The backroom scanners in hospitals

Picture this. An 84-year-old in Kentucky suffers a stroke past midnight, falls down, and breaks a couple of ribs. He is rushed to a hospital where the doctors put him through an MRI scan and send the images to a diagnostic radiologist — the standard procedure. Just that the radiologist, who interprets the images, is in Bangalore.

This is an everyday story with teleradiology having taken root in India over the past decade, with hospitals from the far corners of the globe reaching out to well-qualified specialists here equipped with state-of-the-art equipment.

Dr Arjun Kalyanpur recalls how the idea first germinated in the late nineties when he was with the Yale New Haven hospital. “At night, we reported CT scans for the veterans’ hospital across town, which were electronically transferred to us. On trips to India, I had seen the burgeoning software/outsourcing industry and realised how the night shift for any US operation could be effectively performed from high tech locations such as Bangalore.”

In 1999, when he returned to India with his wife, Dr Sunita Maheshwari, he found it impossible to find a good position with hospitals here. So he kept his faculty appointment at the Yale University School of Medicine and travelled to New Haven for a couple of months of work. “During one such visit to Yale, I mentioned during a conversation with the chairman the possibility of my reading scans for Yale from India. He was intrigued and interested, though cautious.”

Finally, following a feasibility test, Dr Kalyanpur and Dr Maheshwari founded Teleradiology Solution (TRS) with just two computers, two employees and a broadband connection in 2002. Today, TRS caters to the radiology needs of hospitals in several countries, from Singapore to Tanzania, from its own campus in Whitefield.

A number of players followed TRS. This is not surprising, because qualified radiologists are far and few. There are about 12,000 radiologists in India, while the US has about 25,000, points out Deepak Sharma, CEO, Moksha Digita. X-rays, CTs, and MRIs are among the least invasive diagnostic techniques performed in hospitals everywhere, but only a qualified radiologist can interpret these images.

It is tougher in cases when a sub-specialist like an MRI radiologist, neuroradiologist, paediatric radiologist, or musculoskeletal radiologist is needed. “Such professionals are usually based out of big cities, and work during the day. Teleradiology becomes important then as it allows for trained specialists to be available 24/7,” says Sharma.

Rural hinterland
Teleradiology also offers one way to bridge the rural-urban divide in health care. Moksha Digital, for example, is partnering with Bhagwan Mahaveer Jain Hospital in Bangalore to offer remote reads on scans done in rural India.

At the moment, however, there are very few radiologists who provide the service to remote areas in the country. Columbia Asia, already operating in Tier-2 and Tier-3 towns, has extended teleradiology services to a hospital in Bangalore that serves patients from lower socio-economic backgrounds, says Dr Shalini Goval, chief of the teleradiology department, Columbia Asia Hospitals.

“We are now also in the process of setting up a teleradiology link with a remote rural hospital. Although there is a great need for quality radiology reporting within India across all sections of the urban and rural population, it is not an easily sustainable model due to the high cost of radiology services. On the other hand, external teleradiology to the US and other countries can indirectly help in this scenario by cross-subsidising and enabling lower-priced rural teleradiology within urban and rural India,” she says.

Telerad Foundation, set up by TRS, works on such a Robin-Hood model. Under this, they have been reporting on 15-20 scans a day for the Ramakrishna Mission Hospital in Itanagar, free of cost.

“This hospital had the only CT scanner in Arunachal Pradesh, and served a largely tribal population of 1 million people. They did not have a fulltime radiologist as the only radiologists in the area were too busy performing ultrasound exams. In desperation, the Swami who ran the hospital located us on the internet and contacted us on email. We responded and our IT team was able to establish a link between the hospital and our centre, using remote access tools over the internet, without anyone having to physically travel to Itanagar,” says Dr Kalyanpur.

EHA Hospitals in Bangalore is also providing teleradiology services for the North-East. “We have been doing this for the last two-three years with a few hospitals in Assam and Nagaland. Hospitals need to employ high-calibre radiologists, and if they aren’t able to do it, teleradiology is a solution,” says Dr Verghese Philip, director of the EHA Hospitals.

Teleradiology does not fit in the standard offshoring story, because radiologists are in short supply. A study done on offshoring radiology services to India by Dr Frank Levy, a professor at the Massachusetts Institute of Technology (MIT), along with research scholar Kyoung-Hee Yu, found that the world is not as flat for radiologists as it is for textile workers.

They write: “Because the work rests on pattern recognition and extensive tacit knowledge, it requires expensive, multi-year training. As a result, relatively few people world-wide are capable of doing the work and the supply is not increasing very fast.

Because tacit knowledge is so important, radiologists currently face no computer substitution and, in fact, the opposite is true: radiologists are an indispensable complement to computerised medical imaging, and rapid advances in imaging expand demand for radiologists’ services. The result is a tight labour market for radiologists — expanding demand and restricted supply.”

This is one offshoring model about which there can be no quarrel, it appears, especially if it also trickles down to the have-nots on a larger scale than at present.