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Q&A: Coronavirus (COVID-19) & Telemedicine

Lance M. Roasa, DVM, MS, JD, The Roasa Law Group, Omaha, Nebraska

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Q&A: Coronavirus (COVID-19) & Telemedicine
Published Friday, March 27, 2020, at 6:24 PM EST

The current COVID-19 crisis has led to rapid changes in how veterinary care is delivered to patients. In the time of social-distancing, telemedicine can allow practices to maintain client and patient relationships while minimizing health risk to staff and pet owners.

Telehealth/telemedicine are overarching terms that encompass all uses of technology geared to the remote delivery of health information or education. Learn more here.

If telemedicine is new for a practice, what are the potential legal pitfalls to look out for?

Just because we are in a state of emergency does not mean that we are in a free-for-all. Some state boards have relaxed telemedicine requirements, whereas some have communicated that they will not relax their requirements. Veterinarians should consult their state board, state veterinary medical association, and state government’s websites for the most up-to-date information. 

Start with evaluating telemedicine candidates with regards to the Veterinary–Client–Patient–Relationship (VCPR). If you have an active relationship with the client and patient, it is much easier to provide telemedicine services. If a VPCR is not in place, careful attention to the state practice act and advice from state VMAs is advisable before proceeding with telemedicine.

When introducing clients to the concept of telemedicine, ensure they are informed of the risks and they consent to the virtual visit. Inform clients that telemedicine is imperfect but may be an applicable substitute for a hands-on examination. Then, record the informed consent, then the medical record. 

States are unlikely to relax licensure requirements even during the pandemic. Veterinarians should still have a veterinary license in the state in which they are providing telemedicine services. 

How do you document telemedicine appointments in the medical record?

It is essential to document the medical record after a telemedicine visit, just as for a physical examination or surgery. Having the entire visit recorded is an effective way to preserve client communications and consent.

The standard of care for recordkeeping is no different for telemedicine. The normal Subjective, Objective, Assessment, Plan (SOAP) note-taking format works just as well for telemedicine as in-person visits; however, vital signs and organ systems that could not be examined should be noted in the record. 

As in any practice record-keeping situation, such phrases as “Informed owner of…” “recommended…” “client consents to…” and “owner declines…” provide the needed legal language. Also, using these words in client communications sets clear expectations for the client. 

Remember, the medical record has multiple purposes:

  1. To aid memory of the case for later visits
  2. To communicate with other veterinarians and team members
  3. To meet the state board requirements for recordkeeping 
  4. To provide admissible evidence should there ever be a board complaint or litigation. 

The same applies for telemedicine as it does for in-person visits.  

Poll

What platform are you utilizing for telemedicine?


How do you charge for telemedicine appointments?

The telemedicine examination should be charged at a slightly lower rate than a regular examination. An important and convenient service is being provided to the client, but there are still limitations to telemedicine. Incentivized access to telemedicine may also limit traffic in the practice; however, note that diagnostic capabilities will be greatly reduced. Examination fees and any dispensed products will be the only revenue that the practice receives. 

Telemedicine may be an effective option to triage patients and help clients decide if they should come in immediately. In these cases, consider applying the charge for the telemedicine appointment toward the regular examination fee. 

Does it matter what state you are practicing in? Are there some states that allow more to be done via telemedicine than others?

Yes: Some states stipulate that the VCPR can only be created via a face-to-face visit. Some of these states are relaxing this requirement during this pandemic emergency. This is a rapidly evolving environment. Please check with your state board or the American Association of State Veterinary Boards for the most up to date information. 

Is there ever a way to see new clients via telemedicine?

Some states don’t have a VCPR requirement, so services can be provided for new clients. Previously, federal FDA regulations under AMDUCA prohibited veterinarians from prescribing extralabel drugs without a VCPR. As of March 24th, 2020, the FDA has announced they are going to temporarily suspend enforcement and encourage veterinarians to practice social distancing while caring for patients. 

What about logistical challenges?

One doesn’t need to have a dedicated telemedicine platform or app to offer telemedicine services. Email can be used to provide the client with payment receipt as well as a link to a teleconferencing service (eg, Zoom, GoToMeeting). The author’s preference is Zoom, because the entire virtual visit is recorded and saved in the cloud.

Additional Tips for Telemedicine Logistics

  • Make sure the client and pet are in a well-lit area
  • For prescribed or dispensed products, consider either:
    • mailing the product/medication
    • providing a pick-up service
    • providing a delivery service
  • If additional diagnostics are warranted, the client may drop off a patient’s urine or fecal sample from their vehicle.
  • You may need to find a creative way to properly weigh the patient before prescribing or dispensing medications.
  • Think the processes through, and talk to the practice’s veterinarians about the capabilities and challenges of telemedicine.

What conditions lend themselves to telemedicine visits?

Telemedicine can only be used to diagnose certain conditions, which must be visible and not require any palpation or testing. Dermatology, ophthalmology, lameness, and behavior concerns tend to work better for telemedicine than other conditions.

  • Veterinarians will have to rely on clinical judgment, without auscultation, palpation, or diagnostics; this is a different way to practice and requires a thoughtful adjustment. 
  • Telemedicine is a tool; it can be used to decide whether a patient needs to be seen immediately, later, or simply be prescribed medication. 
  • Get the most complete look at the patient as is possible: ask the client to hold the camera close to lesions, open the patient’s mouth, take a capillary refill time (CRT) by asking the pet owner to lift up the lip and press on the gums, and follow the patient as it walks or runs. 
  • For optimal viewing, ask the client to turn on lights, move to a well-lit area, and place the patient on a table
  • Weigh the risks to the client’s health and benefits to the patient. Older clients are transmission risks in public. If there is confidence that the patient will heal with simple medication, don’t risk the pet owner’s health by requiring diagnostics. 
  • Don’t hesitate to ask that the patient be physically seen in the practice, and let clients know that the telemedicine examination fee will apply to the regular examination fee. 
  • The standard of care still applies. Let the client know about the risks of not making a full diagnosis.
  • Thoroughly record the visit, and notify the client that the telemedicine visit is being recorded for recordkeeping purposes. Clearly state if you are uncomfortable with the telemedicine visit and the patient needs to be physically seen. Make your recommendations, and allow the client to accept or decline the recommendations.   

For global readers, a calculator to convert laboratory values, dosages, and other measurements to SI units can be found here.

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