AVMA Guidelines For The Use Of Telehealth In Veterinary .

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AVMA guidelines for the use oftelehealth in veterinary practiceIMPLEMENTING CONNECTED CARE

TABLE OF CONTENTS3INTRODUCTIONAbout veterinary telehealth. 3Definitions. 3What can be accomplishedthrough telehealth technology?. 6Potential applications oftelehealth in your practice. 611 THE PATH TO IMPLEMENTATIONKnow the rules.11Telehealth and the VCPR.11Licensure considerationswhen using telemedicine. 13Define your service offerings and integratethem into your practice operations. 13Check your liability coverage. 15Evaluate technology and service providers. 15Train staff, market your services,and engage clients.16INTRODUCTIONThis document has been developed to help you thoughtfully integrate telehealth into your veterinary practice. Doing soprovides an opportunity to improve access to your services, enhance the medical care you provide for your patients, andbetter support and strengthen your relationship with your clients.ABOUT VETERINARY TELEHEALTHVeterinary telehealth is the use of telecommunication and digital technologies to deliver and enhance veterinaryservices, including veterinary health information, medical care, and veterinary and client education. Technologies thatsupport telehealth have been around in various forms since the mid to late 19th century. The earliest uses of telehealthlikely involved transmission of veterinary health information via telegraph, and later over the telephone. While electronictransmission of veterinary health information has occurred in some form for decades, there is no question that theopportunity and ability to acquire, process, and transmit high volumes and quality of data, including health information,is increasing at an exponential rate. E-mail and text messaging, live audio and audio/video conferencing, store-andforward electronic transmission of a variety of types of data, remote patient monitoring, electronic medical records,and artificial intelligence (AI)-assisted diagnostics are examples of modern technologies currently used in veterinarytelehealth. Telehealth is a tool of practice, not a separate discipline within the profession.DEFINITIONSThere is confusion surrounding the many terms that are used within the field of telehealth. While many are related, theyeach have a specific meaning.Set expectations.1618 TECHNOLOGY AND WORKSPACE NEEDSSPECIFIC TO TELEMEDICINESpecialist,ConsultantClinic setting.19Equipment.19TeleconsultingConnectivity and security.19Test your setup.20Your client's technology needs.20Have a backup plan.20Client& Patientwithin VCPR§TeleatriageTelemedicineNon-ClientNO VCPRTeleadvice20 MONETIZATION OF VETERINARY TELEHEALTHDetermine a pricing strategythat works for you. 21Vendor considerations. 22Will insurance companiescover a telemedicine visit?. 2223 ADDITIONAL RESOURCESTo view hyperlinks found throughout these guidelines,go to avma.org/telehealth and download the electronic version.VETERINARY HEALTHCARE orAnimal§ Veterinarians should consultstate requirements to determinewhether it is possible to establisha VCPR electronically. If so, theywill still need to comply withfederal requirements for the VCPRfor extralabel drug use or issuingVeterinary Feed Directives.AVMA GUIDELINES FOR USE OF TELEHEALTH IN VETERINARY PRACTICE 3

The terms used in this guidance have the following meanings:Connected Care is the integration of digitaltechnologies to enhance and support theveterinarian-client-patient relationship (VCPR)and facilitate proactive and ongoing carethrough improved communication, diagnosis,and monitoring. It is an approach to veterinarypractice that is patient- and client-centered,and actively engages the entire veterinaryhealthcare team.Telehealth is the overarching term thatencompasses all uses of technology to remotelygather and deliver health information, advice,education, and care. Telehealth can be dividedinto categories based on who is involved in thecommunication. For communication betweenveterinarians and animal owners there are twoimportant categories that are distinguished bywhether a VCPR has been established: Without a VCPR, telehealth includes thedelivery of general advice, educationalinformation, and teletriage (to support thecare of animals in emergency situations).Telemedicine includes the delivery ofinformation specific to a particular patient,and is allowable only within the context of anestablished VCPR.Teleadvice includes the provision of anyhealth information, opinion, guidance orrecommendation concerning prudent actionsthat are not specific to a particular patient'shealth, illness or injury. This general advice is notintended to diagnose, prognose, treat, correct,change, alleviate, or prevent animal disease,illness, pain, deformity, defect, injury, or otherphysical or mental conditions. Examples includerecommendations made by veterinarians or nonveterinarians via phone, text or online that allanimals should receive physical exams or premisevisits as part of a comprehensive healthcare plan,or reference to the importance of attending toregular vaccination or parasite prevention as akey part of preventive care.Telemedicine involves the use of a tool toexchange information about a patient’s clinicalhealth status electronically from one site toanother. Examples include using technology tocommunicate with a client and visually observethe patient during a postoperative follow-upexamination and discussion.Teleconsulting refers to a primary careveterinarian using telehealth tools tocommunicate with a veterinary specialist or otherqualified expert to gain insights and advice onthe care of a patient.Telemonitoring, mHealth or mobile healthemploys mobile devices. Some mHealthapplications and wearables are designed toaugment animal health care within VCPRs, whileothers are designed and marketed directly toconsumers for their education and for animalmonitoring without clinical input (outside ofa VCPR).work environment is often diminished. Whiletelesupervision offers innovative means toundertake clinical supervision, there remain gapsin the regulatory parameters of use in clinicalpractice. State regulators will need to addresswhether telesupervision is considered direct orindirect supervision, or some new, to-be-definedcategory of supervision. Telesupervision involvingthe practice of veterinary medicine should not beundertaken without a clear regulatory frameworkin place.Copyright Georgia Tech Research InstituteTeletriage is the safe, appropriate, and timelyassessment and management (immediate referralto a veterinarian or not) of animal patients viaelectronic consultation with their owners. Inassessing a patient’s condition electronically, theassessor determines urgency and the need forimmediate referral to a veterinarian, based on theowner’s (or responsible party’s) report of historyand clinical signs, sometimes supplemented byvisual (e.g., photographs, video) information.A diagnosis is not rendered. The essence ofteletriage is to make good and safe decisionsregarding a patient’s disposition (immediatereferral to a veterinarian or not), under conditionsof uncertainty and urgency.Telesupervision is the supervision of individualsusing mediums such as audio or audio/videoconference, text messaging and email. Clinicalsupervision is integral to continuing professionaldevelopment of health professionals. Whiletelesupervision may be useful in any context,its value is amplified for health professionalsworking in rural and remote areas where inperson access to supervisors within the local4 AVMA GUIDELINES FOR USE OF TELEHEALTH IN VETERINARY PRACTICEAVMA GUIDELINES FOR USE OF TELEHEALTH IN VETERINARY PRACTICE 5

WHAT CAN BE ACCOMPLISHED THROUGH TELEHEALTH TECHNOLOGY?You likely have been using telehealth throughout your veterinarycareer. Every time you take a phone call from a client whose animal yourecently saw in your practice as a means to follow up on a case, you arepracticing telemedicine. You have likely struggled, at times, to determinewhether a patient needed to be re-evaluated sooner than planned.By adding audio/video conferencing to the equation, you now haveinformation from two more senses (sight and sound) and the potentialto obtain visuals of the patient, in addition to the owner’s descriptionof progress (or not), to help you make that decision. Information fromremote monitoring, as well as from AI-assisted diagnostics, may furthersupport your clinical acuity in making decisions and delivering goodrecommendations for your patients’ care.Implementation of telehealthwithin a practice should stayfocused on three goals:1) Improve the level of care forthe patient, 2) Increase accessof underserved populationsto veterinary medical careand 3) improve utilization ofall members of the veterinaryhealthcare team.POTENTIAL APPLICATIONS OF TELEHEALTH IN YOUR PRACTICEHow might telehealth be integrated into your practice? It could take many forms, depending on the needs ofyour current and potential clients, and those clients’ level of interest and comfort with electronic technology andcommunications. Here are some possible applications to consider as you decide how telehealth might support deliveryof services for your existing patients and clients, as well as potential patients and clients.Sharing general animal health informationVeterinarians and their teams already offer general, non-patient-specific information (teleadvice) over the phone,and via text, email, and their practice website or social media pages. Often this information is provided free of charge.Offering more structured teleadvice services can provide an opportunity for veterinarians and their team members (e.g.,veterinary technicians, veterinary assistants) to use and be compensated properly for their training and skills, and canalso create unique opportunities to attract new clients, particularly if your veterinary hospital has one or more areas ofspecial interest or particular expertise and that is evident in your offerings.Expanding access to veterinary careDespite all the advances in veterinary medicine, there are still clients who struggle to access routine veterinary carefor their animals for a variety of reasons. Excessive distances, available transportation (including availability and easeof transportation for the patient), disability, language barriers, and financial issues are some examples of roadblocks.Today's high-quality telecommunication tools and software applications can provide almost seamless communicationbetween clients and veterinary healthcare teams at a distance, making it easier for clients to access veterinary expertise.If you have clients for whom recurring trips to the veterinary hospital serve as a deterrent to accessing veterinarycare, consider customizing a telemedicine offering that makes your services more convenient for them to utilize. Manyservices are possible with telemedicine, as long as a VCPR that satisfies state and federal requirements is in place,and the attending veterinarian is comfortable assessing the patient remotely and feels able to exercise good clinicaljudgment in caring for the patient.Potential clients may benefit from educational offerings addressing the importance of preventive care or safety for andaround animals.After-hours careClients want and expect 24/7 services, including veterinary care. Traditionally, access to after-hours care has meantthat the client leaves a message with an answering service and waits for the veterinarian to call them back. Today’sclient generally expects more. Implementing teletriage services can help meet client expectations and patient needs,assist in scheduling with prioritization given to urgent cases, while also allowing veterinarians to better manage theirwork-life balance.6 AVMA GUIDELINES FOR USE OF TELEHEALTH IN VETERINARY PRACTICE

Assessing client compliance and patient progressEvaluating progress after treatment - including checkingclient compliance with your recommendations andadjusting those recommendations as needed - is criticalfor successful outcomes. Using tools of telemedicine canenhance continuity of care. For example, you can usephotos and video to help evaluate healing of incisionsites; video to monitor the patient's gait and overallmobility; video to see the patient's general demeanorand evidence of return to normalcy after treatment;and electronic transfer of herd records to keep an eyeon health and production. Such consultations can beconducted in real time or asynchronously depending onneeds and preference. Cases that may lend themselvesto electronic appointments include, but may not belimited to, medical rechecks (e.g., chronic dermatologicalcases; gastrointestinal issues pending additional workup;osteoarthritis; herd or other animal group recordevaluations; including assessments of regularly collectedlaboratory, health, and production data), post-surgicalevaluations; follow-up behavioral consults; and digitalnecropsy (a standard set of images is obtained during theprocedure and shared with the veterinarian). Using toolsof telemedicine can support coordination with onsiteparaprofessionals, such as the exchange of diagnosticimages and case status between veterinarians and farriersinvolved in the management of certain conditions of theequine foot. Telehealth tools can also be used to provideclients with up-to-date information about hospitalizedpatients, including - for longer term patients - anopportunity to view their animal and see what progresshas been made during the course of treatment.Artificial intelligence-assisted diagnosticsVirtually every area of life has been touched by AI,enhancing our understanding of complex issues andincreasing the likelihood of better outcomes becauselarge amounts of data can be more rigorously analyzed.With its robust ability to integrate and learn from largesets of clinical data, AI can serve roles in diagnosis,clinical decision making, and personalized patient care.Veterinary medicine is experiencing rapid advancementsin AI, including deep learning, machine learning,natural language processing, and robotics, with currentapplications in the areas of triage, image interpretation(radiologic and pathologic), disease/condition diagnosis,patient monitoring, drug development, and evenrobotic surgery. Applying AI to health care supportsveterinarians, including those in both primary care andspecialty practices, by better integrating informationand increasing the accuracy of a diagnosis, reducing thelikelihood of errors in diagnosis, and earlier identificationof subtle changes in patient health that can lead to moreproactive intervention.Palliative careWhen the stress of a trip to the hospital might exacerbatean animal's already deteriorating health, telemedicineprovides a convenient way to check in on these patients.This is especially helpful for patients when clients mightotherwise forego a veterinary hospital visit because ofthe frequency of visits required and time limitations,challenges the animals themselves may present fortransportation (e.g., cats who dislike both the carrier andthe vehicle ride), and/or how the animal reacts to hospitalvisits overall. A telemedicine evaluation allows you toget a general sense of the animal’s overall wellbeing andcan help determine whether treatment plans should beadjusted or an in-person examination is needed. Remote patient monitoringRemote patient monitoring (RPM) uses digitaltechnologies to collect medical and other types of healthdata from patients in one location and electronicallytransmit that information securely to healthcareproviders in a different location for assessment andrecommendations. It can be used by veterinarians andtheir clients to increase the amount of informationavailable about a patient’s health and, thereby, improvediagnostic and treatment decisions and assess clientcompliance with recommendations. Synchronous or real-time monitoring/communicationis where video or other data are shared andevaluated in real-time. Live video streaming is themost common approach to synchronous RPM, but avariety of technologies are available that can deliverinformation about an animal’s environment, feedconsumption, activity, and physiological parameters(e.g., heart rhythm, temperature) in real time.Asynchronous monitoring/communication is wherevideo or other data are recorded and then sent to theveterinarian at a later time.8 AVMA GUIDELINES FOR USE OF TELEHEALTH IN VETERINARY PRACTICEExamples of RPM being used in veterinary medicineinclude microchips that also measure body temperature,with the potential for earlier detection of certaindiseases and stressors; continuous monitoring ofglucose concentrations in diabetic patients; time lapsevideography to evaluate lying time in dairy cattle asa measure of cow comfort; the use of smart-sensingtechnologies to provide critical environmental informationin poultry production facilities; electronic feeding stationsthat record individual animal feeding patterns and dailyintake; evaluation of lameness in a variety of veterinarypatients via accelerometer-based monitors or cameras;and assessment of growth rate and external parasiteloads of finfish via video sampling. Some veterinarianseven use video monitors in their hospital so that theycan keep an eye on their hospitalized patients or thosecontinuing to recover from anesthesia even when they arenot in the immediate vicinity.in-person appointments in a timely fashion. State andfederal regulations should be clearly understood in thesesituations before taking this approach.EducationConnected Care provides multiple opportunities tosupport your client education efforts. Informed clientsbetter understand their animals’ health status and may bemore likely to comply with your recommendations witha net improvement in patient outcomes. A thoughtfulapproach to client education can also improve utilizationof the training, skills, and time of the entire veterinaryhealthcare team. Digital diagnostics — Digital microscopes andotoscopes can provide clients with a real-time viewof exactly what the veterinarian is seeing, and digitalstethoscopes allow clients to hear exactly what theveterinarian is hearing. These tools can provide greatsupport for client understanding of their animals’health concerns and make them more amenableto following your advice. While still somewhatexpensive for routine veterinary use, digitally enableddrug containers with accompanying smartphoneapplications provide reminders when it’s time toadminister medication and can also provide a gentlecompliance assist. Client webinars — For years it has been common forveterinarians to offer educational classes in the clinicor in community venues, such as the local library. Nowthese same types of classes can be offered via liveand/or recorded webinars or livestreams and videosdelivered via social media. Live presentations allowclients to interact with the presenter, while recordedones offer the convenience of viewing whenever theclient has time. Webinars can be used to providegeneral health or animal care in

services, including veterinary health information, medical care, and veterinary and client education. Technologies that . support telehealth have been around in various forms since the mid to late 19th century. The earliest uses of telehealth . likely involved transmission of veterinary health information via telegraph, and later over the .

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