— An in-person visit by the veterinarian serves to protect patients and clients by assuring that animals have been appropriately evaluated
— Eliminating the requirement for an in-person evaluation can present substantial risks, including suboptimal diagnosis and treatment, misinterpretation of animals’ clinical signs by owners/caretakers, overprescribing, animal disease risks associated with transport of livestock for which an in-person evaluation was not conducted prior to issuing a Certificate of Veterinary Inspection, public health risks associated with delayed or missed diagnosis of zoonotic disease, and claims of malpractice
— Medical care delivered to patients must continue to be of high quality, and technological tools used to support electronic veterinary visits are still in their early stages of development and as of yet do not provide the same amount of information as an in-person encounter
— Addressing care disparities is not as straightforward as allowing the VCPR to be established electronically, and barriers to the receipt of veterinary care include socioeconomic, geographic, knowledge and demographic/culture based
— Through research the lack of physical proximity and the requirement for an in-person visit do not appear to be the primary barriers to accessing veterinary care
— Telemedicine itself is not free of access barriers, right now only 10% of veterinary clients are using it (8% telephone only), and surveys on the human health side revealed technological barriers, such as lack of access to technology, insufficiency of broadband internet, and digital literacy
— Telemedicine is not a clear solution to the problem of cost, results are mixed as to whether telehealth reduces downstream utilization of health care, and study on the human side resulted no reduction in overall spending for patients
— The VCPR language is consistent with federal law, the Food and Drug Administration (FDA) does not allow a VCPR to be established through electronic means and does allow it to be maintained through electronic means, and Wisconsin veterinarians are required under federal law to follow federal VCPR requirement in each applicable circumstance, such as any extralabel drug use or when authorizing a veterinary feed directive
— The proposal is consistent with American Veterinary Medical Association (AVMA) and FDA policies, and is supported by the Wisconsin Veterinary Medical Association (WVMA)
— The practice of veterinary medicine should be as broad and expansive as is allowed under Wisconsin law and as is protective of animal health, and the proposed rule meets both of those criteria
Based on public comments, the Board decided to maintain the same VCPR definition in this final draft as was in the preliminary hearing draft. However, the Board did make changes to make related provisions clearer. The Board moved provisions regarding emergency care, general advice, and consulting, and from the definitions into the body of the rule and added language to the telemedicine section of the rule to make it clearer that those specified items do not require the establishment of a VCPR.
ART Procedures
The hearing draft included creating a new category of delegation to allow a veterinarian to delegate specific acts to a CVT when the veterinarian is available via telehealth technologies within five minutes, rather than requiring that the veterinarian be personally present on the premises as current rule requires. This new category of delegation did not include ART procedures, which are performing amniocentesis, embryo collection and transfer, follicular aspiration, and transvaginal oocyte collection and recovery on livestock.
The comment expressing opposition to the omission of ART in delegation changes expressed that:
— CVTs safely and effectively perform ART under the direct supervision of a veterinarian hundreds of times each week
— The omission of ART will prevent the incorporation of technology into future operations, have a financial effect on farms, and cause delays to procedures due to the lack of large animal veterinarians
— Human medicine has broadly applied telehealth to existing procedures by modifying the definition of direct supervision generally and not based on individual services
Comments expressing support of the omission of ART in delegation changes expressed that:
— ART procedures are very tactile in nature, it is not uncommon to find reproductive abnormalities and pathology that require diagnosis by palpation, palpation is critical for the procedures, and specific tactile manipulations that cannot be visualized in their entirety from the exterior of the animal
— ART procedures pose a significant risk for complications that cannot be managed in a timely fashion unless the veterinarian is present on the premises
— Severe complications can have life-threatening and permanent consequences to a previously healthy animal, and the veterinarian needs to be present on the premises to mitigate the risk of permanent damage
— The required level of care cannot be accomplished via telehealth
— The risk of complications from ART procedures is significant, and the convenience of using telehealth does not outweigh the risk to the animal
— Relaxing these rules could hurt the perception of the Wisconsin dairy industry by giving the impression that Wisconsin quality is not up to standards, while delegating ART procedures could save some money up front, the long-term implications outweigh any potential short-term gain, and we need to continue to set the bar high when it comes to caring for animals and educating the public
— There may be business or financial reasons that could make the delegation of ART procedures using telehealth appealing to practitioners, clients, or businesses, but the argument is inappropriate in this context, the role of the VEB is to define the safe provision of veterinary care for animals and to protect animal health and not to make the practice of veterinary medicine fast or economical, and cited North Carolina State Board of Dental Examiners, Petitioner v. Federal Trade Commission, 574 U.S. 494 (2015) — ART procedures should not be delegated to a CVT at all, and that performing them with telehealth would be a step in the wrong direction for the industry
— A veterinarian must be present on the premises for procedures delegated to a CVT in general, and being available within five minutes when the aorta has been lacerated during a cystocentesis is not acceptable
— The procedures identified in the draft can be safely supervised by a veterinarian using telehealth, but would oppose expansion of the proposed list
Based on public comments, the Board decided not to add ART procedures to the delegation changes. The delegation changes in this proposed final draft are the same as those in the hearing draft.
Other Comments
Six commenters expressed support of language regarding veterinarians filling prescriptions for other veterinarians. No commenters expressed opposition to this aspect of the rule proposal.
One commenter expressed concerns about existing rabies provisions, including that cats also have a risk of rabies, it is restrictive to require a veterinarian to be physically present for a CVT to give a rabies vaccine, and a veterinary assistant should be able to provide the rabies vaccine if the veterinarian is present. This rule draft references Wis. Stat. s. 95.21 (2) (a), which requires that rabies vaccinations required for dogs be administered “by a veterinarian or, if a veterinarian is physically present at the location the vaccine is administered, by a veterinary technician.” This requirement is statutory, and therefore the Board is unable to evaluate a change in rule. Rules Clearinghouse
The Board modified the rule draft to address all Clearinghouse comments. Most significantly, per Clearinghouse comments, the Board evaluated the definitions sections for clarity and consistency. The Board identified several terms that are used only once or twice in rule, or in some cases not used at all in the body of the rule, and moved the content from the definitions into the body of the rule, including:
— In VE 1:
— Complementary, alternative, and integrative therapies
— Consulting veterinarian
— Consultant
— Consultation
— Deception
— Faculty license
— Fraud
— General Advice
— Gross negligence
— Post graduate training permit
— Preceptor
— Standard of care
— Surgery
— Telemedicine
— Tele-triage
— Temporary veterinary permit
— Veterinary consulting permit
— In VE 2:
— Advertising
— Board approved technical school or college
— Gross negligence
— Surgery
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 Iowa would allow telehealth to be used if a VCPR was previously established.
Michigan
