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Cover Story

Teleradiology:

       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'.
sible time.
                                                                  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.   ,
Cover Story




         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:
  Australia. Europe
   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
 timely professional
         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.
                                                                       Conveying reports
       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
Cover Story

 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
                                                                                                                                                Bangalore
 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
                                                                                                                                              bridges the
 services, there is full utilisation of the equipment," he                   abroad.
                                                                                                                                          rural-urban divide
 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



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                                                              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.


                                           CE                                            •


                                                                                                                       AUGUST 2009 IN IMAGING              13
Cover Story

 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
                                                                                                                   KAPIL KHANDELWAL
 high levels of quality, people In the West are still wary of       utilisation is possible. radiological                      Fcunder
                                                                                                                    Dl'"...cas.e P
                                                                                                                                 ..441nag<·mt'f'lt
having Indian radiologists in India interpret swdies:' Dr           equipment are extremely expensive                Assoc ahc" c' India
                                                                                                                                  1



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
                                                                                                                 Technology-enabled
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                                                sonal.vij@expressindia.com
intensive industry with radiology being even more so and

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Teleradiology Industry Report : Kapil Khandelwal, EquNev Capital, www.equnev.com

  • 1. Cover Story Teleradiology: 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'. sible time. 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. ,
  • 2. Cover Story 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: Australia. Europe 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 timely professional 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
  • 3. 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. Conveying reports 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
  • 4. Cover Story 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 Bangalore 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 bridges the services, there is full utilisation of the equipment," he abroad. rural-urban divide 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 ffSt ·T~e MedJxYiew· ~---~...,-~--- 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. ,- FEATURES: - • India's slimmest Medical X-Ray film Illuminator with thickness of one inch only 25mm • High Brightness. Adopted with advanced clipping device Thickness • 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. CE • AUGUST 2009 IN IMAGING 13
  • 5. Cover Story 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 KAPIL KHANDELWAL high levels of quality, people In the West are still wary of utilisation is possible. radiological Fcunder Dl'"...cas.e P ..441nag<·mt'f'lt having Indian radiologists in India interpret swdies:' Dr equipment are extremely expensive Assoc ahc" c' India 1 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 Technology-enabled 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 sonal.vij@expressindia.com intensive industry with radiology being even more so and