In the past, obtaining a radiology specialist’s opinion sometimes meant traveling to a veterinary teaching hospital. This required time and money and certainly delayed treatment.
Today, telemedicine allows radiologists to diagnose patients without ever placing their hands on the animal. Primary care veterinarians can send X-rays and other medical information electronically and receive a report in a matter of minutes or hours.
“Using a telemedicine service means a general practitioner can have a radiology department without having board-certified radiologists on the payroll,” says John Feleciano, DVM, Dipl. ACVR, manager of Idexx/VDIC Telemedicine in Clackamas, Ore. “Veterinarians say they find the service to be professionally and medically enriching and it brings financially tangible and intangible benefits.
“Owners are comforted by having a built-in second opinion by board-certified veterinarians.”
The days, and sometimes nights, of telemedicine veterinarians are filled with exchanges of medical information and questions. Primary care givers ask specialists to confirm a suspicion or help unravel a complex case.
“We have specialists available 24 hours a day, although the cases we receive from midnight to 6 a.m. are generally limited,” says Victor Rendano, VMD, Dipl. ACVR, Dipl. ACVR (RO), president of eVet Diagnostics in Lansing, N.Y. “We read X-rays in the order they come in unless they are marked ‘STAT,’ in which case they’d go to the top of the pile.”
Experts say that advertising all the services a practice provides, including access to telemedicine, may increase owner compliance and enhance the confidence owners place in the primary care giver.
The American Veterinary Medical Association’s policy on fees and remuneration states:
“In connection with consultations or referrals, it is unethical for veterinarians to enter into financial arrangements such as fee splitting, which involve payment of a portion of a fee to a recommending veterinarian who has not rendered the professional services for which the fee was paid by the client.”
This policy can be interpreted in different ways, but some telemedicine veterinarians say it means their consultation fee isn’t to be enhanced by the primary care veterinarian. That is, if they charge $50 for their service, the client’s bill shouldn’t be padded to give the primary care veterinarian a cut of the fee.
“In our experience, if the owners have the option of getting a telemedicine consultation at the time of initial exam, they perceive this as a positive thing,” says Anne Bahr, DVM, Dipl. ACVR, medical director at PetRays in The Woodlands, Texas. “Getting a board-certified specialist involved remotely can save a pet owner the time and expense of another visit to a specialist, oftentimes hours away.”
“Telemedicine evolves every year,” Dr. Feleciano says. “It has been a functional business since the mid 1990s, but its popularity has grown exponentially as the migration of specialists from academia to practice has increased. This growth allows primary care veterinarians to offer a higher level of patient care.”
Some primary care veterinarians look for a fast return at the lowest cost, experts say. But each telemedicine company has policies that may not fit with the primary veterinarian’s needs and wants.
“X-rays aren’t always black and white, pardon the pun,” says Matthew Wright, DVM, MS, Dipl. ACVR, founder of Sight Hound Radiology in San Diego. “Reading X-rays is still a trial-and-error process. It’s not like you look at an X-ray and immediately know the diagnosis, which is why having a relationship with the referring veterinarian is important.”
Feedback from a referring veterinarian is important, telemedicine specialists say, because they want to know how a case ended and they want to improve what they can offer primary care givers and pet owners.
“Some primary care veterinarians use multiple telemedicine veterinarians or companies,” Dr. Wright says. “This isn’t the best route because relationships can’t be built this way. Using one company and sticking with it means the telemedicine veterinarian can learn when he did a great job and when something could have been done differently. One-time relationships typically don’t vastly benefit either party.”
Some telemedicine companies say quality doesn’t have to be sacrificed when speed or cost are involved. Expediting service at the necessary level comes naturally.
“PetRays has a 30-minute STAT turnaround for radiology cases,” Dr. Bahr says. “In immediate life-threatening conditions, this rapid response enables the referring veterinarian to quickly diagnose and treat the critical animal in an expedited fashion. In trauma, saving time is saving lives.”
Digital Imaging and Communications in Medicine (DICOM) permits the integration of scanners, servers, workstations, printers and network hardware from multiple manufacturers. The subsequent picture archiving and communication system (PACS) is the preferred way of receiving images by many telemedicine veterinarians.
A specialist’s opinion through telemedicine can be obtained without the latest technology, but some companies require images of a certain quality. That may pose a problem for a veterinarian with a small caseload who can’t justify the expense of installing digital radiology equipment.
“While DR [direct radiography] or CR [computed radiography] is preferred, oftentimes a digital X-ray is adequate if properly taken,” Bahr says. “High-quality, high-definition digital cameras are widely available now at affordable prices. For consults such as dermatology, a high-resolution color picture can be essential.”
Some veterinarians provide real-time ultrasound images to telemedicine specialists, says eVet’s Dr. Rendano.
“When using technology in real time, the veterinarian needs to be organized before getting the telemedicine veterinarian involved,” Rendano says. “To be most cost effective, the staff needs to be ready, the animal needs to be properly prepared and everyone needs to know their role. There have been times when the animal needs to be prepped still or it isn’t cooperative and more workers need to be called back to help.
“This all takes time, which costs more money. If this capability can be used properly, it can be a great asset.”
Neurologists making assessments remotely sometimes view video of the animal’s movements, which can help in making a diagnosis.
Here are some of the specialties offered by telemedicine companies. Not every company offers every specialty.
• Internal medicine
• Critical care
Telemedicine veterinarians say primary care givers often start off using the service for one or two cases, then choose to send all their X-rays or every case in which the diagnosis is uncertain.
Every telemedicine company proudly touts the times its services were key in making a lifesaving diagnosis.
“We received films from a post-surgical orthopedic case in which the surgery appeared to be a success,” Feleciano says. “We then received the 8 weeks post-operative X-rays that showed an enlarged lymph node behind the knee. We reported the problem lymph node and the veterinarian performed a biopsy, which revealed cancer. The dog wasn’t sick from the cancer yet, and treatment was able to be started much earlier than if we had never seen those follow-up films.”
While human medicine has the American Telemedicine Association, no such organization exists in veterinary medicine. The lack of a formal professional association makes it difficult to break down how many veterinarians use telemedicine and the quality of services performed by individual companies. But everyone agrees telemedicine is growing.
“Younger veterinarians are more likely to use telemedicine services,” Wright says. “I can speculate that veterinarians who have been practicing longer are used to doing everything themselves, but that is just a guess.
“As telemedicine radiologists, we are supposed to ‘mother’ the specialty of radiology, making sure we provide the best report based on the best information available. Sometime veterinarians are turned off when asked for additional information or better quality images, but that is what needs to be done.”