Picking the Perfect PACS Displays

Advances in color viewing for certain modalities, such as MR and color Doppler ultrasound, are forcing hospitals and imaging centers to reconsider their PACS displays. On the monitor front, technology allows for greater longevity and less drift. The result is a wider selection, with the best options depending on an organization’s needs.

Displaying color

Radnet inc., a group of outpatient imaging centers in Maryland, New York, Florida, Delaware, and California, uses a wide assortment of image displays, says Mike Backof, director of clinical applications. They include about 35 sets of 5 megapixel (MP) greyscale monitors, about 30 sets of 3MP greyscale monitors, and about 60 sets of 2MP color monitors. Models include Planar PX212s, Planar Domes C3i and Barco 3MP Coronis, Barco MFGD5621 HD, and Totoku ME551i2. Recently, Radnet began purchasing monitors from U.S. Electronics (USEI).

Radnet started installing PACS in 2003, which required additional displays and diagnostic workstations. Some specialized workstations already existed, but “we certainly bought quite a few displays during the initial PACS installs.”

USEI helped Radnet set up five sets of 5MP monitors in just four days for a mammography workstation project. “We saw some discrepancies in the image quality of the mammography display on the IReadMammo software that we were testing while using the Totoku 5MP displays when comparing the images to [another] workstation,” Backof says. He hooked up the Barco monitors to the IReadMammo workstation so that both were running the same software and was able to verify that there was a difference in the image quality between the Barco and Totoku displays.

“It turns out that the Barco and Totoku 5MP are truly the same monitor glass and panel, but Barco uses a blue bulb to light the display of their mammography 5MP displays where Totoku uses a white bulb,” he explains. The blue bulb tends to mute the bright white in certain areas of the breast image and allows users to see more soft tissue information. “That makes general x-ray exams and mammography look really nice, but it makes ultrasound, MRI, and CT studies look less attractive than the white-bulbed monitor,” Backof says. Totoku also manufactures a 5MP display with a blue bulb, but it’s only sold overseas. USEI helped Radnet acquire those monitors from Japan. When we had a radiologist compare images on the blue-bulbed Totoku monitor to the blue-bulbed Barco monitor, the image quality was identical.”

Meanwhile, Radnet uses the 2MP color monitors for breast MR, ultrasound Doppler and other color-based studies. General x-ray is displayed on the 3 and 5MP monitors. “We build workstations that have two 2MP greyscale monitors and one color monitor for worklists.”

Three levels for displays

Allina Hospitals & Clinics is a not-for-profit system of hospitals, clinics and other care services throughout Minnesota and western Wisconsin. Before upgrading PACS in 2003, the system had several locally managed PACS. Now, those are centralized with 11 hospitals on one PACS and expansion to clinics underway.

According to Bruce Facile, systems administrator, Allina chose NEC Display Solutions’ 21-inch MultiSync LCD2190UXi 2 MP color systems in 2006, when the system made the transition from greyscale to color with diagnostic displays. Facile says the decision in switching to color displays came down to “mostly the requirements by the different modalities to display color.”

In the transition to PACS, Allina considered three levels for displays—diagnostic workstations, critical-care displays and those for reviewing images in physician offices. “Typically, diagnostic workstations get the most attention and highest end displays,” he says. But, “we try to use standardized workstations and displays. That makes it easier for us to support and manage.”

Ultrasound, MRI and even some of the workstations that do 3D reconstructions have been adding more and more color, he says. “You’ll see, in the near future, more and more consumer-level manufacturers producing high-bright color displays of excellent quality.”

Allina’s operating rooms use a combination of displays. “Some surgeons prefer large, 40-inch displays. But most use a combination of 21-inch color monitors. Those using interoperable MRIs use the NEC 2190, a 2MP color display.”

Allina uses 3MP grayscale monitors for CR and DR images. “We made the move from grayscale to color for the added information and flexibility for cardiac imaging,” Facile says.  “We like the image quality and the homogeneity of the brightness across the display—and of course, the cost,” he says.

Facile liked NEC’s uniform color, backlight stability and ease of calibration. The crosslight holds the calibration better over time, he says. “We’ve seen very little drift in NEC monitors.” Facile also likes the glass the company uses which is nonglare and provides very clear images.

Evaluating workflow

When the University of Virginia Medical Center in Charlottesville implemented PACS four years ago, they evaluated workflow to determine where monitors would best serve users’ needs. That helped prioritize the rollout of the displays purchased by Eizo. Initially, users could choose from monitors or film for a “gentle transition,” says David Roberts, senior application systems analyst.

Roberts was specifically hired to oversee the transition to filmless radiology. He and his team started with several of the facility’s clinics, including the cancer center and heart center. “We’ve placed more than 100 workstations in our outside clinics,” he says, which include low-intensity monitors since users are not doing comprehensive readings, but referrals. In the radiology department itself, depending on whether radiologists are viewing bone or chest films, they are using 5MP monochrome displays. They are starting to import 3MP color displays, too.

The applications team identified the clinics that were heavy film users and purchased high-intensity monitors to replace lightboxes in those areas, Roberts says.

“With so many different departments, we had to persuade the docs to buy into our way of thinking,” he says. Although they don’t want to go back to plain film, it’s been a difficult transition, Roberts says. By showing the physicians how much easier digital imaging is, with features such as manipulation to improve viewing of certain details, they realized the benefits they would gain.

Roberts has a four-person applications team that works on all radiology applications. “We also are working closely with IT to implement paperless workflow.” They are working on implementing electronic records so that orders go directly into the electronic system with no need for paper.

Prior to buying new displays, Roberts recommends talking to end-users around your facility to get to know what they need, and then do your homework. “Know what the systems offer. Scope out and evaluate user workflow. Don’t just assume what they need.”

For example, clinicians viewing multiple images or prior images may need more than one monitor. And while most users have 22-inch monitors, Roberts is in the process of deploying 47-inch dual displays in the operating rooms for scoliosis images.

Roberts says clinicians use 2MP low-luminescence monitors for clinical viewing. Normally, these are in outpatient clinics that non-radiology providers need to view the images. Within radiology reading rooms, the organization uses 5MP high-luminescence, monochrome monitors for bone, chest and mammography studies. “When viewing CT, ultrasound or MRI, normally we only provide 3MP, high-luminescence, color monitors,” he says. The high megapixel, high-luminescence monitors are required for diagnostic viewing and meet FDA requirements.”

In the future…

Eventually, Roberts plans to replace all grayscale monitors with color monitors. At this point, he says 3MP is the highest level of monitor, but it is not good for bone images so he’ll wait for further advances. That shouldn’t take long since the highest resolution just a couple of years ago was 2MP.

In the future, Backof expects to replace several 2MP displays. “We really didn’t get the longevity we wanted,” he says. The organization will probably go with medical-grade 2MP displays, even though they are pricier. But they also don’t require as much tinkering as far as brightness levels and other factors, he says.

Radnet is finalizing initiatives to put the remainder of its imaging centers live on digital x-ray. “That is easier to read on 3MP displays, so we’ll probably bump up some of the 2MP workstations,” Backof says. “That will require less tinkering with dome levels and you can really get the image up to a 1:1 display ratio relatively easily.”