Teleradiology: a tale with many twists

“Anything one man can imagine, other men can make real.”
– Jules Verne, Author

Telemedicine! One of the technological marvels in the world which testifies and proves the veracity of Verne’s words without any lingering doubts. Coined from Greek and Latin words, “tele” and “mederi” which mean ‘distance’ and ‘to heal’ respectively, The World Health Organization (WHO) defines it as, “the delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities.” However, Time magazine puts it very simply and succinctly when it termed telemedicine as “healing by wire”.

Telemedicine and teleradiology: tracing the origins

Though telemedicine was born of a need to transcend boundaries of time and distance for ensuring first-class medical assistance to people residing even in the most far-flung and remote locations of the world, initially it was viewed with lot of misgivings. There were many sceptics and non-believers. Even those who were more optimistic considered it as ambitious but ‘futuristic’ and ‘experimental’. However, proving all its cynics wrong, today it is very much a reality. There are several success stories of telemedicine projects across various parts of the world with diverse applications in patient care, education, research, administration and public health which makes it increasingly evident that telemedicine is here to stay.

In the past few years, telemedicine has diversified into more specialised forms, of which teleradiology has shown tremendous growth opportunities and application potential. Here, radiological images are transmitted from one location to another, through telecommunication systems, for analysis of all non-invasive imaging studies like digitised X-rays, CT, MRI, ultrasound, and nuclear medicine studies.

Teleradiology, as every other branch of telemedicine, owes its birth to imbalance of demand and supply. In this case, it is the inadequacy of diagnostic services and qualified radiologists in far-flung corners which gave rise to the need for teleradiology as a measure to bridge this gap. One of the first known instances of teleradiology is when dental X-rays were transmitted via the telegraph to a distant location way back in 1929. There was a time when digital cameras were used to take clinical photographs which were later downloaded, scanned and converted into the required format and then transmitted via the internet. Undoubtedly a tedious task and that too without any guarantees of image clarity and hence accuracy of data.

Since then, the progress of technology for transmitting these images has been phenomenal. Today, radiology equipment is extremely avant-garde and transmitting high-resolution images is a very swift process, thanks to high-speed internet and new-age softwares. The incorporation of picture archiving and communication systems (PACS), radiology information systems (RIS), etc into teleradiology systems have further facilitated the production of instant yet accurate reports to be sent to the clinicians or surgeons.

Global teleradiology market: poised for growth

Studies reveal that while the number of radiologists grew by two per cent annually, the growth rate in the number of examinations carried out registered more than 10 per cent. This has resulted in a widening gap between demand and supply. The imbalance in the distribution of radiologists in different countries and regions has aggravated the problem further. Hence teleradiology; with the potential to make timely diagnostic services available to the patients anywhere, anytime; is being touted as ‘the ideal solution’ to ensure quality radiology service to one and all, irrespective of the time or location. As per data released by Frost & Sullivan, Europe’s teleradiology market amounted to $184.1 million in 2010, of which more than 50 per cent of revenues were generated from the United Kingdom (UK) and Germany.

Now, various reports predict that the teleradiology market would show a northward curve in the next few years. A new market research, conducted by Global Information Inc, a Japanese information service company, forecasts that the global telemedicine market will register a CAGR of 18.7 per cent between 2011 to 2015. Similarly, a report published by Technavio, the research platform of Infiniti Research, predicts that the global teleradiology market will register a CAGR of 19.3 per cent during 2011 to 2015. UK, Spain and Scandinavia etc are expected to lead the teleradiology market globally as a result of their favourable regulatory environments, better clarity in cross border healthcare regulations, Europe’s focus on e-health and pilot research programmes funded by the European Union (EU) like R-Bay to validate teleradiology’s role in expending quality healthcare to all.

Teleradiology in india

While the world looks at adopting teleradiology on a much larger scale than ever before, what is India’s stand on it? Introduced by Jhankaria Imaging, a private imaging centre, teleradiology was first successfully put to use in India in 1996. The motive was to transit images from the imaging centre to the homes of doctors, through a simple yet effective system, to report emergency CT scans. Subsequently, Siemens and then Wipro GE publicly demonstrated the use of teleradiology but Teleradiology Solutions, a Bangalore-based company set up in 2002 by Dr Arjun Kalyanpur was instrumental in projecting teleradiology as an effective healthcare delivery tool in our country.

A slow start

Given the fact that India is a country that faces an acute shortage of medical practitioners including radiologists, teleradiology should have picked up really well. However the reality is that though it has been over 15 years since the concept was introduced in the country; it hasn’t found many takers and its potential remains untapped. Speaking on the evolution of teleradiology in India, Dr Bhavin Jhankaria, Radiologist and Editor-in-Chief, Indian Journal of Radiology and Imaging says, “It has grown as expected with the growth in technology, but as a business and practice, not as much as expected.” However Dr Kalyanpur puts it more mildly and states, “Teleradiology in India has evolved and grown, although not as rapidly as in the West.” He further informs, “The main changes in the teleradiology situation in India have been related to increased availability of broadband, improving infrastructure, increasing awareness of its potential and an increase in the number of providers.”

Benefits galore……

Yet, the benefits that teleradiology can offer to this country are numerous. To name a few:

Bridging the demand-supply gap: There is a shortage of qualified radiologists in our country, especially in the rural areas. Through teleradiology, even those living in the remote regions of the country will be able to avail quality radiology services without having to travel long distances; thereby saving time, effort and often lives as well.

Round-the-clock service: It can also make certain that radiology services are available to those who need it at any place any time. Even in the cities teleradiology can be very useful since it would be a trusty ‘back up’ for on call residents.

Immediate reporting in emergency situations: Another important benefit of teleradiology makes it very easy to seek a second opinion and expert advice during all contingencies, even the ones that occur during “off hours”, and that too without wasting time which is of paramount importance in emergency situations.

Facilitates training and CME programmes: Young and inexperienced radiologists can be trained on the nuances of radiology and experts knowledge can be imparted on the subject through teleradiology, thereby enhancing their skills and abilities, which in turn would translate in better quality services.

A lucrative business model: India, with its time difference, ability to offer cheap labour, and skilled support systems like IT, has the potential to attract outsourced projects for teleradiology from US, UK, Singapore and gradually build it up as a successful business model. It can take on lot of projects for ‘nighthawking’ another term for outsourced ‘on call’ night reporting. This way, while hospitals in the US, UK, and Singapore will get proficient and timely professional help, India will be able to generate lot of jobs as well as revenue from the whole setup. The learning lessons will be an added benefit.

Case Studies: Successful teleradiology projects

Teleradiology Solutions Ramakrishna Mission Memorial Hospital in Itanagar Arunachal Pradesh has an example of a highly successful teleradiology project within India. Supported by the Telerad Foundation, this project has been operational since 2007 and over 10,000 CT and MRI scans have been reported for the hospital by Teleradiology Solutions, free of charge. Similarly, their teleradiology project with the National Healthcare Group in Singapore has been a highly successful one since 2006 with over 200,000 examinations being reported till date. Dr Kalyanpur and his team have been able to reduce the report turnaround time from three days to one hour, an achievement that was acknowledged by the former Prime Minister of Singapore, Lee Kuan Yew in a speech he made. Columbia Asia A remote health care centre in Nagaland, was having difficulty in finding radiologists both in terms of location preference and affordability. The centre outsources its work to Columbia Asia. Today for the last one year the center is able to provide the radiology services of highest quality to its patient by group of radiologist at Columbia Asia, 24 X 7, 365 days. An emergency CT is reported at any point of the day in less than 20 minutes and a routine CT reported in less than three hours. On an average the center does six to eight CT cases per day. Stringent quality control measures have ensured that the reports are accurate and reliable, the discrepancy rate is less 0.5 per cent.

Challenges too….

Now, the question that arises is that with so many benefits in the offing, what is holding back the growth of this sector? Why is it that we have only been able to scratch the surface, where teleradiology’s true potential is concerned? Well, it is attributed to varied reasons. According to Dr Jhankaria, the reason for this is ‘costing’. He says, “Unless teleradiology is used as an in-house service, there is very little money to be made and the margins are wafer-thin.”

However, Dr Kalyanpur gives a detailed view on the topic. “The main challenges are infrastructural, as it is difficult to set up a critical medical service that has zero tolerance for downtime, in an environment where there are frequent power outages, unreliable net connectivity, traffic issues and bandhs preventing staff from reaching work in time. These same challenges result in an increased cost of doing business as redundancy measures need to be planned at every stage of a teleradiology operation. Frequently, issues of regional politics determine whether a project will be successful and enduring, as opposed to such issues as quality of service. Lack of awareness about teleradiology is another constraint to its growth. Finally, a lack of respect for contracts and focus on price as opposed to quality of reporting is an issue that affects the atmosphere in which teleradiology is practiced.” He also states, The main benefit that teleradiology offers, namely to provide immediate reporting in the emergency setting, is yet to be realised as emergency medical services in India are yet not matured enough to derive the full benefit of such radiology support services,” he explains.

Parag Agarwal, Country Manager (India), Pellucid Networks, has his own views as to why teleradiology is not picking up pace in India. He says, “On the infrastructure side, definitely bandwidth and continuous power is needed. On the delivery side, the government needs to play a more active role, at least at the State level, to sponsor the adoption of teleradiology where its needed most.”

Dr Harsha Chadaga, Senior Consultant & Head of Radiology Operations, Columbia Asia Hospitals feels, “the lack of awareness on availability of such services, lack of standards and the inherent fear of losing their jobs on the part of local radiologists have hindered the progress. The demand for quality radiologists have skyrocketed the cost of hiring them, making their utilisation challenging.”

Drawing inferences from these varied sources, it can be concluded that India has to battle several challenges like lack of awareness, low-quality, pricing, lack of infrastructure, unfavourable regulatory environments and narrow mindsets before teleradiology can become really successful in India. As of now, it has played a very limited role in India’s healthcare delivery.

Dr Jhankaria puts it very bluntly, “As yet, it (teleradiology) has not made much difference. While there are individual cases where radiology centres in under-serviced areas can be covered or multiple centres of a single practice can be covered, etc. the overall impact is negligible.” Agarwal from Pellucid also reiterates this view but is optimistic about its future. He says, “Specific to India, teleradiology is yet to make a tangible impact in the way healthcare is delivered. But as alluded earlier, it holds tremendous promise. The largest beneficiary ultimately, would be the patient, especially in critical emergency cases, and in the rural remote areas, where speed of diagnosis and intervention can save lives.”

Future predictions

So, given this situation how will teleradiology fare in the future? Will it go on to achieve its full potential or will it lose ground due to the bottlenecks hindering its progress? Again we receive mixed views on this front. Dr Jhankaria is of the opinion that it will be used more and more within practices and hospitals to consolidate multiple centres. “As a standalone business, I don’t think there is much future”, he says.

However, Dr Chadaga gives a cautious view and says, “The increasing demand, shortage of radiologists and growing cost pressures would make it essential that resources are optimally utilised. The innovation and development in technology would provide options and make it inevitable for healthcare set ups to opt for teleradiology services. In-house radiologist would be the main stay of all the hospitals, teleradiology would support and provide flexibility to the existing department. Teleradiology will be utilised as a load optimiser, used for second opinion services and also to cover beyond working hours and for holidays. With the healthcare centers mushrooming in tier two and three cities all over the country creating a huge demand for skilled manpower. Teleradiology would help, atleast to a certain extent, by taking care of the radiology services in remote areas and helping provide quality healthcare.”

Dr Kalyanpur, on the other hand, is extremely optimistic about teleradiology’s future in India. He claims, ”The future of teleradiology in India is bright, given that there are such major manpower resource issues, and consequently such great potential for transformational impact. With the deployment of 3G telecom networks, the last mile problems of the last decade that hindered the growth of teleradiology over the last decade have been eliminated. As low cost work-flow technologies become available, the access of radiologists to teleradiology is enhanced. Teleradiology will increase the access of people in semi-urban and rural India to high quality diagnostics. Thanks to teleradiology, the day when a patient has to get on a train or a bus simply to obtain an accurate radiologic diagnosis will soon be history.”

Whose claims would be proved right is something that remains to be seen. However, as Agarwal puts it, “We are still some time away from teleradiology becoming the norm.” While, it is evident enough that teleradiology’s potential is tremendous, and it is now firmly ensconced in India, there is a long way to traverse before its true potential is explored and put to use.

Expert Speak

Dr Arjun Kalyanpur, Chief Radiologist and CEO of Teleradiology Solutions, Bangalore shares insight on the teleradiology market in India and its future prospects How has teleradiology evolved since its introduction in India? Dr Arjun Kalyanpur Teleradiology in India has evolved and grown, although not as rapidly as in the West. The main changes in the teleradiology situation in India have been related to increased availability of broadband, improving infrastructure, increasing awareness of teleradiology and its potential and an increase in the number of providers. How fast is it growing? The segment, based on recent media reports, appears to be growing overall, although the precise rate of growth is difficult to determine, based on lack of clarity of scan numbers from other providers. Our own organisation, Teleradiology Solutions witnessed dramatic growth of 100 per cent between 2006-08 which decreased to around 20 per cent from 2009-2010, and is currently in the 10 per cent range. How has it changed healthcare delivery in India? Teleradiology has changed healthcare delivery in India by allowing quality radiology services to be delivered to remote parts of the country – the current situation is that imaging equipment is being installed in various parts of the country by institutions such as the government, the armed forces and by private investors, however the number of radiologists is not increasing parallelly. Also most radiologists are concentrated in the metros. Teleradiology therefore enables the highest quality of radiology reporting to imaging centres in the smaller towns and rural areas. For example, Telerad Foundation delivers high quality reports to remote locations in places such as Arunachal Pradesh and Jharkhand by extending the reach of radiologists in India and allowing them to report from anytime, anywhere. The use of teleradiology, with tools such as TeleradTech’s Radspa allow radiologists to increase their reach and scope of practice and also work more efficiently – additionally the practice of subspeciality reporting is also facilitated, and so the reporting standards in the entire country can be raised. It also shortens report turnaround times. Outsourcing radiology reporting is accompanied by service level agreements whereby the report turnaround times are carefully monitored and tracked, shortening the reporting cycle, decreasing patient waiting times, and benefitting the healthcare delivery system. However, the main benefit, namely to provide immediate reporting in emergency settings, has yet to be realised as emergency medical services in India are yet not matured enough to derive the full benefit of such radiology support services. Which prevents implementation of teleradiology in India? The main challenges are infrastructural, as it is difficult to set up a critical medical service that has zero tolerance for downtime, in an environment where there are frequent power outages, unreliable net connectivity, traffic issues and bandhs preventing staff from reaching work in time. These same challenges result in an increased cost of doing business as redundancy measures need to be planned at every stage of a teleradiology operation. Frequently issues of regional politics determine whether a project will be successful and enduring, as opposed to such issues as quality of service. Lack of awareness about teleradiology is another constraint to its growth. Finally, a lack of respect for contracts and focus on price as opposed to quality of reporting is an issue that affects the atmosphere in which teleradiology is practiced. What is the future of teleradiology in India? The future of teleradiology in India is bright, given that there are such major manpower resource issues, and consequently such great potential for transformational impact. With the deployment of 3G telecom networks the last mile problems of the last decade that hindered the growth of teleradiology over the last decade have been eliminated. As low cost workflow technologies become available the access of radiologists to teleradiology is enhanced. Teleradiology will increase the access of people in semiurban and rural India to high quality diagnostics. Thanks to teleradiology, the day when a patient has to get on a train or a bus simply to obtain an accurate radiologic diagnosis will soon be history.

Parag Agarwal, Country Manager (India) Pellucid Networks gives his views on how teleradiology is shaping up in the Indian market and predicts its future progress Tell us about teleradiology’s growth in India. Parag Agarwal It has become more relevant for entrepreneurial radiologists who are venturing out and starting their own teleradiology service businesses either as a group or as independents. With cloud technology, in the last few years, the cost of providing teleradiology services has not only come down drastically, but with flexible pay per use models, it has also led to the creation of several viable and fast growing businesses run by radiologists. As long as radiologists see the incentive of making themselves available remotely, with the same high levels of image quality, imaging centres will continue to demand and also contribute to the cost of teleradiology. For imaging centres, having a sophisticated workflow on the cloud also improves their turn around time, patient volume and ultimately revenue. So even the smallest of imaging centres in India is now open to teleradiology. What kind of growth has this sector witnessed so far? Growth of imaging centres is at 15-20 per cent per annum while radiologists are only growing at two per cent. As long as this gap remains, the growth rate of teleradiology will remain steady, at least on the demand side. How has it changed healthcare delivery in India? Specific to India, teleradiology is yet to make a tangible impact in the way healthcare is delivered. But as alluded earlier, it holds tremendous promise. The largest beneficiary ultimately, would be the patient, especially in critical emergency cases, and in the rural remote areas, where speed of diagnosis and intervention can save lives. What are the roadblocks hinder the path of teleradiology services in India? On the infrastructure side, definitely bandwidth and continuous power. On the delivery side, the government needs to play a more active role, at least at the State level, to sponsor the adoption of teleradiology where its needed most. What is the future of teleradiology in India? We are still some time away from teleradiology becoming the norm. However, for rural healthcare delivery, the government must step up its effort in partnership with private players as there is no other viable alternative to reach the masses.