18 Sept 2020
The start of the COVID-19 lockdown meant an immediate need for transformative change in the methods, systems and structures of every practice across the country. Challenging, but a tremendous opportunity to try something new; to shake up how we work, our old routines and our bad habits, and use it as an opportunity to improve our customer experience and clinical service.
In the small animal sector, the biggest innovation to be thrust on the profession is the use of telemedicine. As a practice we were involved in developing a telemedicine platform prior to lockdown, seeing the potential to enhance and evolve our clinical service. The advent of lockdown accelerated its introduction as a key part of our clinical service.
This article explores some of the techniques we have developed for successfully using video consultations, using the telemedicine platform for lameness consultations in particular. It will also explore how we see the introduction of this technology into small animal practice as being the first step on a potential transformative period of development, with scope to significantly improve the traditional consultation model.
Medicine is an art, as well as a science, and video consults bring fresh ways of assisting our clinical care. However, numerous challenges exist in making telemedicine work well, and recent market research has described 72% of vets as feeling their clients undervalue their telemedicine service (Pegasus, 2020).
This article outlines what works well for us and what, in our opinion, are the key factors to optimise video consults. These are ideal in situations such as lameness consultations where it is essential to check the mobility of a patient.
The team approach to video consults is an essential feature – ideally with a dedicated video consult central receptionist. While scope exists for a “local” receptionist, such as at branch practices that may also manage usual in-person consults, a dedicated central receptionist ensures a quicker and more responsive conversation with video consult clients – in our experience, a key feature of their success.
The central receptionist also coordinates the pre-consult interactions with clients and assigns/diarises the consults to the relevant clinician. These interactions are important to creating a successful basis for the video consults and, as well as the new skills of vets using video consults, is an area we have developed during lockdown. We would suggest that to do video consults properly, an improvised – or preferably dedicated – “telemed” area of the practice is important (Panel 1).
While this article focuses on lameness video consults, other scenario-specific skills continue to develop as we increase our experience of video consults – and training in these skills will increasingly be recognised as a key part of many small animal jobs.
For vets treating pets’ lameness, the video consult doesn’t replace the physical assessment, but can go a long way to improving how vets correctly identify the most common causes of lameness.
The structure we have developed optimises the interaction with the client and improves the ability to use video consults.
We have found it best to stick to a systematic approach that mirrors the approach taken in a good in-person consult:
Just as not many of us would choose open surgeries, video consults need structure to work well. To be effective they need a team approach, with diarised interactions and scheduled video consults.
Similar to how a good receptionist lines up the consult with a welcome, meet and greet, check of details prior to an in-person consult, the receptionist/customer experience lead is integral to the video consult.
In video consults using the telemedicine platform developed by the practice specifically, the reception team has interaction with clients before the video consult with the veterinary surgeon begins.
This creates an opportunity to create a template interaction for general consults and consider how this may differ for certain specific clinical scenarios.
In some systems, this interaction can be led by the reception team, which can use a script of standard phrases you have created to help assist you in lining up the lameness consult.
While a formulaic approach may have some risks, the scope for an enhanced pre-consult experience is exciting, and we have found video consults to be well suited to enable us to get increased value out of the video consult.
Recent market research described 68% of vet respondents to have difficulty getting diagnostic quality videos or images from telemedicine consults (Pegasus, 2020). Initially, we also had difficulty with poor videos and photos of the wrong part or position of the pet.
For this reason, we tell clients what we want and request they submit a video of their pet’s lameness for viewing before the live consultation. We do this by sending them template text along with a link to our YouTube channel, which illustrates the ideal lameness video (below) and preferred static images (Figure 1) – all of which can be uploaded prior to the consult. This tactic has greatly improved the quality of videos and images uploaded by clients.
Additionally, we have been sending all lameness consultations a list of general lameness questions for them to consider prior to the consult starting (Panel 2). These questions help the client to prepare and think of his or her answers before the real thing – we believe improving the quality of answer we get during the live video consult.
Hi, it is Ross Allan from Roundhouse Referrals here. I will connect with you in around an hour, but here are some starter questions we will likely discuss with you when we connect:
What is also useful is to upload a few short videos and pictures to help us assess your pet’s lameness prior to the consultation starting. Examples of the type of video that helps us assess your pet’s lameness can be seen on our YouTube channel: https://youtu.be/gH7OqUMSwSQ
A third element we have been investigating is the use of questionnaires as part of the lameness consultation, and we have recently started to trial integrating questionnaires such as the Liverpool OA in Dogs questionnaire (LOAD; Walton et al, 2013) as a way of scoring the problem prior to the video consult starting.
These three steps – all of which can all occur at home and prior to the consult beginning – are definite ways to enhance our ability to assess pets’ lameness using video consults: in the owner’s own home, the park or wherever the client wishes.
Similar to an in-person consult, getting a good history of your patients’ lameness is key to helping reach a diagnosis. With video consults we can sometimes find it more difficult to steer the video consult discussion.
The questions in Panel 2 help manage this issue and are a good tool to maintain the flow required to get the information necessary for effective clinical decision-making. This and the fact we are not trying to get live videos/images of lameness at the mercy of Wi‑Fi and bandwidth makes the video consult far more effective.
Occasionally we will use live video to help assess a specific area of interest/concern, but in truth this is rare. In the majority of video consults that author Ross Allen does, the only live video seen tends to be that of the patient dozing on the couch. Pre-recorded video is far easier for you, your client and the patient.
Physical examination via video involves assessing the images and video you have received, and perhaps occasionally getting the owners to use their hands and perceptions to guide your clinical judgements.
Again, the questions we have supplied to owners pre-video consult will help us/them consider if this might be required prior to the video consult starting.
Ultimately, though, physical examination is where video consults fail – they cannot possibly replace in-person assessment of clinical findings such as joint effusion or crepitus. For this reason it is often necessary to back up the video consult with an in-person consult – using the knowledge gained during the video consult – for patients you have concerns about.
While definitive video diagnosis is tricky in veterinary medicine, clinical scenarios exist where the images and assessment will have a specific clinical shape that can help make a highly probable diagnosis:
Can it be any more than this? We all know that in any clinical situation a clinical diagnosis is almost invariably just that – a most probable diagnosis – and while most likely correct can also be wrong.
During the video consult we ensure clients understand that video consults can only allow us to make a most probable diagnosis, and highlight the importance of reviewing for a response to any therapeutics (such as trial NSAIDs) that may be dispensed without a physical examination.
Reviewing and rechecking (whether via live video consult or submitted videos) is essential to checking our treatment has worked, and reducing the risks that occur if getting it wrong.
Where video consults can come into their own, however, is allowing remote assessment prior to a planned admission and treatment day. In these scenarios it can greatly help reduce unnecessary movement of people and pets; allow a relationship (with exchange of info on the patient and possible procedure concerned) to be developed with the client pre-surgery; and facilitate productive remote assessment, and the development of an effective diagnostic and treatment plan.
Telemedicine has raised considerable interest during the lockdown period. Pet owners clearly appreciate the new opportunities it creates for easy and convenient communication with the practice.
It has served to help deal with animal health issues despite the restrictions we have faced, and we have all learned much more about its advantages and disadvantages.
The big question is, do we just shelf this as we return to normality or has it become a key part of our health care package? Common sense suggests the advantages outweigh the disadvantages in our increasingly tech-driven society.
To deny this feels a bit like King Canute trying to turn back the waves. If we accept this then the challenge is to integrate remote contact techniques into our everyday practice and maximise the benefits it affords.
Telemedicine is not just about video consultations. Telephone consultations and text chat interactions have expanded our ability to improve communication with our clients. Using mobile phone capabilities to achieve this has propelled our working agenda into this century and is enabling us to provide our services in a way that suits our customers.
Asynchronous communication, afforded by text, has made it easier for our clients to make contact by leaving messages, and this makes it much easier to develop a conversation with us and get the attention they require. Unsurprisingly, this has proved very popular, with high approval ratings being measured on client feedback (Jenkins, 2020).
We have also found that clients are willing to pay for this new remote communication because of the advantages, so it can be monetised (Jenkins, 2020). Interestingly clients were just as willing to pay for non-video consultation interactions as with video.
Another new understanding is that involvement of the whole practice team – receptionist, nurse and vet – in the remote consultation not only improves client approval rate, but also improves monetisation, with nurse and reception staff better able to ensure all chargeable items are collected during the interaction.
Collecting payment before the actual consultation also held high client approval and this was not diminished, but enhanced when extra essential charges resulted from the remote consultation.
This may be a surprise for many of us, but may be as a result of appreciation of the value given by the client to this process and may be impacted by clearer communication about charging.
These facts clearly demonstrate this has been a viable and efficient way of providing and augmenting our clinical service, so what next as we return to more normal circumstances?
All of these features are likely to increase the contact we have with our clients and pets. In addition, by using specific benefits of the remote consultation process to augment certain investigations, we will improve our clinical effectiveness in certain situations.
For example, situations where evaluation of movement is important are:
These could all benefit from a video of the pet supplied before or at the time of consultation. Adding a list of typical questions – as in the pre-consultation described in this article – could also act to improve the efficiency of our face-to-face consultation. We could incorporate clinical measurement instruments such as LOAD or the new feline pain checklist (Enomoto et al, 2020) into this format.
Finally, adopting this type of convenient method of contact, communication and service delivery works very well in cases with chronic disease where monitoring, adjustment and support are key.
Examples of these include arthritis, renal, cardiac, dermatology and diabetic cases where experience shows more time is required to manage – time we don’t really have under our present system.
Convenient communication allows more frequent contact points and makes management much simpler for everyone. You can even envisage services where the nurses in the practice could run remote clinics for arthritis cases to achieve the following:
Our new abilities with web meetings on common platforms will enable time-efficient case discussions with other professionals such as physiotherapists, which are invaluable in these long-standing cases.
These are exceptional times we are living in, and time will tell the lasting impact of COVID‑19 on our profession, countries and communities.
One thing is for certain, however – the transformation of our interaction with clients using video technology is here to stay. It can be a very efficient way of meaningfully assisting clients and patients if managed correctly.
And that’s the key point – it requires a plan. Just like a good book requires shape – a beginning, middle and end – so a productive video consult requires management. So, work with your team and follow these take-home messages:
