N.J. bill inadvertently permits the remote establishment of VCPRs

Veterinarians around the world grapple with telemedicine

July 20, 2017 (published)
By Jennifer Fiala; Rosette Royale

This story has an important update

New Jersey veterinary leaders met Wednesday with Gov. Chris Christie's staff in hopes of exempting practitioners from legislation that gives medical professionals greater leeway to use telemedicine.

On Christie's desk is SB 291, an act passed June 22 that authorizes all health care practitioners — veterinarians included — to establish a "bona fide relationship" with their patients remotely.

If the governor signs SB 291, New Jersey veterinarians will be permitted to establish veterinary-client-patient relationships (VCPR) online rather than in person. Many in the profession believe such an allowance is dangerous and irresponsible because animals cannot verbally communicate their health status, making a physical exam indispensable to properly assessing the patient's condition.

Widely regarded as the foundation for effective veterinary care, VCPRs are a requisite for diagnosing, treating and prescribing for patients in most jurisdictions.

"They never thought of veterinarians when they wrote this bill," said Rick Alampi, executive director of the New Jersey Veterinary Medical Association. Pointing out that animals can't speak, he added that the bill "references in multiple places that the patient must request things, like waivers."

"... This bill doesn't take into account the uniqueness of veterinary medicine, so we're going to ask for a conditional veto," he said. "I think we have a strong argument."

Under a conditional veto, Christie can dictate changes to SB 291 that exempt veterinary medicine. The Legislature can accept the changes, attempt to override the governor's veto or let the act die.

SB 291 is one of more than 200 telemedicine-related bills introduced this year in legislatures across the country, reports the Center for Connected Health Policy, a nonprofit that tracks and promotes such initiatives. Combining medical care with the technology to remotely deliver it isn't novel among physicians. Yet it's the veterinary profession's Wild West, rife with legal concerns about cross-state licensing, malpractice scenarios and reimbursements, Alampi asserts.

"Clearly, telemedicine is practiced by veterinarians," he said. "It's just not well regulated."

In the United States, veterinary medicine is regulated by state agencies that treat remote practice with little uniformity. While some states have updated their veterinary practice acts to accommodate the use of technology, most — New Jersey included — do not address it.

That's a sticking point for many within the American Veterinary Medical Association, said Dr. Lori Teller, a member of the group's Board of Directors.

To help standardize telemedicine regulations, the AVMA this week is mulling a new policy that preserves physical, face-to-face visits as a requisite for establishing a VCPR. Without one, the policy states, medical advice should be offered "generally, with no specific reference to a patient, diagnosis or treatment."

AVMA policies do not have regulatory authority but are intended to provide guidance to regulatory bodies and lawmakers. As a first step, the draft telemedicine policy says "regulations should be harmonized across the nation and strongly enforced to protect patient and public safety."

The AVMA House of Delegates meets Friday in Indianapolis to vote on the telemedicine policy, among others. If rejected, the House could consider an amended or new version in January.

UK aims to establish position

Veterinarians in the United Kingdom also are wrangling over the creation of regulatory guidelines. The Royal College of Veterinary Surgeons, a regulatory body that governs UK practice, recently polled veterinarians and the public on how they use telemedicine. The RCVS spent six weeks collecting information via a consultation questionnaire published on SurveyMonkey. In the questionnarie's introduction, the RCVS stated that while telemedicine historically has been limited to consultations between general practitioners and specialists, the "industry is changing rapidly."

The RCVS continued: "There are increasing numbers of businesses offering telemedicine services such as video consultation websites and chat apps directly to clients. … Innovative products such as wearable technology for pets are rapidly advancing."

Responses are to be reviewed by the RCVS Standards Committee in hopes of developing new professional standards and guidance for the profession, the group added. The results have yet to be released.

The British Veterinary Association has expressed concerns that language used in the RCVS questionnaire was biased, perhaps prompting skewed results. "… The way in which the consultation is worded does not necessarily allow for the various nuances and scenarios which present themselves within the vet/client/patient relationship," the BVA said in a statement.

The group suggested that more work was needed to examine how telemedicine might "play out in practice."

Ontario adopts hands-off approach

Much like the AVMA, the Canadian Veterinary Medical Association in its policy urges VCPRs to be established in-person — a requirement followed by most provincial regulatory bodies.

But not in Ontario.

The College of Veterinarians of Ontario passed a practice standard in March that permits the province's 4,500 or so licensees to pursue the use of telemedicine and establish VCPRs remotely. The new standard states that telemedicine is permitted in the "context of an existing and valid" VCPR, which can be "established via telemedicine in the same circumstances as when the relationship is established in-person."

Jan Robinson, registrar and chief executive officer of the College of Veterinarians of Ontario, explained by phone that a previous version of the agency's telemedicine standard held that VCPRs must be established in person. The stipulation was relaxed when it became clear that pet owners in remote areas of the province were burdened by it.

Robinson proposed a hypothetical scenario by which elderly pet owners with mobility issues have trouble getting to a veterinary practice. "Now they can call and establish a VCPR," she stated.

In a press release, Robinson explained that the college "expects that a veterinarian will use his/her judgment to determine whether telemedicine is appropriate to each specific circumstance."

She continued: "The need for a physical examination in order to make an appropriate diagnosis will continue to be essential in many cases. As well, drugs cannot be prescribed through telemedicine alone."

Robinson expressed that the college did not want to dictate how veterinarians should practice telemedicine but instead provide guidance "so our rules support quality of medicine and don't get in the way of good delivery." She added that telemedicine's growth and evolving public expectations prompted regulators to alter Ontario's professional standard to reflect advances in technology and veterinary health care.

Regarding veterinarians who embrace telemedicine, "It'll be very interesting to see how they'll change the profession forward in 10 or 15 years," she said.

Update: Gov. Chris Christie signed SB 291 on July 21.

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