Displays: The Complete Experience

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Planar Dome E4c

After a brief inspection, it becomes clear that not all displays are created equally. There are multiple options that seem similar with a cursory analysis; however, experience demonstrates that there are dramatic differences in workflow, efficiency, and ease of use among display systems and vendors. The same credo holds true for the deployment process.

Take for example Sky Ridge Medical Center. The new, 136-bed hospital on the outskirts of Denver, in Lone Tree, Colo., features a state-of-the-art reading room with three workstations outfitted with Domes’ C3i display systems. From initial setup to ongoing system management, Planar simplified IT and PACS management, says Tim Masters, PACS manager for Continental Division HCA of Denver. The streamlined experience begins before shipment with DICOM and calibration. The high-end shipping specifications translate into expedited deployment. Out-of-the-box configuration time on the Dome display solutions was minimal, says Masters. He used Planar’s Dome CXtra software to verify calibration and backlight and right light thresholds, and radiologists at the new hospital were up and running in the digital world. Planar further improved the display setup experience when it launched Dome Dashboard remote management software.

Entering the remote management world

Lahey Clinic, a three-site system in Massachusetts, relies on Dome Dashboard to manage more than 100 Dome display systems. “A single computer provides a remote view of all the displays,” explains John Weiser, PhD, medical physicist with Qualiteering Labs in Thurmont, Md. Each display is identified by serial number, and Dome Dashboard simplifies monitor management by checking calibration and brightness levels and alerting the PACS administrator of issues that might interfere with consistent image quality. The enterprise management system allows IT staff to troubleshoot problems remotely, a significant benefit in a three-site enterprise. If a hospital has a large enough installed base, enterprise management can be a significant workflow boost, says Weiser.

The Right Questions to Ask
PACS workstation buyers face an ever-widening array of choices. It’s possible to purchase the hardware and software separately or deploy a bundled solution from the PACS vendor. Buyers can dabble in commercial monitors or invest in color display systems. Then there are the questions of size and resolution. Other issues center on brightness and contrast ratio. Options run the gamut, but budgets are tight. “At $12,000 to $14,000, each workstation is a tremendous capital expense. It’s important to invest wisely and find the product and partner that best meets the site’s needs,” states Tim Masters, PACS manager for Continental Division HCA of Denver.

Masters prefers to purchase hardware and software from a single source. “I want all-inclusive, one-stop shopping. That way, there’s one phone call for support and no finger pointing,” he rationalizes. In those cases, it’s key to find a provider that markets high-quality hardware and software. Some facilities fall into the trap of accepting whatever hardware the PACS vendor supplies without understanding the technology or comparing various display solutions.

On the other end of the spectrum are the customers who purchase hardware and software separately. This allows the site to construct optimized workstations ... after it completes its homework.

Regardless of the approach, workflow rules. “It’s important to consider the integration of the enterprise and how the display can support or negate workflow,” explains Masters.

The first step in the display workflow process is initial setup. With setup times exceeding 45 minutes per system, it’s important to find a solution that streamlines the process.

Questions to ask include:

  • Is the display DICOM out of the box?
  • How long will it take to configure each display?

Another piece of the puzzle is service and support. The site needs to evaluate vendor and OEM support and consider lifetime support. “Make sure the vendor can support the display through the end of its life,” says Masters. Another variable in the total cost of operation equation is how the vendor handles display failure. Sky Ridge Medical Center just outside Denver and part of the Continental Division of HCA, for example, does not maintain a ‘hot spare,’ which makes it difficult to appease a radiologist if a system fails. “They want a replacement in 15 minutes. Planar will overnight a system if that happens,” notes Masters. 

Be sure to ask:

  • How long are displays supported?
  • What are the expected maintenance costs over the life of the display?
  • What happens when a system fails?
  • What are the replacement and overnight options?
Another major set of questions center on calibration capability. With the increasing, price-driven acceptance of commercial display options it becomes even more important to investigate calibration. It is possible to try to force a commercial display into DICOM calibration with third-party calibration software, but commercial systems include only 256 shades of gray. Inevitably some of those shades fall off the DICOM curve; usually the software adjusts and meets the curve at 18 points. This fit, however, is less than ideal; and the off-the-shelf system tends to lose gray shades in the dark range. Medical grade vendors like Planar employ spatial and temporal modulation techniques to create a much broader grayscale palette, enabling the system to map all 256 shades of gray onto the DICOM curve for an exact match.

The calibration issue affects workflow and efficiency on several fronts, which impacts total cost. Commercial systems require a significant amount of wrangling and ongoing human intervention to reach imperfect DICOM calibration. A medical grade display system with remote QA abilities, however, requires minimal IT intervention and supports reading efficiency. Buyers also should consider how systems balance brightness and contrast ratio. The higher brightness of new color systems is driving acceptance among radiologist; however, brightness and contrast ratio should be linked. That is, the monitor’s contrast should be high enough to support the high brightness; the display should not sacrifice contrast for brightness. The ideal solution maintains high brightness and contrast ratio sufficient to meet the demands of medical image interpretation.

During the display evaluation process a side-by-side comparison is an excellent idea. John Weiser, PhD, medical physicist for Qualiteering Labs in Thurmont, Md., encourages hospitals to ask tough questions during the evaluation process. 

Some of the tough questions that hospitals tend to overlook include:

  • How is brightness reported? “The display won’t be operated at maximum brightness from day one,” notes Weiser. It’s important to understand the recommended operating brightness for a calibrated monitor, says Weiser. 
  • What is the expected lifetime of the backlight with normal use? “This is especially important with color as it’s not as bright as grayscale,” says Weiser. 
  • How is the contrast ratio determined? Is it determined with brightness at the maximum or at the recommended operating brightness on a calibrated display? “How this is measured will make a difference in the contrast ratio,” explains Weiser.
Doing the homework and asking the right questions pays off. When a hospital deploys the right display systems it will tap into that nebulous nirvana where radiologists are happy and reading efficiently and IT is not overburdened by multiple, ongoing glitches and problems.