Just a click away: Will Telehealth Create Virtual Veterinarians?
Digital technology permeates our daily lives and has substantially changed — for better and for worse — how we work, shop, play and interact with those around us. It’s also changing human healthcare, including how it’s accessed and delivered. By “virtually” erasing hundreds, even thousands of miles between physicians and patients, telehealth is broadening access to specialty care, making home health monitoring easier and simplifying chronic disease management.
Veterinary medicine often follows trends in human medicine. Telemedicine is currently a hot, and sometimes controversial, topic across the veterinary profession. As veterinary professionals know all too well, what pet owners want and what’s best for pet safety don’t always align. The big question: Is telemedicine really in the best interest of our pets? Before we answer that question, some definitions and perspective may be helpful.
Welcome to the “tele” world of health and medicine
Telemedicine and telehealth are often used synonymously. However, groups like the American Telemedicine Association (ATA), American Veterinary Medical Association (AVMA) and Veterinary Innovation Council, which was created by the North American Veterinary Community (NAVC), find it useful to differentiate between the two:
Telehealth — As defined by the Veterinary Innovation Council and AVMA, telehealth is the overarching term that comprises all uses of electronic technology to remotely deliver health information, education or care. In human healthcare, services such as wellness coaching, health information websites (e.g., WebMD) and nurse triage or advice lines are considered telehealth services because their primary function isn’t diagnostic. In many companion animal practices, veterinarians and veterinary technicians have been providing telehealth services to their clients for years. Phone calls to follow up on their patients’ condition after surgery, injury or newly diagnosed health issues (e.g., diabetes mellitus, chronic kidney disease), emails to provide additional information about medications or a particular health condition and veterinary practice websites are all examples of veterinary-specific telehealth offerings.
Telemedicine — A subcategory of telehealth, telemedicine is a tool, or use of an electronic tool, to supplement and enhance the practice of medicine. An example from human healthcare is the website Virtuwell.com, where you can consult with a board-certified nurse practitioner about certain categories of medical conditions and receive a diagnosis, treatment plan and prescription (if necessary). In veterinary medicine, a companion animal veterinarian may use Skype or an app to see a patient for a postoperative follow-up exam and communicate with his or her client.
Two additional subcategories of telehealth are also worth defining, especially since many veterinarians and their clients are already using them:
Teleconsulting — The Veterinary Innovation Council defines teleconsulting as a subcategory of telehealth that happens when a general veterinary practitioner uses telehealth tools to discuss a particular patient’s care with a veterinary specialist. Whether sending digital radiographs via email to a board-certified veterinary radiologist located halfway across the country for interpretation or discussing lab results by telephone with a board-certified veterinary pathologist located across town, veterinarians are using this aspect of telehealth regularly and have been for years.
mHealth (mobile health) — mHealth is another subcategory of telehealth that uses mobile devices and the Internet of Things (or more appropriately, the Internet of Animal Health Things). While some mHealth apps and wearables are meant to be used by veterinarians (e.g., CardioPet ECG Device and AliveCor Veterinary Heart Monitor), others are designed for use by and marketed directly to pet parents (e.g., FitBark — think FitBit for dogs).
With this information in mind, let’s take a look at what veterinary industry leaders think about incorporating telehealth and telemedicine into practice.
Key veterinary associations support telehealth and telemedicine
Earlier this year, the AVMA Practice Advisory Panel released its final, 42-page report on telemedicine, which was followed by passage of the association’s policy on telemedicine and revisions to the model veterinary practice act. More recently, the AVMA, the Association of American Veterinary Medical Colleges (AAVMC) and the American Association of Veterinary State Boards (AAVSB) issued a joint statement regarding the role of telehealth and telemedicine in veterinary medicine. The associations recognize the opportunities offered by veterinary telehealth and telemedicine and support veterinarians’ use of digital and mobile technologies to:
- Enhance delivery of top-quality veterinary medical care
- Improve access to veterinary care
- Foster better client communications
There are a couple aspects of the AVMA’s policy on telemedicine that are worth highlighting. First, telemedicine is considered a tool to be used to augment the practice of veterinary medicine. It’s not a separate medical specialty. Telemedicine also isn’t intended to replace a veterinarian’s clinical judgment and expertise.
Second, veterinary telemedicine should be conducted only within an existing veterinarian-client-patient relationship (VCPR), with the exception for advice given in an emergency until the patient can be seen by a veterinarian (e.g., emergency teletriage performed by animal poison control centers). The AVMA’s principles of veterinary medical ethics and the veterinary practice laws of every jurisdiction except Alaska, Connecticut and the District of Columbia spell out the requirements for a valid VCPR, which is traditionally established through an in-person or physical examination of the pet. And several states have laws on the books that specifically prohibit creating a VCPR solely online, via email or over the phone. Without a valid VCPR, veterinarians cannot legally (or ethically) provide diagnoses or prescribe treatments.
In addition, federal regulations limit companion animal veterinarians’ ability to prescribe drugs in an extra-label (or off-label) manner without first establishing a VCPR. While more medications have approved indications for use in dogs and cats, it’s still challenging for companion animal veterinarians to practice without reaching for extra-label drugs.
Third, the same standard of care that applies to face-to-face veterinary medicine applies to veterinary telemedicine. Telemedicine doesn’t permit an easier standard of care; it could actually require a higher standard. The standards for record-keeping are the same, whether care is provided in-clinic or via electronic means. What this means for veterinary professionals and their clients is that telemedicine may not be appropriate for every case or patient presentation.
DRIVING FORCES BEHIND VETERINARY TELEHEALTH AND TELEMEDICINE
Aside from the rapid acceptance and growth of telemedicine in human healthcare, several other forces are behind the spread of telemedicine and telehealth into veterinary medicine.
Access to care is a key advantage of telemedicine, whether we’re discussing human or veterinary healthcare. In fact, the birth of telemedicine was really about providing access to rural and underserved communities. The internet and dramatic growth of increasingly user-friendly mobile technology has driven awareness of online resource availability and enabled access to veterinary services from practically anywhere. In some situations, easy access may mean the difference between life and death for a pet. And if pet parents can’t easily access their regular veterinarian, they’ll turn to other services and online sources, which isn’t always the best for their furry family members.
Financial resources and veterinary care costs are an important issue for some pet owners and are often the reason behind declines in veterinary practice visits. Technology-based solutions that are lower in cost may mean more pets will receive veterinary care or will receive it sooner or longer. At least that’s the prevailing theory.
Pet owner preference for convenience and text-based communication using their mobile devices are key drivers behind the growing demand for telehealth and telemedicine. Millennial pet parents, the largest and fastest growing segment of pet owners, typically prefer to communicate via text whether it’s an appointment reminder, a post-surgical update or diagnostic test results.
So as digital technology continues to change virtually everything we do, it should come as no surprise that a growing number of companies are offering online veterinary consultations directly to pet owners. Some of these startups are being established by veterinarians while others are being founded by entrepreneurs from the technology industry or human medicine looking to fill a niche in veterinary medicine.
WILL PETS REALLY BENEFIT FROM TELEHEALTH AND TELEMEDICINE SERVICES?
Like so much less in veterinary medicine, the answer is “It depends.”
Telehealth offerings that provide 24/7 access to veterinary professionals who can answer pet owners’ questions by chat, email or phone — something that’s already available through several providers — can definitely benefit pets. Pet owners often want more advice than Dr. Google can give, but they might not have the time or money to see a veterinarian. They use telehealth providers to get answers to questions, which can be done without violating the veterinarian-client-patient relationship.
Veterinary practices can cater to their millennial pet-owning clients by tapping into 24/7 telehealth services. These services field client questions and education, but will refer patients and clients back to their regular veterinary practice if an exam is necessary, which helps bond clients to their veterinary practices.
However, to truly benefit pets, their owners and veterinary practices, pet parents need to know about telehealth services, especially those that their clinic has engaged. In March 2017, the Veterinary Innovation Council surveyed U.S. pet owners to better understand their perceptions and uses of telehealth tools. A total of 678 pet owners completed the five-question survey. The council acknowledges that the survey doesn’t represent all pet owners, but does give a sense of their attitudes.
More than 50 percent of surveyed pet owners reported they had not used telehealth tools. While council members were not surprised by that finding, they were surprised by pet owners’ reasons for not using telehealth services. About one-third of surveyed pet owners said they didn’t know that telehealth tools existed, and another 26 percent reported that telehealth tools weren’t available to them.
When it comes to real-time electronic interactions among veterinarians, pet parents and pets, such telemedicine consults may or may not be possible, even within a valid VCPR, depending on the health concern to be addressed. Just as not all health conditions can be diagnosed and treated during an online consult with a human healthcare provider, it won’t be possible to remotely address all animal health concerns — which gets to the heart of many veterinarians’ concerns about veterinary telemedicine.
One notable difference between human and veterinary patients is the inability of veterinary patients to talk. Because pets can’t voice their symptoms and comfort for themselves or give an accurate history, a teleconsult requires veterinarians to rely on a pet owner’s description of what they think is happening with their pet. (That’s also very much the case at the start of in-clinic exams.) Virtual exams also limit veterinarians’ ability to use all of their senses, which could lead them to miss crucial symptoms. For those reasons alone, some veterinary professionals believe animal patients should be examined in person.
Other veterinary professionals believe the lack-of-language argument against virtual veterinary exams doesn’t hold water because many virtual consults in human medicine involve pediatric patients who can’t articulate their symptoms.
Ultimately, the decision to use a face-to-face or virtual consult rests with the attending veterinarian and what she or he believes is the appropriate option for a particular situation.
So to return to the big question: Is telemedicine really in the best interest of our pets? Telehealth — encompassing telemedicine, teleconsulting and mHealth — will be in our pets’ best interest if it’s used appropriately and held to the same standards as in-clinic care. The veterinary community can gain a great deal from adding telemedicine to its practices. For some, the paradigm shift will be difficult; others have already started their transition to a new way of delivering veterinary healthcare and improving client communications. Improving communications between veterinary professionals and pet owners, whether through traditional or digital technologies, could have the most substantial, positive impact on veterinary practices. Greater client communication often results in a better-educated pet parent who tends to be more compliant with veterinary recommendations. And that’s a win-win-win for all parties.