A little bit of science and a whole lot of creativity merge in putting together the perfect soft-copy reading room - whether new or retrofitted - which includes optimizing everything from lighting, ergonomics and acoustics to network connectivity and room size and design itself.
Going digital in radiology is a step in the right direction for greater department, facility and enterprise productivity - as long as that switch to soft-copy reading involves a carefully orchestrated re-do of the conventional reading room. Recent studies have concluded the same thing - radiologists will not benefit from soft-copy reading on picture archiving and communications systems (PACS) unless the environment is conducive to efficient soft-copy interpretation. Thus, specific design elements must be implemented in a hospital's PACS strategy to maximize its investment and smooth the journey to a digital reality.
"One of the huge things a lot of people lose sight of is you really want to make the PACS reading area as comfortable as possible so the radiologist is encouraged to stay within that space," says Ken Johnson, president of Kenneth Johnson and Associates Inc., a medical imaging consultancy company in Columbus, Ohio.
That "space" is usually occupied by radiologists for more than eight hours at a time. End-user performance will not improve unless space, lighting, acoustics, heating and cooling, furniture and workstation ergonomics and scalability are factored into the reading environment.
Design guidelines for PACS were a bit slow to catch on in radiology. "When we switched to the electronic era, one of the things we knew was that we were moving into an era where productivity was going to be higher," says Mukeesh Harisinghani, MD, an assistant professor of radiology at Massachusetts General Hospital. "Originally, the department did not focus on ergonomics, and just replaced the alternators with digital workstations. That's not the way to do it."
As anyone who has installed PACS knows, workflow in the analog world does not translate to effective workflow in a digital world. MGH realized this and has since initiated a redesign project that generalizes their efforts to the end user. Some changes were implemented immediately, says Harisinghani, while others have required more time.
Time is a factor in PACS installations since the system is most effectively implemented in a phased approach. As a result, reading rooms become hybrid environments of digital displays and lightboxes. "Think of the reading room as evolving in a number of phases," says Bill Rostenberg, FAIA, FACHA, principal of Ashen + Allen Architects of San Francisco, Calif. "Therefore, think about the space as something that needs to change over time. Do not build fixed-in casework but instead use movable, adjustable computer design furniture. It will make it easier to pull the alternators out and move closer to an entirely soft-copy reading environment."
ROOM TO RENOVATE
Filmless environments require a sufficient amount of planning, especially in terms of using space. Space is one of the cost-defining elements of PACS, since not every analog reading device needs to be replaced with a digital workstation.
The most common scenario is introducing PACS into an existing infrastructure. Too large of a reading room is not good, says Rostenberg, and the same goes for "tiny phone booth" cubicles. When Children's Memorial Hospital in Chicago went filmless, they divided their large ballroom-size reading area into two smaller rooms with the addition of a wall. Minimally, the room or workspace should measure 80 square feet, Rostenberg says.
Space - and how it is used - factors into the professional needs of the radiologists. "When dealing with the enclosure, there is an inherent contradiction that surrounds the needs of the reading room - privacy and containment," poses Rostenberg. While at the same time needing privacy for patient confidentiality, there is need for intense collaboration amongst radiologists and specialists. It is challenging to create an environment that is inherently quiet, but collaboration-friendly. Rather than positioning workstations around the perimeter of the room, newer designs position monitors in the center of the room, separated by sound-proofing partitions.
Some reading rooms require additional space. "In many cases, you can shut down some existing rooms and create some additional space," explains Johnson. "Hospitals may have a majority of reading rooms congregated in one area. But there also should be some reading rooms distributed in other areas. If [the radiologists] are going to be spending a lot of time in the CT or ultrasound area and that's far away from the main reading room, then there should be a sub-reading room in that area. Another piece of advice is to have a high productivity area - one reading room that is your high-volume room where a radiologist can read for hours straight and get a ton of work done."
Lighting is the most integral element in soft-copy reading room design because, if done poorly, it can increase fatigue and jeopardize productivity. New research suggests that the ambient lighting of a reading room be equal to the lighting level of the display. Conventional lightboxes are 500 to 1,000 foot lamberts, while PACS monitor light sources can be as low as 65 foot lamberts.
Balancing the levels of brightness is done best by equipping reading rooms with a combination of built-in pot (recessed) lighting, adjustable indirect overhead lighting and local task lighting. "To prevent eye fatigue, you should avoid sharp contrast," explains Rostenberg. "You don't want to be looking at a bright monitor with a dark background, nor do you want to look at a bright monitor with a bright background."
"The architect needs to consider both the functional needs of low level illumination during reading, occasional high levels of illumination during clean up and code requirements for exiting in the case of an emergency," adds Rostenberg.
Suzanne Devine, director of medical informatics at the Children's Memorial Hospital in Chicago, says they installed indirect lighting with dimmer controls so the radiologists can adjust the illumination level. Dimmers within close proximity to the workstations are necessary because they do not limit radiologists to on/off fixtures. Devine also says that each workstation is equipped with its own individual reading light. Filmless does not mean paperless - so radiologists require a movable, adjustable and highly focused source of light that does not interfere with surrounding workstations.
Additional methods that help eliminate excess glare on the monitors are non-reflective finishes on the walls and workstation surfaces. Lightboxes, when necessary to include, can either be placed at each individual workstation, in a designated area of the reading room or outside in the hallway.
Shawn McKenzie, senior clinical PACS advisor at Sutter Health, a network of not-for-profit hospitals and physicians organizations in Northern California, suggests creative lighting techniques, such as adjustable canned lighting or a baffled lighting system that comes out of the back of the workstation and reflects upward off of the wall.
NOISE & TEMPERATURE
Soft-copy reading environments are typically quieter than hard-copy reading environments. At the same time, Rostenberg points out that you do not want the room to be too quiet because conversations then become very distracting. Designers can remedy the problem by placing on walls sound dampers, such as carpet, or sound-absorbing panels around each workstation.
Johnson suggests the use of movable partitions to allow flexibility to change the room in the future, as opposed to being locked into rigid fixtures. "You want to maintain flexibility to move things around in the room as technology changes," poses Johnson.
Your PACS also may include the integration of a voice recognition system, for which noise becomes even more of an issue to manage. The sound panels will help minimize extraneous noise, and help with privacy, and ensure the accuracy of the dictation system.
Radiology is naturally a consultative profession and the noise created by physicians, radiologists and residents as they converse over studies is inevitable. While you can't eliminate noise, you can control it. Chicago Children's Hospital installed sliding glass doors so physicians can consult in the hallway. Johnson suggests a "concierge" stand in the reading room to handle requests of physicians and other individuals entering the room. Shore Memorial Hospital in Somers Point, N.J., posted privacy signs outside the reading room to reduce traffic. "I like to build an anti-room, if possible," says Sutter Health's McKenzie, "a small room prior to the reading area that can be used for consultative purposes."
Another important component is temperature control and ventilation. High intensity monitors emit heat (although LCDs emit less than CRTs), so it is important to keep room temperature as comfortable as possible. Some projects may call for an entirely new heating and cooling system. Such was the case at Chicago Children's hospital where both CRTs and LCDs are used. Devine says the radiologists now keep the thermostat about 68 degrees. Johnson includes that ventilation must be addressed because monitors and computers can be sensitive to dust buildup.
Room design and workstation ergonomics go hand-in-hand. Since radiologists spend prolonged periods of time at their workstations, it is important to maximize comfort and efficiency. Ergonomics in the reading room include the configuration of the monitors (most often two, three or four monitors), the relationship between the readers' eyes and the monitor, the relationship between the hands and the keyboard and the relation of the body and the seat.
"The thing to keep in mind most [in design] is that a reading workstation is likely to be shared by multiple people over the course of a day or a week," says Rostenberg. "Each of those people will be a different size and age and have different visual abilities. You need a range of adjustability."
Adjustability was integral to the redesign efforts at Montefiore Health System in the Bronx. According to Nogah Haramati, MD, chief of radiology at Montefiore's Jack D. Weiler Hospital, specific criteria were developed for the workstation before they turned to AFC Industries Inc. for technical input and engineering support. Their main objective was preventing musculoskeletal disorders and eye strain.
"We decided that the desk had to be height adjustable for short and tall people," explains Haramati. "They had to be adjustable for people who had difficulty seeing at a distance. The monitors needed to be able to move either closer to or further from the radiologist. Also they had to be angled above or below the individual's eye line depending on their visual issues or neck conditions. We also wanted the radiologists to get up and stretch and not always have to work while sitting by raising the keyboard level as well as writing surfaces."
Workstation ergonomics also entail how well table space is used - which depends on how equipment and systems are arranged. To reduce glare, monitors should be configured so that they do not oppose one another or doorways. They also should be at least 25-inches from the reader's eyes. Devices used frequently should be placed in closest proximity, such as the mouse and telephone system. Mousepads with wrist guards and wireless devices will also ward off ergonomic and connectivity issues.
And don't forget to be creative. Sutter Health's McKenzie, says desk space is "prime real-estate" and uses mounting systems from Ergotron Inc. to get the monitors up off the table.
Perhaps the best way to build an ergonomic workstation is to create a mock-up of the workstation so that radiologists can first test it before they have to use it everyday.
What about the chairs? "We came up with criteria for optimal chairs in this environment that specifically support the thighs, calves, lower back, upper back, adjustability and fit," says Haramati. Comfortable chairs are height adjustable with large rollers and lumbar support, have a unique cushion design, and adjustable arms.
BUILD A USER-FRIENDLY SPACE... AND THEY WILL COME
Hospitals may not gain acceptance for PACS if the design of the reading room is not conducive to comfortable soft-copy interpretation. Shore Memorial Hospital tried on two occasions to go filmless in the emergency room but neglected to create a reading environment for PACS. Both projects were unsuccessful due to lack of system-user integration. "We needed to create an area where people respected the space," says Elliot Vazquez, administrative director of radiology. Prior to Vazquez's redesign efforts, the reading room was a bright, loud and disruptive environment, impeding PACS integration.
Recent efforts have included extensive research on the layout of soft-copy design and end-user advisory. "You have to understand the radiologists' wants and needs," explains Vazquez. "And we have learned as we go along. We gave in to [their requests] because we wanted them to feel more comfortable in their workspace."
A Guide to Ergonomics
Sitting at an ergonomically designed workstation will ensure comfort and reduce related injuries. Fundamental to the design is adjustability, since workstations are typically shared. Radiologists or other specialists should be able to adjust desk, elbow and seat height so that eye height is level with the top of the monitor, elbow height is level with the top of the keyboard and seat height is adjusted so the back is comfortably supported and feet are flat on the floor.
By raising the keyboard level so radiologists can interpret images while standing, it can help to reduce monotonous, sedentary working conditions. Eye height and elbow height should be adjusted to meet the above seated requirements.
Traits of the Ideal Reading Room
While retrofitting an existing room for soft-copy image reading is usually the case, there is near infinite flexibility in sculpting the perfect digital reading room from the ground up (depending on resources, of course). Bill Rostenberg, FAIA, FACHA, principal of Ashen + Allen Architects, explains the elements of an ideal reading room environment.
"Even for a renovation, I think it is good to aim for the ideal and then work backward based on the limitations that you have if you can not achieve the ideal," he adds.
Rostenberg says two to four workstations in each room is ideal. "For a larger group of radiologists, a couple of rooms can be placed near each other with a small conference area between them."
"In an ideal world, there would be an evenly distributed level of illumination across the ceiling surface. From an indirect lighting perspective, you should have a ceiling height higher than average - 9.5-feet or higher - and hang light fixtures at least 7-feet high."
He highlights a number of rudimentary elements, including carpeting, acoustic-dampening ceiling material, applied wall coverings that are sound absorbent and acoustic partitions surrounding each workstation. "From an acoustic perspective, it is ideally nice to have a lowered ceiling with sound control."
Heating & cooling
"Individualized air volume and temperature control at each workstation are preferred."
He predicts that in the future there will be commercially available ergonomically designed prototypes specifically for digital radiology environments.
"Sometimes you run across nicely designed reading rooms where everything has been addressed properly, but not connectivity. When you actually equip it with monitors, computers and telephones, it's a literal jungle of wires and cables. You can have a conduit drop from the ceiling to the center of the workstation or floor-mounted reciprocals and the power, data and telephone reciprocals integrated into the workstation itself." Wireless devices also will help rid the room of unnecessary wires.