The VCPR and Telemedicine

Introduction

Today’s consumers, especially those from—or younger than­—the Millennial generation, want the convenience of fast, easily accessible information and they have the same high expectations when it comes to the delivery of health care. Telemedicine is an innovation that has the potential to meet these needs in both human and animal health care, and COVID-19 has brought this medical delivery format to the forefront. Unfortunately, challenges still exist in the United States, both in telemedicine usage and acceptance, with laws not yet meshing with today’s reality.

The Human-Animal Bond

The human-animal bond can be a mutually beneficial relationship, influenced by several behaviors that are vital to the health and well-being of both the owner and pet. The role of veterinarians is to augment the potential of this connection between people and animals by supporting the health and well-being of the animal. Many pet owners want the best for their companions, with pets often considered to be members of the family. Because of that, there can be feelings of anxiety when it becomes challenging to provide fully for pets’ needs.

Technology Innovations

Fortunately, technological innovations have made caring for pets more convenient and accessible than ever in multiple ways. New trends and innovations that first gained a foothold in other sectors, especially those in human medicine, are continually being modified and updated to meet the wants and desires of the multi-billion-dollar global pet industry.

Recent innovations include the creation of a technological ecosystem in which owners have access to reliable pet services. Great examples include BabelBark, which helps connect owners to veterinarians and other services, and Rover, which helps match up dogs to local dog sitters. There are also litter box monitors that track usage, fitness trackers like PitPat and FitBark, which monitor activity levels, and smart food bowls like Obe ProBowl. Meanwhile, interactive technology like CleverPet’s hackerpet can keep pets engaged while owners are gone to help maintain or improve their cognitive health.

As increasing numbers of innovative smart solutions provide convenient and accessible pet care, it is likely that demand and usage of them will also continue to rise.

Disasters and Pandemics

How, though, will animal care be delivered when disaster strikes? Natural disasters and pandemics, such as the current COVID-19 outbreak, pose a huge hurdle as to how the veterinary profession will continue to practice the golden standard of medicine. Fortunately, all states have declared veterinary practice as an essential business that can remain open during the pandemic. But, like most other businesses, veterinary practices have had to adapt. The American Veterinary Medical Association (AVMA) suggests that practices temporarily defer all elective procedures, such as routine annual wellness visits, spays, and neuters, and to use personal protective equipment (PPE.)

Struggles faced by many veterinary practices during this pandemic include staffing issues, lack of PPE, cancellations of numerous appointments, dips in revenue, not being able to pay their bills and salaries, and more.

So, how can the veterinary industry continue serving their clients and patients with as little interruption as possible during current and future crises? Telemedicine.

What is telemedicine?

The Federation of State Medical Boards defines telemedicine as “the practice of medicine using electronic communications, information technology, or other means between a licensee in one location and a patient in another location, with or without an intervening health care provider.”

In veterinary medicine, a license may include primary care veterinarians, specialists, and subspecialists. The information may be used for diagnosis, therapy, follow-up, and/or education, and may include but is not limited to any of the following: patient medical records, medical images, real-time text communication, live two-way audio and video, output data from medical devices, and sound and video files.

Multiple platforms exist in veterinary medicine, which includes ones that can connect primary care veterinarians to clients and primary care veterinarians to specialists/consultants, and can focus on after-hours tele-triage. These may be enterprise solutions or they could be homegrown. Overall, these different platforms can provide improved care in multiple ways that otherwise may not have been available to the client, patient, and veterinarian.

Expected Benefits of Telemedicine

Veterinary telemedicine allows for improved access and convenience to medical care by enabling a client and patient to remain at a remote site. This is crucial in situations like the COVID-19 pandemic in which clients are not allowed to bring their pets in for routine care. It can also aid in breaching the barrier of access to veterinary care to clients who live in remote area, as well as possibly being a more affordable option for clients who otherwise would not seek veterinary care due to financial constrictions.

Telemedicine can also offer more efficient medical evaluation and management. Often times animals do not act the way they do at home when they are being seen by a doctor or technician. Unfortunately, many animals experience white coat syndrome and can be stressed due to the car ride, being in an unfamiliar place, being with strangers, or having had previous poor experiences at a practice.

There are plenty of instances, for example, where animals have been taken to see a veterinarian because of lameness and, by the time the doctor sees the animal, the limping has gone away. Lab results, as another example, can become skewed due to stress felt by the pet. So, why place a patient in situations that are scary or stressful to them when it can be avoided in certain cases?  Thanks to modern technology, there are better ways to manage and evaluate many patients.

In addition, obtaining the expertise of a distant specialist can now be possible with telemedicine, no matter where the client lives in the country. Specialists are not typically as readily accessible as general practitioners and now many clients can take advantage of their knowledge and skills in a patient’s care.

Potential Risks of Telemedicine

As with all innovations, there will undoubtedly be an increase in malpractice with the use of telemedicine. For example, before ultrasounds or radiographs, a doctor could have easily missed a specific diagnosis and that could have been considered an acceptable norm. However, as technology has improved and become more readily available, veterinarians are held to higher standards and thus the risk of malpractice is higher.

In telemedicine, such potential risks could include how the information being transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by the veterinarian(s) and consultant(s). Failures of equipment could happen, which could potentially delay medical evaluation and treatment. A breach of privacy of personal medical information could occur if security protocols fail. Plus, a potential lack of access to complete medical records for whatever reason may result in adverse drug interactions or allergic reactions or other judgment errors.

However, the benefits of convenience, efficiency, and easy access for animal health care can far outweigh the potential risks when it comes to the use of telemedicine. When looking at human telemedical care for comparison purposes, a recent Vivify Health survey showed how 83% of consumers are interested in receiving virtual care. Plus, according to the American Hospital Association, 76% of hospitals connect with patients through telehealth and almost every state Medicaid program has some sort of coverage for telehealth services.

The VCPR

Question: What is holding back the veterinary field from jumping with both feet into telemedicine? Answer: the veterinary-client-patient relationship (VCPR) definition. The AVMA currently defines a valid VCPR as one where the following applies:

  • The licensed veterinarian has assumed the responsibility for making medical judgments regarding the health of the patient(s) and the need for medical therapy and has instructed the client on a course of therapy appropriate to the circumstance.
  • There is sufficient knowledge of the patient(s) by the veterinarian to initiate at least a general or preliminary diagnosis of the medical condition(s) of the patient(s).
  • The client has agreed to follow the licensed veterinarian’s recommendations.
  • The licensed veterinarian is readily available for follow up evaluation or has arranged for:
    • Emergency or urgent care coverage, or
    • Continuing care and treatment has been designated by the veterinarian with the prior relationship to a licensed veterinarian who has access to the patient’s medical records and/or who can provide reasonable and appropriate medical care.
  • The veterinarian provides oversight of treatment.
  • Such a relationship can exist only when the veterinarian has performed a timely physical examination of the patient(s) or is personally acquainted with the keeping and care of the patient(s) by virtue of medically appropriate and timely visits to the operation where the patient(s) is(are) kept, or both.
  • Patient records are maintained.

The AVMA also specifically states in Section 5 and commentary of the AVMA Model Veterinary Practice Act that “a veterinarian-client-patient relationship cannot be established solely by telephonic or other electronic means.” A physical exam is necessary in order to establish a VCPR. The U.S Food and Drug Administration (FDA) supports this definition.  Individual states do have the authority to define these specific terms more clearly within the definition of VCPR and, as of May 2020, every jurisdiction, except Alaska, Connecticut, Delaware, and the District of Columbia, has spelled out their requirements for a VCPR.

On the other hand, the American Association of Veterinary State Boards (AAVSR) does not believe a physical exam is necessary in order to determine VCPR. In their opinion a VCPR is established when “both the Veterinarian and Client agree for the Veterinarian to assume responsibility for making medical judgments regarding the health of the animal, the Veterinarian has sufficient knowledge of the animal(s) to initiate at least a general or preliminary diagnosis of the medical condition of the animal(s), and the Veterinarian has provided the client with information for obtaining timely follow up care.”

Challenges with the VCPR

The federal standards for a VCPR were put into place to define when and how a veterinarian “legally” becomes the veterinarian for a particular animal. However, laws often trail innovation, especially during disastrous events, and the VCPR challenges are an ideal illustration of how laws don’t always dovetail with current realities. A study in MDPI, for example, showed that over 90% of cat and dog owners had visited a veterinarian at some time, but that only about 40% of them visited a veterinarian annually. These pet owners, for whatever reason, choose to not go to the veterinarian, which means their pets’ health care can go unattended. COVID-19, meanwhile, adds to the challenge.

Here’s something else to consider. Because 81% of Americans that own cellphones have smartphones, they have access to internet-based information to learn about their pet’s health, and some people are likely use this information to self-diagnose their animal companions. The most accurate source of information and medical treatment is not available to them, though, since veterinarians cannot engage with treating a client’s pet via electronic tools without having done a physical exam according to the current VCPR definition.

So, even though telemedicine is readily available to use, the definition of the VCPR is acting as a barrier instead of a doorway to veterinary care for many pet owners.

The Doctor-Client Relationship in Human Medicine

As of October 2018, all 50 states allow for a physician to establish a relationship with a new patient via telemedicine, though state laws differ in their specifics. A few states, such as Alabama, include some caveats to that general rule, restricting the setting in which a patient must be located in order to establish the doctor-client relationship.

Prior to that, in 2014, physicians voted to approve the following definition of a doctor-client relationship in telemedicine. The relationship can be established in a number of ways, including:

1) A face-to-face examination—an exam using two-way, real-time audio and visual capabilities, like a videoconference—if a face-to-face encounter would be required for the same service in person

2) A consultation with another physician who has an ongoing relationship with the patient

3) Meeting evidence-based telemedicine practice guidelines developed by major medical specialty societies for establishing a patient-physician relationship

 Once the doctor-client relationship is established, physicians can use telemedicine technologies with their patients at their discretion within their licensed state(s).

Current State of the VCPR Amidst Coved-19

The global pandemic has increased the awareness of the use of telemedicine and its challenges. The FDA and state boards have responded by assessing the VCPR, with the FDR reiterating that the VCPR definition cannot solely be met through telemedicine while also loosening the regulations on extra label drug use in animals. Some state boards, such as in Pennsylvania, have softened their stance on the VCPR, with that state deciding that “during the COVID-19 pandemic, there may be instances when your best medical and professional judgment weighs in favor of establishing a VCPR without an in-person physical examination.”

 Other state boards, like in California, have emphasized the importance of the current law with its requirement of a physical exam to establish a VCPR.

Need for Guidance

As telemedicine becomes more customary in veterinary medicine, the need for revised standards and guidelines is evident. During this process, the veterinary field must work through many of the same types of questions and challenges that the human medicine field has needed to deal with. For the veterinary industry, these may include:

  • What is the definition of a VCPR in light of the use of telemedicine?
  • Will state boards still require a veterinarian to be licensed in the state where the patient resides?
  • Can a state board require informed consent forms before a veterinarian can practice telemedicine—and, if so, what should be in these forms?
  • What medical cases can and cannot be managed via telemedicine?
  • What fees and costs are associated with providing telemedicine services?
  • Who is allowed to provide telemedicine services? Is it just the veterinarians or can other qualified staff provide it?
  • How will the client’s privacy and security be maintained?
  • Will the standards of care for telemedicine be the same as those for in-person examinations and treatments? If not, what differences will exist?

The veterinary field can look towards the American Association of Telehealth (ATA) as well as veterinary groups such as the AAVSB, AVMA’s Telehealth Resource Center, the Veterinary Telemedicine Community Facebook Group, and the newly established Veterinary Virtual Care Association (VVCA) for guidance in helping to answer these questions and establishing standards when it comes to the delivery of veterinary telemedicine.

Telemedicine Becoming a Staple of Pet Health Care

For telemedicine to become a staple of pet health care, each state must hold an open and informed debate amongst the veterinarians that are licensed to practice in that state. The veterinarians need to come to a consensus on the issue of telemedicine and whether a physical exam to establish a VCPR should be mandated by law or left to the professional judgment of the attending veterinarian. Once a general agreement is made, the state associations can reach out to their designated state boards to “lobby the legislature to make the applicable changes. This could be as little as authorizing the use of telemedicine and establishing guidelines for providing telemedicine consultations.”

Tips for Veterinarians

Telemedicine will someday become standard in veterinary medicine. It is no long a question of if, but when. Telemedicine is in fact the hot topic in the industry and is frequently being brought up in forums, along with veterinary news and social media outlets, and is being discussed and debated at conferences. Texas A&M College of Veterinary Medicine has even begun a full-time telemedicine position at their teaching hospital and is pioneering the way of incorporating telemedicine into the veterinary students’ curriculums. Not only are future generations of veterinarians being prepped to make telemedicine a part of their daily practice, but so are pet owners.

As human health care technology advances, so will clients’ expectations when it comes to the care of their pets. There is a change in culture happening. As Millennials and Generation Z consumers have become adults, they have embraced the pet-owning and pet-loving lifestyles to a far greater extent than the previous generation. More and more young adults are putting off having children and are getting pets instead. In the American Pet Product Association National Pet Owners Survey of 2019-2020, Baby Boomers account for 32% of pets owned, while households headed by younger cohorts account for 62% of pet ownership.

Millennials are currently the largest consumer group in the world. One can expect this generation to want the convenience of pet care to be at the tip of their fingers, just as easily accessible as ordering food from Grub Hub, booking a ride with Uber, or buying things in One-Click from Amazon. Veterinary medicine therefore needs to be fast, easily accessible, and readily available.

Since this is the wave of the future, it is best that veterinarians prepare for the changes now. Look at it as practicing preventative medicine instead of reactive medicine. Simply put, adapt, or die.

To summarize the future of telemedicine, Joshua Newman, M.D., chief medical officer, Salesforce Healthcare and Life Sciences, said in a statement that “Patients today are choosing their providers, in part, based on how well they use technology to communicate with them and manage their health. Care providers who build deeper patient relationships through care-from-anywhere options, the use of wearables and better communications post-discharge, will be in a strong position to be successful today and into the future.”

 

Telemedicine: From Your Exam Room to Their Living Room

It is the year 2025. You are sitting in your office and your certified veterinary technician (CVT) has just video conferenced you from the living room of a longtime client of yours. The patient in question is Willow, a 7-month-old female spayed Mastiff with an area of alopecia on her head. The CVT completes and shares with you her thorough physical exam and you both determine no other significant findings. She performs a deep skin scraping of the area, examines the slide through the microscope in her truck, and finds Demodex mites. You prescribe Ivermectin for the puppy and, since it is a commonly used pharmaceutical, your technician is able to dispense it from her truck. The client will schedule a video-conference recheck in three weeks. As you hang up from the call, your second technician buzzes in right on time for your next appointment.

Telemedicine in the Human World

The scenario above depicts the future for veterinary medicine general practice. In fact, it is already a current practice in the human medical realm. There is actually an organization called the American Telemedicine Association (ATA) whose members are physicians, academicians, policy makers, and others who promote the safe and effective use of telemedicine to promote the health and well-being of people. They define telemedicine as “the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status.”2

The ATA developed practice guidelines for primary and urgent care as part of their mission to establish standards promoting patient safety and quality services provided via telemedicine.6 These guidelines include rationale for the use of telemedicine in a primary care setting, and they have determined that both acute and chronic medical conditions can be managed effectively by video-based telemedicine. These conditions include – but are not limited to – allergies, dermatologic issues, genitourinary conditions, otitis media, upper respiratory infections, congestive heart failure, and diabetes, a list that sounds all too familiar, also being common conditions seen in veterinary medicine general practice. The difference, however, is that with organizations such as the ATA, telemedicine is generally accepted and more developed in human medicine than it is in veterinary medicine.

The smart phone revolution has provided the human medical would with a powerful set of tools. Many of these tools are taking the form of mobile applications: ECG monitoring and analyzing, mental health monitoring, and rash diagnostics – plus apps with attachments, such as those needed to perform an eardrum exam. Wireless sensors can track pulse, oxygen, glucose, blood pressure, and heart rhythm. Pending FDA approval, the equivalent of an intensive care unit monitoring system can even exist on a person’s wrist. Patients can also demand video consultations with a physician at any time of night for a comparable price of a regular copay.13

Some may argue that human medicine is a more justified arena for establishing telemedicine as a standard practice.  In human medicine, the patients can communicate their problems to their physicians, whereas in veterinary medicine we cannot rely on our patients to verbally communicate with us. Talk can be cheap, though. Talk can be a distraction. Patient evaluation consists of much more than simply communicating complaints and feelings, and that philosophy is at the heart of veterinary medicine.

State of Affairs

The American Veterinary Medical Association (AVMA) does not have an official stance on telemedicine, but they have included in their Model Practice Act that “a veterinarian-client-patient relationship cannot be established solely by telephonic or other electronic means.”1 Included in the requirement of a valid VCPR is “a timely examination of the patient by the veterinarian.” Both sections, interpreted together, conclude that a VCPR is only established when the veterinarian physically examines the patient. States that have adopted this stance on telemedicine in their practice acts include Oklahoma, Idaho, Iowa, Illinois, Mississippi, Tennessee, Texas, Utah, and California. Hawaii has elaborated to specify that a VCPR is established via telemedicine only when one has already been established in person regarding the same illness in question electronically. However, the majority of practice acts have no specific mention of telemedicine as a practice of veterinary medicine whatsoever.8

Many would defend the language in current practice acts on the basis that veterinary medicine would be impossible without a physical exam – and the physical exam is indeed an important component in the evaluation of a patient. However, it is not the only factor that drives a diagnosis. Access to the medical records, clinical history, and laboratory test results are all important components that help veterinarians come to a complete assessment. Others may argue that the lack of a veterinarian-driven physical exam may increase the rate of misdiagnoses, but complaints and malpractice suits against veterinarians already exist with the current standard of care. The reality is that, depending on the set of circumstances and the medical condition, a physical exam may not even be necessary. Note that the purpose of this discussion is not to belittle the physical exam or defend that it is overrated, but to offer an eye-opening perspective on how the profession can grow – because the truth is that veterinary medicine is already changing.

Plus, it’s important to recognize that real-time telemedicine already exists in veterinary medicine through many well-established mediums. Resources such as Ask.vet and Vet24Seven allow clients and veterinarians to communicate via websites and mobile applications, making it easier for clients to connect with veterinarians outside the exam room.4 Other services such as poison control hotlines exist to determine whether certain problems require immediate medical attention.

The bottom-line issue: the language in many states’ practice acts are inconsistent and ambiguous, which is problematic and puts many of these services on shaky ground legally. There is without a doubt a public need for on-demand veterinary services but, as a profession, we have done a poor job of making ourselves available to our clients via modern communication techniques. Dr. Ed Blach, co-founder of Vet24Seven, defends his site, noting that providing a convenient avenue for connectivity between clients and veterinarians promotes greater engagement, which in turn will help to generate client visits and consults.5 The truth is that practically every adult owns a cellular device and is using it multiple times a day. Our society is changing, and it is up to us as veterinarians to adapt and change along with modern communication methodologies.

Plus, when you consider the current education and examination standards for the veterinary medical board, it’s a wonder why telemedicine is not already a standard of practice. Students are practicing telemedicine every day; for three years, we spend hours a day sitting in a classroom making assessments and creating treatment plans based on someone else’s physical exams and diagnostics. Furthermore, the North American Veterinary Licensing Exam contains no practical component as a requisite for students to obtain their veterinary license. How can it be that, during their fourth year, veterinary students are evaluated on their abilities to make a diagnosis based on text, pictures, or video, but it is unlawful for an experienced clinician to give their medical opinions unless they have touched the patients?

Implications in Veterinary Medicine

The veterinary community has much to gain from incorporating telemedicine as a standard practice. In the small animal realm, telemedicine would act as an extension of the exam room, enabling veterinarians to improve efficiency and effectiveness while maintaining high quality care to a larger patient populations. Real time telemedicine would benefit all parties of the veterinary-client-patient relationship. Exotics and large animals would not be excluded, either, as their care would also advance with the implementation of telemedicine.

Perhaps the most substantial beneficiary would be the patients who rarely see the inside of a veterinary hospital. How many clients are unable to get their cats in for timely physicals because they run and hide at the sight of a carrier, or maybe the cat is stressed by simply being in the exam room surrounded by barking dogs? Results of the Bayer veterinary care usage study determined that feline resistance was one of the top factors that clients cited for not taking their cat to the vet regularly.14 Geriatric, arthritic dogs are another potential concern, as their difficulties traveling may prevent owners from bringing them in as often as they should, and perhaps the dog-aggressive 100lb German Shepherd is also lacking in its preventative care. The Bayer study also determined that 40% of cats and 15% of dogs have not been to the veterinarian within a year. These patients are entitled to the regular health care that they deserve.

Not only would telemedicine provide substantial improvements in pet health care, but it would also provide convenience desired by the client.  Imagine the elderly couple who hasn’t been able to bring their pet in for its annual exam for the past three years, or the mother of four who finds it impossible to bring all of the kids and the pet to the clinic. House calls also reduce travel expenses and time commitments on the clients’ end. The cost of veterinary care would also be reduced, as there would be less of a need to pay for as many brick and mortar expenses when the time and space needed to run a veterinary general practice was reduced. (Pet owners have cited the cost of veterinary care as a top contributor for decreased veterinary visits.)14

Telemedicine house calls would also expand the role of the veterinary technician. Sending technicians to the clients and video-conferencing with the veterinarian would provide them with autonomy. They could establish their own personal relationship with the clients and develop their physical exam skills. In conjunction with the veterinarian, they are responsible for triaging the patient and determining if there is a need for immediate medical attention. By entrusting them with greater responsibilities, it empowers and encourages them to do more for the practice and grow as a person.

The role that would change the most, though, is that of the veterinarian. It is difficult to imagine a world where the veterinarian provides his or her services via a Skype session. The truth of the matter, though, is that a veterinarian (owner or associate) has much to gain from telemedicine. Increasing efficiencies and cash flow to the practice would boost the bottom line. They could extend their reach and provide veterinary care across geographic and socioeconomic barriers.8

And, what about veterinary students? They are graduating with a tremendous debt load that has never been more evident. Increasing debt combined with lower salaries and fewer job offers is an increasing concern of many new graduates.10 More specifically, student loan debt has increased annually at an average rate of about 5%, while salaries have decreased at a rate of 0.9%.16 The veterinary profession is in need of reform to combat these issues and restore faith in a profession that has left many students feeling disheartened about their futures upon their graduation dates. Expanding veterinary services to reach more clients and serve more patients would undoubtedly improve overall morale in the veterinary community by improving performance and promoting higher wages.

It is important to emphasize, as mentioned above, that small animal medicine would not be the only arm of veterinary medicine to benefit from telemedicine. Our beloved exotic pets such as lizards, hamsters, birds, and so forth would benefit greatly from telemedicine consults. These exotics are known to stress easily with extensive handling and transport.11, 12 This stress could have a profound impact on the animal’s state of health and well-being.  Why not offer the client the opportunity to leave their Komodo Dragon in the comfort of its terrarium while you evaluate it from afar? This would also be a good opportunity to inspect its husbandry arrangements, as poor conditions have historically impacted the health of these patients.11, 12

Researchers at Kansas State University have developed an infrastructure to utilize telemedicine in the large animal realm. They use Bluetooth monitoring software to continuously assess the state of health of cattle in herds. Monitoring trends in physiological variables and cattle movement to feed and water are extremely helpful in identifying early warning signals for potential disease outbreaks. The implications from such software include improved financial stability of the industry as well as preparation for epidemiologic disasters.15

What about fish? They rarely have physical exams performed, and many diagnoses are made from videos and observation through different material substances. It’s probably safe to assume that there have been many beloved fish who were flushed down the toilet because they “weren’t swimming right,” when maybe all they needed was a Metronidazole-infused fish food.

There are, of course, cases where telemedicine would be deemed inappropriate or unethical. Extensive training has provided veterinarians with the intuition to know which cases are to be managed on an urgent basis, so management and analysis on a case-by-case basis would be the best means to ensure that each patient receives the most appropriate care, and this could be held to current standards. Attention to clinical risk assessment is required so as to avoid any negative consequences from these practices.6

Recognizing that there is certainly a patient population that have never seen the inside of a veterinary hospital is a crucial step in appreciating the need for telemedicine in the veterinary world. How rewarding would it be to offer extraordinary veterinary care to animals who have never received it before?

Challenges Ahead

Telemedicine has a great potential to transform the ways that veterinary medical services are offered for the better, but it does not come without its own set of challenges. Perhaps one of the broadest challenges is reconsidering what veterinary medicine is without a face-to-face relationship with the veterinarian. But relationships are developed via the internet all the time. A study from the Proceedings of the National Academy of Sciences determined that 35% of marriages in America now begin online.3 That’s over one-third of married people who may have never otherwise been married if it weren’t for the advent of online dating. Think of how that could extrapolate into veterinary medicine; the opportunities are endless!

Another challenge that telemedicine faces is adapting the legal and regulatory structure. There are several issues that would need to be addressed before telemedicine can legally become a standard of veterinary care, which would be reflected in changing the regulations in the practice acts. A major concern of telemedicine includes whether or not a proper veterinary-client-patient relationship exists through video and conference calls.7 As mentioned before, several states have scribed their practice acts reflecting the language in the AVMA Model Practice Act, stating that the VPCR cannot be established solely by telephonic or electronic means.1 Must the VPCR be established with each visit? Each diagnosis? Once a year? Once in a lifetime?

Another issue exists in cross-state licensing. Certainly not every client resides in the same state as the veterinary practice. Should the veterinarian be licensed in every state in which he or she is providing medical care and advice? With the current language, it begs the question whether or not medical advice can even be transmitted via telephone on a day-to-day basis as is already occurring. Consults and recommendations are made over the phone every day in veterinary practices. The ambiguity of the laws are wide open to interpretation on a case-by-case basis, and opinions vary dramatically with the lawyer who is providing them.4

The AVMA has recognized the need to make recommendations on the issue of telemedicine practice in veterinary medicine.  At the AVMA board meeting in September, 2015, they included it as one of the topics to be covered by the new AVMA Practice Advisory Panel. The Practice Advisory Panel is responsible for “protecting, promoting, and advancing the veterinary profession by strategically identifying, prioritizing, and processing” veterinary issues. They will work in conjunction with the Regulatory Advisory Panel that focuses on matters of veterinary regulations. These panels are part of a pilot program designed for a more efficient governance by the board, and the AVMA board hopes to work with the state boards and veterinary medical colleges to develop an official policy for telemedicine. 9

Data protection is an important factor to consider for the future of telemedicine. Given the sensitive nature of information communicated via the virtual world, it requires a secure system through which this confidential information is transmitted. One could certainly imagine the possibility of an overzealous breeder in the small or large animal realm who would be interested in obtaining information about their competitors. The ATA recommends that data security be establish by implementing encryption methods such as the Federal Information Processing Standard.6 Any session or device should have authorized access and timeout thresholds, as well as means of protecting contents in the event of loss or theft. Americans have long trusted mobile sources with their personal information, so there is no reason why pet health care cannot be the same, as long as meticulous measures are taken to protect the client and patient’s privacy.

An additional challenge faced by the veterinary profession is how to adapt the technicians to their new roles. CVT education should involve thorough history-taking skills, detailed physical examination techniques, and extensive communication training specifically geared towards the purpose of telemedicine.6

None of these changes come easy, but we should not let the fear of change prevent us from adopting and accepting what will inevitably become the future of veterinary medicine. It is already established in the human health care setting, and our clients will expect the transition to the veterinary field for their pets. It is important to note that this would not be the first big change in veterinary medicine. Think electronic medical records, digital radiography, MRIs and CTs, and these are just a few examples of evolutions in the standard of care that were probably never even imagined decades ago. Technology, and thus societal standards, are changing on a near daily basis, and it is up to us as a profession to keep up with the times and the ever-changing expectations of our clients.