Smart VCPR Reform: Guardrails May Be the Key

Welcome to a new episode of MarkFive: Policy Off Leash. Today Mark reviews in detail the guardrails that might be the best way to approach reform for establishing a virtual-VCPR. We welcome your questions and comments below.

Below is a transcript of the video.

Greetings to season two and episode two of Mark Five Podcast brought to you by the VVCA, the Veterinary Virtual Care Association. And we’re going to begin a deeper dive into the issues. And really there’s a single issue, but the issues surrounding telemedicine that we’re now seeing play out across the United States. And I hope that this overview today, which is a part of a two-part deep dive into the VCPR questions, the veterinary-client-patient relationship. I hope it’s helpful and both individually frames the issues in a way that you can decide where you come out on those questions, and gets the attention of some associations that have kind of held back or had just a default position of opposing telemedicine. And maybe they’ll start to rethink that. I like to think so.  

Now, really, when it comes to virtual care and telemedicine, there’s two aspects to broad topics of interest. The one that’s probably the day-to-day concern and opportunity involves operational questions. How do we implement. How do we use it? How do we staff it? How do we make money with it? How do we give our clients the experience they want? And Ali Macintyre and our team and the many, many consultants and the sponsors we have are continually upgrading and providing guidance there. That’s not my part of the program. My part concerns the second question, which is veterinary-client-patient relationship or the VCPR, excuse me. And really, that’s the only issue. That’s the only policy issue. But it comes up all the time. A phrase, VCPR, that I can go back to my 16 years of involvement with this industry and profession. It never came up. And in the typical veterinary practice, it never came up. It’s actually something that was a legal mechanism to try to have a framework that allows veterinary medical boards to pursue and challenge the license of veterinarians regarding complaints that come in. But it’s turned into the issue when it covers telemedicine. And guess what? It was the same issue for human medicine, which has spent twenty-five to thirty years in advance of veterinary medicine, getting to understand, getting comfortable with telemedicine and virtual care, to where today is a mainstay of any hospital, any practice. Forty-nine states make it legal to create a doctor client relationship through telemedicine. None of them did to start with. All of them had the same kind of concerns and issues, and they took a lot of years to fight the battles. But one by one, the issues went away.  

So, I want to just summarize for you what’s really at the bottom. What’s the foundation of the battle over the VCPR? And then we’re going to walk through today in Episode one, the use of boundaries or guardrails or safeguards that two states, Michigan, and New Jersey, have used to implement the telemedicine VCPR. Let’s understand a bit more how those can work in. The more you understand those, the more you see the thoughtfulness in creating some protections that address people’s needs and issues. 

And obviously, they have potential for states beyond just Michigan and New Jersey.  

The battle over the telemedicine VCPR is really driven by a series of fears that individuals or trade associations, state VMAs, and the AVMA have. And these fears are good to just lay out and then we can dive in the next episode as to what’s behind the fears and just how real they are. There’s a certain fear that veterinarians are going to practice bad medicine if they’re given the chance to use telemedicine tools, digital tools, Zoom, FaceTime and so forth, to get to know pets and get to know clients and start a relationship. People don’t put it in that blunt of term, but let’s just be honest about it. It’s a fear that somehow a veterinarian who’s a good, conscientious, careful, well-trained veterinarian on Tuesday, if she’s given a telemedicine tool on Wednesday, turns into a malpractice suit waiting to happen, a negligence case waiting to happen and is going to make mistakes left and right. And we don’t want that to happen. 

 The second fear is a version of that, and this one really doesn’t get talked about publicly, but again, it it’s sort of implied, right, that we’re going to see injury and harm, maybe even death caused for pets, if veterinarians are allowed to start relationships through virtual tools. Now, there’s really two ways to go with that. One is, did that happen in human medicine? The answer is no. We wouldn’t even be talking today. There wouldn’t be a Veterinary Virtual Care Association in existence if that’s what happened in human medicine. So, it didn’t happen there. We have data available now in veterinary medicine. We’ve been experimenting and beginning with the usage of telemedicine going back to twenty sixteen and all the states that opened up, 17 or so during Covid, the province of Ontario. They’ve all been asked the same thing by the VVCA, to share any data, keep it confidential, of course, but share any data that tells us that pets were hurt, they were harmed or even killed by the use of telemedicine. Not a single zero, not a single example of that. Now, if you’re going to make that your issue, the harm that’s about to unfold, then look at the data and don’t prejudge it, just judge it. And the absence of any data suggests that the worst thing you can say about virtual care is that it’s harmless and we know it’s better than that. But the point is, it’s not causing the injury or death people worry about.  

There’s fear from veterinary associations or boards of directors or members of boards, somewhat generational, about the loss of money that somehow, they fear they’re going to make less money in the care of pets if they take a convenient tool that makes a large number of pet owners who aren’t coming into practices get to know and get started with the veterinarian. There’s a fear that they’re going to lose money. Well, guess what? There’s a lot of experience now, and the VVCA will continue to help people assess that and see if, in fact, as many practices have discovered, it’s just the opposite. But that’s for a different day.  

And the fourth fear, and this is very generational, and I say this as a baby boomer myself, is a fear of technology when you don’t grow up with a certain technology, particularly in your practice. And now that technology seems to be everywhere. And I’m talking mainly about smartphones and real time video exchanges when it’s not something you’re used to. You weren’t taught that in vet school. You’ve been practicing since the 80s or 90s or 2000 and you never had to worry about it. Now you’re told these tools can help you to a lot of people. I don’t think a majority, even though they’re using it and every other aspect of their life, there’s this fear of having to use it with virtual care. And there’s really two answers to that. One is you don’t have to do virtual care if you don’t want to do it. Don’t. And number two, you can outsource, you can train staff, but particularly you can outsource. So, the technology piece, just like practices today, don’t have to design their own pens, their own operating systems. They get off the shelf, they get consulting firms, they get service providers. And you can do the same thing, obviously, with telemedicine. But those fears are out there, however legitimate they are, however real they are.  

And that has led to two states thoughtfully implementing telemedicine VCPR. A big step forward, certainly in the eyes of the VVCA, maybe not every association, but what they’ve done is they’ve put in guardrails. They’ve said you can use it, but we want these certain protections in place. And you might be surprised, but VVCA has applauded that. We welcome that. We think those kind of experiments by states actually make good sense and they get people comfortable. Let’s address the fears, let’s lower the temperature, and let’s make sure things work. So, let’s take a look at what those guardrails are.  

The first one seems obvious, but it’s not as easy to do. Namely, let’s protect the privacy of everybody in the veterinarian’s privacy or vet techs, the privacy of the pet owner and the privacy of the pet. And just as we don’t let the waiting room all come into an exam room and watch and hear the discussion and learn the confidential issues or questions about a particular pet’s medical condition or maybe the financial status of the pet owner, you can and you must put those same protections in place if it’s a virtual encounter. So, you’re not out in the lobby as a veterinarian having a conversation with me about my cats or my dog. It’s private and there’s protections built in for privacy. It’s not hard to do. I think it’s smart. That state said, let’s start with that number one. 

Number two, they anchor the decision to use telemedicine, where the Veterinary State Boards Association, the Veterinary Innovation Council and VIC, which is VIC and the VVCA, have always anchored it. Where’s that and the judgment of the veterinarian? State vet med boards, so let’s be clear about that. They don’t have cameras sitting in every vet practice in any state watching what everybody does and what everybody says and what’s happening with the pet or not happening with the pet, what’s happening with a radiography experience, what’s happening with anesthesia protocols? They don’t do that, do they? They trust the judgment of the veterinarian’s day to day to do the right thing, and they have a complaint process that says if they make a mistake, intentionally or otherwise, you can come to the board and say, hey, this didn’t work out here and you need to take a look at this. But nobody should have any myth that the entire system of veterinary medical practice in this country is based on anything other than the judgment being exercised every day by a veterinarian and by their team on what’s best for the pet and how to implement a treatment, how to discuss it, how to conduct a procedure and so forth. Well, that same judgment is brought to bear to say, can I learn enough? Seeing this pet through a virtual tool like this, that I can begin to help that pet owner deal with that pet, whatever that pest problems may be or may turn out to be? So, that’s required, exercise of judgment. 

Third, give people the option. If you want to come into the clinic, come on in. If you’re not comfortable, if you don’t think this exchange through a virtual tool is covering the situation to your satisfaction. No questions asked, come into the clinic if you want. Let them know they have that choice. It’s not a decision you’re making as a veterinarian alone. It’s a partnership, if you will, with the pet owner.  

Number four, most important. It can only happen if you have real time, which means it’s not tape recorded, it’s not asynchronous, it’s real time exchange with the pet owner and the pet. So, you can do what? So, you can see the pet. It’s not through text, it’s not through an email to get started. Can you use emails and text as you get further down the process? Sure, you can. Practices have been doing that for years. But to get started to create the VCPR that’s on everyone’s mind, you’ve got to see the pet. Now, some people will jump up and say you can’t see everything, well, you know what? You can see a lot and you can see underneath and on top and close up and zoom. You can do a variety of things and it’s all about what gives you comfort to get started. You’re not conducting cardiovascular surgical procedure through telemedicine. You’re getting started with the VCPR to begin to provide health care advice as meaningful to a pet owner, that’s consistent with your medical judgment. And this is a tool. But make sure you’re looking at the pet and you’re having a real conversation with the pet owner.  

Number five is something people forget about. You have the same legal standard of care in conducting a telemedicine engagement exam treatment as you do in person. It’s not in lower standards. It’s not like bad medicine’s tolerated in the veterinary space as long as it’s on the phone, that wouldn’t be in the clinic. It’s the same standard. You don’t get a special break either way. Next, let’s give the pet owner even more authority in this process. In Michigan and New Jersey, they have to give written consent. It could be electronic, of course. But have the process include saying to the pet owner and we’re going to do it this way. But you’ve got to consent to it, and that means you don’t have to consent to. That’s not a small thing. In fact, you wonder how often in a veterinary clinic experience, there’s many choices, as many choices given to the pet owner as there are in the virtual care scenario, because it can’t go anywhere. It can’t even start if there’s not a discussion that leads to the actual consent by the pet owner. And there’s a really easy way not to consent. Hang up. Turn your machine off. Do you feel like the veterinarian’s pushing you too hard, say goodbye and hang up and don’t forget that that veterinarian did that. The point is you’ve got more power as a pet owner than you think.  

There’s two more. One is, make sure that you or a colleague, could be a member of your practice, could be someone else who’s a licensed vet in your state, make sure there’s follow up in person available by a colleague or yourself. That’s nice to know, isn’t it? Let the person maybe they hang up and go, you know what? That was a good exchange. I have some other questions and I need to know that I can see the vet, which isn’t easy these days due to shortages and all. But you have a duty to make sure follow up is available to the pet owner. And finally, and probably most significantly, with greatest consequences, the states are looking at, can you prescribe medications? Some are not controlled substances, some are. Controlled substances, can medications be prescribed through telemedicine if you’ve not physically seen the pe? And I think states one by one will have different views of that, and you can build in protections and many human health care telemedicine laws had done the same. 

So those are the kind of basic set of eight boundaries, safeguards, guardrails that you can consider. And the VVCA is strongly encouraging state boards to look at these, to see what makes the most sense. And that gets me to answer real quickly, are these guardrails possibly the best path to reform age-old, years and decades on the books, veterinary practice acts that discourage telemedicine because, frankly, it wasn’t even thought about before. Are they the path to reform? And we believe they are. We don’t think it’s an accident that the state boards of veterinary medicine in New Jersey and in Michigan enacted these reforms rather than legislatures. Legislatures aren’t in business to do the careful, low key, calm, broad stakeholder engaged conversations and reviews of policies. And it’s the VVCA’s view. And we’re going to be promoting this view strongly that the states, including legislatures, that they need to delegate to veterinary boards, a full scale, broad stakeholder engaged process to consider the telemedicine VCPR, the issue today and different guardrails to make people comfortable if they have issues about that. And I think what’s going to be cool about that and very effective is at the American Association of Veterinary State Boards, the group of all 50 states plus the District of Columbia and Canadian provinces, that organization very professional, very well-run, that has already put model rules out that welcome telemedicine VCPR, along the lines that we’ve discussed, driven by the judgment of the veterinarian with safeguards baked in. They’ve got resources that help state boards work through the process. That organization itself took two years to review, to seek viewpoints from many quarters, to have discussions, to have debate and then have a vote. And they voted strongly and in favor of supporting telemedicine and telemedicine VCPR. So the state boards can access that tool because they’re part of that organization. And I think that’s going to make the process be much smoother.  

And ultimately, this is a word to the state VMAs, the state veterinary medical associations, around the country — get engaged, do what states have done, create a task force, get your board involved, don’t just say no, don’t just say no and say we can’t until somebody else says we can. You’ve got the authority on behalf of your members to figure out what do they want, what do they need, particularly what pet owners want in your state. And if it takes a year, if it takes two years, fine. Take it. We’re not saying hurry up and make a judgment you’re not comfortable with, but to just sort of fold your arms and say, no, we’re not going to even look at this, we’re not going to consider the experience of human medicine. We’re not going to consider the experience under Covid. I don’t know that you’d do your members and ultimately the pet owners and pets in your state any service. So, a lot of opportunity here.  

Next episode, we’re going to dive into where the battle really hits the road, if you will, in legislatures and in state boards and see if we can’t make some sense of it. Again, thanks for watching, and is a go-to site for any questions you have about telemedicine. Thanks.  

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