A valid VCPR is limited to the individual veterinarian and does not include other practitioners in the practice unless they have their own VPR with the client and animals.
Every veterinarian should be familiar with and understand a valid Veterinarian-Client-Patient relationship (VCPR) which defines the type of relationship a veterinary must have in order to dispense drugs to clients and their animals. But with today’s tangle of rules, regulations and often personal interpretations of the law, food animal veterinarians can be confused about what a VCPR means (see VCPR sidebar).
“The spirit of the VCPR is that the veterinarian has sufficient knowledge of the animals and their care that allows him/her to assume responsibility for prescription and extralabel drug use,” says Paul Rapnicki, DVM, MBA, University of Minnesota College of Veterinary Medicine.
Having a VCPR for one group of animals on a dairy does not automatically allow you to prescribe treatments for another group you don’t routinely deal with. “An example is if the veterinarian does routine work at the milking dairy and treats the adult cows in the herd, but the calves are housed at a different site and the veterinarian is not personally acquainted with their care,” Rapnicki explains. “If the client requests prescription drugs for a calf problem, the veterinarian would need to establish a VCPR for calves.”
Jim Brett, DVM, Macon County Veterinary Hospital, Montezuma, Ga., agrees that this is the most common area of confusion about the VCPR. “Veterinarians prescribing or dispensing medications for animals or groups they have not examined or seen on regular farm visits or continue to have an active prescription being used on farms where they have not been in over one year, do not have a valid VCPR.”
Another misconception is whom the VCPR covers. Brett notes that a valid VCPR is limited to the individual veterinarian and does not include other practitioners in the practice. “If a farm is limited to one practitioner, other associates cannot legally dispense or prescribe prescription or extralabel medication to that farm,” explains Brett. However, the other practitioners can establish their own VCPR with this client and the farm can have valid VCPRs with multiple veterinarians.
Protect your VCPR
A VCPR for food-producing animals is not a casual designation and should not be treated as such. A veterinarian who establishes a VCPR with a client should maintain that status with careful documentation of services and drugs dispensed.
“The key is that when prescribing drugs, the veterinarian takes on legal responsibilities for how those drugs are used and so it is very important to gather and document the necessary information,” Rapnicki advises. “Many veterinarians already do what is necessary to establish a VCPR, but today there is a need to document what has been done. Documentation is part of any HACCP program. The FDA and USDA have adopted the use of HACCP in food safety programs. Documentation provides evidence to outside parties that a VCPR does indeed exist.”
Brett serves on the Georgia Board of Veterinary Medicine and says documentation on a medical record, date book, etc. of animal groups seen or examined would satisfy his state board’s requirement for a valid VCPR. “This would include any advice or prescribing of drugs, especially anything that constitutes extra label drug use (ELDU).”
Rapnicki suggests dairy practitioners visit the Minnesota Dairy Best Practices (MDBP) website (see Sources sidebar) which has available for downloading documents that can be used as a starting point to learn more about operations on certain areas of the dairy to help veterinarians establish VCPRs.
The MDBP forms serve as a starting point, but there are many ways to establish and document a valid VCPR. “Veterinarians need to use their own judgment and level of comfort as to when they have done enough to establish a VCPR for different groups of animals,” says Rapnicki. “These forms can be edited and easily incorporated into the medical records that are kept for the client.”
One way to evaluate a VCPR is to view your documentation as if you were an outsider without knowledge of the veterinarian or client. “What does the documentation look like concerning the existence of a VCPR?” asks Rapnicki. “Duration is not defined in the law; in MDBP we are recommending that a veterinarian review the status of each VCPR every six months and decide if situations have changed and if new information should be collected. This is only a guideline of what the ‘best practices’ would be.”
The data collection templates that are available on the MDBP website are for four areas on the dairy: mastitis, reproduction, clinical disease and youngstock. Each herd with a VCPR in any area is required to complete the basic Herd Information Form. Included at the end of each form is a section for the client and veterinarian to sign. This formalizes that they both are acknowledging they have entered into a VCPR. An additional form has been developed for each of the four specific areas of dairy management and has been tested on pilot dairies. Initially, the forms typically take about one hour to complete.
Rapnicki points out that the MDBP is not the only way to achieve a valid VCPR. “The guidelines were created to assist private practitioners by providing a consistent process for establishing VCPRs with client dairies.”
The Animal Medicinal Drug Use Clarification Act of 1994 (AMDUCA) allows veterinarians to prescribe extralabel uses of certain approved animal drugs and approved human drugs for animals under certain conditions. Extralabel use refers to the use of an approved drug in a manner that is not in accordance with the approved label directions. The key constraints of AMDUCA are that any extralabel use must be by or on the order of a veterinarian within the context of a VCPR, must not result in violative residues in food-producing animals, and the use must be in conformance with the implementing regulations published in the Code of Federal Regulations.
The University of Minnesota College of Veterinary Medicine began the MDBP project in an effort to help dairy practitioners to address issues that arise when veterinarians wish to authorize the use of prescription drugs or establish protocols for the extralabel use of drugs for dairy farms in circumstances where those drugs will be stored on-farm and administered by lay farm personnel. The project is developing tools to apply to the process whereby a veterinarian will specify the conditions under which prescription or extralabel drugs will be used when the prescribing veterinarian has not personally examined the animals/group of animals to be treated. For drugs to be used in this manner, a valid VCPR is required.
“The guidelines and tools in MDBP are simply an attempt to develop one approach that would be both efficient and effective in meeting the goals of good practice,” Rapnicki says.
Rapnicki cautions that not all dairy farms will be able to qualify for a valid VCPR for prescribing/specifying drugs for lay use. “There are dairies where the recordkeeping, drug storage situation, operator skills or other factors would make it impossible for the veterinarian to prescribe drugs in good conscience for use by lay personnel for ongoing use or for a new clinical case not seen by a veterinarian.” On these dairies, the veterinarian must attend each clinical event and make the drug use determination based on his/her examination.
Practice acts and pharmacy laws
In most states, the state board of veterinary medicine regulates veterinary practitioners and their dispensing of drugs, while the state board of pharmacy regulates businesses that operate as a pharmacy. State pharmacy laws are fairly standard in language dealing with the labeling and limitation of prescription by a licensed veterinarian under a valid VCPR, but do differ as to their dispensing. Most limit the dispensing of prescription/extralabel drug use (ELDU) medications by the veterinarian who has a valid VCPR or a licensed pharmacist. In Georgia, says Brett, a veterinarian cannot dispense under the prescription of another veterinarian in the same practice or for another licensed veterinarian. “Prescription logs are also mandatory in most states and must be a separate document or file from the farm’s records.”
The physical act of dispensing a prescription drug also varies by state. For example, in Georgia the drug must be delivered by the prescribing veterinarian, a pharmacist or pharmacy technician. “In Florida, lay persons can fill veterinary prescription drugs if employed by a state-licensed business,” notes Brett. “This allows the veterinarian to give the client a prescription for medications and delivery from farm supply trucks.”
State veterinary practice acts contain statutes regulating the practice of veterinary medicine. All practice acts have sections dealing with minimum standards of practice, ethics and professional conduct. In food animal practice, this relates to public health and safety, over-prescribing and improper prescribing of medications.
Most acts delegate manners of minimum standards of practice. Some states’ laws contain provisions as to the appropriate minimum care of animals by the veterinarian in emergency cases. A veterinarian who has established a relationship with a farm must be available for emergencies and adverse reactions. If that veterinarian cannot provide such services, he/she must have a relationship (sometimes in writing) with another veterinarian who will be available for emergencies. “Consulting veterinarians should review their state’s laws for any such requirements,” advises Brett.
The keeping of records is also required by practice acts. Most require the farm name, date, group or individual animal seen, work done, examination findings, medication given or advised to be given with any withdrawal times, and the veterinarian’s name. Most states require that records be held and maintained for a minimum of 3 to 5 years from the date of last entry.
You must have a valid license for each state that you practice in. “Any violation of laws, especially the practice act, pharmacy laws or a felony, can cause a sanction against your license,” says Brett. “What I’ve seen in most state practice acts is if you have your license revoked or suspended by one state, the other (s) where you are licensed has the authority to also revoke/suspend your license.”
The use of certified or registered veterinary technicians (RVTs) and veterinary assistants is becoming more common for bovine practitioners. But, there are limitations to how threy can be used.
“The performing of surgery, making a diagnosis or prognosis, and the prescribing of medication is not allowed,” says Brett. “Some rules have been written to allow certain procedures to be done by either RVTs or assistants, but under different levels of veterinary supervision.” This allows the practitioner to use trained personnel for routine livestock practices (which are not part of the practice of veterinary medicine and listed in most laws) or for follow up care and treatment. “This enables the practitioner to leverage his/her work and provide the client with skilled care at a lower fee,” explains Brett.
Most states have guidelines to what degree of supervision is required for staff to perform certain duties. Brett says you can go to the ‘Definition of the practice of veterinary medicine’ section of the practice act to see what acts are for licensed veterinarians only. He adds that there is usually a section of exemptions, i.e. an owner or full-time farm employee treating and caring for the animals, but he cautions if there is no exemption for veterinary employees and one of your RVTs performs procedures, gives meds/treatments, etc. to the public, that’s a violation of the law.
Guidelines will indicate for registered veterinary technicians and assistants what procedures are either not allowed, require immediate supervision, direct supervision or indirect supervision by a veterinarian. These can vary state-to-state.
Immediate supervision means that the licensed veterinarian is in audible and visual range of the animal patient and the person treating the animal.
Direct supervision means that the licensed veterinarian is on the premises and is quickly and easily available
and that the animal patient has been examined by a licensed veterinarian at such time as acceptable veterinary medical practice requires, consistent with the particular delegated animal health care task.
Indirect supervision means the licensed veterinarian is not on the premises but has given either written or oral instructions for the treatment of the animal patient and the animal has been examined by a licensed veterinarian at such times as acceptable veterinary medical practice requires, consistent with the particular delegated health care task.