Mia Cary, DVM, NAVC Chief Collaboration Officer, Veterinary Innovation Council Executive Director
Aaron Massecar, PhD, Veterinary Innovation Council Telehealth Project Manager
Attend a conference, pick up a trade publication, or simply talk with other veterinarians and one word keeps coming up again and again: telehealth. The term is as misunderstood as it is polarizing. It promises to open up new markets by catering to millennials and threatens to displace the veterinarian’s place at the center of care.
An issue that causes so much concern and presents so many opportunities calls for an industry-wide, collaborative approach. In January 2016, the Veterinary Innovation Council (VIC) was formed to tackle the largest challenges and opportunities facing the profession. Spearheaded by the NAVC, the VIC includes stakeholders from across veterinary healthcare (navc.com/veterinary-innovation-council/our-team/). Its first mission is to make sense of telehealth so that veterinarians can sidestep its impediments and capitalize on its benefits.
The VIC has been working with telehealth providers (Box 1), veterinarians, state boards, pet owners, and industry stakeholders to develop success models and best practices that will be shared with the profession. The VIC seeks to delineate between cases for which telehealth is appropriate and those for which it is not. We are pairing clinics with telehealth providers and learning where and when telehealth tools are most effectively used.
So far, we have learned that:
- The term telehealth is ambiguous.
- Many veterinarians, companies, and pet owners already use telehealth.
- Appropriate uses for telehealth include pre-existing business models.
- There are easy ways to begin using telehealth tools.
- Telehealth can be used without violating the veterinary–client/patient relationship (VCPR).
BOX 1. Veterinary Telehealth Providers
WHAT IS TELEHEALTH?
To start with, a few definitions may be useful:
- Telehealth: The overarching term that encompasses all uses of technology geared to remotely deliver health information, education, or care.
- Telemedicine: A subcategory of telehealth that is a tool, or use of a tool, to augment the practice of veterinary medicine (eg, using Skype or an app to communicate with a client and visualize the patient for a postoperative follow-up examination and discussion).
- Teleconsulting: A subcategory of telehealth that occurs when a general practice veterinarian uses telehealth tools to communicate with a veterinary specialist to gain insights and advice on the care of a patient.
HOW IS TELEHEALTH BEING USED?
Professional Use of Telehealth
If you’re texting a client to see how Fluffy is doing or answering a question about medication side effects, you’re using telemedicine. If you’re monitoring an animal remotely, even if it is in the clinic and you are watching vital signs from another computer, you’re using telemedicine. Clients often want more advice than Dr. Google can give, but don’t have the time or finances to see a veterinarian, so they use telehealth providers to answer questions through text or online services.
Because the providers are aware of the VCPR legislation, most neither prescribe nor diagnose online. We have all heard of companies or veterinarians who use secret forums, like those found on Facebook, to diagnose and prescribe. VIC condemns the use of telehealth tools when it is inappropriate and violates state legislation. We favor promoting the judicious use of these tools to extend more healthcare to more animals. Examples are emails, texts, instant messages, phone calls, sending of photos and videos, and live videos.
Appropriate Use of Telehealth Tools
The telehealth scenarios that we see most frequently and those with the greatest success are the following:
- Postoperative follow-up
- Dermatologic concerns
- Behavioral issues/training
- Transportation issues
- Hospice care
- Basic triage (whether the pet should be seen by the veterinarian)
- Environmental concerns/hazards that might contribute to a particular condition
- Long-term care monitoring
For these scenarios, telehealth tools provide sufficient information to assist pet owners without the necessity of a hands-on physical examination. In some cases, the tools are insufficient and an in-person exam is required; in those instances, veterinarians are discounting the in-person visit according to the cost already paid for the telehealth service.
Three models are effective:
- No-charge first exam
- Often results in need for in-person visit (anecdotally, people who connect through telehealth first tend to visit 50% more and sooner and spend 20% more in person)
- Additional feature of a pre-existing wellness package
- No charge (or charge included in package)
- Convenience for client
- Per-usage charge
- By-the-minute or usage charge
- If in-person exam still required, costs credited to client’s account
The most effective way of getting started with telehealth is to follow the “lean startup” method: Start with 1 or 2 low-risk cases and 1 or 2 doctors and clients. Learn what is successful and measure the outcomes. Slowly expand to include another doctor, another client, and another use case. Then measure and repeat. An example of this is using a text service to inform clients of negative fecal results. Slowly add more use cases and clients until you can diagnose and prescribe within the confines of your state legislation.
Using Telehealth Within State Legislation
All states except Connecticut (as well as the District of Columbia) forbid diagnosis and prescription without a valid VCPR that is established through an in-person exam. As was found in human healthcare, this legislation might be challenged in court because of its antitrust properties. Whether company- or client-driven, there are many examples of legislation crumbling under consumer pressure. A protectionist strategy of reinforcing legislation that goes against client demands is never a good approach. Veterinarians who are gaining an understanding of and comfort level with telehealth will be in a better position to use telehealth tools appropriately as pet owner demand increases.
Veterinarians must be allowed to exercise their best judgment regarding when telehealth tools should be used and when they should not. If the veterinarian does not feel that sufficient information can be gathered through remote, electronic means, then those tools should not be used. However, if veterinarians can gather enough information from remote digital tools, then they should use these tools as long as doing so is in the animal’s best interest. The VIC, the American Veterinary Medicine Association (AVMA), the American Association of Veterinary State Boards, and the Veterinary Medical Association Executives are just a few of the organizations working collaboratively to address these concerns.
Pet Owner Use of Telehealth
In March 2017, the VIC conducted a telehealth survey of pet owners in the United States to better understand their perceptions and uses of telehealth tools. A total of 678 pet owners completed the 5-question survey; while the survey does not represent all pet owners, the results do give a sense of pet owners’ attitudes. The charts show the results of the survey. (Figure 1).
Unsurprisingly, most respondents have not used telehealth tools. What is surprising are the reasons for the lack of use. Roughly one-third of respondents said that they didn’t know that telehealth tools existed. When that number is combined with the 26.4% who said that the tools are not available to them, more than 50% of pet owner respondents are not taking advantage of telehealth tools.
Overall, the responses are clearly mixed (Figure 1). This could be because the market for telehealth tools is still nascent; the tools are being developed and awareness is growing, but they are not yet in widespread adoption. Our preliminary results show an appetite for telehealth tools, and that appetite is satisfied when pet owners are aware of where and when to use the tools.
The pet owner survey will be conducted again in March 2018, and those results will be shared with the profession.
WHAT’S NEXT FOR VETERINARY TELEHEALTH?
We have not only learned that veterinary telehealth is coming but how it is coming. Telehealth tools reduce client wait times while increasing veterinarian revenue, all while operating within the confines of the VCPR.
The future presents 2 main opportunities for veterinary healthcare: (1) further clarifying legislation and implementation and (2) incorporating new technologies. Many open questions about telehealth remain, from informed consent and liability issues to revenue models and practice workflows. These issues are being clarified by lawyers and state boards from a legal perspective and by veterinarians, telehealth providers, and pet owners from a practical perspective. For example, earlier this year the University of California, Davis, released an update1 on how their telemedicine services save time and money and help improve air quality. Practitioners of human pediatrics2 have addressed patients’ inability to speak, and we would be wise to learn from their experience.
Telehealth has primarily focused on communication tools. Incorporation of new technologies will only continue, from connected litterboxes and implantables to wearable devices3 and in-home diagnostics (Figure 2). We are moving from an era of once- or twice-a-year visits to an inexpensive and constant stream of 24/7 360° data that will provide deeper insights into our pets’ health. Veterinarians must be at the center of animal care, but this will happen only if they adapt to and incorporate these new technologies. By working together as a profession, we can create solutions and best practices that bring us into the future of veterinary healthcare, a future that emphasizes a personalized, customized, patient-centered approach.
For more information, read the comprehensive AVMA telemedicine report, along with the VIC Board of Directors consensus response.4
While telehealth is the current VIC focus, we are considering future projects to run in parallel with the telehealth pilots. Please email your perspectives on challenges and opportunities facing our profession to VIC@NAVC.com. For information on the VIC Veterinary Innovation Awards, see Box 2.
BOX 2. VIC Veterinary Innovation Awards
The VIC launched the first annual Veterinary Innovation Awards program in February 2017. This program seeks to cultivate and celebrate innovation within the veterinary profession. The nomination phase for individual contributors and organizations ended May 1. To incorporate feedback from the community, a crowd-sourced voting phase will continue from July 1 to September 30. Runners-up will be promoted throughout the profession, and the winners in each category will be announced at VMX 2018 in Orlando, Florida, where they will be invited to participate in an innovation-themed panel discussion. Visit VICAwards.com to cast your vote.
- Casey C. Telemedicine saves patients time, money. University of California. March 21, 2017. edu/news/telemedicine-saves-patients-time-money?utm_content=bufferb60c9&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer. Accessed April 2017.
- Burke BL, Hall RW. Telemedicine: pediatric applications. Pediatrics 2015;136(1):e293-308.
- Plummer L, Allison C. The best pet trackers: GPS and smart collars for dogs and cats. Wareable. February 22, 2017. https://www.wareable.com/internet-of-things/the-best-pet-wearables-trackers-and-gps-for-dogs-cats-and-more. Accessed April 2017.
- North American Veterinary Community. Interested in telehealth? navc.informz.net/informzdataservice/onlineversion/ind/
bWFpbGluZ2luc3RhbmNlaWQ9NjM2NDA1OCZzdWJzY3JpYmVyaWQ9MTA2NTg2Mzk4OQ==. Accessed April 2017.