Point of Care Ultrasound can Transform Primary Care in India

The National Health Policy 2017 recommends strengthening primary health care delivery by establishing “Health and Wellness Centres” to deliver comprehensive health care to rural India. The recommendation is to transform existing “Sub Health Centres” and “Primary Health Centres” (PHC) to “Health and Wellness Centers” (H&W centers) to ensure universal access to an expanded range of primary healthcare services. Some of the services provided by these H&W centers will include Care in pregnancy and child-birth, Neonatal and infant health care services, Screening, Prevention, Control, and Management of Non-Communicable Diseases, Elderlyand Palliative care services, and Emergency Medical Services.

Point of Care Ultrasound (POC-US) can help improve diagnostic accuracy, reduce the time taken for diagnosis, improve patient safety, and decrease complication rates. If deployed with appropriate controls at the PHC-H&W centers, this can help reduce the disease burden in Rural India. In addition to pregnancy monitoring, there are several areas that POC-US can help to improve the quality of care in rural India. Below are some examples:

• Nearly a quarter of all deaths in India is due to cardiovascular diseases (CVDs). The CVD mortality rates for rural populations are higher than in urban areas. More women die than men every year due to this disease. The prevalence of cardiovascular risk factors among the elderly in rural India is high. Ultrasonography is effectively used to monitor cardiac health, presence or absence of cardiac function during cardiac arrest, determine the underlying cause, monitor the response to cardiopulmonary resuscitation, etc.
• POC-US can be used as a rapid and accurate technique to evaluate the critically ill, including conditions ranging from life-threatening trauma to shock.
• Chronic Obstructive Pulmonary Disease (COPD) is the second-highest cause of death in India after heart disease, killing ~1 million Indians every year. The prevalence of COPD is higher in the rural population when compared to urban areas. Spirometry is the most reproducible, objective, and non-invasive lung function test for COPD. POC-US can be used to differentiate between different emergent pulmonary conditions, including COPD exacerbations, pneumonia, pulmonary embolism, and pulmonary edema.
• The burden of echinococcal disease is high in rural India (~ 150000 people are affected every year). Early detection can help in improved management of the disease. Portable ultrasonography has proven to be beneficial in the diagnosis and monitoring of the treatment of this disease.
• Elevated intracranial pressures can be detected using Ocular ultrasonography, e.g., pediatric cerebral malaria.

There is a lack of comprehensive understanding of the benefits of diagnostic ultrasonography in primary care.  Sex determination of the baby during pregnancy is prohibited to prevent female feticide in India. This prohibition has restricted the use of ultrasound in a primary care setting for fear of being misused. Though it is necessary to take all steps to prevent female feticide, this inadvertently has reduced the quality of care and increased the economic burden on people living in rural India. People now need to travel long distances to a district hospital for an ultrasound scan.

Over the years, significant advances have taken place in Information and Communication Technology, Artificial intelligence (AI), Cloud, and Transducer technology. Tools to train ultrasound technicians are more intuitive. Specialized ultrasound transducer probes to scan different soft-tissue body parts have helped improve image quality. The cost of data storage has come down significantly.

Regulators need to take cognizance of these technological advances and work with health-tech companies to find a solution to deploy ultrasound machines at the PHC-H&W centers while preventing sex determination. While addressing this challenge, these are some of the aspects that can be explored further :

• The Pre-conception & Pre-natal Diagnostics Techniques (PC & PNDT) Act, 1994, was enacted in response to India’s decline in sex ratio over the years. The primary purpose of passing the act is to ban sex-selection techniques before or after conception and prevent the misuse of a prenatal diagnostic method for sex-selective abortion. The amendment in 2003 brought ultrasonography under the gamut of the act by allowing their use only to detect a few types of cases. Given the changes in technology and the benefits of using ultrasonography, a more pragmatic approach is the need of the day.
• For example, a radiologist operating out of a district hospital should be able to register the portable ultrasound machine at a remote site (PHC-H&W center). Guided by the radiologist ( who does the diagnosis) the locally trained staff can capture the image. This process would require shorter, more accessible training courses for rural practitioners in ultrasound probe placement.
• A log of all activities such as scheduling patient appointments, patient registration for the scan, image capture, ultrasound probe used, time stamps, radiologist and rural practitioners involved, etc., could be automatically captured in cloud infrastructure and linked to the patient’s Unique Health ID (UHID) to prevent misuse. Temporary local storage would be required to automatically store the data locally in the event of connectivity issues.
• Ensuring that the portable ultrasound machine has GPS tracking will help track the device’s location 24×7 and prevent it from being moved out of the registered location.
• AI algorithms will need to play a crucial role in deploying Ultrasound devices in rural India. There are several areas where AI can make an impact. While performing a scan, identifying the organ, capturing the image, and recording the required measurements is possible now in some ultrasound devices. A default masking of the genital area of the fetus, ensuring proper controls and accountability to unmask the genital area, can be explored further. The stored images and related data are currently audited manually on a small randomly selected sample for suspicious activity. This process can be automated using AI algorithms for 100% coverage.

There are several examples where POC diagnostic ultrasonography has been used safely and successfully in low-resource settings. Several non-medical professionals have the training to use ultrasound for various types of scans, including echocardiography, rheumatic heart disease, trauma, lungs, etc. Some examples are the triaging of trauma patients during the 2010 Haitian earthquake, primary care clinics in Ghana, Lugufu refugee camp in Tanzania, Dutch medical helicopter crew, etc.

For ultrasound deployment in a primary care setting to be successful several challenges need to be addressed. These challenges include the lack of healthcare staff at PHC’s, communication infrastructure, maintenance of the ultrasound machine, intermittent power supply, etc.

PHC- H&W centers will help improve access to care for people living in rural India. There is a need to review the list of medical devices made available at these centers. A Portable Ultrasound device can enhance the screening and diagnostic capability at these centers. A more pragmatic view of the PC & PNDT Act is required. The solution needs to ensure improved controls to prevent sex determination of the fetus.

Emerging technologies like AI, Cloud, 5G, and advances in ultrasound transducer technology will play a vital role in this deployment.

(Srinivas Prasad is Founder and CEO of Neusights and the views expressed in this article are his own)