Breaking With Tradition

The veterinary establishment needs to trust the judgment of practitioners and appreciate what a virtual VCPR can do for pet care.

Originally published in Today’s Veterinary Business.

As the adoption of telemedicine rises, discussions persist on the details surrounding virtual care. A point that pet health stakeholders haven’t agreed on is whether the veterinarian-client-patient relationship (VCPR) should be established virtually. This past April, May and June helped to sort out the differences in how organizations view the telemedicine VCPR, or more precisely, whether pet owners may start their relationship with a veterinarian through digital communications.

Three organizations that don’t restrict membership to veterinarians are open to pet owners using telemedicine to get started if the veterinarians are comfortable in their judgment that they have enough information. In other words, these organizations trust that veterinarians are capable of making sound judgments. If the veterinarians determine they cannot get started without an in-person visit, then the VCPR will be created only after a hands-on visit.

These three organizations are the:

• American Association of Veterinary State Boards (AAVSB)
• Veterinary Innovation Council (VIC)
• Veterinary Virtual Care Association (VVCA)

On the Other Side

The American Veterinary Medical Association and many state VMAs take the opposite view that veterinarians should not be permitted to judge that they received enough information during a real-time video engagement to launch a relationship with the pet owner and pet. These organizations insist the VCPR must be created only through an in-person visit.

There is irony in the fact that veterinarian-only organizations do not favor allowing veterinarians to use their judgment to make good decisions in establishing a VCPR. Put differently, the AVMA and certain state VMAs believe they must protect veterinarians from their own professional judgment. These organizations and their lawyers might use different words to characterize their positions, but the issue comes down to a fundamental difference in:

• Valuing the convenience or preference for how pet owners want to access care.
• Trusting otherwise good veterinarians not to make bad decisions if they are allowed to use telemedicine.
  In all but one state, human medicine ultimately elected to trust the judgment of doctors, much like the AAVSB, VIC and VVCA have chosen to trust veterinarians.

One of the benefits of telemedicine is improving access to care, which these three organizations have identified as a common goal and substantial issue. If the pet owner’s circumstances make getting to a clinic difficult or impossible, then respecting the consumer’s preference to use telemedicine to get started and supporting a veterinarian’s desire to provide quality care through telemedicine bode well for all.

It is difficult to understand how allowing a veterinarian to start pet care only through an in-person visit will expand access to care in America.

The Virtual VCPR at Work

During the COVID-19 pandemic, rules were relaxed to ensure pets received care. Support for the telemedicine VCPR relied on the use of a remote VCPR. The result? No data from any U.S. or Canadian jurisdiction about complaints filed over pets harmed through telemedicine.

If the data does not back up predictions that a telemedicine VCPR leads to harm, then what is the basis for the arguments advanced by some veterinary organizations? Is it a fear that veterinarians will be sued? Those fears are unfounded so far. The only malpractice lawsuits against U.S. veterinarians derive from situations in which an in-person VCPR was created.

Is it a fear that veterinarian incomes will decline? Again, no such evidence exists from telemedicine-friendly jurisdictions. Evidence over the past year suggests that practices performed better financially when telemedicine was part of the toolkit. And surely, public policy regarding the legal foundation of a client-pet-veterinarian relationship shouldn’t be based on a theory about how to maximize earnings.

Is it a fear that allowing a telemedicine VCPR will force all veterinarians to adopt the technology and change their manner of practice? That doesn’t sound fair, and it’s not accurate. Veterinarians aren’t required to practice a certain way, nor must they adopt specific technology tools. The organizations supporting a telemedicine VCPR are not calling for its mandatory use, only that veterinarians decide whether they are comfortable using it. It’s their choice.

A Recent Work-Around

Consider that all veterinary organizations embraced curbside service during COVID. The protocol change forced many veterinarians and staff members to communicate remotely with clients (the “C” in VCPR), and no one complained about an imperfect VCPR. The digital communication seemed to work just fine.

Is opposition by traditional veterinary organizations based on problems with telemedicine in human medicine? The evidence points in the opposite direction, and it’s hard to argue that 49 states are wrong after 30 years of human health care experience with telemedicine.

That might be the key to how we bridge the gap between the different organizations. Human telemedicine laws often utilize guardrails, or protective measures, to ensure best practices and good outcomes. The guardrails include:

• Privacy protections.
• A medical judgment that the telemedicine engagement provides adequate information to get started.
• Written consent by the patient (the pet owner in the veterinary instance).
• Providing the patient/owner with a choice.
• Restricting the right to prescribe certain medications without an in-person visit.
• These are the guardrails that the Michigan and New Jersey veterinary medical boards insisted on in approving a telemedicine VCPR. The Michigan VMA is attempting to pass legislation to reverse the Michigan board’s decision, so we’ll see how the case turns out. Perhaps the Michigan VMA could wait to see whether the state board’s regulations cause harm.

The remaining argument against the virtual establishment of a VCPR relies upon a U.S. Food and Drug Administration regulation that an in-person VCPR must be in place when a veterinarian prescribes an extra-label drug. Just remember that telemedicine was not an issue in veterinary medicine when the regulation was established. The FDA did not weigh a telemedicine VCPR versus an in-person VCPR, coming down on one side or the other.

The American Association of Veterinary State Boards, the Veterinary Innovation Council and the Veterinary Virtual Care Association are not calling for the end of a VCPR, only for the use of an alternative form if the veterinarian supports it and the pet owner agrees that it makes sense under the circumstances.

Ultimately, there are more similarities than differences among these veterinary organizations regarding virtual care. We encourage continued discussions in the areas of agreement and disagreement and with the common goal of advancing veterinary health care and access for pet owners.

Editor’s note: Five other founding members of the Veterinary Virtual Care Association contributed to this report. They are Deb Leon, Dr. Eleanor Green, Dr. Audrey Wystrach, Dr. Kerri Marshall and Dr. Aaron Smiley.