Telemedicine

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The AVMA is proposing an updated “Model Veterinary Practice Act” to its House of Delegates in the near future.  Included in the draft, which is not legally binding by any state unless specifically incorporated into the state laws, are issues involving the provision of veterinary care via telephonic or other electronic means.  As reported by AVMA in its JAVMA Nov. 1, 2018 publication,

The AVMA Model Veterinary Practice Act continues to state that veterinarian-client-patient relationship ‘cannot be established soled by telephonic or other electronic means’ . . .

As decided in Hines v. Alldredge, 783 F.3d 197 (5th Cir. 2015), “the requirement that veterinary care be provided only after the veterinarian has seen the animal, at a minimum, rational: it is reasonable to conclude that the quality of care will be higher, and the risk of misdiagnosis and improper treatment lower, if the veterinarian physically examines the animal in question before treating it.”  At least in Texas, the requirement for in person examinations by veterinarians of their patients must be conducted before diagnosis and treatment ensues.

Other issues included in the AVMA’s model act include:

  • Permitting a veterinarian to provide care to an animal during an emergency in the absence of a valid VCPR;
  • Incorporation of federal laws, including definitions and provisions of FDA’s Veterinary Feed Directive;
  • Rejection of a farrier exemption;
  • Discussion of the use of the term “veterinary nurse” and
  • The ability of lay personnel to provide veterinary massage services.

The model act will be presented to the AVMA’s House of Delegates for a vote this January.  Even if adopted, the model act is not legally binding, and its use will be individually determined by each state’s veterinary examining board.

Interestingly, in the same JAVMA publication, the results of a study of “Owner satisfaction with use of videoconferencing for recheck examinations following routine surgical sterilization in dogs” was reported:

Owners were equally satisfied with recheck examinations performed by videoconference and in-clinic appointments. Owners of dogs in the telemedicine group indicated that their dogs were less afraid during the virtual appointment, compared with what was typical for them during in-clinic appointments, but the difference was not statistically significant. Most owners who completed a postsurgical recheck  examination by videoconferencing preferred this method for similar appointments in the future.

The fact is, telemedicine has been utilized by veterinarians since telephones have been available.  Clients calling in after-hours have consulted with veterinarians across the country who have provided advice and direction when immediate in person examination was not deemed to be necessary, based on the information provided by those clients.

With the increasing deficiency of veterinarians available to service certain rural animal producers and owners, it seems inconceivable that such remote, digital provision of veterinary services would not be permitted.

A proposed bill “authorizing the provision of health care services through telemedicine and telehealth” (S291) is now on the desk of the Governor of New Jersey for action.

The bill, which authorizes “the provision of health care services through telemedicine and telehealth” governs such services provided by veterinarians, as “[h]ealth care providers,” fails to acknowledge or provide for issues specific to veterinary medicine.  For example, several provisions require the “patient’s request” before providing health care services through telemedicine.  Clearly animal patients cannot request treatment or provide consent.  The bill fails to distinguish a “patient” from a “client” or “animal owner” or to permit such services at the request of a client/owner for the patient which is the fundamental way in which services are provided in a veterinary practice.

The bill also requires “[e]ach telemedicine or telehealth organization operating in the State . . . [to] annually register with the Department of Health” and submit an annual report providing

the total number of telemedicine and telehealth encounters conducted; the type of technology utilized to provide services using telemedicine or telehealth; the category of medical condition for which services were sought; the geographic region of the patient and the provider; the patient’s age and sex; and any prescriptions issued.  The commissioner may require the reporting of any additional information as the commissioner deems necessary and appropriate, subject to all applicable State and federal laws, rules, and regulations for recordkeeping and privacy.

Such information would be publicly accessible pursuant to the State’s Open Public Records Act, which may be of concern to biomedical research entities since reported information can reveal confidential information and trade secrets.

That said, the evolution of veterinary medicine necessarily involves telemedicine.  The American Veterinary Medical Association (AVMA ) acknowledges as much in its published “Final Report on Telemedicine” dated Jan. 13, 2017, drafted by the association’s Practice Advisory Panel (AP).

The AP concluded, in part:

Telemedicine is a tool of practice, not a separate discipline within the profession. The AP recognizes that using telemedicine in the delivery of veterinary medical services offers benefits to animal owners, animal patents, and the profession itself. The appropriate application of telemedicine can enhance animal care by facilitating communication, diagnostics, treatments, client education, scheduling, and other tasks within the veterinary profession. Practitioners must apply existing laws and regulations to the provision of telemedicine services in the state they have license to practice veterinary medicine.

The AP recommends that telemedicine shall only be conducted within an existing VCPR [veterinarian client patient relationship], with the exception for advice given in an emergency care situation until that patient(s) can be seen by or transported to a veterinarian. Without a VCPR, telemedicine should not be practiced, and any advice given should remain in general terms, not specific to an individual animal, diagnosis, treatment, etc.

AVMA’s Greg Cima outlined the issues involving telemedicine in “Defining relationships: AVMA considering what medical services can be provided at a distance” posted on May 10, 2017.

At issue is the line between advice and the practice of veterinary medicine, the very issue-in-suit in Hines v. Alldredge, 783 F.3d 197 (5th Cir. 2015) where “a Texas veterinarian . . . was found to have violated the state practice act by performing veterinary medicine without a physical examination or premises visit” when he provided advice via the internet.”

With the decreasing numbers of food animal practitioners across the country, issues of telemedicine will be increasingly important to ensure that livestock receive appropriate and timely medical care.

Companion and other animals will also benefit from the proper use of telemedicine by veterinarians, after the veterinarian-client-patient relationship has been established.