The unsolicited email survey to Dr. Lance Roasa asked what fees should be charged for over-the-Internet exams, and whether he would like to offer real-time remote veterinary care online.
Illustration by Tamara Rees and Adobe Stock
As a board member of the American Veterinary Medical Law Association, Roasa immediately knew his reply: Not interested.
“I wrote the author back saying I was concerned with the legality,” said Roasa, a veterinarian and third-year law student located near Lincoln, Nebraska.
As websites and apps offering veterinary advice to pet owners proliferate, veterinarians increasingly want to know, “Is this legal?”
Roasa may have a better idea than most, being a law student who’s also co-taught courses on veterinary practice acts, but no one has a straightforward, simple answer. In short, it depends.
“It will be very difficult, if not impossible, to provide a one-size-fits-all statement concerning what is legal to veterinarians nationwide,” Roasa told the VIN News Service. That’s because laws that govern the practice of veterinary medicine in each state vary, and attitudes toward telemedicine appear to range from lax to highly restrictive.
“The state practice acts have zero uniformity as to the language concerning telemedicine,” Roasa said. “Some states’ statutes discuss it at length, some describe a valid VCPR [veterinarian-client-patient relationship] and some have absolutely nothing relevant.”
Dr. James F. Wilson, a lawyer as well as veterinarian, agreed that the laws collectively are murky and may be wide open to interpretation.
“I wish there was some type of clarity when it comes to the provision of Internet veterinary medical counsel versus the unlawful practice of veterinary medicine,” Wilson said. Instead, there are likely as many opinions about what is legal and illegal as there are lawyers asked to provide them, he said, because many opinions will be case-specific.
Add selective enforcement by state boards and/or attorneys general, and it’s no wonder practitioners are confused, Roasa added. “If I had to guess, the selective enforcement of the statutes is what has kept some of the websites [providing veterinary telemedicine] up for so long,” he said. “But it takes [only] one good complaint by a consumer to draw the attention of the AG or state board.”
At one time, veterinary telemedicine referred mainly to specialists being available as-needed for remote consultations with general practitioners. Now pet owners are invited to call a number or type a question onto websites for presumably instant, round-the-clock advice, some of it said to be free.
Variations on the theme have veterinarians signing up for services that provide apps for their clients to support video visits or digital chats.
The growth of veterinary telemedicine follows the spread and popularity of telemedicine in human medicine. Raphael Moore, general counsel for the Veterinary Information Network, an online community for the profession and parent of the VIN News Service, noted, “Telemedicine in human medicine is generally accepted and also more developed.
“For instance, there already exists an American Telemedicine Association and telemedicine is used in government programs, such as Medicaid,” Moore said in a VIN message board discussion. “Further, in 1996 California passed the Telemedicine Development Act, which is still in effect today and was further supported by the Telehealth Advancement Act of 2011.”
Moore explained in an interview that the 2011 legislation, an update to the 1996 act, was intended to expand telehealth in California. It specifically permits a broader range of services to be provided using technology, expands the list of professionals who can provide those services and sets a credentialing system for providers. Among other things, Moore said, it is meant to provide better care in rural and underserved areas of the state.
By one prediction, U.S. human telemedicine revenues will rise from $240 million in 2013 to $1.9 billion in 2018 — a growth rate of nearly 700 percent over five years.
Veterinary medicine isn’t exactly comparable to human medicine, however. One big difference is that veterinary patients can’t talk, making physical exams key. The American Veterinary Medical Association Model Practice Act requires that veterinarians treating patients have an established relationship with the pet and the person responsible for the patient, a relationship that must originate in person.
Accompanying this section of the Model Practice Act is the notation: “This section, which was added in 2003, emphasizes not only that veterinary medicine must be practiced within the context of a veterinarian-client-patient relationship (VCPR), but also emphasizes that because a VCPR requires the veterinarian to examine the patient, it cannot be adequately established by telephonic or other electronic means (i.e., via telemedicine) alone. However, once established, a VCPR may be able to be maintained between medically necessary examinations via telephone or other types of consultations.”
Some states’ practice acts follow the AVMA model, but not all, according to Adrian Hochstadt, former assistant director for state relations at the AVMA. Some jurisdictions require a VCPR only for certain aspects of practice, such as prescribing medication. Still others have no VCPR requirement at all.
Even those states calling for a VCPR may not follow up. “I suspect that many state boards don’t enforce VCPR provisions strictly,” Hochstadt said.
As for the specific practice of telemedicine, he said, “I see this as somewhat of a gray area, as boards and courts have not faced the issue in any significant way.”
Clarifying and standardizing the profession’s approach to telemedicine is one of the first goals of the Veterinary Innovation Council, a new group formed by the North American Veterinary Conference. Hochstadt, the council’s new executive director, said that its Board of Directors — which will meet for the first time in January — may look at ways to expand veterinary markets and client services through telemedicine.
The board “will likely examine how that technology can aid in the delivery of care,” Hochstadt said. “These transformational technologies are being deployed effectively in the human health sector and hold a lot of promise in improving access to veterinary care for many animals.”
Meanwhile, in the absence of clear guidelines, Roasa prefers to steer clear of telemedicine. “The risks far outweigh the benefits,” he maintains.
Among other arguments, he believes there is no substitute for physically examining an animal. Moreover, Roasa said, he invested a quarter-million dollars in his education to become a veterinarian; it makes no sense to jeopardize his hard-won license to work in an area that generates relatively small fees.
He points for illustration to the case of Dr. Ron Hines, one of the few instances involving telemedicine to be adjudicated. Hines is a veterinarian in Texas whose license was suspended in March 2013 by state authorities after he dispensed medical advice to pet owners online – a business that reportedly netted no more than $3,000 a year.
Texas is among a few states that follow the AVMA language that a VCPR cannot be established solely through electronic means, according to Hochstadt; a court upheld that prohibition in Hines’ case.
Another aspect of telemedicine that’s come up for question is electronic consultation between two veterinarians who are licensed in different states. Hochstadt said that’s typically allowed. But not always.
Wilson cited what he called a “worst-case scenario” involving the New York State Board of Veterinary Medicine. That board's administrator interpreted the state law on consultations to mean that any consultant providing diagnostic or therapeutic advice must either “meet” with the referring veterinarian in New York State or hold a New York veterinary license, Wilson said.
This interpretation dates back to at least 2011, Jonathan Burman, a spokesman for the New York State Education Department, under which the veterinary board operates, told the VIN News Service.
Burman said by email that in New York, the practice of providing radiology consultations to veterinarians constitutes the practice of veterinary medicine. “That is the case whether the consult is carried out personally or via ‘teleradiology,’ ” he said. “As such, any person carrying out such a consult must be licensed to practice veterinary medicine in New York state.
“Out-of-state practitioners who desire to practice in New York state, ‘teleradiology’ being one form of such practice, are expected to comply with New York state law and regulations governing the practice of veterinary medicine,” Burman continued. “Practitioners licensed in New York state are expected to ensure that persons not licensed to practice veterinary medicine in New York state are not aided, abetted or facilitated in any manner to engage in practice within New York state.”
Wilson said he reviewed New York state’s position at the request of the American College of Veterinary Radiology and Idexx Teleradiologists. “Based on other legal opinions on this subject found in the AVMA Model Practice Act and the AVMA Principles of Veterinary Medical Ethics, and on the definition in Webster’s Dictionary,” Wilson said, “I believe that New York’s interpretation of the word 'meet' is absurd.”
In Wilson’s mind, there’s a big difference between a specialist providing a remote consultation regarding a diagnosis and suggested course of treatment with a local licensed practitioner who has a valid VCPR with a client; and a specialist who is dispensing general information electronically or via other media directly to an animal owner.
Between a veterinarian and an animal owner, Wilson believes it’s possible to have legally appropriate electronic communications without a valid VCPR as long as the telemedicine provider does not prescribe drugs or diagnose diseases or ailments.
What about hotlines?
Nationwide (formerly known as Veterinary Pet Insurance) considers its live Vet Helpline for policyholders an example of a source of only general advice. Dr. Carol McConnell, the company vice president and chief veterinary officer, said: “Veterinarians and veterinary technicians begin every call with, ‘This service is not a substitute for a visit to your veterinarian.’ They do not diagnose, treat or prescribe. Callers are encouraged to visit their primary care veterinarian for a diagnosis.”
McConnell said the main purpose of the round-the-clock hotline is to help policyholders determine whether a problem needs immediate attention. “It’s really, more than anything, to help them figure whether it’s an urgency or not,” she said. “ ‘Is it something I should really be concerned about before I go to bed?’ It’s more an advice line about timing. We will always redirect the person to their veterinarian.”
Questions about the legality of new telemedicine enterprises in pet health has led some practitioners to wonder about established forms of remote veterinary consultation, such as poison-control hotlines.
Moore, VIN’s general counsel, researched the issue and concluded that poison-control lines, whether nonprofit or for-profit, are on shaky ground for the same reason as new forms of remote veterinary care: The laws are inconsistent and ambiguous.
“I'm hard pressed to see how poison control DVMs can skirt a finding that they are ‘administering treatment’ (the usual language used) when they give advice,” Moore said on a VIN message board.
He added: “There is no question in my mind that the services offered by poison control centers are needed by the public. Based on what we can see, the issue is that the law does not really match reality … If these call centers are providing needed services, there should be efforts to seek legislation that broadens the definition of emergency and exempts DVMs from liability, from VCPR requirements, etc., regardless of whether the services are paid for or not. Otherwise, it is a matter of time before we see licensing-board claims.”
The VIN News Service contacted operators of two poison control hotlines for their views on the issue. The nonprofit American Society for the Prevention of Cruelty to Animals, which runs the Animal Poison Control Center, declined to comment. A spokeswoman for Pet Poison Helpline, which is owned by SafetyCall International PLLC, said the company regards its helpline as a poison control center and not veterinary telemedicine.
Opportunities or risks?
The rise of virtual consultation websites and video chat apps have prompted several news organizations to examine the pros and cons of specific businesses.
Things to consider
- Check the regulations in the state or states where you practice. The AVMA provides a starting point with a summary of each state’s treatment of the veterinarian-client-patient relationship.
- To play it safe, establish in person a relationship with the client and patient before giving guidance to the client by telephone or Internet.
- Consider consulting a lawyer before signing up for a telemedicine gig.
Curt Revelette, a restaurateur who owns VetOnDemand, says in a DVM360 Magazine article that his service fills a need that’s otherwise unmet: “There are so many common questions that people want to know. They currently are not going to a veterinarian to wait an hour or spend a couple hundred dollars for these minor questions, so what they’re doing is going to Google, and there’s a lot of misinformation out there.”
In California, Ed Blach, a veterinarian and co-founder of the mobile app Vet24seven, was quoted in the Sacramento Bee newspaper as saying, “Not every call requires a VCPR. There is no law that says a veterinarian can’t be an educator to a potential client.”
Blach told the VIN News Service that he did not mean to give the impression that Vet24seven is not supportive of the VCPR. “Telemedicine provides an opportunity to strengthen a VCPR,” he said by email. “Veterinarians are using it to communicate better with clients after surgery, to manage chronic illness or to assess pain management. It builds client loyalty and provides peace of mind and convenience when it matters most to your clients.”
So many veterinarians have called the California Veterinary Medical Association asking about the legality of registering with video consultation services that the association sent members a missive on what to keep in mind. It stresses that a VCPR “must be established prior to a veterinarian making medical judgments regarding the health of the animal patient,” which includes, among other things, “an in-person medical exam.”
“Just like with a phone call, if you receive a message or video chat via a virtual service regarding an animal patient and have not previously established a VCPR, you may not diagnose or treat the animal’s condition,” the CVMA advises. “If you have established a VCPR and are using a virtual service, you still must be careful that the established VCPR is valid for the condition the client is contacting you about.”
In the end, it’s up to veterinarians to protect themselves by knowing and following the law in the state or states in which they’re licensed. If rules pertaining to veterinary telemedicine are violated, it’s more likely that the licensed professional will be disciplined than the business proffering the telemedicine service.
As Annemarie Del Mugnaio, executive officer of the California Veterinary Medical Board, explained, her board doesn't have jurisdiction over telemedicine websites or online services because unlike veterinarians, they don't have a license that the board can restrict.
“The most we can do in terms of the websites and these online entities is advise them that either their services or their advertising are a violation of the Practice Act — so more like a cease-and-desist type [of] letter,” Del Mugnaio said. She noted that “it would be more of an advertising violation — possibly unlicensed practice — if it's not a veterinarian who is providing these services.”
Edie Lau contributed to this report.
VIN News Service commentaries are opinion pieces presenting insights, personal experiences and/or perspectives on topical issues by members of the veterinary community. To submit a commentary for consideration, email firstname.lastname@example.org.