Artificial Intelligence & Machine Learning in Healthcare Industry:

Case Study of an Indian Healthcare Service Provider – “ Niramai “

Capstone Project

Submitted to
Indian Institute of Management, Lucknow

In partial fulfilment for the requirements of the degree

Executive Program in Business Management, 2021-22

Authors:

S No Name Details
1 Ms.Shweta Patel
2 Mr.Achin Kapur
3 Ms.Mansi Chitroda
4 Mr.Tushar Gawande Senior Manager- International Business Services-Medline Plc.
5 Mr.Prasanna Venkatesh Head of Health & Safety , Compliance & Governance - Diageo India
6 Ms.Rajani Bahety
7 Ms.Sakshi Agrawal
8 Mr.Sourav Mukherjee

Certificate of authorship

We certify that our team as listed above is the author of this paper and that any assistance that we have received in
its preparation is fully acknowledged and disclosed in this paper. We have also cited any sources from which we have
used data, ideas, or works, either quoted directly or paraphrased. We also certify that this paper was prepared by us
specifically for this course

Submission date: 30/01/2022

Contents:

S No Description Page No
1 Title 1
2 Introduction
3 Background
4 Methodology
5 Goals/Deliverables
6 Findings/Results – a.) Marketing
                                b.) Financial Management
                                c.) Economics
                                d.) Supply Chain
7 Discussion & Interview link
8 Challenges
9 Recommendations & Way forward
10 Suggestions & conclusion
11 Bibliography
“AI and ML combined with robotics and the Internet of Medical Things (IoMT) could potentially be the new nervous
system for healthcare.”
NITI Aayog , the apex policy think tank of Government of India

What motivated us towards this project

Artificially intelligent computer systems are used extensively in medical sciences. Common applications include
diagnosing patients, end-to-end drug discovery and development, improving communication between physician and
patient, transcribing medical documents, such as prescriptions, and remotely treating patients. While computer
systems often execute tasks more efficiently than humans, more recently, state-of-the-art computer algorithms have
achieved accuracies which are at par with human experts in the field of medical sciences. Some speculate that it is
only a matter of time before humans are completely replaced in certain roles within the medical sciences. All these
motivated us to work on a project about “ Niramai “ which is using software , artificial intelligence and machine
learning to in a novel way to provide breast cancer screening solutions

Why Artificial Intelligence in healthcare is a big opportunity area in India and for rest of the world

India’s think tank NITI Aayog, put healthcare on top priority in the list of domains that need an AI push. Barriers
within the healthcare domain, particularly in rural areas of India that suffer from poor connectivity and limited
supply of healthcare personnel can get hugely benefitted with the intervention of AI. According to NITI Aayog, in
India, AI adoption for healthcare applications is expected to see an exponential increase in the next few years. The
healthcare market globally driven by AI is expected to register an explosive CAGR of 40% through 2021, and reach
$6.6 billion this year.

The think tank believes the advances in technology, and interest and activity from innovators will allow India to solve
some of its long-existing challenges in providing appropriate healthcare to a large section of its population. AI
combined with robotics and the Internet of Medical Things (IoMT) could potentially be the new nervous system for
healthcare, presenting solutions to address healthcare problems and help various governments meet mission critical
objectives. Moreover, India is the perfect petri dish for enterprises and institutions globally to develop scalable
solutions which can be easily implemented in the rest of the developing and emerging economies.

In simple terms, solve for India means to solve for 40% or more of the world.
Nothing comes without a challenge

AI-driven diagnostics comes with its own set of challenge. Firstly, data availability for different age groups, genders,
and regions is not adequate to make a smart machine learning model. The biases show up in the results, which in
turn translates to inaccurate diagnosis for that group.

While machine learning models are already getting good at helping radiologists , how legitimate are these
algorithms ? Have they been thoroughly vetted by government bodies? For example, when Google AI, in partnership
with the Ministry of Public Health in Thailand, conducted deep learning experiments in a handful of clinics, they
found fundamental issues in the way the deep learning systems were deployed. Though the model improved
regularly, the challenges came from factors external to the model like Software as a medical device .

To tackle these most pressing challenges, it is recommended to focus on five principles:

1. Acknowledge that medical data can be incomplete, incorrect, missing, and biased
2. Recognise how ML systems can result in centralising power at the expense of patients and health care
providers alike
3. Machine learning designers must emphasise on how new systems will interface with medical systems
4. Recognise that patients have their own expertise distinct from doctors
5. A shift of focus from bias and fairness to focus on power and participation

AI incorporation also must work around challenges such as shortage of qualified healthcare professionals and
services and non-uniform access to healthcare.

NIRAMAI Health Analytix is a Bangalore-based deep-tech startup addressing critical healthcare problems through
automated solutions

Mission: To create a Universal Cancer Screening Method that can save lives

How is traditionally breast cancer detected ?

Breast cancer is the leading type of cancer in women. According to WHO, one in every 8 women is at risk of
developing a breast abnormality in her lifetime. It is well-established that early diagnosis is very critical in saving a
life of a cancer patient.

The current gold standard for breast cancer screening, Mammography, requires high capital cost for equipment and
experienced radiographers. It is recommended once every 2 years and only to women above 45 years because it
cannot identify tumors effectively for younger women, and uses of X-rays for scanning, which can make women
more susceptible to cancer if screened multiple times. In addition, it is also very painful for the subject (about 20
pounds weight is applied on the breasts while screening). Other common method of clinical exam can detect tumors
only after they are large enough to be palpable.
How is NIRAMAI different and better than traditional way of breast cancer diagnostics?

NIRAMAI has developed a new cancer screening software that uses machine intelligence over thermography images
to enable a low cost, easy to use, portable solution and requires minimal human supervision. It can detect cancer at
a much earlier stage than traditional diagnostic methods and self-examination and can therefore improve survival
rates. This method of breast cancer screening is of non-contact type, painless and free of any radiation, apart from
being low-cost, and universally accessible. With this solution, women of all age groups can undergo frequent
screening without any side-effects.

The core of NIRAMAI solution is Thermalytix, a computer aided diagnostic engine that is powered by Artificial
Intelligence. The solution uses a high-resolution thermal sensing device and a cloud hosted analytics solution for
analyzing the thermal images. SaaS solution has been developed using big data analytics, artificial intelligence, and
machine learning for reliable, early and accurate breast cancer screening.

Leaders leading from the front at NIRAMAI

Dr.Geetha Manjunath Founder, Chief Technology Officer, and Chief Executive Officer, NIRAMAI Health Analytix

Decided to put the organization forward for Launchpad – A global accelerator program that helps start-
ups scale by matching them with Google's people, networks, and technologies. "We wanted to learn how to scale
our business, including our mobile and cloud infrastructure," she says.

"From a technology perspective, we wanted to accommodate traffic from the nine installations we had operating at
the time, while from a business perspective, we wanted to continue to gain acceptance from doctors and clinicians
who were cautious about adopting new technologies," she adds. "In addition, we wanted to understand what legal
and regulatory clearances and clinical trials had to be completed to expand into markets such as the United States,
Asia, and Europe."

Nidhi Mathur, Chief Operating Officer and Co-founder, NIRAMAI Health Analytix

Launchpad gave us an opportunity to be in an environment with 100 mentors from all parts of the world,"
says. "We were exposed to mentors from different industries and with highly specific skills." These mentors provided
the technical and business assistance NIRAMAI Health Analytix needed to realize its ambitions. One mentor helped
the business modify the interface to its product to be more intuitive and easier to use for the clinicians and nurses
who would be its primary users.

Going beyond hospitals and Diagnostic centres

While the initial operational model was to focus on hospitals and diagnostic centers , NIRAMAI soon realized that
hospitals could be considered as simple distribution channels and there may be many more places where we could
reach our end users, who were the actual beneficiaries.

This paved the way to add new channels, so NIRAMAI established innovatively established its presence in a shopping
mall. While it's still an experiment, this initiative has enabled women who may hesitate to go to a cancer centre for
screening when they are well , to just visit the screening centre in a mall !

NIRAMAI Health Analytix is retraining its ML models in a few months to account for any false positives and false
negatives, typically coming from patients that present to tertiary cancer centre’s with difficult cases.

Goals and Deliverables of NIRAMAI

A 2018 report of Breast Cancer statistics recorded 1,62,468 new registered cases and 87,090 reported deaths.
Cancer survival becomes more difficult in higher stages of its growth, and more than 57% of Indian women suffer
from stage 3 and 4 of breast cancer at the time of detection which is highly alarming.
Risk of breast cancer increases with age, about 80% of women diagnosed with breast cancer each year are 45 or
older, and about 43% are 65 or above. Hence it is very important to detect cancer at its very early stages even before
symptoms crop up

NIRAMAI came up with the below mentioned goals and objectives

 Early detection: Detect breast cancer at its early stages through reliable patented software / machine
learning algorithms. The advantage of machine learning algorithms is it gets better and better with time
 Risk free detection: Provide radiation free, non-touch, non-painful and most importantly for women of all
ages. The current practice of detection through radiation has its own risk and aftereffects in the long run.
 Accuracy and reduction of manual intervention : Manual analysis of thermal images requires highly trained
and skilled professionals, and many times results in several false positives. However, NIRAMAI Thermalytix
has 70% higher positive predictive value than Thermography
 Low-cost detection: To provide a low cost, quick, accurate, automated, portable cancer screening tool that
can be operated in any clinic. NIRAMAI is offering screening through standalone health pods at an inaugural
offer of Rs 99 and the report gets generated instantly. End to end time taken to screen a patient is
approximately 20mts and the screening time is only 5mts
 Mass outreach and scalability: Realizing the dream of running largescale cancer diagnosis test and screening
in urban, rural, and semi-urban areas
 Cancer screening at our doorsteps: Ultimately, it’s about bringing breast cancer screening to the doorsteps
of women all over the world

Having developed a proof of concept to secure market acceptance, technology and clinical validation, Niramai
needed support to take its business to the next level

Diagrammatic representation of AI

Artificial Intelligence applications in medical imaging as applied to common cancers. Artificial intelligence tools can
be conceptualized to apply to 3 broad categories of image-based clinical tasks in oncology:

1) Detection of abnormalities

2) Characterization of a suspected lesion by defining its shape or volume, histopathologic diagnosis, stage of
disease, or molecular profile
3) determination of prognosis or response to treatment over time during monitoring. 2D indicates 2-dimensional;
3D,

The central part of the figure shows the relationship between commonly used terms in the field of AI. The arrows
point to the two categories, “Broad AI” and “Narrow AI”, where AI is applied in breast imaging. Examples of these
applications are outlined in the lists under each heading

NIRAMAI using digital technology and platform to scale seamlessly

"With support from Google, NIRAMAI is making its product fully accessible and scalable within India and beyond."

NIRAMAI Health Analytix broke its original monolithic web services architecture into smaller pieces that could
seamlessly scale in parallel. By utilizing Google Kubernetes container orchestration system to deploy containerized
applications in a managed, production-ready environment, NIRAMAI quickly realized a new opportunity to meet its
scalability challenges. The business is already running its applications and nine ML models in containers through
Google Kubernetes Engine. According to Dr.Geetha , they are already seeing improvements with Google Kubernetes
Engine because of its scalability by design. With support from Google, NIRAMAI is aiming to make its products fully
accessible and scalable within India and beyond
The business is also using the Firebase mobile application platform to run an application that enables doctors to view
and certify images on mobile devices.

Niramai Health Analytix Private Limited has its own cancer screening SaaS software that uses machine intelligence
over tomography images. The company provides hardware-software solutions, such as compact screening device
with cloud processing for specialty hospitals; handheld device with real-time cloud-based diagnostics for
independent medical practitioners; and a portable solution for large-scale screenings

The business has grown to 25 installations and over the next year, plans to expand across India. It has created two
products to maximize reach

 A real-time triaging report for women in rural screening camps

 A detailed report for women taking the test in diagnostic centers and hospitals in urban areas

The business is being recognized for its achievements – Dr. Manjunath was a winner at the Women in AI Leadership
Awards, and Niramai also won the Gold Prize in the Hack Osaka International Competition held in Japan in 2019. In
February, the business raised US$6 million in Series A venture capital funding.

Source: https://cloud.google.com/customers/niramai

Financial Management

Healthtech is the next frontier and in India, there are a million problems waiting to be solved using technology.
According to a recent KPMG report, “Even though multiple advantages are provided by healthcare start-ups, they
have not yet received a steady stream of funding to support their venture.”
Health tech start-ups tend to be service-based platforms – and these tend not to be unicorns. Other barriers that
funders face include low returns and long lead times to get those returns.
Niramai was founded in 2016 and had raised seed funding of $1 million in April 2017.  Post that it has raised $6
million in Series A funding led by Japanese VC firm Dream Incubator, Beenext and other investors such as Binny
Bansal, Co-founder, Flipkart, pi Ventures, Axilor Ventures and Ankur Capital. 

It is almost 5 years of operation, and the broad financials of the company is tabled below:

Rs in Crores

Items FY 2016-17 FY 2017-18 FY 2018-19 FY 2019-20

Turnover 0.00 0.16 0.61 0.75
Less: Operating Cost 0.01 1.64 3.29 8.38
EBIDTA (0.01) (1.48) (2.68) (7.63)
Other Income 0.00 0.23 1.22 2.16
PAT (0.01) (1.07) (1.36) (8.23)
Net worth 2.30 5.27 46.95 39.57
Net Fixed Asset 1.36 1.80 2.37 2.15
Investment 0.00 3.07 45.85 40.12
Inventories 0.00 0.00 0.24 0.15
Accounts Receivable 0.00 0.00 0.33 0.11
Accounts Payable 0.02 0.00 0.14 0.84
Cash Conversion Cycle (Days) - 4 262 -281

All start-ups in their initial phase, face the problem of lack of 360-degree approach and professional guidance. With
the infusion of money by Dream Incubator in the year FY2017-18, Mr. Eto Munehiko, Managing Director, Dream
Incubator joined Niramai board, bringing in the experience & professional guidance. The company is still making
losses because this kind of business has long gestation period for making returns. It is an asset light company and
currently funded with money which is lying in investment under asset side. In FY2019-20, the company is taking
advantage of using creditors money & hence the cash conversion cycle is negative.

As of now, the company has support from various investors. However, the support needs to continue given the
gestation period for getting return. Local and national governments should encourage funding by setting up start-up
hubs and a healthcare innovation fund. Meanwhile, the private sector has a dual responsibility of a guide and
investor for the development of healthcare start-ups in India.
Over and above offering funding, it is essential that the major hospital chains, pharmaceutical companies, and
diagnostic labs take charge as mentors to the healthcare start-ups.
Source:

http://techportfolio.net/2016/09/theres-a-30-billion-opportunity-in-indian-healthcare-tech/#ixzz7F79qa0Pf

https://www.mca.gov.in/mcafoportal/

NIRAMAI : A Non-Invasive, Low-cost, Portable device curbing breast-cancer

NIRAMAI's AI-led cancer detection test is called Thermalytix. It is radiation-free, portable, automated, affordable that
can be conducted at hospitals or rural areas. Very cost-effective compared to a standard mammography. In fact,
hospitals must spend one-tenth on NIRAMAI hardware when compared to mammography. While a
mammography machine costs over a crore, NIRAMAI can do it for under 10 lakhs. For the end-user too, it is
subsidized and costs one third of a mammography.
 

CEO Geetha Manjunath also claimed that the test is more accessible and affordable than the standard breast cancer
screening techniques.

NIRAMAI’s plan is to provide testing at Rs 100 per scan as against a mammography which costs Rs 2,500 . In case of
Thermalytix
 There is no need for a doctor to administer the test as it can be done by a health worker as well
 To complete a mammogram report in hospitals and diagnostic centres signature of virologist is needed ,
which adds to overall the cost of the test . Whereas its not needed for Thermalytix

The device cost itself is 1/10th or 1/15th the cost of a mammogram. And more hospitals and diagnostic centres are
able to buy the device which improves accessibility for women to go to nearby hospitals and do a mammogram test.
https://www.moneycontrol.com/news/business/how-niramai-is-using-artificial-intelligence-to-change-the-face-of-
breast-cancer-detection-4937181.html

Questionnaire with Company Heads-

https://www.indiainfoline.com/article/editorial-interviews-leader-speak/nidhi-mathur-coo-and-co-founder-niramai-
118082700167_1.html

Nidhi Mathur, COO and Co-founder, NIRAMAI, is responsible for the product roadmap and go-to-market strategy at
NIRAMAI.
 
In an interaction with Shweta Papriwal, Editor, IIFL, Nidhi Mathur, COO & Co-founder, NIRAMAI, said, “We provide
our solution to hospitals and diagnostic centres as well as to organizations conducting large-scale health screenings.”
 
1-Brief us about your business and products.
Niramai in Sanskrit means being free from illness. It is also an acronym for Non-Invasive Risk Assessment using
Machine AI. NIRAMAI has created a revolutionary technology to identify breast abnormalities in a privacy-aware,
radiation-free way that is effective for women of all age groups. Thermalytix is our patented technology that uses a
high-resolution thermal sensing device and a cloud-hosted analytics solution for analysing the thermal images using
Machine Learning and Artificial Intelligence and automatically generating detailed reports with medical parameters
that can help doctors in their clinical decisions.
 
NIRAMAI offers breast health screening and diagnostic solutions that are portable, age-agnostic, zero radiation, and
non-contact. These benefits very effectively address the concerns and limitations for greater adoption of screening
for women across all segments.
 
2-What is the process of screening breast cancer with your software? How does this software operate?
The solution attempts to remove the common inhibitions that stop women from coming forward for a breast
screening. Many Indian women feel reluctant to opt for breast cancer screening because they feel their privacy is
being invaded. But, with NIRAMAI's software, women can walk in confidently and get their breasts examined with no
touching or even seeing them. Our hardware-software technology solution, called Thermalytix, uses Artificial
Intelligence and Machine Learning to automatically analyze heat patterns of the chest to detect abnormal patterns
using remotely operated thermal sensors.
 
The process of screening is very simple. The thermal device is placed about three feet in front of the patient to
capture thermal readings of her chest region. The NIRAMAI software tool automatically analyses these images and
sends the analysis report for certification to radiologists.
 
3-What is the level of accuracy?
The solution has good accuracy of detection and has published detailed clinical studies in international peer
reviewed journals, showing clinical validity of their solution. Those studies also show effectiveness of this test in
young women for whom mammography is inconclusive due to breast density issues and highlight the ability to
detect lumps so small that they could not be felt in hand examination.

 
4-How did you develop this technology?
We were working on developing the technology since 2013. The team had deep competence in the field of AI and
worked on closely with radiologists and oncologists to perfect the solution and bring the accuracy level on par with
the standard of care.
 
What is your strategy of creating awareness regarding your products?
It is important for us to increase awareness about our products among doctors as well as women who need
screening. We are working very closely with leading radiologists, oncologists, gynecologists, and other breast cancer
focused partners to increase awareness and confidence among their peers. We are also consciously working towards
evangelization among women through communities, content, and social media. The unique experience our product
delivers has also been a great source of positive word-of-mouth for us.
 
5-Who are your clients at the current stage? What is your geographical presence?
We provide our solution to hospitals and diagnostic centers as well as to organizations conducting large-scale health
screenings. The test is available in ten centers in India across four cities.
 
6-Is this technology affordable and effective?
Our solution works with a wide range of thermal sensors. Today, FDA-approved thermal sensors of desired
specifications are available at a fraction of a cost of mammography machines, bringing the cost of ownership down
and enabling hospitals and diagnostic centres to offer the test at a much lower price point than mammography. With
increased volumes, the prices can be brought down even further.
 
7-Are you associated with hospitals/ individual practitioners?
NIRAMAI aims to expand the availability of breast health screening solutions to women, and for that purpose, we
work with various stakeholders including hospitals, diagnostic centres, individual practitioners, NGOs, Government,
and corporates. We work closely with the medical community for bringing our solution to women. Our solution is
available in more than ten hospitals and diagnostic centres in Bengaluru, Mysore, Pune, and Dehradun, and we
continue to add more locations. We provide end-to-end solutions to the institutions, including equipment, training,
report generation, and doctor certification service to those centres.
 
We also work closely with gynaecologists and general practitioners who are very often the first touchpoint for
women seeking medical advice regarding breast health issues.
 
8-Are you spreading awareness regarding breast cancer in rural areas too, where there is very less knowledge and
limited avenues?
Awareness remains low among the rural population leading to lack of emphasis on preventive screening. We
conduct and support the screening camps for the rural and urban poor in collaboration with organizations such as
Karnataka Cancer Society, outreach arms of various reputed hospitals and health-focused NGOs. In addition, we are
launching a number of initiatives to increase awareness of breast health for women and men in general.
 
We are also looking at setting up a mobile screening van to enable us to visit rural areas along with the equipment
and enable more women to be screened for early-stage breast cancer. 
https://youtu.be/hxjwbOD2hBQ

https://youtu.be/5xFytMAThQY

India specific initiatives in the field of AI and ML in Healthcare

According to Satya Nadella, recent advances in AI have been “pretty stunning” but what the humanity is going to see
soon will be even more profound across the spectrum and health care is set to become an AI-first industry.

Microsoft CEO Satya Nadella kicked off “AI for Accessibility” — a $25 million, five-year programme for developers
globally including in India. The programme has put AI tools in the hands of developers to accelerate the development
of accessible and intelligent AI solutions for nearly one billion people with disabilities. Designed for the low-vision
community, one such Microsoft app called “Seeing AI” is harnessing the power of AI to describe people, text and
objects. It can tell visually-impaired persons what is around them.

Amazon’s Cloud arm Amazon Web Services (AWS) has a ML service called SageMaker that is helping developers
create AI models for health care. GE Healthcare is training computer vision models with Amazon SageMaker that are
then deployed in its MRI and X-Ray devices. Amazon Comprehend Medical is a natural language processing (NLP)
service for medical text which uses ML to extract disease conditions, medications and treatment outcomes from
patient notes, clinical trial reports and other electronic health records.

Google is also using AI models on smartphones to help the blind. It is working on an app called “Lookout” that uses
image recognition and AI to describe a scene through a phone’s camera. Touted as the world’s “most human” AI
assistant, Amelia — created by New York-headquartered AI company Ipsoft — combines automation, cognitive and
emotional intelligence with ML capabilities to perform as a digital colleague. Amelia allows patients to self-manage
in scheduling doctors’ appointments, tests and medicines. She also offers condition-specific advice and well-curated
health management tips.

Google announced it has developed an AI model that can detect diabetic retinopathy with a level of accuracy on par
with human retinal specialists. Google is working on rolling out this diabetic retinopathy initiative in clinics in India
with Verily — an Alphabet-owned company which works on life sciences research and development. According to
Google, the new assistive technology can help doctors and staff screen more patients in less time, sparing people
from blindness through a more timely diagnosis.

NITI Aayog in October entered into a partnership with Microsoft to deploy AI technologies in areas such as
agriculture, health care, natural language computing and sustainable environment. In a novel effort to predict the
risk of cardiovascular disease (CVD) among the Indian population, Microsoft India and Apollo Hospitals in August
launched the first-ever AI-powered heart disease risk score API (application programme interface). Part of
Microsoft’s “AI Network for Healthcare” initiative, it will help doctors across the Apollo network of hospitals leverage
the AI-powered API to predict risk of CVD and drive preventive cardiac care across the country.The company also
applied AI to devices for early detection of diabetic retinopathy to prevent blindness. Microsoft India also announced
a partnership with SRL Diagnostics to expand the “AI Network for Healthcare” to pathology to detect cancer.

The Telangana government also adopted Microsoft Intelligent Network for Eyecare (MINE), which was developed in
partnership with Hyderabad-based LV Prasad Eye Institute. MINE uses ML and advanced analytics to predict
regression rates for eye operations, enabling doctors to pinpoint the procedures needed to prevent and treat visual
impairments. The Telangana government is already using Microsoft’s Cloud-based advanced analytics solution to
screen children from birth to 18 years of age for major conditions affecting their health.

In October, global health technology firm Philips selected 19 start-up companies for its first global start-up
collaboration programme that is focused on the application of artificial intelligence (AI) in healthcare. The
programme focuses on the application of AI-based clinical decision support tools, such as image interpretation,
analysis and integration and workflow tools, such as intelligent treatment plans for radiology, ultrasound and
oncology.

IBM in November joined hands with IIT-Delhi (IIT-D) to partake in a multi-year research collaboration on AI in India,
with a focus on sectors such as healthcare and medicine

Conclusion

We seem to be at the doorstep of a revolution in breast cancer screening. The developments in AI interpretation of
medical images over the last few years seem to have opened the door for incorporating stand-alone computer
interpretation of images into breast cancer screening programs. Current evidence shows that these algorithms are
approaching, if not yet have reached, expert human performance, although definitive studies that compare their
performance to actual screening results are not yet available. If and when such performance levels are achieved and
demonstrated, it seems feasible that, at least, an important reduction in the work-load for human interpretation
could be achieved, with no decrease in performance. Even if future improvements are not achieved, and therefore
the impact on performance discussed earlier remains unchanged, there might be subsequent changes down- and up-
stream that could result in an improvement in the quality of the screening program. A reduction in workload with an
unchanged AUC could allow more time for interpreting radiologists to spend on the cases that do need human
review, presumably improving accuracy. In addition, a reduction in human workload could ease the challenge of
transitioning to a more accurate but slower to interpret, imaging technology, such as DBT, again resulting in an
overall improvement in performance. Further improvements in algorithms and training sets, combined with
evidence from more definite, prospective, actual-screening-prevalence trials, could finally usher in the age of
computers having a direct role in breast cancer screening. The next few years will be very dynamic in this field

Key Highlights: -

 AI-based mammography interpretation systems are feasible for stand-alone mode use.
 Studies to date have shown that their performance approximates that of radiologists.
 Larger scale, prospective screening trials are needed to determine their impact.
 Once proven, AI identification of normal cases could reduce the radiologist workload.

Practical Challenges & Limitations- https://www.nature.com/articles/s41416-021-01333-w#Sec15

Technical level
 Whilst the NHS has state-of-the-art scanners and treatments, it is also still reliant on certain record systems
that are paper-based. Thus, technological advancement is a pivotal challenge facing the NHS to allow for the
integration of new technology and the flexibility for exporting data on a mass scale.
 The NHS is also a tightly sealed system; however, companies will need access to update and modify their
algorithms. Conversely, caution is needed when opening up systems due increasing the vulnerability to
“cyber-attacks
  Despite the reported successes of AI within cancer imaging, several limitations and hurdles must be
overcome before widespread clinical adoption. With the increasing demand for CT201 and MR202 imaging,
care providers are constantly generating large amounts of data. Standards, including the Picture Archiving
and Communication System (PACS) and the Digital Imaging and Communications in Medicine (DICOM), have
ensured that these data are organized for easy access and retrieval.

Clinical level
 The curation of medical data represents a major obstacle in developing automated clinical solutions, because
it requires trained professionals, making the process expensive in both time and cost.
 The training of radiologists is also set to change with the recent incorporation of AI into the national
curriculum.
 An openness from commercial companies to disclose the limitations of their algorithms and training
radiologists how to interpret these is vital.
 Conversely, whether the adoption of such technology will require radiologists to reach a higher level of
performance to keep ahead of AI, is subject to ongoing speculation.
 Although AI can detect incidental findings that may be clinically beneficial, these findings also may be
clinically irreverent and, if not carefully framed in the correct clinical context, may increase patient stress,
health care costs, and undesired side effects from treatment.

Governance level
 The legal accountability of algorithms has been at the forefront of healthcare professionals’ questions, as no
clear guidance has been produced
 Discussions around the use of AI alongside a radiologist point towards the ultimate responsibility lying with
the clinicians, but no specifics have been detailed as to how this would fit with NHS indemnity.
 Further guidance as to the accountability of the companies, reviews of “accidents” and “near misses” arising
from the use of AI should be included in department discrepancy meetings.

By harnessing new insights and benefits offered by AI and Machine Learning we can increase the precision of
healthcare information to enable a new world of prediction and analysis that sees the delivery of a new citizen focus
in the care that is delivered