NAVC Keynote Commentary for the Veterinary Community: A Regulatory Road Map for Telehealth & Pet Health Care
Mark Cushing, JD
Animal Policy Group, LLC, Knoxville, Tennessee; Washington, DC; Portland, Oregon
The veterinary profession in the United States decided to take telemedicine seriously in 2016.
The NAVC (navc.com) launched its Veterinary Innovation Council (VIC) a year ago and numerous organizations stepped up to participate in its first project—a telehealth pilot. In April 2017, Texas A&M College of Veterinary Medicine (vetmed.tamu.edu) and the NAVC are collaborating to host the Veterinary Innovation Summit, which will include a robust examination of telemedicine and the VIC pilot results.
Also in 2016, the American Veterinary Medical Association (AVMA, avma.org) convened telemedicine task force meetings, while Banfield Pet Hospital (banfield.com) devoted a session of its September Pet Healthcare Industry Summit to telemedicine.
Most important, the American Association of Veterinary State Boards (AAVSB, aavsb.org) devoted a full afternoon of its 2016 annual meeting to the topic of telemedicine. Under the leadership of new AAVSB Executive Director, Jim Penrod, state veterinary board regulators decided to proactively address telemedicine and explore its implications for veterinary medical care.
Let’s Talk About Telemedicine
Telemedicine does not refer to telephone consultations among veterinarians and diagnostic specialists, which have been happening for a long time. Rather, it describes real-time electronic encounters among veterinarians, pet owners, and pets, during which the parties see and talk to each other. Add to this the electronic communication tools of email, texts, and the like, and suddenly pet health care begins to mirror 21st century human health care.
IT’S GOING TO HAPPEN
Was there something in the water throughout the country? Or has the intersection of consumer-friendly electronics and human health care advances finally prompted veterinary medicine to “jump into” telemedicine with both feet?
It’s no longer a question of whether veterinarians will embrace telemedicine technologies, but when…and how. The veterinary profession and its animal health partners are eager to get this right, so how do we make it happen, not just at conferences, but every day in practices across the U.S.?
What veterinary telemedicine needs is a regulatory road map that removes barriers to making telemedicine a reality. Hopefully, this article is a start. It’s written for the veterinary practitioner in any state in this country who asks a simple question: if telemedicine is a good idea for pet health care, then how do we make it happen?
WHAT’S IN A NAME?
Telemedicine is more than a telephone call; it describes the use of the internet in veterinary medical practice.
The Federation of State Medical Boards (FSMB, fsmb.org) 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.
The American Telemedicine Association (ATA, americantelemed.org) uses a shorter version, defining telemedicine as a tool to facilitate health care delivery…to augment, and not replace, the clinical practice, judgment, and the expertise of the health care provider.
Insert veterinary before the words medicine or health care and you have veterinary telemedicine—a real-time electronic engagement among veterinarians, pet owners, and pets.
DETERMINING THE DIRECTION
To design a road map, we need to determine the direction of telemedicine in veterinary medicine. The 2 broad goals discussed most often are:
- To provide familiar electronic tools to existing clients, which allows communication between veterinarians and pet owners after visits or in lieu of visits, if the situation warrants.
- To reach out to pet owners who do not have a veterinarian and provide convenient and familiar tools that introduce them to the path of veterinary care for their pets.
The first category of pet owners presents a different set of challenges than the second: put simply, the telemedicine road map for existing clients does not pose regulatory barriers, but this is not the case with telemedicine for potential clients.
EXISTING CLIENT CHALLENGES
When a veterinary–client–patient relationship (VCPR) exists, the veterinarian may communicate with the client in any way she chooses: in person or by telephone, internet, fax, Skype, carrier pigeon…you name it. All that matters, for regulatory purposes, particularly in the area of prescription medicines, is the veterinarian’s familiarity with the pet through a relatively recent in-person examination.
The challenge of telemedicine in this context is one of staffing, pricing, technology, and standard of care requirements spelled out in state veterinary practice acts. Technology can be a key to client engagement, which is important because it drives client satisfaction and nurtures a long-term relationship between the veterinarian and the pet owner.
These are important issues, but not the focus of this article. I will leave it to trade associations and technology providers to determine how best to engage practitioners with the array of telemedicine tools for existing clients.
NON-CLIENTS FACE REGULATORY WALLS
Here’s the dilemma for the veterinarian brimming with enthusiasm and ready to reach out to new clients through telemedicine: If this practitioner attends a veterinary conference, he or she is likely to run headlong into a gale force of resistance asserting that a VCPR cannot be created through telemedicine.
Every jurisdiction, except Connecticut, Alaska, and the District of Columbia, spells out the requirements for a VCPR, which includes an in-person physical examination of the pet. But here is the real-world challenge:
- Between 40% to 50% of pet owners—who love their pets—do not seek regular veterinary care.
- While ads, social media, neighbors, friends, the Partners for Healthy Pets initiative, and every known tool of persuasion have implored pet owners to visit veterinary clinics, they consistently vote no. Hence, no VCPR.
- As such, these pets receive no medical care, although their owners may access all manner of internet-based information to learn about their pets’ health.
- These pet owners probably use smartphones and other electronic tools to manage much of their lives, including personal medical care. However, 48 states forbid a veterinarian from attempting to engage an owner through electronic tools, or vice versa, without a VCPR in place.
- Once again, the pet’s health care goes unattended since the pet owner already has decided against visiting the clinic.
The result? The VCPR serves as a wall, rather than a door into the world of veterinary health care. Does this make sense?
HUMAN MEDICINE LEADS THE WAY
If you’ve read this far, then you’re scratching your head, wondering how many lobbyists or lawyers (favorite professions of this author) are required to fix the problem. However, I’m pleased to say very few, thanks to human medicine.
Lawyers and lobbyists, with doctors, have been busy for 2 decades in human health care arenas, working through the exact issues facing veterinary telemedicine:
- Doctor–client relationship: Can this be formed via telemedicine? Yes, in 47 states.
- Multi-state licensure: Can state boards still require the treating doctor to be licensed where the patient resides? Yes, although some states are more flexible.
- Online prescriptions: Is a doctor–client relationship still a requirement? Yes.
- Informed consent: Can state boards require that a client consent to being served through telemedicine? Yes, although some states do not require this.
- Privacy/security: Can state boards require that telemedicine adhere to the same requirements as in-person examinations and treatment? Yes.
- Standards of care: Are they the same for telemedicine as for in-person examinations and treatment? Yes.
Supplemented by FSMB and ATA resources, the states have learned from each other and, subsequently, all 50 have developed some level of telemedicine laws and regulations. Most important, human health care treats telemedicine as a staple of health care delivery.
IF WE WANT IT, WE CAN HAVE IT
All we need to do is follow the lead already set in place by human telemedicine and learn from their lessons. It really is that simple.
State veterinary medical boards can walk across their state capitols and consult sister state medical boards. The AAVSB can reach out to its sister FSMB and the ATA. These organizations have worked through the issues and created templates we can adapt with relatively little effort.
The veterinary profession in each state may partner with its state veterinary board, and nationally with the AAVSB, to initiate task forces and implement appropriate regulations in relatively short order, if we want to. It’s not a matter of complexity, but of interest or willpower.
I can hear skeptics howling that it’s not that easy. It actually could be—we don’t have to start from scratch—but, of course, there will be work involved (and some need for lawyer/lobbyist services). And the argument we often hear—that veterinary medicine is different because pets cannot speak for themselves—does not hold water since a large share of human health care involves pediatric patients who cannot articulate their conditions or symptoms.
Forty-seven states now allow a human doctor–patient relationship to be created through telemedicine. You can be assured that virtually every state resisted this when the process started decades ago, but experience, shared learning, and consumer familiarity with electronic technologies and devices changed people’s minds and opened up state medical boards to the possibilities of telemedicine. In veterinary terms, these boards turned the VCPR into a doorway for health care, not an impenetrable wall. Why can’t veterinary medicine do the same thing?
Veterinary and human medicine are governed at the state level, but practice acts vary among states. Solutions are readily available—no state can say it doesn’t have the resources to tackle telemedicine. Also, the AAVSB has taken the lead to provide valuable resources for the states. Other veterinary organizations, including AVMA and state veterinary medical associations, can also step up and push for a more modern, flexible view of the VCPR.
State of Telemedicine
In human medicine, Texas, Alabama, and Arkansas are the most conservative states, with limited telemedicine privileges. In veterinary medicine, Connecticut, Alaska, and D.C. have no VCPR rules and may be more flexible with regard to telemedicine privileges, but telemedicine is not being actively practiced in any state beyond consultations between veterinarians.
CALL TO ACTION
So let the discussions begin by studying state medical practice acts and telemedicine precedents. In a year, we could see state veterinary medical associations and boards working in tandem to offer practice act reforms to state legislatures, opening the door for pet telemedicine.
Just think about the possibilities, as we take advantage of existing models, to make the process simple, streamlined, and practical.