Telemedicine? ...telehealth? …Maybe you should tell me more?

The terms telemedicine and telehealth have a roughly similar meaning, “the remote diagnosis and treatment of patients by means of telecommunications technology” (1). Both are used in human and veterinary medicine. In food animal practice, it could be a way to provide veterinary services to clients, often agricultural businesses. In this column, Dr. Megan Bergman describes aspects of the regulatory environment when providing remote services; Dre. Valérie Harrisson describes the evolution of telemedicine as she offers services to a diverse and widespread clientele; Dre. Annie Fréchette describes the collaborative effort to develop an application to facilitate providing and charging for telemedicine services; and Dr. Meredith Behr Petersen summarizes her research comparing in-person to virtual veterinary services in for swine.

TELEMEDICINE — OPPORTUNITY OR THREAT?

Megan Bergman, DVM, Registrar, Alberta Veterinary Medicine Association

Telemedicine has been a hotly debated topic with much of the discussion initially driven by the need to provide veterinary services during the COVID-19 pandemic. However, veterinarians have long used telemedicine; they just weren’t calling it telemedicine or often charging for it. The scope of telemedicine capacity has changed, but the principles of practicing quality veterinary medicine have always applied.

Many veterinarians would hesitate to provide a prescription or diagnosis for animals or clients they have never seen or have no opportunity to see without solid justification with supporting information that their recommendations are informed and in the best interest of the animal’s health and welfare.

Provincial regulatory requirements for telemedicine may vary but some core principles are universal:

1. Informed Consent — ensuring the client understands the limitations of the service.

2. Continuity of and Access to Care — ensuring the animal/animals can receive in-person follow-up care through a bricks and mortar veterinary practice — this may differ among provinces, but there must be a mechanism for animal/animals to be seen in-person at an approved practice by a veterinarian.

3. Justification — could you explain to a group of your peers that telemedicine provided sufficient information to inform diagnosis and treatment decisions?

4. Registration — you must be registered to practice in the province where you provide the service.

5. Standard of Care — telemedicine must meet the same expected standards as veterinary care delivered in person.

To ensure you understand regulatory requirements where you practice, consider the following:

1. Can you establish a veterinarian-client-patient relationship (VCPR) through telemedicine alone?

2. Can you provide care without first establishing a VCPR in person? If so, are there limits to the scope and extent of care you can provide until an in-person examination can be completed? If you can proceed with telemedicine care without first establishing a VCPR in person, is this only in extenuating or emergency circumstances?

3. Is a follow-up in-person visit required after the initial telemedicine appointment?

4. Are there limitations on prescribing in telemedicine?

5. Do you need to be affiliated with a practice located in the province where you are providing the telemedicine service to provide telemedicine-based care?

Large animal medicine may be a leader in telemedicine service. Remotely collecting herd information by training herd owners and managers on information collection has evolved, and many practitioners are comfortable in diagnosing and prescribing treatment based on the reliability of information provided. Diagnostic samples can still be collected and submitted, remote visual assessments can be made, and software can provide more information remotely than veterinarians can collect in-person. What is missing is the physical examination. Depending on the situation, this may not have a negative impact; you might be able to collect enough information about animals and their environment without an examination. In these established relationships, the veterinarian must use their discretion as to when an examination or site visit is necessary.

To be efficient and effective, we need to continue to expand our horizons regarding telemedicine and delegation of appropriate medical tasks to veterinary technologists. Many veterinary technologists already visit farms to collect information, do “calf-checks,” take wellness appointments, and undertake advanced responsibilities deemed appropriate by a supervising veterinarian. These activities are supported by robust regulations and standards of practice that establish checkpoints in which a veterinarian may need to be engaged. But are we really enabling our veterinary technologists to use the full scope of their skill sets? Can we and should we do more?

Can we expand further by being more progressive in how we trust, train, and support veterinary technologists? In some provinces, veterinary technologists currently work under indirect tele-supervision by a veterinarian or work on farms with virtual access to a veterinarian. Can we allow further delegation by veterinarians based on their assessment of the technologist’s skills and experience? Can we develop veterinary technologist career pathways to offer and recognize additional training to acquire skillsets beyond their 2-year diploma curriculum? Empowering veterinary technologists could create a more efficient veterinary team. Additional opportunities and training for technologists may improve job satisfaction and access to care. This does not mean a different professional classification within the veterinary team, simply that a veterinary technologist who has undertaken additional training or certification could assume additional responsibilities. To be successful, we also need to be prepared to compensate for these new skills. Clients need to recognize that whether a veterinarian or a veterinary technologist provides a service, they are part of the veterinary professional team, and as such the cost does not vary with the professional that provides this service.

Many rural and remote locations in Alberta and elsewhere in Canada struggle to access veterinary care. Innovative applications of telemedicine and expanded roles for veterinary technologists could improve access to care without compromising animal health and welfare or impacting public trust. We can advance the role of technologists by first optimizing the use of their current skills and further through training opportunities, and regulatory change. If this is done well, I am confident that this would enhance animal health and welfare in Canada, and further build public trust.

The veterinary profession needs to continue to evolve in creative and appropriate ways to ensure that expected standards of care are met and the profession is both successful and sustainable. Telemedicine is just one tool to help make this happen.

PROVIDING VETERINARY SERVICES FOR DISTANT AND DIVERSE LARGE ANIMAL CLIENTS

Valérie Harrisson, MV, Bureau vétérinaire des Hautes-Laurentides. Mont-Laurier, QC

I began my food animal practice in 2006, in the MRC Antoine-Labelle, a remote region of Quebec in Hautes-Laurentides north of Montreal. My practice includes cattle, small ruminants, deer, camelids, laying hens, and horses spread over a large geographic area.

When I started, our practice made limited use of computer technology and I mainly used a landline to chat with clients, mostly to request farm visits. However, telephone consultations gradually increased as did the options to receive and answer questions such as by text message, email, Messenger, etc., facilitating contact.

Around 2016, veterinarians in our practice began to find that cases being managed by telemedicine were becoming more complex. We noticed that we were not keeping good records; if one practitioner dealt with a situation by telephone, it was very difficult for a colleague to return to that case later. We decided that we had to maintain better records!

We initiated a formal structure for telemedicine consultations. For new clients, we made a face-to-face visit in order to establish a valid client-veterinarian-patient relationship. We had a growing clientele that was less familiar with basic animal care (backyard birds, domestic farm animals, etc.) who needed basic training on health and management. We managed most cases using decision trees and treatment protocols which we then left to the client. We always kept a record of the animals we discussed whether they were treated or not.

We are now able to further expand our ability to offer telemedicine services using recently developed technology. The Association des Médecins Vétérinaires Praticiens du Québec (AMVPQ) worked with partners including Quebec veterinary regulators to develop a telemedicine computer tool. AMVPQ collaborated with MAPAQ, the Quebec ministry of agriculture, to deploy the tool starting with a subsidized farm visit. Dre. Fréchette describes the tool below.

DEVELOPMENT OF A COMPUTER APPLICATION TO FACILITATE REMOTE VETERINARY CARE

Annie Fréchette, DVM, PhD, DSAHR, AMVPQ, QC

Veterinary practice constantly evolves. During the COVID-19 pandemic, smart phone use exploded, not only for traditional voice calls but for messaging and video, reducing travel and allowing information about animal care to be collected quickly and efficiently. In a survey by Groupe AGECO (2), 70% of Quebec agricultural producers were very interested in obtaining veterinary services remotely. However, veterinarians were concerned that providing services through telemedicine would not meet the standards of practice.

In 2022, the AMVPQ received a grant from the province of Quebec to develop a veterinary telemedicine service as part of its Digital Transformation Offensive. The objective was to allow agricultural producers throughout Quebec to gain access to veterinary services. A working group was created at the University of Montreal, Faculty of Veterinary Medicine, l’Union des producteurs agricoles, Québec’s veterinary regulators, MAPAQ and practitioners. As the AMVPQ could not find appropriate technology to adapt, a private company developed an application with financial support from Fonds d’aide en Santé Animale (FASA), an independent, non-profit organization that supports development of tools for practitioners. The telemedicine app is integrated into the Vet-Expert^® veterinary billing software, which is used by all veterinarians in Quebec. The telemedicine app is available free of charge to producers. The mobile app facilitates communication between veterinarians and farmers. It allows veterinarians to easily record a complete case history which is then archived and available to both the farmer and veterinarians. It supports text messages with attachments (photos and videos) and telephone calls. File archiving is compliant with the minimum standards of practice dictated by the provincial regulator, l’Ordre des médecins vétérinaires du Québec. The app can be made available to producers of dairy cattle, beef cattle, sheep, and goats by MAPAQ in the form of farm visits that are subsidized by the provincial government. During the visit, veterinarians train producers on the benefits of using telemedicine and the situations in which it might be used. Producers can learn technical procedures to support the veterinarian remotely. During this visit, personnel from DSAHR (3) help present the telemedicine tool and validate that there are no technological issues on the farm. Personalized solutions may be offered to ensure Internet access, as required to use the service.

Further development is planned to meet user needs and to adapt to more species.

TELEHEALTH: RESEARCH INVESTIGATING ITS USE IN SWINE PRODUCTION

Meredith Behr Petersen, DVM, MPH, Swine Medicine Education Center, Ames, Iowa

Although telehealth is used commonly in veterinary medicine, there is little documented research investigating the capabilities and limitations of telehealth technology compared to in-person visits. Therefore, we’ve investigated several uses of telehealth in swine production to better understand its capabilities and limitations (4).

In the first study, we evaluated telehealth for transferring clinical skills. Fifty-nine naïve students were trained on collecting oral fluids and blood: i) in person, ii) through virtual instruction using a tablet, or iii) through virtual instruction using smart glasses. There were no significant differences among training methods; all students were successful in collecting oral fluids and most were successful in collecting blood.

For site evaluation, 20 wean-to-finish sites were visited through live, synchronous telehealth consults using either a handheld tablet (standard telemedicine package) or smart glasses (specialized telemedicine package). For each site evaluation, the telemedicine evaluators assessed objective criteria under the categories of records, ventilation, feed, and water. Over 90% of all criteria assessed in site evaluations by telemedicine were considered correct interpretations based on on-farm confirmation.

To compare in-person to telehealth for evaluating clinical signs, the 20 wean-to-finish farms were visited both in-person and through telemedicine consults using the same two virtual methods. Both in-person and telemedicine evaluators recorded clinical signs. Agreement between in-person and telemedicine evaluators was relatively low for all clinical signs (13/70 consultations). However, agreement between in-person and telemedicine evaluations was significantly improved if telemedicine evaluations used the standard telemedicine package (handheld tablet device) rather than the specialized telemedicine package (smart glasses). Agreement was improved when clinical signs with < 5% prevalence were removed. Furthermore, “new” or “additional” clinical signs were listed frequently by both in-person and telemedicine evaluators, indicating significant variability between veterinarians in the actual interpretation of clinical signs, regardless of evaluation method.

A final study investigated the perception of color using telehealth technologies — as color is important when evaluating lesions during either physical or post-mortem examinations. This evaluation compared the ability of veterinarians to visualize various colors and locations of marks on pigs at set prevalence levels through synchronous telemedicine, or asynchronous telemedicine (using 1080p or 4K video). In synchronous telemedicine, real-time video is used; in asynchronous telemedicine, previously recorded video and images are used. Significant limitations in color transference were observed, and the observed prevalence of colored marks on the pigs was consistently underestimated by the veterinarians using any telemedicine method.

This research supported telehealth for virtual instruction and evaluating objective farm criteria. These techniques can be used by practitioners but telemedicine techniques for evaluating clinical signs or estimating prevalence of disease should be further investigated before being used clinically.

CONCLUDING REMARKS

Telemedicine is becoming increasingly feasible from the regulatory and technological standpoints. As Dr. Bergman proposes, telemedicine and extended use of technologists/technicians has the potential to expand the business model for food animal veterinary care. Dr. Behr Petersen’s research as shown that much work needs to be done to understand the strengths and limitations of telemedicine techniques so that we can assure that veterinary services delivered using telemedicine meet an appropriate professional standard. More field research is needed to better understand how well telemedicine can work.