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Healthbizinsight

January Issue 2018

CENTER STAGE

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Center-stage

How India is Optimising it's Radiology Resources

As in most other specialties, there is not only an acute shortage of radiologists (100 per million) but a lopsided distribution too, further increasing the urban rural health divide. The 550 radiologists produced every year from 270 medical colleges (out of 410) and an additional 250 through the National Board of Examinations clearly indicate that teleradiology is the only answer for a huge country like India. So, what steps are the players adopting to fight the shortage and optimise their resources? Let's find out

By: Neelam Jhangiani

Diagnostics has become an integral part of most patients' work-up in today's scenario and with phenomenal advances in imaging, imageologists i.e. radiologists of yesteryears are now increasingly in demand.
As in most other specialties, there is not only an acute shortage of specialists (100 per million) but a lopsided distribution, further increasing the urban rural health divide. The 550 radiologists produced every year from 270 medical colleges (out of 410) and an additional 250 through the National Board of Examinations clearly indicate that teleradiology is the only answer for a huge country like India. The present 15,000 plus diagnostic centres are also rapidly increasing. Interestingly, major teleradiology players in India cater to patients outside our country, which places India-based radiologists on the world map.

Center-Stage

Our country with a population of over 1 billion people has a radiologist strength of only 10,000, which means the ratio between the radiologist and the patients is 1:100,000


Current situation

The demand for diagnostic and image interpretation services in radiology is growing at a rapid pace. This increased demand has highlighted two issues in particular: the lack of adequate staff for providing interpretative coverage and the lack of specialty expertise. To some extent, these problems can be overcome by utilising robust communication and image transfer systems to draw on the expertise of distantly-located radiologists, defined as the teleradiology system. Hospitals across the globe and in our country, draw the benefit of teleradiology and other solutions provided by companies in this domain such as Philips, Fujifilm, GE Healthcare, Cyber Tele Rad Pvt. Ltd., and more to overcome the shortage of radiologists/radiology services. "Fujifilm has PACS, 3D and Computer Aided Detection (CAD) to help radiologists report faster," points out Chandrasekhar Sibal, EVP & Head - Medical Division, Fujifilm India. In addition, their teleradiology solutions assist in reporting from anywhere with the use of X-rays digitised by computed radiography (CR). Sharing similar views on the increasing popularity of teleradiology, Prof. K Ganapathy, Director, Apollo Tele Health Services & Apollo Telemedicine Networking Foundation, says, "Teleradiology helps ease staffing shortages across the country, delivers emergency radiology services, connects to remote and underserved areas, thereby increasing the reach of subspecialty diagnosis and emoluments for the radiologist. Newer digital technologies such as voice recognition and structured formatted reporting significantly enhance radiologists' workflow, productivity, and reporting accuracy."
Newer technologies are emerging in India contemporaneously with their launch in the Western world. Philips offers intelligent diagnosis for an image with its technology-based patient centric solutions resulting in faster diagnosis and essentially highlights any lesion or anomaly present in the image. "Since we are able to provide a higher resolution through the use of multi slice technology, we aid in faster diagnosis and help radiologists speed up image processing to a whole new level," informs Jitesh Mathur, Senior Director, Philips India Limited. He further adds that where there are limited number of radiologists or have higher duty hours, they are able to provide faster diagnosis to help finish their work sooner and in turn, hospitals achieve a higher reporting rate.

Dr K Hari Prasad

Fujifilm is now working on adoption of artificial intelligence in radiology, where the computer can do the reporting and the radiologist will verify the report


Chandrasekhar Sibal,
EVP & Head - Medical Division,
Fujifilm India


Dr. Amit Kharat, Domain Consultant, Cyber Tele Rad Pvt. Ltd., also informs of the way they handle the shortage. He says, "Short gap reads, that is when the transitions of radiologists happen in the hospital, typically in early morning, mid afternoon and evening, are done to save time. This ensures that stat reports reach the referring clinicians in time so that patients with critical issues like infarct or a bleed, receive these reports faster and resultantly, receive a timely treatment."

Demand and supply gap

The Indian economy has been growing at a fast pace and the consumers today are more aware of their healthcare and diagnostic needs. Thus, the need for quality imaging has moved up significantly. But, India faces a severe scarcity of radiologists. Our country with a population of over 1 billion people has a radiologist strength of only 10,000, which means the ratio between the radiologist and the patients is 1:100,000, which is extremely low. The corresponding ratio in the US is 1:10,000.
Also, countries like Japan or USA have 50 MRIs for a million population. For that matter, even countries like Latin America or developing countries have around 2 ½ to 3 MRI's, informs Mr. Mathur. So the opportunity and demand in India is very high and it depends solely on how we are able to increase the access of this and get more MRIs installed in the market.
Moreover, the demand is also growing at a significant pace in tier II and tier III areas where new diagnostic centers and greenfield hospitals are coming up. The government on its part is putting digitisation of CRs in smaller places so that more reports can be sent to be read; this demand is being met mainly through public private partnerships. When there is such a huge scarcity of radiologists, teleradiology offers big benefits and therefore, has a high market potential. However, the teleradiology market has two pain points as points out Dr. Kharat, "It is extremely cost conscious and at the same time focused highly on delivery time of reports (quick TAT - turnaround time)."

Dr K Hari Prasad

Even the 3 years of full time post graduate training is barely sufficient. The trend is to follow this with sub speciality training. It is a matter of deep concern that bridge courses in radiology are being contemplated for non-allopathic doctors


Prof. K Ganapathy, Director,
Apollo Tele Health Services & Apollo Telemedicine Networking Foundation


The demand and supply ratio is not that stiff as before, however the need for senior consultants in this field is very much felt. Teleradiology practices and consultants, which are able to timely interact with referring clinicians, manage proper quality assurance methodology and maintain feedback loops with clinicians, hospitals, diagnostic centers indeed turn up as a winning combination. The major areas of demand are emergency radiology reporting throughout the world, reporting for remote areas in Asia and Africa, reporting and postprocessing of complex subspecialty cases, and reporting for clinical research in the pharma/biotech sector. With a large team of radiologists located across the globe (India, US, Israel, Turkey, Singapore etc.), Teleradiology Solutions provide 24/7 reporting services to locations anywhere in the world, with 30-45 minutes report turnaround for emergency reports. "We have reported over 5 million studies so far, making us the largest teleradiology provider in India," says Dr. Arjun Kalyanpur, CEO and Chief Radiologist, Teleradiology Solutions. They use an intelligent teleradiology workflow platform RadSPA to make the process of image transfer and reporting rapid, seamless and efficient for teleradiologists, as optimal utilisation of radiologists' time is most critical. Their Telerad Foundation draws on a team of international radiologist volunteers who provide honorary reporting for charitable hospitals in areas of need in India and Africa. Essentially, Teleradiology Solutions leverages its technology expertise in image data management and its operational experience of providing immediate and high-quality reporting services to meet the demands as they arise.
While radiology service providers are working in multiple domains to tackle the shortage of radiologists, hospitals on their part are working round the clock to meet the increasing demand. Teleradiology Solutions follows a scale model, which involves upscaling their technology infrastructure and continuous recruitment to meet the demands as they increase and a model of operational staffing and scheduling efficiency for most optimal deployment of radiologist resources across geographies and time zones. "In essence, this allows us to closely approximate the 100% mark of SLA compliance although there are obviously challenges when working in such a complex and demanding environment," says Dr. Kalyanpur.

Dr K Hari Prasad

More and more radiologists from tier II and tier III towns need to be trained in bigger cities so that they go back to the city of their origin armed with huge amount of knowledge and expertise to establish their own imaging centres


Jitesh Mathur,
Senior Director,
Philips India Limited


Indian Spinal Injuries Center (ISIC) tackles demand in its own way. An average group of radiologists at ISIC calls for stretching timelines to meet the demand. Having an additional radiologist in their team has solved the issue to an extent as they extend maximum cover up of services to their patients. "After office hours, for emergencies the images are digitally transferred to radiologists and they can report from home as well," says Dr. Anita Aggarwal, Sr. Consultant & HoD-Radiology, ISIC.

Optimising resources

Every country is unique as they have different ways to practice radiology; Indian practice is also different in terms of regulations and modalities practiced by radiologists. As we see that the number of radiologists keep on moving in the positive direction, at the same time the number of images which the radiologists have to process has also seen a multi fold increase, this makes it important that a proper distribution model of cases is done (triage), adequate history is made available and a constant dialogue between the support team and onsite technicians is done to ensure adequacy of the scans. This saves immense amount of time. Also, harnessing the power of cloud PACS, data mining tools helps in optimising time in report generation thus improvising report turnaround times.
Radiology service providers and hospitals alike work out multiple measures to augment resources at their end. Dr. Aggarwal believes that the quality of reports, good machines and interaction with consultant doctors to know the clinical picture of patients to correlate with radiology are some of the measures to optimise resources. "Having an experienced team of operators is also equally important in addition to having standard equipment for quality imaging, she adds.
Teleradiology Solutions uses its platform RadSPA to its fullest. Dr. Kalyanpur gives an example here, "Using a process of digital image acquisition and our technology/workflow platform, we deliver high quality radiology reports to small community health centers across the state of Tripura by deploying teleradiology for the whole state of Tripura (https://tripuradashboard.telradsol.com/#/dashboard/home)."

Dr K Hari Prasad

The teleradiology market has two pain points: it is extremely cost conscious & focused highly on faster delivery time of reports


Dr. Amit Kharat,
Domain Consultant,
Cyber Tele Rad Pvt. Ltd.


While Fujifilm is working on artificial intelligence, where the computer can do the reporting and the radiologist will verify the report. "This will happen 2-3 years down the line and will help in faster reporting," says Mr. Sibal.
The teleradiology division of Apollo Telehealth Services provides 24/7 remote diagnostic image reading services, using high-end technology infrastructure and experienced sub-speciality radiologists. Correct interpretation of an image presupposes correct initial acquisition and correct transfer with adequate clinical data. Clients are provided with PC based teleradiology software, interfaced with DICOM compliant radiology equipment. "Reports (made available within the contracted Turn Around Time) can also be directly updated on the patient's RIS/PACS system," Prof. Ganapathy informs.
Quality radiologists are able to provide excellent base to the surgeon who need correct imaging and that forms the basis of treatment and surgical procedures.

How to tackle the shortage

The demand supply ratio is always a challenge, whether it is in developed or developing countries. The reasons are slightly different but the problem exists. While developed countries are highly focused on intensive scan protocols, developing counties typically have a population problem and therefore are strained to provide sufficient services due to high demand and a typical demand-supply gap. Experts in the industry point towards digitisation as the only way to tackle the shortage of radiologists and radiology services. They are of the common view to digitise all the hospitals, put everything on the net and send these cases directly to the radiologists who can then report and send it faster to the hospital. "In addition, CAD solutions and artificial intelligence will help to bridge the gap between radiologists and the people," as points out Mr. Sibal of Fujifilm.
Hub and spoke model offered by Philips is one other way to solve the shortage of radiologists in a big country like India where radiologists are concentrated in bigger cities. The model has radiology diagnostic centers or radiology clinics established across the tier II and tier III towns and they get connected to one big hub centre where everything can flow together through advanced imaging modalities and central processing of images can happen. Training and education is another important area to look upon if we were to tackle the problem of radiology services.
"More and more radiologists from tier II and tier III towns need to be trained in bigger cities so that they go back to the city of their origin armed with huge amount of knowledge and expertise to establish their own imaging centres," Mr. Mathur says.

Dr K Hari Prasad

We use an intelligent teleradiology workflow platform RadSPA to make the process of image transfer and reporting rapid, seamless and efficient for teleradiologists


Dr. Arjun Kalyanpur,
CEO and Chief Radiologist,
Teleradiology Solutions


Similar views have been expressed by Dr. Kalyanpur of Teleradiology Solutions as they work to mitigate this factor by using e-learning resources (www.radguru.net) to enhance postgraduate training in radiology and supplement the radiology workforce. We are in the process of deploying artificial intelligence algorithms, which have the potential to make radiologists more efficient and productive. "Our use of efficient manpower scheduling software and productivity tracking dashboards with analytics is also key to our continued improvement in this area," says Dr. Kalyanpur. Developing training content for ongoing radiologist education is another area of focus for the company, which is essential for continuous performance improvement.
Similarly, Columbia Asia Hospitals India, as a part of its E-health initiatives, has successfully leveraged technology to consolidate its radiology operations across the country to establish the Columbia Asia Radiology Group (CARG). The objective of CARG is to provide easy access to expert & reliable radiology services. The group, a multinational hospital chain of 30 hospitals across 4 countries, has successfully established the 'Radiology Group Practice' by connecting all its radiologists across India on a secure virtual platform (HIPPA compliant, FDA approved) and instituted system-based approach for effective operations and reliable reporting. In addition to serving its own hospitals spread across the country, CARG provides tele-radiology support to over 100 clients reporting over 2000 images a day in the Indian Subcontinent and across the globe including Indonesia, France, Uganda, Saudi Arabia, Kenya, and Bahrain.
The group also runs educational programs, which includes a post-graduate radiology course (DNB), cross sectional fellowship, sub specialty program and FRCR 2B course in association with the Royal College examiners.
CARG also provides consultancy services for other players to tackle the shortage in the industry.

After office hours, for emergencies the images are digitally transferred to radiologists so that they can report from home as well


Dr. Anita Aggarwal,
Sr. Consultant & HoD-Radiology,
Indian Spinal Injuries Center


"We have done this twice now, ones for ourselves and for a non-Columbia Asia publicly listed hospital chain. The implementation was challenging and satisfactory considering the culture and language barriers. The program has reaped large benefits in terms of 17% increase in radiologists' productivity and estimated savings to the tune of USD 2,50,000 in its first phase of implementation. In terms of accuracy, it has made a significant improvement from where it started to achieve 94.7% in the same phase," says Dr. Harsha Rajaram, Vice President – Diagnostics & Telemedicine, Columbia Asia Hospitals.
While further adding, "The group itself has gained significantly by consolidation in terms of manpower cost, optimising it by 18% and increasing productivity by 60% (over 3 years), and achieving cross utilisation of 34% amongst hospitals."
Lastly, some of the things that can be done at a policy level are to increase the number of training spots for radiologists post MBBS. Currently, the numbers of postgraduate spots are grossly inadequate in proportion to our country's needs. Additionally, if MBBS doctors can be trained to perform ultrasound scans under radiologist supervision, radiologists can in parallel focus on CT/MR reporting, which are the areas of growth in radiology and teleradiology. "In the anxiety to mass produce radiologists we should not sacrifice quality. Even the 3 years of full time post graduate training is barely sufficient. The trend is to follow this with sub speciality training. It is a matter of deep concern that bridge courses in radiology are being contemplated for non-allopathic doctors," points out Prof. Ganapathy.

In summation

Cost of technology (both software and storage hardware) are progressively decreasing. Faster telecommunications are resulting in more efficient data transfer. Awareness of quality assurance parameters is leading to implementation of interpretation standards, standardising imaging protocols, communication and security standards and periodic assessment and reassessment of quality. However, there are several grey areas regarding regulations and medico legal implications. Potential liability issues and availability of insurance for teleradiologists also need to be addressed.

Dr K Hari Prasad

This shortage is a global issue, and is not limited to radiologists; there is a shortage of quality radiographers also


Dr. Harsha Rajaram,
Vice President – Diagnostics & Telemedicine,
Columbia Asia Hospitals


Many government and municipal hospitals in suburban districts have CT scanners, but no qualified and competent radiologists on the premises. Outsourcing reading of images in government hospitals to radiologists in the private sector is slowly becoming a reality but there are many pending concerns.
India has a golden opportunity in terms of teleradiology servicing for the world and we should not allow a national shortage of radiologists to jeopardise this. We need to be continuously on the lookout for tools to make radiologists more efficient. By embracing and harnessing the use of Artificial Intelligence, we can make radiologists more productive and thereby magnify the contribution of radiology to the healthcare industry. Current trend shows high investments in startups focused on machine and deep learning toolkits. This could be an interesting development as radiology images though in a different format (Dicom) can also be tagged, annotated and processed by algorithms. Although these are in a nascent phase at present, but the near future can be an interesting space to watch out for, as the tools sharpen and cloud-based solutions offering domain specific specialised services as a platform on a pay per use model start gaining traction.