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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 problem could be dealt with the next day at the clinic on a nonemergency basis. Pet owners know that emergency clinics can be expensive, but without being able to speak with someone they trust, they may make the decision (to go or not to go to the emergency facility) without the benefit of appropriate advice. It is important to appreciate that such monitoring does not need to be constantly available, and that such teletriage can be provided when teams have the time and inclination to provide such services.

There are many other situations when virtual care is indicated. Monitoring pets receiving hospice care often lends itself to telehealth options. Nursing visits to the home of patients can also be augmented with such consultations, and nurses/technicians can add an additional level of expertise since they can provide hands‐on evaluation. For pets that cannot be easily brought in to the clinic for any number of reasons, telehealth provides one more way for them to still benefit from veterinary advice. Finally, nearly half of all pet owners are not currently bringing their pets to the veterinary clinic with any regularity, so virtual care removes one barrier to them being able to seek veterinary advice, as long as appropriate VCPRs are in place.

      When considering fee options for virtual care, it is best to approach this in a team‐based manner so value can be built into the system from the start. Initially, virtual care might be offered during certain time slots in the day when there are appointment gaps. The fee can be based on what the time slot would typically command as a 10‐, 15‐, or 20‐minute appointment. Other options might include prioritizing a virtual visit over an in‐clinic appointment for a premium, if such a call could be accommodated in such an interval. For example, a client may want to hear from a doctor or nurse quickly, and be prepared to pay a premium for someone to schedule a virtual visit within a certain time frame (such as two hours, etc.). The same rationale can be used for premium pricing on consults after hours, on weekends, and in other instances where the client is being accommodated. Pricing can also reflect technology used, such as telehealth platforms, accessing wearables, etc.

      Finally, not all telehealth consults need to be provided exclusively by doctors. For some virtual care, nursing staff may be appropriate experts.

      For clients with pet health insurance (see Скачать книгу