Position Statement on Veterinary Telemedicine

Background

Telemedicine – the delivery of medical services via telecommunications technology – has been widely implemented in human medicine. During the COVID-19 pandemic, telemedicine was essential to minimizing the spread of illness while ensuring continuation of healthcare delivery.^[1] The human medical community generally recognizes that in-person physical examinations may not be necessary in many cases, and that telemedicine technologies can expand access to healthcare.^[2] In all fifty states, physicians may use telemedicine to establish new doctor-patient relationships and may employ telemedicine technologies to diagnose and treat both current and new patients, including infants and nonverbal adults.^[3]

In veterinary medicine, however, the use of telecommunications technology remains limited, its growth stymied by outdated laws and policies, including laws that directly prohibit veterinarians from establishing new veterinarian-client-patient relationships (VCPRs) electronically and laws that indirectly prevent veterinarians from using telemedicine by requiring the veterinarian to conduct an in-person physical examination of the animal patient before they can legally practice veterinary medicine or prescribe medication.

The ASPCA believes that licensed veterinarians should be legally and professionally empowered to determine when to use telemedicine in the practice of veterinary medicine. When used broadly, responsibly, and effectively, telemedicine has the potential to reduce animal suffering, address financial and logistical barriers to veterinary care, improve pet retention, and extend the capacity of animal shelters to serve animals and their communities by increasing their access to veterinary care. Given the many potential benefits of expanded access to veterinary telemedicine, the ASPCA supports the reduction of legal limitations to telemedicine access.

While telemedicine is not appropriate for all veterinary cases, the ASPCA believes that public policy should explicitly empower veterinarians to create veterinarian-client-patient relationships (VCPRs) through telephone, digital, or other electronic communication, as well as enable veterinarians to prescribe medications through electronically established VCPRs at the discretion of the individual licensed veterinarian.

State laws govern the practice of veterinary medicine within each state.

• Most state laws require veterinarians to establish a “veterinarian-client-patient-relationship” (VCPR) before they can legally practice veterinary medicine or treat an animal patient.
• Some state laws explicitly prohibit veterinarians from establishing a VCPR using telemedicine technologies.
• Many laws require a recent, in-person physical examination as a prerequisite to establishing a VCPR or to prescribing medication. Such laws often place a time limit on the duration of the VCPR, which restricts veterinarians to using telemedicine exclusively with existing patients, and generally only patients the veterinarian has physically examined in person within the most recent twelve months.

At the federal level, United States Food and Drug Administration (FDA) regulations require a VCPR for the use of pharmaceuticals in veterinary medicine only if the prescription applies to one of the following categories:

• Extralabel drug use, which is the use of a drug in an animal in a manner that is not in accordance with the approved labeling,^[4] and
• Veterinary Feed Directives for the use of drugs used in or on animal feed.^[5]

The federal regulations relating to extralabel drug use and veterinary feed directives stipulate that a valid VCPR “can exist only when the veterinarian has recently seen and is personally acquainted with the keeping and care of the animal(s) by virtue of examination of the animal(s), and/or by medically appropriate and timely visits to the premises where the animal(s) are kept.”^[6]

In many situations when using modern telemedicine technology, a licensed veterinarian can appropriately “see” and “examine” an animal while the animal remains in its normal environment, which can potentially be more informative than seeing an animal in an unfamiliar place where the animal is not behaving as it customarily would. In a clinic setting, dogs and cats may become fearful and withdrawn, and, in a situation they perceive as threatening, may mask their pain as a survival mechanism. Veterinary telemedicine technology is useful for treating a range of conditions experienced by existing patients as well as new patients for whom the veterinarian has yet to conduct an in-person examination, raising questions about outdated VCPR examination requirements in state and federal law.

The fear and stress that visiting a veterinary clinic may cause can pose a significant barrier to pets receiving veterinary care. A growing body of research explores the relationships between fear, anxiety, and stress related to veterinary visits.^[7] Research has documented that clinical veterinary examinations are stressful for most dogs and cats.^[8] One study found that almost 78% of dogs studied showed fearful behavior during a standardized clinical examination, with 13% so frightened they had to be physically dragged or carried into the examination room.^[9] Dogs who are generally friendly to people may become defensively aggressive or extremely fearful when handled by veterinary medical personnel, especially if they are in pain.^[10] Furthermore, in the clinic environment, dogs and cats are sometimes separated from their owners for medical exams and, in many cases, the separation results in even greater stress than if the owner remains with the pet.^[11] One study found that cat owners reported taking their cat “to the veterinarian highly stressful for the animal and themselves,” and summarized the cat owners’ perceptions in the following way:

They indicated that their cats hid when the cat carrier appeared; aggressively, physically resisted being put in the carrier; cried during the car or bus ride to the veterinary clinic; showed signs of stress and fear in the waiting area, particularly when unfamiliar animals, especially dogs, were present; displayed physical signs of tension during the examination; and acted remote and unfriendly for several days after returning home. Many cat owners expressed a desire to avoid the difficulties and unpleasantness associated with bringing their cat to the veterinarian.^[12]

For fearful pets, whose owners may postpone clinic visits to avoid causing their pet undue stress, telemedicine can provide more options for accessing care from the pet’s home or for mitigating fear and stress when pets must be transported to a clinic, by prescribing pre-visit medications to reduce stress experienced during transportation or clinic visits. Quality of life assessment, palliative care, and end-of-life or hospice care provided through veterinary telemedicine technologies have the potential to reduce unnecessary clinic visits, minimize stress, and lessen animal suffering for senior or terminal animal patients.

Studies indicate that many pets do not regularly see a veterinarian, often because their owners may confront significant barriers to obtaining veterinary care for their pets, including affordability, and such obstacles can result in pet owners forgoing or postponing veterinary care or relinquishing pets.

• In 2020, the chief economist for the American Veterinary Medical Association estimated that over 50 million U.S. pets, approximately one-third of all pets in the U.S., do not see a veterinarian at least once a year.^[13]
• One study found that 40% of cat owners had not taken their animal to a veterinarian in the past year.^[14]
• A study published in the Journal of the American Veterinary Medical Association indicated that cost of care was cited frequently as an obstacle to veterinary care.^[15]
• A national study initiated by the Access to Veterinary Care Coalition (AVCC) found that one out of four pet owners experience barriers to veterinary care, and the “overwhelming barrier for all groups of pet owners and types of care (preventive, sick, and emergency care) is financial.”^[16]
• A study the ASPCA conducted in Los Angeles revealed that the majority of owners relinquishing pets were doing so based on inability to afford or access medical or spay/neuter services.^[17]
• A national study showed that 40 percent of low-income owners who rehomed their pets reported that access to affordable vet care would have helped them keep their pet.^[18]

Telemedicine may help address financial barriers if cost-effective virtual care services are available. Better access to telemedicine may also enable pet owners to avoid ancillary expenses related to transportation, travel time, or missed work.

While finances are a frequently-cited obstacle for pet owners seeking veterinary care, many people live in areas with few or no veterinary services or face other logistical obstacles.^[19] Such factors, especially when combined, can force families to make difficult decisions to forgo basic veterinary preventive care, which can lead to more urgent medical conditions.^[20] Access to telemedicine can address geographic and logistical problems with bringing pets to the clinic that may be encountered by many pet owners, including, but not limited to, seniors, disabled individuals, those lacking transportation, and those who live in underserved urban or remote areas.^[21] Telemedicine can also be useful for addressing logistical challenges associated with transporting large or aggressive animals to clinics.

The current shortage of veterinarians and other veterinary professionals in the workforce may worsen problems with access to care.^[22] A September 2020 study found that 75 million pets in the U.S. could be without veterinary care by 2030 if we do not update our approach to providing these services.^[23] Expanded use of telemedicine technology can help bridge gaps in care caused by workforce shortages, increase access to the veterinary healthcare system, and help keep pets and people together.

Animals in the custody of shelters who need veterinary care—including but not limited to lost animals and/or animals in foster homes—stand to benefit from expanded access to telemedicine. Animal shelters with veterinarians on staff may face situations where these veterinarians cannot be on the premises but can still provide care through telemedicine. For animal shelters without veterinarians on staff, third-party veterinarians may be able to provide valuable, lifesaving services through telemedicine. Animal sheltering facilities operating veterinary clinics that are open to the public may be able to increase their community’s access to veterinary care via telemedicine, thereby helping keep pets in loving homes, while preventing disease spread and conserving limited resources.

Veterinary care should be accessible to all animals, regardless of their owners’ socioeconomic status, physical limitations, or geographic location. Telemedicine has the potential to bridge gaps in care caused by workforce shortages and to mitigate financial, geographic, and logistical barriers to veterinary medical treatment, which can reduce animal suffering and may help more pets remain with caring owners. Virtual veterinary care technologies may help reduce unnecessary clinic-related pet stress and may particularly enhance access to care for anxious, large, potentially aggressive, senior, or terminally ill animals.

Veterinarians train for many years to reach a high level of expertise; they take the veterinarian’s professional oath seriously and should be trusted to make the right decisions about when to use telemedicine technology and when an in-person visit is medically necessary. The ASPCA supports policy changes that expand access to veterinary telemedicine and encourages veterinarians to employ telemedicine technology, whenever it is medically appropriate and legal to do so, to help more animals receive vital veterinary care.