Comparing Telemedicine Policy | AVMA, AAVSB, and VIC

Hello, this is Mark Cushing with series 6 of Mark Five, Policy Off Leash. We’ve had five good discussions on telemedicine and virtual care and the law, if you will, of the regulations in place across the country and how they affect veterinarians and their teams. Today, we discuss the approach that three major organizations have taken. These are national organizations addressing the VCPR in telemedicine and it’s both to tell you what they say, what they write, how it might affect you and then give you an idea where we may go in the future.

The three organizations are the AVMA, the Veterinary Innovation Council, or VIC as it’s known, which was created by the North American Veterinary Community back in 2016, and the Association of American Veterinary State Boards or AAVSB, which is the group of all 50-state Veterinary Medical Boards around the country and their national organization which really focuses on best practices and they took on the issue of telemedicine and the VCPR and you’ll hear what they say about that in just a few minutes.

Let’s start though with a question I get asked often which is, why do we even use a VCPR? How was a VCPR created originally, who created it and what’s the point? That’s a fair question. I think you need to understand it to know somewhat about how telemedicine fits in here. 

First of all, understand that the VCPR is not something that a veterinary organization created. These are laws adopted by legislatures around the country. Legislatures are not full of veterinarians or full of medical personnel or medically trained personnel. So, what was the purpose of this? 

It may surprise you it wasn’t designed to protect animals under the care of veterinarians; it was designed to create a legal basis. I’m a lawyer talking now, I’ll try to make good sense of this. It was designed to create a legal basis for state boards to take disciplinary actions against veterinarians from the manner in which they practice, and they felt they needed some definition of what the relationship was with a client, the owner, and with the animal itself, the patient, to be able to do what — to take action against someone they think may have done something wrong. That’s interesting, isn’t it? So, it kind of sets forth the terms of engagement.

What strikes you, probably, when you hear about the VCPR (or if you’ve taken the time to ever read it in a statute) is it’s very legalistic. Now you know why it was designed — to serve a legal purpose, if you will, for enforcement actions against veterinarians. 

Now, I can tell you for decades and certainly the last decade, up until 2016, you almost never went to a veterinary conference, you never had a veterinary discussion that brought up the term VCPR. It was on the books, people kind of understood it; maybe they understood it well. But the point is, it didn’t warrant discussion and then telemedicine came along in the human sector and for 25 years human medicine shaped their version of the client-patient relationship to fit telemedicine and finally in 2016, it became a topic for the veterinary world.

What I find ironic, as the veterinary world struggles with this question of the telemedicine VCPR, is that the stakes for accountability and enforcement action are so much higher in human health care than they are for veterinary care. Why? Remember in veterinary medicine the pets are deemed property and you can’t recover non-economic damages or emotional damages against a veterinarian. In human healthcare those are the explosive, multi-million-dollar rewards that are granted by juries or settled by parties because they don’t have those limits. So, in human health care when a medical board goes after a doctor for malpractice of some sort in an enforcement action using their definition of a patient-client relationship, the implications can be much more expensive. Interestingly, as you’ve heard me say before 49 of 50 states on the human side have already said a telemedicine client patient relationship can be utilized and created. So, you would think they would have much more to fear — but they’ve obviously worked it out over the last 25 years.

So, let’s start with the AVMA. The AVMA has what you would call a traditional policy regarding the VCPR and that shouldn’t surprise you and it had this before telemedicine discussions grew intense and so active over the past four years and it really hasn’t changed them since. But they have made some reforms — but the basic rule, of course, is you can’t treat or do anything with a pet or an animal until you have a VCPR and you can only create the VCPR through a physical examination, an in-person examination, which almost always takes place in your clinic. That’s the basics and everything flows from that. But the hopeful news, if you will, or the encouraging news about the AVMA view now regarding telemedicine (and they are a member of the Veterinary Virtual Care Association) is that they embrace new technologies and they have a policy that explicitly encourages the development and the use of new technologies to deliver care to pets and to animals — that’s a good thing. Better yet I’m going to read this precisely, the AVMA policy in telemedicine says:

“Future policy in this area will be informed by evidence-based research on the impact of telemedicine on access to care and patient safety.” 

Evidence-based research, that’s a major step and that’s one of the reasons that the VVCA has taken the step to reach out to Ontario, Canada, and to the 17 US states that allowed telemedicine VCPRs during COVID and to the FDA, which did the same thing. Because now we have virtual VCPR being tested, which generates evidence that we can study and analyze. I think that’s going to be the challenge in 2021 and hopefully 2022, that we pull together at the VVCA all that evidence and take a look at and see what it tells us. We do know that in Ontario, after nearly three years, there have been no complaints about harm to pets or harm to animals due to the use of telemedicine. Let’s see if that applies elsewhere and, if so, don’t we need to as the AVMA suggests, form policy based on that evidence.

Now the two reform efforts were done by the Veterinary Innovation Council, or VIC, and by the AAVSB in 2016. When the Veterinary Innovation Council was formed — it had an elite group of people around the table representing many different associations and backgrounds and they took on the question of telemedicine. They adopted a view in line with human healthcare that recognizes virtual care or telemedicine as a tool to augment or support or enhance veterinary practices and bring more pet owners into the system and of the goals that the VIC board had in adopting their telemedicine policy, access to care ran through each of the goals. That was clearly the focus.  You take rural, you take low income, you take underserved pet owners, and you pull them into the system because it’s easy to get healthcare, at least started, through telemedicine. The foundation of the VIC rule, to keep in mind, is very simple: the veterinarian should be trusted to decide when she has enough information from whatever means she chooses, including digital or electronic, to begin to work with a pet. It’s not a legislative decision, it’s a veterinarian’s decision based on her training and experience.

Basically, the VIC board said VCPRs serve a purpose, but they have to be flexible and match where society is going with technology and other tools, rather than veterinarians basically turning their head from new ideas and new ways to deliver healthcare.

The AAVSB or the Association of State Boards, in part because of dialogue with the VIC group back in 2016, took two years in a very methodical, very thorough process led by their executive director Jim Penrod and in September of 2018 they adopted a policy on telemedicine which included the VCPR. This is important because this was a policy now that all 50-state Veterinary Medical Boards could access, study and be comforted that their national organization recommends that these be adopted and I will tell you it’s a balanced view, they took sort of all sides into account. It’s premised on the same principle that VIC based its telemedicine policy. What’s that? The sound professional judgment of the veterinarian. That telemedicine is appropriate in whatever situation they’re facing in, other words, if you don’t think you have enough information don’t rely upon it. If you don’t think it gives you what you need to diagnose or treat and you need in person, include that — but if you’re comfortable and you make the judgment (the veterinarian not a legislator) go ahead and do that. They want consent on the part of the pet owner. Human medicine has done that in many states, what they call informed consent. So, you’re advising the pet owner that I think this treatment plan of this diagnosis makes sense from what I can see and what we’re sharing electronically, and I’m prepared to go forward with that, I want you comfortable — if you’d rather come into the clinic that’s your choice. That’s not a bad idea, of course, and I think you’ll see a lot of states follow that. 

The other thing that the AAVSB encouraged is to make the current practice of what I would say is a “practice-based VCPR,” go ahead and make that the law. What’s that mean? If you go to every state’s definition of VCPR,  it’s something that an individual veterinarian has with a particular patient pet and a particular pet owner but, in fact, if you go on vacation, if you’re sick, if you’re not at work today you would expect someone in your practice who can access a medical record to go ahead and give advice and treat electronically if, you want, the pet and the pet owner and that’s something the state Vet Med Boards frankly look the other way and knows is going on, but in reality the law doesn’t say that. I think it makes sense as the AAVSB calls out let’s go ahead and make that the practice everywhere.

All three: AVMA, VIC and the AAVSB do agree you make exceptions and emergencies, including poison control, for a telemedicine VCPR, but otherwise you have VIC and the AAVSB comfortable with the judgment of a veterinarian allowing for a telemedicine VCPR and the AVMA remains of the view that you have to see the pet in person, but they’re open to evidence as they call evidence-based research serving as a basis to make a change and we’ll see if that happens in 2021 and 22.

1 Comment

  1. Carolyn Shadle on December 2, 2020 at 11:06 pm

    Very clear. Very useful. Very hopeful! Thanks. ~ Carolyn Shadle

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