Pet-Specific Care for the Veterinary Team. Группа авторов

consumers may see programs in human health that have telemedicine more completely integrated into overall care. Thus, there might be programs integrated with insurance groups, public health, and other endeavors that increase patient access and lower healthcare costs. Technologies can also be used to establish a valid physician–patient relationship in human medicine without the need for an in‐person examination.

      It is important to realize that most veterinary regulations do not permit the establishment of a VCPR by electronic means alone. Clients may be exposed to such human programs and infer that it should be possible for those same services to be provided by veterinarians. It should not be inferred that because a type of service is available in human health that it is legally permissible to provide the same or similar service in the veterinary business space. The American Association of Veterinary State Boards (AAVSB) has expanded the definition of the VCPR to include establishing a VCPR using telehealth tools but since the AAVSB does not dictate licensing requirements, veterinarians are advised to consult with their applicable organizations to determine what is allowed in their specific circumstances. The field and its applications are clearly evolving.

      Veterinarians have often given advice by telephone, email and even text (SMS) for years; most of this has occurred within the bounds of a VCPR, but some advice is likely to have also been offered to prospective clients with whom such a relationship may not have been legitimately established.

      Veterinarians with a valid VCPR have professional discretion to confer with specialists and consultants, but they remain the physicians of record and do not transfer that VCPR to the specialist or consultant. Most telehealth services with experts are not a replacement for specialist referral, but may increase accessibility, and may possibly be the only alternative for some clients who do not have a specialist within a reasonable referral area.

      2.5.3 The Marketplace

      Most demographic groups have embraced technology that allows instant gratification and do‐it‐yourself (DIY) applications. There is a growing trend among pet owners to access information online, purchase products online, encourage the monitoring of their pets with wearable technology, and seek medical opinions online.

      Pet owners want applications that allow them to be in contact with veterinary professionals at the time and via the medium of their choosing, even if veterinary practices have some qualms with this, may have concerns about the legalities of such actions, and have even more concerns about how to be compensated for such services.

      Clients may attempt to contact veterinary hospitals by email or text (SMS), through social media and through online resources, including sending images and video; veterinary hospitals need to have a strategic plan for how to deal with such contact. Primary care veterinarians may try to use the same strategies with specialists, hoping for insights without having to refer the patient, and are faced with the same limitations.

      Clients may have reasonable or unreasonable expectations that the veterinary hospitals with which they do business should be responsive to such contact. In some cases, it may be a follow‐up question to services that have already been provided (e.g., “Sheba chewed out one of the stitches from the procedure she just had, but it isn't bleeding. Do I need to bring her in?”). In other instances, it might be an attempt to save money or avoid the necessity of bringing a pet into the hospital (“Lily has had a bout of vomiting. Can I just give her the medicine I use when I have an upset stomach, and I'll bring her in if she doesn't get better?”).

      2.5.4 Professional Considerations

      Telemedicine consultations should only occur within a valid VCPR; this is true regardless of whether the consultation occurs by telephone, email, or other medium. If it is allowed by a jurisdiction to create a virtual VCPR, it is still important to check with the appropriate authorities if prescribing is allowed under such a telehealth relationship.

      Veterinary hospitals should be careful not to inadvertently provide telemedicine to new or prospective clients, since there is legal liability when a legitimate VCPR is absent.

      In the United States, there is considerable variability between states as to laws for the provision of telemedicine services, so veterinarians should consult with their state licensing boards about what is permitted in the state Practice Act. It is particularly important to be aware of jurisdictions that require a physical examination or temperature/pulse/respiration notation for visits, or every time a patient is presented for a new clinical problem. It is also important to be aware if a jurisdiction requires some form of informed consent by the client for telehealth consultations. These rules can make telemedicine extremely challenging.

If no VCPR exists, it still might be possible for veterinarians to answer basic questions that would not constitute providing specific medical advice for any specific pet (e.g., “what is mange?,” “can dogs get chicken pox?,” “my cat is bleeding. Should I bring her in, or go to an emergency clinic?,” etc.).

      Consultations with pet owners for which a VCPR has not been established are generally considered as either teleadvice or teletriage, rather than telemedicine. Both are still a subset of telehealth, even if they are not telemedicine. Teletriage might include providing advice for a pet that has consumed poison, whether that involves having them call a poison control hotline or advising them to go to the nearest emergency clinic. There are also now a variety of applications for pets using wearables, including remotely measuring pulse, respirations, temperature, position, and activity level, and this also constitutes teletriage, but this typically happens within a sanctioned VCPR.

      Veterinarians providing telehealth must be legally authorized to practice veterinary medicine. Depending on the local jurisdiction, licensing requirements, and Practice Act, they may also be required to be licensed to practice in that specific state where the patient is located.

      2.5.5 Implementation

      Most veterinarians are already providing some forms of telehealth, but it is worthwhile creating hospital guidelines regarding the delivery of such services. It is also important to ensure that all aspects of the telehealth consultation are recorded appropriately in the medical records.

      There are essentially two different ways in which virtual health can be delivered – synchronous and asynchronous. Synchronous consultations occur on a real‐time basis and technology is typically used to provide an audiovisual encounter. In most cases the client is using their own smart device to communicate, but in some cases visiting paraprofessionals may be remote and act as telepresenters on the client's behalf, providing more hand‐on evaluation. With asynchronous telemedicine, sometimes referred to as “store‐it‐forward” care, the consultations do not happen in real time. The client can submit questions, images, videos, laboratory results, etc. for the veterinary team to comment on and respond at a later time. While this lacks the personal touch of synchronous consultations, it is often much easier for both busy clients and veterinary team members to accommodate in their schedules.

      Other than teleconsultations, the most common forms of telehealth relate to things like provision of prescriptions based on VCPR, recheck evaluations, after‐hours care, postsurgery check‐ups, patient monitoring through wearable devices and other technologies, and even following up on hospice care patients and others for which in‐hospital visits are not possible or not convenient.

      Telehealth can be provided directly by a hospital (e.g., telephone, teleconferencing, email, etc.), but there are now several companies, programs, platforms, and applications that facilitate the interaction and monetization of the process.

      2.5.6 Remote Monitoring

      Technology is now available that allows remote monitoring of pets, and this can be an important resource when considering virtual care. The most common forms of remote monitoring are wearable collars, but other options for remote monitoring include glucometers, blood pressure devices, Holter monitors, and even sensors that can allow auscultation and other features.

      Wearable collars with sensors are the most common form of remote monitoring. These collars can