1. International Teleradiology Experience in Developing vs Developed World Dr Ashish Dhawad COO, TeleDiagnosys CEO, Medsynaptic Africa Telehealth Conference 2010 Cairo, Egypt

2. Definition of Teleradiology

3. Definition Needs no introduction Teleradiology is a means of electronically transmitting radiographic patient images and consultative text from one location to another* Teleradiology is the most mature of Telemedicine areas Source: http://www.radiology.uiowa.edu/MoreRAD/Teleradiology/Tele.html

4. History of Teleradiology

5. Beginning Alexander Graham Bell Mr Watson, Come here, I want you In 1876, simultaneous beginning of telephone and telemedicine

6. Early Adoption 1930 – Queen Mary ocean liner used the ship radio for medical consultations with onshore experts

7. Middle Ages 1960-1970 – Closed circuit and broadcast Television used for medical consultations

8. Evolution 1980 – Computer usage began for telemedicine

9. Maturity 1990 – Internet becomes popular 21 st Century – Modern Teleradiology using High speed Internet and mobiles iphone

10. Concept of Teleradiology

11. Conceptually simple Imaging data acquired at one site Network transmits images to a server or receiving station Data is reviewed and interpreted at the remote site Report generated and transmitted electronically back to the parent site

12. Teleradiology: Components 1. An image sending station 2. A transmission network 3. A receiving/image review station

13. Sending Station: The Source What can be sent? Anything! –Non-digital (conventional) films can be digitized using scanners –Most studies are now digital from the start:  Computed Radiography, Digital Radiography  CT  Ultrasound  MRI  Nuclear Scans  Mammography

14. Sending Station: The Source Connection can be directly from the equipment (CT scanner, etc.) or from a PACS (Picture Archiving System) or a Workstation Requires adherence to the Digital Imaging and Communication in Medicine (DICOM) lossless compression standard. DICOM gateway is required between the source and the transmission network.

15. Sending Station: The Source CT Scanner DR/CR MRI Scanner Mammography Nuclear Scans Ultrasound DIFFERENT IMAGING MODALITIES

16. Sending Station: The Source A virtual private network (VPN) is required to assure compliance with the Health Insurance Portability and Accountability Act (HIPAA) VPN’s can be software or hardware based

17. Transmission Network Wire Fiber optics Microwave Internet

18. Receiving/Image Review Station Consists of: 1.Network interface 2.Personal computer with storage medium (e.g. hard disk drive) 3.One or more Medical monitors 4.Optional hard copy device printer

19. Receiving/Image Review Station

20. What is the need of Teleradiology Increase in radiology workloads worldwide Shortage of radiologists is a worldwide phenomenon More and more imaging procedures being done Radiologist compensation getting higher increasing costs Inefficient operations, declining stability of radiology staff Faster services required by patients

21. Advantages To Customers Reduced Costs and increased profits Quality Service Access to quick opinion from experts speeding up treatment and enhancing patient care 24 X 7 X 365 Service Faster Reporting in critical cases Higher Levels of Patient Satisfaction Higher Cash flows to remote centers due to patient retention No worries about shortage of radiologists

22. Requirements to Setup Space Finance Technology Manpower Clients!!!

23. Space Assume 5 Workstations Thumb rule - 200 Sqft per person Total required – 1200 – 1500 sqft Includes space for reception, radiologists, executives, Server / IT room, Conference room

24. Finance Self funded Angel / VC Debt Finance required variable on location

25. IT Requirements to Start Server with Backup PACS/Teleradiology Software Storage – SAN, NAS Radiologist Workstations Medical Displays Internet with Backup Transcription hardware Routers/LAN Fax, VOIP, Telephones, Email

26. PACS/Teleradiology Software Web based vs Point to Point

27. Sending Station Receiving Station Transmission Network Older technology Less flexibility

28. Sample Architecture Sending Station Receiving Stations

29. Web Based Sending Station Central Server Transmission Network Multiple workstations can be connected to the Central Server More manageable and flexible Allows access from anywhere in the world

30. Sample Architecture Sending Station Central Server Radiologist WS

31. Storage Medical Imaging generates large data –Eg: 64 slice CT Scans generate 1 GB per scan Need to store images online for access Prior studies are sometimes required by radiologists Storage solutions like SAN or NAS can be considered Storage policy needs to be in place

32. Radiologist Workstations Need to have better configuration than standard computers Used for Image processing & Interpretation by radiologists Handles large data Good Graphics card helpful Connected to Medical Displays

33. Medical Displays Different models available Grayscale/Color option Single Head/Dual Head 5 MP – Used for Mammography –Approx cost $ 15000 3 MP – DR/CR/CT/MR –Approx Dual Head cost – $ 5000 (Color) – $ 10000 (B& W) 2 MP – CR/MR/CT –Approx Dual Head cost – $ 5000 (Color) – $ 8000 (B& W) Leading vendors are Barco, Planar, Totoku, Eizo, NEC etc

34. Internet Bandwidth requirements depends on the study volume Option of Wired/Wireless Needs to be fast and reliable Take a backup connection – preferably from another provider

35. Transcription Inhouse or outsourced Speech Recognition Keep control of Quality

36. Routers/LAN LAN –CAT 5 –CAT 6 –Wireless Gigabit Routers VPN Routers

37. Other Requirements VOIP phones Fax Telephones Toll Free numbers Ergonomic Furniture Printers

38. Processes Training QA process JCI/JCAHO ISO

39. Training Radiologists need to be trained on PACS Staff needs to know the defined protocols for reporting –STATs –How to handle client questions –Error reporting –Rereads

40. Quality Policy Should make all efforts to follows guidelines issued by organizations like HIPAA, ACR, ESR etc Clearly defined Quality assurance policy

41. Regulatory requirements License Credentialing Insurance Data Security Legal

42. Standards ACR – American College of Radiology ESR – European Society of Radiology CAR – Canadian Association of Radiology UK – Royal College of Radiology

43. Market Hotspots USA Canada UK Africa Singapore India Australia China Europe –Germany –Spain –Sweden –Norway

44. Marketsize - 2010 More than 1 billion imaging procedures performed worldwide every year (X Ray, US, CT, MRI, Nuclear) More than 300 million in US alone ! –200 million X Rays –35 million MRIs –75 million CTs –35 million Ultrasounds –18 million Nuclear scans Europe performing more than 150 million procedures

45. Potential Market Potential Market anywhere between 2.5 to 5 billion USD Increasing by atleast 10 % per year as imaging volumes grow Not enough radiologists being trained every year Creating a opportunity for service providers

46. Developing vs Developed World Infrastructure –Variable from country to country –Urban areas in Developing world as good as Developed world Manpower –Advantage for developing world Regulations –Missing in developing countries Licensing & Liability –Major barrier in developed world Marketsize –Large in developed world –Moving towards subspecialist services

47. Barriers to Success

48. Regulations No uniformity or Teleradiology license Every country has different standards Need to follow regulations for each country May not be possible to provide services to certain sectors like government insurance

49. Language Majority of the market does not pose challenge as English accepted More prevalent in Europe Many countries require reports in local language Translation costly and prone to errors

50. Expertise Getting the right manpower may be difficult Radiologists with required skillsets unavailable –Training, subspeciality –Licensing –Language –Time schedules –Relocation trouble Good IT support crucial

51. Summary Teleradiology is an excellent empowering technology which enhances patient care Teleradiology is an excellent empowering technology which enhances patient care Legal issues on teleradiology are still vague Legal issues on teleradiology are still vague A safe strategy is the best strategy A safe strategy is the best strategy –Do not compromise patient care –Appropriately qualified radiologists –Clear contracts and insurance a must to cover liability issues –Efficient communication in a clinical setting –Quality assurance programme –A very friendly lawyer!

52. The world is becoming a Global Village

53. For any questions please contact Dr Ashish Dhawad Tel: +91-9823041375 Email: dhawad@telediagnosys.com