Practice Management

Telemedicine Slowly Advances in Equine Practice

By Paul Basilio

In human medicine, telemedicine is old hat. It’s been around for decades and, mostly because of the COVID-19 pandemic, it has been thoroughly integrated in the everyday clinical workflow.

Veterinary medicine, on the other hand, has been slow to adopt telemedicine, in part due the constraints of the veterinarian-client-patient relationship (VCPR), which can vary from state to state.

“That’s the specific issue,” said Charlotte Lacroix, DVM, JD, during a presentation at the 70th AAEP Annual Convention in Orlando. “Do I need to examine the animal, and should that requirement be dictated by the law, or should it be determined by the professional judgment of the veterinarian at the time, for the specific patient and circumstances?”

What’s the Law?
The American Veterinary Medicine Association is a trade association with no legal authority. It does, however, have a model practice act, and if a state adopts that practice act, it then becomes law. According to the AVMA’s practice act, “veterinary telemedicine should only be conducted with an existing [VCPR],” except in the cases of emergency. The following conditions must also be met to establish a VCPR:

• The veterinarian has assumed responsibility for making clinical judgments regarding the patient’s health, and the client has agreed to follow the veterinarian’s instructions.
• The veterinarian has sufficient knowledge of the patient to initiate a general or preliminary diagnosis of the patient’s medical condition.
• The veterinarian is readily available for follow-up evaluation or has arranged for veterinary emergency coverage and continuing care and treatment.
• The veterinarian provides oversight of treatment, compliance, and outcome.
• Patient records are maintained.

The key condition, according to Dr. Lacroix, is what constitutes “sufficient knowledge.” She identified several key questions that must be answered before the issue of telemedicine can be settled, and large-scale implementation can proceed:

• At what point do veterinarians have sufficient knowledge so they can make an assessment, a preliminary diagnosis and a treatment plan?
• Who decides whether the veterinarian has sufficient knowledge?
• Must a physical exam be performed every time a veterinarian sees a patient to have sufficient knowledge?

“These are the questions before you, these are the questions before the industry, and these are the questions before the public,” said Dr. Lacroix, who is the owner of Veterinary Business Advisors in Whitehouse Station, N.J. “Telemedicine is readily available for [clients] to see their physicians, and they’re trying to figure out why they can’t do it with their veterinarians in the states that prohibit it.”

The AVMA model practice act goes on to say that a VCPR cannot be established solely by telephonic or other electronic means, but that once established, a VCPR may be maintained between medically necessary examinations via telephone or other types of consultations.

“Once you’ve seen an animal, you can go ahead and do virtual exams after that,” she said.

The laws are slow to change, but they do change—sometimes. In 2017, the AVMA approved language that stated any advice given by any medium outside of an established VCPR must be general in nature and not specific to an individual animal, diagnosis or treatment. However, the AVMA also states that an exception can be made in emergency care situations. In those cases, medical advice can be given via telemedicine until the patient can be seen by or transported to a veterinarian.

Before those exceptions, veterinarians could easily be in violation of the practice act in common situations.

“I would be suturing a horse at 10 o’clock at night, and then I would get a call from someone who tells me their horse has colic,” Dr. Lacroix said. “I would tell them to give the horse 10 mL of flunixin, and I’d be there as soon as I could. That would have been a violation of the VCPR [before 2017].”

Over time, she said, a scenario in which a client must wait for a veterinarian to arrive and perform a physical examination on the horse may be considered substandard care.

“Sometimes it may be better for a veterinarian to have seen the environment that the horse is in beforehand, or see a picture of the horse first,” she said

The question of whether a physical examination is necessary to establish is largely left up to individual states. The Veterinary Virtual Care Association (VVCA) has an interactive map to show each state’s requirements for establishment of a VCPR (https://vvca.org/resources/telemedicine-map/), but Dr. Lacroix is confident that the law will come around, and that practitioners will be able to fully employ a telemedicine aspect of their practice.

“My recommendation is that every practice in America should be trying to figure out how they’re going to practice telehealth,” said Dr. Lacroix. “Put in the technology, put in the guardrails, beta test it, see how it works for rechecks and cases where you’re already allowed to use it. When it does become legal—and I think it will, eventually—you’re already set and you can do it the right way.” MeV

For more information about the AVMA’s Veterinary Model Practice Act, visit: https://www.avma.org/resources-tools/avma-policies/model-veterinary-practice-act