Collaboration Through Consolidation
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 group's strategy is to assist organisations in training radiologists, increasing efficiency and enhancing business opportunity by establishing reach, optimising resources and providing quality radiology services
By: Jayata Sharma
Shortage of radiologists is a pressing concern in Indian healthcare. It's one of the 'most-wanted' breed in the sector right now with increased focus on imaging in patient care. This, coupled with the fact that setting up a radiology lab costs big bucks, is not helping the cause much.
However, there is one organisation, which is not only working on tackling this hurdle, but also doing it with quality in mind. 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 group assists organisations to increase efficiency and enhance business opportunity by establishing reach, optimising resources and providing quality radiology services. CARG has been successfully providing teleradiology reporting services, radpeer reviews, radiology quality assurance programs, radiology academic programs, collaborative research with equipment vendors and consultancy in radiology business transformation.
The objective of CARG is to provide easy access to expert & reliable radiology services. Columbia Asia Group of Hospitals, 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.
Achieving a task as big as this requires team effort. Columbia Asia too has a team that handles this function. In a combined interview with them, we find out in detail about how exactly does CARG work and how is it making a difference in the education system of the sector.
Dr. Harsha Rajaram: Vice President – Diagnostics & Telemedicine, Columbia Asia Hospitals;
Dr. Shalini Govil: Senior Advisor & Quality Controller - Associate Professor at CMC Vellore;
Dr. Harsha Chadaga: Head of Radiology, Former Professor, Ramachandran Medical College, Chennai; Anto Ramesh Delvi: General Manager - Radiology Operations, Columbia Asia Hospitals; and
Dr. Sundeep Reddivari: General Manager - Columbia Asia Radiology Group.
Columbia Asia Radiology Group has been successfully providing radiology academic programs, teleradiology reporting services, radpeer reviews, radiology quality assurance programs, collaborative research with equipment vendors and consultancy in radiology business transformation
What are the main reasons for India's shortage of quality radiologists?
Dr. Govil: Many hospitals recognised for radiology training in India lack a dedicated faculty with subspecialty experience or training, wide spectrum of pathological cases and clinical & pathology support and feedback. In addition, a 2-year diploma or a 3-year degree is not long enough to master the length and breadth of radiology, which involves the study of all body systems and all pathologies as depicted on multiple imaging modalities. In countries like the US and UK, trainees go through 5 years of formal training before becoming independent consultants.
Dr. Rajaram: This shortage is a global issue, and is not limited to radiologists; there is a shortage of quality radiographers also. In the last two decades, rapid development in imaging technology and its enormous impact on patient care has seen an unprecedented growth of radiology studies, which is not matched by the growth in radiology professionals creating a significant gap between demand and supply.
In addition, there is a huge disparity in quality of radiology professionals entering mainstream due to high degree of variability in education, especially in India and other emerging economies. This is due to lack of quality teachers, the methodology of teaching and non-availability of higher modalities, particularly at radiography institutes.
Dr. Reddivari: The foremost reason for a general shortage is the practice of evidence-based medicine now a days. Also, rapid advances in technology has opened avenues for advanced diagnostics to be available in a shorter timeframe. For instance, acute appendicitis in the 80's was reliant on 3 aspects a. Clinical examination b. Blood counts c. Surgical biopsy. This approach resulted in high number of unnecessary surgical procedures. With the advent of ultrasonography surgeons had the ability to accurately diagnose appendicitis before attempting a surgical procedure; thus, bringing down the number of unnecessary procedures.
Mr. Delvi: There is a shortage of equipment like mammography, CT, MRI; and even a basic X-ray machine is not shown during training period. This results in no proper technical training for equipment like the X-ray, CT, MRI, mammography, BMD, OPG, bedside radiography, dental, and so on.
How relevant is training & education in such a scenario?
Dr. Govil: If 'top-up' training and assessment after MD can be provided in an intensive collegiate atmosphere that goes beyond mere attendance at CMEs, radiology accuracy will improve logarithmically. Obviously, an accurate diagnosis will then result in correct treatment and good clinical outcomes.
Dr. Rajaram: Today, PACS and high-end monitors are a part of any radiology professional's life, hence it is important that he/she understands the IT systems and the workflow. The acute shortage has also pushed young professionals to be independent and efficient right since day one and to have a willingness for self-learning. Considering the above factors, CARG's aim has been to provide training, which is flexible & integral in day-to-day practice, provide exposure to a wide variety of cases & latest technologies, and prepare them to take up international examinations and assessments in view of the 'internationalisation' of radiology services.
Dr. Reddivari: Relevance of radiology education is multifaceted. The shortage can only be addressed by increasing the volume of skilled personnel, hence training and education is the only avenue. The vast and rapidly increasing applications of radiology in areas of medicine have opened up areas of specialisation and professional streams such as ultrasound technologist, 3D technologists, reporting radiographers (new concept being explored in UK to address the shortage) and subspecialisation in clinical radiology have come up. Also, radiology as a subject is a 'new kid on the block' in relation to the other fields of medicine and is in a stage of rapid evolution. This causes a situation where skills have to be learnt, improved and relearnt (e.g.: a lot of radiologists who learnt their skill in the 80s were formally educated in X-ray and ultrasound modalities only. The present market trends are showing a huge shift into the use of CT & MR; thus, forcing the old timers to train again or fall behind).
What kind of programs and training models do you run?
Dr. Chadaga: One of the challenges of training is deciding whom exactly you train in your organisation and when you train them, considering the impact it would have on pulling a radiologist out of routine reporting. CARG does pre-assessment prior to employment and before any training program. In addition, our annual appraisal helps us tailor the trainings. We also ensure training is continuous & on the job without compromising on either the training or the operations. At CARG, both incentive and time, are provided to an individual to learn and develop skills.
• DNB course: In an effort to increase the volume of radiologists, this is a post graduate program running for 6 years.
• FRCR training program: To standardise the quality of radiologists by preparing them for a standardised exam accepted across the world. Yearly, a mock exam for the FRCR 2B exam is conducted by the Royal College of Radiology.
• Cross-sectional fellowship: An effort to fast track the learning curve for a fresh post graduate radiologist, this 1-year course is focussed on CT & MR for doctors who have freshly completed radiology training.
• Online subspecialty fellowship: To keep practicing radiologists up to pace with the latest in subspecialty areas of radiology while continuing to work.
• Radiographer training programs: To increase the number of trained radiographers in a rapidly expanding market for medical imaging.
How do you ensure designing the right training modules?
Dr. Govil: By re-training professionals both before and after they attain their degree. Our curriculum and courses are based on decades of teaching experience and modelled on existing training programs in pedigree institutes in India and all over the world. We also provide unique training material that uses facial recognition and Facebook tagging to fast track learning for busy, working radiologists.
We also stress the learn-by-doing method and widely employ draft-validate mentoring and run reporting workshops centered on disease specific reporting templates.
Dr. Chadaga: We follow international guidelines and get inputs from internal and external resources for development of the curriculum. Also, feedback is taken from the students and constant changes are made in the course design based on that.
Dr. Reddivari: Columbia Asia takes an approach of problem-focused skill building. For example, the aspect of 3D processing is a rapidly-developing application in the field of medicine that is being constrained by a lack of skilled manpower to do the processing of images. Columbia Asia has identified this as a need and developed a training module to address this skill need and we are currently conducting a 3D processing course for radiographers to specialise in.
What role does technology play in imparting such an education/training?
Dr. Govil: We employ learning management systems, PACS, teleradiology, videoconferencing and social media applications that enable distance learning in the form of online modules, assessments, draft-validate mentoring, virtual real-time mentor contacts and case discussions.
Dr. Chadaga: CARG believes highly in leveraging technology to deliver training at the fingertips of practising professionals. In fact, because of technology, distance is no more a barrier and availability of training tools at suitable time for students has made training really easy.
Dr. Rajaram: Also, CARG has hosted its own academic server by adopting MIRC TFS, a free software developed by RSNA.
It seems CA also helps other organisations by proving radiology services.
Dr. Rajaram: Yes, Peer Review, an assessment of image acquisition quality and reporting accuracy is provided as a service. The reviews are done for clinical information, appropriateness criteria, image quality, clinical interpretation accuracy and clarity in communication maintaining confidentiality of all stakeholders. The group has done nearly 1,00,000 peer reviews till date. Additionally, CARG's experience in setting up enterprise radiology practice and its expertise in consolidating radiology manpower & operation, is being offered as a Consultancy Service.
Infact, we have helped a publicly-listed hospital chain in Indonesia to replicate our success using this model.
We also collaborate with industry stakeholders for product development, software development & validation, workflow management and imaging analytics, helping drive excellence in radiology.
Setting up a radiology division can burn a hole on an organisation's pocket. How does CA assist other institutions in business transformation and optimisation consultancy for the same?
Dr. Rajaram: We have been successful in operating CARG across India as one group for nearly a decade now. The service includes establishment of clinical governance, quality assurance practice, clinical operations, accreditation support, equipment planning and skill development to enhance clinical excellence and optimise investment.
Dr. Reddivari: Setting up a radiology department burns a hole and running the radiology department burns a bigger hole! We have actively pursued avenues to constantly improvise and improve the efficiencies of running a radiology department. CA has devoted resources to build a Consolidated Virtual Radiologist team across its hospitals to ensure the hospitals enjoy the benefits of a larger subspecialty service while optimising on the costs. During the consolidation effort, CA has been able to fine tune its processes across the operational spectrum of radiology (from prescription to collaborative patient management with the treating physician). This experience has been packaged into a program for implementation and is offered to other institutions as a consultancy.
Kindly share with us the most successful implementation till date and the reasons that makes it special.
Dr. Rajaram: 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.
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.
Both the organisations have also seen other intangible benefits such as expertise availability 24/7, 365 coverage, standardisation, and load optimisation has tremendously improved the support to clinical specialties.
How does all of this make business sense for Columbia Asia? As the Hospital Group in itself is large enough to perhaps consume all of these services in-house.
Dr. Rajaram: From a business perspective, the intent is to optimise the high cost of radiologists, by utilising them efficiently. Effective cross utilisation and maximising their subspecialty expertise helps us retain talent and make financial sense. Our model has been 'collaboration through consolidation'. We have consolidated our radiologists across all our hospitals in India, which has helped us standardise and create greater capacity. We are able to leverage expertise, provide seamless coverage and also extend it to other needy institutions.
Training also keeps our radiologists updated with the latest in the speciality. There are many radiologists who want to be associated with academics and such programs are a good avenue for their ambitions.
What challenges do you face in providing these services & how do you manage them?
Dr. Rajaram: The challenges have been in making the program relevant for day-to-day practice and keeping the cost affordable. In view of the shortage faced, it is important that the program is designed in a way that it does not pull the radiologist from the running practise and create further shortage. The challenge is to integrate training as part of their work and make it interesting.
Who are your partners in these initiatives and their roles in the services provided?
Dr. Rajaram: We associate with leading equipment manufactures and their research division to train radiologists and technicians on sub-speciality applications. Siemens has been supporting our cardio imaging, neuro imaging and onco-imaging sub-speciality programs. Also, for the past 6 years, we are privileged to be associated with distinguished faculty and examiners from Royal College of Radiology, UK who are at our facility to train the FRCR 2B prospectus. We have also worked with leading LEEDS, UK faculty members in organising MSK imaging workshop & training. The radiology department of CMC, Vellore has been always supportive and have been participating in many of our training programs as faculty.
Additionally, we work with Aradhana Skills, Pune as their associates in providing radiographer training, a program that is recognised by the Skill Council of India. We provide practical training to young students & help them expose to latest technologies & workflows. We have also partnered with many radiographer training institutes for providing practical training programs.
Kindly share with us some statistics: number of people trained, in how many geographies, and such.
Dr. Rajaram: We have many budding radiologists & radiographers from India, Uganda, Bangladesh, Kenya and Philippines in skill development post their radiology education. Not only this, we will soon be hosting our 6th edition of Bangalore FRCR 2B course-2018; each edition accommodates 32 students and we get students from across SE Asia. Our DNB course is in the 5th year, and we have been authorised for 6 seats annually.
Lastly, CARG has been training engineers from Siemens and Samsung R&D centres, helping them orient towards radiology speciality and help them develop better products.