Topic: Telemedicine

A motion to conduct a trial of remote prescribing without performing a physical examination (ie. via telemedicine), thereby redefining what it means for an animal to be "under the care" of a veterinary surgeon, was put before RCVS Council last week. I was there to hear the arguments …

The motion was introduced by Kate Richards MRCVS, Chair of the RCVS Standards committee, who explained that it'd been driven by three things, namely: the Vet Futures Initiative, the RCVS Strategic Plan signed off by Council in 2017 and the RCVS telemedicine consultation that took place earlier this year. 

The latter of these showed that 69% of vets opposed the idea of prescribing without a physical exam, which rather beggars the question why it's being discussed at all. However, as Kate explained, when asked whether certain types of products could be remotely prescribed, the answer was more equivocal: 52% of vets said "yes".

Kate also explained that over the last two years, there had been a number of good quality discussions at Standards Committee and Council, but that decision-making had been "hampered by a paucity of evidence on the opportunities, risks and benefits of telemedicine to animals and the public".

The full wording of motion was: "Council is invited to consider the recommendation of Standards Committee to conduct a limited and time-bound trial to assess the benefits and risks of allowing the remote prescription of POM-V (excluding opiates, sedatives and potentially also critically important antibiotics) where there has been no physical examination."

However, in order for the trial to take place, it would be necessary to make a temporary change to the Supporting Guidance of the Code of Professional Conduct concerning the definition of "Under his care" (Ed's note. C'mon RCVS, isn’t that a bit anachronistic? Both your CEO and your President are now "her". "Under Care" would do it.), adding the words in italics to para 4.1: "A veterinary surgeon cannot usually have an animal under his or her care if there has been no physical examination; consequently a veterinary surgeon should not treat an animal or prescribe POM-V medicines via the Internet alone, other than in circumstance where a telemedicine service is a part of the RCVS telemedicine trial".

In the best interests of animal welfare

Amanda Boag (MRCVS, Vets Now, RCVS President) then reminded everyone that: "RCVS Council needs to act in the best interest of animal welfare and the public, and whilst sustainability of veterinary services is important, it isn't our role to promote anything novel or to protect traditional models."

Really? Strikes me that the sustainability of veterinary services isn’t just "important", it's an essential part of ensuring good animal welfare. Surely, therefore, it most certainly is the role of Council to protect traditional business models or, for that matter, to promote novel methods if (and I stress "if") doing so protects or enhances animal welfare.

Don’t confuse telemedicine with remote prescribing

Jo Dyer (MRCVS, small animal locum, Devon) opened by pointing out that this is not about telemedicine per se. Telemedicine has been going on since the invention of the telephone in the late 1800s, supplemented over the last 20 years or so by photography and video sent over the internet. Telemedicine does not, in and of itself, require a change in regulation.

What this is about, she explained, is the much narrower act of remote prescribing without physically examining the animal, something which would require the profession to redefine "under his care", which in turn "makes up the foundation of what forms the relationship with the owner and the animal in order that we can safeguard the use of medicines, safeguard the animals under our care and safeguard our clients."

No evidence remote prescribing increases access to veterinary services

Jo argued that the only reason Council should be considering the prescription of medicines without a physical examination would be if it were in the interests of animal welfare. And yet, she said, there is no evidence to support this idea.

Some have suggested that it could increase access to veterinary care. However, Jo said she had been unable to find any evidence to support this idea either. Not just in the veterinary profession, but in the medical profession in the Western and the developing world.

Jo also noted that the trial proposal was to use commercial organisations which have a financial interest in a positive outcome, which would render the results biased and unreliable.

She then raised the issue of antimicrobial resistance, highlighting the use of cytology and culture sensitivity to make sure the right antibiotics are used. Remote prescribing, she said, would be a retrograde step, even if only non-critical antibiotics could be prescribed remotely.

Spawning a new class of limited service provider

Next she highlighted the impact of the trial on 24-7 cover. Under the proposal, "Those under a trial would be required to actively support clients in identifying a veterinary practice that could physically see their animal in both routine and emergency situations."

As Jo pointed out, this would by definition mean that any veterinary surgeon, not just those practising telemedicine, could set themselves up as a limited service provider and refer all cases they didn’t want to see (whether OOH or not) to a local practice. This, she argued, should only happen after a proper debate, and not be just the unintended side-effect of regulation change to allow remote prescribing.

In fact, there is evidence that this is exactly what is happening in human medicine. Only the following evening, the BBC aired Diagnosis on Demand: The Computer Will See You Now, a documentary about telemedicine and artificial intelligence in human medicine. It should be required watching for all RCVS Councillors.

The programme makers visited GP at Hand, a telemedicine business based on the Lillie Road in Fulham, London that has been formed in partnership with Babylon. Coincidentally just up the road from where I used to live, it's a pretty nondescript sort of a place, but now home to the fastest-growing GP surgery in the UK. Since late 2017, it has amassed a staggering 30,000 clients from across London, virtually none of whom will ever visit the place. The problem is that GP at Hand has skimmed away fee-paying clients from across the capital that had in effect been helping to subsidise local care elsewhere.

More information needed for such an important decision

Jo concluded by saying that a decision of this magnitude, particularly when it seems to go against the wishes of the majority of the profession, demands checks to ensure no conflicts of interest, legal advice and wider consultation with organisations such as the VMD, Defra, the BVA and its subdivisions and the VDS. Therefore, she would propose a new motion to delay the decision until more information is made available.

Chris Barker (MRCVS, small animal practice, Cumbria) was up next. He felt that the RCVS consultation was very effective and gave a good picture of what veterinary surgeons see as the risks inherent in remote prescribing. However, he felt that the analysis has been marshalled to suit an agenda and minimises the concerns of general practitioners.

Fragmentation and multiple consultants leading to a loss of responsibility

The trial, he said, will lead to fragmentation of veterinary provision and send the message to the public that it is quite OK to go to more than one vet for advice and treatment, and that will lead to confusion and the loss of individual responsibility for the veterinary care of an animal that exists today.

An inspection with no history: not a proper examination.

Chris argued that the act of prescribing demands a physical examination, but that a video consultation could only ever be an inspection. He also highlighted the importance of patient histories and argued that the immediacy of telemedicine simply doesn’t allow a practitioner to get the patient history from another vet.

Chris also argued that the profession is not structured to allow for clients to consult multiple veterinary service providers simultaneously: once a client leaves his practice, he has a duty under GDPR to expunge much of their records, and he for one didn’t much care for the idea of re-registering a client at 2:00am.

Some of the issues Chris raised may of course be solved by technology in the foreseeable future. GDPR already calls for data portability, presumably it will not be long before owners expect the same data portability for their animals' clinical histories.

Who wants clients who only ever call when telemedicine has failed?

Still, his overall point was an important one: whether or not there will be vets out there who are happy to pick up and see failed telemedicine cases at 3:00am in the morning from people who are not clients of their practice and who don’t otherwise contribute financially to the business.

90% of vets say remote prescription is high risk or inappropriate

Lastly, Chris drew attention to a question in the RCVS consultation which asked respondents what risk they thought there would be in a remote consultation when the consulting vet did not know the owner, did not know the animal and does not know the situation in which the animal is kept: "90% of responding veterinary professionals either chose it as high risk or simply not appropriate at all. I know of no better body of people than practitioners in Britain to understand the welfare and the risk to the welfare of animals."

The risk of misdiagnosis

Martin Peaty (MRCVS, equine practitioner, Wiltshire) spoke next, highlighting the risk he saw to animal welfare from misdiagnosis. He drew attention to concerns raised by the Quality Care Commission in human medicine, in particular that there is no access to the long term medical records of the patient, and the risk of misdiagnosis: "And that’s in human patients who can fluently articulate their symptoms", he said, "I think we should be much more cautious in exercising care before allowing remote diagnosis and prescription."

Martin's point seemed especially apposite in the light of an article which appeared in The Times two days later: 'NHS app 'no match for trip to the GP', in which Professor Helen Stokes-Lampard, chairwoman of the Royal College of GPs expressed concerns about online consultation systems, particularly for vulnerable groups, such as children.  

Remote prescribing demands that vets sacrifice principles

Martin also outlined the three principles which underpin current practice: physically examining the animal, considering its history and providing 24 hour care, the latter in part in case of a reaction to a prescribed medicine.

"These proposals ask us to sacrifice these principles for telemedicine businesses whilst for good reason they remain in place for other veterinary practices. I think that is hypocritical. I think it is wrong."

Not enough follow-up

Sue Paterson (MRCVS, a referral specialist who offers a dermatology telemedicine service to the profession and the public, Merseyside) jumped in next. She was unashamedly enthusiastic about the benefits of telemedicine, in particular how it allows practitioners to engage with the public and make veterinary advice more accessible, not to mention because: "I am sick to death of people coming into consults when they have been on Facebook or they’ve been on to talk to Dr Google."

However, despite her enthusiasm and despite finding that users of her service do not want antibiotics, just advice, help and reassurance from people they trust, Sue was still against the idea of remote prescription: "I don’t want to prescribe because I can't follow those cases up, because I can’t maintain the level of client care that I think is really important, so for me, I would not want to see this change to the code."

We won’t know what we missed, or the consequences of what we missed

Caroline Allen (MRCVS, charity veterinary director, London) said the biggest issue for her is that without a physical examination, she won’t ever know what she missed (the heart murmur, the goitre, the subtle muscle wastage), or for that matter, the animal welfare consequences of what she missed.

As others had done, Caroline highlighted the importance of getting a weight every time and how difficult it is for clients to measure accurately.

Lastly, she made the thought-provoking point that allowing the remote prescription of drugs without a physical examination would risk legitimising Dr Google in the eyes of the public. After all, if no veterinary physical exam is needed, surely owners can just look it up on the internet for themselves?

In defence of the RCVS

At this point in the discussion, RCVS CEO Lizzie Lockett addressed the suggestion that the whole process of investigating and voting on telemedicine was being driven by hidden agendas, something she absolutely and eloquently rejected. She explained that sure, some parties had been more engaged in the whole process than others, but emphatically denied there had been any influence. Council, she said, had asked Standards to investigate and develop a proposal, which it had done diligently. Now it is down to Council to decide whether the proposal stands or falls; the College exists to implement the decision.

RCVS Vice President, Professor Stephen May went further, saying that many present would be aware that he'd been a vocal critic of the way that a number of other regulators in modern society push things out to court for decisions, rather than taking decisions collectively and then sticking by them. "I’m really proud that we are discussing this and I’m really pleased that this is up to us how we move things forward in the interest of animal health and welfare and supporting the public in that."

The need for a more nuanced, less polarised debate

However, he said he was worried about the way the debate was being polarised into a yes or no when he felt the profession should thinking about how it should adapt to the changing circumstances, thinking about cases which are amenable to a distant relationship and in what context that is appropriate, taking into account the risks. 

Remote prescription is already happening, illegally

Melissa Donald (MRCVS, small animal practice, Scotland) questioned whether telemedicine and remote prescription is what the public wants. She said that remote prescription is already happening, illegally from abroad, and that the College needs to have a more robust response than "it’s not our problem". She therefore recommended a further period of consultation, particularly with public focus groups, and internet research to see how much remote prescription is already happening. 

Vets are professionals

Tim Walker (Lay) said he was struck by the need to assemble better evidence. He felt there needs to be more thought given to the transference of responsibility for cases between a telemedicine provider and a traditional practitioner. Tim also felt that the definition of "under his care" will almost certainly need to be rethought in the not-too-distant future, because the idea of a patient being under the care of just one practitioner is starting to look dated; in the human sphere, patients are looked after by teams of people.

Tim highlighted the approach he said is taken by the GMC, which obliges doctors to be able to demonstrate that they have done sufficient due diligence to prescribe, not that they can simply do so automatically under certain circumstances. That, he said, is what professionalism should be about.

Taking the lead

Mark Castle (Lay) said he thought that the public was looking for a choice, that technology is constantly throwing up new opportunities, and he expected that in the future more and more will be able to be done remotely, so he wanted the RCVS to take the lead in this area.

Lucy Goodwin (MRCVS, BSAVA Head of Education) was positive about the idea of conducting a time-limited, controlled trial: "We say we want evidence, so let’s go and collect it", but had a number of reservations. Not least of these was the fact that the participants in any trial would be on best behaviour, so it may not be able to extrapolate the numbers to the profession at large. Beyond that, she was also concerned that the scope of the trial should be better defined, in particular which categories of drug could be included within it. 

Vets don't want a trial of telemedicine

Mandisa Greene said that whilst she is positive about telemedicine as it had been described, and not averse to a trial, she didn’t see the point in a trial when the people who actually do the prescribing don’t want it. 

A voice in favour

Chris Tufnell (Past President) began by declaring that he consults to the Affordable Pet Care Company which is shortly to launch a telemedicine service, although he said the service would be unaffected by the decision being taken by Council. He was also at pains to stress that he hadn’t had any other fingers in this particular pie, in particular that he hadn’t been to any of the Standards Committee meetings or presented to them, or been involved in formulating the proposed trial.

Whether you agree or disagree with Chris, it was at least good to hear someone speaking in favour of the motion. Chris opened by arguing that veterinary surgeons are good at making decisions based on imperfect information: "Client histories, as we know, are of variable quality. We make decisions daily on whether we are happy with the information we get from the practice lab or whether we need to send the sample to a reference lab. When I started in practice, practice lab machines were routinely described as random number generators."

"We make decisions on a daily basis on what the limitations of our abilities are. It’s called professional judgement and what we are proposing here is actually a test of our definition of 'in our care'. We’re talking about testing the possibility of making remote prescriptions. The responsibilities around prescribing won’t change, and those responsibilities include the responsible use of antibiotics."

Chris then argued that all the motion was calling for is a trial of something that unlike, for example, deregulating advertising and practice ownership, is not going to give a slice of the consultation fee to non-vets. He also pointed out that people will always be able to highlight cases that would be completely unsuitable for remote prescribing, but that this is not about replacing the consulting room.

Filling the void

What it is about, he said, is removing barriers to care; filling the vacuum between a concerned owner, and the £60 - £100+ they’ll be charged for a consultation. It’s a vacuum that is currently filled by the 'free' (except it's not) phone advice given out by practices, by Facebook and by Dr. Google. 

He then pointed to an example from the US, where 83% of people who visited https://www.whiskerdocs.com for pet advice and thought their problem was suitable for home treatment, were in fact wrong and ended up being instructed to visit their veterinary practice. This, he said, could lead to better productivity in practice.

Could telemedicine help retention?

Telemedicine, he said, could also provide a role for people thinking of leaving practice, which is potentially an important factor at a time when retention is proving such an issue. 

Evidence-gathering, clinical freedom and professional judgement

Like others, Chris argued that the trial is about putting the RCVS at the forefront of progression in our increasingly digitised society, at a time when remote information from wearables is going to become more and more common. In summary, he said: "This trial is about an evidence-based profession looking for evidence, it’s about clinical freedom and it’s about putting professional judgement in the hands of the professionals."

A two-tier service

Lynne Hill (Past President) said her main concern is about having to redefine "under his care" and how remote prescribing via telemedicine would lead to a two-tier level of care, which she thought would be wrong.

She also highlighted that the College had debated the definition of "under his care" in relation to farm animal practice, where some farmers have multiple vets, some of which offer herd health care and nothing else. Deregulating to account for this has, she said, been responsible for the demise of farm animal practice. Quite simply there are less vets around to see animals. 

Show me the money

Lynn also noted the altruistic nature of the debate thus far, and reminded everyone that this is really about business and making money. The companies that are set up to provide telemedicine and possibly take part in the trial will not be in it for the welfare of animals, but to make money.

She also scoffed at the idea that telemedicine and remote prescribing will mean the 10% of people who do not currently have a vet are "now going to get madly involved in telemedicine." The reason they don’t have a vet at the moment, she said, is because they don’t want to pay. Telemedicine doesn’t change that. 

Lastly, as others had done, she highlighted the difference between human medicine, where patients can describe their symptoms, and veterinary medicine, where they can’t.

Leadership is about taking the right decision, not jumping on the bandwagon

"Leadership is not always about jumping on the bandwagon and going forward because something is out there. Leadership is actually about looking and deciding and making the right decision."

The disingenuous antimicrobial argument

Dave Leicester (MRCVS) was up next, arguing that it would be wrong to say that a body of professionals can be trusted to make decisions about animal welfare, but not about prescribing. He also felt it was a little disingenuous to do a lot of hand-wringing over antimicrobials when, as a profession: "We’ve managed to make a 3rd generation cephalosporin the most prescribed antibiotic in cats."

Finally, Dave made the point that in his 15-year experience working for OOH emergency service providers, they’d managed to work very successfully without access to patient medical histories.

Setting veterinary standards

Claire McLaughlin (Lay) reiterated that the role of the RCVS is to set veterinary standards, something it can’t very well do without knowing what is going on in practice, and finding out how these things work in practice. “We need to be in a process which takes us to able to set those standards. Whether the trial that is proposed is the right trial or not, we can’t just say no, it’s fine as it is because people will work within their professional competence. As Eleanor [RCVS Registrar] will tell you, they don’t work within their professional competence because they come before disciplinary committee all the time. I think we would be remiss if we didn’t start a process now or continue this process in a way that allows us to set appropriate standards.”

Colonel Neil Smith (MRCVS, Chief Veterinary Office for the Army) began by declaring that he provides telemedicine services for animals in disparate parts of the world as part of his day job, but these animals are very much under care and there is an existing relationship with patients. He is also involved with the provision of limited veterinary services for homeless people via StreetVet, a charity which has had to form relationships with practices that can cover the 125 hours per week when it is not present. 

Lowering veterinary standards

Neil explained that his "massive" concern with the proposal lies in particular with the part that says: "Given the limited nature of the service that can be provided by telemedicine alone, however, it is proposed that those under a trial would be required to actively support clients in identifying a veterinary practice that could physically see their animal in both routine and emergency situations."

This, he said, would lower veterinary standards, if all somebody providing telemedicine has to do is point people in the direction of a practice. 

For that reason, Neil said, he could not support the proposal as is, and would instead recommend that it goes back to Standards and is then brought back at the next council meeting with a clearer idea of what the trial is all about.

Accessible care

Caroline Allen then jumped in again, saying that whilst she agreed with the idea that more data is needed, she also thought that telemedicine and remote prescription is being driven by the issue of accessible care, and it is that, in fact, which needs to be investigated and understood and debated first.

The digital age

Past President Professor Stuart Reid highlighted that the veterinary students of today live their lives in the digital environment and their world will be very different from ours. The same goes for pet owners. He reiterated that as the regulator, the RCVS needs to be ahead of the game, and that if this is what the public wants, then it has to find a way of regulating it. 

Stuart finished by saying that he felt conflicted about the vote; that he had significant problems with the proposal and is not entirely sure that a trial is the right thing, but: "In the referendum we're about to have, I want to say yes but I want to see what the deal is as well." He added: "I didn't vote out by the way, in case this gets back to my employers, but I do think we have to think very carefully about throwing the baby out with the bathwater here."

Pressure to prescribe

Martin Peaty then recounted how at a Vivet Conference last year, a provider of telemedicine (which he thought was Babylon) explained that doctors on its system were retained on the basis of a post-consultation customer satisfaction survey. That, he thought, would make it difficult for practitioners not to prescribe things when they know it will affect their job. 

David Bray (Lay), said he believed the telemedicine and remote prescribing will come and it will become more common to have pets treated by multiple vets, so he was fully supportive of a trial. 

When it came to the vote ...

Guessing at which way the people who spoke might have voted, it seemed as though there were probably enough councillors with sufficient reservations about the motion, which would have given the go ahead for the trial, for it to be voted down.

That said, the overall sentiment in the room seemed to be that the discussion about the regulation of telemedicine and remote prescription needs to continue, and not get kicked into the long grass simply because of a disagreement over the proposed trial. 

At this point, Jo Dyer and others stepped in to argue that the decision to proceed with the trial should not be made until the issues raised in the debate had been addressed. There was then a lot of going backwards and forwards, discussing whether this would need a new motion, which is not allowed under Council rules, or whether the existing motion could be amended, which is allowed.

In the end, the decision was taken to hold two votes, the first being to refer the issue back to the Standards Committee which was carried by 18 to 12, with one abstention. 

The second vote was:

"Council is invited to consider the recommendation of Standards Committee to prepare and develop a proposal for a time-bound and limited trial to assess the benefits and risks of allowing the remote prescription of POM-V with appropriate stakeholder engagement and with consideration of the issues that we've discussed today and the detail on them, including 24/7 care and classes of drugs, especially antimicrobials. So we are asking for the detail on that to be worked up on the basis that it will at some time come back to Council."

The second vote was carried by 21 to 8 with 3 abstentions. 

In other words, the trial will not now go ahead unless Standards can develop a new proposal which addresses the concerns raised by Council.

VetSurgeon Conclusion

Looked at solely in terms of its impact on animal welfare, this debate seems to come down to one question, which is whether more animals will benefit from easier, cheaper access to veterinary services available via telemedicine and remote prescription than will suffer as a result of misdiagnoses and missed diagnoses that will surely be the inevitable consequence of veterinary surgeons working only from the more limited, and potentially inaccurate or even false information they will get from a video consultation.

For sure, more wearables are coming, and they will overcome some of the problems caused by the fact that animal patients cannot describe their symptoms. Doubtless someone will also invent a set of weighing scales that makes it possible for owners to do the job reliably accurately. Patient histories will surely become more portable. But these things are not with us just yet. 

In any event, it is not just about the immediate impact on the quality of care delivered to patients. The way the trial has been framed thus far takes us in the direction of a two-tier profession. What happens if more veterinary surgeons prefer, or make a better living from working from the comfort of their own home without the added responsibility that comes with providing the physical care. Who’ll do the ‘real' vetting?

If you look at the popularity of human telemedicine, the 30,000 patients who have signed up for telemedicine at the small practice in the Lillie Road in London, it seems obvious that patients want the convenience of consulting online, without having to schlep to the practice and find a parking space. It also seems self evident that if online consultations are offered at a lower price point, it will inevitably lead to more pet owners availing themselves of veterinary advice, though as Lynn Hill said, it’s unlikely to cause a mad rush whilst Dr Google is still free. 

Perhaps, though, there is another valid way to solve this conundrum. Rather than rushing headlong into a trial that could irrevocably change the very nature of the profession, how about establishing some pragmatic ground rules from the outset. For example, that unless by unanimous agreement of Council in the future, telemedicine should only be allowed as an extension of the service offered by existing bricks and mortar practices to their existing clients. 

When it comes to remote prescribing, surely the safest way to regulate it (if you’re going to allow it at all) is to do so on a drug-by-drug basis. Perhaps trial it with the endo- and ecto-parasticides for existing clients of existing practices. Find out whether the convenience of the online consultation leads to higher standards of parasite control for greater numbers of pets. If it doesn’t, then ditch it. Either way, it doesn't preclude trying another category of drug.

That’s my tuppence worth, for what it’s worth, which probably isn’t quite tuppence!