Telemed art

In a controversial decision that's rocking the veterinary community, the United Kingdom's professional regulator will allow practitioners to prescribe medicines over the internet without first needing to see a patient in the flesh.

The change, approved Thursday by the Royal College of Veterinary Surgeons, is especially significant because it is based on a years-long review of telemedicine rules that predates the Covid-19 pandemic, during which jurisdictions around the world permitted only temporary waivers.

The new change is scheduled to apply permanently sometime between June 1 and Dec. 31.

How one of the world's oldest and most influential veterinary medicine regulators has decided to proceed on the question may be noted abroad as deliberations on telemedicine rules rage in other countries.

The RCVS's move immediately drew a rebuke from the British Veterinary Association, the profession's chief representative group in the U.K., which has always maintained that prescribing medicines without an initial hands-on examination undermines animal welfare.

Remote care is generally considered to pose a higher risk of misdiagnosis for nonhuman animals because they, unlike people, can't tell doctors how they feel. Consequently, many regulators mandate that practitioners must see a patient physically to establish a veterinarian-client-patient relationship (VCPR) before prescribing medicines.

Temporary waivers to such rules were introduced by national and state governments to limit the spread of Covid-19, sparking speculation that the pandemic might lead to permanent relaxations.

The emergence of new technology, such as wearable monitoring devices and innovative diagnostics tools — alongside the proliferation of sharper and more accessible videoconferencing services — has made the remote care of animals more feasible, proponents argue.

Freedom to decide comes with caveats

The change was passed 20-3 by RCVS councillors at a meeting held at the University of Nottingham's veterinary school.

Now, the policy states that a need for a physical examination of an animal before prescribing medicines "is a matter for the veterinary surgeon's judgement."

The change comes with caveats, including that a physical examination is required "in all but exceptional circumstances" when veterinarians prescribe antimicrobials such as antibiotics. More judicious use of antimicrobials is desired due to concerns their overuse contributes to drug resistance, which occurs when pathogenic microbes evolve to withstand treatments meant to kill them.

"Veterinary surgeons should be prepared to justify their decision in cases where antimicrobials are prescribed without a physical examination and record this justification in the clinical notes," the new rules state.

Moreover, veterinarians who don't conduct a prior physical examination must ensure that a 24/7 follow-up service involving physical examination is immediately available to the client should they need it — either offered by that veterinarian or another provider.

The RCVS said its decision folowed an "extensive review process" that commenced in 2019 and included consultations with veterinary professionals and animal owners, legal advice and independent research.

Its president, Dr. Melissa Donald, acknowledged in a press release today that "not everybody will be happy with this outcome." But she added that "many, many hours of thought and consideration have been put into how it will affect veterinary practitioners across all sectors, and animal health and welfare on the ground, while ensuring that the guidance is legally sound and consistent with the current legislation."

Dr. Malcolm Morley, the BVA president, said the change marks a "watershed moment," and acknowledged that technology "presents exciting opportunities" to enhance veterinary services.

"However, the BVA has been very clear that we believe remote prescribing can only be safely delivered where a vet-client-patient relationship has been established," Morley said in a press release. "This is an internationally recognized concept, and we are disappointed that the RCVS has decided not to embrace it."

Implementation of the new policy will be subject to a review decision by RCVS officials in March, which, according to Morley, gives the profession an opportunity to scrutinize how it plays out. "It is now vital that a timeframe for a review is quickly put in place, so any negative impacts on animal welfare or the sustainability of veterinary services can be dealt with swiftly," he said.

Change appears at odds with community consensus

Opinions on telemedicine vary considerably in the veterinary realm.

Proponents argue that practitioners are capable of deciding for themselves what's in their patients' best interests, rather than regulators. Purported benefits of telemedicine include allowing veterinarians to observe clinical signs in real time, and making care accessible to people living in areas where there are no veterinarians, or to people with mobility issues. Traveling to a veterinary practice might cause some animals undue stress, especially if they have heart problems, for instance.

Still, veterinarians opposed to looser rules have numerous concerns about telemedicine, in addition to the risk of misdiagnosis.

Deregulation, some fear, will put more power in the hands of companies that offer only veterinary telemedicine, severing a relationship between clients and clinics, and impeding the potential for practitioners to uncover health problems through a hands-on exam.

Another worry is that practices might lose business to telemedicine providers and close, leaving some already underserved communities with no access to hands-on care.

A spectrum of views about telemedicine is apparent on a message board of the Veterinary Information Network, an online community for the profession and parent of VIN News. At the same time, a clear majority of practitioners in the discussion oppose the use of telemedicine without a prior physical examination.

That's also apparent in results from a survey commissioned by the RCVS. In 2021, between May 11 and June 16, consultancy Rand Europe surveyed 53,181 British veterinary professionals on behalf of the RCVS, to which 5,544 responded, including 4,545 veterinarians and 999 veterinary nurses. When asked if a recent physical exam "is essential" for an animal to be considered under a veterinarian's care, 41% strongly agreed and 32% somewhat agreed. Of the remainder, 9% neither agreed or disagreed, 10% somewhat disagreed and just 7% strongly disagreed.

Asked whether regulations should allow veterinarians to use "remotely-provided video" to prescribe medicines for animals that they've never physically examined, 60% strongly disagreed and 20% somewhat disagreed.

Still, responses to other questions indicated that participants felt veterinarians should have latitude to make their own decisions. For instance, when asked whether "regulations should allow space for professional judgement when interpreting and applying them," 39% of respondents strongly agreed and 43% somewhat agreed.

In the lead-up to its decision, the RCVS maintained that the survey was "not a referendum" on whether the rules should change. Rather, the regulator said its decision hinged on an interpretation of the U.K.’s Veterinary Medicines Regulations, which state that practitioners must carry out a clinical assessment of an animal under their care before prescribing medicines. The RCVS sought legal advice, which it said indicated that the terms "clinical assessment" and "under that veterinary surgeon’s care" as stated in the legislation should be interpreted to include both in-person and remote assessments.

On Friday, the RCVS said an imminent U.K. government review of the Veterinary Medicines Regulations drove its decision to wait until at least June 1 to implement its new telemedicine guidelines, which will be reviewed at the RCVS's council meeting in March.