Telemedicine has knocked at the veterinary profession's door for nearly a decade.
It's taken a global pandemic to pry it open.
This week, Arizona became the latest jurisdiction to tell veterinarians that they may use telemedicine to diagnose and treat animals for the "duration of the state's public health emergency." No hands-on physical exam required.
That stance, adopted by the U.S. Food and Drug Administration and a number of states with stay-at-home orders in the wake of COVID-19, capsizes a near-universal belief that a hands-on exam is needed to establish a veterinary-client-patient relationship (VCPR), widely regarded as the foundation for all care.
The notion that remote care is risky for animals because they, unlike humans, can't tell doctors how they feel, has kept telemedicine advocates and vendors at bay — until now. As 2020 unfolds, the COVID-19 pandemic has upended the rules. Gone, at least temporarily, are many of the regulatory barriers that hindered widespread adoption of veterinary telemedicine.
The U.S. Department of Health and Human Services has responded to the public health emergency by temporarily allowing all medical professionals, veterinarians included, to prescribe certain controlled substances without first having a face-to-face exam.
The urgent calls for veterinary telemedicine beget larger questions about the future role of remote care in the profession, said Dr. J. Scott Weese, a zoonotic disease expert who heads infection control at the University of Guelph's veterinary teaching hospital in Ontario.
"If anything causes a revolution in veterinary medicine in terms of telemedicine, it would be this," Weese during a recent rounds session for the Veterinary Information Network, an online community for the profession and parent of the VIN News Service. "In two or three years, if we are not doing a lot more telemedicine, we are not going to be doing much telemedicine ever, because this is what is going to spark it."
While all cases can't be managed remotely, many can, Weese said. "If you have a dog that has acute diarrhea, and it's a household with an infected owner, we can manage that pretty well over the phone, Skype or FaceTime."
The value of remote care is its utility during a time that most Americans — and people around the world — are being asked or required to limit their activities in order to slow the spread of COVID-19. The disease has been confirmed in more than 213,000 people in the U.S., and killed more than 9,000. Worldwide, COVID-19 has claimed more than 52,000 lives, and the case count has topped one million, according to the Johns Hopkins University Coronavirus Resource Center.
In Arizona, an executive order issued by Gov. Doug Ducey asks the Arizona State Veterinary Medical Examining Board, which regulates the practice of veterinary medicine, to establish "reasonable requirements and parameters" for telemedicine services, including record keeping. Those requirements are under development, according to the board's website. "Please check back for updated information," it says.
Ducey's order doesn't give carte blanche. For telemedicine to work in Arizona, a veterinarian must be able to "gather sufficient information" to make a preliminary diagnosis, following minimum care standards. It also requires veterinarians to inform clients about telemedicine's limitations and "not charge more for a telemedicine visit than they would an in-person visit."
Many veterinarians first need to figure out how to charge clients at all.
The sudden need for veterinarians to provide care remotely has prompted a deluge of solicitations from telemedicine platform providers and spurred uncertainty among practitioners, many of whom have logistical and safety concerns regarding privacy, medical record keeping and invoicing.
In search of guidance, Dr. Kathy Doty of Eagle River, Alaska, posed a series of questions to colleagues in a recent VIN message board discussion:
"I just had my first FaceTime consult with a client of mine. But I do have a couple of questions: 1. Are you able to record your virtual conversations using FaceTime or Zoom? 2. If so, do you download them into your record software? 3. How are you charging for this service? This is definitely new territory for most of us."
Inroads for telemedicine
As of March 31, the American Veterinary Medical Association listed nine states — Alaska, California, Oregon, Pennsylvania, North Carolina, North Dakota, South Carolina, Texas and West Virginia — that have revisited their telemedicine rules for veterinarians in response to the COVID-19 crisis.
But not all have relaxed them. In a notice to practitioners, North Carolina clarified that the state's VCPR rules haven't changed. "The practice of veterinary medicine in the state of North Carolina requires the establishment of a veterinary-client-patient relationship," the notice said. "This can only take place with a physical examination of the animal in question. It cannot be established over the phone, Skype or other online source."
The federal government has done the opposite. Last week, the FDA announced that it would ease restrictions, effective immediately.
That means suspending its enforcement of VCPR guidelines that, under normal circumstances, require veterinarians to conduct in-person examinations before prescribing extra-label drugs and issuing veterinary feed directives. Both of those tasks now can be done remotely, thereby limiting human-to-human interaction and potential spread of COVID-19, the agency said.
"This pandemic has had impacts on many of our everyday lives and professions, and during this time, we need to provide veterinarians with the latitude to expand the use of telemedicine in the care of animals, not only pets but also the animals that produce our food," FDA Commissioner Dr. Stephen Hahn said in the press release.
The FDA's authority is limited to veterinary feed directives and extra-label drug use. When it comes to other aspects of veterinary telemedicine, state boards govern when and how veterinarians are permitted to care for pets remotely.
FDA spokesperson Siobhan Delancey said by email that the eased federal VCPR requirements are "not meant to supersede state authorities, which are still in effect," adding, "(although it's come to our attention that some states are making their own determinations about enforcement discretion during this time)."
Conflicting messages
Executive orders regarding telemedicine aren't unique to Arizona.
In mid-March, Pennsylvania Gov. Tom Wolf announced that he'd permit the use of telemedicine by health professionals licensed by boards within the Pennsylvania Bureau of Professional and Occupational Affairs, veterinarians included, during the coronavirus emergency.
He also granted the department authority to allow out-of-state professionals to treat Pennsylvania residents via telemedicine. "Currently, no Pennsylvania law prohibits the practice of telemedicine," the executive order states.
While that's true, Dr. Mary Jane McNamee, a veterinarian and attorney with the Pennsylvania Veterinary Medical Association, cautions practitioners against using telemedicine to treat patients without first having established a VCPR with a "reasonably recent" in-person physical exam. "[K]eep in mind that our Pennsylvania Board of Veterinary Medicine and Veterinary Practice Act clearly states that a VCPR is required in order to diagnose, treat and deliver medical services," she wrote in a letter to PVMA members dated March 25.
McNamee surmised by phone that the governor's inclusion of veterinary medicine in his order might have been an oversight: "Basically, we don't believe veterinary medicine should have been listed in the exemption for out-of-state telemedicine. Our state board has that VCPR in place, which supersedes anyone coming in to Pennsylvania to practice medicine via telemedicine."
For in-state veterinarians, McNamee urges the use of "your best professional judgment" when assessing non-emergencies that can be addressed remotely. "The necessity of physical exam and an established relationship cannot be overstated," she said in the letter. "However, we must temper this with human public health and safety, and mitigate interaction with clients."
Even if state regulations do not specify that the basis of a VCPR is a hands-on physical exam, regulatory board policy can dictate it. That's the case for some 3,500 veterinarians practicing in Ohio, said Jack Advent, executive director of the Ohio Veterinary Medical Association.
Similar to how regulators treat veterinary telemedicine in other states, Ohio Revised Code implements the "same parameters for VCPR that you basically see everywhere: that you have recently 'seen the animal,' " Advent explained. "The board's interpretation, however, is that you've actually physically seen it, not just observed on a screen, within the prior year.
"And so the view of the [Ohio Veterinary Medical Licensing Board] is that there needs to be a physical, in-person exam for a VCPR to be established," he said.
That doesn't mean regulations can't bend temporarily.
On behalf of OVMA members, Advent has asked the licensing board to discuss whether VCPR rules should be relaxed on telemedicine. "The issue has been raised, so they should at least say, 'yes, we're going to do it,' or 'no, it's not appropriate,' " he said.
Such discussions could happen during the board's meeting on May 13, which will take place remotely. The VIN News Service was unable to reach board staff to confirm that telemedicine is on the agenda.
Advent hasn't heard from many veterinarians clamoring to use telemedicine, but he knows there's interest — and likely to be more as COVID-19 spreads. The question of VCPR is just one hurdle; the logistics of implementing telemedicine is a lot for a practicing veterinarian to digest, especially during a crisis, Advent said.
"The hard part is trying to figure out how to charge for it, and making sure the communication with clients is captured appropriately in medical records," he said. "Once we're through all this, I can see people coming back and revisiting this, and trying to get something established. When we get that window, we'd better be thinking about how we're going to deal with telemedicine [post crisis]."
Global perspective on remote care
Other countries that have implemented measures, from travel bans to lockdowns, to quell the spread of COVID-19 also are looking to veterinary telemedicine as a means for striking a balance between providing care for animals and safeguarding profession and public health.
In mid-March, the World Organisation for Animal Health (OIE) declared veterinary services to be "essential activities," in response to shutdowns across Europe of non-essential businesses. In a joint statement with the World Veterinary Association, the OIE deemed veterinarians an "integral part of the global health community." Many governments agree, permitting veterinary practices to stay open.
But in Italy, where COVID-19 has killed more people than in any other country to date, plenty of veterinarians are doing much of their work remotely, limiting in-person exams to emergencies. In a statement on March 20, the National Association of Italian Veterinarians said practitioners in the country are "applying rigorous biosecurity protocols and measures for limiting social mobility prescribed throughout the national territory."
Authorities in other countries, too, encourage veterinarians to use telemedicine when possible and defer non-urgent procedures. Last week, the Royal College of Veterinary Surgeons, the U.K.'s chief regulatory body, temporarily suspended its code of professional conduct to allow veterinarians to prescribe medications remotely without first physically examining patients.
Under normal circumstances, the RCVS Code of Professional Conduct for Veterinary Surgeons mandates a physical exam as a prerequisite to remote care. Suspending the requirement adheres to government-imposed stay-at-home orders in the U.K. by reducing face-to-face contact between veterinarians and the public. RCVS officials say they'll periodically review the change, which they say is unlikely to extend beyond June 30.
Until then, veterinary practices should remain open only for urgent and emergency care and to maintain the food-supply chain; non-urgent and non-emergency cases should be handled remotely, according to the British Veterinary Association. To help clinicians determine whether cases are critical, BVA officials developed a guide to what constitutes emergency, urgent and routine care.
"Vets and members of the veterinary team deemed essential to deliver this emergency care can travel to and from work," a BVA notice states. "Other members of the team should work from home if possible (for example, handling calls and triaging cases) or not work …"
In response, CVS Group, the largest publicly traded veterinary corporation in Britain, has temporarily shuttered half of its small animal practices. CVS owns more than 500 veterinary practices throughout the U.K., Netherlands and Republic of Ireland.
"All clients will continue to be able to access practices for urgent and emergency care within a 40-minute drive," the company said in a statement posted last week for investors. "Teleconsultations will continue to be offered to clients with non-urgent or non-emergency cases, and these will be charged for at normal consultation rates. The RCVS has relaxed the rules on remote prescribing in support."
Update: On Feb. 21, 2023, the FDA ended its temporary relaxation of the requirement that a hands-on examination be done to establish a VCPR.