Today's Veterinary Business

AUG 2018

Today’s Veterinary Business provides information and resources designed to help veterinarians and office management improve the financial performance of their practices, allowing them to increase the level of patient care and client service.

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43 August/September 2018 • TODAYSVETERINARYBUSINESS.COM a medical or drug history is ob- tained; (ii) provide information to the patient about the benefits and risks of the drug being prescribed; (iii) perform or have performed an appropriate examination of the patient, either physically or by the use of instrumentation and diagnostic equipment through which images and medical records may be transmitted electronically; except for medical emergencies, the examination of the patient shall have been performed by the practitioner himself, within the group in which he practices, or by a consulting practitioner prior to issuing a prescription; and (iv) initiate additional interventions and follow-up care, if necessary, especially if a prescribed drug may have serious side effects. Analyzing the Language So, what does all this mean? For- ty-seven states use some version of: • "actual examination" • "recently seen and is person- ally acquainted" • "has seen … in a professional capacity … within 12 months" • "face-to-face history and physical examination" • "has examined the animal" These all sound similar, give or take a word or phrase. While all but the "face-to-face" definition of Hawaii could be construed to per- mit a live, real-time video examina- tion, none of these states would accept a purely digital encounter as sufficient. And four states — Missouri, Texas, Utah and Wash- ington — expressly forbid creation of the VCPR through electronic or telephonic means. Only Virgin- ia appears to allow for a digital VCPR but, to our knowledge, this definition has never been tested in a Virginia court or by the Virginia Board of Veterinary Medicine. The open question in most states (and resolved definitively only in a few) is how "recently" the veterinarian must have examined the animal. For example, a Califor- nia drug prescription may not last for more than one year, meaning a new examination is required before the animal continues usage beyond a year. Is there still a VCPR in any of these states, meaning can you treat or diagnose over the telephone or via texts if you haven't seen the dog or cat in three, five or 10 years? This is a difficult question, and remember that it will not come up unless someone files a com- plaint with the veterinary medical board. The odds of this are slim at best, but do not assume that a court will agree that a VCPR exists for the life of the pet based upon a single examination. A companion issue is whether an examination by one veterinari- an in a practice transfers to anoth- er. Common practice says yes, and veterinary medical boards are not seeing complaints to the contrary. This means that Doctors 2 or 3 may work with the pet owner over the telephone regarding a treatment plan and compliance even though the VCPR technically resides only with Doctor 1. Human medicine has allowed for digital creation of the doctor-client relationship through one of two paths: • Relying on the judgment of the doctor as to whether he or she has acquired sufficient information to assume responsibility for a medical judgment, treatment or diagnosis. • With requirements such as client appearance in a med- ical facility during a digital encounter, client execution of a written consent to a telemedicine encounter, or presence of a paraprofession- al from the doctor's practice with the patient during the telemedicine encounter. Politics & Policy columnist Mark Cushing is founding partner of the Animal Policy Group. He can be reached at Dr. Char- lotte Lacroix is founder and CEO of Veterinary Business Advisors Inc. Both serve on the Today's Veterinary Business editorial advisory board. The Federal Government's Role Practitioners must bear in mind that the FDA entered the VCPR dis- cussion with a requirement related to feed directives and extralabel use of drugs. A VCPR must be in place in both of these circumstanc- es, which requires a veterinarian to have recently seen and be person- ally acquainted with the animal via physical examination. The argument could be made that states may modify "physical examination" to include real-time examinations through digital or electronic communications, but this surely would be challenged. However, once a majority of states adopts a version of a digital VCPR, then the odds increase substan- tially that Congress and the FDA would yield to the profession — as federal agencies and Congress have done in human health care — and conform the FDA requirements to current practice as it evolves. Proposed Changes What are the differences between a traditional VCPR and the position recommended by the Veterinary Innovation Council? The council board published "7 Guiding Princi- ples for Telehealth." These includ- ed a modification of the VCPR as follows: "The VCPR should be able to be established through: (1) phys- ical examination or (2) visit to the patient's premises or (3) electronic means based upon precedents established in human medicine." The board adopted this position to help veterinary practices by: • Lowering the barriers of access to veterinary care. • Driving more patients to veterinary practices. • Providing care to under- served communities. • Allowing veterinarians to com- pete with non-veterinarians. What alternatives are available for consideration by the veterinary profession? Veterinarians, state legislatures and boards have many options to consider: 1 Maintain the status quo in all but four jurisdictions and insist on a physical, in-person examination in order for the doctor-client-patient relationship to commence. 2 Allow for a digital VCPR as a valid alternative to an in-person examination through some form of electronic means, which could include a live video examination of the animal. 3 Allow for a digital VCPR (video or not) but limit drug prescriptions to when the veterinarian has examined the animal in person. (Time frame to be determined.) 4 Allow for a digital VCPR (video or not) but require written consent from the animal owner. 5 Allow for a digital VCPR (video or not) but require a veterinary nurse to be present with the animal at the time of the digital encounter. What steps could be taken to examine alternatives for a digital VCPR? State legislatures will not consider amendments to veterinary practice act definitions, such as the VCPR, unless task forces or working groups are formed and meet in their state to explore the alternatives. The first step for any reform is to launch a task force or working group with key stakeholders and work with the American Associa- tion of Veterinary State Boards. Only Virginia appears to allow for a digital VCPR but, to our knowledge, this definition has never been tested in a Virginia court or by the Virginia Board of Veterinary Medicine.

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