Q. 21st Century Health is a major player in health consulting and IT solutions space in India with your own indigenously designed solutions for HIS, LIS, EMR and AIS/PACS. You have been closely observing rapid changes in the healthcare sector for the last 10-12 years. How do you view emerging technologies like telemedicine, their impact on healthcare in India and your own contribution in this new arena?
A. Satish Kini: We in 21st Century Health have adopted the vision 2020 espoused by our former Hon. President Dr A P J Abdul Kalam i.e. to achieve “Healthcare for All by 2020”. Dr Kalam has repeatedly mentioned that Telemedicine has to play a very significant role if we have to achieve this difficult goal.
In India we have about 5 lakh doctors, even though as per WHO norms, we need an additional 15 lakh more doctors to service our population of 1.1 billion. As if that was not skewed enough, 70% of our population lives in villages or small remote towns while 30% live in metros and cities. But 75% of doctors live and practice in cities and big towns. In fact, a lesser-known but shocking fact is that 98% of medical specialists are available only in state capitals. Let us not forget that we also lose many trained doctors to advanced countries like US, UK and to oil rich countries of the Middle East. This mismatch of demand and supply of healthcare resources is impossible to be bridged by traditional methods of healthcare. The real challenge here is to see how doctors can continue to live in cities and yet provide expert medical services to people in the remote places without wasting time and money on traveling. The solution we think is telemedicine because when people can’t travel, images and information can.
Q. You have made a very good case for telemedicine; but these statistics are not new, so why is telemedicine being talked of now?
A. The three factors that make telemedicine feasible and have impact are technical feasibility, time and cost.
Today, communication and Internet in India are very affordable and have already reached the remotest areas in the country. Coincidentally, most modern medical equipment used for diagnosis give digital output (ECGs, XRays, CTs, MRI machines) which can be transmitted across time and space; the first two factors are in place in India, it is time to take the next big step to activate this fantastic innovation of telemedicine.
If we can set up the infrastructure and technology to effectively use telemedicine in small towns and villages, millions of patients and their relatives (mostly poor) can be spared the cost, time and agony of traveling hundreds or miles just to see a doctor. It will also save valuable time for doctors who can give expert advice on patients’ conditions without having to travel large distances. Besides saving millions of lives and suffering, this can save crores of Rupees for the national economy by way of saving lost man-days of productivity.
Telemedicine is indispensable in case of emergencies and accidents where even if you have the money you may not have the time to save lives. A CT scan of a patient with skull injury in a remote place can be seen at any given time by a radiologist remotely at his home and in a matter of minutes correct action can be taken to save that life. This in fact has happened. It sometimes makes me wonder why we can’t make people to adopt these processes faster. Perhaps, we have to spread greater awareness about such technologies and prove that it can be put in place with minimal investment.
Q. 21st Century Health specialises in teleradiology. Can you explain a little more about teleradiology, its importance in modern day diagnostics?
A. Telemedicine is an umbrella term used when using telecommunication medium for providing medical services. Even a telephonic consultation between doctor and patient can be loosely called telemedicine.
Teleradiology is transmitting radiology images (X-rays, CT scans, MRI scans etc.) across space via telecommunication. Imaging plays a very critical role in modern day diagnosis. Our imaging team is very strong in their understanding of how radiologists use imaging to diagnose and have designed interfaces with 100+ modalities from all big suppliers of modalities like Philips, Siemens, GE, Agfa etc.
Aniruddha: There should be no doubt about the need for Tele-radiology. It is a well-known fact that the radiologists are too few in number compared to the increasing patient load all over the world. The reason why it took off suddenly is because of the sudden rise of ‘flatteners of the world’ as described by Thomas L. Friedman in his famous book – “The world is flat”. These include:
Superb connectivity of Internet across continents.
Conformance to standards by digital imaging equipment that unshackled the world of radiologists from the clutches of proprietary technologies.
And with this we really see the distance between the Referring clinician and the Diagnostic centre from the radiologist disappearing.
Q. Are there different applications of Teleradiology that make it necessary and viable?
A. Devesh: Today, almost every hospital or diagnostic centre practices remote reporting of radiology images in one form or another. The situation in which teleradiology is warranted and useful is obvious but let us lists some of them:
When radiologists are not available on site, such as at night, or when they are on leave
When on site the institute does not employ services of a radiologist, either because there is a scarcity of radiologists or because the services are too expensive and outsourcing the services is the only viable option like in case of western countries.
When a radiologist is available on site, but higher skills are required to diagnose an exam.
When the examination load increases, and on site radiologist cannot cope with the load.
When the on site radiologist would like to take another opinion on the report.
When a chain of health institutes wants to pool the radiologists in the group.
When a region lacks qualified radiologists, such as parts of Africa.
Looking at the list, it seems natural that the health institutes routinely carry out teleradiology. There are many ways in which it is practiced:
Analog/Manual: The traditional way of printing films and then delivering them by hand to the radiologist. Though it looks archaic, this practice is prent in most
hospitals for night reporting, when the films are carried to the radiologist’s home.
Digital/Manual: Here, digital images are carried manually (in form of a CD/DVD).
Digital/Networked: The digital images are transferred over a network.
Of course, it is the third type that is teleradiology that we will discuss, but one must keep in mind that the first two are followed because of lack of a standard and infrastructure for teleradiology.
Q. Most of the image archive solutions, more popularly known as PACS claim to have built-in teleradiology. How do you see this utility for various scenarios you discussed?
A. Devesh: If you take a review of how the health institutes practice teleradiology of the third type that is Digital Network, we will see many variations:
The most expensive method is to implement a PACS and allow VPN connections to radiologists. This is teleradiology looking from the hospital’s side. Secure, but highly restrictive in nature.
A stripped down variation of the above has a small scale DICOM and Web Server implemented in the hospital. The radiologist logs on to the web application and uses it to report.
Point-to-point transfer programs transfer the images from the institute computer to the radiologist’s computer.
There are many providers of teleradiology solutions in the industry, including the big PACS providers and the smaller scale regional providers.
The PACS-VPN solutions address only one situation of teleradiology need when a hospital wants its regular radiologists to access exams from outside. This method of teleradiology assumes a long term and concrete contract between the hospital and radiologists, so that the hospital allows the radiologist an access to its internal network.
All other situations call for more flexible and universal method to transfer exam and report between a source of images and a radiologist. Though there are many solutions in use, no standard method is available, which is very similar to the story of e-mail or Instant Messaging that will drive us to a true teleradiology portal.
Q. Before we go to the details of these advanced portals, can you give us some idea of the challenges one faces while implementing such solutions?
A. Aniruddha: Of course, ultimately it is the implementation of a good concept that matters. While the ‘flatteners’ have provided us with the unique situation of a Global level playing field, it is up to the users to quickly adapt to the change to exploit full benefits of the situation.
The first challenge, at least in India, is the soft copy viewing by radiologists. While there are umpteen number of DICOM viewers available, not all radiologists are actually used to this process. Softcopy reading with today’s technology is as good in quality of the image and much superior in terms of the tools to process the image! Fortunately most of the new generation radiologists in India are aspiring to be global tele-radiologists and are adapting to softcopy reading fast.
The second hurdle is connectivity to the modalities, which of course is easily surmountable if the modalities are ‘DICOM 3’ ready. But it may require a visit from the engineer from the vendor’s side to enable this data transfer. It is a thankless task to get a non-DICOM machine to hook on to the digital portals.
A portal solution must be plug-and-play. If it requires any installation/support effort on site, the growth of this model is impacted. All that the Diagnostic Centre/Hospital needs is an ordinary PC and very good Internet connectivity. Ideally such solutions ought to be in the form of downloadable/browser based software solutions so it has least dependency on the local infrastructure. This is a big challenge faced by most well designed solutions.
Lastly, it is not just transferring the DICOM files that will address teleradiology need. Many tech savvy radiologists, even today are using emails and FTP solutions to access the imaging data and report. Not knowing what exactly constitutes teleradiology workflow is the biggest hurdle. The
aspects that are completely ignored in the process are:
Security and privacy of the data: Without this the service seekers will always be hesitant to outsource the services.
Accountability and process quality ensured through the systems: Adherence to turn around time (TAT), ensuring patient history and prior investigation data availability and continuous uation of people involved in the process will make the system reliable and safe.
System for all stakeholders: Teleradiology process has multiple stakeholders apart from the radiologist and the technician. Referring consultants, Teleradiology Company, administrative staff and transcriptionist to the radiologists, KPO operation staff, and management/owners of the Hospitals/Centers etc. All have some input to the process and output from the process. The portal should rope in all of them to make a meaningful solution.
Q. How do you gauge the future of teleradiology in general and the teleradiology portal solution?
A. Aniruddha: Let’s split the answer in two – a) for the populous and emerging economies like India, China, Brazil, etc. and b) for developed economies.
For countries like India, it will be a mission-critical, life-saving service. The fact is that the number of radiologists in cities is not going to grow suddenly, let alone the interiors of the country. I believe that increasing the throughput of the existing skilled radiologists through technology like teleradiology is the only way to move forward. Pay for use commercial models are most suited for any teleradiology operation and it should be affordable for Indian operations.
In India we have a large number of independent Diagnostic Centers, unlike the western culture of prominently hospital bound diagnostic centres. Few of the Centres in the country are owned by radiologists; thus, teleradiology solution can provide the owners access to the radiologists anywhere and ease out their dependence on local skills. We are sure to see a marked rise of corporate chains of such Centers. So consolidating the radiology skills to optimise the throughput is an obvious choice.
Teleradiology KPO (Knowledge Process Outsourcing) is now an established feature and some of the Indian radiologists have demonstrated the success of this business model. As many as 60000 examinations go unreported every day because of spill over in the US alone. There exists a huge opportunity to be tapped. A quality pre-read by an Indian radiologist can always help the board certified radiologist to read the examination in a fraction of the time taken otherwise. In addition, the cost differential in the US and Indian services leads to a sound business model. If the teleradiology KPO offers sub-specialty based skill set, it becomes a more promising solution.
In short, I see Indian radiologists will look at the portal as a great convenience and at times as a life saving tool. Domestic application of teleradiology will mould them for digital culture for huge patient load to handle and they would look at overseas teleradiology as a good revenue model. A Portal will project the combined strength of Indian Radiologists to the outside world for years to come.