-Clarifies that the VCPR, once established, extends to other veterinarians within the practice, or relief veterinarians within the practice, that have access to, and have reviewed, the medical history and records of the animal.
-Clarifies that records must be kept, regardless of the encounter type.
-Clarifies, in accordance with Wis. Stat. s. 89.02 (8) (c), that an animal owner must be able to easily seek follow-up care or information from the veterinarian who conducts an encounter while using telehealth technologies. -Expands the delegation of medical services to allow a veterinarian to delegate the following items to a certified veterinary technician (CVT) if the veterinarian is available to communicate via telehealth technologies within five minutes. Under current rules, these items may only be delegated to a CVT if the veterinarian is personally present on the premises.
-Performing diagnostic radiographic awake contrast studies not requiring general anesthesia.
-Sample collection via a cystocentesis procedure.
-Placement of intravenous catheters.
-Suturing of tubes and catheters.
-Fine needle aspirate of a mass.
Summary of, and Comparison with, Existing or Proposed Federal Statutes and Regulations
Pursuant to 9 CFR 160 to 162, a veterinarian must be specifically authorized by the United States Department of Agriculture – Animal and Plant Health Inspection Service to perform animal disease eradication and control functions under federal animal health laws. Licensure requirements to practice veterinary medicine are established by each state and should not be affected by federal requirements.
Comparison with Rules in Adjacent States
The structural changes and minor language changes in the proposed rule are unique to Wisconsin rules and make the rules clearer and easier to use. Veterinary telehealth regulations in Wisconsin, Illinois, Iowa, Michigan, and Minnesota are compared below. Regulatory recommendations by the American Association of Veterinary State Boards, the American Veterinary Medical Association, and the Wisconsin Veterinary Medical Association are also included for comparison.
Wisconsin
Under both the existing rule and the proposed rule, a veterinarian must be licensed in Wisconsin in order to practice veterinary medicine and have an established VCPR with the client. A VCPR must be established via an in-person physical exam, or timely medically appropriate visits to the premises on which the patient is kept. It may not be established by telehealth technologies.
The proposed rule clarifies items related to telehealth and also expands the delegation of medical services to allow a veterinarian to delegate the specific items to a CVT if the veterinarian is available to communicate via telehealth technologies within five minutes.
Illinois
In Illinois, a valid VCPR cannot be established solely by telephonic or electronic communications. No further information was provided regarding whether Illinois would allow telehealth to be used if a VCPR was previously established.
Iowa
In Iowa, a valid VCPR cannot be established solely by telephonic or electronic communications. No further information was provided regarding whether Illinois would allow telehealth to be used if a VCPR was previously established.
Michigan
Michigan recently promulgated a new rule related to the practice of veterinary medicine using telehealth technologies, which became effective April 15, 2021. The Michigan rules now require:
-Disclosure of the identity and contact information of the veterinarian providing telehealth services. Licensing information shall be provided upon request.
-Ensure that the technology method and equipment used to provide telehealth services complies with all current privacy-protection laws.
-Employ sound professional judgement to determine whether using telehealth is an appropriate method for delivering medical advice or treatment to the animal patient.
-Have sufficient knowledge of the animal patient to render telehealth services demonstrating by satisfying one of the following:
-Have recently examined the animal patient in-person or have obtained current knowledge of the animal patient through the use of instrumentation and diagnostic equipment through which images and medical records may be transmitted electronically.
-Have conducted medically appropriate and timely visits to the premises where the group of animal patients is kept.
-Act within the scope of practice.
-Exercise the same standard of care applicable to traditional, in-person veterinary care service.
-Be readily available to the animal patient for follow-up veterinary services or ensure there is another suitable provider available for follow-up care.
-Consent for medical advice and treatment shall be obtained before providing a telehealth service.
-Evidence of consent for medical advice and treatment must be maintained in the animal patient’s medical record.
-A veterinarian providing a telehealth service may prescribe a drug if the veterinarian is a prescriber acting within the scope of practice and in compliance.
Minnesota
Minnesota only allows patient-specific telemedicine within a VCPR. A VCPR cannot be established without an in-person examination. A veterinarian licensed in another state can serve as a consultant to the Minnesota veterinarian that holds the VCPR for that patient. The same standards of care apply to services rendered via telemedicine as to in-person visits.
American Association of Veterinary State Boards (AAVSB)
-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.
