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BANGALORE (Reuters) - On a computer monitor in his office in the high-tech hub of Bangalore, Indian radiologist Arjun Kalyanpur examines a scan of the skull of a six-year-old boy who fell off his bicycle.
A few minutes later, thousands of miles away, doctors at a hospital in Philadelphia prepare the boy for surgery after receiving an urgent email from Kalyanpur diagnosing a subdural hemorrhage in the child's brain.
It's the middle of the night in the United States, but it's daytime in Bangalore and Kalyanpur and his team of 35 radiologists are reading hundreds of scans sent by hospitals across the United States during the night shift.
"ERs in the U.S. find it difficult to staff at night. There's a radiologist shortage in the U.S. as well," Kalyanpur told Reuters.
Bangalore, the outsourcing capital of the world, is becoming a global center for telemedicine thanks to a pool of Western educated doctors, extensive outsourcing infrastructure, lower costs and a convenient time zone to diagnose medical conditions during the U.S. night.
Teleradiologists in India read x-rays, CT scans, MRIs and other medical images of patients in the United States, Singapore and a host of other countries around the world.
It's ideal for hospitals facing ballooning costs and a shortage of radiologists. And it's not just teleradiology, experts say just about every area of medicine that does not require direct patient interaction could be outsourced in the future.
This could include scans of pathology samples, ECGs, EEGs and other diagnostic systems used to determine a preliminary diagnosis.
"Telemedicine is on the rise," said Avinash Vashistha, the CEO of Tholon Inc, a private equity advisory firm, who has written a book about outsourcing.
"Once it acquires critical mass in 2 to 3 years, we expect the thrust to come from insurance companies as they recognize the cost benefits and lower premiums for the plans that have components of telemedicine."
There are some concerns, though, that it might lead to dangerous misdiagnosis and even those in the industry admit that regulation hasn't caught up with technology when it comes to medical malpractice, ethics and legal liability.
Liability, privacy and malpractice issues pose challenges as this new industry expands without a supporting international regulatory framework as well as an ethical code of conduct.
"In the end the challenge really is when you're doing something for the U.S. and something happens, who's liable for it?," said Vashistha.
The business is lucrative and already there are 10 or more teleradiology firms in India as well as several in the United States, some of which are listed companies.
Kalyanpur's clinic can make as much as $1,500 per scan, about 35 percent less than the price charged in the United States. With an average of 1,000 scans read a day, that adds up to hefty revenues.
Hospitals are in favor because by stepping in at night, teleradiologists in India save U.S. hospitals the need to put radiologists on night-shifts, allowing them to save on salaries.
"This kind of outsourcing which is time zone related is very beneficial. The same job done as a day job is much more productive," Kalyanpur remarked.
Kalyanpur and his wife, Dr. Sunita Maheshwari founded Teleradiology Solutions from a home office in Bangalore six years ago. Both are U.S. board certified physicians and are graduates from Yale University.
Today, they have a 118-member team in a swank, five-story setup where they provide radiology services for over 70 hospitals in the U.S., 10 hospitals in Singapore, a few in the former Soviet republic of Georgia as well as hospitals and medical clinics in cities and villages across India.
"We make the process more efficient by using technology and time zone advantages," said Kalyanpur.
The maximum time at Teleradiology Solutions for a radiologist to read an x-ray and provide analysis is 45 minutes. Diagnosis are provided within 10 minutes for urgent cases such as acute strokes.
Teleradiology has a sales office in Connecticut and radiologists in China, Netherlands and U.S. who backfill when the India operation is closed.
Ironically, India faces an acute shortage of radiologists even as teleradiology clinics sprout up in Bangalore. The biggest players are Kalyanpur's firm and his main competitor Wipro Ltd, a leading software services exporter.
"We are currently focused on consolidating this service line and building our expertise in this as this practice requires strict adherence to quality and norms," said Achaiah Palekanda of the clinical processing services of Wipro Technologies. The firm has five permanent radiologists and several who work part time.
Indian hospitals such as Apollo, Fortis and Wockhardt are other players that are gradually increasing their imaging clientele by reading scans for hospitals in the United States.
Other U.S.-based players include Virtual Radiologic Corp which provides teleradiology services to over 900 medical facilities in America. Nighthawk Radiology Holdings Inc. is another U.S. based teleradiology company whose physicians are located in the U.S., Australia and Switzerland.
Patients are not always aware their scans are being read abroad, although they are told if they ask.
"We act as an extended arm, offering 24X7 services, thereby enhancing productivity for the doctors and 3D lab teams in the U.S.," said Wipro's Palekanda. "However, they are the final sign-off authority and quality approvals on our services."
The teleradiology business has not penetrated into the Europe as yet, largely due to data protection laws in the European Union and difficulties in obtaining accreditations by authorities, according to an Indian government planning commission report.
"There are other issues as well ... such as malpractice policies, liability insurance and jurisdiction issues for settling disputes that might arise," said the report.
Kalyanpur feels teleradiology is just the beginning.
"Telecardiology, telepathology, teledermatology, telephathology and robotic telesurgery," he said, naming a few.
Regardless of whether the medicine is practiced in person or remotely, the most important factor for patient care is the quality of the doctor doing the diagnosis.
"The first and the foremost requirement here is a qualified doctor at the other end. That's very important," said Dr Sanjiv Sharma, the head of cardiac radiology at the All India Institute of Medical Sciences (AIIMS) in New Delhi.
Editing by Megan Goldin