BRIV_adv
Annals of Indian Academy of Neurology
  Users Online: 13602 Home | About the Journal | InstructionsCurrent Issue | Back IssuesLogin      Print this page Email this page  Small font size Default font size Increase font size

Table of Contents
VIEWPOINT
Year : 2020  |  Volume : 23  |  Issue : 5  |  Page : 587-591
 

Virtual Care for Neurological Practice


1 Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada
2 Consultant Intensivist, Royalcare Super Speciality Hospital, Coimbatore, Tamil Nadu, India

Date of Submission07-May-2020
Date of Acceptance24-Jun-2020
Date of Web Publication8-Dec-2020

Correspondence Address:
Ramana Appireddy
Division of Neurology, Department of Medicine, Queen's University, Kingston, ON
Canada
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aian.AIAN_415_20

Rights and Permissions

 

   Abstract 


The COVID-19 crisis has worsened the pre-existing barriers to accessing neurological specialist care in Low and middle income countries. Telemedicine has been available for well over 2 decades but has not been widely adopted in LMIC’s due to issues around cost, feasibility, infrastructure and regulation. Virtual care is an offshoot of traditional telemedicine leveraging the widely available internet enabled devices to connect patients with their healthcare providers. In this manuscript, we provide an overview of the virtual care, relevance to neurology and some guidance on implementing virtual care in an Indian context.


Keywords: eVisit, teleneurology, telemedicine, virtual care


How to cite this article:
Appireddy R, Bendahan N, K Chaitanya J S, Shukla G. Virtual Care for Neurological Practice. Ann Indian Acad Neurol 2020;23:587-91

How to cite this URL:
Appireddy R, Bendahan N, K Chaitanya J S, Shukla G. Virtual Care for Neurological Practice. Ann Indian Acad Neurol [serial online] 2020 [cited 2021 Dec 6];23:587-91. Available from: https://www.annalsofian.org/text.asp?2020/23/5/587/302594





   Overview of Virtual Care Top


Telemedicine is defined as remote delivery of healthcare services and clinical information using telecommunication technology.[1] Virtual care, an offshoot of telemedicine, is defined as any interaction between patients and members of their circle of care occurring remotely, with the aim of facilitating or maximizing the quality and effectiveness of patient care.[2],[3],[4],[5] Secure messaging, secure email, and secure video conferencing are some of the most common types of virtual care modalities. The difference between traditional telemedicine and virtual care is the technology used. Traditional telemedicine is usually performed between two remote hospitals with dedicated videoconferencing equipment, hard-wired network connection, and personnel to help with the telemedicine visit. Virtual care, however, is set up by the patients and/or family using their own personal internet-enabled devices like smartphones, tablets, and computers. Virtual care in the form of video visits is ideal for providing follow-up care, symptom management, conveying diagnostic results, and collaborating in therapeutic decision making for many neurological conditions.[6]

Virtual care has been making steady gains globally, particularly in response to the COVID-19 pandemic.[4],[7] Virtual care is largely patient centered, reduces healthcare costs, efficient for the providers, lncrease acc to healthcare, and has the potential to improve health outcomes.[6],[8],[9],[10] A transition to virtual care has been advocated by patients, physicians, and policymakers for the last few years.[2],[6],[9],[11],[12],[13],[14],[15],[16],[17]

Since 2016, Queen’s University/Kingston Health Sciences Center (KHSC) has been an early adopter of virtual care for ambulatory specialist care and the local virtual care program is considered as a model for delivery of care by Ontario Telemedicine Network.[6],[18] The lead author (RA) also has an active multidisciplinary virtual care research group. Leveraging our long experience with virtual care, virtual care has been rapidly rolled out to all 450 specialist physicians, 575 medical residents, and 160 allied health professionals at the start of April 2020 at Queen’s University.[19]

In the following sections, we will discuss the regulatory aspects of virtual care, our recommendations for setting up a virtual care practice, and the current applications of virtual care for neurological conditions.


   Regulatory Framework Around Virtual Care in India Top


There are several laws and regulations protecting Personal Identifiable Information and healthcare data in the US, Canada, and Europe.[20],[21],[22] However, similar laws do not exist in India. The Digital Information Security in Healthcare Act (DISHA) was introduced as a draft document by the Ministry of Health and Family Welfare (MoHFW) in order to bring a healthcare security law in India.[23] The DISHA act has not been formally passed as a law. Until recently, telemedicine and virtual care have been frowned upon by legal and regulatory bodies in India. However, given the COVID-19 crisis, the Medical Council of India has released a telemedicine practice guideline in partnership with NITI Aayog.[24] These guidelines provide an in-depth overview of various virtual care modalities and should be referred to by any physician planning to provide virtual care services to their patients.

Patient selection

Selecting which patient or a specific medical condition is appropriate for virtual care may be challenging. Physicians must use their professional judgement to decide when it is appropriate to offer virtual care. This is the general recommendation from other regulatory bodies where telemedicine is routinely practiced.[25] Though virtual care is often demanded by the patients and/or their families due to the convenience it offers, physicians should be careful to only provide this service when they feel it is appropriate and safe. Physicians should be cognizant of the patient’s level of education and their familiarity and ability to use the technology. Based on this information, physicians can select the most appropriate virtual care modality (i.e., text messaging vs. video conference) for individual patients, or instead, offer an in-person visit.

Consent

There are broadly two types of consent—expressed and implied consent. For practical purposes, the use of implied consent is reasonable to provide virtual care. However, it is preferable to obtain and document expressed consent. The MCI Telemedicine practice guidelines provide further direction on consent for virtual care.[24]

Documentation, prescriptions, and medical negligence

Virtual care visits should not be taken as casual encounters and any interaction should be considered as a professional medical interaction. All standards for professionalism and consent should be maintained during a virtual visit. Standards for documentation should be adhered to as much as possible. Any virtual care interaction (video/audio/messaging/email) could be used as a piece of evidence in a medico legal litigation.[26],[27],[28]


   Advantages and Limitations of Virtual Care Top


Virtual care offers transformational change to the healthcare landscape in the way physicians and patients interact. This is a very exciting time and, like any significant change in the industry, it is easy to be carried away by the advantages that virtual care has to offer. It is equally important to be aware of the limitations of the virtual care to optimally utilize this platform. The advantages and limitations of virtual care differ based on the modality used (video conference vs. secure messaging vs. audio only). An excellent overview of these is provided in the Telemedicine practice guidelines released by Medical Council of India.[24] Some of these are provided below in [Table 1]. For physicians, it is ideal if the virtual visits can be integrated with the EHR and HIS (Hospital information system) for easy availability of the past clinical data and access to previous laboratory reports and prescriptions of the patient. Scheduling virtual care visits along with routine in-person visits.
Table 1: Advantages and limitations of virtual care

Click here to view


We must keep in mind, however, that access to this technology is not universal. Patients with neurological conditions often have cognitive impairment or poor dexterity, both of which will impair their ability to use this technology. Caregivers may need to assist them. Furthermore, patients of poor socioeconomical status may not be able to afford these devices or have a reliable internet connection. Nonetheless, creative solutions can be found, for example, using one devices and internet connection for several residents of a single village or residential area.


   How to Set Up a Virtual Care Practice Top


Virtual care platforms

Broadly speaking, there are two kinds of platforms for providing any form of virtual care. These can be divided into regulated and unregulated platforms. Regulated platforms refer to software platforms that are designed for healthcare use and adhere to all privacy and security regulations mandated for safeguarding personal health information.[20],[21],[22] Unregulated platforms do not fulfill the privacy and security regulations. These tnregulated applications commonly used for personal video-conferencing: Facetime, WhatsApp, Zoom, Skype, or Google Duo. Given the lack of a regulatory framework for healthcare data in India, it is difficult to compile a list of regulated and unregulated platforms available to physicians in India. Given the sociocultural context in India and the knowledge/attitudes and practices of patients and healthcare providers in India, it is thus reasonable to use a platform that is available, accessible, and reliable to both the physician and patients. This may include the unregulated platforms listed above. Virtual care is a reliable alternative for providing medical care during the COVID-19 lockdown, and likely beyond it. The abundance of digital payment available options available in India should be leveraged to deal with payment and reimbursements.[29]

Equipment, etiquette, and working environment

Virtual care can be provided through any of the widely available internet-enabled devices including smartphones, tablets, or computers. For physicians, it is preferable to use a desktop or laptop with external video/audio conferencing equipment. As this setup offers a reliable internet connection with high quality audio-video conferencing. Below is a list of steps one should take to set up the virtual care workplace [Table 2].
Table 2: Equipment, etiquette, and working environment

Click here to view


Etiquette

Physicians may initially find the interaction through the virtual platform challenging. The etiquette for virtual visits is largely similar to in-person visits; however, there are a few key differences. Physicians should resist the temptation to stare at the screen or to look away, but rather, should look directly into the camera to provide the ‘virtual’ eye contact when talking to the patient. As audio quality may sometimes be suboptimal, healthcare providers should speak in a loud and clear voice. Physicians should dress professionally, preferably with a white coat. Identification badges should be clearly visible or, at the very least, shown at the beginning of the interview when the physician introduces themselves. In order to avoid delays, it is important to verify that all audio and video equipment is working properly prior to the visit. It is also preferable to have a second screen with electronic medical records and investigations readily available.


   Virtual Care in Neurology Top


Certain characteristics of the practice of neurology and its patient population make virtual care an ideal method for delivering care. In the following sections, we will discuss why virtual care should be adopted in neurology practice, with a focus on the context of Low and Middle Income Countries (LMIC).

Increased access to neurological expertise and consultation

Neurological conditions are very common in India and other LMIC.[30],[31] The limitations of the neurological workforce in these settings are also widely known.[30],[32],[33] Access to neurology consultation, a highly specialized field is limited in India and other LMIC’s. Generally, specialists and subspecialists tend to work in academic centers in metropolitan areas.[33] Unfortunately, this leaves many populations, particularly those living in rural communities, underserved. This challenge has only been exacerbated by the recent massive migration to villages in response to the COVID-19 lockdown in India.[34] Virtual care has the potential to allow patients all over the country to have increased access to neurological as well as to reduce the economic burden associated with attending medical appointments.[6],[35] In fact, in a study based out of Cleveland, Ohio, it was estimated that patients saved a median of 137 miles of travelling to access specialty neurology clinics*. Similarly, stroke centers tend to be clustered in urban centers. Telestroke has revolutionized access to stroke care and improved health outcomes globally for hyperacute stroke treatments.[36],[37] The value of Telestroke in improving access and outcomes in resource-poor settings is well recognized.[38],[39],[40] Telestroke allows physicians to call upon the expertise of a cerebrovascular specialist who can examine patients through video, interpret relevant imaging findings, and make critical decisions. A virtual care platform using low cost rapidly deployable system could be used as a modified telestroke system.

Neurological burden and vulnerable population

The burden of neurological conditions in India and other LMIC’s is very high.[41],[42] The neurological conditions affecting the patients make them vulnerable.[43] Patients with neurological conditions often suffer from physical, mental disability and often require mobility assistance. Virtual care allows physicians to provide medical care to these patients who cannot leave their homes and saves the patient and caregivers a huge amount of physical, financial, and psychological trouble. Similarly, patients with physical and cognitive disability related to stroke or other neurological illness, as well as those with epilepsy, may be unable to travel/drive alone due to restrictions related/restrictions. This makes it more challenging for them to visits their physician at the clinic. Many patients with neurological conditions are also elderly, frail, or immunocompromised—more specifically, those with autoimmune conditions such as multiple sclerosis, autoimmune encephalitis, or CIDP who are being treated with immunosuppressants. By visiting hospitals, these patients are putting themselves at risk for infectious diseases, particularly in a time of pandemic. Lastly, neurologists treat many chronic conditions which require frequent follow-up for medication titrations. This includes Parkinson’s disease, epilepsy, multiple sclerosis, myasthenia gravis, and other neuromuscular conditions.

Neurological conditions ideal for virtual care

Virtual care could be employed in a wide variety of settings and patients. Virtual care could be used in all three practice settings—emergency care, in-patient care, and out-patient care settings.[44] Traditional telemedicine systems of care are costly and difficult to setup. Use of virtual care for delivery of Telestroke services is feasible and should be explored.[45] Similar virtual care solutions could also be used for providing in-patient consultation, thus improving access to specialist care. The value of virtual care is very high in the out-patient setting.[6],[18] Virtual care for out-patient care could be used for a wide variety of conditions and purposes. Virtual care is currently used for a wide variety of neurological conditions, for both new consultations and follow-up care. These include triaging new neurological referrals and consultations, assessing new neurological consultations for simple and straightforward conditions, follow-up on symptom severity, symptom management, titration of medication doses, follow up on test results, education, reassurance, counselling, general advice as well as suggest consultations with other physicians/referrals to other locations. Post stroke care: virtual visits can enhance the availability of neuro-rehabilitative support which is very scarce in rural India. Ease of frequent monitoring and provision of supporting audiovisual literature for physiotherapy and occupational therapy can greatly enhance the functional recovery of the patients reducing the burden on the family and society. This will certainly reduce the caregiver burden associated with frequent medical visits. Virtual visits to a specialist can help patients with neurodegenerative disorders for routine follow-up visits, more frequent screening questionnaires, better follow-up after the change of prescriptions for adverse effects, and also reduce the burden on the caregivers which usually is the case.

In our experience, cerebrovascular conditions, headache, epilepsy, sleep disorders, headaches, and non-specific conditions are among the most suited conditions for virtual care for new consultations.[6],[18] Virtual care is ideal for follow-up in a wide variety of conditions. This is generally the case for conditions where the physical examination noncontributory or can be easily replaced by ancillary testing. Excluding those conditions, neurology is a specialty that tends to heavily rely on the physical examination for diagnosis and assessment of patients. Clearly, certain physical examination maneuvers cannot be realistically performed over a screen, including auscultation, palpation, tone, or strength testing. Thus, certain clinical presentations such as focal weakness, or parkinsonism are more challenging to diagnose over teleconference. Still, new research suggests some tests can be adequately performed through videoconferencing. In fact, a group from Germany has validated several neurological examination maneuvers over teleconferencing, such as general observation, gait examination, cranial nerve testing, and coordination testing.* While certain aspects of the physical examination may be reliably performed through teleconferencing, physicians must carefully select which patients may be best served through in-person visits.


   Conclusion Top


Virtual care offers a more accessible, convenient and less costly service to patients. For many years, telemedicine has allowed to bridge the access gap in medical care, allowing patients living in remote rural areas and those with disabilities to access care previously unavailable to them. Many physicians are now turning to virtual care during the pandemic in order to limit the spread of the virus. While this novel technology appears to be an ideal solution on many fronts, we must keep in mind its limitations in order to carefully select which patients are best suited for virtual care.

Financial support and sponsorship

Nil.

Conflicts of interest

Dr. Appireddy reports grants from CIHR, Canada Health Infoway, Department of Medicine, Queen’s University, PSI Foundation, Ontario, AHSC Innovation Fund, SEAMO, KGHRI, towards virtual care research and during the conduct of the study.; Dr. Chaitanya, Dr. Shukla and Dr. Bendahan has nothing to disclose.



 
   References Top

1.
American Telemedicine Association. Resources - Common Questions Answered 2020 [Available from: https://www.americantelemed.org/resource/why-telemedicine/./.  Back to cited text no. 1
    
2.
Shaw J, Jamieson T, Agarwal P, Griffin B, Wong I, Bhatia RS. Virtual care policy recommendations for patient-centred primary care: Findings of a consensus policy dialogue using a nominal group technique. J Telemed Telecare 2018;24:608-15.  Back to cited text no. 2
    
3.
CMA/FRCPC/CFPC. Virtual Care: Recommendations for scaling up virtual medical services: Report of the Virtual Care Task Force: Canadian Medical Association 2019. [Last updated on 2019 Feb 11].  Back to cited text no. 3
    
4.
Lougheed T. Time to embrace the promise of virtual health care. CMAJ 2019;191:E320-1.  Back to cited text no. 4
    
5.
Canadian Medical Association. Virtual Care in Canada: Discussion paper. CMA Health Summit [Internet]. 2019. Available from: https://www.cma.ca/sites/default/files/pd f/News/Virtual_Care_discussionpaper_v1EN.pdf.  Back to cited text no. 5
    
6.
Appireddy R, Khan S, Leaver C, Martin C, Jin A, Durafourt BA, et al. Home virtual visits for outpatient follow-up stroke care: Cross-sectional study. J Med Internet Res 2019;21:e13734.  Back to cited text no. 6
    
7.
Dare F. Voting for Virtual Health: Accenture; 2017 [cited 2018 Dec 14]. Available from: https://www.accenture.com/us-en/insig ht-voting-virtual-health-survey; http://www.webcitation.org/74fBs03Gu.  Back to cited text no. 7
    
8.
Picker Institute. Picker Principles of Person Centred Care 2018. Available from: https://www.picker.org/about-us/picker-principles-of-person-centred-care/. [Last citeded on 2018 Oct 15].  Back to cited text no. 8
    
9.
McGrail KM, Ahuja MA, Leaver CA. Virtual visits and patient-centered care: Results of a patient survey and observational study. J Med Internet Res 2017;19:e177.  Back to cited text no. 9
    
10.
Bodenheimer T, Sinsky C. From triple to quadruple aim: Care of the patient requires care of the provider. Ann Fam Med 2014;12:573-6.  Back to cited text no. 10
    
11.
Bhatia RS, Falk W. Modernizing Canada’s Healthcare System through the Virtualization of Services [Healthcare Policy E-Brief]. C.D.Howe Institute 2018. Available from: https://www.cdhowe.org/sites/default/files/attachments/research_papers/mixed/E-Brief%20277.pdf.  Back to cited text no. 11
    
12.
Nochomovitz M, Sharma R. Is it time for a new medical specialty?: The medical virtualist. JAMA 2018;319:437-8.  Back to cited text no. 12
    
13.
Rozario D. Optimization of communication in the surgical program via instant messaging, Web-based surveys, newsletters, websites, smartphones and telemedicine: The experience of Oakville Trafalgar Memorial Hospital. Can J Surg 2018;61:E4-6.  Back to cited text no. 13
    
14.
Canada Health infoway. Access 2020: Canada Health Infoway; 2020. Available from: https://access2022.ca/.  Back to cited text no. 14
    
15.
Canada Health Infoway. Connecting Patients for Better Health:2018 2018. Available from: https://www.infoway-inforoute.ca/en/component/edocman/resources/reports/benefits-evaluation/3564-connecting-patients-for-better-health-2018. [Last citeded on 2020 April 28].  Back to cited text no. 15
    
16.
Canada Health Infoway. 2018 Canadian Physician Survey: Canada Health Infoway; 2018. Available from: https://www.infoway-inforoute.ca/en/2018-canadian-physician-survey. [Last citeded on 2020 April 28].  Back to cited text no. 16
    
17.
Dare F. Virtual Care:Just what the consumer ordered: Accenture; 2017. Available from: https://www.accenture.com/_acnmedia/pdf-88/accenture-strategy-dd-virtual-care-pov.pdf. [Last citeded on 2020 April 28].  Back to cited text no. 17
    
18.
OTN. Video visits enhance access to neurology follow up care: OTN; 2019. Available from: https://otn.ca/virtual-care-in-action/video-visits-for-stroke-follow-up/.  Back to cited text no. 18
    
19.
IIT Reacts | Interactive audio-video platform. 2020. Available from: https://reacts.com/.  Back to cited text no. 19
    
20.
General Data Protection Regulation (GDPR) Compliance Guidelines. 2020 Available from: https://gdpr.eu/.  Back to cited text no. 20
    
21.
Cavoukian A. A guide to personal health information protection act. 2020 Available from: https://www.ipc.on.ca/wp-content/uploads/Resources/hguide-e.pdf.  Back to cited text no. 21
    
22.
Health Information Privacy | HHS.gov: @HHSgov; 2015 [updated 2015-08-26T15:20-04:00]. Available from: https://www.hhs.gov/hip aa/index.html.  Back to cited text no. 22
    
23.
Gov of India. Digital Information Security in Healthcare Act (DISHA). In: Welfare MoHaF, editor. New Delhi: Government of India; 2017.  Back to cited text no. 23
    
24.
Board of Governors - Medical Council of India. Telemedicine Practice Guidelines - Enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine: Medical Council of India; 2020. Available from: https://www.mohfw.gov.in/pdf/Telemedicine.pdf. [Last updated on 2020 Mar 25].  Back to cited text no. 24
    
25.
CPSO. Telemedicine: CPSO; 2014 [cited 2020 Apr 06]. Available from: https://www.cpso.on.ca/Physicia ns/Policies-Guidance/Policies/Telemedicine.  Back to cited text no. 25
    
26.
Thomas J. Medical records and issues in negligence. Indian J Urol 2009;25:384-8.  Back to cited text no. 26
[PUBMED]  [Full text]  
27.
Raveesh BN, Nayak RB, Kumbar SF. Preventing medico-legal issues in clinical practice. Ann Indian Acad Neurol 2016;19(Suppl 1):S15-20.  Back to cited text no. 27
    
28.
Gajera G, Srinivasa P, Ameen S, Gowda M. Newer documentary practices as per Mental Healthcare Act 2017. Indian J Psychiatry 2019;61(Suppl 4):S686-92.  Back to cited text no. 28
    
29.
Putrevu S. Here are the 5 e-payment platforms accelerating India’s digital economy growth Bengaluru: YourStory; 2019. Available from: https://yourstory.com/2019/09/digital-wallets-india-amazon-google-paytm-phonepe-economy. [Last updated on 2019 Sep 25].  Back to cited text no. 29
    
30.
Fleisher JE, Mateen FJ. Neurology goes global: Opportunities in international health. Neurol Clin Pract 2014;4:239-46.  Back to cited text no. 30
    
31.
Mohammadi D. Neurology in resource-poor countries: Fighting for funding. Lancet Neurol 2011;10:953-4.  Back to cited text no. 31
    
32.
Gupta NB, Khadilkar SV, Bangar SS, Patil TR, Chaudhari CR. Neurology as career option among postgraduate medical students. Ann Indian Acad Neurol 2013;16:478-82.  Back to cited text no. 32
[PUBMED]  [Full text]  
33.
Khadilkar SV, Wagh S. Practice patterns of neurology in India: Fewer hands, more work. Neurol India 2007;55:27-30.  Back to cited text no. 33
[PUBMED]  [Full text]  
34.
Pandey G. Coronavirus in India: Migrants running away from quarantine New Delhi: BBC; 2020. Available from: https://www.bbc.com/news/world-asia-india-52276606. [Last updated on 2020 April 15], [Last cited on 2020 April 29].  Back to cited text no. 34
    
35.
Jacobs JC, Hu J, Slightam C, Gregory A, Zulman DM. Virtual savings: Patient-reported time and money savings from a VA national telehealth tablet initiative. Telemed J E Health 2019. doi: 10.1089/tmj. 2019.0179.  Back to cited text no. 35
    
36.
Bladin CF, Cadilhac DA. Effect of telestroke on emergent stroke care and stroke outcomes. Stroke 2014;45:1876-80.  Back to cited text no. 36
    
37.
Porter J, Hall RE, Kapral MK, Fang J, Khan F, Silver FL. Outcomes following telestroke-assisted thrombolysis for stroke in Ontario, Canada. J Telemed Telecare 2018;24:492-9.  Back to cited text no. 37
    
38.
Srivastava PV, Sudhan P, Khurana D, Bhatia R, Kaul S, Sylaja PN, et al. Telestroke a viable option to improve stroke care in India. Int J Stroke 2014;9(Suppl A100):133-4.  Back to cited text no. 38
    
39.
Sharma S, Padma MV, Bhardwaj A, Sharma A, Sawal N, Thakur S. Telestroke in resource-poor developing country model. Neurol India 2016;64:934-40.  Back to cited text no. 39
[PUBMED]  [Full text]  
40.
Bagchi S. Telemedicine in rural India. PLoS Med 2006;3:e82.  Back to cited text no. 40
    
41.
Chin JH, Vora N. The global burden of neurologic diseases. Neurology 2014;83:349-51.  Back to cited text no. 41
    
42.
Gourie-Devi M. Relevance of neuroepidemiology: Burden of neurological disorders and public health issues. Ann Indian Acad Neurol 2018;21:237-8.  Back to cited text no. 42
[PUBMED]  [Full text]  
43.
Waisel DB. Vulnerable populations in healthcare. Curr Opin Anaesthesiol 2013;26:186-92.  Back to cited text no. 43
    
44.
Waldman G, Mayeux R, Claassen J, Agarwal S, Willey J, Anderson E, et al. Preparing a neurology department for SARS-CoV-2 (COVID-19): Early experiences at Columbia University Irving Medical Center and the New York Presbyterian Hospital in New York City. Neurology 2020;94:886-91.  Back to cited text no. 44
    
45.
Majersik JJ, Reddy VK. Acute neurology during the COVID-19 pandemic: Supporting the front line. Neurology 2020;94:1055-7.  Back to cited text no. 45
    



 
 
    Tables

  [Table 1], [Table 2]



 

Top
Print this article  Email this article

    

 
   Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (313 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Overview of Virt...
    Regulatory Frame...
    Advantages and L...
    How to Set Up a ...
    Virtual Care in ...
   Conclusion
    References
    Article Tables

 Article Access Statistics
    Viewed650    
    Printed12    
    Emailed0    
    PDF Downloaded35    
    Comments [Add]    

Recommend this journal