delivered – synchronous and asynchronous. Synchronous consultations occur on a real‐time basis and technology is typically used to provide an audiovisual encounter. In most cases the client is using their own smart device to communicate, but in some cases visiting paraprofessionals may be remote and act as telepresenters on the client's behalf, providing more hand‐on evaluation. With asynchronous telemedicine, sometimes referred to as “store‐it‐forward” care, the consultations do not happen in real time. The client can submit questions, images, videos, laboratory results, etc. for the veterinary team to comment on and respond at a later time. While this lacks the personal touch of synchronous consultations, it is often much easier for both busy clients and veterinary team members to accommodate in their schedules.
Other than teleconsultations, the most common forms of telehealth relate to things like provision of prescriptions based on VCPR, recheck evaluations, after‐hours care, postsurgery check‐ups, patient monitoring through wearable devices and other technologies, and even following up on hospice care patients and others for which in‐hospital visits are not possible or not convenient.
Telehealth can be provided directly by a hospital (e.g., telephone, teleconferencing, email, etc.), but there are now several companies, programs, platforms, and applications that facilitate the interaction and monetization of the process.
2.5.6 Remote Monitoring
Technology is now available that allows remote monitoring of pets, and this can be an important resource when considering virtual care. The most common forms of remote monitoring are wearable collars, but other options for remote monitoring include glucometers, blood pressure devices, Holter monitors, and even sensors that can allow auscultation and other features.
Wearable collars with sensors are the most common form of remote monitoring. These collars can typically measure position (lying, sitting, standing), activity, pulse, respiration, and even heart rate variability. The measurements are generally collected continuously and in real time. For many of the devices, the veterinary healthcare team can access the information any time of the day or night through a cloud‐based server.
There are many reasons why practices would choose to monitor pets remotely. For pets with existing medical issues, especially chronic problems, wearables allow measurements to be taken continuously and analyzed in real time. For certain devices, systems can be set up to send alerts when specific thresholds are exceeded. This can alert the pet owner and the veterinary team when action is required, including bringing the pet in for a visit or taking it to an emergency facility.
One of the most useful features of wearable collars is that they can allow the team to determine actual resting heart and respiration rates for pets, which may be difficult if not impossible to collect during office visits. Many pets are anxious or stressed during visits to a veterinary hospital, and heart and respiratory rates taken during those visits may be significantly altered. However, in the comfort of a pet's own home, such measurements are much more likely to be indicative of actual resting rates. It might also be possible to use wearables to infer relative stress levels in pets in different circumstances, including shelters and other environments.
Another important development in remote systems is continuous glucose monitoring, which is available for both dogs and cats. Glucometers are available that can be used to sample interstitial blood for glucose determinations, but it can be difficult to collect enough samples over time to approximate a glucose curve in pets on insulin therapy. Similar to the human devices, veterinary continuous glucose monitors have a sensor that is inserted under the skin to read blood glucose levels. A garment is typically used to cover the device so that it is not dislodged. In general, the devices sample the capillary fluid every five minutes or so, and once analyzed can provide a more complete picture of glucose status. Without such home testing, it would typically take hospitalization of the pet and sampling of the blood glucose every few hours to determine glucose peak and nadir. Older remote systems offered only retrospective analysis of the glucose concentrations after disconnecting the sensor and uploading the data. Newer systems measure and display glucose reading in real time, allowing direct intervention and altering insulin doses accordingly.
Remote monitoring can also play a key role in wellness care. With overweight and obese animals constituting a near‐epidemic in small animal practices, exercise is often recommended as part of the solution. Fitness wearables, in most cases accelerometers, can be used to track effectiveness of a prescribed regimen, and additional devices such as connected scales can be used to monitor weight at home between office visits. Wearable devices with accelerometers can also be used in rehabilitation after surgery or injury and can provide the veterinary healthcare team with real‐time data.
Expect that in the years ahead remote monitoring will become an even more important part of pet‐specific care, and clients will expect this option from veterinary teams.
2.5.7 Financial Aspects of Virtual Care
Pricing for telehealth services will vary depending on how the telehealth service is to be integrated into the practice workstream, vendor‐associated charges, and the costs associated with offering telehealth solutions
Telehealth pricing can be used to drive other health‐related services. For example, it might be included with payment (wellness) plans (see 10.17 Payment and Wellness Plans) as a less costly way of honoring the ongoing provision of services in a bundled care plan. It could also be priced in an à la carte fashion based on a time‐based teleconsultation (either the length of the consultation or how quickly the response is needed). As a variation on a bundled service, teleconsultation could also be subscription priced. The opportunities are only bounded by one's imagination and clients' requests for services.
Virtual care services do not need to be problematic for the hospital team, and there is much flexibility that can be built into the system. Initially, teams may determine when in the schedule there are more likely to be gaps not filled by regular appointments, and those times can be allocated for virtual care. When clients cannot be immediately accommodated when they request same‐day appointments, they can be offered a telehealth option in its place. It is important to realize that times that may be inconvenient for clients to bring their pets in to the clinic are not necessarily times when the client cannot make themselves available for a virtual consult.
Veterinarians may initially have some worries that offering telehealth services will cannibalize their office visits, but such fears are generally unfounded. In most cases, clients request virtual visits for assurances on whether in‐clinic visits are needed. In many situations, clients will request telehealth consults so they have a better appreciation for what may be needed, but probably 70% or so of virtual care visits eventuate in the clients bringing their pet to the clinic. If human telehealth is any indication, making access to healthcare more convenient triggers new use of medical services rather than a loss of doctor office visits.
For practices that already offer payment (wellness) plans for their clients, virtual visits are a very effective way to leverage those plans, as well as to triage patients online or over the telephone to determine if the care required is part of the plan or actually constitutes a level of care that is not covered by the plan. In many cases, clients are prepared to have access to a veterinary expert just to allay their fears or to justify the need to actually bring their pet into the hospital. Virtual visits can either be incorporated into existing payment plans or clients could be asked to pay an additional fee to the payment plans to entitle them to pose questions by email, text or telephone as part of a monthly or prepaid subscription plan.
Part of the triage system that can be useful for both pet owners and veterinary teams is to allow doctors and/or nurses to screen potential emergency calls to determine whether a pet really needs to go to an emergency center, or whether the
