These days, the veterinary care model is challenged to change to a consumer-driven, pet health-care model. As we look at adopting connected care in veterinary medicine, many ethical issues emerge that, when ignored, cause inertia, but when thoroughly reviewed and discussed, may allow us to participate in good conscience in the new data- and technology-driven economy. Therefore, it is critical veterinary professionals become engaged in this ethical discussion, ensuring a role in shaping their own future that allows pets to receive the best care possible and their owners to be given access to accurate health information. The rapid adoption of telemedicine in human health care has led to an expectation of the same adoption in veterinary care. As with anything new, the terminology is changing in both human and veterinary medicine. “Telemedicine” was renamed “virtual care” last year and has now evolved to be referred to as “connected care.” With the generational shift in demographics, technology now dominates the way sustainable businesses interact with consumers. The current model of veterinary practice is outdated when compared to most other industries. For instance, would you do business with a bank that only offered check deposits at a branch? Similarly, the veterinary model is being disrupted because it no longer fully serves the needs of the modern pet parent who is looking for more convenient care and better access to it as part of its value proposition. Consider the following key ethical issues related to the adoption of technology-driven pet health virtual interactions: 1) Access to care: Does our current veterinary-client-patient-relationship (VCPR) as defined in state practice acts limit access to care? Is this ethical and always in the best interest of the animal? 2) Democratizing medical and health records: Do our current laws and software systems allow access to medical records when a pet needs to be seen in an emergency? Connected care technology can provide the platform for this concept, but eventually, laws will need to change. Further, should it be a requirement that medical records be portable and owned by the pet parent? 3) Privacy and security of a pet’s medical records: Seven states have already passed stronger pet record privacy laws, while privacy regulations in California will come into effect this year. Is our ethical framework strong enough to support these consumer protection laws? Said another way, do we really have the ethical framework in veterinary medicine that is driving a commitment to protecting client privacy? Where to begin To provide a starting point for the connected care discussion, consider the dilemmas, differing arguments, and the need for ethical guidelines raised by the following questions: 1) Should we work to establish a VCPR by virtual means along the lines of a televeterinary-client-patient-relationship (TCPR)? 2) How is data from the connected care visit accessible to other care providers and the client? What are the ethical questions raised by medical record-sharing so live or asynchronous (journaling, texting, email) communication with the client is well-informed? 3) What about all other forms of connected care, such as asynchronous connected care, “pet two-way journal,” and remote patient monitoring? What are the issues and benefits that will inform our ethical discussion for making these technologies available to pet owners? The slow adoption of technology within the veterinary profession may be causing pet parents to go directly to Dr. Google, omitting the veterinarian from the consultation entirely, to the patient’s detriment. The current business model of independent veterinary practices is proving no longer as sustainable as it once was. They are, instead, experiencing flat revenue, declining visits, and decreasing new-client metrics. Given the trend over the last several years that veterinary medicine as a category is not growing nearly as fast as the pet space overall, it is clear a change is needed. If we don’t adjust the veterinary practice role from “hands-on heroes” to “digital guides,” it is highly likely veterinarians will no longer be the trusted advisor informing pet parents; they are likely not informing many pet health decisions even now. Millennial pet parents routinely turn to blogs, Dr. Google, and other online sources of information for health and illness solutions for their pet, rather than veterinarians. This is because technology is this generation’s preferred mode of communication, as opposed to the phone or face-to-face interaction. If adopted by veterinarians, technology can move them into the space where the decisions are made that impact the pet the most—in the home and dramatically expanding the 16 minutes a year veterinarians currently spend with clients on average. If veterinarians are not informing pet health decisions in the future, pets—our valued family members—will be at great risk. This is clearly the path we are on; we must work together as a whole to make changes and stay relevant to pet parents.1-5 “In a Salesforce survey, six out of 10 millennials support telemedicine, such as video chats, instead of in-person visits,” notes Morris Panner, CEO of Ambra Health. “Even more want their [own] doctor to give them a mobile app for booking appointments, reviewing health records, and managing their preventive care. Most would consider wearable devices that share health data with their doctor.”12 If millennials want this for themselves, they certainly want it for their beloved pets. Ethical issues surrounding veterinary connected care Connected care comprises real-time (live audio/visual) and asynchronous consultation, as well as remote patient monitoring (e.g. vitals, activity, medication, and weight) while the patient is at home. Because most veterinary medical boards are driven by consumer concerns, the convenience of communicating with a veterinary team through connected care consults will move the VCPR from the exam room to the client’s home. Imagine a future where 80 percent of veterinary medicine is conducted remotely through telehealth, telemedicine, and e-commerce products, including auto-shipment of medication or preventive care products and home diagnostics. Some would argue one of the barriers holding veterinarians back from embracing connected care is the confidence to move forward to implement technology solutions in their practice because they can’t change their paradigm as fast as clients’ have changed theirs. To change the paradigm, veterinarians must step back and think hard about all the pets that do not receive care due to ethical barriers of the traditional model of veterinary clinics. Other categories of connected care ethics include data usage, privacy, and record accessibility or sharing.7 Within these areas, some very good discussions are starting to take place regarding medical record confidentiality and client privacy.6 The American Veterinary Medical Association (AVMA) has come up with a policy regarding principles of veterinary data ownership and stewardship.8 Further, AVMA and American Animal Hospital Association (AAHA) have collaborated on a connected care brochure 9 that is useful for furthering the connected care discussion. The future of connected care medicine Given technological advances in home diagnostics and the availability of online pharmacies, will we be able to “prescribe to the level you can defend?” Will we be able to practice from anywhere in the world? Can we imagine veterinary medicine without a brick-and-mortar practice concept? There are so many issues requiring examination—the future is unfolding with or without us. Professional organizations, including AAHA, AVMA, and Association for Veterinary Informatics (AVI), should be actively involved in developing guidelines for practicing televeterinary medicine. Some veterinarians, such as Rolan Tripp, DVM, founder of the Veterinary Future Society, have even started engaging the chief veterinary officer of the U.S. in discussions on the future of connected care. Connected care in practice spans all segments of our profession: food animal, companion animal, equine, and exotics. The time is now for veterinarians to get actively involved in their state and national organizations, and for governments to shape the health care of animals and people in the right way, in the future.13 HOW ETHICS AFFECT VETERINARY CONNECTED CARE The following points are at the center of the connected care ethical discussion: 1) Access to care 2) Veterinary practice efficiency and team’s quality of life 3) Quality of care—standard of care 4) Medical record-sharing 5) Data privacy, security, and accessibility to all care providers for the pet (interoperability, etc.) 6) Monetization of connected care 7) Prescribing and diagnostics 8) Crossing state or country boundaries—national and global televeterinary medicine 9) Access to a pet’s medical records during the televeterinary consultation Kerri Marshall, DVM, MBA, is a second-generation veterinarian focused on veterinary innovation. She received her DVM at Washington State University and her MBA at the University of Oregon. After 10 years of private practice and being on staff at UC Davis, Dr. Marshall joined the founding management team at Banfield Pet Hospitals. In 2011, she joined Trupanion, leading the development of Trupanion Express and was awarded North American Veterinary Community’s (NAVC’s) 2018 Veterinarian Innovator of the Year Award for this invention. Marshall was the chief veterinary officer, board member, and investor at BabelBark, a technology platform connecting pet parents to pet care providers. She is currently chief information officer and vice president of innovation at Compassion-First Pet Hospitals, advisor to BabelBark, and on the board of directors for Inulogica. She can be contacted via email at kerri.marshall@compassionfirstpets.com. References Reversing the Decline in Veterinary Care Utilization: Progress Made, Challenges Remain, Partners for Healthy Pets. 2014. (Cited by State of Pet Health-Banfield 2015) VHMA Insider’s Insights 2019, Veterinary Hospital Manager’s Association Monthly Insider Insights, May 2019 A View From The Trenches, Karen E. Felsted, CPA, MS, DVM, CVPM, CVA and Travis Meredith, DVM, MBA, Diplomat ACT, KC Animal Health Corridor Market Insight Seminar, August 20, 2018 US Animal Health Market Insights 2019 Mid-Year Update, Animalytix, LLC and Axxiom Consulting, Kansas City Corridor Market Insight Seminar, August 26,2019 Total Pet Spending Report, A GPS for Pet Business, John Gibbons, The Pet Business Professor, Pet Age, November 14, 2018. bit.ly/2skEsWO Maintaining medical record confidentiality and client privacy in the era of big data: ethical and legal responsibilities. Anthony P. Aaron, MS, JD, Martha L. Kohlstrand, JD, Link V. Wellborn, DVM, Stephen T. Curvey, BS. JAVMA Aug 1, 2019, Vol 255, No 3. pp 282-288 Ethical issues for today’s veterinarian in the digital age: How the digital revolution raises ethical and legal questions in veterinary medicine. Kerri Marshall, DVM, Veterinary Practice News, February 1, 2019 bit.ly/2KV83fZ AVMA Policy on Telemedicine, 2019. bit.ly/34pWJ31 The Real-Life Rewards of Virtual Care: How to Turn your Hospital into a Digitally Connected Practice with Telehealth. AVMA and AAHA sponsored brochure on telehealth, 2018. bit.ly/2OZMyMj AVMA Pet Owner Demographics and Sourcebook, 2017-18 edition. bit.ly/34owslK Making Pet Care Personal: Banfield State of Pet Health Report 2015, bit.ly/2OnYacQ Five Ways Millennials Do Health Care Their Own Way, Morris Panner, Ambra website April 10, 2019, originally published in Forbes, April 9, 2019. bit.ly/2OmXW5t Personal communication, Mark Cushing, founder and CEO of the Animal Policy Group. animalpolicygroup.org
