Teleradiology Industry Report : Kapil Khandelwal, EquNev Capital, www.equnev.com
I PE SPECT VE
Despite the huge potential the teleradiology market in India is still in its
infancy, BY SONAL VIJ
WHEN a patient in a hospital at Philadelphia needs these countries are not sufficient to match the growing
an emergency brain scan in the middle of the night, a doctor demand. Reportedly, In the US, while the number of scans
in Bangalore, India, is asked to interpret the results within being performed has been increasing. there is a persisting
minutes. shortage of radiologists. In Singapore. there is a paucity of
Welcome to the world of Teleradiology! radiologists for night coverage. In the UK, a radiologist
'Teleradiology' is a means of electronic transmission of takes 21 days on average to submit an MRI report.
radiological images, such as X-rays, CTs (computed tomo- The immediate availability of diagnostic services.
grams). and MRls (rpagnetic resonance images). from one which Is extremely important during medical emergen-
location to another for the purposes of interpretation cies, is a big advantage that outsourcing offers.
and/or consultation. Outsourcing of 'on-call' night reporting is popularly called
Digital images are transmitted over a distance using 'night-hawking.'
Standard telephone lines, satellit.e connections, or Wide Demand in the West: According to an estimate.
Area Networks (WANs).Teleradiology is therefore a facil- approximately 50 per cent of the 6,OOO~odd hospitals in
Itator for more optimal medical care. It is not a form of the US stiff do not have the technology for teleradiology.
imaging but rather the technology or process of image and this therefore represents the future potential market
transfer/transmission. size in the US alone. While our country has over 4,650
Teleradiology increases the efficiency of the doctor trained radiologists and Indian nighthawk companies are
by ensuring that s/he spends the most part of his time able to offer reports in 20-30 minutes in cases of emer-
delivering quality care to the maximum number of gency.ln 2009, the imaging modalities of X-ray,. ultrasound,
patients. One doctor based in one location can simultane- CT and MRJ are collectively estimated to account for 68.6
ously provide services to several hospitals in multiple dif- per cent of the health imaging market. according to esti-
ferent locations.It breaks geographical and time barriers mates by London-based market intelligence firm Tekplus
and helps achieve accurate diagnoses in the shortest pos- research report 'Indian Health Imaging Market'.
The Rural Arm
Potential Galore Rural India does not have good radiological services and
There are multi-faceted reasons for the potential in tele- personnel. Even if enough machinery would be available
radiology there. the local 'not-so-competent' radiologist dominates
Regulations: Apart from the demand and supply gap. the small town. But with tele-radiology. this skill deficien-
what triggers the growth of the teleradiology market is cy can be overcome by using more experienced person-
the fact that in the West it is mandatory to proVide 24-7 nel in the larger centres in the cities. Speaking on the need
radiology services. Says Dr Bhavin Jankharia, Consultant of teleradiology. especially in remote areas, Dr Arjun
Radiologist, Plramal Diagnostics - Jankharia Imaging, ''The Kalyanpur, CEO and Chief Radiologist, Teleradlology
Health Care Financing Administration (HCFA) in the US Solutions, says. "Many remote parts of India face significant
mandates round-the-clock services in every hospital. By heaJthcare challenges related to non-availability of trained
outsourcing radiology reporting to places such as radiologists. Teleradiology bridges the rural·urban divide
AustraJia. Europe. and some Asian countries (including and allows rural India to have access to the best quality
India) hospitals in the US, the UK. and Singapore can be diagnostic skills in radiology in a timely manner. Our serv-
assured of competent and timely professionaJ help."There ices to the Ramakrishna Mission Hospital in leanagar,
is an increase in demand for radiology services in coun- Arunachal Pradesh. have been of great value to the pre-
tries like the US, the UK and Singapore.The radiologists in dominantly tribal population of this remote part of our
AI 1(':1 JC:T ,nnQ IN IMAC.INC. ,
The leleradlology centre at Oiwan Chand Sons Private Umited The call centre at Teleradlology Solutions
country.The po ential is immense." pregnant mothers receive ante-natal care. It is no wonder
With the imment consolidation of the healthcare that our IMR (56 per 1000 live births - more than double
and diagnostic services, including radiology services in of China & Brazil) and MMR (44 -10 times of China) is
India, one an witness a potential to integrate the small way behind even most developing countries and closer to
town radiology centers with urban hubs. ''Technology- sub-saharan Africa. Use of tele-radiology by government
enabled models like teleradiology organised in a hub- n- and private entrepreneurs is one way for us to reach clos-
spoke would be the key driver," comments Kapil er to Millenium Development Goals.
Khandelwal.TeleradioJogy expert and Independent Board Dr Kalyanpur remarks, 'We cover hospitals in loca-
Member and Founder of Disease Management tions such as Croatia. Georgia (republiC in the former
Association of India. "We are already wi01essing some USSR) and in Iranagar, Arunachal Pradesh where radiolo-
consolidation activity in Southern India States of Tamil gists are unavailable or in eXtremely short supply.
Nadu,Andhra Pradesh and Karnataka," he affirmed. Diagnostic interpretations and as a result accurate treat-
On the domestic from, the key driv- ment would be gready delayed in these locations were it
er for teleradiology is an acute shortage of not for teleradiology."
radiologists.As per DECD (an organisation
by the developed countries) average of Advantage India
0.22 scans (CT I MRI) per annum per indi- For international outsourcing. India has distinct advan-
vidual even if decreased to 0.12 - 0.15 tages when it comes to teleradiology.
scans (CT I MRI) per annum per individual Cose "An MRI in India. performed on a State-of-the-art
to factor the age difference in populations, scanner. costs Rs. 6,000 (approximately $ ISO USD). The
we would need about 450,000 scans per professional fee component is usually 10-15 per cent, I.e.,
day and therefore 40,000 machines and a 15-25 USD,II states Dr Jankharia.At these rates, having an
pool of 30,000 radiologists compared to Indian radiologist report outsourced scans can offer a sig-
less than 3,500 radiologists currently. nificant monetary advantage."Reduced costs due to the
Going forward considering 30 years of economy of scale. For each small hospital to have a radi-
By outsourcing radiologists' active professional life just ologist awake all night to cover emergencies is prohibi-
radiology reporting replacement would require 1,100 new tively expensive. An outsourced model works Out to be
to places such as radiologists to pass out each year com- far more cost-effective," opines Dr Kalyanpur:
and so e Asian pared to less than 300 new radiologists Cheap labour': ''The salary of an Indian radiologist
coun nes including passing OUt each year. working in the field of CT and MRI, five years post-MD
India hospitals in The most urgent need is for making (Indian board certification). would usually be close to or
the US. the UK. and
Singapore can be ultrasound facilities available to the mass- less than Rs 2,00,000 per month (approximately $ 5.000
assured 0 es.Today. less than 10,000 USG machines per month or 60,000 USD per year ; in contrast, a com-
compelen and cater to about 10 million instiOJtional deliv- parably qualified radiologist in the US would be earning
help eries, which represent only 44-4S per cent approximately $ 350.000 per year," says Dr Jankharia.
of total deliveries. Only 52 per cent of Time difference: The time difference betWeen the US
8 IN IMAGING AUGUST 2009
Images need to be acqUired. stored. transferred and
Cover Story viewed.
Acquisition of Images
Today. Virtually all radiology equipment is fully DleOM
compliant.Thus. images can be stored on a network or a
and India is a distinct advantage. especially for nighthawk workstation In the DleOM format. Lossy and lossless
services.When it is night in the USA. it is daytime in India. compression is possible. Varying degrees of loss of
This means that it would be possible for an Indian radiol- information may be acceptable. depending upon the
ogist, working dUring the daytime. to interpret images modality and the clinical situation. ptain radiographs
with better quality and a greater accuracy than would the obtained non-digitally may need to be scanned. Currently.
US radiologist in his night shift hours. "The day night mammography images remain the last barrier to reliable
advantage that India affords results in greater productivity teleradiology. This is due to the large file sizes and issues
of radiologists who are in short supply. II adds Dr related to the image resolution required to detect
KaJyanpur. "Moreover. with a number of US.based third- microcaJcifications.
party teleradiology service providers already offshoring. Transfer of Images
they are creating capacity to support 'day hawking' or day- In the early days, transfer of Images was performed over
time services as well," affirmed Kapil KhandelwaJ. telephone lines using modems. sometimes with speeds as
Skilled support staff: India also has a distinct advantage low as 2.400 bps. Today. high-speed lines are avaJlable.
in the form of high<alibre Information Technology (IT) allowing different centres to connect directly or over the
and Business Process Outsourcing (BPO) manpower. as internet for transmissIon of Images. Images may be
also a great number of engineers trained in the basic skills directly transferred or streamed. depending upon the
required for offshore jobs. software being used.
Technology innovation: India is a1reacly an Innovation VIewing of Images
hub for medical companies GE, Siemens and Honeywell. Image viewing requires a workstation that can display
This coupled with world-class technology outsourcing high-resolution images. Many types of software are
service providers like Infosys.TCS.Wipro and so on. India currently available like ERlm. which aJlows viewing.
does have a potential advantage to roll out innovative manipulation. measurements. 30 reconstructions, etc.
technology solutions in this space.
The Players With the advent of PACS and RIS (radiology information
Companies like Teleradiology Solutions and Wipro system) now Integrated into the teleradiology system. It
Technologies have been early movers in providing .night gives efficient and Instant communication of findings to
hawking'services. Diagnostic companies such a.s the clinician or surgeon.
Metropolis, Wellspring and others are readying them-
Source: &InM }«*Jlotio a. Tdeo dliot'Y. The ,,., ~.IncfonJ Ao<SoIofY
se.tves to grab a share of this large pie.The most dominant ~ 2009;I9:IU
one is Teleradiology Solutions founded by Dr Arjun
Kalyanpur. aYale-trained physian, who set it up with anoth- now providing teleradiology support for 3D reconstruc-
erYale-trained physician Dr Sunita Maheshwari.lnitially he tions. thus speeding up the work for radiologists and tech-
set it up to provide hospitals in the US with night shift nologists in the US.
radiology solutions. now it also proVides teleradiology to
hospitals in Singapore and India with other countries on Domestic Market
the anvil. Services to hospitals around the gtobe, includes The domestic market is unstructured right now.There are
interpretation of aJl non-invasive imaging studies, namely a number of radiologists who have tied up with three to
CT. MRI. ultrasound. nuclear medicine studies and digitised four diagnostic centres to interpret the tests but barring
X-rays. Emergency reportS are provided within thirty min- a handful, nothing Is organised. In the domestic market,
utes to locations diametrically across the gtobe. one of the pioneers in the successful use of teJeradiology
The company provides sub-specialty consultations in India was attempted by a private-sector imaging centre
in cardiovascular and oncologic imaging to hospitals in called Jankharia Imaging in Mumbai which was started off
India as well. and has joint research partnerships with in 1996. A simple system for transferring images from the
major technology vendors such as GE. to explore new imaging centre to the homes of the individual doctors was
techniques in 3D imaging analysis. The company has a set up. primarily. to report emergency CT scans.Also. one
number of US-trained and board certified radiologists. of the oldest Delhi-based diagnostic chain, Diwan Chand
This means that they have the authority to sign a report Medical Services (P) Ltd (DCMS) has linked all other
and not merely give a second opinion. three centres. flIt is excess and specialsied work load com-
A couple of companies, including Wipro ing to the central location. Its free radiologists. an also
Technologies and the Manipal Group of Hospitals. are 'speciaJist' radiologists - enabling high end care to the
10 IN IMACiINCi AUGUST 2009
peripheral sites" informs Dr Bharat Aggarwal, Consultant abroad. A couple of companies including
Radiologist, OCMS. Wipro Technologies and the Manipal
He also informed us that in the future OCMS will Group of Hospitals, are now providing tel-
open a chain of diagnostic centres using teleradiology in eradiology support for 30 reconstruC- OR ARJUN KALVANPUR
CEO Gnd Ch,cl Rad,olog'SI
the domestic market. Right now, OCMS does interpreta- tions, thus speeding up the work for radi- Telornd,ology Solulions
tion for Haldwani Sushila Trivari Forest Hospital in ologists and technologists in the US. This
Uttarakhand. "This has been quite beneficial for the hos- doesn't require board certification. They
pital. Previously, the machines were installed but not fully provide the reportS. but not sign it. These
utilised. After we have prOVided them our interpretation reportS are then signed by the radiologists Teleradiology
services, there is full utilisation of the equipment," he abroad.
adds and allows rural
Challenges India to have access
to the best quality
Reality Check The main hurdles for Indian teleradiology
dlagnos c skIlls in
While there are so many factors that should have logical- are as follows: radiology In a timely
ly spurred the growth of the teleradiology industry in Lack of board-certified radiologists in manner
India, the rrliey is that except for one company, India: This is one of the main hinderances.
Teleradiology Solutions. there is no other company prac- Most radiologists who go to the US for
ticing teleradiology to any significant extent in the coun- board certification may be reluetant to return to India In
try. ExpertS remark that there are some enterprises view of the large differences in salaries and compensa-
doiJ'lg preliminary 'ghost reporting' for facilities in the US, tions. However, ro sign a report for developing countries,
but this work is either in ethical grey zones. This is also one needs to be board certified. On the formula of suc-
spoiling trust and the goodWill of Indian medical services cess, Or Kalyanpur remarks, "Qualiey is paramount in this
The Medixview ed-cal x-
ay LCD II uminator design is truly an innovation,
Scientific & Safe way to View Medical X-Ray, RI & CT Scan Films.
• India's slimmest Medical X-Ray film Illuminator with
thickness of one inch only
25mm • High Brightness. Adopted with advanced clipping device
• Excellent uniformity of light distribution (More than 80%)
Long lamp lifespan (20.000 hours)
Japanese made light source • Blue light Is more suited to read X-RAY films
• Flicker free hence reduced eye-fatigue
Avail bl in Slnole film 14" II 17". Two film 28" II 17",
Three film 42" II 17", Four film 56" II 17"
Apollo Hospitals, Hinduja Hospital, Ramachandra Hospital, Artemis Health Institutes,
Ram Manohar lohia Hospital, Alchemist Hospital, Sahara Hospital, Nanawati Hospital,
Paras Hospital, Crosslay Pushpanjli Hospital, PGI Chandigarh. Mumbai Port Trust
Hospital, Indian Railways & list Keeps on Increasing.
AUGUST 2009 IN IMAGING 13
industry and players that are not obsessively attentive to therefore asset utilisation holds the key
this are unlikely to have much success." to profits. However, unlike tele-pathol-
'Third-wond' status and credibility: "Despite the ogy wherein pooling of equipment at a
growth of medical facilities in India and the reasonably single location to achieve better asset
high levels of quality, people In the West are still wary of utilisation is possible. radiological Fcunder
having Indian radiologists in India interpret swdies:' Dr equipment are extremely expensive Assoc ahc" c' India
Jankharia says.The market is fragmented and smaller play- and the 'samples' are not portable. Bar-galore
ers typically lack the credibility necessary to scale up. Quality Issues: Many rural and semi-
The hard-earned reputation by few companie.s has urban centres do not have qualified
lately been jeopardised by controversial hard-sell advertis- radiologists but they do not mind the models like
ing by some newer Indian players. Reportedly, hard selling lack of quality reporting and oft.en leave teleradio ogy
badly written e-mails are being sent to players in the it to the referring clinicians to read the in a hub- n-spot<.e
auld be he key
developed countries claiming to provide reportS 'of such images themselves. Here, teleradiology driver
high quality that no additional review by a European or can help to provide quality services.
American radiologist would be necessary'. This truly Low Quality Equipment: "Since
makes on doubt the credibility of Indian outsourced many diagnostic centres buy refur-
radiology services. bished equipment or second hand old
Small markets: The countries that are likely to seek tel- and outdated machinery. these machines are not compat-
eradiology outsourcing would be English-speaking coun- ible with teleradiology softwares." says Dr Aggarwal.
tries and the ones where the cost differential makes eco- Connectivity: Dr Jankharia opines that although tele-
nomic sense. Not too many countries fulfill these criteria. radiology has been talked about for more than seven to
In fact, some European countries as well as Australia and eight years in India. it was initially connectivity and band·
New Zealand have been successful in leveraging their width which slowed growth though the impetus by ISRO
advantages to become hubs for outsourcing. and spread of broadband (> 2 Mbps) has eased out that
Insecurity: 'We are seeing many radiologists in the US issue now.
and Europe fear about their future as the newer models Currently. the use of teleradiology within the coun-
are operating models are emerging." says Khandelwal. He try is confined to practices with multiple centres transfer-
comments, "From the offshoring perspective some of the ring images to each other or to a central hub. Rural-urban
risks include outsourcing the wrong studies, outsourcing or generalists-to-specialists transfers are not yet very
tOO many studies, choosing the wrong vendor. legal factors popular, mainly due t.o cost constraints.
and resistance from in-house physicians." A Yale study 'The key to success of tele-radiology is the spread
affirms that there are potential benefits for teleradiology of radiological equipment to the interiors of India coupled
and the concerns with respect to outsourcing through with the ability of masses to afford these services.
teleradiology is fairly overstated. Therefore, unless medical technology is individualised to
Level playing field: "Offore-based teleradiology servic- Indian needs. wherein cost of MRI scans can be brought
es have tax. SEZISTPI benefits while third-party domestic down and health insurance (both private and government
player have to bear the service tax burden and compen- sponsored) takes off, tere-radiology is likely to remain a
sate that cost disadvantage by either flogging the teleradi- technology with great potential. There needs to be a dif-
ologist to do more reads:' opines Khandelwal. ferent approach from corporate based to a sector based.
There should be sharing of collaborative effortS between
Domestic Woes the healthcare provider, telecommunications and health-
The main issues affecting the growth of teleradiology care technology. Only then there will be optimal utilsation
within the country are the following: of resources," remarks Murli Nair, Partner. Business
Cost Radiology studies in this country are priced low, Advisory Services Ernst & Young.
and centres can find it difficult to afford the services of tel- For the domestic market. the costs of the teleradi·
eradiologists. Moreover, a large amount of the profit ology services needs to be reduced and for the interna-
earned goes as refferral fee to the doctor who has rec- tional market, for a player to be successful. one must be
ommended the test at a particular centre. This. thus, pre- obsessed with quality! _
vents a large share of profits to be ploughed back.
Also. healthcare is well-acknowledged as a capital firstname.lastname@example.org
intensive industry with radiology being even more so and