Abstract
Objectives
This research seeks to identify an existing policy stream around the establishment of a veterinarian–client–patient relationship (VCPR) through telemedicine to provide evidence of, and advance policy alternatives for, states and countries looking to allow this practice responsibly. This is seen as an important step for access to veterinary care, particularly for cats.
Methods
The multiple streams policy framework requires identification of a centering event, problem stream, policy stream and politics stream in order to have the necessary conditions for policy change to occur. This research identifies that policy stream through thematic content analysis. State-level policies from across the entire USA that address the virtual establishment of a physician–patient relationship were analyzed to provide themes that could be applied to similar policies in veterinary medicine.
Results
Ten key themes were identified and further organized into four high-order concepts through the thematic content analysis. Detailed accounting of the specific policy alternatives is provided in the supplementary materials.
Conclusions and relevance
The themes and concepts presented provide evidence of a robust policy stream. This content analysis, and the supporting supplementary details, provide many options to guide states in the development of sound policies for the virtual establishment of a VCPR by drawing from the more matured field of human medicine.
Introduction
Telemedicine is the practice of medicine using remote technologies so that the patient is in a different location from the practitioner. 1 The practice of telemedicine can include both the diagnosis and treatment of health conditions. The overarching term ‘telehealth’, broadly used in human healthcare, encompasses telemedicine but also includes practices that may not involve diagnosis and treatment, such as triage or general advice. Telemedicine has been advanced as one solution to access-to-care disparity in the human health field, with a scoping review of the recent literature on telemedicine returning evidence across multiple studies that it both reduces costs and addresses place-based disparities. 2 Given the similarities to access-to-care disparities in the veterinary industry, 3 telemedicine is well positioned to have similar impacts in that field.
A recent commentary in the Journal of Shelter Medicine and Community Animal Health argues for an increase in efforts to ‘legalize’ and ‘normalize’ the use of telemedicine in veterinary care settings, while acknowledging the key policy limitation that currently exists around using virtual technologies to establish a veterinarian–client–patient relationship (VCPR). 4 Another editorial appearing in Vet Record, the British Veterinary Association journal, echoed the notion that continued expansion of telemedicine would be positive for animals, clients and veterinarians. 5 In retort, another author highlighted a primary concern about the implications of telemedicine for the integrity and trust of the public in veterinary medicine. 6 Clients have been found to see value expressed in terms of willingness to pay for telemedical services, 7 and veterinary professionals in Canada have argued that there are a number of benefits to telemedicine for animals and providers. 8 A survey of small animal veterinarians who were utilizing telemedicine during the COVID-19 pandemic found that less time was needed for the consultation and that fees were lower, but that concerns remained around the legal issues as well as potential inferiority in delivered care. 9 Research in both human and animal medicine has found that some patients may find navigating the technology difficult or that adequate technology may not be available to some clients, 10 particularly in rural areas where access to high-speed Internet may be limited or unreliable. 11 In addition, international research has found that veterinarians may not be very exposed to the use of telemedicine modalities and that more education for veterinary students may be needed to effectively use telemedicine. 12
Cats historically receive veterinary care at approximately half the frequency as dogs, 13 and so may benefit disproportionately from telemedicine. This is in part due to the stress to both cat and caregiver in traditional clinic visits. 14 It has also been found that demand for veterinary care for cats is more elastic relative to cost of care (in other words, increases in care costs are more likely to reduce care demand).15,16 Cats being seen through telemedicine visits exhibited lower levels of stress compared with in-clinic visits as reported by their owners’ experience with telemedicine visits during the pandemic. 17 An additional study showed similar results, with cats exhibiting fewer stress responses, owners perceiving benefits for reducing their own stress, owners perceiving benefits for reducing their cats’ stress and further agreeing that telemedicine had increased their ability to have access to veterinary care. 18
Yet adoption of telemedicine by the veterinary community is quite limited in scope and scale in the USA. 19 The main barrier to the implementation of telemedicine in veterinary medicine is the legality of establishing a VCPR through virtual means. 4 The VCPR is generally considered to be a prerequisite for care and a requirement before a veterinarian is able to offer any diagnosis, treatment or individualized care, though telemedicine can be used once a VCPR is in place and maintained. 20 Not all states, however, make mention of the VCPR as a requirement for care in their Veterinary Practice Acts. 21
The federal government in the USA regulates specific aspects of veterinary care as it relates to VCPRs through the Food and Drug Administration’s (FDA) rules governing the off-label use of medications and feed directive drugs. Specifically, the FDA requires an examination or recent visit to the premises where the animals are kept to meet the minimum expectation to establish a VCPR in order to prescribe the previously mentioned medications.22,23 The United States Department of Agriculture (USDA), who has regulatory authority over veterinary biological products, has adopted VCPR requirements identical to the FDA. The American Veterinary Medical Association (AVMA) policy statement on the issue states that the virtual establishment of a VCPR is not recommended, due to potential confusion and possible conflicting requirements and the limitations that exist due to the federal regulations. 24 The Model Practice Act, developed by the AVMA to guide state-level policymakers, states that a VCPR must meet several standards, including a timely examination of the animal by the veterinarian or appropriate and timely visits to the operation where the animal is managed, prohibiting, in their interpretation, virtual establishment of VCPRs. 25
While the AVMA prohibits the virtual establishment of a VCPR under their Model Veterinary Practice Act, the American Association of Veterinary State Boards (AAVSB) takes a more nuanced stance. In the AAVSB Guidelines for Telehealth, as well as their Practice Act Model, they state that each jurisdiction should evaluate and implement policies appropriate to their areas for establishing criteria of VCPR. 26 As part of the Guidelines for Telehealth, the AAVSB specifically indicates that this could include ‘A recent examination of the Animal or group of Animals, either physically or by the use of instrumentation and diagnostic equipment through which images and medical records may be transmitted electronically’. 26
In March 2020, the FDA temporarily suspended enforcement of the animal examination and premises visit VCPR requirements relevant to their regulations governing extra label drug use in animals 23 and veterinary feed directive drugs 22 out of recognition of the important role of telemedicine in animal health during the pandemic. 27 This action removed, albeit temporarily, a huge hurdle for telemedicine in the veterinary context, and the enforcement waiver was withdrawn as of February 2023. 28 The action shows that there remains a potential for this complicated policy issue to be addressed by policymakers, given that this temporary change does not appear to have resulted in any abuses or harm to humans or animals. Further, this issue is open to interpretation and the potential exists for state-level policies to open more doors for virtual VCPRs; there is much to be learned by looking to the way this has been handled in human medicine. 1 Policy analysis is one tool that can be used to identify this type of opportunity and to fill areas of knowledge that may be needed in order for policy change to occur.
This research attempts to fill a gap in the understanding of potential ways policy could be structured around the virtual or remote establishment of a VCPR by examining the policies that exist guiding the remote establishment of physician–patient relationships (PPRs) in human healthcare, a practice that is currently permitted in all 50 states. 29 Themes and high-level concepts are identified through content analysis of the existing state policies across the USA.
Materials and methods
Theoretical framework
Kingdon’s multiple stream framework (MSF) has been widely applied in the field of policy analysis. 30 Kingdon theorizes that a centering event, problem stream, policy stream and politics stream are necessary to bring together policy problems, policy solutions and politics in order to bring an issue on to the agenda of policymakers, and that crisis can serve that function. 31 One of the strengths of this framework is its ability to highlight the policy alternatives that exist for complex problems. 32 The framework envisions the policy process as consistent of three metaphorical streams that operate independently of each other until a centering event provides an opportunity to bring the three streams together, resulting in policy formation. 31 The MSF was used as a framework to analyze telehealth reimbursement in the human health policy arena. 33 Following that use of this framework by Giese, 33 this work applies the MSF to explore telemedical policy in veterinary medicine as a tool to mitigate access disparities to veterinary care. Specifically, the establishment of a VCPR through virtual and/or remote technology is identified as the key policy area in which to apply the MSF, with the identification of a parallel policy stream hypothesized to exist in human healthcare. This policy stream is then qualitatively analyzed to summarize the policy alternatives available in telemedicine and the virtual establishment of a VCPR, including both themes and broader concepts.
The policy stream, which is the focus of this research, can be conceptualized as the flow of policy alternatives and strategies that may be considered in order to resolve a policy problem. 31 A policy stream exists when there are a multitude of competing ideas or alternatives around a policy problem. 31 These alternatives could be living in the minds of policy entrepreneurs or in existing comparative policy alternatives. 34 Policy entrepreneurs are advocates who are willing to invest resources toward policy change with an anticipation of future benefit. 35 Identifying and describing the telemedicine VCPR policy stream in veterinary care requires a modified approach because policy alternatives are quite limited at the state level in veterinary care in the USA, 36 with only a few states providing some level of comparative policies. 21 Instead, it is hypothesized that an adjacent policy stream can be positively identified by looking to state-level policies governing the use of telemedicine to establish a PPR in human healthcare. The PPR is the functional equivalent of the VCPR. 37
Analysis
A content analysis research design was devised in order to identify the main themes associated with policies covering the establishment of a PPR in the telemedicine environment at the state level. Data were derived from the policy statements and legislative records from each of the 50 states in the USA and the District of Columbia. The American Medical Association curates a collection of the state laws and policy statements that address the establishment of a PPR in telemedicine. 29 This compilation provided the text for the analysis completed in this research.
A thematic content analysis was completed on the data. Content analysis has been applied in policy analysis studies in a variety of policy fields.38–41 The focus on thematic analysis is to identify the main themes that emerge from a large set of text. 38 In this case, the thematic analysis was used to identify central issues surrounding the establishment of a PPR through telemedicine in the USA to identify a set of policy alternatives under the MSF with two sets of reviewers completing the analysis.
The policies for each of the states plus the District of Columbia were systematically reviewed and key components of the policies were extracted. Definitions of specific terms were not included in the analysis. Key provisions were then organized by theme. If more than two states had a provision that were related, then a theme was identified on that topic. It is important to note that the themes provide a category describing policy provisions and does not imply that there is a consensus on how the provisions are governed. In several instances, states differed in how each theme provision was addressed. Thus, the results can be interpreted as policy areas for consideration more than policy prescriptions.
The objective of the analysis applied herein has two distinct purposes. The first is to provide evidence of a vibrant policy stream in an adjacent field to veterinary medicine by looking to the governance of PPR telemedicine in the human healthcare setting. The second goal is to describe the policy stream through the use of thematic coding. The themes comprise the policy stream and identify the main considerations that make up the policy on the human medical policy field that could be applied to the same policy system in veterinary medicine. The identification of a set of feasible choices is seen as a key step in applying the MSF theoretical approach. 30 The combined effect of the identification of a proximal stream and the thematic aspects of that stream provides a framework that is both evidenced and described.
Results
The results of the first phase of the thematic analysis are summarized in Table 1. The table represents a crosswalk through the policies of each of the 50 states plus the District of Columbia as they relate to the establishment and practice of a PPR through telemedicine in the human healthcare sector. Table 1 includes the 10 themes that were identified during the content analysis and a final theme for the miscellaneous policies. Any policy that did not fit into a theme is recorded in that section. The middle column provides the references for each policy identified as fitting within that theme and the final column summarizes the key concepts from the policies within each theme.
Results of thematic content analysis of state virtual physician–patient relationship (PPR) policies (derived by the authors from content analysis of US state policies)
Further details are provided in Appendix A contained in the supplementary material. This appendix provides a summary of the actual policies referenced in Table 1.
Figure 1 further summarizes the findings. The themes were grouped into main concepts for policy consideration.
Policy concepts for consideration in developing virtual veterinarian–client–patient relationship policies (derived by the authors from content analysis)
Discussion
There is significant variation in the types of policies, and concerns addressed, across states in the USA. Despite this variation, there are key themes and high-order concepts that emerged during the content analysis. These themes and concepts provide a rich set of policy alternatives apparent in the virtual establishment of the PPR in human health that could have direct application in similar state-level policies. This also exhibits that a ‘one size fits all’ approach is not requisite for policy adoption and that states can craft unique policies addressing the concerns of their boards, practitioners, residents and particular operating climate.
Themes
Ten distinct themes were identified through the content analysis in addition to some miscellaneous considerations. These themes each contain a series of policy alternatives that were identified during the review of the state laws and policy statements and together represent a robust policy stream in the Kingdon policy model. While the themes are laid out in Table 1, Appendix A in the supplementary material includes more detail by state. The theme that occurred most often in the content analysis was standards for establishing a PPR through virtual methods. As seen in Appendix A, most of these are general statements around disclosure, identity and the conditions of mutual consent that are necessary for establishing a relationship. The second most common theme was technological requirements. These are minimum expectations to ensure that the technology being used is appropriate and limits potential abuse by ‘prescription mills’ using online forms to prescribe medications for example.
Prescription of both controlled and non-controlled substances were both additional themes. There is an obvious need to monitor the prescribing of certain substances, particularly addictive narcotics. For example, a study by the University of Pennsylvania School of Veterinary Medicine found a 41% increase in the prescription of opioids to small animals in the past 10 years. 42 They argue that this increase positions veterinary care as one potential route for individuals to access opioids that may be abused. A survey of veterinarians in Colorado concluded that veterinarians recognized their role in preventing opioid abuse but indicated that veterinarians felt that they lacked formal education on the topic. 43 One potential solution advanced by this research could involve limiting the prescription of opioid medications when a relationship has only been established through virtual means. This could provide a reasonable alternative whereby electronically established VCPR providers could still prescribe narcotics but with state legislated safeguards that again mirror the human medical policy. Another substance that may warrant special consideration is the prescribing of antibiotics as research has found higher rates of antibiotic prescribing through telehealth consultations vs in-office visits with medical doctors. 44 Though it is important to note that in veterinary medicine, a study of over 22,000 video telemedical visits found low overall prescribing rates and judicious antibacterial stewardship. 45 Given the rise of concern around antimicrobial resistance, this issue is worth considering even though it did not appear in the examination of PPR policies.
One significant difference between human healthcare and veterinary care is the lack of standards of care in veterinary medicine.46 ,47 In part due to this lack of evidence-based standards of care, the need for policy provisions surrounding the theme of practitioner judgment are perhaps even more critical in the veterinary field than in human medicine. Both traditional and telemedical care must recognize that veterinarians are licensed and trained professionals who have a moral, if not legal, obligation to provide the best possible care for their animal clients. The access to care problem in the USA is complicated, however, and the need to balance the client’s financial limitations and limitations inherent in telemedicine ought not to impede the adoption of these policies. Provisions that establish gold standard care can interfere with the potential access to care gains in telemedicine. Further, gold standard care is not always the most appropriate care for the welfare of the animal depending on a number of factors. 48 In the UK, the term ‘contextualized care’ has been proposed in recognition that gold standard can be a problematic term that may result in feelings of guilt or shame in the veterinary provider as well as the client when it is not adhered to. 48 The proposed term is meant to reflect that ‘different treatment modalities may be equally valid in different contexts’. 48 An alternative way to address this is to consider telemedicine as part of the spectrum of incremental care – a philosophical and ethical approach to medicine that acknowledges that gold standard care is not always financially feasible nor always in the best interest of the animal. 49 This could be made explicit, consensual and transparent by including disclosures as part of the informed consent process. Both informed consent and practitioner judgment policy themes existed in the PPR review as evidence to support these potential policies.
Concepts
The concepts that emerged from the summarization of the analysis are ethical, practical, technological and public health concerns. Ethical concerns are those that revolve around questions of standard of care and practitioner judgment. Providers have an ethical obligation to ensure that the care they are able to provide via telemedicine and telemedically established PPRs is consistent with the standard of care for the condition they are diagnosing and treating and is directly relevant to virtual VCPRs. Practical concerns, another key concept, include the obligations around follow-up care availability and referring relationships as well as informed consent.
Another highest-order concept is public health. This is captured by rules that cover the prescribing of medications and the prescribing of controlled substances. As discussed earlier in this work, the FDA governs the prescribing of medications in the veterinary medical field and has specific limitations relevant to the use of telemedicine for prescribing off-label uses of medications, a common practice in veterinary medicine. Further, any individual state laws pertaining to prescribing controlled substances must be considered.
The final highest order concept that emerged was the appropriate use of technologies. This includes how and what types of records are maintained, what technology is used to facilitate the patient-provider relationship and how the identification of the patient/client and the provider is substantiated.
When considered together, these high-level concepts, specific themes and individual policies all provide a rich policy stream for the development of a customized framework that fits the needs and concerns of individual states as it relates to the establishment of a VCPR through virtual means.
Limitations and future research
The first main limitation of this research is that the policies analyzed are from the human healthcare sector. While there are many similarities, there may also be differences in how policy translates to the veterinary medical sector, including the specific interactions with the FDA and USDA regulations. This research also relied on state policies from 2018. The pandemic was a system disrupter to the field of telemedicine, and many policies were quickly put into place to expand access to telemedicine during the pandemic, which changed the landscape. The final impact of the pandemic to the policy space in human telemedicine is still uncertain, however, and so this research reports on established policy as opposed to the uncertain current conditions. Much of the pandemic change surrounded the reimbursement and financial aspects of telemedicine as opposed to changes directly impacting the establishment of the PPR through telemedicine. 50 Other changes currently under consideration include expanding geographic limitations to allow for more use of out-of-state providers and continued issues around handling the prescribing of controlled substances. 51 In addition, some emerging issues are yet to be dealt with that were negative outcomes of widespread use of telemedicine during the pandemic, including inscrutable actors prompting increased government scrutiny and the issuance of a fraud advisory from the Office of the Inspector General. 52 Continued monitoring of the trends in regulation will remain important and a continued topic for future research on this ever-evolving topic.
The second main limitation of this research is that the policies analyzed are all from the USA. International policy examination, particularly a comparative policy analysis on the establishment of a VCPR through virtual methods, would be a prime area for further research that could build off from this methodology.
Lastly, as a matter of scope, this research does not cover the varying definitions of the terms associated with telemedicine in the state-level policies. Doing so may require a different methodological approach than thematic qualitative analysis but could provide additional important information and is another avenue for future research.
Conclusions
The review yielded a large number of alternatives for policymakers to consider in the formulation of state policy surrounding the virtual VCPR. It is these alternatives that provide the direct evidence of a vibrant policy stream, one of the three essential streams conceptualized in the MSF policy theory. These policy alternatives provide a menu for ways that state Veterinary Medical Boards and legislative bodies could create policies that allow for the establishment of a VCPR through telemedicine that addresses their individual states’ unique needs and concerns. By choosing from this menu of policy considerations, policymakers could design policies that would help address disparities in access to veterinary care through the use of telemedicine to establish a VCPR and to treat and diagnose conditions in companion animals without necessitating a clinic visit. Enabling veterinarians to establish a VCPR through telemedicine ensures they could reach clients who live great distances from a veterinary clinic, who live in an area where demand outstrips supply or those who find the scheduling or logistics of a veterinary appointment a barrier to accessing care, collectively helping to tackle major concerns in the field of animal welfare and veterinary medicine.
Supplemental Material
Appendix A:
Policy alternatives for virtual PPR identified through content analysis of state PPR guidlines and policies.
Footnotes
Acknowledgements
The authors would like to acknowledge the contribution of (then) Southern Utah University student Shelby Wilkey for her efforts to validate the referenced legal documents in Appendix A and for her assistance reviewing the content analysis for consistency.
Supplementary material
The following file is available as supplementary material:
Appendix A: Policy alternatives for virtual PPR identified through content analysis of state PPR guidlines and policies.
Conflict of interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Ethical approval
This work did not involve the use of animals and therefore ethical approval was not specifically required for publication in JFMS.
Informed consent
This work did not involve the use of animals (including cadavers) and therefore informed consent was not required. No animals or people are identifiable within this publication, and therefore additional informed consent for publication was not required.
References
Supplementary Material
Please find the following supplemental material available below.
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