-Veterinarian-Client-Patient Relationship (VCPR) exists when:
-Both the Veterinarian and Client agree for the Veterinarian to assume responsibility for making medical judgments regarding the health of the Animal(s); and
-The Veterinarian has sufficient knowledge of the Animal(s) to initiate at least a general or preliminary diagnosis of the medical condition of the Animal(s); and
-The Veterinarian has provided the client with information for obtaining timely follow up care.
-The AAVSB recommends that each jurisdiction promulgate appropriate regulations clarifying who may be included within the scope of a single VCPR such as a Veterinarian or another Veterinarian within the same practice group with access to medical records. The AAVSB recommends that each jurisdiction promulgate appropriate regulations defining how to establish sufficient knowledge of the Animal(s), including the following:
-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; or
-Through medically appropriate and timely visits to the premises at which the Animal or group of Animals are kept.
-The AAVSB recommends that each Jurisdiction promulgate appropriate regulations for the Veterinarian to provide instructions to the Client for obtaining follow up care that may include directing the Client to another Veterinarian or emergency clinic. It is essential for the VCPR to be easily established in order to require the Veterinarian to assume accountability for the Veterinary Medical Services rendered. Furthermore, as standards of practice and codes of conduct change over time, it is easier to promulgate new rules incorporating such changes rather than adopting legislative modifications.
American Veterinary Medical Association (AVMA)
-Having a VCPR in place is critical whenever practicing veterinary medicine, whether practicing in person or remotely using telemedicine. The AVMA Model Veterinary Practice Act, which many governmental bodies use as a guide when establishing or revising laws governing veterinary practice, includes the following definition of the VCPR: The veterinarian-client-patient relationship is the basis for veterinary care. To establish such a relationship the following conditions must be satisfied:
-The licensed veterinarian has assumed the responsibility for making medical judgments regarding the health of the patient(s) and the need for medical therapy and has instructed the client on a course of therapy appropriate to the circumstance.
-There is sufficient knowledge of the patient(s) by the veterinarian to initiate at least a general or preliminary diagnosis of the medical condition(s) of the patient(s).
-The client has agreed to follow the licensed veterinarian’s recommendations.
-The licensed veterinarian is readily available for follow up evaluation or has arranged for:
Emergency or urgent care coverage, or
Continuing care and treatment has been designated by the veterinarian with the prior relationship to a licensed veterinarian who has access to the patient’s medical records and/or who can provide reasonable and appropriate medical care.
-The veterinarian provides oversight of treatment.
-Such a relationship can exist only when the veterinarian has performed a timely physical examination of the patient(s) or is personally acquainted with the keeping and care of the patient(s) by virtue of medically appropriate and timely visits to the operation where the patient(s) is(are) kept, or both.
-Patient records are maintained. Both the licensed veterinarian and the client have the right to establish or decline a veterinarian-client-patient relationship within the guidelines set forth in the AVMA Principles of Veterinary Medical Ethics. A licensed veterinarian who in good faith engages in the practice of veterinary medicine by rendering or attempting to render emergency or urgent care to a patient when a client cannot be identified, and a veterinarian-client-patient relationship is not established, should not be subject to penalty based solely on the veterinarian’s inability to establish a veterinarian-client-patient relationship.
-Many states have adopted this definition of the VCPR, or a very similar one, as a component of their state veterinary practice act or regulations. In addition, federal law requires a veterinarian to establish a VCPR before undertaking any extra-label drug use in animals, issuing a Veterinary Feed Directive, or the creation and use of certain types of biologics. It is also important for veterinarians to understand that they must comply with the federal law requiring a VCPR under these circumstances, regardless of how a state may ultimately define a VCPR in state law or regulation.
-Given current technological capabilities, available research, and the existing state and federal regulatory landscape, the AVMA believes veterinary telemedicine should only be conducted within an existing VCPR. An exception may be made for advice given in an emergency until a patient can be seen by a veterinarian. Ultimately, how a state defines the VCPR, the congruence of that state VCPR with federal requirements, and whether or not a VCPR exists in a given situation based on those definitions, determine what services can be offered.
-Within an established VCPR: A variety of telehealth and telemedicine service models are available to veterinarians and veterinary practices. Client-facing telemedicine services may include use of tools that allow the veterinarian to remotely and securely gather essential patient health information from the animal owner or another caretaker; access the patient’s medical records; and conduct a virtual evaluation of the patient through real-time video or transmitted photographs or other data.
-Without an established VCPR: The veterinarian may provide non-patient-specific advice, but must stay clear of diagnosing, prognosis of, or treating patients. Two exceptions may apply: (1) if state law allows a VCPR to be established electronically, the veterinarian has met the requirements for doing so, and activities that would invoke a requirement for adherence to the federal VCPR are not conducted or (2) advice given in an emergency until a patient can be seen by a veterinarian. Non-client electronic communications that include the provision of non-patient-specific advice and general educational content are usually acceptable.
Wisconsin Veterinary Medical Association (WVMA)
WVMA formed a Telehealth Task Force and submitted suggested guidelines to the Board on December 19, 2019. Regarding the VCPR, the WVMA suggested guidelines state that:
-VCPR Required: Veterinary services may only be provided using telehealth technologies where a VCPR is established. If an existing VCPR relationship is present, then telehealth technologies may be used as long as the VCPR is maintained in accordance with Wis. Stat. s. 89.02 (8) and the requirements in this Section. If an existing VCPR relationship is not present, then a veterinarian must take appropriate steps to establish a VCPR consistent with Wis. Stat. s. 89.02 (8) and the requirements in this Section. -Establishing an Initial VCPR for Telehealth: For purposes of establishing an initial VCPR prior to engaging in the practice of veterinary medicine using telehealth technologies, the veterinarian must meet the requirements of Wis. Stat. s. 89.02 (8) and: -For livestock, (food and fiber animals), the veterinarian must have either conducted an in-person physical examination of the patient or must have visited the premises on which the patient is kept at least once in the immediate six (6) months prior to engaging in any telehealth treatment or services.
-For companion animals and equine animals, the veterinarian must have conducted an in-person physical examination of the patient at least once in the immediate six (6) months prior to engaging in any telehealth treatment or services.
-Maintaining a VCPR for Telehealth: Once a VCPR is established, for purposes of maintaining that VCPR and engaging in the ongoing practice of veterinary medicine using telehealth technologies, the veterinarian must meet the requirements of Wis. Stat. s. 89.02 (8) and: -For livestock (food and fiber animals), the veterinarian must either conduct an in-person physical examination of the patient or must visit the premises on which the patient is kept at least once every six (6) months.
-For companion animals and equine animals, the veterinarian must conduct an in-person physical examination of the patient at least once every twelve (12) months.
Summary of Factual Data and Analytical Methodologies
The proposed rule makes the rules clearer and easier to use. Restructuring the chapters makes the rules easier to read and reference quickly. Adding a chapter for relevant complaint procedures makes these procedures clearer and more accessible to credential holders and members of the public. The fee amounts remain the same, but are stated in the proposed rule to make them readily accessible. Minor language changes relating to procedures and processes, technical changes and updates, delegation of veterinary medical acts, references to statutory requirements, and terminology make the proposed rule more consistent and easier to understand. The proposed rule includes language changes to respond to public interest in the use of telehealth technologies in veterinary medicine. The proposed rule could reduce the burden to veterinarians, veterinary technicians, and consumers of veterinary services, as the proposed rule is easier to read and understand quickly.
The Board held a preliminary public hearing on SS 125-19 on February 17, 2020, with a written comment period through February 24, 2020. The Board received three comments. All three comments requested that the statement of scope be expanded to address the use of telehealth technologies in the practice of veterinary medicine. One comment also requested that the statement of scope address the circumstances under which a veterinarian may dispense a drug for a patient of another veterinarian. This statement of scope for this rule proposal (SS 064-20) includes both of these topics. The Board held a preliminary hearing on SS 064-20 on August 19, 2020, with a written comment period through August 26, 2020. The Board received three comments. One comment was for information. Two comments expressed support of the scope, both expressed support of including telehealth in the scope, and one also expressed support of including addressing the circumstances under which a veterinarian may dispense a drug for a patient of another veterinarian in the scope. The Board convened a Telehealth Advisory Committee (Committee) to advise the Board in relation to the veterinary telehealth. The Committee was comprised of 13 representatives: 10 veterinarians and 3 certified veterinary technicians. Of the veterinarians, 1 works in large and small animal practice, 3 work in large animal practice, 1 works in equine and small animal practice, and 5 work in small animal practice. The veterinarians included representatives from the Wisconsin Veterinary Medical Association, Sexing Technologies, and the Dairy Business Association. The Department submitted a notice to JCRAR with the names of the Committee members on February 9, 2021.
The Committee met on March 4, March 25, and April 8, 2021, to discuss potential veterinary telehealth options. The following is a summary of proposals that the Telehealth Advisory Committee discussed, as well as the responses of the Committee members:
A. Definitions
Attending Veterinarian: means the veterinarian who holds the Veterinarian-Client-Patient Relationship and is responsible for the medical care and treatment of the animal.
Consulting Veterinarian: means the veterinarian who gives advice or assistance, whether in-person or by any method of communication, to the attending veterinarian, for the benefit of an animal patient.
Consultant: means a person whose subject matter expertise, in the opinion of the attending veterinarian, will benefit an animal patient, and who gives the attending veterinarian advice or assistance, whether in-person or by any method of communication.
Consultation: means the advice or assistance given by a consulting veterinarian or other consultant to the attending veterinarian where the responsibility for patient treatment, prescriptions, and welfare remain with the attending veterinarian.
A consulting veterinarian or other consultant may not do any of the following:
-Visit the patient or client or communicate directly with the client without the knowledge of the attending veterinarian.
-Take charge of a case or problem without the consent of the attending veterinarian and the client.
Informed Consent: means the veterinarian has informed the client or the client’s authorized representative, in a manner understood by the client or representative, of the diagnostic and treatment options, risk assessment, and prognosis, and the client has consented to the recommended treatment.
General Advice: means any advice provided by a veterinarian or certified veterinary technician, via any method of communication within or outside of an established VCPR, which is given in general terms and is not specific to an individual animal or group of animals, diagnosis, or treatment.
Telehealth: is the collection of technology tools used to remotely deliver virtual veterinary medical, health, and education services, allowing a veterinarian to deliver enhance care and education.
Telemedicine: is the remote delivery of veterinary healthcare services, such as health assessments or consultations, over the telecommunications infrastructure, allowing a veterinarian to evaluate, diagnose and treat patients without the need for an in-person visit.
Tele-triage: means emergency animal care, including animal poison control services, for immediate, potentially life-threatening animal health situations, including poison exposure mitigation, animal CPR instructions, and other critical lifesaving treatment or advice that may be performed within or outside of a VCPR.
Members asked for clarification about the consulting veterinarian, consultant, and consultation definitions but no member expressed opposition to these definitions. No member expressed concerns about any of the other definitions.
B. Location of Practice
