June 01, 2017

 

 Defining relationships

​AVMA considering what medical services can be provided at a distance

Posted May 10, 2017

For Dr. Christopher B. Meehl, nothing can replace a physical examination.

“We give great service by being physically present with our clients,” he said.

The Massachusetts veterinarian is a practice owner of 34 years, the son and nephew of veterinarians. He is also the owner of LiveVet, a service he is developing to increase access to veterinarian advice. He said pet owners already have access to other sources, such as breeders and pet food companies, that sell products or services rather than provide medical care.

However, he has suspended some development pending results of the AVMA’s deliberations on telemedicine, to ensure his work is consistent with any new guidelines.

A proposal before the AVMA’s governing bodies would have the Association advocate for limiting use of telemedicine to follow-up care and consultation with patients or herds already seen in person, with exceptions for emergency services such as poison control center calls. The proposal, made in a January report from the AVMA Practice Advisory Panel, aligns with a statement in the AVMA Model Veterinary Practice Act that the relationship needed to practice veterinary medicine cannot be established through electronic communication alone.

The American Association of Veterinary State Boards contends that, with a new patient, some medicine could be practiced from a distance, and the standards of care are more important than the tools used. Plus, AAVSB representatives said AVMA policies should be able to accommodate developments that could benefit veterinarians and their patients. Notably, restrictions on human telemedicine have drawn scrutiny from federal regulators.

Dr. Meehl is among the veterinarians who offer or plan to offer advice from a distance but stop short of providing medical care, a limit set under most state laws. Action by the AVMA could reinforce those regulations or encourage expansion of the range of services that can be offered. 

The AVMA House of Delegates has recommended that the AVMA Board consider modifying the AVMA Model Veterinary Practice Act to state that telemedicine shall be conducted only within an existing veterinarian-client-patient relationship, as described in the panel report. The AVMA Board also approved in April spending $135,000 through 2018 on advocacy, member education, and public information on telehealth.

The AVMA Board could act on the panel and House recommendations as early as June, which could send the matter to the House of Delegates for consideration during its regular annual session in July in Indianapolis. 

Advice short of medicine 

Dr. Meehl agrees with the proposal described in the January report, a position that aligns with existing state regulations in Massachusetts, where the VCPR definition is based on the AVMA definition. About 40 states require a patient examination or premises visit to establish a VCPR, typically using language similar to that in the AVMA model, according to AVMA information. The Food and Drug Administration’s definition, which applies in connection with some federally regulated practices, includes similar language.

Dr. George E. Robinson III, chair of the AVMA Practice Advisory Panel, said the panel and its working groups developed a reasonable working document, intended to guide a new area of medicine that otherwise could develop unchecked.  

“It’s a work in progress that should be adjusted, adapted, reintroduced, redeveloped as time and technology changes,” he said.

States will develop exceptions, such as accommodations for people living in isolated areas, he said. In the absence of AVMA guidance, veterinary telemedicine has been a free-for-all, with companies developing their own interpretations of rules and regulations.

It’s a work in progress that should be adjusted, adapted, reintroduced, redeveloped as time and technology changes.”

Dr. George E. Robinson III,
chair of the AVMA Practice Advisory Panel, which wrote January’s report recommending AVMA actions on telemedicine

Dr. Robinson said it is obvious some are establishing as their niche the notion that they can help a pet owner avoid a trip to a veterinarian’s office or an appointment with a house call veterinarian.

“The general advertising is to try to get that person who thinks they may save a little money by getting a quick answer and not necessarily having their pet seen by a veterinarian,” he said. “Some people have used telemedicine for second opinions—for confirmations, things like that—but I don’t think that’s as frequent, and they’re not really marketing to those individuals.” 

As the Practice Advisory Panel report states, state laws determine when advice crosses into the practice of veterinary medicine, and the definition of practice varies by state.

Complaints and prosecutions over veterinary telemedicine have been rare. The AVMA panel’s telemedicine report, for example, cites only one 2015 court case involving a Texas veterinarian who was found to have violated the state practice act by performing veterinary medicine without a physical examination or premises visit.

Companies offering remote advice to pet owners within current laws and regulations will praise the medical expertise of their staff but state in their terms of service that they provide no medical care.

One company, for prices starting at $13, offers answers from an experienced veterinarian for “educational and entertainment purposes only.” Another provides a forum connecting pet owners with health, nutrition, and behavior experts—for 40 percent of any fees charged—but the forum owners claim no responsibility for information or advice, and they stipulate that “Consultations should not be intended for nutritional, fitness or other health-related diagnosis, prescription or treatment.” 



James T. Penrod, executive director of the American Association of Veterinary State Boards, describes the AAVSB position on telemedicine during the April meeting of the AVMA Board of Directors. (Photo by R. Scott Nolen)

Dr. Edward Blach is president and chief medical officer for Vet24seven, which operates the text message–based ask.vet. The company advertises access to veterinarians through subscriptions starting at $10 per month as well as a subscription service to field calls for veterinary clinics. He said the sessions tend to provide general education, nutrition advice, and thoughts on behaviors, with veterinarians answering basic questions that many veterinary practices don’t want to deal with.

“Clients get access to every other service at their fingertips, and they get it right now,” he said. “And yet we, as veterinarians, our model typically has been, ‘We don’t answer questions over the phone, you need to come in,’ right?”

Dr. Blach said his company makes clear to clients that the service cannot diagnose, prescribe, prognose, or treat, and tries to be transparent, having given demonstrations to groups including the AVMA and AAVSB. He also said most interactions with clients end in referral to a veterinary clinic.

While ask.vet offers advice from veterinarians, the terms of service clarify that information provided “does not constitute veterinary or any other professional advice.”

“Our doctors will have a conversation; it’ll be educational, they provide listening, education, guidance in the form of ‘with what you’re describing, you might be facing one of these three or four things,’” he said.

They also may describe the tests another veterinarian may perform and the expected price range.

Dr. Blach sees potential to expand access to veterinarians by offering services beyond those that clinics are willing to deliver.

 “We believe there’s a much larger demand out there amongst the customer base to access the expertise and guidance that veterinarians have in many of those non-injury and -illness areas,” he said.

Equal standards of care

James T. Penrod, executive director of the American Association of Veterinary State Boards, said the AAVSB board of directors sees potential for veterinarians to establish VCPRs from a distance when circumstances allow the practice of medicine performed this way to be consistent with traditional standards of care. Those situations would vary by clinical situation, he said in an interview. 

The AAVSB board members think veterinarians must be licensed or within the jurisdiction of the veterinary board where a patient is located, and clients should know the veterinarian’s identity, location, and license status as well as the privacy and security risks involved in the service. Owners also should be able to seek follow-up care from the veterinarian or a designee. 

Because of the importance of health care competition to the economy and consumer welfare, anticompetitive conduct in health care markets has long been a key focus of FTC law enforcement, research, and advocacy. In particular, many of our recent state advocacy comments have addressed scope of practice and supervision provisions that unnecessarily limit the range of procedures or services a practitioner may provide, or unnecessarily restrict a particular type of practitioner from competing in the market.”

Federal Trade Commission staff,
in a letter to the Delaware
Board of Dietetics/Nutrition

The AVMA advisory panel report recommends that, for interstate telemedicine, legal accountability and recourse should be available in the states where the veterinarian and patient are located. And establishing legal accountability is critical for liability purposes when interstate or international telemedicine is performed outside a VCPR, the report states.

The AAVSB is planning discussions later this year on prescribing in connection with telemedicine and whether a licensing compact among states would be appropriate in veterinary medicine, Penrod said.

In April, Penrod read to the AVMA Board of Directors a statement by Dr. Frank Walker, AAVSB president, that the AAVSB sees telemedicine as a tool. When it is used, a veterinarian still needs sufficient information to make judgments in an animal’s best interest.

Penrod also said Federal Trade Commission staff have expressed concerns in human medicine when statutes and regulations of telemedicine have been more stringent than those for in-person visits. He also said in the interview that companies developing telehealth technologies have the financial backing and opportunities to influence how those technologies could be viewed in medicine, including veterinary medicine.

An FTC spokeswoman said the agency had no comment on the AVMA advisory panel’s proposal to require an in-person visit prior to veterinary care.

In an August 2016 letter to the Delaware Board of Dietetics/Nutrition, FTC staff members wrote that a proposal to require face-to-face initial evaluations by dietitians or nutritionists “could unnecessarily discourage the use of telehealth for assessment and diagnosis and restrict consumer choice.” Telehealth could increase practitioner supply, encourage competition, improve access to affordable health care, and improve health care quality, the letter states.

“Because of the importance of health care competition to the economy and consumer welfare, anticompetitive conduct in health care markets has long been a key focus of FTC law enforcement, research, and advocacy,” the letter states. “In particular, many of our recent state advocacy comments have addressed scope of practice and supervision provisions that unnecessarily limit the range of procedures or services a practitioner may provide, or unnecessarily restrict a particular type of practitioner from competing in the market.”

Penrod noted to the AVMA Board that, on March 29, the Texas Senate passed a bill that would eliminate a requirement for a face-to-face consultation between a patient and physician following a telemedicine service if the two had not met in person as well as state that a practitioner-patient relationship can exist in telemedicine. The Texas House of Representatives had not voted on the bill by press time.

Board members for the Veterinary Innovation Council, a nonprofit started by the North American Veterinary Community, wrote in a March 1 letter to AVMA CEO Dr. Janet Donlin that they want organized veterinary medicine to place more confidence in individual veterinarians’ judgment when it comes to telemedicine. Confidence, they said, has proved pivotal in 20 years of debate over telemedicine in human health care.

Dr. Meehl said that, as communication technology changes, veterinarians should embrace evolution with care. He said there is no substitute for in-person contact, but veterinary medicine needs economical means for veterinarians to increase interactions with clients.

If they don’t, others will find ways to give out their own information.    

Definitions vary  

The AVMA, Food and Drug Administration, and states have various definitions for the veterinarian-client-patient relationship, although many state definitions are close to the AVMA model. Here are a few of the variations:   

AVMA:

A VCPR means that all of the following are fulfilled:  
A. The veterinarian has assumed the responsibility for making medical judgments regarding the health of the patient and the client has agreed to follow the veterinarian’s instructions.
B. The veterinarian has sufficient knowledge of the patient to initiate at least a general or preliminary diagnosis of the medical condition of the patient. This means that the veterinarian is personally acquainted with the keeping and care of the patient by virtue of:
  1. a timely examination of the patient by the veterinarian, or
  2. medically appropriate and timely visits by the veterinarian to the operation where the patient is managed.
C. The veterinarian is readily available for follow-up evaluation or has arranged for the following:
  1. veterinary emergency coverage, and
  2. continuing care and treatment.

D. The veterinarian provides oversight of treatment, compliance and outcome.
E. Patient records are maintained.

FDA:

A valid veterinarian-client-patient relationship is one in which:
  1. A veterinarian has assumed the responsibility for making medical judgments regarding the health of (an) animal(s) and the need for medical treatment, and the client (the owner of the animal or animals or other caretaker) has agreed to follow the instructions of the veterinarian;
  2. There is sufficient knowledge of the animal(s) by the veterinarian to initiate at least a general or preliminary diagnosis of the medical condition of the animal(s); and
  3. The practicing veterinarian is readily available for followup in case of adverse reactions or failure of the regimen of therapy. Such a relationship can exist only when the veterinarian has recently seen and is personally acquainted with the keeping and care of the animal(s) by virtue of examination of the animal(s), and/or by medically appropriate and timely visits to the premises where the animal(s) are kept. 

Oregon:

“Veterinary Client Patient Relationship (VCPR)”: Except where the patient is a wild or feral animal or its owner is unknown; a VCPR shall exist when the following conditions exist: The veterinarian must have sufficient knowledge of the animal to initiate at least a general or preliminary diagnosis of the medical condition of the animal. This means that the veterinarian has seen the animal within the last year and is personally acquainted with the care of the animal by virtue of a physical examination of the animal or by medically appropriate and timely visits to the premises where the animal is kept.  

California:

A veterinarian-client-patient relationship shall be established by the following:
  1. The client has authorized the veterinarian to assume responsibility for making medical judgments regarding the health of the animal, including the need for medical treatment,
  2. 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). This means that the veterinarian is personally acquainted with the care of the animal(s) by virtue of an examination of the animal or by medically appropriate and timely visits to the premises where the animals are kept, and
  3. The veterinarian has assumed responsibility for making medical judgments regarding the health of the animal and has communicated with the client a course of treatment appropriate to the circumstance.

Alabama:

Veterinarian-Client-Patient relationship (VCPR). A relationship when the veterinarian has assumed responsibility for making medical judgments regarding the health of the animal or animals and the need for medical treatment and is created by actual examination by the veterinarian of the animal or a representative segment of a consignment or herd.
 

Telehealth CE available at AVMA Convention 2017

The AVMA plans to include a two-hour, seven-speaker session on telehealth during the AVMA convention in Indianapolis. The session, “How does telehealth work in veterinary medicine?” was scheduled at press time for 4 p.m. Sunday, July 23, in rooms 138-139. 


Related JAVMA content:

Advisory panel report offers guidance on telemedicine (March 1, 2017)

AVMA panel to scrutinize telemedicine (Nov. 1, 2015)