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POINT OF VIEW

Teleradiology: The Indian perspective

Nishigandha Burute, Bhavin Jankharia
Radiologists, Piramal Diagnostics – Jankharia Imaging, Mumbai 400 004, India.

Correspondence: Dr Bhavin Jankharia, Bhaveshwar Vihar, 383 Sardar V P Rd, Mumbai 400 004, India. Email: bhavin@jankharia.com

Introduction the demand and availability of diagnostic services. The high

demand for radiology services in places such as USA, UK,
The demand for diagnostic and image interpretation services and Singapore often could not be fulÞlled by the number of
in radiology is growing rapidly all over the world. This available in-house healthcare professionals. In the USA, while
has highlighted two issues: the lack of adequate staff for the number of scans being performed has been increasing,
providing interpretative coverage and the lack of specialty there is a persisting shortage of radiologists. In Singapore,
expertise. To some extent, these problems can be overcome by there is a paucity of radiologists for night coverage. In the
utilizing robust communication and image transfer systems UK, a radiologist takes 21 days on average to submit an
to draw on the expertise of distantly located radiologists. This MRI report.
process whereby images are transferred to distant locations
for the purpose of interpretation and diagnosis is termed The lack of availability of timely diagnostic services causes
teleradiology. great problems for clinicians during emergencies and during
the night hours. Moreover, the Health Care Financing
Telemedicine Administration (HCFA) in the US mandates round-the-clock
services in every hospital. By outsourcing radiology reporting
Telemedicine is a broad term encompassing all methods to places such as Australia, Europe, and some Asian countries
where the doctor–patient interaction is not on-site and some (including India) hospitals in the USA, UK, and Singapore
form of telecommunication is used. Also called telehealth, can be assured of competent and timely professional help.
online health, or e-health, telemedicine has made long strides The immediate availability of diagnostic services, which is
since its inception. extremely important during medical emergencies, is a big
advantage that outsourcing offers. Outsourcing of ‘on-call’
Teleradiology night reporting is popularly called ‘nighthawking.’

Teleradiology is a branch of telemedicine in which Another reason for the growth of teleradiology is that most
telecommunication systems are used to transmit radiological parts of rural India do not have good radiological services
images from one location to another. Interpretation of all and personnel. With teleradiology, this deÞciency can be
noninvasive imaging studies, such as digitized x-rays, CT, overcome by using the help of more experienced personnel
MRI, ultrasound, and nuclear medicine studies, can be carried in the larger centers in the cities. Also, even in the cities, not
out in such a manner. all imaging centers have subspecialty expertise; difficult
cases in speciÞc areas of radiology can be sent to experts for
The earliest efforts in teleradiology probably date back to their opinion.
1929, when dental x-rays were transmitted with the help of
telegraph to a distant location.[1] An early attempt at using Acquisition, transfer, and viewing of images
the Web in an emergency medical situation describes the use
of digital cameras to take clinical photographs and scanners Images need to be acquired, stored, transferred, and
to scan radiographs, conversion of the resulting digital viewed.
images to a JPEG format using Adobe Photoshop, and then
transmission via the Internet. Acquisition of images
Today, virtually all radiology equipment is fully DICOM
Today, digitized images are transmitted around the globe via compliant. Thus, images can be stored on a network or
high-speed telecommunication links on a regular basis. a workstation in the DICOM format. Lossy and lossless
compression is possible; varying degrees of loss of information
Need for teleradiology may be acceptable, depending upon the modality and the
clinical situation. Plain radiographs obtained non-digitally
Teleradiology took birth partly due to the imbalance between may need to be scanned. Currently, mammography images
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Burute et al.: Indian teleradiology

remain the last barrier to reliable teleradiology; this is due to for example:
the large Þle sizes and issues related to the image resolution 1. Cost: An MRI in India, performed on a state-of-the-art
required to detect microcalciÞcations. scanner, costs Rs. 6000 (approx. 150 USD). The professional
fee component is usually 10–15%, i.e., 15–25 USD. At these
Transfer of images rates, having an Indian radiologist report outsourced scans
In the early days, transfer of images was performed over can offer a signiÞcant monetary advantage.
telephone lines using modems, sometimes with speeds as low 2. Cheap labor: The salary of an Indian radiologist working
as 2400 bps. Today, high-speed lines are available, allowing in the Þeld of CT and MRI, 5 years post-MD (Indian
different centers to connect directly or over the Internet for board certiÞcation), would usually be close to or less
transmission of images. Images may be directly transferred than Rs. 2 lakhs per month (i.e., approximately 5000
or streamed, depending upon the software being used. USD per month or 60,000 USD per year)[2]; in contrast, a
comparably qualiÞed radiologist in the USA would be
Viewing of images earning approximately 350,000 USD per year.[3]
Image viewing requires a workstation that can display high- 3. Time difference: The time difference between the USA and
resolution images. Many types of software are currently India is a distinct advantage, especially for nighthawk
available, e.g., EFilm, which allows viewing, manipulation, services. When it is night in the USA, it is daytime in
measurements, 3D reconstructions, etc. India; this means that it would be possible for an Indian
radiologist, working during the daytime, to interpret
Conveying reports images with better quality and a greater accuracy than
With the advent of PACS (picture archiving and would the US radiologist in his night shift hours.
communication system) RIS (radiology information system) 4. Skilled support staff: India also has a distinct advantage in
is now integrated into the teleradiology system, resulting the form of high-caliber information technology (IT) and
business process outsourcing (BPO) manpower, as also
in efficient and instant communication of Þndings to the
a great number of engineers trained in the basic skills
clinician or surgeon.
required for offshore jobs.
History of teleradiology in India
Ideally, these factors should have led to a signiÞcant growth
The practice of teleradiology in India dates back to not of the teleradiology industry in India. However, the reality
more than a decade. The Þrst successful use of teleradiology is that except for one company, i.e., Teleradiology Solutions,
in India was in 1996 by a private-sector imaging center there is no other company practicing teleradiology to any
called Jankharia Imaging in Mumbai. A simple system for signiÞcant extent in the country. There are some enterprises
transferring images from the imaging center to the homes doing preliminary ‘ghost reporting’ for facilities in the USA,
of the individual doctors was set up, primarily, to report but this work is either in ethical grey zones, if not actually
emergency CT scans. The first public demonstration of illegal, as far as the USA is concerned though not illegal from
teleradiology in practice was made by Siemens at the Annual the Indian perspective. A couple of companies, including
Congress of the Indian Radiology and Imaging Association Wipro Technologies and the Manipal Group of Hospitals, are
(IRIA) in 1997, where they demonstrated the transfer of now providing teleradiology support for 3D reconstructions,
radiological images from a Siemens AR.C scanner to the thus speeding up the work for radiologists and technologists
conference site. Subsequently, Wipro GE demonstrated in the USA.. This work does not require board-certiÞcation
teleradiology capabilities for their entire range of scanners. since there is no actual interpretation being done.

The Þrst teleradiology company in India, Teleradiology The main hurdles for Indian teleradiology are as follows:
Solutions, was set up in 2002 with its base in Bangalore. 1. Lack of board-certiÞed radiologists in India: A radiologist
Dr Arjun Kalyanpur and his colleagues, all US board- who goes to the US for board certiÞcation may be reluctant
certiÞed radiologists, read scans for hospitals in the USA; to return to India in view of the large differences in salaries
these services were offered for places in Singapore and and compensations. Those few who do come back and
India as well. Wipro Technologies has been an early mover practice teleradiology may do so for lifestyle, “Indian”
in providing nighthawk and 3D reconstruction services. values, or family reasons.
Many companies have announced their intentions to enter 2. ‘Third-world’ status and credibility: Despite the growth of
this market and some small enterprises provide services for medical facilities in India and the reasonably high levels of
preliminary reads. quality, people in the West are still wary of having Indian
radiologists in India interpret studies.
Current situation and issues 3. Political concerns: The media hype on outsourcing to
India, which is true for many Þelds, has had an impact on
International outsourcing teleradiology outsourcing. In reality, however, there has
India has distinct advantages when it comes to teleradiology; not been much outsourcing of radiology services to India
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Burute et al.: Indian teleradiology

and the growth of this industry remains pretty dismal. Other potential applications and business
4. Small markets: The US, UK, and Singapore[4] are the main opportunities
markets now open for Indian teleradiology. The countries
that are likely to seek teleradiology outsourcing would Research
be English-speaking countries and the ones where the Many research groups or clinical research outsourcing
cost differential makes economic sense. Not too many (CRO) practices need radiology images to be reported,
countries fulÞll these criteria and in fact some European e.g., measurement of the size of tumors in oncology trials.
countries as well as Australia[5] and New Zealand[6] have Here there are very few entry barriers such as the need for
been successful in leveraging their advantages to become board certiÞcation, etc., and there is signiÞcant scope for
hubs for outsourcing. teleradiology outsourcing in this area.

All these points are also issues with respect to the UK, more Teaching
so because of how politically sensitive all heath-care issues Using multiple Web-based applications that allow real-time
in the UK are. display of presentations, lectures can be now taken for
audiences across the globe.
National teleradiology
Conclusion
The main issues affecting the growth of teleradiology within
the country are the following: Teleradiology has potential as a business model. However,
1. Cost: Radiology studies in this country are priced low, numerous logistical issues have prevented its growth in
and centers can Þnd it difficult to afford the services of India.
teleradiologists.
2. Quality issues: Many rural and semiurban centers do not References
have qualiÞed radiologists but they do not mind the lack
of quality reporting and often leave it to the referring 1. Sending dental X-rays by telegraph. Dent Radiogr Photogr
1929;2:16
clinicians to read the images themselves.
2. Levy F, Yu KH. Offshoring radiology services to India. IPC.
Massachusetts Institute of Technology. Working Paper Series. 2006.
Currently, the use of teleradiology within the country is p. 3.
conÞned to practices with multiple centers transferring 3. Some U.S. hospitals outsourcing work. Shortage of radiologists spurs
images to each other or to a central hub. Rural-urban or growing telemedicine trend MSNBC news. Dec. 6, 2004
generalists-to-specialists transfers are not yet very popular, 4. Levy F, Yu KZH. Offshoring radiology services to India. IPC.
mainly due to cost constraints. The earlier barriers related Massachusetts Institute of Technology. Working Paper Series. 2006;
28-36
to the nonavailability of adequate bandwidth no longer
exist in most parts of the country due to the rapid growth 5. Crowe BL. A review of the experience with teleradiology in Australia.
J Telemed Telecare 2001;7:53-4.
of telecommunication provider companies. The need of
6. Lawrence S. Lau clinical teleradiology in Australia: Practice and
teleradiology though is considerable. Many district hospitals standards. J Am Coll Radiol 2006;3:377-81.
have CT scanners, but qualiÞed and competent radiologists 7. Kalam Urges for Using Tele-radiology to Help Rural Poor. News
are few and far between. Most such hospitals are government on IT in Healthcare. MedIndia. Saturday, June 30, 2007
and municipal facilities, and it has been difficult to get them
to go in for teleradiology solutions from private practitioners.
This is despite the request by ex-President Dr Abdul Kalam,
who advised those concerned to take advantage of the
beneÞts of telemedicine for helping the needy in the rural Source of Support: Nil, Conflict of Interest: None declared.
areas in a cost-effective manner.[7]

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