DCJack Veterinary telemedicine and telecare

the initial reactionto our teleconsultationsystemshow. A videooriginatingfromthe supervisingdoctor’s stationduring

request that was made almost as soon as the doctors sawthe
system, especially those with previous experience with our
teleradiology application, was to be able to include images
fromother modalities, such as digitized radiographs, DICOM
images and video.
One issuethat remains tobe investigatedwiththe systemis
the image quality at the remote station. The qualityof the
remote video-streammust be achievedthrough a proper
balance betweenframe rate andimage quality. The frame rate
inthe systemis variable, depending onimage content, and
canvary from1 to 25 frames/s. The preliminary results we
have obtained reflect the doctors’ reaction to a system
configuredwiththedefault settings for thevideoconferencing
boards. These default settings, which seek the best balance
betweenframerate andimagequality, appear tobeunsuitable
for M-mode images. We will therefore experiment by
changingthebalancebetweenframerateandimagequalityin
bothdirections, and reducing the video-streambetween the
stationstothat strictlynecessary(e.g. bytemporarilydisabling
the study), to find the best configurationfor each type of
ultrasound study.
Acknowledgements: This work was funded by Portugal
Telecom.
References
1 Ribeiro R, Godinho A, Oliveira M, et al. Interact Sistema de
Telemedicina. In: Proceedings of BioEng ’96. SPEB Portuguese
Society of Biomedical Engineering, 1996: IV3.1–IV 3.6
2 Elford DR. Telemedicine innorthernNorway. Journal of Telemedicine
and Telecare 1997;3:1–21
3 Malone F, Athanassiou A, Nores J, D’Alton M. Effect of ISDN
bandwidth on image quality for telemedicine transmission of
obstetric ultrasonography. Telemedicine Journal 1998;4:161–5
4 Wootton R, Dornan J, Fisk NM, et al. The effect of transmission
bandwidth on diagnostic accuracy in remote fetal ultrasound
scanning. Journal of Telemedicine and Telecare 1997;3:209–14

....................................................................................................................................................................

c The legal implications of veterinary

telemedicine and telecare
Douglas C Jack
Wilson, Jack &Grant, Fergus, Ontario, Canada

Summary
This paper presents an overviewof some legal implications of the application of telemedicine to veterinary medicine. As in
otherareasof medicine, veterinarypractitionersneedtobeawarethat remotepracticeor consultationrequiresadherenceto
the same professional standards as in normal clinical veterinary practice. Licensing, confidentiality and malpractice are
discussed.

Introduction
...............................................................................
The seeming enthusiasmemerging for use of modern
technology among veterinary practitioners gives rise to a
heightened need for the same practitioners to be mindful of
some of the professional consequences of such use. As a
regulatedprofessionthe veterinarycommunitymust be made
aware of the legal implications and framework withinwhich
certaintechnologies and methods must be used. There are
many legal considerations of whichthe practitioner must be
aware, suchas thecollectionofaccounts bytheteleconsultant
inadifferent jurisdiction, determining the proper jurisdiction
to begin legal proceedings against the teleconsultant, the
forms of telconsultative agreements and various intellectual
property issues relating to ownership of software. However,
this paper will limit the discussionof the legal implications to
three: licensing and the unlawful practice of veterinary
medicine, patient/owner confidentiality and malpractice
theories. Whereappropriate, acomparativejurisdictionreview
of these issues will be presented.
Licensing and unlawful practice
...............................................................................

Correspondence: Douglas CJack, Wilson, Jack &Grant, 265 Bridge Street, The regulation of the veterinary professionin NorthAmerica
POBox 128, Fergus, Ontario N1M2W7, Canada (Fax: +1 519 843 6888; is uniformin its requirement that veterinary services be
Email: d.jack@sympatico.ca) performed, withsome limited exceptions (including

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veterinarycare providedbytheowner of ananimal), solelyby
apractitioner licensedtopractiseinthejurisdictionwherethe
service is being performed. With the onset of telemedicine
techniques it is possible for the veterinary practitioner inone
state or province to consult with another practitioner or
specialistinanotherstate, provinceor evenadifferentcountry
who is not licensed to practise in the jurisdiction of the
general practitioner. It is without question that, froma
constitutional lawpoint of view, the ability of the state1 or
province2 to regulate the profession is apparent; what is less
apparent though is whether or not a veterinary practitioner
who is providing teleconsultative advice is requiredto be
licensed in the jurisdictionof the remote practitioner. A
division is erupting on this issues betweenpractitioners who
find the costs and administrative requirements for extra-
jurisdictional licensing distasteful and the regulatory bodies
who have the legitimate desire to control the activities of
practitioners involvedina case withintheir state or province.
IntheProvinceof Ontariotheprofessionis governedbythe
provisions of the Veterinarians Act (‘VA’)3, which, among
other things, provides for strict licensing requirements, not
unlike many other jurisdictions. The ability to practise
veterinarymedicineis restrictedto‘members’ oftheCollegeof
Veterinarians of Ontario, each of whommust meet the
licensing standards4. The regulations under the VA dictate
several forms of licences, themost appliedfor of whichis for a
general licence requiring eachapplicant, among other things:
to be a Canadian citizen or permanent resident, to be able to
comprehend English or French, to complete the prescribed
applicationform, to provide evidence of the previous practice
of veterinary medicine by the applicant, to provide evidence
that there has not beena finding of professional misconduct,
to pay the applicable applicationfee and to submit proof of
the granting of a degree in veterinary medicine froman
approvedschool. Inaddition, asuccessful applicantmust have
achieveda standardof at least 1.5 deviations above the mean
mark in both parts of the National Board Examination
Committee of the AmericanVeterinary Medical Association
and have been successful in a local examination4. The
requirements for other types of licences in Ontario vary with
the type of licence sought; in our context a ‘short-term
licence’ can be issued by the College provided evidence of a
veterinary degree is provided and the ‘local’ veterinarian
provides awrittenundertakingtothe Collegeconfirmingthat
he or she will ‘supervise’ the applicant for the short-term
engagement and be responsible for the continuation of
veterinarycareafter theapplicant has left thejurisdiction5. All
servicesdeliveredbytheapplicantmustbecompletedwithina
periodwhichterminates onthedateset out inthelicence, the
day the applicant leaves Ontario and30 days after the licence
is issued. The granting of a short-termlicence is particularly
germane to our discussionof the delivery of teleconsultative
veterinary advice: does the consultant require licensing in
Ontarioinorder topermit thelawful exchangeof information
to a remote location? If so, is the consultant likely to seek a
short-termlicence for each consultation? Does the regulatory
body evenrequire a newapplication? Is the local veterinarian
going to be willing to provide the necessaryundertaking each
time teleconsultative advice is provided by various veterinary
experts?
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DC Jack Veterinary telemedicine andtelecare
By comparison, the Ohio Revised Code appears specifically
to contemplate the use of a ‘consultant’ in the delivery of
veterinaryservices. Under section4741.01oftheOhioRevised
Code a ‘consultant’ is defined as a ‘veterinarian who is not
licensedinthis stateandwhoprovides adviceandcounsel toa
requesting veterinarian licensed in this state in regard to the
treatment, diagnosis or healthcare of ananimal or animals in
a specific case’6. While similar provisions for the general
licensingof apractitioner tothoseinOntarioappear toapply7
the Ohiostatute provides for the issuance of a ‘temporary
permit’ which ‘authorizes the permit holder to act as a
consultant or to provide veterinary medical services in this
statefor aspecificanimal or animals’ for aperiodnotinexcess
of six months8. More recent amendments to this portionof
the legislation dictate that, among other things, a consulting
temporary permit may be issued to a requesting licensed
veterinarianto be held by himor her provided all of the
particulars of both the resident practitioner and the
consultant are divulged and the requesting veterinarianis
physically present during the consultation period. This latter
requirement does not, in my view, act to prohibit the
teleconsultation as the licensed practitioner in Ohio will, in
most circumstances, be physically present inOhio during the
consultation.
What is evident fromthis comparativeviewisthat thereare
formal requirements that must be met by anout-of-jurisdic-
tionveterinarian to be licensed in the region of the licensed
veterinarian. Also, it is apparent that the notion of telecon-
sultation is not specifically contemplated by the regulatory
statute; presumably, these notions can be properly addressed
only through specific amendment to the governing
legislation.
Perhaps the broader issue is whether or not a veterinary
consultant froma different jurisdictionis evenengagedinthe
practice of veterinary medicine by reasonsolely of the
teleconsultation. Once again, a reviewof the legislative
provisions inOntarioandOhioprovides a broaddefinitionto
the term‘practice of veterinary medicine’; however, neither
specificallycontemplates the concept of anout-of-jurisdiction
consultation. InOntario, the term‘practice of veterinary
medicine’ is defined in inclusive terms of the practice of
dentistry, obstetrics, including ova and embryo transfer, and
surgery, inrelationtoan‘animal other thana humanbeing’9.
The Ohiolegislation is similarly broad but is provided in
greater detail: ofsomeimport is thattheOhiocodeincludesin
thedefinitionanypersonwho‘uses anywords, letters, ortitles
in suchconnection or in suchcircumstances as to induce the
belief that the personusing themis engagedinthe practice of
veterinary medicine’10. Presumably, this definition is broad
enough to capture any practitioner withinor beyond the
jurisdiction who is merely referred to as ‘Dr’ or uses degree
acknowledgements such as ‘DVM’ or ‘VMD’. To the extent
that the ‘practice of veterinary medicine’ is restricted to only
those properly licensed withinthe jurisdiction, then,
arguably, any teleconsultant is breaching the provincial or
state lawof the jurisdictionwhere the consultative services
are being provided.
Inhumanmedicine the threat of revocationof a licence or
prosecution for unauthorized practice has beenremoved in
those states where medical teleconsultation is not only
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DCJack Veterinary telemedicine and telecare
permissible but, in some instances, desirable11. These juris-
dictions, similar toOntariolaw, require the local physicianto
make a specific request for such consultation and often place
restrictions on the ability of the out-of-state practitioner to
solicit patients in other states or prohibit the opening of an
office or receiving telephone calls in that state. It would
appear that a test of the need for ‘direct patient contact’ may
be of assistance; that is, a radiologist fromout-of-state who
merelyprovides interpretiveadvicemight arguethat heor she
is not ‘practising veterinary medicine’ while the veterinary
dermatologistwhovideoconferences withtheclient andviews
realtime images of the skin disorder will, in my view, have a
more difficult task. InKansas, a regulationpassedby the state
legislatureat therequest of theStateBoardofHealingArts and
knownas the ‘telemedicine regulation’ appears tobe the only
specificstatutetodeal withthe issues requiring anyphysician
who treats, prescribes, practices, or diagnoses a condition,
illness, ailment of an individual who is located in Kansas to
obtain a Kansas medical licence12. This regulation effectively
prevents a non-Kansas physician fromtreating a patient
located in Kansas without obtaining a Kansas licence. Maine
has provided for a similar regime; however, the proposed
Maine code provides an exceptionfor ‘out-of-state consulta-
tions’ whereinthe out-of-state physiciancannot furnish
services whichare the ‘primary provisionof care or the
primary interpretation of the diagnostic test’13. Similar
legislative initiatives are inprocess inOregonandColoradoin
ahumanmedicinecontext; presumably, itwill not bedifficult
to adopt a newregime in a veterinary medical context.
Patient/owner conŽdentiality
...............................................................................
It is clear that veterinary practitioners throughout North
America are subject to maintaining strict confidence in their
relationships withpatients andclients; whether oneviews the
necessity of confidentiality as a legal consideration or an
ethical tenet, keepingveterinarymedical informationsecret is
clearly required. ‘Telemedicine, like other forms of medicine,
has the potential for breaches of confidentiality.’14 Particular
care must be takenby the veterinary practitioner in that the
‘click of a mouse’ can instantaneously transmit client
information across state and provincial boundaries.
In general, practice regulationstatutes require the practi-
tioner to maintainstrict confidence: the veterinarianis under
a legal obligationnot to reveal any information about an
animal or the treatment of ananimal to anypersonexcept to
the owner of the animal or another veterinarianinthe course
of the continued care of the animal15. In Ontario, exceptions
tothegeneral confidentialityruleexistinthreecircumstances:
first, when the client consents to suchdisclosure; second,
whensuchdisclosure is required by law; third, to prevent, or
contribute informationfor the treatment of a disease, or
physical injury of a person16. Various states have similar
legislationor treat the issue of confidentiality as an ethical
issue the breach of whichgives rise to disciplinary sanctions.
The introduction of telecare techniques to the practice gives
rise to unique problems for the veterinary professional. ‘The
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cross-border transmissionof patient histories and other
identifiable material suchas scans andbiological analyses can
beproblematicfromthepointof viewof confidentiality, since
not all countries have developed uniformsystems of data
protection. International telemedical consultations therefore
raise particularly difficult problems for ensuring patient
confidentiality.’17
In this context one must be particularly sensitive to
avoidance strategies. The practitioner is well advised to seek
the unqualified consent of the client to the release of
information into ‘cyberspace’. The prudent veterinarianwill
ensure that adequate data-protection systems are in place.
Each of these aspects will be addressed.
Client consent
Anabsolute defence to anallegation of breachof confidence
against the veterinary practitioner is evidence that the client
hadgrantedconsent tosuchdisclosure (as notedabove, client
consent represents one of the fewexceptions to the legal
obligation of confidentiality). ‘Consent to disclosure,
although usually express, can be impliedin circumstances
suchas those withwhichweare concerned, where thepatient
is inthe careof morethanoneperson. Insuchacaseapatient
[owner] maybeassumedtoconsenttoanyrelevantthirdparty
as well as the teleconsulting doctors being properly informed
so as to carry out their obligations. The members of the
telemedical ‘‘team’’ therefore, which would include all the
health-care providers at all stages of the telemedical line,
wouldbe deemedtoreceive the informationinconfidence.’18
Notwithstanding this assumption, it wouldbe better to
develop a specific ‘telemedical’ consent formwhich, among
other things, addresses the issues of disclosure to telemedical
consultants throughelectronic media.
Data protection
One of the detractions fromthe introductionof full-scale
telemedicinesystems for theprivateveterinarianrelates tothe
oft-told stories of ‘hackers’ breaking into computer networks
for the purpose of stealing personal information or altering
the data in the hospital’s computer system. ‘Hackers have
penetrated hospital computer systems, altered patient data
and cause problems within the system. In 1988, hackers
accesseda computer systemat Barrow’s Neurological Institute
of St. Joseph’s Hospital in Phoenix, Arizona. No patient
records were obtained, nor was any information stolen, but
the incident created some problems for the Institute in
accessing the database.’19 One need not be particularly
creative to envisage rival equine owners seeking out medical
information about the competitor’s horse before a race; dog
breeders mayseek a competitive edge armedwiththe medical
information provided by the veterinary practitioner.
Theveterinarycommunityandtheiradvisers mustbeaware
that some formof data protection needs to be present in the
transmissionof sensitiveandconfidential information. ‘Given
the newness of most telemedicine systems, the prospect of
uniformconfidentiality/privacy guidelines for the national
informationinfrastructure inthe near future is dim. However,
even though no security systemwill be completely immune
Journal of Telemedicine and Telecare Volume 5 Supplement 1 1999

fromdiscontented insiders or determined hackers, health
information managers should implement a systemwhich
ensures high levels of clinical access and utility while
maintaining secure and confidential patient information’20.
Technological safeguards include cryptography, whichis used
to encode data before they are transmitted (encryption),
and message authentication, whichrequires an electronic
signature or password. In any case, only authorized indivi-
duals should have access to the system.
M alpractice
...............................................................................
Compared with other professionals, there are relatively few
lawsuits brought against veterinary practitioners for negli-
gence or malpractice; however, as consumer demands and
knowledge increase, the incidence of suchclaims is increas-
ing21. Clinical risk management will be deserving of more
attention as telemedical techniques are introduced into the
practice. Theuseofnewtechnologycomeswithnewlitigation
issues that the veterinary community should be mindful of.
Standard of care
It is clear that the test for the determination of veterinary
negligence is whether the conduct of the particular practi-
tioner meets the standardof a reasonable practitioner in
similar circumstances. Howdoestheuseof telemedicineaffect
the determination of ‘reasonableness’? Some argue that the
use of these technologies actually lowers liability as practi-
tioners have the opportunity to work together easily to
provide a more comprehensive examination of the animal;
access tomedical databases mayfind diagnosis andtreatment
enhanced, thusreducingtheriskof negligent conduct. Onthe
other hand, some argue that the use of telemedicine increases
the risk of malpractice claims as client expectations increase
with the ability to consult withexperts inother jurisdictions.
One might even argue that the failure of the general
practitioner to access a teleconsultant or forward diagnostic
images for a secondopinion may, in itself, be negligent; this
will, of course, dependonwhether or not telecare becomes an
‘accepted practice’. ‘Animportant component of any defence
raised by hospitals or clinicians against litigation for mal-
practice is whether or not the practice being questioned
accorded with what a responsible body of medical opinion
would consider accepted practice’22. As the costs for the
telemedicine technology continue to be reduced and the
availability of cheap, reliable digital data transmission
increases then the notionof a newpractice standard comes
into the foreground for consideration.
Informed consent
A closely related issue to malpractice is the obtaining of
informedconsent totreatment fromthe owner of the animal.
Too oftenthe cliniciantreats the informedconsent process as
pedestrianand little or no evidence of consent is available.
Providing evidence of consent and that such consent was,
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DC Jack Veterinary telemedicine andtelecare
indeed, informed is of great significance in defending any
particular claimfor malpractice. This potential problemis one
well served by telemedicine techniques.
In1995, the Kentucky TeleCare Network initiateda project
of obtainingpatient consent ina humancontext throughthe
creationof avideo-tape. Thestudyinvolvedthepreparationof
two videos, one with and one without the informed consent
segment, whichwere distributedamongthe various sites from
whichthe organizationconductedbusiness. Onthe dayof an
arrangedteleconsultation, patients were asked to watchthe
video-tape before signing the informed consent form. Site
coordinators thenasked the patients whether they had any
specific questions about telemedicine; patients indicated a
high level of satisfaction and acceptance withthis method of
consultation23. As consumers of veterinary services become
more familiar with these technologies in their own homes,
they have higher degrees of acceptance for the use of them;
some evenexpect such technologies to be used.
Veterinary practitioner–client/patient
relationships
Before one considers the issue of whether or not particular
conduct was negligent, the client/plaintiff must establishthat
a veterinary practitioner–client/patient relationshipexists.
Courts have found that the relationshipcanexist even inthe
absence of payment for such service24. ‘Most telemedical
consultations would likely be viewedas establishing the
requisiterelationship. It isless certain, however, whether such
arelationshipcanbeestablishedthroughother nontraditional
means such as an emergency care hotline or an Internet
discussiongroup’25. One might expect that a practitioner in
another jurisdiction would be somewhat surprised to be
named in a particular lawsuit in another jurisdiction arising
froma videoconference; however, both the local practitioner
and the teleconsultant may be involved in situations giving
rise to liability for each. It is crucial that the terms of
engagement with a client be discussed and documentedprior
to the consultation in order to avoid claims.
In Ontario, at least in connection with the dispensing of
drugs, the legislation details whena proper veterinary
practitioner–client/patient relationship exists. Four factors
must be present: the practitioner must have assumed respon-
sibilityfor medical decisions relatingtothe care of the animal
with a demonstrated willingness of the owner to accept such
advice; the practitioner must have sufficient knowledgeof the
historyof the animal through inquiry or physical examinationor
make medically appropriate visits to the place where the
animal is kept toreacha general or preliminarydiagnosis; the
practitioner mustbelievethatthedrugwill behelpful; andthe
practitioner must be readily available in the event of an
adverse reaction26.
At first sight, it would appear that the actual physical
presence of the animal with the veterinarian is not necessary
inorder toestablishtheproper relationship, thus permittinga
teleconsultation. More difficulty is presented withthe
requirementtobereadilyavailableforfurthertreatmentinthe
event of adverse reactions.
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DCJack Veterinary telemedicine and telecare
As is thecasewithmost litigationwhether inCanadaor the
USA, theplaintiff inanyactionislikelytoinitiateproceedings
againstall partieswhichhadanyinvolvementinthenegligent
conduct (could the Internet service provider also be joined
inan appropriate action?). The teleconsultant should
define the relationship at the outset. Appropriate insurance
coverages and judgement proofing techniques should be
implemented in all jurisdictions where advice is being
provided.
Given the anticipatedincreased use of technology the
prudent practitioner would be well advised to be aware of
these litigation issues. Veterinary practitioners may be just as
liable for not using the technology available as they are for
applying the technology inappropriately.
A suggested protocol
...............................................................................
There is no doubt that the legal issues arising fromveterinary
telemedical techniquesareinastateofflux. Itwill behelpful if
a standardprotocol couldbe introducedintoaclinical setting
so as to avoid some negative legal consequences. In this
manner someof theuncertaintyrelatingtotheseissues canbe
addressed.
Once again, in a human medicine context some protocols
have been suggested27 whichare adopted here withsome
amendment for consideration (these suggestions are particu-
larly apt for videoconferencing but can be adapted for other
techniques). A 10-point planis as follows:
(1) Explaintotheclient/owner what isgoingtohappenand
obtain consent to the use of the method and the costs
associated withit. Indicate the possibility of the loss of
confidentiality and obtain consent to disclosure to the
teleconsultant.
(2) Establishcontact withthe teleconsultant and define the
relationshipof the teleconsultant withthe client/owner,
ensuring that the local practitioner will have carriage of
the case.
(3) Summarize the problemin plain language, making
reference to appropriate history and presenting
complaints.
(4) Conduct the physical examination by teleconference,
describing the physical findings sufficiently for the
teleconsultant to understand.
(5) Reviewany laboratory test results.
(6) Discuss the diagnosis.
(7) Discuss the treatment planandmanagement of thecase.
(8) Discuss the needfor referral or follow-upteleconference.
(9) Complete any clinical notes for permanent records.
(10) Note any subsequent follow-up with client/owner.
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Through the development of a standardprotocol and
candid, open discussion with clients, the veterinary profes-
sional can take preventive steps to avoidsome legal pitfalls.
Conclusion
...............................................................................
Theuseof telemedicineandtelecareexpandsthegeographical
boundaries of clinical veterinary practice andmay enhance
the professional aspects of the delivery of veterinary services.
‘The [vetri]medicolegal implications of telemedicine are
currently unclear, and are currently based upon conjecture
because there is noclear bodyof legal judgement uponwhich
todetermineprecedent’28. Theprudent veterinarypractitioner
andhis or her professional advisers will becomeawareof these
emerging issues and take preventive steps to avoid negative
consequences.
References
1 Under thepolicepower thestateispermittedtoregulateintheUSA
2 Under section 92 of the BritishNorth America Act the province is
permitted to regulate in Canada
3 RSO1990, c. V-3
4 Ontario Regulation1093, section 3
5 Ibid., section 8
6 Ohio Revised Code, paragraph 4741.02(J)
7 Ibid., paragraph 4741.09(A)(B)
8 Ibid., paragraph 4741.14
9 See Veterinarians Act (Ontario), section1(1)
10 See Ohio Revised Code, paragraph 4741(B)(4)
11 Website of Arent, Fox, Attorneys, WashingtonDC, http://
www.arentfox.com
12 Ibid.
13 Ibid.
14 Stanberry B. The legal and ethical aspects of telemedicine. 1:
Confidentiality and the patient’s rights of access. Journal of
Telemedicine and Telecare 1998;4:179–87
15 Ontario Regulation1093, section 17(1)6
16 Ibid., section 17(1)6
17 Stanberry B (op. cit. ref. 14): 179
18 Ibid.: 181.
19 Arent Fox (op. cit. ref. 11): 6
20 Ibid.: 7
21 See Proceedings of the AmericanVeterinary Medical Law
Association, 1995, Pittsburgh, Pennsylvania
22 Darkins A. The management of clinical risk intelemedicine
applications. Journal of Telemedicine and Telecare 1996;2:179–84
23 Burton DC, Huston JL. Use of video in the informed consent
process. Journal of Telemedicine and Telecare 1998;4(suppl. 1):38–40
24 Arent Fox (op. cit. ref. 11): 1, ‘Taming Liability of Telemedical
Transactions’, Lynn Frendt Shotwell
25 Ibid.
26 Ontario Regulation1093, section 33
27 Tachakra S, Mullett STH, Freij R, Sivakumar A. Confidentiality and
ethics in telemedicine. Journal of Telemedicine and Telecare 1996;2
(suppl. 1):68–71
28 Darkins A (op. cit. ref. 22): 183
Journal of Telemedicine and Telecare Volume 5 Supplement 1 1999