One of the most common questions I hear from veterinarians who are looking into or have just begun offering telemedicine is: What cases are appropriate for a virtual visit? Indeed, proper case selection is imperative if we are to achieve success in veterinary telemedicine.

But taking a step back, we DVMs soon realize we already know which cases are good fits and which are not. Every phone consult we’ve ever performed during our skipped lunches and end-of-day call backs falls under the guise of telemedicine. We are, in fact, admirably able to decide from a chief complaint, signalment, and history whether we can provide proper care through client communication alone or a hands-on physical exam with diagnostics. 

The real question my colleagues have, then, is rather: 

“Is there a list of cases that our CSRs and veterinary technicians can use to schedule telemedicine visits appropriately?” 

Yes, but first, let me highlight two things I’ve just done: 

1. I’ve included veterinary technicians in the list of players necessary for telemedicine success.
2. I’ve called telemedicine interactions “visits” instead of “appointments” to focus your attention on the fact that the patient has skipped the front lobby and landed in your virtual exam room. In my practice, this is vet tech territory. 

The Paradigm Shift

Your CSRs, who are already drowning in curbside phone calls on top of their other duties, have NO FORMAL MEDICAL TRAINING. Yet we are tasking them to triage calls in order to fill our telemedicine schedules. Wouldn’t it make more sense to use your trained-to-the-gills RVTs (and superbly experienced veterinary assistants) to determine if questionable cases can be directed to a virtual visit? For a deeper dive into this idea, check out Dr. Jessica Vogelsang’s delightful interview with Liz Hughston, RVT, here. 

The 4-Step Telemedicine Decision Tree

1. The clinic establishes basic guidelines for straightforward telemedicine cases (ex. post-op incision rechecks).
2. A client calls with a presenting complaint.
3. The CSR automatically schedules straightforward telemedicine cases. 

           a. The CSR conveys telemedicine is being offered to increase client convenience and decrease patient stress. 

            b. The CSR also informs the owner that the DVM may desire an in-clinic exam based on the telemedicine visit if deemed necessary. 

      4. When a client presents a questionable case, the CSR transfers the call to the vet tech “telemedicine liaison” for further evaluation and scheduling.

In this scenario, realize the initial clinic guidelines for automatic telemedicine cases will adjust as exceptions arise and as staff members gain confidence. In the beginning, keep your list of default telemedicine visits small and rely heavily on your RVTs to fine-tune your case selection. 

The List

According to the GuardianVets FAQs, telemedicine MAY be appropriate for the following situations, provided that a valid VCPR is in place and that professional services can be safely provided to your patient. (Note: I’ve listed these in order—from most straightforward to least—to aid the drafting of initial clinic guidelines.)

• Post-operative follow ups.
• Recheck exams (that do not require lab work or cytology).
• Fear-free evaluations of anxious patients (popular with the cat crowd).*
• Hospice care.*
• Behavioral consultations.*
• Nutritional consultations.
• Management of stable chronic conditions (including DM, Cushing’s, hypothyroidism, epilepsy, OA, IBD, EPI, KCS, atopic pruritis without alopecia, allergic conjunctivitis, etc., assuming bloodwork is performed as needed).
• Dermatology concerns (that do not require cytology or palpation of masses).
• Weight-bearing orthopedic concerns (best with video of gait and posture ahead of time).
• Daytime triage to determine the need for a physical visit for any non-emergent presenting complaint.
  
  

* Conditions for which telemedicine can be superior to the in-person exam. 

Telemedicine is NOT appropriate for the following situations:

• New, non-established patients or clients (look to your state practice act for COVID exceptions).
• Presentations that require an in-person physical exam (i.e., emergent, complex, or your Spidey sense is tingling). 
• Presentations where the patient is not residing within the state that you practice in and are licensed in.
• Any medical or practice scenario that does not meet your state’s practice act regulations.
• Situations where you do not have adequate lighting, telecommunication, or cannot effectively communicate with the owner in order to advise, diagnose, and/or treat.

It will take years of compiled case studies to establish a list of specific diagnoses for which telemedicine proves useful, but here’s a start, nose to tail:

• Reverse sneeze
• Atopy with bilateral rhinitis, conjunctivitis, and/or epiphora (without blepharospasm)
• Cherry eye
• Feline URIs (still eating and drinking)
• Brachycephalic strabismus, stenotic nares, and stertor
• Bee-sting focal swelling (short of angioedema)
• Collapsing trachea
• Ruptured cat bite abscess
• Papillomas
• Superficial skin wounds (unless associated with major trauma)
• Hair ball (vomiting)
• Regurgitation vs. vomiting (with appropriate video)
• Mild gastroenteritis
• Umbilical hernia
• Mild (moist) paraphimosis
• Colitis (with photos of hematochezia)
• Uncomplicated avulsed toenail 
• FAD

Feel free to grow the list as you gain experience. The guiding principle for case selection is simple: if you can see it, you can probably telemedicine it. If you have to smell it, feel it, auscult it, image it (or cytology, skin scrape, Schirmer, fluorescein, tonometry, or lab work it), you can’t. In addition, most dental disorders cannot be properly assessed through cell phone video due to patient movement and needing five hands to get the job done. 

Nonetheless, as long as we rely on well-honed clinical judgment to provide the best care possible, our clients, our patients, and our staff will all benefit from the tool of telemedicine.