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The original version of the VCPR
At the time, however, the VCPR was still a loosely defined concept. The legal upshot was non-VCPR holders could not legally prescribe drugs. However, what exactly constituted a VCPR was somewhat murkier. Here's what U.S. federal law states:
"A valid veterinarian-client-patient relationship is one in which:
1) A veterinarian has assumed the responsibility for making medical judgments regarding the health of the animal and the need for medical treatment, and the client (the owner or other caretaker of the animal) has agreed to follow the instructions of the veterinarian;
2) There is sufficient knowledge of the animal by the veterinarian to initiate at least a general or preliminary diagnosis of the medical condition of the animal. This means that the veterinarian has recently seen and is personally acquainted with the keeping and care of the animal by virtue of examination of the animal, or by medically appropriate and timely visits to the premises where the animal is kept; and
3) The practicing veterinarian is readily available for follow-up in case of adverse reactions or failure of the regimen of therapy."
Those are the basics. Reading between the lines, however, the exact details on what constitutes a physical examination, what "sufficient," "recently," "timely," "acquainted," "available" or "appropriate" means remains relatively opaque.
These vague legal gestures prompted the AVMA and American Animal Hospital Association (AAHA) to build ethical frameworks around the VCPR, which were later embedded into state practice acts. Nevertheless, interpretations varied based on species, circumstances, and local standards of care.
Hence, why our states' practice acts stepped in, tweaking the laws to their specific interpretations. However, even the most restrictive states have left most definitions and timelines intentionally vague (until recently, in some notable cases); and while a physical examination was always implied, it was rarely (if ever) explicitly stated.
Note: Our state boards have historically enforced the contents of our practice acts as if the in-person physical exam were an explicit requirement (unless stated otherwise). In these cases, it seems that local standards of care and the AVMA's own ethical guidance served as the default setting and not the federal law or state practice acts.
Today's VCPR in practice
Fast forward to the post-pandemic age and things have gone beyond murky into the fully muddled. Now that our professional powers-that-be have deemed telemedicine an existential threat that deserves a reckoning, our state practice acts have by now adopted some kind of telemedicine-specific rules, which are still changing and vary widely by state. Here's a quick snapshot of what the landscape looks like now:
- All 50 states regulate telemedicine through the VCPR.
- Only about six states clearly allow establishing a VCPR virtually.
- Around 40+ states still effectively require in-person exams.
- The rest sit in ambiguous statutory language.
Then there's the fact some state bills got layered on top of our practice acts. This happened in both California and Florida, where the states went against the profession's wishes to enact bills that allowed consumers greater access to veterinary telemedicine. This legal layering has given us a system of clashing laws that are clearly incompatible.
Where does this leave veterinarians?
We're in legal limbo, folks (and headed the wrong way if you practice in Florida or California). While, on paper, it may look "easier" to practice telemedicine in states with "permissive" laws, it's not. The laws didn't make telemedicine easier, they simply made them more discretionary. This means we have more permission to practice telemedicine, but there are more ways we can be held responsible for doing so.
For example, we can now establish VCPRs online in California or Florida, but the new definitions for the VCPR make it harder for all veterinarians to get into trouble for issuing refills without physically re-examining patients—even for those they might have examined as recently as the day before.
Be careful what you wish for
The laws are now so convoluted and hard to read, stacked as they are, not even the legal expert giving this year's mandatory three-hour "laws and regulations" CE in Florida wanted to tackle the issue. (He barely gave it a mention.) Meanwhile, those of us in the trenches now have to watch our backs each time we speak to clients by telephone or write prescriptions for pets we haven't seen for the same exact condition for a specified amount of time. (Is it two weeks for antibiotics and four for other meds or was it the other way around?)
None of this would be the case, mind you, if we hadn't actively engineered this morass for ourselves. In trying so desperately to thwart the efforts of those who would elect to practice online (ethically or otherwise), our profession has regulated itself into self-destructive knots. All because we're so ethically high-minded we can't bear to see our profession ruined by non-veterinary actors, online or otherwise. (Get a grip, guys: That ship has already sailed, and we've done precious little about that problem.)
The law of unintended consequences
Sure, it'll be harder to practice telemedicine safely in any form. Which is what we obviously wanted, wasn't it? But what will happen to clients who can't bring their pets in immediately for legitimate reasons? What happens to the pregnant doxie treated by UT via telemedicine a couple years back? She'd be out of luck too. Or your sister's dog that no vet will treat because he's an aggressive farm dog who needs a controlled med cocktail to be safely knocked on his ass? (And no one wants to get that close.)
Many legitimately teleconsult-needy patients would never see a vet, much less a script, if the newly sainted VCPR had its way nationwide. How is that humane? Or fair?
Oh, and by the way, those of you in certain states should tell all your friends and family to stop calling you for advice. If you haven't examined their pets in X number of days for the condition they're concerned about, I'm pretty sure any medical advice involving at-home treatment is illegal now, too.
We were already pretty worked up about getting sued or disciplined. I don't know about you, but this new layer cake of anti-telemedicine-related VCPR legalese is absolutely compounding that sensation for me.
As if all that weren't enough, more unintended consequences are sure to follow. The one I'm most concerned about involves Dr. Chatbot. When we stop telling our clients they can't get any help or refills without a very recent physical exam, I promise you some of them will defect to other practices. A subset of these will go one step further: They'll substitute us with their favorite chatbot's teleconsult session. Guess what? It's absolutely legal for them to do so.
Patty Khuly, VMD, MBA, runs a small animal practice in Miami and is available at drpattykhuly.com. Columnists' opinions do not necessarily reflect those of VPN Plus+.
