Solving the global radiology gapone ultrasound at a time

A healthcare worker in Kamuli, Uganda acquires a prenatal scan to be transmitted to the U.S. Image source: Imaging the World

After deciding to specialize in radiology in his second year of medical school, University of California, San Diego medical student and avid volunteer Benjamin Johnson came to a disheartening realization about his chosen specialty—radiology is one of the specialties least engaged in medical outreach and humanitarian efforts. Undeterred, Johnson scoured the internet for opportunities to wed his specialty with his passion.

He learned that access to imaging in the developing world is severely lacking. According to the World Health Organization, two-thirds of the world population lack access to radiology.

At its most basic level, radiology requires three inputs: an acquisition device, a means to transmit or view images and diagnostic review. Indeed, developments in imaging and network technologies, specifically the diffusion of low-cost, portable ultrasound systems and ubiquity of cellular phones and networks, offer fresh hope for developing nations. The missing ingredient, surmised Johnson, seemed to be diagnostic expertise.

After more than a year of searching, the medical student located Rad-Aid, a global network assisting developing countries to implement and optimize radiology and health imaging services, and Imaging the World (ITW), a nonprofit that integrates technology, volunteers and education to bring medical expertise and high quality healthcare to remote and underserved areas worldwide.

In May, Johnson will embark on his second trip to Uganda to work on an ITW-developed teleradiology project that offers ultrasound imaging to pregnant women residing in rural regions of the country.

Johnson paints a stark picture. “One in 22 Ugandan women die during childbirth, most frequently due to bleeding that could have been prevented by ultrasound scanning.” A mere 35 radiologists practice in the country, which has a population of 30 million.

According to Johnson, radiology has lagged behind other specialties in outreach efforts, because in addition to expertise, it requires a large initial investment in imaging infrastructure, followed by the costs of training staff to maintain and operate the equipment. “ITW’s model takes advantage of the falling costs and increasing portability of modern ultrasound units to address those challenges. It also takes advantage of the proliferation of cellular networks to perform outreach without ever traveling overseas.

“The model is really clever. It uses volumetric ultrasound imaging to remove the need for an expert sonographer on the front end of image collection,” he explained. During a five-week volunteer stint in the summer of 2010, Johnson trained local Ugandan midwives and healthcare workers in Kamuli to perform basic ultrasound scans that capture volumetric cine-loops based on external anatomy. (Pre-set acquisition parameters are programmed into the system.)

In the model, a local healthcare worker identifies a pregnant woman who might benefit from ultrasound scanning and performs a basic five-sweep scan. At the end of the scan, the cine loops are compressed and transmitted over cellular networks back to a PACS in the U.S., where volunteer radiologists interpret the DICOM datasets.

The minimalist scans do not provide the diagnostic fidelity of a scan performed by a trained sonographer, Johnson admitted. However, the protocols suffice to diagnose the basic complications associated with the country’s high maternal death rate, such as placenta previa.

Reporting is equally bare bones. That is, a standardized template sends a text message to the local clinic, categorizing results from 0 (normal) to 10 (STAT). For urgent and emergent cases, radiologists send relevant images and a detailed report to a hospital, so local physicians have the information needed for follow-up and tertiary care.

During the pilot phase last summer, the team completed an image quality validation and determined the viability of the model. In fact, the key requirements for success are quite simple and include a compact ultrasound system and DICOM compatibility.

The primary challenge as the project heads into its second year, said Johnson, is the cost of the ultrasound system. “Once the model has been set up, the main cost is the machine. The diagnostic expertise is back-loaded to the U.S. where people can provide volunteer expertise.” Other costs include the wireless router and a netbook computer to run the software that compresses the cine loops.

This summer, Johnson and his ITW colleagues plan to test a new ultrasound system to determine if it provides image quality to meet established diagnostic standards.  He noted that the model is not specific to Uganda and could be deployed nearly anywhere across the globe.

“Johnson's work can really make a difference,” summed Dolores H. Pretorius, MD, professor of radiology and director of imaging at the University of California, San Diego Center for Fetal Care and Genetics. “The results are quantifiable. The participating clinic in Uganda has seen a significant increase in visits during the first six months since the program was implemented. Those visits provided proper diagnosis and care to women with urgent medical needs in order to hopefully prevent catastrophic injury to the mother and fetus at delivery.”

To learn more about ITW, click here.

To learn more about Rad-Aid, click here.