Telehealth bill advances in California Senate

Update: California Assembly Bill 1399 passed the California Senate on September 12 by a 36-3 vote. Governor Gavin Newsom signed it into law on October 8. It will take effect in January 2024.

A California bill that would allow a veterinarian-client-patient relationship (VCPR) to be established remotely is making progress despite opposition from the California VMA (CVMA), AVMA and others. Veterinarians worry that the use of telemedicine without a previously established in-person relationship will produce more incidents of inaccurate diagnoses and ineffective treatment plans, more unnecessary prescriptions, and delays in accurate diagnoses and correct therapy.

California Assembly Bill 1399 passed the California Senate Appropriations Committee on September 1. The next step is a vote on the state senate floor, which is scheduled for next week.

The bill eliminates California's VCPR minimum standard, which currently requires a veterinarian to have previously physically examined an animal prior to recommending treatments and prescribing medications. The proposed bill goes against the Food and Drug Administration's (FDA) federal VCPR definition, which "requires animal examination and/or medically appropriate and timely visits to the premises where the animal(s) are kept" and "cannot be met solely through telemedicine," for covered activities, including extralabel drug use—including over-the-counter human products and compounded medications—and issuing veterinary feed directives.

During COVID, in-person examinations and premise visits were more challenging because of social distancing protocols. In response, several states and the FDA said they would temporarily not enforce requirements for an in-person animal examination or premise visit to establish a VCPR.

Virtually all states that offered such exemptions have now withdrawn them and the federal government reinstated its requirement for establishing a VCPR in-person at the end of 2022.

Notably, the California bill states that the "sufficient knowledge of the animal patient" that a veterinarian must possess to initiate at least a general or preliminary diagnosis of the animal patient's medical condition can be acquired through a virtual visit.

Not only that, but the bill also allows for the continual care of an animal through telehealth without ever having established an in-person relationship.

Supporters of the bill include the American Society for The Prevention of Cruelty to Animals (ASPCA), San Diego Humane Society, and the Virtual Veterinary Care Association (VVCA). VVCA membership includes several pet industry companies whose business models would directly and substantially benefit from being able to establish a VCPR remotely. The AVMA is concerned about the negative impacts to animal care of companies whose focus may be more on product sales than patient care.

Proponents claim that being able to establish the VCPR through synchronous real-time video communication would improve access to care, particularly for animals and clients in rural communities.

However, organizations such as the CVMA and AVMA recognize the degree to which an in-person physical examination and meeting with the client informs both the diagnosis and the suitability of a treatment plan for that particular patient or group of patients.

Because telemedicine does not involve an in-person physical examination or diagnostic testing, it limits a veterinarian in gathering critical information about the animal patient, especially for patients that might not regularly be receiving veterinary care. Ultimately, these organizations say a wrong, missed, or delayed diagnosis or an inappropriate treatment plan can result in prolonged illness and animal suffering and ultimately costs the animal's owner more.

Dr. Rena Carlson, AVMA president, said: "When people talk about ‘access to care,' they are often referring to basic care, including preventive care. An effective preventive care plan requires more familiarity with the patient and client than can be gained through an electronic encounter.

"Unfortunately, it's also true that animals that don't regularly receive veterinary care are among those most likely to have undiagnosed medical conditions. In both cases an initial in-person visit is critical to creating and delivering the right plan of care for that patient."

Keith Rode, CVMA president, wrote in a letter to one of the state senators who introduced the bill: "The fact of the matter is that pet owners who, for economic or other reasons, have difficulty taking their animals to a veterinary practice will not be better served by veterinary telemedicine. Telemedicine only allows the veterinarian to make an educated clinical guess based on limited information (when compared to a diagnosis pursuant to a physical examination of the animal patient). Thus, those who utilize only telemedicine, without a recent in-person visit with a veterinarian, are at risk for receiving a lower quality of care as compared to those who physically present their animal to a veterinarian.

"Lower quality care is not an appropriate substitute for the level of care that California consumers have come to expect from the veterinary profession, and perpetuates the very disadvantages being observed in underserved populations. Nor is it likely that there would be a significant cost savings associated with telemedical care versus in-person service, particularly if it initially takes the patient, client, and veterinarian down the wrong path."

Also of concern are the risks posed by an electronically established VCPR for inappropriate prescribing of medications, including antimicrobials and controlled substances. Evidence of how telemedicine has contributed to inappropriate prescribing (both overprescribing and poor selection) is readily available from human medicine's experience.

The California proposal comes with several stipulations that attempt to address some of these concerns to varying degrees, including the following:

• Prohibits a VCPR from being established solely by an audio-only communication or by means of a questionnaire.
• Authorizes only a person licensed in California to practice veterinary medicine via telehealth on an animal patient located in California.
• Prohibits a veterinarian from prescribing, via telehealth, any drug or medication for use on a horse engaged in racing or training at a facility under the jurisdiction of the California Horse Racing Board.
• Prohibits a veterinarian from ordering, prescribing, or making available a controlled substance, as defined, or xylazine unless the veterinarian has performed an in-person physical examination of the animal patient or made medically appropriate and timely visits to the premises where the animal patient is kept.
• In the case of an electronically established VCPR, prohibits prescribing of an antimicrobial drug for a period longer than 14 days. No further antimicrobial drug prescriptions, including refills, may be issued without an in-person examination of the animal patient.

AB 1399 was introduced February 17 by Laura Friedman and Josh Lowenthal. The California State Assembly passed the bill on May 31. The state legislature adjourns on September 14. If passed, then signed by the governor, the legislation would take effect in January.

Regardless of the bill's outcome, California's Veterinary Medical Board (CVMB) indicates it will continue to uphold the same clinical standard of care for patients seen via telemedicine as for patients seen in person.

Clarification: After publication, the California VMA changed its position on the bill to neutral. The AVMA did not change its position and believes telemedicine is most appropriate subsequent to establishing a veterinarian-client-patient relationship through physical examination or medically appropriate and timely visits to the premises where animals are kept.