Veterinarians are busy, and not always with animals. Emails, voicemails, and our EMR worklist grows like a field of foxtail grass in the spring. However, while technology is often sold to make life or work easier, things can also go awry.

One of the big “disruptors” in contemporary veterinary medicine seems to be the looming specter of telehealth. This term does not really have any standardized definition, but in general, means “medicine at a distance.” The patient and the provider are connected in different locations through technology. In fact, at some level, if you have ever been emailed a photo of a cat’s rear end and asked, “Are these tapeworms?” you have already practiced telemedicine!

Most veterinarians spend multiple (often unpaid) hours each week responding to calls and emails instead of working with animals.¹ Newer forms of telemedicine (e.g. video appointments) have not been incorporated into most clinics, possibly because veterinarians want to spend less time in front of their computers and more time with their patients.

What is it about telemedicine that makes it so controversial? Take a base of spicy legislative battles over the last few years,² stir in the contentious issue of changing the rules to allow electronic veterinarian-client-patient relationships (eVCPRs), and sprinkle in some changing demographics and a dash venture capitalism, and you have now got a steamy bowl of “Hot and Spicy Veterinary Telemedicine Controversy Soup.” There are surprisingly few peer-reviewed articles on the subject. In fact, the majority of all the studies on telemedicine deal with how people feel about it.

The evidence of telemedicine

Telemedicine is difficult to define, and, as such, may be difficult to form specific clinical questions for investigation. How does it compare to being in the clinic? Are there benefits? Downsides? What is it like for the patients? For clients? Veterinarians? Even wearable devices are considered telemedicine, but currently, the field is largely undefined.³ 

In addition, questions such as, how well remote visits compare to in-clinic visits in terms of efficiency, patient care, and client satisfaction is inherently tricky to study. The variables cannot be controlled well (the entire environment is different), participants cannot be blinded, and it is not yet clear which clinical problems are most amenable to telemedicine. Studying telemedicine is a challenge.

Clinical evaluation

The earliest veterinary telemedicine studies even lacked a video component. In the mid-2000s, a couple of papers came out showing that using fax and email without an in-clinic examination was an effective way to treat certain canine behavioral disorders (owner-directed aggression⁴ and separation anxiety⁵). These are interesting, although perhaps not surprising, since behavioral therapy requires a lot of at-home management. Still, both studies concluded there was no advantage to seeing the dog in the clinic.

As for video-based veterinary telemedicine, a case report was published in 2018 about a military working dog that became acutely sick in Iraq.⁶ No veterinarian was available locally, so the team FaceTimed one in, and medical evacuation was recommended after coordinating some basic care and diagnostic testing remotely. However, a senior officer initially denied the medevac request based on a written description of the dog’s condition. The authors argue the dog would have gotten care sooner had this officer been able to visualize the animal. However, that conclusion is speculative.

The first clinical trial of video-based telemedicine also was published in 2018: a head-to-head trial of live video versus in-clinic rechecks for routine post-surgical care.⁷ It was a small study and not blinded, although groups were randomized. The study concluded clients were equally happy with the results of either method. While most study participants had no previous experience with video telemedicine, they indicated they much preferred telemedicine to in-person visits in the future, possibly because they saved an average of 50 minutes of travel time and felt their dogs were much more comfortable than they would have been in the clinic.

Evaluation of eVCPR

In 2019, an interesting paper looked at how telemedicine use impacts the veterinarian-client-patient relationships (VCPR). Users of a telemedicine app that offered recommendations from licensed veterinarians based on text and photos in the absence of a pre-existing VCPR were asked a few follow-up questions.⁸ Most respondents (about 75 percent) already had a primary care veterinarian, and a follow-up exam was recommended in most cases (about 60 percent). Of the people who did follow up, roughly 90 percent felt better informed after the telemedicine visit, and 82 percent reported that their primary care vet agreed with the assessment made by the telemedicine veterinarian. Financial constraints were the most common reason for the lack of follow-up.

A somewhat similar, but much larger study, was published in 2022, based on experience in the U.K. in 2020, when VCPR requirements for prescriptions were suspended due to COVID. In this study, a telemedicine company went through six months of records from video exams and looked at their rate for prescribing medications.⁸ From over 20,000 telemedicine exams, only 17 percent resulted in a prescription. Topical antibiotics and parasiticides were the most common. Only two percent received oral antibiotics. Of the exams that did not result in a prescription (n=approximately 17,000), roughly a third were advised to go to the clinic for a full exam, another third were advised to recheck through telemedicine, and the final third were advised to either monitor at home or that no medical concern was found.

These two studies about telemedicine services outside of the VCPR differ in their findings. However, they studied different services, using different methods, thus, it is hard to draw generalities from them. Regrettably, the U.K. paper’s authors were employed by the telemedicine company and did not state a conflict of interest.

The rest of the evidence

The remainder of the published evidence (about seven papers) has investigated people’s feelings. These studies tend to show that although telemedicine is not difficult to implement,¹⁰ many veterinarians do not use it and do  not particularly like it.^10,11,12 In contrast, clients seem to have a more favorable opinion of telemedicine,^13,14 especially those who have financial difficulties.¹⁵ Interestingly, as veterinarians gained experience with telemedicine, there was a shift toward a more favorable opinion of it.¹⁶

Conclusions

So far, telemedicine has not been shown to be neither the electronic savior of the veterinary profession, nor an apocalyptic nightmare. Most of the literature on veterinary telemedicine is about stakeholder perception. While it is too early to draw firm conclusions, clients seem more willing than veterinarians to give it a try.

Veterinary hesitancy to use telemedicine seems to dissipate with experience. No available evidence suggests anything harmful about veterinary telemedicine. In human medicine, where the literature about telemedicine is more robust, there is some nuance regarding antibiotics and direct-to-consumer services.¹⁷

Knowledge gaps

Currently, the knowledge gaps pertaining to veterinary telemedicine are considerable. It is not clear where it will be most beneficial, or most harmful, or even exactly what it is.  Although big investments are being made in veterinary telemedicine,¹⁸ the economic impact on the veterinary profession is uncertain. Telemedicine is a new tool. It appears to have potential, offering flexibility for vets and convenience for clients. It may make care more accessible. There will be tradeoffs, no doubt.

Independent research is needed to answer questions about telemedicine. Clinical audits of places where eVCPRs are now legal, such as the U.K. and Ontario, Canada, should be conducted. Places using telemedicine should be documenting and publishing their experiences, and studies should be designed to evaluate specific areas where telemedicine might be most helpful.

Greg Bishop, DVM, is a small animal veterinarian and part time Veterinary Technology Instructor in Portland, Ore. Dr. Bishop is a member of the Evidence-Based Veterinary Medical Association (EBVMA), with different members writing this column. While all articles are reviewed for content, the opinions and conclusions of the author(s) do not necessarily reflect the views of the EBVMA or Veterinary Practice News. For information about the association or to join, visit https://www.ebvma.org.

References

1. Kogan, L. R., Hellyer, P. W., Ruch-Gallie, R., Rishniw, M. & Schoenfeld-Tacher, R. (2016). Veterinarians’ Use and Perceptions of Information and Communication Technologies. Medical Research Archives, 4(2), Article 2. https://www.researchgate.net/publication/308632578_Veterinarians’_Use_and_Perceptions_of_Information_and_Communication_Technologies
2. Kelly, R. In watershed decision, UK relaxes telemedicine rules. VIN News Service. Jan 2023. https://news.vin.com/doc/?id=11329593
3. Mitek A, Jones D, Newell A, Vitale S. Wearable Devices in Veterinary Health Care. Veterinary Clinics: Small Animal Practice. 2022 Sep 1;52(5):1087-98. https://pubmed.ncbi.nlm.nih.gov/36150786
4. Dodman NH, Smith A, Holmes D. Comparison of the efficacy of remote consultations and personal consultations for the treatment of dogs which are aggressive towards their owners. Veterinary record. 2005 Feb;156(6):168-70. https://pubmed.ncbi.nlm.nih.gov/15736697/
5. Cottam N, Dodman NH, Moon-Fanelli AA, Patronek GJ. Comparison of remote versus in-person behavioral consultation for treatment of canine separation anxiety. Journal of Applied Animal Welfare Science. 2008 Jan 1;11(1):28-41. https://pubmed.ncbi.nlm.nih.gov/18444025/
6. Donham MB, Wickett CM. Novel use of FaceTime video calling in a deployed setting to assist with the care of a military working dog. Canadian Journal of Surgery. 2018 Dec;61(6 Suppl 1):S232. https://pubmed.ncbi.nlm.nih.gov/30418010/
7. Bishop GT, Evans BA, Kyle KL, Kogan LR. Owner satisfaction with use of videoconferencing for recheck examinations following routine surgical sterilization in dogs. Journal of the American Veterinary Medical Association. 2018 Nov 1;253(9):1151-7. https://pubmed.ncbi.nlm.nih.gov/30311532/
8. Roca RY, McCarthy RJ. Impact of telemedicine on the traditional veterinarian-client-patient relationship. Topics in companion animal medicine. 2019 Dec 1;37:100359. https://www.sciencedirect.com/science/article/abs/pii/S1938973619300960
9. Smith SM, Day T, Webster SG, Davies S, Hardcastle TP, Williams A. Clinical audit of POM-V/POM prescriptions by remote consultation via a veterinary video telemedicine smartphone application. Veterinary Evidence. 2022 Jun 8;7(2). https://veterinaryevidence.org/index.php/ve/article/view/553
10. Bishop GT, Rishniw M, Kogan LR. Small animal general practice veterinarians’ use and perceptions of synchronous video-based telemedicine in North America during the COVID-19 pandemic. Journal of the American Veterinary Medical Association. 2021 Jun 15;258(12):1372-1377. https://pubmed.ncbi.nlm.nih.gov/34061604/
11. Becker B, Tipold A, Ehlers J, Kleinsorgen C. Veterinarians’ perspective on telemedicine in Germany. Frontiers in Veterinary Science. 2023;10. https://www.frontiersin.org/articles/10.3389/fvets.2023.1062046
12. Magalhães-Sant’Ana M, Peleteiro MC, Stilwell G. Opinions of Portuguese veterinarians on telemedicine—A policy Delphi study. Frontiers in Veterinary Science. 2020 Aug 21;7:549. https://www.frontiersin.org/articles/10.3389/fvets.2020.00549/full
13. Hawk C. Veterinary telemedicine perception and utilization intention. Chancellor’s Honors Program thesis, University of Tennessee, Knoxville, Tenn, 2018.
14. Caney SM, Robinson NJ, Gunn‐Moore DA, Dean RS. Veterinary surgeons’, veterinary nurses’ and owners’ experiences of feline telemedicine consultations during the 2020 COVID‐19 pandemic. Veterinary Record. 2022 Sep;191(5):no-. https://pubmed.ncbi.nlm.nih.gov/35661164/
15. Lundahl L, Powell L, Reinhard CL, Healey E, Watson B. A Pilot Study Examining the Experience of Veterinary Telehealth in an Underserved Population Through a University Program Integrating Veterinary Students. Frontiers in Veterinary Science. 2022;9. https://www.frontiersin.org/articles/10.3389/fvets.2022.871928/full
16. Wells J, Watson K, Sharma M, Davis RE, Gruszynski K, Robertson SR, Nahar VK. Application of the multi‐theory model to explain veterinarians’ intentions to use telehealth/telemedicine. Veterinary Record. 2023 Feb;192(4):no- https://pubmed.ncbi.nlm.nih.gov/36342030/
17. Bishop, G. Direct to Consumer Telemedicine’s Flaws. Science Based Medicine. June 2019. https://sciencebasedmedicine.org/direct-to-consumer-telemedicines-flaws
18. Fiala, J. Calls to expand veterinary telemedicine clash with regulations. VIN News Service. May 2021. https://news.vin.com/doc/?id=10237164