Why not a virtual VCPR?

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As telemedicine appointments become more common in veterinary medicine, a few states are moving toward allowing the veterinarian-client-patient relationship (VCPR) to be established virtually, without a previous in-person examination of the animal or visit to the premises where the animal is kept. This change has largely been driven by direct-to-consumer companies that have business models that are only sustainable and more profitable in an operating environment that allows a virtual VCPR. Here’s what veterinarians need to know to protect patients, clients, public health, practices, and ourselves.

Complying with applicable law

The veterinary profession has been implementing telemedicine successfully for years, largely because we have done so while complying with the federal definition of the VCPR. That definition requires an in-person examination or premise visit to establish the VCPR, after which the relationship may be maintained by telemedicine between periodic examinations of the animal(s) and/or timely visits to the premises where the animal(s) is kept.¹

Historically, the federal and state VCPR rules have been the same, so veterinarians didn’t have to think much about which rules apply in each scenario. However, confusion arises for both clients and veterinarians when a state’s VCPR definition differs from the federal one, as the rules that apply will depend on various factors. For veterinarians, that confusion can lead to an increased risk of being called before a state licensing board, federal agency enforcement action, and can cause problems in malpractice litigation if the veterinarian doesn’t comply with the federal definitions in the specific situations where the federal laws supersede state law.

For example, an in-person VCPR is required for extralabel drug use¹ and issuing Veterinary Feed Directives, according to the FDA.² Engaging in these activities outside an in-person VCPR could result in use of the drug being deemed by federal law as unsafe or feed being deemed adulterated—and the potential for the veterinarian to be held accountable. There are also other situations to which the federal definition of the VCPR applies, including the use of certain types of biologics³ and when practicing on horses covered under the Horseracing Integrity and Safety Authority.⁴

Examining access-to-care arguments

Arguments in favor of a virtual VCPR generally focus on expanding access to care and reducing its cost. However, this argument is based on flawed assumptions. One assumption is that more animal owners will seek and be able to access veterinary care if there’s no requirement to establish a VCPR in person. Another is that telemedicine saves clients’ money.

Frequency of care

Looking at the first assumption, it’s not definite that relaxing VCPR requirements will enable more animals to receive care. Indeed, reasons other than not being able to physically access a veterinarian appear to be more influential in determining whether an animal receives veterinary care. For example, the top reasons pet owners cite for not visiting the veterinarian in the past 2 years reflect a lack of perceived need, not a lack of physical access or convenience (Figure).⁵

A virtual VCPR won’t ensure access to care for animals that don’t regularly see a veterinarian. Unfortunately, these animals are more likely to need a complete physical examination, other diagnostics, and hands-on veterinary care because they are more likely to be ill and have complex or multiple health issues. Such care cannot be delivered by telemedicine alone. However, telemedicine can be used after that initial visit to monitor the patient for continued improvement and ensure continuity of care.

Telemedicine’s ability to “fix” access to care is also limited by gaps in access to technology and digital literacy, as well as challenges with reliable internet access in some rural areas. On the other hand, one surefire way we can expand access to care is by delivering information on the importance of preventive care through tele-education and teleadvice,⁶ neither of which requires that a VCPR be established.

Affordability

As for cost, telemedicine is not necessarily easier on clients’ pocketbooks than in-person visits. Certainly, the thoughtful use of teletriage⁶—which does not require a VCPR to be established—can reduce costs associated with unnecessary emergency visits, and telemedicine consultations can sometimes be less expensive and more time efficient than in-person consultations for follow-up care.⁷ Nevertheless, experience from human medicine indicates that using telemedicine may actually increase overall cost of care, particularly when an in-person visit is ultimately recommended (resulting in duplicate charges) or when patients aren’t receiving regular primary care and there are delays in addressing health issues that only a physical examination can identify.⁸

Assuring access to high-quality care

Of paramount importance is the need to protect animal health and welfare, prevent and relieve animal suffering, and protect public health. The reality is that animal owners are not always able to accurately interpret and describe their animal’s clinical signs, and critical information may escape an owner’s notice or recollection. The in-person encounter provides veterinarians with a wealth of information about both the patient and client and allows veterinarians to deliver the right diagnosis and most effective treatment plan within the owner’s resources and capabilities. Timely visits to the animals’ premises also can provide veterinarians with information about current husbandry practices and how the animals are kept. Once the VCPR has been established in person, veterinarians have the knowledge of the animal, the client, and other factors that they need to appropriately integrate telemedicine into the care plan.

A lack of this background information can result in missed or delayed diagnoses and threaten quality of care. This is particularly true when clinical signs are atypical or nonspecific, and where palpation, auscultation, and other diagnostics could reveal abnormalities such as a distended bladder, enlarged uterus, or gastrointestinal obstruction.

Misdiagnosis or inappropriate treatment plans can result in prolonged illness and suffering and increase the cost of care. Further, when highly contagious and/or fatal diseases are involved, such as highly pathogenic avian influenza or rabies, delays in diagnosis can result in consequences that are devastating not only for the animals but also for humans. The result can be untold animal suffering, public health risks, food supply interruptions, and economic impacts in the billions of dollars.

There are other risks to skipping the in-person relationship that warrant consideration. Some evidence suggests that increased use of telemedicine in human health care, when used as a replacement for in-person visits, has resulted in reductions in delivery of preventive care—particularly vaccinations.⁹ In veterinary medicine, a decrease in vaccination rates could jeopardize not only animal health but also public health.

Protecting access to necessary medications

Virtual provider-patient relationships, including a virtual VCPR, have been associated with overprescribing of antibiotics and increased risks for misuse and diversion of controlled substances. Multiple studies^10-13 in human medicine indicate that overprescribing antimicrobials can occur when patient-provider relationships are established electronically. In fact, a virtually established patient-provider relationship that resulted in an opioid overdose was the impetus behind the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, which aimed “to address the threat to public health and safety caused by physicians who prescribed controlled medications via the internet without establishing a valid doctor-patient relationship through such fundamental steps as performing an in-person medical evaluation of a patient.”¹⁴

Antimicrobial resistance and controlled substances are top-of-mind concerns for federal and state lawmakers. In-person examinations and premise visits provide them with confidence that veterinary professionals are good stewards and partners. An in-person VCPR helps safeguards veterinarians’ access to antimicrobials and controlled substances for our patients and protects public health.

The bottom line

An in-person VCPR best serves and protects the needs of patients, clients, veterinarians, and public health. Proper use of telemedicine can improve effectiveness and efficiency in delivery of veterinary care. In the absence of an established VCPR, veterinarians are free to provide tele-education, teleadvice, and teletriage—just not telemedicine. These services, which do not provide a diagnosis, prognosis, or treatment for a specific patient, have great potential for promoting preventive care and reducing unnecessary emergency visits.

The AVMA is pro telemedicine and pro in-person VCPR. Find resources that empower veterinarians to explore and integrate telehealth at avma.org/Telehealth.

References

1. Extralabel drug use in animals. In: Code of Federal Regulations Title 21. FDA; November 7, 1996. Accessed January 10, 2023. https://www.ecfr.gov/current/title-21/ chapter-I/subchapter-E/part-530
2. New animal drugs for use in animal feeds. In: Code of Federal Regulations Title 21. FDA; March 27, 1975. Accessed January 10, 2023. https://www.ecfr.gov/current/ title-21/chapter-I/subchapter-E/part-558
3. Veterinary services memorandum No. 800.214. United States Department of Agriculture. Accessed September 22, 2023. https://www.aphis.usda.gov/animal_health/vet_biologics/publications/memo_800_214.pdf
4. HISA registration rule. Federal Register. May 11, 2022. Accessed October 4, 2023. https://www.govinfo.gov/ content/pkg/FR-2022-05-17/pdf/2022-10709.pdf
5. Expenditures and visits. In: 2022 AVMA Pet Ownership and Demographics Sourcebook. American Veterinary Medical Association; 2022:10. https://ebusiness.avma. org/files/ProductDownloads/eco-pet-demographic-report-22-low-res.pdf
6. Veterinary telehealth: the basics. American Veterinary Medical Association. Accessed September 22, 2023. https://www.avma.org/resources-tools/animal-health-and-welfare/telehealth-telemedicine-veterinary-practice/ veterinary-telehealth-basics
7. Bishop GT, Rishniw M, Kogan LR. Small animal general practice veterinarians’ use and perceptions of synchronous video-based telemedicine in North America during the COVID-19 pandemic. J Am Vet Med Assoc. 2021;258(12):1372-1377. doi:10.2460/javma.258.12.1372
8. Ashwood JS, Mehrotra A, Cowling D, Uscher-Pines L. Direct-to-consumer telehealth may increase access to care but does not decrease spending. Health Aff (Millwood). 2017;36(3):485-491. doi:10.1377/hlthaff.2016.1130
9. Cortez C, Mansour O, Qato DM, et al. Changes in short-term, long-term, and preventive care delivery in US office-based and telemedicine visits during the COVID-19 pandemic. JAMA Health Forum. 2021;2(7):e211529. doi:10.1001/jamahealthforum.2021.1529
10. Ray KN, Shi Z, Gidengil CA, Poon SJ, Uscher-Pines L, Mehrotra A. Antibiotic prescribing during pediatric direct-to-consumer telemedicine visits. Pediatrics. 2019;143(5):e20182491. doi:10.1542/peds.2018-2491
11. Uscher-Pines L, Mulcahy A, Cowling D, Hunter G, Burns R, Mehrotra A. Antibiotic prescribing for acute respiratory infections in direct-to-consumer telemedicine visits. JAMA Intern Med. 2015;175(7):1234-1235. doi:10.1001/ jamainternmed.2015.2024
12. Li KY, Ngai KM, Genes N. Differences in antibiotic prescribing rates for telemedicine encounters for acute respiratory infections. J Telemed Telecare. 2022:1357633X221074503. doi:10.1177/1357633X221074503
13. Suzuki H, Marra AR, Hasegawa S, et al. Outpatient antibiotic prescribing for common infections via telemedicine versus face-to-face visits: systematic literature review and meta-analysis. Antimicrob Steward Healthc Epidemiol. 2021;1(1):e24. doi:10.1017/ash.2021.179
14. Telemedicine prescribing of controlled substances when the practitioner and the patient have not had a prior in-person medical evaluation. Fed Register. March 1, 2023. Accessed October 9, 2023. https://www.federalregister. gov/documents/2023/03/01/2023-04248/telemedicine- prescribing-of-controlled-substances-when-the-practitioner-and-the-patient-have-not-had