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Virtual Care: Advancing the Practice of Veterinary Medicine

Article  in  Advances in Small Animal Medicine and Surgery · April 2019

DOI: 10.1016/j.asams.2019.04.001

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 IN S M A L L A NI M A L M E D ICINE A N D S U RGERY
www.advancesinsmallanimal.com Volume 32, Issue 4
Virtual Care: Advancing the Practice
of Veterinary Medicine
Lori M. Teller, DVM, DABVP
(canine/feline)
Texas A&M University College of
Veterinary Medicine & Biomedical
Sciences
College Station, Texas
Virtual care is an extension of veterinary
practice that aids in the delivery and
enhancement of medical care or gen-
eral health advice between veterinarians
and their clients. Telemedicine is not a
standalone practice but another tool for
veterinarians to utilize, just as they would
any other new piece of technology in their
practices. Providing virtual care to clients
is much more effective than a having a
­client randomly search the internet or
­consulting “Dr. Google” for help.
Per the Center for Connected Health
Policy, “first and foremost, telehealth is a
collection of means or methods, not a spe-
cific clinical service, to enhance care deliv-
ery and education. Ideally, there should
not be any regulatory distinction between
a service delivered via telehealth and a
service delivered in person. Both should
be held to the same quality and practice
standards.”1 Furthermore, “utilizing tele-
health has the potential to increase access
to care, reduce travel time to receive care,
improve communication among clinicians,
and increase cost-effectiveness of service
­delivery.”2
Where Can Virtual Care Be Used?
Opportunities abound with virtual care,
particularly with the ability to expand
services in underserved or remote areas,
increase access to care, provide aid during
times of major disasters or large disease
outbreaks, increase client compliance
with treatment recommendations, and
maintain or strengthen the bond between
veterinarian and client. Some of these
services can include virtual consults with
specialists in other areas or the provision
of after-hours triage. Part-time associates
and those on family or short-term disabil-
ity leave may appreciate the opportunity
to continue practicing via telemedicine as
an extension of the services they normally
provide within the brick-and-mortar facil-
ity where they are employed.
“The Veterinarian must employ
sound professional judgment to
determine whether using Telehealth
is suitable each time veterinary
services are provided and only
furnish medical advice or treatment
via Telemedicine when it is
medically appropriate.”
There are also challenges associated with
providing virtual care that need to be
addressed. These include providing care
when a physical exam is not part of the
visit, obeying regulations and laws within
the veterinarian’s jurisdiction, competition
from others, limitations of technology,
and obtaining reimbursement for services
rendered. Security of medical records
and credit card data is also of the utmost
importance. There are various payment
models for veterinarians to choose from,
including pay-per-use, subscription-based,
or bundled with services. A veterinarian
may want to utilize more than one option.
Veterinarian-Client-Patient
Relationship is Important
The Veterinarian-Client-Patient
Relationship (VCPR) is at the center of
what can be accomplished with virtual
care. The law and regulations vary from
• April 2019
state to state, so it is important for veteri-
narians to understand the rules in each
jurisdiction where he or she is licensed.
Most states, but not all, define the VCPR
similarly to what is outlined in the
American Veterinary Medical Association’s
Model Veterinary Practice Act,3 and some
regulations further say that a VCPR can-
not be established solely by electronic or
telephonic means. When prescribing drugs
for extralabel use or issuing a Veterinary
Feed Directive, a veterinarian must also
be aware of the federal VCPR require-
ments, which are the same as the AVMA
definition. These requirements must be
followed, even in jurisdictions that do not
have a defined VCPR.
Also In This Issue
Behavior, 3
Assessment of Cat Litter Substrate
Preferences
Clinical Pathology, 3
Basal and TRH-Stimulated Growth
Hormone to Differentiate
between Canine Hypothyroidism
and Nonthyroidal Illness
Gastroenterology, 4
Serologic and Fecal Markers for IBD
Nephrology, 5
Effects of a Nutrient-Enriched
Water With and Without
Flavoring on Water Intake in Cats
Neurology, 6
Population Pharmacokinetics of
Levetiracetam in Epileptic Dogs
Oncology, 6
Toceranib Use in Feline Mast Cell
Tumors
Surgery – Soft Tissue, 7
Long-term Outcome of Permanent
Tracheostomy in Dogs
Full text of Advances in Small Animal
Medicine and Surgery is available at
www.advancesinsmallanimal.com
Page 2 A D V A NCES

Recently, some organizations and regu-
latory agencies are revisiting their defini-
tion of the VCPR. In September 2018, the
American Association of Veterinary State
Boards (AAVSB), revised their Practice Act
Model and issued guidelines for the appro-
priate use of telehealth in veterinary prac-
tice. Their revised version of the VCPR
removes a requirement for the in-person
examination of the patient(s), though it
is important to note: “The Veterinarian
must employ sound professional judgment
to determine whether using Telehealth is
suitable each time veterinary services are
provided and only furnish medical advice
or treatment via Telemedicine when it
is medically appropriate. A veterinarian
using Telemedicine must take appropri-
ate steps to establish the VCPR, obtain
informed consent from the client, and
conduct all necessary patient evaluations
consistent with currently acceptable stan-
dards of care. Some patient presentations
are appropriate for the utilization of
Telemedicine as a component of, or in
lieu of, hands-on medical care, while
­others are not.”4
Most recently, in October 2018, the
Colorado State Board of Veterinary
Medicine, issued guidelines for the appro-
priate use of telehealth in the practice of
veterinary medicine.5 The guidelines allow
for the creation of a VCPR using telehealth
technologies. They also state: “Treatment
and consultation recommendations made
in an online setting, including issuing a
prescription via electronic means, will be
held to the same standards of appropriate
practice as those in traditional in-person
settings. Treatment, including issuing a
prescription based solely on an online
questionnaire, does not constitute an
acceptable standard of care.”
Both the AVMA and AAVSB provide
for exceptions to the VCPR in cases in of
emergency. Some examples would include
intoxication, major trauma, or cardiac
arrest, or in the time of a major disaster,
such as a devastating hurricane or wild-
fire, or during a highly contagious disease
outbreak, such as avian influenza. During
these times, a virtual visit may be the only
option available to save an animal.
Valuable in Teletriage
Some veterinary practices that utilize vir-
tual care start with after-hours teletriage.
They may do this in-house or engage an
outside vendor to handle it. Many of these
cases do not require a trip to the emer-
gency clinic and can be handled either
completely virtually or by scheduling an
appointment with the regular veterinarian
for the next day. This saves the client time
and money and keeps the client within the
veterinarian’s practice. The most common
reasons that a pet owner utilizes tele­triage
is for skin or gastrointestinal problems,
followed by pain/limping and behavioral
issues. The telemedicine service reassures
the client that someone is available to help
when needed and can further enhance the
client’s bond to the veterinarian who maint­
ains the established VCPR. Veterinarians
may also utilize virtual care for follow-up
visits, such as post-surgical or minor
­infections.
Other practices engage in virtual visits
to work with specialists. Many regions
around the country cannot support or
attract boarded specialists, but general
practitioners can access their expertise
through virtual consultations. There are
examples of remote-guided ultrasounds
and other procedures to help further diag-
nose a patient’s problem and develop a
more appropriate treatment plan.
In the absence of an established VCPR,
veterinarians may provide general advice
to an animal owner. First-time pet owners
have been known to reach out about the
unusual behavior noted when a puppy is
sleeping that turns out to be the normal

AIMS AND SCOPE

Each month, Advances in Small Animal Medicine and Surgery features a guest editorial from a leading veterinary expert sharing up-to-date information, supported by
scientific data and documentation, on a specific topic. In addition, veterinary experts in various fields select pertinent publications and presentations to be abstracted. These
abstracts are followed by commentaries from the specialist’s knowledge thereby bridging published data to clinical practice in a practical, dynamic and concise format.
Veterinarians and veterinary technicians are provided with practical information (provided digitally or in print) with the goal of translating current information from the
literature to practice situations.
If you would like to contribute to the journal, please email the Editor at ldmcgill.vetpath@gmail.com.

E di t o r Clinical Pathology: General Practice: Ophthalmology:

Lawrence D. McGill, DVM, PhD Johanna Rigas, DVM, MS Shawn Finch, DVM Ralph E. Hamor, DVM, MS
Veterinary Pathologist Diplomate ACVP Gentle Doctor Animal Hospitals Diplomate, ACVO
Cottonwood Heights, UT Idexx Laboratories, Inc. Omaha NE Clinical Professor, Ophthalmology
Mukilteo, Washington College of Veterinary Medicine
Nephrology/Gastroenterology: Gainesville, FL
Sec t ion Edi t or s Critical Care: Marilyn Mikiciuk, DVM
Avians/Reptiles/Small Mammals: Nancy A. Sanders, DVM Diplomate, ABVP and ACVIM Orthopedics:
Angela M. Lennox, DVM Diplomate, ACVIM (Internal Medicine) (Internal Medicine) Douglas L. Hammer DVM, DACVS
Diplomate, ABVP-Avian and ACVECC ANTECH Diagnostic Norwood Park Animal Hospital
Avian and Exotic Animal Clinic of IDEXX Laboratories, Inc. Lehigh Acres, FL
River Forest, IL
Indianapolis Westbrook, ME
Neurology:
Indianapolis, IN Dentistry: Anne Chauvet, DVM, DACVIM Neurology Respiratory:
Behavior: Brook A. Niemiec, DVM Certified Neurosurgery Elizabeth Rozanski, DVM
Lisa Radosta, DVM Diplomate, AVDC & EVDC Sarasota, FL Diplomate ACVIM and ACVECC
Diplomate, ACVB Veterinary Dental Specialties and Tufts University
Oral Surgery Oncology: North Grafton, MA
Florida Veterinary Behavior Service
West Palm Beach, FL San Diego, CA Glenna E. Mauldin, DVM, MS
Surgery – Soft Tissue:
Dermatology:
Diplomate, ACVIM (Oncology) and ACVN Tina Wolfe, DVM, MS
Cardiology:
Jason Pieper, DVM, MS, DACVD PetCure Oncology Diplomate, ACVS
Mark Rishniw, BVSc, MS Poland Veterinary Centre
Diplomate, ACVIM (Internal Medicine Service Head, Dermatology and Chicago, Illinois
Poland, OH
and Cardiology) Otology Clinic
Cornell University University of Illinois
Ithaca, NY Champaign, IL
 A D V A NCES Page 3

dream state. Telehealth visits can be used

to reinforce conversations that occur in
the exam room, such as how to housetrain
a dog, or can be utilized when an uncoop­
erative patient doesn’t limp during the
in-person visit but is holding up its leg as
soon as returned home.

Wearables in Telehealth
Wearables also have a place in telehealth.
In addition to heart rate and activity levels,
devices are in development to measure sei-
zure activity, blood glucose levels, and car-
diac rhythm. Pet owners can also employ
Bluetooth stethoscopes to monitor their
pet’s heart and lung sounds and upload
them. Also, the role that credentialed vet-
erinary technicians (licensed/registered/
certified) play in telehealth is yet to be
determined. They may be able to help
with remote monitoring of patients,
­especially in rural or underserved areas.
Virtual care is a rapidly evolving
field that can enhance how veterinar-
ians practice and improve patient care.
Consideration should be given to how and
why a practice would incorporate virtual
visits into the daily work flow and how
these services will be introduced to clien-
tele. The service needs to be easy to use by
all involved, provide for medical record
integration, and maintain data security.

References
1. https://www.cchpca.org/sites/default/files/
2018-10/Telehealth%20Definintion%20
Framework%20for%20TRCs_0.pdf
2. https://www.cchpca.org/sites/default/files/
2018-11/Texas%20Report%20Nov.%20
26%202018%20FINAL.pdf
3. https://www.avma.org/KB/Policies/Pages/
Model-Veterinary-Practice-Act.aspx
4. https://www.aavsb.org/Download?url=s/
zvw7kz187dic8zu/Guidelines%20for%20
Telehealth.pdf
5. https://drive.google.com/file/d1UFTLgis8X-
DwO_gaTnPN_PxC-oRgqebfC/view

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