There has been much written about the related topics of telemedicine, teleconsulting and being a “virtual vet” in recent issues of this and other veterinary journals. Perhaps as a result of my career path, two main aspects particularly interest me: remote viewing of ultrasonographic images and professional indemnity aspects of telemedicine. For the first 25 years of my career, I spent large amounts of time interpreting ultrasound images of the mare’s reproductive tract. For the past 10 years of my career at the VDS, I have been concerned with potential legal pitfalls facing equine vets going about their daily work.
At the BEVA Annual Congress in 2019, the future of telemedicine was the subject of a “moral maze” type debate and proved very popular (find out more in this event report published on Veterinary Practice). I was notionally the “foe” of telemedicine. In reality, this simply meant I would point out and share some of the real or potential scenarios involving telemedicine which could land a colleague in hot water with a civil negligence claim, or cause them to fall foul of our regulatory body.
Telemedicine has many definitions, but in my opinion, it is essentially the use of electronic communication and information technologies to provide clinical healthcare remotely. The ability to deliver effective veterinary care via remote appointments has gained enormous significance in recent years, especially in the face of a global pandemic, and it has been an extremely useful tool to have in our arsenal. However, it is important to appreciate that whilst development of these technologies to provide telemedicine has many advantages, there will be a price to pay and “ground rules” must be understood.
Clearly the ability to look at images remotely can be of huge benefit where geographical distances preclude regular physical veterinary contact. It is also true that veterinary practitioners can now consult with specialist radiologists on their conventional radiographs, MRI or CT images. However, we need to be wary of “cherry-picking” those aspects of telemedicine that a practitioner likes and disregarding the rest. Even with a simple task such as examining an image taken on a mobile phone, once you have passed a professional opinion on that image, it is possible you will be held accountable.
So, I was enthusiastic about participating as a moderator in a live panel discussion titled “Benefits and pitfalls of telemedicine in equine veterinary medicine” run by VetPD last month. A stellar panel was comprised of Cris Navas, an internal medicine specialist working at Penn Vet, Simon Staempfli, a theriogenology specialist working in equine practice in the UK, and Elizabeth Woolsey Herbert, who worked for many years in Australia. All three detailed how they have used telemedicine to wonderful effect.
I was particularly interested in a system Cris described, and I am indebted to him for providing me with additional information. By way of background, I always enjoyed helping colleagues in practice when they had a reproduction query or difficult case. If it involved the ovary and/or uterus they would usually simply try to recount their findings verbally, and believe me the descriptions I heard over the years often left me none the wiser as to what was going on! After a while, I persuaded colleagues that some sort of image would be preferable in order for me to assist them.
Over time this progressed from a mobile phone picture of the ultrasound screen (hopefully with the customary debris at least partly removed from the screen of the ultrasound machine and phone camera!) to a still image taken directly off the machine. Finally, we arrived to where we are now with colleagues sending a short video clip. However, often the angle of the transducer was not optimal to show the relevant structure.
It was with much interest that I listened to Cris explaining in detail about an amazing system which allows the ultrasound examination to be performed elsewhere, and live-streamed back to him in his office. Cris is a cardiology specialist so his main interest was in cardiac evaluation. However, his system would apply to any structure being imaged. As Cris explained it, the system is relatively easy to set up and not particularly expensive.
Initially, Cris sends out a document to the veterinarian who will perform the ultrasound examination, detailing what is needed (Box 1), and how to set it up (Figure 1). For in-house use among university clinicians there are laminated instructions with pictures for each machine followed by Zoom joining instructions. These are simply kept in a “ready to go bag” comprising the cables and the laminated instructions, so when someone needs remote assistance (often at night or the weekend) they can just come and grab the bag.
The first time Cris used the system with a practitioner vet in the field, he factored in time to troubleshoot. There is a list of common little things that have to be taken into account. Some examples are: live video port of the ultrasound machine, compatible video out with video capture, type of USB port of the computer/tablet, internet speed, settings in the computer (system video and sound) and settings in the Zoom app of the person connecting. The video port and the type of video signals it generates can change from different versions of the same make and model of machine so there is a little trial and error. Overall, there has not been a device that they have not been able to connect. Newer ultrasound machines are of course easier and usually you just connect the cables and all is good. The older ones tend to give more work.
To me this is a wonderful and relatively simple system enabling me to see the actual video image as the ultrasound examination is being performed on the mare. It would allow me to much better assist with what is being shown on the ovary or uterus, helping with diagnosing ovulation failure, optimal time to breed and any queries with early pregnancy diagnosis such as the presence of twin pregnancies or a diagnosis of early pregnancy failure.
Now the title of this article did indicate I would mention one aspect of telemedicine to be wary of and that is when the work done could be considered as being undertaken overseas. Outside telemedicine, we know that many colleagues who are insured with VDS do work overseas. To clarify the position there is an excellent VDS Advice Note “Work undertaken overseas – considerations for VDS members”. In brief, the insurance cover provided is not dependent on where the work giving rise to a claim was carried out. However, it is dependent upon the legal jurisdiction in which the civil claim is (to be) brought. This means that if a claim is brought from work undertaken abroad, you will be indemnified against it by your policy if (and only if) the claim is brought within the United Kingdom or the Republic of Ireland. Recently it has become possible to have your territorial limits extended to include the European Union, the European Economic Area and Switzerland. This is available to VDS members on request and incurs an additional premium.
Now the situation can be clouded when a vet is involved in telemedicine involving an overseas situation. In that situation, do they adhere to the licensing rules and regulations of the country/state in which the animal is located? Would their professional indemnity cover apply in such circumstances? These are difficult questions and the definitive answer may not currently be available, but such issues must be thought about when offering veterinary services via telemedicine to colleagues or clients overseas. So, it is vital that colleagues familiarise themselves with the requirements of relevant professional bodies in foreign countries and their obligations therein. There are often specific registration processes to comply with in order to practise legally in the relevant jurisdiction. Working illegally will invalidate your VDS Professional Indemnity Policy.
