When queried about telemedicine, veterinary practitioners and professionals will differentiate between its two schools of thought: Telemedicine used for consulting with specialists, and the type where a practitioner looks at video of a patient’s limp sent by a client via smartphone. “The definition I’m hearing more and more is telemedicine is an entire diagnosis or visit without it being physically done on premises,” said Jason Otis, CEO of Asteris Inc., a Stephentown, N.Y.-based provider of imaging technology solutions. Asteris is focused on veterinary diagnostic imaging, and Otis wants confusion removed from the discussion. “I’m being told this will need to eventually be called ‘teleconsultation,’” Otis said. Ted Rue, DVM, owner of Fremont, Calif.-based Ardenwood Pet Hospital, which is focused on small animals, embraces the convenience of telemedicine for himself and his clients. “The speed in which you can get answers is probably the best thing,” Dr. Rue said. He now sends radiographs for a consult via email that he used to have through mail or courier. “I’ll have results back sometimes within in hours,” Rue said. Expedience is just one of the advanced capabilities that practitioners now have because of telemedicine, according to Eric Lindquist, DMV, DABVP, CEO of SonoPath.com. “Teleconsultation enables us to offer specialist care to the client in every situation even if you don’t have a specialist on site,” Dr. Lindquist said. “Its use changes the world of the general practitioner and specialist completely so that he has specialist support at hand for himself and his clients, and can also expand the diagnostic options of a practice or clinic to improve the service for their clients to a state of the art care.” However, there is a “garbage in, garbage out” element of teleconsultation that can occur with just about any modality—radiographs, ultrasound, CT, MRI—because of incorrect technique, Lindquist said. “We see both beautiful and mediocre image sets on all imaging modalities,” he said, and added that most often, poor quality imaging is a result of human error or equipment problems, but lack of sufficient bandwidth also could be the culprit. “Maximize it on the upload and download before you do anything else,” Lindquist said. “So many clinics still run on economy-level bandwidth. Teleconsultation specialists already know that bandwidth is like oxygen, and we get asphyxiated rapidly if we don’t have it.” Know the limits Nathan Glaza, DVM, owner of Licking Valley Veterinary Service in Butler, Ky., uses telemedicine to consult with specialists and as an early-warning system with clients who have an established veterinarian-client-patient relationship (VCPR). “In an active case, I will let clients text me images for a basic ‘Do you need to come out or is this normal recovery,’ with the understanding on their end that they know the limitations of images,” he said. “I will not diagnose client’s pets over a digital medium if I have never seen the animal or it’s a problem that I have not previously diagnosed myself.” This is the point where he sees impracticality, or worse yet, a danger, in relying too much on telemedicine. “It seems everyone these days has technology, and it’s great to try to use it to make a patient’s life better, but results can be so easily misinterpreted over the digital medium that it sometimes becomes a disservice,” Dr. Glaza said. Jeannine Taaffe, senior vice president of sales and marketing at Vancouver, Wash.-based Banfield Pet Hospital, said knowing the limitations of telemedicine has been widely discussed among Banfield practitioners. “One aspect of telemedicine that can be impractical is diagnosing without physically seeing or examining a pet,” Taaffe said. “While it’s ideal for triage and advice, the inability of a pet to tell you what is wrong in a telemedicine environment makes full-scale diagnostics challenging.” Banfield practitioners are finding that the triage approach to telemedicine can be utilized for most problems, and they tend to view telemedicine as a more convenient form of communication that can also be useful in emergency situations, Taaffee said. “Doctors often find themselves with a 30-minute appointment on the schedule for a pet with itching, red eyes, or a scratch,” Taaffe said. “Providing triage advice via telemedicine can prevent unnecessary trips to the hospital, making it an ideal and timely solution for the client, their pet, and the doctor. While the patient may end up needing an in-person visit, in the meantime, client is educated and prepared.” “Telemedicine can never—and never should—replace in-person veterinary care, but it can greatly enhance the way care is delivered by enabling doctors to qualify cases and ensure clients are educated on the most appropriate next steps for their pet,” she said. Use tools and rules, not shortcuts “There are appropriate times to use telemedicine and inappropriate times,” said Lori Teller, DVM, DABVP, CVJ, with the American Veterinary Medical Association. “If a veterinarian examines a patient for intermittent lameness, the patient may not demonstrate symptoms while in-office, and the veterinarian may not be able to diagnose the location or cause of the lameness during the exam.” However, if the pet starts limping at home after the visit, the client could take a video and send it to the veterinarian to help determine the next course of action, such as a follow-up exam or diagnostic imaging, Teller said. “If the veterinarian determines that radiography is the appropriate next step, then he or she may use a form of telemedicine, known as teleconsulting, and have a radiologist review the radiographs and give input on the differential diagnoses,” she said. It’s inappropriate to use telemedicine in place of a necessary physical exam or outside the existing laws regarding the VCPR, Teller said. “States have different laws with regards to the VCPR, and there is also a federal VCPR that plays a role in how veterinarians can write veterinary feed directives or prescribe medications in an extra-label fashion,” Teller said. “Veterinarians need to make sure they are following the laws in the states in which they are licensed, as well as the federal rules.” Returning to the example of the hypothetical dog with intermittent lameness, Teller said that if the pet owner sends a video of the limping dog without the practitioner having done an exam, a potential bone tumor or luxating patella that is causing the lameness could easily be missed. “The exam, and the video shared via telemedicine, each enhance the other,” Teller said. “One does not exclude the need for the other.” Minor problems are more likely to be a better choice than major issues for telemedicine, as is monitoring chronic disease processes, Teller said. Besides missing things, there are myriad health conditions in which using telemedicine alone could be detrimental to a pet’s health. “There are many metabolic conditions that cannot be diagnosed electronically and will require an exam and other diagnostics,” she said. “Just like you wouldn’t ultrasound every single patient that comes through the door, you won’t be able to use telemedicine to diagnose or treat every concern that a client contacts you about via a telemedicine platform.” More importantly, the best- and worst-case use scenarios for telemedicine still need to be worked out, she added. “Veterinarians are just now dipping their toes in the water to determine when using telemedicine will be useful and when it could cause harm to a patient,” Teller said. “They need to exercise good judgment when determining what they can do electronically or telephonically and what needs to be done face-to-face.” Telemedicine has the potential to enhance the bond between the practitioner and the client, according to Teller. “Many times clients just want to know that someone will be available to answer a question or reassure them that everything is okay, or that conversely, this issue is a problem and your pet needs to be seen urgently,” Teller said. TELEMEDICINE IS THE FUTURE: VITUSVET CHIEF VitusVet is an app-based company that serves about 500 veterinary practices across nearly 40 states. Veterinarians pay the firm 99 cents every time a pet owner uses the app for a refill, question or appointment request. Mark Olcott, CEO and co-founder of VitusVet, thinks telemedicine will be a crucial part of the veterinary industry and that practitioners should accept that as fact whether they like it or not. VitusVet is an app-based company that serves about 500 veterinary practices across nearly 40 states. Veterinarians pay the firm 99 cents every time a pet owner uses the app for a refill, question or appointment request. The company currently houses records on four million pets. Olcott said he sees that number hitting 10 million within the next year. It’s only a matter of time until veterinarians see the value that telemedicine can bring to their practices, he added. What about practitioners who may feel that telemedicine is just a fast and cheap way of replacing veterinary services? “It’s kind of irrelevant what they think,” he said. “It’s kind of like what they think about Facebook. It doesn’t matter. It’s coming. It’s going to be a disruption. My message to colleagues is we should embrace this.” Instead of ignoring telemedicine, Olcott said veterinarians should use it to find ways to “anchor clients” to their own practice by making them feel much more in touch with their veterinarian practitioner. “This is just another communication channel if you will—another way to connect with your clients,” Olcott said. Before he was an app developer, Olcott himself was an emergency veterinarian. “Our phones rang off the hook every night between 8 p.m. and midnight,” Olcott said. Most callers were interested in knowing whether their pet’s symptoms were cause for immediate concern or if they could wait until the next day or a future visit to get help for their pet, he said. “Right now, it’s really difficult for them to get answers,” he said. “Dr. Google is there. The answers are instant. They may not be accurate, but it’s something.” He doesn’t see telemedicine becoming commonplace in veterinary clinics overnight, but he does see it happening quicker than most may believe. “It’s not going to sweep over the profession in 12 months,” Olcott said. “But I think it will be here sooner rather than later. Certainly, it will be increasingly relevant over the next three to five years. I think if there’s anything we’ve learned from technology, it’s that consumers are much more powerful these days.” He recommends that practice owners and their staff prepare for the next steps now by discussing what telemedicine means for the clinic. “Ask yourselves ‘What’s our position on telemedicine? How do we define it? What are we going to tell our clients when they ask about it?’” he said.
