When the COVID-19 pandemic hit Mumbai, one of the most densely populated cities in the world, the Municipal Corporation of Greater Mumbai (MCGM) promptly embraced newer technologies, while creatively utilising available resources. Here is a deeper dive into how the versatility of chest x-rays and Artificial Intelligence helped the financial capital of India in efforts to containing this pandemic.

The COVID-19 pandemic is one of the most demanding adversities that the present generation has had to witness and endure. The highly virulent novel Coronavirus has posed a challenge like no other to the most sophisticated healthcare systems world over. Given the brisk transmission, it was only a matter of time that the virus spread to Mumbai, the busiest city of India, with a population more than 1.5 times that of New York.

The resilient Municipal Corporation of Greater Mumbai (MCGM), swiftly sprang into action, devising multiple strategies to test, isolate, and treat in an attempt to contain the pandemic and avoid significant damage. Given the availability and effectiveness of chest x-rays, they were identified to be an excellent tool to rule-in cases that needed further testing to ensure that no suspected case was missed out. Though Mumbai saw a steep rise in cases more than any other city in India, MCGM’s efforts across various touchpoints in the city were augmented using Qure’s AI-based X-ray interpretation tool – qXR – and the extension of its capabilities and benefits.

In the latter half of June, MCGM launched the MISSION ZERO initiative, a public-private partnership supported by the Bill & Melinda Gates Foundation, Bharatiya Jain Sanghatana (BJS) and Desh Apnayen and CREDAI-MCHI. Mobile vans with qXR installed digital X-ray systems were stationed outside various quarantine centers in the city. Individuals identified to be at high-risk of COVID-19 infection by on-site physicians from various camps were directed to these vans for further examination. Based on the clinical and radiological indications of the individuals thus screened, they were requested to proceed for isolation, RT-PCR testing, or continue isolation in the quarantine facility. Our objective was to reduce the load on the centers by continuously monitoring patients and discharging those who had recovered, making room for new patients to be admitted, and ensuring optimal utilization of resources.

A patient being screen in a BJS van equipped with qXR

The approach adopted by MCGM was multi-pronged to ascertain that no step of the pandemic management process was overlooked:

• Triaging of high-risk and vulnerable and increase in case-detection in a mass screening setting to contain community transmission (11.4% individuals screened)
• Patient management in critical care units to manage mortality rates
• Support the existing healthcare framework by launching MISSION ZERO initiative and using chest X-ray based screening for optimum utilization of beds at quarantine centers

Learn more about Qure.ai qXR COVID in our detailed blog here

Triaging and Improvement in Case Finding

Kasturba Hospital and HBT Trauma Center were among the first few COVID-19 testing centers in Mumbai. However, due to the overwhelming caseload, it was essential that they triage individuals flowing into fever clinics for optimal utilization of testing kits.  The two centers used conventional analog film-based X-ray machines, one for standard OPD setting and another portable system for COVID isolation wards

From early March, both these hospitals adopted

1. qXR software – our AI-powered chest X-ray interpretation tool provided the COVID-19 risk score based on the condition of the patient’s lungs
2. qTrack – our newly launched disease management platform

The qTrack mobile app is a simple, easy to use tool that interfaces qXR results with the user. The qTrack app digitizes film-based X-rays and provides real-time interpretation using deep learning models. The x-ray technician simply clicks a picture of the x-ray against a view box via the app to receive the AI reading corresponding to the x-ray uploaded. The app is a complete workflow management tool, with the provision to register patients and capture all relevant information along with the x-ray. The attending physicians and the hospital Deans were provided separate access to the Qure portal so that they could instantly access AI analyses of the x-rays from their respective sites, from the convenience of their desktops/mobile phones.

qXR app in action at Kasturba Hospital

Triaging in Hotspots and Containment Zones

When the city went into lockdown along with the rest of the world as a measure to contain the spread of infection, social distancing guidelines were imposed across the globe. However, this is not a luxury that the second-most densely populated city in the world could always afford. It is not uncommon to have several families living in close quarters within various communities, easily making them high-risk areas and soon, containment zones. With more than 50% of the COVID-19 positive cases being asymptomatic cases, it was imperative to test aggressively. Especially in the densely populated areas to identify individuals who are at high-risk of infection so that they could be institutionally quarantined in order to prevent and contain community transmission.

Workflow for COVID-19 management in containment zones using qXR

The BMC van involved in mass screenings and qXR in action in the van

Patient Management in Critical Care Units

As the global situation worsened, the commercial capital of the country saw a steady rise in the number of positive cases. MCGM, very creatively and promptly, revived the previously closed down hospitals and converted large open grounds in the city into dedicated COVID-19 centers in record time with their own critical patient units. The BKC MMRDA grounds, NESCO grounds, NSCI (National Sports Council of India) Dome, and SevenHills Hospital are a few such centers.

NESCO COVID Center

The COVID-19 center at NESCO is a 3000-bed facility with 100+ ICU beds, catering primarily to patients from Mumbai’s slums. With several critical patients admitted here, it was important for Dr. Neelam Andrade, the facility head, and her team to monitor patients closely, keep a check on their disease progression and ensure that they acted quickly.  qXR helped Dr. Andrade’s team by providing instant automated reporting of the chest X-rays. It also captured all clinical information, enabling the center to make their process completely paperless.

The patient summary screen of qXR web portal

“Since the patients admitted here are confirmed cases, we take frequent X-rays to monitor their condition. qXR gives instant results and this has been very helpful for us to make decisions quickly for the patient on their treatment and management.”

– Dr Neelam Andrade, Dean, NESCO COVID centre

SevenHills Hospital, Andheri

Located in the heart of the city’s suburbs, SevenHills Hospital was one of the first hospitals that were revived by MCGM as a part of COVID-19 response measures.

The center played a critical role on two accounts:

1. Because patients were referred to the hospital for RT-PCR testing from door-to-door screening by MCGM. If found positive, they were admitted at the center itself for quarantine and treatment.
2. With close to 1000 beds dedicated to COVID-19 patients alone, the doctors needed assistance for easy management of critical patients and to monitor their cases closely.

As with all COVID-19 cases, chest x-rays were taken of the admitted patients periodically to ascertain their lung condition and monitor the progress of the disease. All x-rays were then read by the head radiologist, Dr. Bhujang Pai, the next day, and released to the patient only post his review and approval. This meant that on most mornings, Dr. Pai was tasked with reading and reporting 200-250 x-rays, if not more. This is where qXR simplified his work.

Initially, we deployed the software on one of the two chest X-ray systems. However, after stellar feedback from Dr. Pai, our technology was installed in both the machines. In this manner AI, pre-read was available for all chest X-rays of COVID-19 patients from the center.

Where qXR adds most value:

• several crucial indications are reported up by qXR
• percentage lung affected helps to quantify improvement/deterioration in the patient lung and provide an objective assessment of the patient’s condition
• pre-filled PDF report downloadable from the Qure portal makes it easier to finalize the radiology report prior to releasing to the patient, especially in a high-volume setting

Dr. Pai reviews and finalizes the qXR report prior to signing it off

“At SevenHills hospital, we have a daily load of ~220 Chest X-rays from the admitted COVID-19 cases, sometimes going up to 300 films per day. Having qXR has helped me immensely in reading them in a much shorter amount of time and helps me utilise my time more efficiently. The findings from the software are useful to quickly pickup the indications and we have been able to work with the team, and make suitable modifications in the reporting pattern, to make the findings more accurate. qXR pre-fills the report which I review and edit, and this facilitates releasing the patient reports in a much faster and efficient manner. This obviously translates into better patient care and treatment outcomes. The percentage of lung involvement which qXR analyses enhances the Radiologist’s report and is an excellent tool in reporting Chest radiographs of patients diagnosed with COVID infection.”

– Dr Bhujang Pai, Radiology Head, SevenHills Hospital

Challenges and learnings

During the course of the pandemic, Qure has assisted MCGM with providing AI analyses for thousands of chest x-rays of COVID-19 suspects and patients. This has been possible with continued collaboration with key stakeholders within MCGM who have been happy to assist in the process and provide necessary approvals and documentation to initiate work. However, different challenges were posed by the sites owing to their varied nature and the limitations that came with them.

We had to navigate through various technical challenges like interrupted network connections and lack of an IT team, especially at the makeshift COVID centers. We crossed these hurdles repeatedly to ensure that the x-rays from these centers were processed seamlessly within the stipulated timeframe, and the x-ray systems being used were serviced and functioning uninterrupted. Close coordination with the on-ground team and cooperation from their end was crucial to keep the engagement smooth.

This pandemic has been a revelation in many ways. In addition to reiterating that a virus sees no class or creed, it also forced us to move beyond our comfort zones and take our blinders off. Owing to limitations posed by the pandemic and subsequent movement restrictions, every single deployment of qXR by Qure was done entirely remotely. This included end-to-end activities like coordination with the key stakeholders, planning and execution of the deployment of the software, training of on-ground staff, and physicians using the portal/mobile app in addition to continuous operations support.

Robust and smart technology truly made it possible to implement what we had conceived and hoped for. Proving yet again that if we are to move ahead, it has to be a healthy partnership between technology and humanity.

Qure is supported by ACT Grants and India Health Fund for joining MCGM’s efforts for the pandemic response using qXR for COVID-19 management.

When the pandemic hit the world without discretion, it caused health systems to crumble across the world. While a large focus was on strengthening them in the urban cities, the rural areas were struggling to cope up. In this blog, we highlight our experience working with some of the best healthcare centers in rural India that are delivering healthcare to the last mile. We describe how they embraced AI technology during this pandemic, and how it made a difference in their workflow and patient outcomes.

2020 will be remembered as the year of the COVID-19 pandemic. Affecting every corner of the world without discretion, it has caused unprecedented chaos and put healthcare systems under enormous stress. The majority of COVID-19 transmissions take place due to asymptomatic or mildly symptomatic cases. While global public health programs have steadily created evolving strategies for integrative technologies for improved case detection, there is a critical need for consistent and rigorous testing. It is at this juncture that the impact of Qure’s AI-powered chest X-ray screening tool, qXR, was felt across large testing sites such as hospital networks and government-led initiatives.

In India, Qure joined forces with the Indian Government to combat COVID-19 and qXR found its value towards diagnostic aid and critical care management. With the assistance of investor groups like ACT Grants and India Health Fund, we extended support to a number of sites, strengthening the urban systems fighting the virus in hotspots and containment zones.
Unfortunately, by this time, the virus had already moved to the rural areas, crumbling the primary healthcare systems that were already overburdened and resource-constrained.

Discovering the undiscovered healthcare providers

Technologies are meant to improve the quality of human lives, and access to quality healthcare is one of the most basic necessities. To further our work with hospitals and testing centers across the world, we took upon ourselves if more hospitals could benefit from the software in optimising testing capability. Through our physicians, we reached out to healthcare provider networks and social impact organisations that could potentially use the software for triaging and optimisation. During this process, we discovered an entirely new segment, very different from the well equipped urban hospitals we have been operating so far, and interacted with few Physicians dedicated to delivering quality and affordable healthcare through these hospitals.

Working closely with the community public health systems, these secondary care hospitals act as a vital referral link for tertiary hospitals. Some of these are located in isolated tribal areas and address the needs of large catchment populations, hosting close to 100,000 OPD visits annually. They already faced the significant burden of TB and now had to cope with the COVID-19 crisis. With testing facilities often located far away, the diagnosis time increases by days, which is unfortunate because chest X-rays are crucial for primary investigation prior to confirmatory tests, mainly due to the limitations in a testing capacity. No, sufficient testing kits have not reached many parts of rural India as yet!

“I have just finished referring a 25-year-old who came in respiratory distress, flagged positive on X-ray with positive rapid antigen test to Silchar Medical College and Hospital (SMCH), which is 162kms away from here. The number of cases here in Assam is increasing”

– Dr. Roshine Koshy, Makunda Christian Leprosy and General Hospital in Assam.

On the left: Chinchpada mission hospital, Maharashtra; Right: Shanti Bhavan Medical Center, Jharkhand.

When we first reached out to these hospitals, we were struck by the heroic vigour with which they were already handling the COVID-19 crisis despite their limited resources. We spoke to the doctors, care-givers and IT experts across all of these hospitals and they had the utmost clarity from the very beginning on how the technology could help them.

Why do they need innovations?

Patients regularly present with no symptoms or atypical ones and conceal their travel history due to the associated stigma of COVID-19. Owing to the ambiguous nature of the COVID-19 presentation, there is a possibility of missing subtle findings. This means that, apart from direct contact with the patient, it puts the healthcare team, their families, and other vulnerable patients at risk.

qXR bridges underlying gaps in these remote, isolated and resource-constrained regions around the world. Perhaps the most revolutionary, life-saving aspect is the fact that, in less than 1 minute, qXR generates the AI analysis of whether the X-ray is normal or abnormal, along with a list of 27+ abnormalities including COVID-19 and TB. With qXR’s assistance, the X-rays that are suggestive of a high risk of COVID-19 are flagged, enabling quick triaging and isolation of these suspects till negative RT PCR confirmatory results are received. As the prognosis changes with co-morbidities, alerting the referring Physician via phone of life-threatening findings like Pneumothorax is an added advantage.

Overview of results generated by qXR

Due to the lack of radiologists and other specialists in their own or neighbouring cities, Clinicians often play multiple roles – Physician, Obstetrician, Surgeon, Intensivist, Anaesthesist – and is normal in these hospitals that investigate, treat and perform surgeries for those in need. Detecting any case at risk prior to their surgical procedures are important for necessitating RT PCR confirmation and further action.

Enabling the solution and the impact

These hospitals have been in the service of the local communities with a mix of healthcare and community outreach services for decades now. Heavily dependent on funding, these setups have to often navigate severe financial crises in their mission to continue catering to people at the bottom of the pyramid. Amidst the tribal belt in Jharkhand, Dr. George Mathew (former Principal, CMC, Vellore) and Medical Director of Shantibhavan Medical Center in Simdega, had to face the herculean task of providing food and accommodation for all his healthcare and non-healthcare staff as they were ostracised by their families owing to the stigma attached to COVID-19 care. Lack of availability of  PPE kits and other protective gear, also pushed these sites to innovate and produce them inhouse.

Left: the staff of Shanti Bhavan medical center making the essentials for protecting themselves in-house; Right: staff protecting themselves and a patient.

qXR was introduced to these passionate professionals and other staff were sensitized on the technology. Post their buy-in of the solution, we on-boarded 11 of these hospitals, working closely with their IT teams for secure protocols, deployment and training of the staff in a span of 2 weeks. A glimpse of the hospitals as below:

Others include hospitals in Khariar, Odisha; Dimapur, Nagaland; Raxaul, Bihar and so on.

Initially, qXR was used to process X-rays of cases with COVID-19 like symptoms, with results interpreted and updated in a minute. Soon the doctors found it to be useful in OPD as well and the solution’s capability was extended to all patients who visited with various ailments that required chest X-ray diagnosis. Alerts on every suspect are provided immediately, based on the likelihood of disease predicted by qXR, along with information on other suggestive findings. The reports are compiled and integrated on our patient workflow management solution, qTrack. Due to resource constraints for viewing X-ray in dedicated workstations, the results are also made available real-time using the qTrack mobile application.

Left: qTrack app used by the Physicians to view results in real time during while they are attending patients and performing routine work; Right: qTrack web used by Physicians and technicians to view instantaneously for reporting.

“It is a handy tool for our junior medical officers in the emergency department, as it helps in quick clinical decision making. The uniqueness of the system being speed, accuracy, and the details of the report. We get the report moment the x rays are uploaded on the server. The dashboard is very friendly to use. It is a perfect tool for screening asymptomatic patients for RT PCR testing, as it calculates the COVID-19 risk score. This also helps us to isolate suspected patients early and thereby helping in infection control. In this pandemic, this AI system would be a valuable tool in the battleground”

– Dr Jemin Webster, Tezpur Baptist Hospital

Once the preliminary chest X-ray screening is done, the hospitals equipped with COVID-19 rapid tests get them done right away, while the others send samples to the closest testing facility which may be more than 30 miles away, with results made available in 4-5 days or more. But, none of these hospitals have the RT-PCR testing facility, yet!

In Makunda Hospital, Assam, qXR is used as an additional input in the diagnosis methodologies to manage the patient as a COVID-19 patient. They have currently streamlined their workflow to include the X-ray technicians taking digital X-rays and uploading the images on qXR, to  follow up and alert the doctors. Meanwhile, physicians can also access reports, review images  and make clinical corroboration anywhere they are through qTrack and manage patients without any undue delay.

Dr. Roshine Koshy using qXR system during her OPD to review and take next course of action

“One of our objectives as a clinical team has been to ensure that care for non-COVID-19 patients is not affected as much as possible as there are no other healthcare facilities providing similar care. We are seeing atypical presentations of the illness, patients without fever, with vague complaints. We had one patient admitted in the main hospital who was flagged positive on the qXR system and subsequently tested positive and referred to a higher center. All the symptomatic patients who tested positive on the rapid antigen test have been flagged positive by qXR and some of them were alerted because of the qXR input. Being a high volume center and the main service provider in the district, using Qure.ai as a triaging tool will have enormous benefits in rural areas especially where there are no well-trained doctors”

– Dr. Roshine Koshy, Makunda Christian Leprosy and General Hospital in Assam.

There are a number of changes our users experienced in this short span of introduction of qXR in their existing workflow including:

• Empowering the front-line healthcare physicians and care-givers in quick decisions
• Enabling diagnosis for patients by triaging them for Rapid Antigen or RT-PCR tests immediately
• Identifying asymptomatic cases which would have been missed otherwise
• Ensuring safety of the health workers and other staff
• Reducing risk of disease transmission

In Padhar Hospital, Madhya Pradesh, in addition to triaging suspected COVID cases, qXR assists doctors in managing pre-operative patients, where their medicine department takes care of pre-anaesthesia checkups as well. qXR helps them in identifying and flagging off suspected cases who are planned for procedures.  They are deferred till diagnosis or handled with appropriate additional safety measures in case of an emergency.

“We are finding it quite useful since we get a variety of patients, both outpatients and inpatients. And anyone who has a short history of illness and has history suggestive of SARI, we quickly do the chest X-ray and if the Qure app shows a high COVID-19 score, we immediately refer the patient to the nearby district hospital for RT-PCR for further management. Through the app we are also able to pick up asymptomatic suspects who hides their travel history or positive cases who have come for second opinion, to confirm and/or guide them to the proper place for further testing and isolation”

– Dr Mahima Sonwani, Padhar Hospital, Betul, Madhya Pradesh

Left: technician capturing X-ray in Shanti Bhavan medical center; Right: Dr. Jemine Webster using qXR solution in Baptist hospital, Tezpur

In some of the high TB burden settings like Simdega in Jharkhand, qXR is used as a surveillance tool for screening and triaging Tuberculosis cases in addition to COVID-19 and other lung ailments.

“We are dependent on chest X-rays to make the preliminary diagnosis in both these conditions before we perform any confirmatory test. There are no trained radiologists available in our district or our neighbouring district and struggle frequently to make accurate diagnosis without help of a trained radiologist. The AI solution provided by Qure, is a perfect answer for our problem in this remote and isolated region. I strongly feel that the adoption of AI for Chest X-ray and other radiological investigation is the ideal solution for isolated and human resource deprived regions of the world”

– Dr.George Mathew, Medical Director, Shanti Bhavan Medical Centre

Currently, qXR processes close to 150 chest X-rays a day from these hospitals, enabling quick diagnostic decisions for lung diseases.

Challenges: Several hospitals had very basic technological infrastructure systems with poor internet connectivity and limitations in IT systems for using all supporting softwares. They were anxious about potential viruses / crashing the computer where our software was installed. Most of these teams had limited understanding of exposure to working with such softwares as well. However, they were extremely keen to learn, adapt and even provide solutions to overcome these infrastructural limitations. The engineers of the customer success team at Qure, deployed the software gateways carefully, ensuring no interruption in their existing functioning.

Conclusion

At Qure, we have worked closely with public health stakeholders in recent years. It is rewarding to hear the experiences and stories of impact from these physicians. To strengthen their armor in the fight against the pandemic even in such resource-limited settings, we will continue to expand our software solutions. Without limitation, qXR will be available across primary, secondary, and tertiary hospitals. The meetings, deployments, and training will be done remotely, providing a seamless experience. It is reassuring to hear these words:

“Qure’s solution is particularly attractive because it is cutting edge technology that directly impacts care for those sections of our society who are deprived of many advances in science and technology simply because they never reach them! We hope that this and many more such innovative initiatives would be encouraged so that we can include the forgotten masses of our dear people in rural India in the progress enjoyed by those in the cities, where most of the health infrastructure and manpower is concentrated”

–Dr. Ashita Waghmare, Chinchpada hospital

Democratizing healthcare through innovations! We will be publishing a detailed study soon.