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Are opinions on telemedicine changing?

01 May 2019, at 9:30am

At BSAVA Congress, a panel discussed the drivers behind digital healthcare innovation in the veterinary world

Telemedicine was once again brought to the forefront in the Big Issues stream at BSAVA Congress on 5 April 2019. Chair of the RCVS Standards Committee, Kate Richards; founder and CEO of veterinary care app Gula, Thom Jenkins; investor and former Chief Marketing Officer of Babylon Health, Richard Guest; and BVA President, Simon Doherty, made up the diverse panel tasked with navigating the complex world of digital patient care.

The journey so far

The availability of information has changed and the RCVS Standards Committee is looking at vet-to-client telemedicine and how it might best be regulated. Kate provided background to the session’s topics with an update on progress that has been made by the RCVS. There are two fundamental principles, she said: we must not compromise animal health and welfare and we must not compromise public safety.

The RCVS Strategic Plan describes an ambition to become a Royal College with leadership and innovation at its heart, and support this creatively and with determination. And so, after much deliberation, the Standards Committee decided that the key issue going forward was whether to change supporting guidance regarding the term “under care”. Responses have been very diverse, and Kate explained that this demonstrates the complexity of what we’re trying to deal with.

“To work out what the risks of telemedicine are, we proposed a trial for discussion at Council.” This discussion took place in November 2018. There were two recommendations: firstly, to amend the guidance to make it clearer and secondly, to undertake a time-limited trial managed within strict boundaries. Council’s opinions were diverse, the discussion was heated and there were concerns, so it came back to the Standards Committee.

Several issues were raised for further consideration:

  • The 24/7 requirements
  • The impact on antimicrobial resistance
  • Whether more species should be included
  • Potential wider impacts of “under care”
  • The need for wider stakeholder involvement
  • More details on trial design and administration

The conversation is ongoing and the main challenge, Kate said, is trying to navigate the RCVS code of conduct, regulators’ code and the RCVS charter 2015 with a profession with very divergent views. “We want to facilitate and enable professional judgement,” she said. Is this an opportunity to be more inclusive and reach out to those owners who are not registered with a vet? And to reach those who are registered with a vet but don’t always go when they should?

Kate used the term “technological myopia” to describe our tendency to underestimate the potential of tomorrow’s applications by evaluating them in terms of today’s technology. She reminded us of Richard Susskind’s research; when asked if the professions need to change, every profession said something along the lines of “Yes, professions do need to change, but it won’t work for this profession."

To conclude, she asked the audience to consider whether we can afford not to “square the circle”. And here, to consider “afford” not just in terms of cost, but in terms of maintaining our regulatory status and upholding animal health and welfare. “It’s about public safety interest, it’s about proper standards and conduct of welfare.”

A view from the innovators

Thom Jenkins is the founder of an app, Gula, that offers veterinary video consultations to pet owners. Before starting Gula, the team surveyed over 200 pet owners, the results of which provided two resounding conclusions: people love their pets, but they don’t always love going to the vet. We often think about cost in these discussions, but interestingly, only 5 percent of respondents to that survey mentioned cost as a barrier. It seems that perhaps the barriers are in the effort it takes to undertake a visit to the vet clinic.

The client and patient journey can be long: find a clinic, book appointment, get pet to vet, wait at reception, nurse check, consultation, communicate next steps, check out and payment, follow up, client feedback... “Most clinics have a website; many have digital appointment booking, digital pharmacies, email, sms and push notifications. But fundamentally, the experience still looks very similar.”

The experience can be very effortful for the client who thinks their dog has a lump, but it turns out it’s a nipple, Thom said. “Telemedicine can provide a curated, tailored experience for each pet and owner, instead of shunting them down the same customer corridor.”

With telemedicine, the hope is that owners will come in earlier because we are reducing the barriers. It will be good for pets, owners, vets and clinic

Why should we bother? Recent research indicates that vets currently only address 8 percent of all pet issues, Thom said. And rarely will somebody book an appointment at the vets in the early stages of a problem. “With telemedicine, the hope is that owners will come in earlier because we are reducing the barriers. It will be good for pets, owners, vets and clinics.” Thom doesn’t expect telemedicine to replace veterinary practices, but rather, augment them and allow better access to expertise.

It was interesting to hear the data that have accrued from the early stage of Gula’s launch. Most pets have more than one caretaker, but often it is the female caretaker that brings a pet into a practice. It was interesting then, to hear that 55 percent of callers on the Gula app have been male. Telemedicine may be engaging a different group of owners, Thom suggested.

Insight from human health

Richard Guest continued the conversation with his view from the human healthcare perspective; Richard helped to launch the NHS “GP at hand” service in conjunction with Babylon Health. In children down to about four to five years of age, the problem was resolved through telemedicine 60 percent of the time. With babies, because things can go downhill quite fast, the telemedicine service is often used as reassurance for parents, he said, suggesting that users like to be reassured either that their baby is fine or that they do need to book an appointment at a practice.

We can compare this to the early data from Gula: 50 percent of calls resulted in a non-emergency recommendation to see a vet; 40 percent of issues were resolved on the call; and 10 percent were genuine emergencies with recommendations to go and see a vet immediately.

In terms of improving the client journey for human healthcare, prescriptions were available within hours and could be picked up from any pharmacy; it was designed to be very convenient. And as you would expect, prescriptions were banded depending on the medication.

One big benefit was that young female GPs who had just had babies found it very useful to be able to work remotely and flexibly. These doctors could manage a four-hour stint on telemedicine when they wouldn’t have been able to rejoin a surgery, so it adds capacity back into the system. Given the retention issues in the veterinary profession, this would surely be a benefit in our profession too – perhaps helping to ease the transition from maternity leave back into practice.

Another benefit is that video appointments can be recorded and are easily accessible by the patient and doctor – which is useful for both the patient (who may forget what has been said) and the doctor (particularly if there is a complaint about what happened in that consult).

The big question when developing the human healthcare app was, from a clinical point of view, “is it safe?” Richard believes that the right question to be asking is “is it safer than what normally happens?” “Practically nothing is totally safe – including not seeing the doctor,” he said.

Food for thought

Simon Doherty, President of the BVA, added some food for thought in his contribution to the session. The Veterinary Surgeons Act does not provide a clear definition of “under our care”. There is a clear concept, but that is changing, he said. James Herriot had a very hands-on approach with the animals under his care, but consider aquaculture and the poultry industry in the current day. “We don’t lay our hands on all these animals. Fish farms have a huge amount of video technology, robots and sensors that give us a lot of real-time information, and it’s going that way with poultry.”

Richard told delegates that the NHS has a long-term plan which dictates that there will be a new patient right to web and video consultations by 2021. There is an expectation arriving that what’s happening in human health should be available in animal health and veterinary medicine, Simon said, but the question we should start asking ourselves is: are the drivers slightly different? We’ve got non-vocal patients. “That model of reassurance is a powerful one,” he said, “we’ve all been in a situation where we’ve had clients phone us in an evening looking for some reassurance that actually something is OK to wait until the morning”.

In a 2014 BVA survey, 82 percent of vets said clients have challenged their diagnosis, recommendation or professional opinion based on their own internet research. Simon urged delegates to remember that many more will undoubtedly be Googling things that they won’t then bring to the vets.“

Clever use of technology could cause increased productivity, helping vet businesses remain sustainable and keeping costs down for clients. We can refuse to talk about that change, but sooner or later we’re going to be forced to. It’s better that we embrace some of the digital disruptive technology now.”

Senior Editor at Veterinary Practice

Jennifer Parker, Bsc, MSc, PgDip, is Editor of Veterinary Practice magazine. She studied zoology at the University of Reading, palaeoanthropology at University College London and completed a postgraduate diploma in endangered species recovery with Durrell Wildlife Trust and the University of Kent.

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