Healthcare startups have revolutionized the healthcare delivery process for better patient experiences. The Indian healthcare ecosystem is witnessing innovative changes that are solving big challenges of the healthcare system like affordability, accessibility, and availability. Through this startup series, Medicircle aims to create awareness about the impact of these initiatives, the latest developments on this front, and the areas in which there is some scope for improvements. 

Dr. Geetha Manjunath is the Founder, CEO, and CTO of NIRAMAI Health Analytix. Under her leadership, the startup has developed an AI-enabled solution for detecting breast cancer in the early stages itself in a radiation-free, non-invasive manner. Dr. Geetha holds a Ph.D. in IISc and management education from Kellogg’s Chicago and has over 25 years of experience in IT innovation. She led multiple AI projects at Xerox Research and Hewlett Packard India. Before starting NIRAMAI, Dr. Geetha was working as Lab Director for Data Analytics Research at Xerox India. She has received several international and national recognition for her innovations and entrepreneurial work, including CSI Gold Medal, and BIRAC Women in Entrepreneurial Research Award 2018. Dr. Geetha also features in the Forbes List of Top 20 Self-Made Women 2020. She has been awarded Woman Entrepreneur of the Year 2020 by BioSpectrum India and Accenture Vahini Innovator of the Year Award from Economic Times. Dr. Geetha is also an inventor of 16 US patents. 

The solution to the burning issue of breast cancer 

Dr. Geetha informs, “We have developed a platform and a solution or test through which we can detect early-stage breast cancer, in complete privacy. It is a breakthrough innovation. Mammography is the default standard for breast cancer today, but it does not work on women under 45 years of age. It also uses radiation. So, it's not recommended to repeat the test every year. For breast cancer, where we are losing 680,000 women every year globally, early detection is the key. Otherwise, we would end up in a stage where India is today, which is a 50% survival rate. Every alternate woman with breast cancer is dying. This late detection issue can be solved if we solve affordability and accessibility issues. In addition, we need a test that can work for women of all age groups, which means any lady about 25 to 30 years of age, should be able to take a simple breast health check annually. This way it will be possible to detect the smallest lesion. Early detection means better treatment efficacy, saving lives, and reducing treatment costs. This is very important in India. Also, taking care of the health of the person after the surgery is important.”

NIRAMAI fills in the gap

Dr. Geetha mentions, “So how do you enable this, given so many gaps in the current methods? That's where NIRAMAI has made a huge difference by bringing out the platform of thermal sensing. Everyone is aware of it in COVID time and knows what thermal screening is. So, it's exactly that but we use a high-resolution thermal camera and measure the temperature variations on the chest just like a click of a photo, but it's not a photo exactly. It measures temperature. If you measure 400,000 temperature points, then the artificial intelligence-enabled software device that we have developed analyses these temperatures and generates a report automatically saying whether the breast is abnormal and the probability of it having cancer by providing a score. It also indicates the exact location of where cancer cells are so that a follow-up test can be done at that particular location. So, in a biopsy, another pathological test can be more accurate and more confirmatory. All this can be done by a simple health worker and can be done not just in a hospital but anywhere. This is because our test is completely radiation-free. There is no x-ray involved. We can just set it up and then do it,” says Dr. Geetha.

No-see, no-touch method of breast examination

Dr. Geetha emphasizes, “It's very important to keep the privacy of the lady intact. There are so many tests where there could be a male technician and seeing and touching of the breast gets inevitable. This becomes very uncomfortable for ladies. We have worked on the no-see, no-touch methodology. It's a booth-like structure. The lady has to go there and lie down for 10 minutes and that's all. Not even a technician sees her. I call it a changing room experience. This enables more and more tests due to the ease of getting the test done. We have seen that once a woman gets the test done, she recommends her friends and family members to do so as well. It is a very simple test and extremely important for preventive health care in particular. That's when we can move from illness to wellness.” 

Few good changes brought down by pandemic

Dr. Geetha says, “The mentality of the patients, or people in general, has changed in multiple ways. One strong component of this is a focus on illness to wellness. They know what it means to take the vaccination, they know what it means to get detected with Covid. They know the severity between stage 1 vs. stage 4 where the person has to wait for an ICU bed or an oxygen cylinder. So, everybody knows what it is to get detected early. The consciousness and the mindset are moving towards wellness like proactively taking medicines, doing exercises, etc. We see a lot of it happening now. That's good and one of the very few things that have happened due to Covid.

The second thing is teleradiology, telehealth, and telemedicine have picked up quite a lot today. Of course, it's not that computer systems and video conferences like this were not existing before but were rarely used by patients and doctors. Now it has become more common. It could be just a voice call and both the doctor and the patient are comfortable with it. There is a trust element that is built on the computer system that is in between and there is trust in digital healthcare implicitly. Due to the recent huge load on telehealth systems, they have been tested rigorously, and the policies also have loosened allowing prescriptions to be done across the wire.”

Impact of Covid on NIRAMAI and how it helped to find a larger solution

Dr. Geetha informs, “At NIRAMAI, we were affected by COVID too. We were providing breast health screening services in many hospitals, and people stopped going to hospitals, especially for preventive care. Only emergency cases or Covid cases were going to the hospital. It affected our revenue. But it's not just about revenue. Just because Covid is there, cancer is not going away. Many women needed the cancer tests to be done, they needed the preventive tests to be done, but they could not come to the hospital. So, we thought, what can we do about this? Since we had done so many camps before, and of course we had done lots of screenings in the hospitals, we launched a home screening service for cancer detection of breast health, the first of its kind in the world. We got covered by the European media and all because they had never heard about breast screening being done at home as a huge mammogram machine definitely cannot be taken to the homes of people. 

This was not just about doing something new, but we were actually able to unearth at least three to four cancer patients in the first 100 patients at-home screening and then they went to the hospital for further tests and treatment. This was something new that NIRAMAI did because of COVID,” says Dr. Geetha.

NIRAMAI’s new testing device for Covid 

Dr. Geetha says, “The technology that we have developed is about thermal imaging and analysis of thermal imaging using AI software. So, we brainstormed on how we can help as technologists and experts in thermal imaging in the fight against Covid? And we came up with a new device for Covid detection. After the first wave, people started going back to offices and it had to be ensured that nobody who is entering has Covid. So, we developed a device like a thermal camera with simple imaging like CCTV to be placed at the entrance of the building. As and when people were walking, it screened the temperature of the head. It did face detection and recognition. Whether one is wearing a mask or not, whether there are respiratory abnormalities etc. were automatically detected. If someone was detected with the likelihood of Covid, the device took an image and alerted the sensor and alarms, directing the individual to move to the side. This was the automated system that was created as a solution by NIRAMAI and is still being used in many places in India today, with more than 30 - 40 installations.”

NIRAMAI’s initiatives to fight COVID more effectively in the rural ecosystem

Dr. Geetha emphasizes, “We played a role in enabling the rural ecosystem to fight Covid more effectively. Most of the cases detected in rural areas were late, and then they were going to the ICU late. There used to be no beds and oxygen. We wanted to help people in this situation. We figured out that something can be done in the arena of RT PCR tests. When a person comes in with symptoms for RT PCR, taking a swab for testing is quick, but then sending back for an actual diagnosis, used to take 7 to 10 days because from villages this had to be transported to a city, and then the report took time to come back. And then there was so much load on the RT PCR requirements itself, it was just taking ages. By then, of course, the person would fall into the next stage, and so on. That was a major issue. So, we released a service where as soon as a rural doctor came across a patient who has some symptomatic condition, he would just take an X-ray of the chest, send it to us on Whatsapp so that the process of detection becomes quicker. We named this service X-raySetu. So, this is how we were able to be of service to 1000s of people.”

How can AI meet healthcare demand in rural areas?

Dr. Geetha mentions, “Accuracy of the system is very important and AI is making a huge difference to the healthcare ecosystem. There is a huge divide between the rural healthcare ecosystem and urban ecosystem and this is affecting so many people because healthcare is both not affordable as well as accessible to many people. So how do we bridge the gap? I think AI is an excellent tool for that because there are so many points of care devices, which can sense the different parameters of the body, be it thermal sensing, ECG devices, BP measurement devices, or sugar measuring devices. We can actually place these automated devices, in a rural healthcare system, and write an AI-based software to read this data from a patient and analyze it to see, does this person falls in the abnormal category or normal category. It need not diagnose, it just needs to figure out if this person requires a doctor, and it will help in bringing her or him to the hospital. So, this can be done today, effectively and accurately by an AI system. 

That's what we have done for breast cancer. Our AI system that is deployed in villages can automatically detect whether somebody is likely to have a breast abnormality. Likewise, other devices can detect other abnormalities. Since these are quantitative numbers, it's not a health worker assessing the problem. These numbers enable objective decision-making, and removes subjectivity, and removes the need for expertise in interpreting whether there is an abnormality or not. Once that is done, we could also transmit this to telehealth, where the patient can be visually examined, as well as sensor-based data is available to the doctor to take a concrete call. So, this enables affordability because there are no people involved, there is no major expertise required which makes healthcare more affordable. Also, this can be enabled in every village. This is one clear way of enhancing our healthcare infrastructure to meet everybody's demands.”

How can AI meet healthcare demand in urban areas?

Dr. Geetha says, “When we are talking about urban areas, what happens is that there are expert doctors, and they are flocked with patients. There are long queues, and people have a waiting time of one week to get an appointment. This problem can be addressed by AI because the AI tool now will become an assistant to the doctor. It can collect all the history of the patient and then give a summary of the patient to the doctor. Let's say, if there is a chest X-ray, or a mammogram, or thermal screening, AI can mark the area of abnormality. So, what the doctor does is quickly take a look, and make sure that the derived result is correct and that hardly takes a few minutes. It saves a lot of time for the doctor in the urban setting. So that way, I think AI-based tools have multiple usages, both in the rural and urban ecosystem. 

Dr. Geetha further mentions, “Of course, technology has reached greater heights, you know, you have augmented reality (AR), virtual reality (VR), and other things where the doctors are dealing with multiple types of imaging during surgery or using a robot to do the surgery. There are so many ways in which technology is helping mainly as tools to the doctor in one way or the other, or extending the bandwidth, extending the access of very high-quality healthcare to all. So, I am very excited to be born in this era, I would say, to help enable this in some of the diseases.”

Efficacy of X-raySetu for Covid detection

Dr. Geetha emphasizes, “Talking about AI on chest, x-ray machines are there in almost every town and many of the villages because they have been deployed for controlling TB, which is being fought well so far. Even though x-ray machines are there, there is an acute shortage of radiologists. Also, just doing the x-ray is not sufficient, we need to understand what the issue or the problem is? So, we decided that we would just make it very simple WhatsApp base detection. One has to just take a picture of the x-ray report and forward it on the Whatsapp number. Once that is done our AI algorithms analyze that to generate a report.”

Dr. Geetha says, “Unlike other tools, where we try to replace radiologists or help radiologists, in this particular case our focus has been to detect the smallest of the smallest indications of Covid so that the person can be put on treatment immediately so we fine-tuned with an RT PCR report. Using a chest x-ray, we can try and do an early intervention because we can guess very accurately whether the person is likely to have Covid and that has been tested with RT PCR results, also that comes later on. Many times, the doctors have said that we got RT PCR results after 3 days, your report matches with it. We have had several testimonials like this. Lots and lots of people are using this technique now. So basically, if you go by the real benchmark, or data set-based analysis, we have more than 95% sensitivity and more than 75% specificity that is required.”

Challenges of X-raySetu

Dr. Geetha mentions, “There are a lot of challenges in developing this AI model itself, because of the low resolution of images sent on WhatsApp. Images are not always accurately visible or there has been the use of a flash or too many unnecessary objects in the images. Despite these challenges, we have been able to develop a very interesting and accurate solution. The response has been so great, that more than 8,000 people have used this solution. Thankfully, now the wave has come down, but when the Covid was at its peak, we were able to read 1000s of images within a week, and not only in India, it has been used in some 40 plus countries because anybody can send an image to us on Whatsapp. We have not intended to replace the RT PCR report, it's just another tool that definitely can be used for enabling early intervention in Covid.” 

Positive feedback leads to an expansion plan

Dr. Geetha informs, “We have received enormous feedback from multiple fronts requesting not to stop after Covid because chest x-ray-based analysis on WhatsApp is really helpful. So, we are planning to enhance our services to detect tuberculosis and 14 other abnormalities. We should be able to tell the radiologist why the machine is making this decision, we call this explainable artificial intelligence model. We are also able to mark the area of potential abnormality in the chest X-ray as well. I am very thankful to my peers and collaborators to enable this to happen on a big scale. We have got a really big exposure, thanks to the collaboration.”

Message from Dr. Geetha Manjunath

Dr. Geetha mentions, “If you have a passion to solve a problem, go for it, don't think twice. I remember four-five years back I had the opportunity to stay back in my previous organization to become the head of the organization and so on. But I deeply felt about solving the problem of breast cancer detection. It's okay to try and fail, but if you don't try, you will never get this chance again. So, if you feel deeply about solving a problem, go for it, don't think twice, you can always come back and have the cushy job all the time, but you will learn a huge number of things. 

Secondly, particularly for women entrepreneurs, or aspiring women entrepreneurs, I would say, keep the courage, don't be afraid. Don't worry about what others will say. Like Shri Shri Guruji says, “Don't be a football of others opinion.” So, I mean, people will say, you are leaving the kid and going. It's fine, you know, that you have done the best thing possible in the current circumstances. So, I say, just do what your heart says. And obviously, your mind will follow. Keep the courage. 

And thirdly, we always have a lot of doubt about ourselves rather than doubting others. Of course, if you are trying to solve something bigger than yourself, you will get the courage and you will get the confidence and there will be some kind of supernatural power, which helps you and you learn. There will be people like you who are trying to create awareness about it, and investors, and the startup community and the government is also supportive. So, all of them will come and help you learn the gaps, because nobody can know everything. There's so much to do, so much to learn. You learn on the go. And so, the only thing is don't be afraid, jump off and you'll do good. Enjoy the journey,” advises Dr. Geetha.

 

(Edited by Amrita Priya)