Remote Prescribing

RE: Remote Prescribing

Arlo Guthrie — Tue, 13 Oct 2020 08:46:39 GMT

[quote userid="9239" url="~/001/nonclinical/f/life-in-practice-discussions/29391/remote-prescribing/225852#225852"]Soon, CVS or Pets at Home will anyway have an online vet national service for all their registered clients which may draw more people away from independents.[/quote]

Erm. Hmm. I've always thought that the main advantage that corporates have is the economy of scale. To my mind, remote prescribing (to clients) reduces that advantage (as in the cost of a vet providing that service is not presumably going to vary that much whether you work for an independent or a corporate). Therefore, independent practices should be offering remote consultations to their clients already, to make sure that the independents do NOT lure their clients away. Or am I wrong?

RE: Remote Prescribing

Anthony Dennison — Mon, 12 Oct 2020 14:04:33 GMT

[quote userid="9239" url="~/001/nonclinical/f/life-in-practice-discussions/29391/remote-prescribing/225852#225852"]I just finished reading the post about what stresses vets most on Vet Voices [/quote]

I bet that was a busy thread on that group. Everyone loves to moan there.

RE: Remote Prescribing

Dinu Catilina — Sat, 10 Oct 2020 09:12:24 GMT

Well, until this morning I was vociferously against remote prescribing but I just finished reading the post about what stresses vets most on Vet Voices (I know there are a lot of moaners in that group but there is no smoke without fire). The vast majority is overworking, overbooking, no time and realistically there is no solution to this other than remote prescribing.

I prefer to see it connected to an existing practice but this is also not a perfect solution. Soon, CVS or Pets at Home will anyway have an online vet national service for all their registered clients which may draw more people away from independents.

Realistically, we loose money from an appointment for diarrhoea when the pet goes home with one probiotic and some food. Maybe this is the future, it is more and more clear that conventional practices are more and more difficult to manage in the current climate. We can all have one vet on the rota doing remote prescribing half day every day and that will allow more slots for relevant appointments.

RE: Remote Prescribing

bob lehner — Thu, 08 Oct 2020 10:05:33 GMT

[quote userid="3607" url="~/001/nonclinical/f/life-in-practice-discussions/29391/remote-prescribing/225817#225817"]

bob lehner said:
I presume you have audited it

... in-house 'Clinical Audit' - the epitome confirmation bias!!

[/quote]

Interesting observation. I take it you have audited loads of in-house audits?

RE: Remote Prescribing

Iain Richards — Wed, 07 Oct 2020 14:32:49 GMT

[quote userid="8991" url="~/001/nonclinical/f/life-in-practice-discussions/29391/remote-prescribing/225818#225818"]Completely disagree. There are many new presentations - the bulk of first opinion practice - that can be managed remotely from the first contact. Chronic skin issues, acute onset lameness, vomiting, diarrhoea, eyes. [/quote]

So I'll disagree with your disagreement. Especially on eyes.

RE: Remote Prescribing

Julie Innes — Wed, 07 Oct 2020 12:24:43 GMT

We're still doing a few, but seeing far more at the surgery now- mainly to placate the owners, because that is what they want rather than because we feel they "need" seen. We are still initially booking things as a "telephone consult", then it is the vet who decides if/ when the animal should come down, and means when the pet arrives at the surgery we already have a clinical history, so the whole exam/ call owner to discuss bit is that bit shorter (We are still not allowing clients in, so are trying to make appointments more efficient. I have a snazzy little bluetooth headset so that I can chat to the client and examine the patient/ write up notes at the same time!)

I'm actually surprised- for years people have moaned that we won't just give them out medication (despite us never having seen their animal in 6 years!), but now everyone feels that everything needs to be seen, and they don't want remote prescribing!! Maybe it's just the thrawn nature of folk...

We did have one complaint- a client who called and said his dog was a little lame and was prescribed meloxicam, which he said "didn't work". It was only when we offered to see the dog that he mentioned the dog had been a "bit off colour" Blood tests showed quite advanced CRF, so obviously he googled and the 3 days of meloxicam caused it, and had we seen the dog, having no clinical history other than lameness, we would have known. It has reminded me to take a full clinical history for everything, and not to just accept that the animal is otherwise "fine", however during a busy surgery even with the client present I'm not sure I would have immediately jumped to doing blood tests on this dog, but we'll never know. The outcome would have been the same (dog euthanased eventually) but client perception would more favourable.

RE: Remote Prescribing

Lucy Fleming — Wed, 07 Oct 2020 11:48:39 GMT

I think David (and others who have said similar above) are right, the history from the owner is the most important thing (I've found photographs useful in some cases, not so much in others, we haven't tried video) and in most cases I think there was very little difference in how a lot of these cases were managed compared to being seen and examined by the vet. Often the actual physical exam serves only to check or confirm a few things, for peace of mind or completeness, but it is manageable without. A lot of mild acute lamenesses, GI upsets, conjunctivitis or uncomplicated corneal ulcers etc would resolve without being seen by us in a similar time frame anyway: if we are being really honest, our main function is to reassure the owner, and maybe provide some analgesia or anti-emetics so the pet feels a bit more comfortable while it gets better naturally.

Triaging and history taking is a skill - for vets and for reception staff - especially if practices are busy and a "same day" appointment for an unwell pet isn't readily available. Covering your own OOH work definitely is helpful in developing this!

[quote userid="8991" url="~/001/nonclinical/f/life-in-practice-discussions/29391/remote-prescribing/225811#225811"](leaving aside the removal of a spleen from a multi-morbid eldelrly animal)[/quote]

Happily, a splenic haematoma in this case, and she's doing well now. I wouldn't necessarily call her multi-morbid either, it's just OA, but appreciate that's not your point.

[quote userid="8991" url="~/001/nonclinical/f/life-in-practice-discussions/29391/remote-prescribing/225818#225818"]the swathes of people you have attending site, putting at risk both your employees and business?[/quote]

Without meaning to sound petulant, is that massively reduced if they are coming to pick up some medication after the telephone consultation (as will be happening in many cases)? Are we any different from the retail and hospitality businesses that the government has been encouraging everyone to go back to?

I didn't mean to join a general hand-wringing over the "great dangers of remote prescribing". It's definitely had its place in managing during Ye Olde Plague Times, and while there's ongoing need for the vulnerable to shield there's an ongoing need for the option. In longer terms, though it's vaunted as being a game changer for those in remote regions, I feel that the majority of users will be those who could very easily reach a vet if then needed, but that don't see the value in a regular veterinary check up, and where the pets will lose out in terms of welfare (and practices will in terms of income) will be the creaky old dogs that won't get nsaids, the periodontal disease that won't be managed until the teeth fall out, the elderly cats that have lost 20% of their body weight since they were last seen that we so often find at booster appointments but that owners don't perceive as a problem.

RE: Remote Prescribing

David Mills — Wed, 07 Oct 2020 11:24:36 GMT

[quote userid="4367" url="~/001/nonclinical/f/life-in-practice-discussions/29391/remote-prescribing/225812#225812"]Where they are inappropriate is the first contact, no knowledge of client or patient, no knowldege of previous history, no attmept to get previous history consultation and no ability, let alone intent, to offer OOH care. They can only offer generic advice and that's fine, but going beyond generic advice and moving to prescibing, should not occur, for all the reasons we keep listing.
[/quote]

Completely disagree. There are many new presentations - the bulk of first opinion practice - that can be managed remotely from the first contact. Chronic skin issues, acute onset lameness, vomiting, diarrhoea, eyes. It isn't just a phone call - photos, videos, and other media can be very useful. It amuses me how inflexible some people have become throughout this - now wanting cytology on every ear when they probably did two or three in the previous 12 months.

[quote userid="6897" url="~/001/nonclinical/f/life-in-practice-discussions/29391/remote-prescribing/225816#225816"] A half decent veterinary practice (in normal times) should be able to offer same day appointments if the owner is concerned.[/quote]

Missing the point, perhaps wilfully. The examples those gave wouldn't, if coming through reception in normal times, necessarily have been offered a same day appointment. My point is there isn't a fundamental weakness with remote consulting that would have caused these cases to be 'missed' - the system is only as good as the information going into it and those processing that information. The examples given are somewhat silly in terms of logic, confusing the imprecision of an owner's perception of disease with a 'problem' with remote consulting - a problem not circumnavigated in normal times. Unless you have vets answering all calls into the practice I suppose.

[quote userid="6897" url="~/001/nonclinical/f/life-in-practice-discussions/29391/remote-prescribing/225816#225816"]Are you sure about this - I presume you have audited it - e.g. telephoned every triage case a few days later to establish outcomes?[/quote]

A better question would be have you audited the necessity - according to government and H/S guidelines - the swathes of people you have attending site, putting at risk both your employees and business?

There is an element of chickens coming home to roost here with the avoidance in small animal practice of emergency work and the development of prioritisation and effective triage. For too long it has been put back onto the client - well, come for an appointment - and a defensive medicine stance of seeing everything. OOH providers are particularly culpable. But if you haven't been exposed to emergency work it is no wonder people are floundering, panicking, and trying to find any excuse why remote consulting doesn't work - any excuse other than look at their own skill set and performance, that is. There should be no shame in it, in the same way that I wouldn't operate on a spine, some people just might not have the skills or approach to risk that are demanded by remote consulting.

RE: Remote Prescribing

Malcolm Ness — Wed, 07 Oct 2020 09:55:17 GMT

[quote userid="6897" url="~/001/nonclinical/f/life-in-practice-discussions/29391/remote-prescribing/225816#225816"]I presume you have audited it[/quote]

... in-house 'Clinical Audit' - the epitome confirmation bias!!

RE: Remote Prescribing

bob lehner — Wed, 07 Oct 2020 09:38:03 GMT

[quote userid="8991" url="~/001/nonclinical/f/life-in-practice-discussions/29391/remote-prescribing/225811#225811"]The labrador would have been booked for a couple of days hence for a meds check up (leaving aside the removal of a spleen from a multi-morbid eldelrly animal), the blocked cat would have been a non-urgent check up. [/quote]

Are you perhaps confusing private veterinary practice with NHS GPs? A half decent veterinary practice (in normal times) should be able to offer same day appointments if the owner is concerned.

[quote userid="8991" url="~/001/nonclinical/f/life-in-practice-discussions/29391/remote-prescribing/225811#225811"]the effective triage that happens through these consults means we miss very little important stuff.[/quote]

Are you sure about this - I presume you have audited it - e.g. telephoned every triage case a few days later to establish outcomes?

RE: Remote Prescribing

Bob Russell — Wed, 07 Oct 2020 08:22:44 GMT

In a few years time I dare say there will be a lot more technology at home/implanted etc so a hands on consultation will become less beneficial. This is already happening in human medicine.

At the moment the veterinary remote consultation is a poor second best much of the time and totally different from seeing a GP. I cannot remember when a GP last did a physical examination on me!

RE: Remote Prescribing

Clive Ansell — Wed, 07 Oct 2020 08:20:35 GMT

Yes. I think as triage tool it is fairly good, and lets not forget we (the profession) have been doing this successfully for many years.

My first job in a busy Birmingham practice involved 1 in 3 OOH on call, where the MO was very much we only would see cases if absolutely necessary OOH, and would fob off until morning where possible. I think all 3 vets were fairly good at it; I can't remember any cases going wrong or dying because they were not seen when they should have been. If anything, we were all a little cautious and if in doubt we would see. Worked well. Happy days (except for being on call 1 in 3 of course - ain't doing that again :-) )

RE: Remote Prescribing

Iain Richards — Wed, 07 Oct 2020 08:01:04 GMT

Fair points David, once one removes the waspish bits.

Remote consulting as you describe, as a triage and in the hands of an experienced vet is no different to a phone call. We've all had them, those that we can happily say, "See you in the morning" to or those that have you out of bed in a flash. They'd also work well for follow-ups. If I was still workign , I would be usign them more and using them to proactively contact clients on long term meds. I'd agree that the issue is a learnign set.

Where they are inappropriate is the first contact, no knowledge of client or patient, no knowldege of previous history, no attmept to get previous history consultation and no ability, let alone intent, to offer OOH care. They can only offer generic advice and that's fine, but going beyond generic advice and moving to prescibing, should not occur, for all the reasons we keep listing.

RE: Remote Prescribing

David Mills — Tue, 06 Oct 2020 21:49:58 GMT

These kind of grand announcements are unhelpful.

The key to remote consults is triage, and assessment of risk, sadly something lacking in a profession in which the vast majority have happily and smugly divested themselves of OOH work. There is a defensiveness and a 'straight to worst case' rush to show how everything should be seen (just not too close to 6pm thanks). All the examples above aren't a problem of remote prescribing - do the vaunted heroes of these tales think the outcome would be different had the owners requested an appointment via the usual route in normal times via reception? The labrador would have been booked for a couple of days hence for a meds check up (leaving aside the removal of a spleen from a multi-morbid eldelrly animal), the blocked cat would have been a non-urgent check up.

We are still doing 30-50 remote consults per day at our hospital, and they are working well. Whilst our demographic and the fact the service is free to most clients undoubtedly skews consults towards 'lower end' stuff, the effective triage that happens through these consults means we miss very little important stuff. This triage runs through reception, nurses, remote vets, and vets on site.

There isn't an issue with remote consults. Just the skill set of those performing them. People will take this personally. They shouldn't. It's somewhat of a particular skill that is easy to virtue signal your way out of by saying "I must see the animal". The latter will, in a few years, be seen as archaic and out of touch. It's the future. Rather than having scores of people sitting in cars, why not embrace it, and, I don't know, try and get better at it?

RE: Remote Prescribing

Iain Richards — Tue, 06 Oct 2020 21:07:10 GMT

[quote userid="2185" url="~/001/nonclinical/f/life-in-practice-discussions/29391/remote-prescribing/225807#225807"]Timely piece in the news today - does the veterinary profession really want to be going down these lines? [/quote]

This issue has been highlighted before, articles in the TImes, the Guardian and on Panorama.

There are good reasons why medicines have greater restrictions on them than standards consumer products.

RE: Remote Prescribing

Gillian Mostyn — Tue, 06 Oct 2020 20:31:22 GMT

I've locumed at 4 practices in the last month....none are doing the quantity of 'routine' remote consultations of a few months ago. However, all will do occasional remote consultations where there is a good reason - usually a couple of them daily. They are all also still doing the majority of 'simple' post op checks, that would previously be a nurse consultation, remotely. This is probably due to the fact that as nurses are having to assist the vets there are very few nurse clinics running.

RE: Remote Prescribing

Utlendigur — Tue, 06 Oct 2020 19:53:11 GMT

Experience of it was frustrating and on the basis of it being better than nothing in the circumstances. Was usually left with a faint sense of unease that I'd missed something, and knowing that I was making decisions based on very limited and sometimes incorrect information. I'm a locum but the practices I work in are doing very few now, if at all, and those are usually on-going or recurrent problems where an owner is concerned about coming in (shielding, lack of transport because of coronavirus restrictions on meeting/concerns over public transport). Most owners seemed relieved to get back to normal(ish) consults.

Timely piece in the news today - does the veterinary profession really want to be going down these lines? (Couple of GPs suspended by GMC for running unregistered clinic amongst other things, move abroad, register business in Hong Kong, prescriptions for minors for controversial treatment done by phone consult, then filled by on-line pharmacy) without the knowledge of their GP, without any in-person consult or any safeguarding.

https://www.thetimes.co.uk/article/chemist-sells-hormones-for-trans-children-online-cbgtxlbdr

Or previous similar problems with controlled drugs with no overall regulation or records

https://www.pharmaceutical-journal.com/news-and-analysis/features/the-deadly-online-prescribing-loophole/20207565.article

RE: Remote Prescribing

Gillian Mostyn — Tue, 06 Oct 2020 15:40:31 GMT

[quote userid="10320" url="~/001/nonclinical/f/life-in-practice-discussions/29391/remote-prescribing/225795#225795"]She had a telephone consultation as she appeared to be less mobile than normal. Could easily have just upped some of her pain medication and "seen how she got on" but something about the owner's description just rang some alarm bells for a true weakness rather than pain - booked her in for a consultation and found a large abdominal mass and a haemoabdomen. One splenectomy later she's doing very well.[/quote]

But, to be fair, you obviously did a good job of the remote consultation and picked up that this was weakness rather than lameness.

I agree that animals are always better being examined, and this is to be the aim whenever possible. But where this isn't possible for whatever reason (such as a self-isolating family I dealt with this morning) it does have its place. But it does need an experienced vet who knows exactly what questions to ask.

RE: Remote Prescribing

Lucy Fleming — Tue, 06 Oct 2020 11:19:33 GMT

I had something similar early in lockdown - an elderly golden retriever who suffers from fairly severe osteoarthritis and is on multiple analgesic meds. She had a telephone consultation as she appeared to be less mobile than normal. Could easily have just upped some of her pain medication and "seen how she got on" but something about the owner's description just rang some alarm bells for a true weakness rather than pain - booked her in for a consultation and found a large abdominal mass and a haemoabdomen. One splenectomy later she's doing very well.

I'm sure we all have similar stories of the cases that narrowly missed a disaster (or didn't) due to remote consultation - they're undoubtedly in the minority but the individual consequences for that animal and owner are potentially severe. We still offer remote consultation if the owner requests (for example if owner shielding etc) but prefer the animal to come in if at all possible. About all we are doing remotely now are occasional meds checks for long term, low-risk medication, and the occasional consultation for prescription parasite control. But given we are being encouraged back into shops, pubs, cafes etc (albeit with precautions) I think routinely replacing a hands on consultation with a phone or video consultation is hard to justify.

RE: Remote Prescribing

bob lehner — Tue, 06 Oct 2020 10:57:17 GMT

[quote userid="5012" url="~/001/nonclinical/f/life-in-practice-discussions/29391/remote-prescribing/225759#225759"]last week I had things like possible blocked cats, vomiting for days lost weight. These can only be assessed face to face really.[/quote]

Yes indeed - this was brought home to me just as Covid was kicking off and remote consulting was being discussed.

I had a cat booked in for a routine appointment - the appointment notes just said 'Cat off colour'. Before looking at the cat, as usual I asked the owner (an elderly lady) what she was concerned about . 'Oh, he's just a bit off - not himself'' . 'Nothing else you've spotted?' 'No'.

I opened the box and lifted the cat out. It was not the work of a diagnostic genius to instantly feel the blocked bladder.

If this had been a remote consultation, on the poor quality evidence provided by the owner, I suspect many of us might have been inclined to advise 'Give it a day or two and see what happens'. Thus signing the death warrant of the unfortunate patient.

RE: Remote Prescribing

Chris Barker — Tue, 06 Oct 2020 10:40:29 GMT

Difficult to comment directly as I am down to working only one day a week and during the initial Covid lockdown spent my time attending those animals which could be brought in to the clinic. But perhaps I could highlight what we risk missing by relying on remote consultations. In our own practice we did a small study of animals >7yrs of age brought in either for a routine booster or a prescription check; more than half of these ostensibly ‘normal’ animals were found to have previously unrecognised health issues. And our findings have been confirmed by others - Prof David Williams and Agata Grudzien published a short communication at BSAVA Congress in 2015. Analysis of >1000 vaccinations showed that 40% of the clinical examinations associated with the booster injection resulted in detection of a condition which might otherwise have gone unrecognised.

RE: Remote Prescribing

Mark Rowland — Mon, 05 Oct 2020 20:19:04 GMT

Works for most exotics (esp reptiles)

It means I get to see their setup first hand

Sure some need to be seen but as husbandry is most commonly the issue Ive had some very positive experiences.

RE: Remote Prescribing

Evelyn Barbour-Hill — Mon, 05 Oct 2020 15:20:45 GMT

I haven't been doing any beyond this sort of thing:

Owner I know well phones about a female cat I know well, that has had lower urinary tract disease now and then for years "Binky seems to have cystitis again, it's the same as before, I can't bring her in, can I have some more Metacam?" Me: "Yes, but if she doesn't improve as expected I must see her".

Other than that, I must see the patient and get my hands on it.. I refuse to look at photographs or videos.

RE: Remote Prescribing

Clive Ansell — Mon, 05 Oct 2020 11:51:18 GMT

just finished one.

12 year old ex rescue cat, history of dental disease, not eating and losing weight for 5 days. That changed within 1 minute to "he only eats 2 pouches a day whereas he used to eat 4", and "I don't know if he's lost weight, but he probably has because he doesn't eat. "He doesn't go outdoors, but could be eating at the neighbour's". Don't know if he's toileting because he goes outside (although he doesn't go out)

Some pictures sent via email; one can just about make out it is a cat, no more.

Nonsense, and an utter waste of time. Needs to be seen to be assessed, no other way. In fact on a busy Monday Morning it took up a consultation slot and took me away from seeing clients.

RE: Remote Prescribing

Joyce Whitehead — Mon, 05 Oct 2020 08:59:40 GMT

We are really not doing any any more. Clients can make appointments and bring pets to us (they stay outside still as we take pets in). Personally I like this much more, it is really hard to assess an animal from rubbish photos or video taken by the owner. Obviously it was easier To prescribe for a mildly lame dog, for instance, but many other things I’d prefer to have my hands on the patient.

I’ve mentioned this before here but I had photos of a little llasa apso with what appeared to be a nasal discharge, looked a bit snotty and the dog was off colour. I prescribed antibiotics over the phone (I think I agree with Beats that we maybe presecribed more AB than usual with phone consults). We saw him a week later as he was no better. He was in heart failure. No cough, owner hadn’t noticed anything else. He’s doing fine now on heart meds.