AVMA seeks your opinions on telemedicine recommendations

ComputerDr-GettyImages-508064826You may recall that the AVMA has been investigating telemedicine and how it might be used appropriately within the veterinary profession. A benchmark in that investigation has been reached in that the AVMA’s Practice Advisory Panel, which was assigned the issue, has provided its final report to the Board of Directors.

The AVMA now wants your input, especially on the Practice Advisory Panel’s recommendations regarding the AVMA’s Model Veterinary Practice Act and the policy on Remote Consulting, the summary of which starts on page 37 of the report.

Please send comments to Telemedicine@avma.org no later than March 15, 2017.  Your input is important! AVMA leadership will consider input received by the deadline as it deliberates potential AVMA policy, strategy, and resources on telemedicine.

20 thoughts on “AVMA seeks your opinions on telemedicine recommendations

  1. While I do feel that telemedicine is the way to go for humans, I admit to feeling somewhat reserved about using the process for my pets. The only reason being that they cannot speak to tell me what their symptoms are, and their veterinarian can palpate and do physical testing that simply cannot be completed via Skype.

  2. I think one root question that that needs to be assessed is “Who does telemedicine benefit?” The VIC holds it out as the long-sought-after key to getting more veterinary visits and more veterinary income for clinics as if somehow a telemedicine consultant will make for an A-list client. I doubt very much it will.

    Clients are notoriously inaccurate when it comes to their assessment of their pet’s medical status. Sole reliance on their input, rather than a physical examination, will not help patients.

    Telehealth consultation from doctor to doctor can help patients. We speak a common language and collaboration will help better patient care and outcomes. But the relationship of one doctor to another is vitally different from the relationship of pet owners to veterinarians.

    I can see this as a service that some clinics will offer for some patients in some circumstances, but diagnosing and treating veterinary patients needs to start with a hands-on examination and meeting of doctor and client. Those form the core of the VCPR and basis for accurate thinking (as well as establishing the reputation of veterinarians).

    Variance from the VCPR, if the relationship can *start* with a telehealth consultation (rather than be a part of overall case management) will not help the profession or its patients.

  3. Telemedicine may benefit startups or those trying to make easy money without much investment. I think telemedicine in the form of remote diagnosis, consult and treatment with a licensed DVM is a terrible idea and the animals will suffer -as will the reputation of our profession.
    After 32 years in the profession I know how frequently clients get it wrong over the phone. Sometimes the pictures and videos they send me are very helpful (when they are already patients or have followup consults) BUT-there is no substitute for a good physical exam by a DVM.
    I do not think telemedicine can fulfill a valid VCPR and is an idea that our profession will be sorry if it ventures down this path. If the goal is reaching more underserved pet owners then invest/develop/help expand House Call DVMs. I see telemedicine as companies just trying to make another exploitive $ off of pet owners.

  4. The only place I see telemedicine reliable is inter-doctor communication. As far as clients, there are few exceptions with a valid VCPR and recent exam where it is reasonable. An example being a home BG curve for a diabetic patient. This is a situation where adjustments without exam MAY abnd could very well be reasonable.
    I see no place for telemedicine without a recent exam and valid VCPR. For all the reasons stated above, this is a topic that needs to be carefully worded and strongly apposed. Telemedicine opens up bad precedent for care and tons of liability. Animals are not people, we can’t always follow everything in the human medicine world, no matter how much people like convenience. I could go on and on about why this is a bad idea, but it’s already been said.

  5. Last week I, and likely many reading this, received an email from NAVC (now renamed VMX) asking for comment on what appears to be an emerging struggle between NAVC’s Veterinary Innovation Council (VIC) and the AVMA.

    In the minds of its membership, AVMA is supposed to exist to support its membership. I have been an outspoken critic of AVMA’s failure to represent its membership on several fronts. However, in this case I think AVMA has gotten it right.

    The email from NAVC is a call for comments on AVMA Practice Advisory Panel’s white paper on telemedicine/telehealth. It also contains a link to the NAVC’s response to the white paper: http://navc.com/download/VIC_Letter.pdf?_zs=KXcPd1&_zl=qwrf3 .

    Curiously NAVC’s email does not provide a link to the AVMA’s public comment site. It contains links that launches emails to NAVC and AVMA. A suspicious mind might wonder why, and if all comments received will be shared or will they be cherry picked? I encourage all with opinions to post them publicly at: http://atwork.avma.org/2017/01/20/avma-comments-open-telemedicine-recommendations/

    Most of the comments posted on the AVMA site thus far concur with my sense of the views of colleagues in practice.

    The debate does not center around what most colleagues think of as telemedicine — technology based interactions that allow them to consult with a specialist or other colleagues. Instead it centers around technology that enables interactions with patients and clients and whether a prior VCPR should be required before a veterinary consultation can be conducted via these technologies.

    Many veterinarians already use technologies to remotely monitor their current patients and make healthcare decisions with the patient’s owners — including telephone follow-up, text messaging, email, videos, Facetime, and even early versions of bio-sensors (similar to Fitbits).

    As a veterinarian, I can derive a lot of information from history and information clients can collect under my direction, such as body temperature, respiratory rate, and even heart rate. But there are severe limitations to client-derived observation, and I have countless personal examples where owner-derived data and images shaped a very different clinical picture than what emerged from putting my hands and eyes upon the patient.

    As much as our profession looks toward our MD counterparts as examples to follow, diagnosis in our non-human patients is very different from diagnosing human patients. We can assess clinical signs, but not symptoms.

    Humans can report where it hurts, the location of lumps and bumps on their body and how they feel. As most of us can attest from our own medical experiences, this has increasingly driven the myopic focus of a physician visit today, with less and less emphasis on complete physical examinations. This is not a trend our profession should emulate.

    I have little doubt that in human medicine, the technologies under debate are effective for triage, but there is not much literature documenting effectiveness vs. limitations for diagnosis. This form of triage is useful for helping determine whether a patient needs to be seen by a doctor and to address routine concerns such as fleas and minor lacerations, but should not, in my opinion, be used to determine diagnosis or therapy for anything but the most minor of complaints without a prior and recent understanding of the patient’s medical history, in essence an existing VCPR.

    Even on the human side, with the growing availability of “video appointments” and other telemedicine options, there is a recognition of both the lack of convincing research regarding these technologies and of the need for an established physician-patient relationship. The 2015 American College of Physicians position paper on the subject http://annals.org/aim/article/2434625/policy-recommendations-guide-use-telemedicine-primary-care-settings-american-college, includes several statements relevant to veterinary medicine:

    ACP believes that there is a need to develop evidence-based guidelines and clinical guidance for physicians and other clinicians on appropriate use of telemedicine to improve patient outcomes.

    ACP believes that a valid patient–physician relationship must be established for a professionally responsible telemedicine service to take place. A telemedicine encounter itself can establish a patient–physician relationship through real-time audiovisual technology. A physician using telemedicine who has no direct previous contact or existing relationship with a patient must do the following:

    a. Take appropriate steps to establish a relationship based on the standard of care required for an in-person visit, or

    b. Consult with another physician who does have a relationship with the patient and oversees his or her care.

    ACP believes that episodic, direct-to-patient telemedicine services should be used only as an intermittent alternative to a patient’s primary care physician when necessary to meet the patient’s immediate acute care needs.

    True, a large segment of pets and pet owners fail to seek veterinary care, and technology has the potential to bring better health care to some who do not have ready access to a veterinarian. However, after decades of overseeing online forums for pet owners, I believe these technologies are unlikely to overcome the desire of many of these pet owners to obtain information free.

    The four primary competitors for the public’s trust as the main source for credible information are breeders, groomers, Dr. Google and big box pet retailers.

    Each of these sources contribute to the well-being of pets and education of the pet owning public, but they are not experts in medicine. Veterinarians are. We should not try to compete with these other pet information sources by lowering our standards of care.

    As an outsider to this disagreement between the AVMA Practice Advisory Panel’s findings and NAVC/VMX’s Veterinary Innovation Council (VIC), I suspect the VIC is motivated by industry affiliations and a desire to participate in and profit from a platform central to the interchange between veterinarians and pet owners.

    If this is the best solution for pets, pet owners and veterinarians, there is nothing wrong with profit. However I don’t believe that is the case, especially in the absence of a prior established VCPR.

    This issue will evolve, as will technologies. I can’t say that someday we won’t be able to perform a thorough examination of a patient via remote technology. But that day is far off.

    In this case I think the AVMA report has it right by emphasizing the need for a VCPR and is standing up for their members’ best interests – as well as the best interests of their members’ patients and clients.

    What do you think?

    >>Paul<<

    Paul D. Pion, DVM, DACVIM (Cardiology)
    co-founder, VIN
    Davis, CA

  6. The Practice Advisory Panel’s recommendations are both comprehensive and direct. The diligence and research efforts of the working groups are evident.

    As the AVMA continues to develop strategy for ensuring the appropriate use of telemedicine I would encourage attention to the difficulties that state boards of examiners face when attempting to enforce adherence to the practice acts and the definition of the VCPR within those acts.

    The practice act in Tennessee includes this statute: The veterinarian-client-patient relationship cannot be established or maintained solely by telephone or other electronic means. (TCA 63-12-103 (17)(f). There is at least one corporation that is actively recruiting clients and veterinarians for telemedicine services in Tennessee that flagrantly violate this statute. The corporation has ignored a cease and desist order from the Tennessee Board of Veterinary Medical Examiners. When the Tennessee VMA leadership called this to the attention of the Bof E we were told that no action could be taken without a complaint from a client who had used the services of this corporation.

    I am sure that other state VMAs have encountered similar situations when advocating for their members and for equal application of state laws governing veterinary medicine. Going forward, I encourage AVMA to not only assist states in clarifying the VCPR in their practice acts, but to also look at ways to support and advise those charged with enforcing these practice acts in order to better protect veterinary patients and their owners.

    Susan Moon, DVM, Immediate Past President, Tennessee Veterinary Medical Association

  7. Hi AVMA, i really appreciate the initiative of this Draft and It’s been an honor for me to contribute to this work as a member of the T-Working Group.

    I have a few comments (Chapter after Chapter) detailled below. Some of These comments were discussed previously with the member of the Working Group but I think that in the finally Draft some precisions must be completed.

    1) 1. Executive summary: Telemedicine practice situations without VCPR: “…The AP recommends that telemedicine shall only be conducted within an existing VCPR, with the exception for advice given in an emergency care situation until that patient(s) can be seen by or transported to a veterinarian.”

    Those emerging care situations should be listed or specified in this section or in another part of the Draft.

    2) 3. Definitions / Same remark as for the section: 4.4. Telemedecine and veterinary medicine regulations/
    The VCPR definition, and requirements: …The notion of timely visits to the patients” :
    In my opinion in some cases such as Planned preventive health program for herd/flocks (vaccination, deworming programs…as stated in the Section 4.4.2.: Physical examination of the animals by a veterinarian may not be systematically done, instructions can be sent to the animal health technicians or to the animal’s owners.

    3) 3.3. VCPR in conjunction with the MVPA / “…The practice veterinary medicine in the State is not allowed without the context of VCPR /The same remark as in the sub section: 4.4.3.2. Accountability for advice given.

    The list of the 4 states: (Alaska, Maine, Washington, and Columbia) without existing of VCPR conditions that are an exception to this requirement must be listed in the section.

    The other exceptions for which VCPR conditions may not be required, such emergency cases, and consultancy should be added to the definition.

    4) 3.4. Telehealth, telemedicine, and mHealth scheme, Same remark as in the section: 4.3. Categories of telemedicine regarding The scheme of telemedicine

    If we look at the definitions of telemedicine subcategories there may be wrong interpretation of the scheme: About me Telemedecine should encompass the whole: tools (technologies) and the practices.
    In the section 4.3 Categories of telemedecine: telemarketing and Advocacy doesn’t involve animal care or veterinary medication:

    Can this subcategory be considered as veterinary care or veterinary medicine?

    5) 3.5. Consultant and veterinarian of VCPR/ Same remark as in the section 4.4.1. Location(s) of the act of practicing veterinary medicine when utilizing telemedicine/ Same remark for the section: 8.1. Recommendations pertaining to existing AVMA policy : The definition of a consultant: a consultant does not establish a VCPR, but advises the veterinarian of VCPR

    Without any other specified requirements in this definition (location for example) a consultant can be located everywhere and outside the USA. Does the AP agree with this ?

    6) 4.3.1. Client-facing telemedicine: The virtual exam of the patient through real-time video or by attached pictures in store and forward modalities…” Isn’t the virtual examination of the patient in opposition with VCPR act ?/ Physical examination is required in VCPR

    7) 4.3.2. Nonclient, public-facing electronic communications/ Non clients and the electronic communications

    For me in this section a veterinarian is only delivering advices in general terms and anyone else can substitute the veterinarian as he/she is not delivering animal care, and no VCPR is required. Is this practice can be considered as veterinary medicine practices?

    8) 4.3.2.2. Educational websites and applications / Same remark as in the section: 7.2.2.2. Non veterinarians offering animal health and welfare advice

    This subsection refers to telehealth, teleeducation, or on health information websites broadly: For me in some cases telemedicine car rely on these tools, but not in all the cases: publishing some tips on animal health on a website doesn’t necessary means practicing veterinary medicine on delivering animal care.

    The section 7.2.2.2: Can education websites for consumers about animal welfare for example, or animal health information websites be included in telemedicine while they don’t involve the practice of veterinary medicine itself ?

    9) 4.4.2. Advice vs. practice, and accountability for both: “Any advice given via any medium outside an established VCPR must be given in general terms, not specific to an individual animal, group of animals, diagnosis, or treatment.”

    In some cases advices or recommendations have to be adapted to an animal as an individual: for behavior specialists for example, their advices may be adapted to an animal as an individual, based on the patient past health records in order to be effective…

    10) 6.2. Technology and data use by consumers the same remark as in the section: 7.2.1.1. Veterinarians and veterinary students: “…Technologies without any clinical input…”
    “Without a VCPR and until current regulators are modified, telemedicine should not be practiced, and any advice given should remain in general terms…”

    At this point I think that there should be a distinction between technologies that provide or improve patients wellness and technologies that are involved in the practices of telemedicine (diagnosis, analysis,…) as it is the case in human medicine.

    In the absence of any regulatory basis such as in this case of policy vaccum, a practice cannot be forbidden about me.

    11) 8.2. Recommendations and guidelines not pertaining to existing AVMA policy: “The legal accountability and recourse for telemedicine should be at both places: where the patient is and state of the veterinarian”:

    What if the regulation is different in both States or countries?

    Thank you again, i hope that all the comments will be helpful for the needed updates of the regulations for telemedecine practice in animal health.

  8. Others have said it more eloquently. I agree with them. We are dealing with animals who cannot speak and tell us their symptoms, unlike humans. The animal’s signs are being filtered through the perceptions of their human owners. I think telemedicine has its place and could be used as part of a physical examination, in a sense “seeing” the pet. However, I am very concerned that the lack of the ability to palpate, auscult, etc., will cause injury.

  9. As I often say to my staff, do we want to copy human medicine practices? How’s that been working for you as the patient? (Most have been dissatisfied) I think telemedicine is great the way we use it now….As veterinarians consulting other veterinary specialists. As we all have experienced, the description owners give on the phone when making the appointment often is far different than the problem that presents on arrival at the appointment! How can you weed that out without being “hands on”? Is that really in the best interest of the client or the patient?

  10. As I often say to my staff, do we want to copy human medicine practices? How’s that been working for you as the patient? (Most have been dissatisfied) I think telemedicine is great the way we use it now….As veterinarians consulting other veterinary specialists. As we all have experienced, the description owners give on the phone when making the appointment often is far different than the problem presents on arrival at the appointment! How can you weed that out without being “hands on”? Is that really in the best interest of the client or the patient?

  11. I spent 7 years on the Veterinary Examining Board for Wisconsin. I embrace the VCPR. However, we practice in a rural area and do a LOT of canine reproduction. Sadly, we see a lot of badly handled reproduction cases and think that advising the client accurately would be better than what their local vets are doing. The frustration is the local vet should be collaborating with us for pyometras, high risk pregnancies, prostate disease, neonatal care, infertility and so on. However, they trip over their egos and can’t pick up the phone to talk to us, despite our open approach.
    So yes, I believe telemedicine has its place. If they are OK with it in humans, why not our veterinary patients?

  12. I like the idea of Tele- Veterinary Medicine and to some extend I already practice it, mainly with old time clients that live in distant locations where I had practice before semi retiring and with whom I have had a good, solid profesional relationship and their trust with their newer pets.
    Some of the topics that will be of interest for me to pursue will include:

    1. English/Spanish Veterinary Medical Interpretation and translation services.

    2.Case consultation on Integrative Veterinary Medical care and nutrition.

    3.Wellness advise for their pets.

    4. Hospice care and advise.

    5. How to charge for my services?

  13. In this digital age, I believe the human animal bond is ever more important. This bond extends to veterinary medicine in the form of the VCPR. Closely observing and examining a patient over a lifetime gives priceless information to the clinician and builds trust with the owner. There are just too many instances where the observation of the live animal made all the difference in its diagnosis for me to endorse telemedicine. The smell of a ketotic diabetic, the feel of tacky mucous membranes – those would be missed by telemedicine. Additionally, having the client describe the patients situation second hand is different than a human describing their own personal problems to a physician.
    Let’s watch our footing on this slippery slope.

  14. There is no appropriate use for telemedicine. We give advice over the phone to existing clients about existing problems – end of story. If the veterinarian in question has never seen the animal (and no one in their practice has either) then making recommendations for it (beyond “go to a vet near you”) is foolish at best, malpractice at worst.

  15. Veterinary telemedicine is a solution looking for a problem.We can draw comparisons to human telemedicine but it really is a completely different ballgame.In human medicine there is a need to reduce the workload on MD and ERs and telemedicine makes sense in weeding out the simple and routine problems.Secondly the specialization in human medicine means that the telemedicine services can be targetted and limited in their scope and the compensation for these services by insurance companies makes them attractive as a way to lower medical care costs.

    In veterinary medicine we potentially have a much broader range of potential problems to deal with and we have to be very careful we dont weaken the VCPR. The licensing and state to state board differences make telemedicine a potential minefield to legislate.Would it be OK to have a vet answer a question for a patient in a state he/she isnt licensed? is something goes wrong with a telemedicine consult and the patient dies due to bad advice or the owner not following advice where does the liability lie? Would it be OK for a telemedicine vet to interpret blood reports, review radiographs or comment on cell phone pictures or would that be considered malpractice since there is no way to verify that the tests you are looking at belong to the patient you are discussing. What happens if a client gets a telemedicine review as a second opinion that disagrees with the vet that saw the patient.If that patient does poorly can the telemedicine vet be called as a witness?

    Telemedicine is also a poor way of generating revenue and it potentially can reduce patient visits to veterinary hospitals.Unlike human medicine there is no shortage of veterinary care in most areas and in the “underserved” areas telemedicine cannot in any way replace a veterinary examination.

    Technology is advancing faster than legislation so there is a need to plan for this and I am sure there will be veterinarians wanting to provide this service.We must ensure that a sensible and well thought out approach to this is figured out for the sake of our patients and the next generation of veterinarians.

  16. I firmly believe that telemedicine is opening us up for a huge amount of liability. However teleconsultation is much more appropriate with a primary caregiver directly connected to the patient and being the profesional consulting other profesionals. Teleconsultation though needs to be perhaps more regulated.

    • Anne: My thoughts exactly. The VPCR is absolutely necessary to prevent medical errors and the resulting liability. Teleconsultation has great potential, but only via an established VPCR on the other end as the communicator and medical manager. Telemedicine as a substitute for a primary veterinarian is unethical, and will only harm our patients and our profession!

  17. Strongly approve of the careful wording about VCPR and telemedicine, and the role of consultants without VCPR. Nice job.