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Radiology reading room design: The next generation

Eliot Siegel, MD and Bruce Reiner, MD

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n the current era of dwindling reimbursement, undersupply of diagnostic radiologists, and increasing volume of studies, imaging departments are asking radiologists to interpret more studies than ever before. The use of picture archival and communication systems (PACS) has resulted in
Dr. Siegel is the Director of Imaging at the VA Maryland Healthcare System (VAMHCS) and an Associate Professor at the University of Maryland School of Medicine; Dr. Reiner is the Director of Radiology Research at VAMHCS and an Associate Professor at the University of Maryland School of Medicine, Baltimore, MD.

improved departmental efficiency in most cases, especially when associated with the re-engineering of departmental workflow. Technological development, such as improved network infrastructure and speed, faster workstations with more reliable and brighter monitors, improved image presentation and navigation software, image enhancement, computer-aided diagnosis, and integrated speech recognition have received a good deal of attention in the research community as candidates for improved radiologist efficiency and productivity. However, surprisingly little attention has been paid to the potential of improvements in radiology reading room design as a means to enhance

the performance of radiologists.1 Experience and research performed at our facility, the Baltimore VA Medical Center, suggest that relatively small investments in room design and workstation ergonomics can result in major gains in productivity and accuracy with a concomitant decrease in radiologist fatigue. The Baltimore VA Medical Center opened in 1993 as a replacement facility for an older hospital previously located in the northern part of the city. Although the hospital was designed originally as a high-technology replacement medical center with an emphasis on the infrastructure to support digital imaging and a paperless electronic medical record, the concept of filmless

April 2002

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However.6 examinations to 1 in 42 (and has continued to decrease since we published the study).appliedradiology. This change has also been confirmed by other facilities with FIGURE 1. The room was located adjacent to a large area designated as the “file room. 45 40 35 30 25 20 15 10 5 0 Baltimore '93 Film Baltimore '96 Filmless 42. how not to design a filmless reading room. soft-copy reading environment. 12 I APPLIED RADIOLOGY © www. perhaps more importantly. as shown in figure 2. in-person consultations has also altered the requirements for a central congregating place for clinicians and consultations.” This design was modeled after most “general read” areas in other imaging departments (figure 1). a large central reading room for general radiography is no longer necessary.1 7. No partitions were used to isolate the radiologists from each other since glare from overhead lights or adjacent view boxes is typically not a problem in a conventional reading room.2 In our department. since images are available or can be retrieved to any location on the PACS network. the consultation rate for general radiographic examinations fell from 1 consultation per 7. A large central reading room is typically necessary in a film-based environment to accommodate not only the radiologists interpreting films but also the film room carts brought with batches of studies to be interpreted and the many clinicians who “round” in the radiology reading room using light boxes or film alternators. The government rules concerning hospital design and construction precluded “last-minute” changes to the departmental or reading room design.com April 2002 .5 years. The other traditional reason for a large central reading area was to serve as a central location for radiographic consultations with the clinicians.5 Studies Per Consult FIGURE 2. The easy access to PACS workstations throughout the hospital has resulted in a dramatic decrease in the frequency of “in-person” clinician consultations in radiology from 1 in 7. operation came relatively late in the planning phase for the facility. Our experience has allowed us to share with visitors and others how to and.1 for conventional radiography. However. despite the fact that we knew that we were purchasing an enterprise-wide PACS for a conventionally designed department. Radiologists can read from any location in the department or potentially anywhere in the hospital (or outpatient center).Room layout The initial design for the radiologist reading room called for a single large reading area with workstations for four or five radiologists to interpret primarily the conventional radiographic studies performed in the department. The reading room at the Baltimore VA Medical Center was designed originally for a conventional.5 to 1 in 42. This resulted in the need to place 5 four-monitor diagnostic imaging workstations in a reading room that was originally intended for film. Our PACS has been in operation for almost 9 years and radiologists have been reading using soft-copy interpretation for the past 8. this dramatic decrease in one-on-one. in a filmless. film-based operation. It serves as a “poster child” for an improperly designed filmless reading environment. This means that we have the dubious distinction of having more experience not only with soft-copy interpretation but also with the consequences of a poor PACS reading room design than any other facility in the United States.

Fatigue levels increased significantly as the ambient room light levels increased from off.com APPLIED RADIOLOGY © I 13 .000 foot lamberts. Room lighting Background room lighting. and the fact that films from outside institutions are infrequently submitted for evaluation. Number of Monitors FIGURE 3. Other studies performed in our reading room have documented that ambient room lighting is also very important in radiologist performance. As the number of consultations has decreased. and increased fatigue levels were seen when using monitors that were less bright when compared with those with higher luminance. or via fast report turnaround times. Fortunately. report turnaround has dropped considerably. annotation of images by radiologists. consultations are much more likely to take place via phone. This is due to the very low levels of light associated with a typical highresolution 5 megapixel (2. are often interpreted prior to the patient returning to the emergency room from the radiology department. to completely on (using overhead fluorescent lights). As was the case with decreased monitor lumi- 70% 60% 50% 40% 30% 20% 10% 0% Low Fatigue Medium Fatigue High Fatigue Off Half On Full On FIGURE 4. Radiologist interpretation times dropped substantially when using two rather than one monitor. for example. there is even less need for a large. to half-on. centralized reading room. which was thought to be relatively unimportant in the original design for a filmbased reading area. our research has demonstrated that the use of two-monitor workstations results in comparable radiologist efficiency when compared with a four-monitor configuration (figure 3). the radiology report itself. We have performed studies previously that have documented the importance of an optimal balance between monitor light and background ambient room lighting. For example.500 pixel) PACS monitor. but they can be very helpful in reducing unwanted glare and noise in a filmless room since clinicians visit less often. April 2002 www. This figure is approximately 1/10 of the light that is associated with conventional lightboxes. the use of window/level workstation tools increased from 45% to 72% to 91% as the background light levels in our reading room changed from off.000 by 2. becomes critically important in a soft-copy environment. Our current reading room environment is still a hybrid that features both light boxes for film and PACS workstations for soft-copy interpretation for each radiologist. decreased accuracy. but there was only a minimal improvement when using four monitors. Our new room design will include only a single viewbox to be shared by all radiologists. Consequently. and our radiologists who interpret conventional radiographic images prefer four monitors. In a soft-copy reading environment. becomes the means of communication of the imaging findings.100 80 60 Seconds 40 20 0 1 2 3 Although we originally utilized four-monitor workstations to emulate film alternators more closely.appliedradiology. to the point where studies from the ER. filmless imaging departments. to half on. rather than an “in-person” consultation. Fatigue levels increased dramatically as background light levels increased as well (figure 4).3 Decreased radiologist productivity (increased interpretation times). This is despite the fact that old films from our own hospital are never reviewed now that we have been filmless for almost 9 years. e-mail. to full-on. which can range between 500 and 1. which has an output typically in the range of 60 to 70 foot-lamberts. Room partitions may be unwieldy for clinician traffic in a conventional radiology department.

digital dictation. freeing radiologists (as was the case decades ago with developments in fluoroscopy equipment) from the constraint of reading “in the dark. But this solution is a very poor substitute for adequate individual task lighting. coupled with the lack of true task lighting in our reading room.nance. These lights have on/off switches located near the entrance to the room and cannot be dimmed or individually controlled by the radiologists. often hung upside down or sideways. The radiologists place old films. Additional lighting is provided by conventional light boxes that were originally intended for film display prior to the implementation of the PACS. Abe Obuchowski. active-matrix LCD displays is likely to permit radiologists to once again increase the background lighting levels in reading rooms. Dr. must have access to the PACS workstation. small cursor size. a combination of indirect overhead lighting and local task lighting. and temperatures exceeded 100 degrees Fahrenheit when the door to the reading area was closed. in some cases. and Microsoft Office (Redmond. redesigned reading 14 I APPLIED RADIOLOGY © www. view. using dimmable sources. and the more active role required for image manipulation. Monitor life expectancy at that time (due to a combination of increased temperature and inherently unreliable first-generation PACS monitors) was a surprisingly short 3 months and radiologists’ coffee break frequency and duration soared until additional air conditioning capacity was installed. Director of Neuroradiology at the Baltimore VA Medical Center. Radiologists who are already subject to increased fatigue as a result of the transition to soft-copy interpretation may be even more vulnerable to the effects of increased heat and poor ventilation. Our plans for the new. A number of sites have repainted the walls of the reading room with dark colors in an attempt to further reduce reflected light from the walls. We are not aware of any studies that suggest a specific color or color combination to reduce fatigue and improve productivity in a radiology reading room. The use of newer generation.appliedradiology. Moveable partitions can be helpful to further fine-tune the control of local and general lighting (as well as to reduce ambient noise levels). on the light boxes. WA) programs. the electronic medical record. higher brightness. When the Baltimore VA PACS first became operational in the summer of 1993. the Internet and Intranet. Other factors that might have contributed to the increased fatigue are monitor flicker.” The lighting in our radiology reading room currently uses overhead industrial-type fluorescent fixtures that are comparable in brightness to the film viewboxes. 2) illumination for reading tasks using localized light sources. Improved air handling is especially important. 3) balance of brightness levels in the user’s field of FIGURE 5. it is important to remember four primary objectives in the radiology reading environment: 1) general illumination levels for computer tasks. can be used to provide maximum flexibility for each radiologist. higher ambient light levels were also associated with significantly decreased interpretation accuracy. e-mail. Our experience underscores the importance of adequate planning for air conditioning and ventilation in the reading rooms.com April 2002 . Temperature and ventilation The contribution of improved air conditioning and individual temperature and ventilation controls is typically underestimated in the design of filmless radiology reading environments. which results in a modicum of light for the radiologists. In order to improve ambient lighting. we quickly discovered that the reading room air conditioning and ventilation systems were overwhelmed. In order to accomplish these objectives. and 4) control of monitor reflection. The suboptimal brightness of the early PACS monitors. These studies underscore the importance of striking a balance between ambient room lighting and monitor brightness. has resulted in an increase in the number of complaints of eyestrain and fatigue comparison with that expected in a film-based environment. due to the high heat output of high-resolution computer monitors and workstations and because of the greater sensitivity of the PACS equipment to temperature and humidity than film and film-based viewboxes.

FIGURE 6. will ameliorate some of these problems. Despite the fact that our corporate counterparts have documented the importance of optimizing the ergonomic design of the workstation user. Although one-onone consultations have decreased considerably. room include not only better individual control of local and general lighting. although we have not yet rigorously tested this in our laboratory or reading room. the Baltimore VA has soft-copy reading areas in other locations in the department. mouse. the Internet and Intranet. a speech-recognition or digital-dictation system. we believe background noise can have an adverse effect on radiologist fatigue and productivity. the radiology literature has paid scant attention to the importance of this in reading room design. which is used primarily for the interpretation of conventional radiographs (computed radiography. and ventilation. The radiologist’s chair. we quickly learned that computer workstations generate a good deal of background noise that can be distracting during image interpretation and dictation. Emergency Room physician. digital radiography. Thomas Stair. large reading space without carpeting or other sound-absorbing partitions. keyboard. The architectural literature makes specific recommendations concerning optimal viewing angle and distance for computer monitors. or other radiologists dictating in the same room. office software (such as word processing). the hospital “paperless” electronic medical record.com APPLIED RADIOLOGY © I 15 . In a single. and an inadequate chair and table. After we made the transition to a softcopy department. overhead hospital paging system. e-mail. neuroradiology. Other reading environments within and outside the radiology department In addition to the main reading room. often with limited ability to control room lighting. it becomes April 2002 www. workstation table. We believe that the use of acoustic dampening materials. The recent. or even active sound cancellation has not been documented adequately in the radiology literature and these are consequently interesting avenues of future research in our laboratory. Dr. but also individual ventilation controls similar to those available in most automobiles. and fluoroscopy). partial introduction of speech-recognition systems in our department has made us much more aware of distracting background sounds such as a noisy ventilation fan. the phone. telephone communications with clinicians have increased. increasingly evident that these systems must be integrated. We believe that a small expenditure in improved air handling will result in improvements in productivity and decreased fatigue. Radiologists at the Baltimore VA currently require access to the PACS workstation. noise. and monitors should be designed to maximize comfort and efficiency. We plan to attempt to quantify the effect of background noise on radiologist performance in future studies. cross-sectional imaging. and nuclear medicine. white noise. These functions should be able to run on a single multitasking workstation that should be designed to allow easy access to all of the features on demand. cramped space. such as angiography.appliedradiology. Each of these locations has its own unique challenges with regard to lighting and sound depending on its proximity to other working areas in the department. is pictured with a PACS workstation located in a typical physician workroom with poorly designed overhead fluorescent lights. Integration of information systems and ergonomic workstation design As the hospital moves toward an electronic medical record and radiologists become increasingly reliant on computer information systems and other electronic systems. The impact of background music. and the telephone (figure 5). all of which can decrease the accuracy of these systems.1 A large body of literature exists regarding airplane cockpit design that clearly documents the importance of ergonomic factors. such as carpets and sound-absorbing panels. Sound Another key factor that was not considered in the initial reading room design was the impact of ambient noise.

will require additional technologic developments such as a radiofrequency-controlled identification card that can automatically sign users onto and off of a PACS workstation in a relatively “public” location. Rostenberg B. restricted physical access to these workstations. it becomes apparent that these environments are even more difficult to control (figure 6). Hooper F.173:1169-1172. 2. acoustics. 16 I APPLIED RADIOLOGY © www. Surprisingly.appliedradiology. increased diagnostic accuracy. 3. The Architecture of Imaging. Variation of monitor luminance on radiologist productivity in the interpretation of skeletal radiographs using a picture archiving and communication system. one of our PACS workstations is located in the admitting area of the emergency department where lighting and sound are clearly impossible to control as is true. Reiner B. but also our reading environments. As some radiology departments are considering relocating from the imaging department to a more distributed model with radiologists located in the trauma areas or intensive care units. 1997. Reiner B.. and the operating rooms. In our opinion. In these areas.10(3 Suppl 1):176.As we move outside the imaging department to workstations located in the emergency department. these background sound and lighting concerns become more important. For example. Acknowledgment The Baltimore VA Medical Center Department of Diagnostic Imaging gratefully acknowledges the partial support of our work by General Electric Medical Systems (Milwaukee. et al. optimization of workstation ergonomics. of the operating rooms and the intensive care units. J Digital Imaging. Chicago: American Hospital Publishing. 1999. We have performed a study that has documented large variations in background sound (both average and instantaneous) in the numerous areas throughout the hospi- tal that have PACS workstations. which will be mandated under the HIPAA regulations. Siegel E. AJR Am J Roentgenol. increased productivity. filmless environment presents us with the opportunity to redesign not only our workflow. Inc. and possibly increased job satisfaction. and alternative display devices. Impact of filmless radiology on frequency of clinician consultations with radiologists. this redesign is likely to result in substantial improvements in radiologist performance resulting in reduction of fatigue. the intensive care units. Conclusion The transition from a film-based to a soft-copy. AR REFERENCES 1. ventilation. Siegel E. of course. et al. this opportunity has received little attention in the diagnostic imaging literature and presents the radiology research community with fertile grounds for future investigation. Protopapas Z.com April 2002 . WI) who have provided us with a research grant to design and implement a second-generation PACS reading room to test the impact of various environmental factors such as lighting. 1995.