June 2008

New Age Diagnostic Miracle

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Q. 21st Century Health is a major player in health consulting and IT solutions space in India with your own indigenously designed solutions for HIS, LIS, EMR and AIS/PACS. You have been closely observing rapid changes in the healthcare sector for the last 10-12 years. How do you view emerging technologies like telemedicine, their impact on healthcare in India and your own contribution in this new arena?  
A. Satish Kini: We in 21st Century Health have adopted the vision 2020 espoused by our former Hon. President Dr A P J Abdul Kalam i.e. to achieve “Healthcare for All by 2020”. Dr Kalam has repeatedly mentioned that Telemedicine has to play a very significant role if we have to achieve this difficult goal.

In India we have about 5 lakh doctors, even though as per WHO norms, we need an additional 15 lakh more doctors to service our population of 1.1 billion. As if that was not skewed enough, 70% of our population lives in villages or small remote towns while 30% live in metros and cities. But 75% of doctors live and practice in cities and big towns. In fact, a lesser-known but shocking fact is that 98% of medical specialists are available only in state capitals. Let us not forget that we also lose many trained doctors to advanced countries like US, UK and to oil rich countries of the Middle East. This mismatch of demand and supply of healthcare resources is impossible to be bridged by traditional methods of healthcare. The real challenge here is to see how doctors can continue to live in cities and yet provide expert medical services to people in the remote places without wasting time and money on traveling. The solution we think is telemedicine because when people can't travel, images and information can.

Q. You have made a very good case for telemedicine; but these statistics are not new, so why is telemedicine being talked of now? 
A. The three factors that make telemedicine feasible and have impact are technical feasibility, time and cost.

Today, communication and Internet in India are very affordable and have already reached the remotest areas in the country. Coincidentally, most modern medical equipment used for diagnosis give digital output (ECGs, XRays, CTs, MRI machines) which can be transmitted across time and space; the first two factors are in place in India, it is time to take the next big step to activate this fantastic innovation of telemedicine. 

If we can set up the infrastructure and technology to effectively use telemedicine in small towns and villages, millions of patients and their relatives (mostly poor) can be spared the cost, time and agony of traveling hundreds or miles just to see a doctor. It will also save valuable time for doctors who can give expert advice on patients' conditions without having to travel large distances. Besides saving millions of lives and suffering, this can save crores of Rupees for the national economy by way of saving lost man-days of productivity.

Telemedicine is indispensable in case of emergencies and accidents where even if you have the money you may not have the time to save lives. A CT scan of a patient with skull injury in a remote place can be seen at any given time by a radiologist remotely at his home and in a matter of minutes correct action can be taken to save that life. This in fact has happened. It sometimes makes me wonder why we can't make people to adopt these processes faster. Perhaps, we have to spread greater awareness about such technologies and prove that it can be put in place with minimal investment.

Q. 21st Century Health specialises in teleradiology. Can you explain a little more about teleradiology, its importance in modern day diagnostics?
A. Telemedicine is an umbrella term used when using telecommunication medium for providing medical services. Even a telephonic consultation between doctor and patient can be loosely called telemedicine.

Teleradiology is transmitting radiology images (X-rays, CT scans, MRI scans etc.) across space via telecommunication. Imaging plays a very critical role in modern day diagnosis. Our imaging team is very strong in their understanding of how radiologists use imaging to diagnose and have designed interfaces with 100+ modalities from all big suppliers of modalities like Philips, Siemens, GE, Agfa etc. 

Aniruddha: There should be no doubt about the need for Tele-radiology. It is a well-known fact that the radiologists are too few in number compared to the increasing patient load all over the world. The reason why it took off suddenly is because of the sudden rise of 'flatteners of the world' as described by Thomas L. Friedman in his famous book – “The world is flat”. These include:

  • Superb connectivity of Internet across continents.
  • Conformance to standards by digital imaging equipment that unshackled the world of radiologists from the clutches of proprietary technologies.

And with this we really see the distance between the Referring clinician and the Diagnostic centre from the radiologist disappearing.

Q. Are there different applications of Teleradiology that make it necessary and viable?
A. Devesh: Today, almost every hospital or diagnostic centre practices remote reporting of radiology images in one form or another. The situation in which teleradiology is warranted and useful is obvious but let us lists some of them:

  • When radiologists are not available on site, such as at night, or when they are on leave
  • When on site the institute does not employ services of a radiologist, either because there is a scarcity of radiologists or because the services are too expensive and outsourcing the services is the only viable option like in case of western countries.
  • When a radiologist is available on site, but higher skills are required to diagnose an exam.
  • When the examination load increases, and on site radiologist cannot cope with the load.
  • When the on site radiologist would like to take another opinion on the report.
  • When a chain of health institutes wants to pool the radiologists in the group.
  • When a region lacks qualified radiologists, such as parts of Africa.

Looking at the list, it seems natural that the health institutes routinely carry out teleradiology. There are many ways in which it is practiced:

  • Analog/Manual: The traditional way of printing films and then delivering them by hand to the radiologist. Though it looks archaic, this practice is prevalent in most
  • hospitals for night reporting, when the films are carried to the radiologist's home.
  • Digital/Manual: Here, digital images are carried manually (in form of a CD/DVD).
  • Digital/Networked: The digital images are transferred over a network.

Of course, it is the third type that is teleradiology that we will discuss, but one must keep in mind that the first two are followed because of lack of a standard and infrastructure for teleradiology.

Q. Most of the image archive solutions, more popularly known as PACS claim to have built-in teleradiology. How do you see this utility for various scenarios you discussed?
A. Devesh: If you take a review of how the health institutes practice teleradiology of the third type that is Digital Network, we will see many variations:

  • The most expensive method is to implement a PACS and allow VPN connections to radiologists. This is teleradiology looking from the hospital's side. Secure, but highly restrictive in nature.
  • A stripped down variation of the above has a small scale DICOM and Web Server implemented in the hospital. The radiologist logs on to the web application and uses it to report.
  • Point-to-point transfer programs transfer the images from the institute computer to the radiologist's computer.

There are many providers of teleradiology solutions in the industry, including the big PACS providers and the smaller scale regional providers.

The PACS-VPN solutions address only one situation of teleradiology need

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