Telemed art

Governments are starting to reapply rules that limit how liberally veterinarians can use telemedicine, as the rising availability of COVID-19 vaccines gives people more latitude to take their animals to practitioners in person.

The United Kingdom and California in the United States have in recent days ended or announced they will soon end waivers of their telemedicine restrictions.

Remote care is generally considered to pose a higher risk of misdiagnosis for nonhuman animals because they, unlike humans, can't tell doctors how they feel. Consequently, many regulators have traditionally required practitioners to see a patient in the flesh to establish a veterinarian-client-patient relationship (VCPR) as a foundation to prescribe medicines.

Waivers to rules, however, were introduced early in 2020 by some jurisdictions to allow practitioners to prescribe drugs remotely, no hands-on examination required, to limit the spread of COVID-19.

An end to waivers indicates working conditions for veterinarians are returning to some semblance of normality, while cooling expectations that the pandemic might herald permanent relaxations of remote-prescribing rules advocated by telemedicine proponents.

Still, some jurisdictions have yet to end their telemedicine waivers. Officials in Massachusetts and Pennsylvania in the U.S., for instance, told the VIN News Service that their waivers have been extended to the end of December and the end of March, respectively. Other jurisdictions with waivers in place include Arizona in the U.S. and Ontario in Canada.

In California, regulators have ended the state's waiver quietly, with no public announcements. The California Veterinary Medical Board last extended its waiver on Aug. 31 to continue until Oct. 31. Michelle Cave, a spokesperson for the state's consumer affairs department, confirmed to VIN News that the extension expired on Oct. 31.

Asked whether the CVMB was aware of any cases of misdiagnosis occurring because of the waiver, Cave referred VIN News to its records of disciplinary actions, none of which appears to single out problems caused by using telemedicine specifically.

California has a relatively high vaccination rate, with 64.1% of its population fully inoculated, compared with the national average of 59.5%, according to a tally kept by John Hopkins University. Some states with telemedicine waivers still in place, however, also have comparatively high vaccination rates, including Massachusetts (70.9%) and, to a lesser extent, Pennsylvania (61.8%).

At the national level, the U.S. Food and Drug Administration in March 2020 permitted the prescription of veterinary drugs without an in-person examination. Its waiver still is in effect.

"At the time we announced the guidance, we said that given the temporary nature of this policy, we plan to reassess it periodically and provide revision or withdrawal of this guidance as necessary," FDA spokesperson Siobhan Delancey said by email. "If we decide the guidance is no longer needed or needs to be revised, we will provide notice."

In Britain, industry regulator the Royal College of Veterinary Surgeons announced in a press release that a national telemedicine waiver there will end at midnight on Nov. 21. The decision has been welcomed by the British Veterinary Association, a key lobby group for the profession, which had been pushing for the waiver's end for more than a year.

"While we supported the move at the height of the pandemic, we later queried why the temporary guidance was still in place and raised concerns this may fuel unrealistic expectations among clients, as well as resulting in some risks to welfare should health issues not be picked up during remote consultations," BVA president Dr. Justine Shotton said in an email to VIN News.

The RCVS said Britain's telemedicine rules would be kept under review to account for any changes associated with the pandemic, including government advice and regulations. Use of telemedicine, it said, already had been on the decline as vaccination rates increased and government restrictions eased.

Asked whether the RCVS had seen a specific incidence of misdiagnosis in the U.K. related to its waiver, agency spokesperson Luke Bishop said, "We don't categorize concerns that we receive in a way that would allow us to easily identify those specific circumstances within our caseload."

Can the telemedicine genie be put back in the bottle?

Opinions on telemedicine in the global veterinary community vary greatly, with enthusiasm for its potential often tinged with wariness about the risk of misdiagnosis. The use of telemedicine increased markedly during the pandemic, according to a study published in June in the Journal of the American Veterinary Medical Association. The research was based on a survey of 550 U.S.-based members of the Veterinary Information Network, an online community for the profession and parent of VIN News. Among participants, who responded in September and October 2020, 29.6% were using live videoconferencing with pet owners, up from 4.2% before the pandemic. Many respondents, however, said they planned to discontinue using telemedicine once the pandemic was over.

An end to waivers in California and the U.K. could put pressure on other jurisdictions to consider doing the same, especially in areas of high COVID-19 vaccination.

"I think these rule relaxations have gone on long enough," said Dr. Bruce Henderson, a practitioner based in New Jersey. "There is no reason any more that a pet cannot be seen in the exam room."

Henderson last year voiced his concerns on the message boards of VIN about the rising use of telemedicine. In an interview, he expressed doubts about the quality of examinations conducted remotely. "As my patients cannot communicate easily to me about their problems, I am very hard pressed to find a situation in veterinary medicine where a physical exam is not required," he said.

At the same time, even some groups wary of telemedicine's pitfalls, such as the BVA, posit that remote consultations may be beneficial in certain circumstances post-pandemic — such as when a trip to a veterinarian could put stress on an animal with a heart condition, in remote areas with no veterinarians, or in cases where elderly or disabled pet owners have limited mobility.

Others believe that veterinary practitioners, rather than regulators, should be allowed to judge when remote prescribing is warranted.

Among them is Jan Robinson, the registrar and chief executive of the College of Veterinarians of Ontario, who said she is disappointed by the repeal of telemedicine waivers.

"In my personal opinion, I don't think you can put the genie back in the bottle unless there's good evidence to indicate why," Robinson said during a panel discussion on telemedicine, held remotely on Saturday at the World Small Animal Veterinary Association Congress.

Later, in an interview, Robinson confirmed that the College of Veterinarians of Ontario hasn't seen any cases of misdiagnosis arise since it relaxed its remote prescribing rules last year. (Ontario's definition of VCRP doesn't include prescribing medicines, so its waiver pertains specifically to remote diagnosing and prescribing).

"We continue to expect the veterinarians to use their judgment," Robinson said. "And it's not any different if you're seeing an animal in person: Don't prescribe if you don't believe you've got enough information to know what's going on."

She continued: "If one uses the tenet that telemedicine is a tool that a veterinarian may use in their judgment, then it's not any different than using other kinds of tool that a veterinarian uses to make judgments."

The College of Veterinarians of Ontario is mulling whether to relax its telemedicine rules permanently; its leadership council is set to debate the issue in early December, Robinson said.

In the U.K., too, the RVCS is in the midst of a years-long review of remote prescribing rules that included the launch in May of a survey of veterinarians and veterinary nurses, the results of which have yet to be published. Feedback received from the survey will be used to determine any proposed changes to U.K. policy that will be put out for public consultation, likely early next year, Bishop at the RCVS said.

In the U.S., rules around remote prescribing have varied significantly among states for some time. Some, such as Texas, have continued through the pandemic to mandate a hands-on examination to establish a VCPR. Florida also is one of those states, though moves are afoot there to relax its telemedicine rules permanently, making it a key battleground in the tussle between proponents and detractors of remote prescribing.

Update: The Royal College of Veterinary Surgeons in the U.K. reintroduced on Dec. 16 its telemedicine waiver, again allowing remote prescribing. The regulator cited high levels of COVID-19 infection, stricter rules on isolation and the threat of the omicron variant for making its decision. It said it would review its position again in February.