"Unanimous" with 140 "yea" votes is how Lori Teller, DVM, DABVP, American Veterinary Medical Association (AVMA) board member, described the vote by members of the house of delegates (HOD) as they adopted a new telemedicine policy at the 2017 Convention in Indianapolis. The policy now becomes part of the AVMA's Model Veterinary Practice Act (MVPA).
House delegates represent some 90,000 AVMA members and vote at the twice-yearly meetings on policy issues that have the potential to affect the veterinary profession across the board.
All 50 states, the District of Columbia, Puerto Rico, and 18 constituent allied organizations, such as the Uniformed Services of the United States, Student American Veterinary Medical Association, American Animal Hospital Association, and American Association of Equine Practitioners, send a delegate and an alternate to the biannual meetings.
Basic versus broad policy
"A lot of policies are automatically dealt with at the board [of directors] level," Dr. Teller said. "But if it is a policy that has an impact on the practice of veterinary medicine, those all go to the House [of Delegates. [Telemedicine] is such an up-and-coming area in veterinary medicine … it's not just a companion animal policy or a federal government policy—it has the potential to impact such a wide swatch of the profession."
According to Teller, telemedicine is the dispensation of any veterinary medical advice, such as prescribing meds and treatment, through either telephonic or electronic means, such as phones, text messaging, or email.
The AVMA and most of its members are all for it—but framed within the context of an established veterinarian-client-patient relationship (VCPR).
The thrust of the new AVMA telemedicine guidelines state: "With the exception of emergency teletriage, including poison control services, the AVMA opposes remote consulting, including telemedicine, offered directly to the public when the intent is to diagnose and/or treat a patient in the absence of a VCPR."
Feedback loops
The policy is the culmination of a two-year process that included the creation of a 45-page Final Report on Telemedicine by the AVMA Practice Advisory Panel (PAP) and feedback from more than 100 AVMA members from across the U.S.
"Members of the board of directors, members of PAP, and some AVMA staff, as well as feedback from all state AVMA members and allied groups and individual members—we had a ton of feedback—all of that was consolidated and synthesized and the policy was created from all of that," Teller said.
"The AVMA does a lot of environmental scanning to see what topics are of importance to the profession and telemedicine was one of those topics," she said. "We check in with members a lot to see what kind of things they're concerned about and then, if needed, a policy can be created from there."
The AVMA quickly found that telemedicine was a topic that the rank and file was vocal about, moving the board of directors to appoint PAP to investigate the subject more thoroughly to see if it warranted inclusion in future policy.
Once the proposed policy was on the House agenda, AVMA members had the opportunity to provide a second round of comments to their delegates, said Teller, who added that it was this second wave of feedback that delegates used to amend the policy paper and direct their votes.
"Telehealth consultation from doctor to doctor can help patients. We speak a common language, and collaboration will help better patient care and outcomes. But the relationship of one doctor to another is vitally different from the relationship of pet owners to veterinarians," wrote one veterinarian during the second comment phase.
In fact, this very comment addresses a third-party aspect included in the language of the original policy that was written out of the final policy by the HOD.
The removed verbiage read: "Remote consulting directly with the patient's owner is acceptable when authorized by the veterinarian who has established the VCPR. This authorization should be documented in the patient's medical record."
"This way the veterinarian who has the VCPR is always the person who is doing the communicating," Teller said. "I would say the feedback was really a cross-section of the profession, which helps because that makes it easier to draft a policy when you're getting feedback from such a diverse population."
Getting out in front
Telemedicine isn't a huge factor in the veterinary profession now, but the AVMA sees it on the horizon, Teller said.
"We want to be proactive so we don't get in the mess human medicine was in for many years before they figured it out," she said.
A definitive telemedicine policy also smooths the
waters swirling around the morass of state regulations governing VCPRs.
"Every state's laws and rules are different," Teller said. "There are a couple states that have no VCPR requirement, and then there are some states that … you only have a VCPR if you're going to diagnose or treat. The meeting allowed us to have the best policy for the AVMA at this time."
Of course, policy is just that, and "not a law, rule, or regulation, so there's no enforcement power to it," Teller said.
The new guidelines are useful nonetheless.
"We use it if somebody decides to propose a law—a state legislature, or if the federal government decides to get involved in regulating veterinary telemedicine—or companies that are looking to get involved in the telemedicine industry, it can help guide those kinds of conversations."
Now that the AVMA has a foundational policy on telemedicine, perhaps New Jersey will use the guidelines to reshape its own telemedicine law, which was put on hold early this summer, because critics argue that the bill, written with human medicine in mind, doesn't take veterinary medicine into consideration.
"They never thought of veterinarians when they wrote this bill," said Rick Alampi, executive director of the New Jersey Veterinary Medical Association.
Resources coming
"Our next step is creating a toolkit so members can start incorporating some of the telemedicine tools into their practices," Teller said, and added that print and online formats should be ready by the 2018 AVMA convention.
The toolkit will include all the various state and federal VCPR rules and regulations, potential industry partners for practices to look at, a guide on how to start, specific ways to introduce telemedicine to staff, ways to appropriately charge for it, areas where it could be useful to a practice, and areas where it probably shouldn't be used.
