Guide to Veterinary Telemedicine Consults
The veterinary profession has been rapidly adapting to meet the current challenge of Covid-19, meaning that staff are under more pressure than ever to learn new skills within a tight time-frame. Video consultation forms an essential cornerstone of the arsenal vet practices can use to maintain client loyalty, generate revenue and survive this crisis. The RCVS recommends remote consultation as a step in their Flowchart - Guidance for clinical practices during COVID-19: ‘Can I do it?’1. For those that are new to telemedicine, it is important to acknowledge that consulting via video has key differences from face-to-face consults. We have put together our top tips as a guide for vets and vet nurses to help.
Planning for consistency
It is vital for internal practice communications to have regular (virtual) practice meetings, and one of these should be dedicated to clearly and effectively communicating how to implement the remote consulting protocols to ensure a consistent, streamlined experience for clients and staff alike. The IRIHS research group at the University of Oxford have put together a guide for human medicine GP practices2, which stresses that staff members and clients are more likely to respond positively to this development if it is presented as an improvement in service, rather than an introduction of new technology. This review also suggests agreeing which appointments can be given via teleconsults, deciding what software will be required, and ensuring that there is technical support on hand. The team at VisioCare Services are available to support veterinary practices with implementing Linkyvet, a highly practical telemedicine app with advanced features that allow the vet to direct the consult for example by zooming to examination areas or applying light (read more here).
Of course, a degree of flexibility and case-by-case professional reasoning is necessary to decide when a video consultation is appropriate. However, it is helpful to have a framework in place to help practitioners decide when teleconsultations might be used. Decision flow-charts have been developed in human medicine3 and each veterinary practice can look to develop their own equivalent on the basis of the most recent professional guidance by RCVS, BVA and other veterinary organisations. This should also take into account staffing levels and practice resources.
At this stage, pricing of consultations should be considered — vets and nurses are still offering their valuable expertise, clinical knowledge and time so appointments should be charged accordingly. Practices that are already using Linkyvet across France, Switzerland and Canada tend to charge 80%-100% of what they would for a face-to-face appointment of equivalent length.
If clinicians are working from home, it’s helpful to put in place a GDPR compliant system for remote access to client records. This helps with consistency of care as vets and nurses are able to read and update the clinical history.
Transferring clients from phone call to chargeable video consult
When possible, it is helpful for a member of the veterinary reception team to answer and triage calls. This way it is easier to direct owners over to a chargeable video consult (unless an emergency face-to-face is clearly required) than if the vet or vet nurse has answered the initial phone call. Otherwise owners are more likely to request advice free-of-charge over the phone. On the initial phone call if it is decided that a video consult would be appropriate as a next step, use clear and professional language to signpost this to the owner. Refer to the option as a ‘video consultation’ or ‘remote consultation’, so it is clear that this is a paid-for professional service. Have a list of reasons to hand for suggesting this e.g. the ability to visualise the pet and make better assessment of their condition, or booking a proper appointment slot into the diary so that you have time dedicated to that patient and their owner.
Communicating the new service to clients
Websites and social media platforms must be updated to reflect the new service that the practice is offering. This should include benefits that the service will bring to clients (during and post Covid-19 social distancing measures). You can get ideas here. It is helpful to include basic instructions for clients on how to book a virtual appointment, and any software that they need to download prior to their session, and remind them to charge their device prior to the call. It can be helpful to ask them to send in videos and images taken prior to the consultation so you can refer to these during the consultation. This can help if the pet isn’t showing a particular behaviour (e.g. circling) during the live consultation.
Preparing for a consultation
Ensure that you have access to the patient’s records, where possible, ideally visible on a second screen. Try to perform the consultation in a quiet and professional surrounding, avoiding busy reception areas if you are at the veterinary practice, or removing any personal items if you are in a room at home. Request a back-up telephone number when taking the appointment booking so that you are able to contact the client if the software is not working or if the video call drops part-way through the consultation.
Getting started with the consultation 2,4
It is essential to develop strong communication with clients by taking the time at the start of the consultation.
1. Confirm that the client is able to see and hear you, and then introduce yourself (if you have not met before) or signpost the fact that you saw their pet on a previous date (if relevant and detailed in available records).
2. Refer to the service as a remote consultation or telemedicine consultation, trying to avoid informal terminology that devalues the service or your advice such as ‘catch up’ or ‘chat’.
3. Double-check the client’s telephone number in case their (or your) internet drops and you need to contact them.
4. If necessary, explain that you are working remotely so records are taking longer to update. Confirm whether they have spoken to another vet within the past few weeks and whether their pet is on any on-going treatment.
5. Briefly let the client know what to expect from the call and let them know that it is secure and confidential.
6. Tell the client that you may occasionally go quiet if you are taking down key notes or referring back to the history, but that you will do your best to let them know.
7. Pay attention to body language – try to show the client that you are listening through non-verbal cues.
8. Make it clear whether or not the pet needs to be there for the whole consultation, and that you may ask to see certain parts of the pet closer-up. Ask whether the owner feels comfortable handling their pet for any such examination, and reassure them that it is ok to tell you if they would prefer not to carry out a certain instruction. They must take care not to get injured, and even the loveliest of pets can nip if they are feeling sore or poorly.
9. Start history taking with an open question that allows the client to give an overview of their concerns. Try to achieve a balance of open and closed questions, in the same way that you would during an in-person consultation. You may notice you have a greater tendency to ask questions quite rapidly via remote call, so try to keep a slower pace.
10. Summarise the owner’s history – make sure that they feel listened to. This is even more important than with a face-to-face consultation and it offers clients the opportunity to fill in any gaps that they or you have missed.
11. There is an element of thinking on your feet during a teleconsult and fewer opportunities to create space for yourself as you conduct the examination. Ways that you might do that include asking the pet owner to slowly scan the pet with their phone from nose to tail. You can also ask to look at the pet’s surroundings or observe its gait.
12. Some people might find it easier to have a checklist to hand to recreate the structure that they automatically instigate when doing a physical exam. This also helps you listen to answers rather than trying to think what your next question might be.
13. Be clear about what you can’t do – so for instance: Now I’d normally listen to your pet’s heart and lungs but we can’t do that remotely so I’m going to ask you a few questions that will help me find out if there is likely to be a problem here….(having a list of those questions you need to ask, where you would normally fill that gap with the physical exam is really helpful at this point).
14. Take the time to explain possible diagnoses, and whether any further tests are required down at the practice. At time of writing the RCVS are allowing vets to prescribe remotely5 , using their clinical judgement to deem where this is appropriate to balance social distancing measures. If you decide to prescribe during a telemedicine call, make the owner aware that this may not be possible post-lockdown, and explain the process for receiving prescriptions or medications.
15. Before the end of the call ask the patient whether they have any further questions, try to avoid putting the onus on the owner (e.g. did you understand?) as this can come across as patronising. More positive wording such as ‘is there anything else I can help with today?’ or ‘is there anything you would like to discuss in more detail?’
16. Ending a call can come across as much more abrupt via video consult than in-person consultations. This is because you do not have the same time during which the client is leaving the room or you bring medication to reception. Make sure it is very clear to the client what the next step is (e.g. check-up appointments or prescriptions) and then say that you are ending the call and that when you do they just need to close their window on their device.
17. Taking notes is just as important as with face-to-face consultations. Software such as Linkyvet enables you to make brief notes during the consultation which you can add to later and then integrate into your Practice Management Software (PMS).
Striking the right tone
Keep the pace of communication slower than with face-to-face consultations. Think about the consultation as a professional service, and use language that reflects this. Try to use affirming body language to show the client that you are listening and engaged with what they are saying. It is perfectly fine to watch them on the screen; you do not need to worry about maintaining eye contact with the camera as this will feel very unnatural. You may have to use words more frequently to show you are still listening if the client is giving a longer explanation. Otherwise don’t rush to fill a silence and do feel comfortable to explain that you are taking a few minutes to write down their details on the clinical record. Remember the client probably finds the process as strange as you did the first time, so a few words of encouragement and praise will help them too. Like us as professionals, owners will quickly accept, adapt and embrace this tool, which is a huge asset both during this period of social distancing and beyond.