was introduced for the first time, it was used on a non-human animal. During the Space Race, prior to Yuri Gagarin becoming the first human ever to travel into space, one of the most important question the U.S. and the Soviet Union had to answer was whether the absence of gravity would impede cardiovascular and pulmonary functions. To solve this problem, they launched multiple test flights with animals attached to medical monitoring systems, which were capable of telemetering biometric data to Earth.4

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.” There is a distinct difference from telehealth, which is an umbrella term that encompasses all means of technology use for remote exchange of health-related information. 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

Veterinarian-Client-Patient Relationship

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 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 engage in teletriage, assessment of urgency to determine the need for immediate referral to a veterinarian, and teleadvice, provision of guidance and recommendations that are not specific to the patient, both of which must be performed without rendering diagnosis, prognosis, or treatment.5,7 Establishment of a VCPR for each case is extremely important, especially since pets are incapable of verbally conveying their medical issues to veterinarians, making a physical examination 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 health of the patient, and the client has agreed to follow the veterinarians’ instructions.
  • The veterinarian has sufficient knowledge of the patient to initiate at least 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 by virtue of a timely examination of the patient by the veterinarian, or medically appropriate and timely visits by the veterinarian to the operation where the patient is managed.
  • The veterinarian is readily available for follow-up evaluation or has arranged for the following: 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.” Given the current situation, however, FDA has suspended enforcement of some of the regulations amid COVID-19 outbreak. Veterinarians now do not require a VCPR for prescription of extra-label drug and issuance of Veterinary Feed Directives as of January, 2022.6,8

Veterinary Telemedicine Market

According to the Grand View Research, the veterinary telehealth market size was valued at $119.6 million in 2021 globally. Among different telehealth types, teleconsulting held the majority of revenue share of 29.1 %, as more general practitioners seek consultations from the specialists, followed by telemedicine, which still accounted for more than 25% of the share. These services have successfully been reducing 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. 37% of global revenue came from North America in 2021, and this can be attributed to factors including 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 size 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 that are contributing to this rapid growth in the veterinary telehealth market. They are strategically collaborating with major animal health companies as well as corporate consolidators of veterinary practices 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 major telehealth service provider, partner with Cornell University’s veterinary teaching hospital, Hospital for Animals, to deploy its first virtual care platform for the university’s 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, PawSquad, and more.9

Implementing Telemedicine

Service Models

The AVMA introduces different service models for telemedicine, indicating it is customizable and should be used to fulfill 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 a variety of 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 for free of charge. By utilizing telemedicine and systemizing such a process, they can start getting compensated properly for providing the same service. Telemedicine will become a whole new revenue stream and even become an opportunity to attract new clients who are willing to pay extra money for convenience.
  • Urgent care: Not every veterinary practice has an emergency service while every animal has a 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 in place 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, use of 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 remotely monitor patients to ensure seamless recovery after surgery, but it also enables them to support their owners through the process and improve client compliance.
  • Palliative care: Telemedicine can also aid in optimizing 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 may be caused by the veterinary environment. This is especially the case for feline patients. Veterinarians can evaluate those patients’ condition remotely through telemedicine and provide guidance as to any change in treatment plans and/or 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, the definition of telemedicine is any virtual clinical services given VCPR has been established. Therefore, not only video- but also telephone-, text-, email-based communication with existing clients regarding their pets’ health can be considered telemedicine. It is up to the practitioners how extensively those technologies should be integrated into their workflow.12

Step-by-Step Guide

Since email, phone calls, and texts are already used widely as means of providing telemedicine and much more straightforward when it comes to implementation, the focus in this section will be on video chat.

Here are the 9 steps in implementing telemedicine into clinical workflow:13,14

  1. Understand the rules

Before even formulating a plan for implementation, it is essential to know how a VCPR can be established and be able to differentiate telemedicine from the other types of telehealth services as explained earlier. In addition, there are mainly two important licensure considerations pertaining to telemedicine and the VCPR that have not been discussed. Those considerations are as follows:9

  • When conducting telemedicine across state line, the veterinarian needs be licensed and legally authorized to practice in both states.
  • While use of telemedicine for specialty consultation does not require the specialist to have a VCPR as long as s/he is working with the patient through the consultee who has established a VCPR. However, 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 important to review the state-specific requirements, especially regarding veterinary practice act, pharmacy act, patient confidentiality, and record retention. Failure to follow these regulations can result in disciplinary proceedings, which involve steps including hearing with a board subcommittee dedicated to issues of veterinary liability and punishment to determine if the veterinarian is criminally liable. In severe cases, these proceedings can lead to license revocation or restrictions.1

  1. Identify needs

First step in an implementation planning is to identify what can be addressed and improved by implementing a telemedicine program by prioritizing issues that align with the strategic goals of the team. These issues 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 were able to overcome by incorporating telemedicine and what challenges they encountered throughout the process. It is also a good idea to start considering the cost of implementation and an anticipated return on investment. This will help justify the project and incentivize the team thereafter to move forward with the plan.14

  1. 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 success of the telemedicine program. Examples of the metrics are improved client experience, increased access for patients, and reduced no-show rates just to mention a few.14

Here is an example of some steps take 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 3–5 goals that are most important for the practice and feasible with the anticipated solutions.
  • Decide on success metrics that are most appropriate for assessing progress.
  • Establish specific checkpoints to collect data and track progress.

As much as it is important to document the progress along the way, defining the baseline in each success metric is essential before implementing the telemedicine program. This will later help the team demonstrate how the program has specifically contributed to its long-term goals and evaluate how truly impactful the program is from a big-picture perspective.14

  1. Check the liability

While implementing a telemedicine service usually does not require an additional liability coverage, it is still worthwhile to double check for any additional recommendations.13

AVMA PLIT, the leading professional liability insurance in the veterinary industry, does not have any additional requirement as of January 2021.13,16

  1. Evaluate options

Depending on what telemedicine service is being use, there are unique requirements pertaining to hardware, software, and back-office support. Therefore, choosing the right service type that would 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 COVID-19 outbreak. Some veterinarians may feel more comfortable using those familiar technologies that they use to communicate with their family members and friends. They are not only easy for the practice to implement but also 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 ability to be integrated into practice management software and secure messaging.13
  • Outsourcing a telemedicine service: There are many third-party partners that are specializing in veterinary telemedicine as mentioned earlier. 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, 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 of the 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.
  1. Design the workflow

After deciding on what type of telemedicine service to implement, it is time to start considering how to incorporate telehealth appointments with the least amount of workflow disruption. This is important in seamless introduction of the new technology into the practice. This is when clear understanding of the capacity each team member—both clinical and non-clinical—has and any barriers the team might encounter once the program is rolled out. Here are some of the technological and workspace needs to consider:14,17

  • Location in the practice dedicated for telemedicine services that provides 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

Furnishing and overall appearance are also important when setting up the location to convey a professional atmosphere. If partnering with a vendor, make sure to ask for any additional equipment needed to fully support the service. Also keep in mind that, while use of modern equipment with high-resolution audio and excellent video capability is preferable, it is also important to consider how comfortable each team member is with novel technologies. 17

Visualizing workflow with the team is extremely important to streamline the process as much as possible. The workflow should be practice specific, but it is essential for every team to set clear expectations to avoid missteps. Some important 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 case for general practices) or advising them to take their pets to emergency services
  • Understanding what codes are available for telemedicine visits
  1. 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 for when setting up an appointment, as it would be more helpful if every team member uses the same professional language.
  • Discuss with the vendor any available training material and ask them if they would offer any training session 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.
  1. Engage clients

Now it is time to create marketing materials to advertise and promote the new services not only to existing clients but also to potential clients in the area. There may be pet owners who are not visiting the practice only due to long distance. Having a telemedicine program will certainly help the practice attract those clients and give the practice an edge over competitors around the area.14

Marketing method include in-hospital displays, email, displays on the practice website or patient portal, and social media promotions. It is also a good idea to advertise the service in person at the time of appointments with the existing clients. Again, implementation is only successful when clients are aware of the 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

  1. Launch

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 as not every client is fluent in technology. Walk the clients through how to download the application, the check-in process, and the payment and billing process. If possible, create online guidelines with links to provide.14

Consider technology access and savviness. If a client does not have the technology need to conduct a telemedicine visit, make sure to identify community-based resources and places they would be able to take advantage of, such as schools and internet cafe, so they would be able to facilitate the visit. For those clients who have harder time adjusting to the new service, have the team host a brief training session to help them prepare.13,14

It would also be beneficial for the team to get satisfaction feedbacks from the clients, especially during the first few months from the launching. If there are any issues or complaints, make sure to address them and adjust the process as necessary. Make sure that the success metrics set during the Define Success step are being tracked so that the team can evaluate success later.14

Pricing

Determining the pricing model is not one-size-fits-all. Understand how the telemedicine service fits the overall workflow as well as the needs and interest of the clients and the practice. Ultimately, the goal is to develop a strategy unique to the practice. However, there is no need to decide on one specific pricing model. Offering multiple models to let clients decide how they want to pay is one of the methods. Other considerations include in-person consultation time that will be taken away by implementing telemedicine services, whether clients would be willing to pay more for telemedicine visits, comparted to in-person visits, and whether sequential in-person visit after a telemedicine visit should be bundled.18

Here are some pricing models to consider as suggested by the AVMA:18

  • Pay-per use/time: This model is for practices that consider telemedicine visits as a separate service. It may be beneficial to use this plan if the practice is planning on incorporating telemedicine visits after-hours and/or for emergency. This is most flexible for clients and should be offered along with other plans.
  • Bundled pricing: This allows for budling a telemedicine visit with existing plans the practice already offers, such as wellness plan, as value-added service.
  • Subscription pricing: If there is a team dedicated enough to implement 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 service fee is structured by the vendor in detail. In this case, a percentage of the revenue earned from conducting a telemedicine visit is taken by the vendor. Make sure to know how much of the consultation fee the practice gets to retain 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 a good idea to find out how the pet insurance companies recommended by the practice are handling fees associated with virtual care.1

Conclusion

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 a much more technology-driven work culture, and there is no going back—animal health care is no exception. With increasing number of pets and stronger human-animal bond, the lawmakers and industry leaders are recognizing the strong need for reforming regulations and systems around pet care to adapt to its constantly changing landscape. Not only is the pet care sector experiencing a significant surge in market value, but it is also feeding into the veterinary medicine, including telehealth industry. Many believe telehealth along with other innovative digital solutions are indispensable in optimizing the delivery of care to our beloved companions. Some even think that veterinary telehealth will establish as its own pillar and be recognized as an individual discipline. Veterinarians, whether desired or not, need to gear themselves toward what is called “new normal” by understanding what resources and infrastructures needed to successfully implement virtual care into the clinical workflow.

 

References

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  13. 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
  14. 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
  15. , 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
  16. AVMA PLIT Professional Liability for Veterinarians. AVMA PLIT Professional Liability for Veterinarians | AVMA PLIT. (n.d.). Retrieved January 25, 2022, from https://www.avmaplit.com/products/primary-professional-liability/
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