The patchwork quilt of state veterinary telehealth laws

As COVID bore down in 2020 and veterinary teams raced to develop new remote workflows overnight, telemedicine seemed poised to finally have its moment in the sun. New companies sprung up seemingly every week, ready to take advantage of a demand that no one yet fully understood. But almost half a decade later, has veterinary telemedicine lived up to the hype?

Utilization of technology to improve the delivery of healthcare is nothing new–after all, no one argues with the need for a telephone or a computer to communicate with clients and share information. The debate surrounding telemedicine in the veterinary world is not about use of technology overall, but centers instead on one specific question: should veterinarians be able to establish a virtual veterinary-client-patient relationship (VCPR) without seeing the pet in person first? And if so, what limitations or guardrails should be in place to protect pets?

The answer is: it depends. The practice of veterinary medicine is governed by a confusing interplay of federal and state laws that vary widely from state to state, making it challenging to comprehend even for the deeply vested. Add in the current legislative changes taking place across the country, and keeping up with such developments becomes almost impossible for all but the most intrepid observers.

The differences in VCPR laws at the federal and state levels

There is no one universal definition of what needs to be in place to establish a valid VCPR. While some states have explicit definitions, other states’ regulations may be vague, incomplete, or open to interpretation.

According to the Veterinary Virtual Care Association’s map of VCPR laws by state:

• 19 states stipulate that a VCPR cannot be established via a virtual exam
• 1 state (New York) has no mention of the term VPCR (and therefore no rules around it) in their practice act
• 22 states require veterinarians to have “seen” or “become acquainted” with the patient before a VCPR can be established, with it being unclear as to whether this can be accomplished via a virtual exam
• 8 states expressly allow the establishment of a virtual VCPR

In addition to variations in state laws, veterinarians must consider federal regulations regarding prescription of medication when the prescriptions fall under FDA purview. In those situations, the FDA indicates that “a valid VCPR cannot be established solely through telemedicine.”

Extralabel use or prescription of drugs by veterinarians requires an in-person exam. As for other circumstances not overseen by the FDA, the organization advises veterinarians to refer to their respective state laws for guidance.

It is fair to say this is a confusing situation for many if not most veterinarians, and there are arguments both toward and against a virtual VCPR.

Arguments for a virtual VCPR

Additionally, the field of veterinary medicine is divided on whether or not it is ever appropriate for a VCPR to be established virtually. The fundamental question of whether no care at all is better than virtual care inspires passionate debate.

Mark Cushing, JD, is the president of the Animal Policy Group, cofounder of the Veterinary Virtual Care Association (VVCA), and an advocate for the virtual VCPR who has worked towards that end in states such as Arizona, California, and Florida.

Cushing describes the scenario of a woman in her 80s living in an apartment building with her two cats. She won’t be “reaching under the bed, pulling her cats out, putting them both in carriers, carrying them down to the street, getting an Uber or taxi and trying to find a vet,” he said. Opponents of a virtual VCPR, he said, would argue that in such a situation no care is preferable to care only via telemedicine, an attitude Cushing calls “absurd.”

Furthermore, he says he and his team, along with various shelters and humane societies including the American Society for Prevention of Cruelty to Animals, have been advocating for the inclusion of a virtual VCPR in veterinary state practice acts across the country because pet owners aren’t able to access in-person care consistently when they need it, whether due to finances, transportation challenges, location, pet stress, and other causes.

“Telemedicine is used in all 50 states for people…why not [for] pets?” Cushing asks.  “You’ve got good safeguards built,” such as informed owner consent and limitations on prescribing. These safeguards vary by state.

Arguments against a virtual VCPR

In contrast, the American Veterinary Medical Association (AVMA) and some state veterinary medical associations oppose a virtual VCPR. Gail Golab, PhD, DVM, MANZCVS, DACAW, Associate Executive Vice President and Chief Veterinary Officer of the AVMA, said that the AVMA’s extensive investigation of the use of telemedicine in community outreach efforts reinforced the importance of in-person exams in the accurate diagnosis and treatment of pets and in establishing trust with pet owners.

According to Golab, the feedback is clear. “We have direct experience in providing telemedicine services for underserved populations and have found that telemedicine is best used in a hybrid model, rather than as a substitute for in-person care,” she said.

“In that regard, some care isn’t better than no care, when it’s the wrong care or when it removes incentive to physically go into these communities and deliver the care that our patients really need,” she added.

There is still a place for telehealth, Golab said, as a supplement to an in-person exam. This can include virtual follow up appointments, teleadvice, teletriage, and teleconsulting. A VCPR based on an in-person physical exam, Golab argued, is “one of the greatest safeguards we have to protect animal health, the safety of the food supply, and public health.”

New and recent state veterinary telehealth legislation

State laws regarding the use of telemedicine are changing day-by-day as advocates for both sides of the issue argue their case. Some of the recent changes are as follows:

Florida

Effective July 1, 2024, FL H0849 amended the Florida Veterinary Practice Act via the Providing Equity in Telehealth Services (PETS) Act. This section authorizes veterinarians licensed in Florida to practice veterinary telehealth as follows:

• A valid VCPR must be present. A synchronous (live) video visit may be used to establish the VCPR.
• Prescriptions made based on this virtual VCPR can be for no more than 1 month of flea/tick prevention and no more than 14 days’ worth of other animal drugs before an in-person exam is required. Veterinarians may not prescribe compounded drugs, controlled drugs, or drugs that are to be used in an extralabel fashion without having previously conducted an in-person physical exam.

The District of Columbia

Effective July 19, 2024, the Health Occupations Revision General Amendment Act of 2023 included veterinarians along with many other types of healthcare practitioners permitted to enter into a “practitioner-patient or practitioner-client relationship” via telehealth. This act defines telehealth as the use of “synchronous or asynchronous telecommunication technology” to perform an exam or otherwise become acquainted with the patient but does not modify any other parts of the veterinary practice act or impose any restrictions on the prescription of medication when a VCPR is established virtually.

Ohio

Ohio Senate Bill 268, currently pending in the Agriculture and Natural Resources Committee, would allow for veterinarians to establish a VCPR by either an in-person exam or an exam via live video consultation.  If this bill passes, veterinarians would be permitted to prescribe up to 30 days’ worth of medication with up to one 30-day refill after a recheck visit via telehealth.  Beyond this, an in-person examination must take place before any more refills can be authorized.  As with other states, prescriptions for controlled substances always require that an in-person exam be performed prior to authorization.

California

California Assembly Bill 1399 amended the state practice act to effectively allow virtual VCPRs on November 17, 2023. This amendment added examination of the patient by use of “synchronous audio-video communication” as a means of establishing a VCPR.  Additional restrictions include:

• Drugs cannot be prescribed for a patient for a duration of more than six months from the date of the original exam without the veterinarian conducting another physical exam, either in-person or via synchronous audio-video communication.
• Antimicrobial drugs cannot be prescribed for periods of more than 14 days–and cannot be refilled—without an in-person exam.
• Controlled drugs and xylazine cannot be prescribed without an in-person exam.

Michigan

Michigan House Bill 4980 of 2023 was introduced to the state legislature in September 2023 and has been referred to the Committee on Agriculture. If passed, this bill would amend the state public health code to allow for the establishment of a VCPR using “real-time interactive audio and visual electronic technology” provided the patient is a companion animal. An in-person examination would still be required for issuance of a certificate of veterinary inspection or a pet health certificate (a certificate for the sale of dogs, cats, and ferrets).

As with legislation in other states, the Michigan bill places some restrictions on the prescription of animal drugs. They include:

• A veterinarian who establishes a VCPR via a virtual exam may not prescribe more than a 14-day course of medication with no refills. One additional 14-day course may be prescribed if a second electronic exam is performed.  Beyond this, an in-person exam is required.
• Controlled drugs cannot be prescribed without an in-person exam.

Colorado

Effective August 7, 2024, CO HB 24-1048, the Providing Veterinary Services through Telehealth Act, amended state law to clarify that an in-person physical exam is required to establish a VCPR. Once established, this in-person VCPR permits veterinarians to treat their patients via telehealth, and it also allows veterinary specialists to treat patients via telehealth under the referring veterinarian’s VCPR.

Voters in the state of Colorado will not have a chance to weigh in on the Colorado Veterinary Telehealth Initiative, a proposed ballot initiative for the general election on November 5^th, 2024, because the sponsors of the measure did not submit the required signatures by the August deadline. This ballot measure would have asked if the Colorado Revised Statutes should be changed to allow licensed veterinarians to establish a VCPR via electronic examination.

A path forward

Both sides of the virtual VCPR debate agree that the use of technology is a valuable way for veterinary professionals to enhance their treatment offerings and that telehealth can increase access to care, particularly in underserved communities.  They also agree that efforts to amend state practice acts are likely to continue as the interest shows no sign in waning any time soon.

What will veterinary telemedicine look like in 2025, 2030, and beyond? Only time will tell.

Further reading:

AAHA 2021 Telehealth guidelines and toolkit

FDA Statement on VCPRs, Prescribing/Dispensing Animal Drugs, and Telemedicine

The Veterinary Virtual Care Association website

AVMA’s page on telehealth and telemedicine in veterinary practice

Photo credit: Ivar Østby Simonsen/E via Getty Images

Disclaimer: The views expressed, and topics discussed, in any NEWStat column or article are intended to inform, educate, or entertain, and do not represent an official position by the American Animal Hospital Association (AAHA) or its Board of Directors.