Dream Reading Rooms Require Team Effort

Reading images, Terence Matalon, MD, chair of the Department of Radiology at Albert Einstein Medical Center  in Philadelphia, stands at his Biomorph interactive desk, while two colleagues sit at a Biomorph desk.Dynamic changes in radiology from film-based practice to PACS has necessitated transformational shifts in the reading environment. It started with big picture items: lighting, sound, overall room configuration and has now moved into the arena of individual workstation design that includes furniture and displays taking center stage.

The importance of these issues cannot be denied, because de-veloping an appropriate setting for reading electronic images impacts the efficiency and effectiveness of radiologists while protecting their health through ergonomic design.

The scarcity of radiologists combined with increased complexity of studies and exponential rise in workload added to the usual imperative for accuracy has placed overwhelming demands on stretched-thin radiology departments. Ergonomic research has revealed that repetitive stress injuries as well as fatigue are potential hazards to new workflow design unless departments are cognizant of necessary environmental changes. 

These issues were raised first in looking at the total environment of the reading room that includes issues of lighting, sound reduction, temperature regulation and utilization of workspace. Often the new radiology suite is located where film-based practice was previously conducted, and that fact alone may involve challenges that must be met.

The big picture

A trailblazer of ergonomic considerations in radiology reading rooms, Eliot Siegel, MD, professor and vice-chair of the Diagnostic Radiology Department at the University of Maryland School of Medicine and chief of imaging for the VA Maryland Healthcare System in Baltimore, describes the challenges they faced secondary to the physical location of their new reading room. On one side of the radiology department, an MR scanner was installed, another side features a busy corridor and a third involves a patient waiting room where public restrooms are currently being installed.

Obviously, sound reduction gained paramount importance as this convergence of circumstances impacted their re-designed reading room of the future that opened late last year. Siegel explains that, especially with the MR scanner next door, they needed to create an environment that is as quiet as possible because they are using speech recognition. Extraneous noises may be recognized as small words such as “ah” or “the” and placed in the report in error.

To meet this challenge, they added acoustic baffles to sound-absorbing material on the walls, ceilings and in the corners to minimize internal reflection of noise. They increased the insulation on the walls in a room that already featured noise-reducing materials on the floor, walls and ceiling. 

“One of the technologies we’re using is a system that generates background noise that is in a frequency range that approximates the sound of the human voice, which is similar to the noise that the MR scanner generates,” Siegel explains. “When you walk into the room, you don’t even notice it, or if you notice anything, it sounds like you are hearing a heating system or air system.”  He says it is quite effective in masking not only extraneous sound, but also the noise of radiologists dictating and does not interfere with the dictation system.

The entire reading room is 532 square feet, which is relatively small, but Siegel describes that with clever planning, partitioning and lighting, their interior design team was able to help the individual radiologists’ 10’X10’ work space seem larger. LCD glass partitions between the work spaces are activated with the same computer icon that controls individual lighting. The radiologist can make the glass surrounding the workstation transparent or opaque. They usually leave it clear if they don’t mind someone coming in to speak with them, but if they don’t want to be interrupted, they make it opaque.

In terms of overall lighting, this group recommends achieving a balance by matching ambient room light with monitor light as a means to reduce eye strain. One of their research projects revealed that without this critical balance, 80 percent of the cases they read were required to use window/level functionality. But when the room light matched the brightness of the monitors, they only had to window/level 40 percent of the time. Another study showed that the percentage of radiologists who complained of a high level of fatigue dropped from 50 percent to zero when the room light matched monitor brightness. The finding that concerned them most was the study that revealed that diagnostic accuracy rate dropped by 11 percent when the ambient light was too high.

Planning a re-design

When launching into a reading room, redesign experts suggest an assessment of the working culture of the radiologists involved. Do they prefer to work undisturbed and in isolation or like a more collegial interactive style? 

Larry Schwartz, MD, vice chair of radiology at Memorial Sloan Kettering Cancer Center in New York explains that they have many different reading rooms, each configured for different purposes.  Their PACS reading stations were constructed from existing reading rooms, maintaining the historical practices of their old reading room where studies would be read in a particular location. 

At the main hospital campus, they have six reading rooms which accommodate between one and seven workstations apiece. Throughout their re-design process, they consciously built in as much flexibility as possible as they considered lighting, heat generation, sound, voice and distractions based on entry points into reading areas. They factored in distance between workstations, with half-height walls between stations in addition to ergonomic principles for each workstation. Because this is a major academic center, they had to arrange the final areas to allow more than one person to view images at a time.

The 392-square-foot redesigned reading room at Philadelphia’s Albert Einstein Medical Center prior to the installation of Planar Dome E4c displays. Terence Matalon, MD, FACR, FSIR, chair of the Department of Radiology at Albert Einstein Medical Center in Philadelphia describes their large rectangular room where they read approximately 270,000 imaging studies each year. The reading room is organized both by organ system and modality. For example, one area is used for computed radiography or plain radiography of all body parts, the neuro section includes both CT and MR of the brain and spine, while another area is for body MR and musculoskeletal studies.

All of the lighting is indirect, designed not to reflect on a monitor screen, and all of the surfaces including floor, wall, ceiling and dividers were selected not only for their cosmetic appeal, but also for their sound absorbancy. 

“Although many of these areas are somewhat compartmentalized, the individual dividers between adjacent workstations are only about 3- to 4-feet high,” Matalon says. This allows eye contact by individuals in a sitting position, while the sound-absorbing material permits conversation between clinicians at adjacent workstations while not disturbing someone on the other side of the room or even a couple of carrels away. They purposefully retained the collegial environment while optimizing the efficiency and workflow issues that are necessitated in a voice recognition PACS environment.

Meanwhile, Mark D. Herbst, MD, PhD, president of St. Petersburg Independent Diagnostic Radiology (Spin-DR) in Florida, prefers to work without interruption as he reads between 20 and 40 studies per day, 60 percent of which are MRIs. Contracts with more than 40 imaging centers, primarily in the Tampa Bay region, fuel his practice. Their office is not paperless, but is considered low paper usage. All patient information that is sent via facsimile is stored electronically along with the digital images that are kept both onsite and in New Jersey to build redundancy into the system.

Herbst purchased Anthro’s Carl’s Table and the Verté chair last fall which were placed in a separate reading room where he can close the door when he does not wish to be disturbed. He instituted a culture that means he can read uninterrupted, unless a physician calls with a question, or a technologist with a patient on the table calls for clarification about technique.

He appreciates the adjustability of the Carl’s Table, and says that he finds standing the most efficient way to read, something he never would have predicted. The foot rest on the Carl’s Table enables him to shift his weight from one foot to the other. He begins his day seated at the desk, later in the day he reclines and tilts the table, and then in the later afternoon, he stands. He works in a cool, darkened room with music playing in the background. “I’ve found this system has increased my productivity close to 50 percent when I compare January ’06 with January ’07.”

The Verté chair by RFM Seating is designed to mould to the individual’s spine to provide adequate support based on customized orthopedic fit.  There are three ergonomic back zones, adjustable arm rests and a “waterfall” seat.

Herbst’s approach reflects the current themes of reading room design: Once the basic ergonomic elements are in place, these days the buzz is about customizing a workspace for the individual.

It’s all about YOU

Although big picture issues are important to enhanced function in a PACS world, the key to an effective environment is building in as much flexibility as possible. Walls that move to change room configuration as needed will enable future upgrades of your systems. Making sure design components enhance connectivity is of paramount importance. And selecting furniture and displays that meet the needs of all of the radiologists in the practice leads to increased efficiency while diminishing opportunities for work-related injuries.

Besides attending to the major components of a perfect reading room like lighting, sound-absorbing materials on walls and ceilings, and multiple HVAC units for flexible control of the their environment, Matalon’s group at Albert Einstein installed Biomorph interactive desks with split surfaces for both the monitors and the keyboard and mouse. Each of those areas are capable of being placed at independent heights, and they are motorized for ease of adjustment. No matter where a radiologist sits, he or she can modify the position of work surfaces to be ergonomically efficient for body size and type. “That allows you to have your hands and arms at the proper angle so you don’t get carpel tunnel, and you can place the monitor at eye level so you don’t get back and neck strain associated with stretching to look at the monitors,” Matalon says. The desks also are capable of elevating to a radiologist’s standing height.

Although the photograph of their reading room was taken before their Planar Dome E4c bezel-less diagnostic display monitors were installed, Matalon describes the new displays as beneficial to their practice for two reasons.  The first is that the 30-inch wide screen, 4 MP color monitor is able to behave as though there were two monitors, from an electronic standpoint, because there is no physical barrier in the middle. The other advantage he notes is the fact that they are high-resolution, high-brightness color monitors that offer the ability to view both color and monochrome images on the same physical platform without having to compromise the diagnostic information available on the image. This fact offers a broader array of procedures that can be viewed on a single display.

Schwartz at Memorial Sloan Kettering selected AFC Industries workstations to facilitate customization of their reading areas. He notes that there are some stations where they have special circumstances such as in their nuclear medicine reading room where ancillary specialized workstations must be incorporated into the workflow. AFC built tables that were able to accommodate more CPUs and monitors, and appropriate switchboxes to enhance workflow and to share monitors for an ergonomically efficient system.

In their general reading room, they have basic workstations, but they need flexibility in terms of table height — whether minor adjustments or shifting from sitting to standing positions. With the variety of furniture options from AFC, they were able to accommodate multiple needs.

Kelvin Lee, MD, FRCPC, staff radiologist, Department of Radiology and Diagnostic Imaging at the Royal Alexandra Hospital and assistant clinical professor at the University of Alberta in Canada, describes their hospital-based practice where they cover a number of community and tertiary practice hospitals. They installed Anthro’s Carl’s Tables throughout their region because they appreciate the adaptability it affords their 70-radiologist group.

He notes that the way this table is configured is beneficial because their radiologists rotate through different settings. They need to be able to adjust the height of the table depending on the stature of their staff as they read a wide variety of electronic studies. “We have found that the Carl’s Table is versatile enough to accommodate all types of situations,” Lee explains. “One of our partners uses a wheelchair, and it is able to accommodate him as well.”

Henry Krebs, MD, radiologist at Saint Joseph Hospital in Atlanta relates that their 13 radiologists read imaging studies for the hospital as well as several outpatient centers. They redesigned their reading room two years ago, and chose Carl’s Table to hold their Barco displays. “We knew that ergonomics was very important and makes a difference between whether you’re feeling pretty good at the end of the day, or you’re feeling miserable.” He believes they are between 20 percent and 25 percent more efficient based on the comfort factor. 

They configured the reading room into individual offices where they can close the door, although at any given time, one of the radiologists maintains an open door to accommodate referring physician consultations. In each of the offices, the radiologist can control the lighting, thermostat and have personal touches to create a warm and inviting environment.

The St. Joseph group selected the Barco DuraLight Coronis 3 MP Medical LCD display system to meet their need for 30 or 40 displays throughout their reading stations. They appreciate not only the built-in calibration functionality, but also the remote control calibration software that facilitates biomedical department interaction with the displays. In addition, the DuraLight has a five-year guarantee on the backlight.

“We have all of our PACS integrated into 3D, so that on every single node, the radiologist can do 3D directly,” Krebs explains. For a color display, they selected a 24-inch Dell monitor. “Even though it is not medically calibrated, which can be somewhat of an issue, we don’t think it is as important because all of our calibrated studies and the plain films are all done on the Barco displays.” 

Radiologist Joe Chen, MD, finds comfort in the Steelcase Think chair and workstation at Baltimore VA Medical Center. Considering their need for nearly 40 displays, cost effectiveness was an important issue. Krebs notes that despite the fact that at the time they were deciding to purchase, the Barco displays were more expensive than others they reviewed, they believe that the image quality was well worth the cost. “You would think an LCD is an LCD, but it is not.” He believes that they experience less eye strain with the displays.

Anthony Levering, RT(R)(CT)(MR) who serves as the manager of Imaging Core Laboratory Services at the American College of Radiology Imaging Network in Philadelphia, explains that their committee of specialized radiologists from all over the country review between 2,000 and 2,500 imaging studies per year. They have MR and CT and PET core labs where the environment is optimized for reading and comparing images from various clinical trials.

“We have multiple workstations from the major vendors that the reviewers use, and with them we use NEC displays for viewing,” Levering explains. They have two displays at each workstation, some that are NEC SpectraView 2180 LCD color monitors, and they recently purchased a NEC SpectraView 2190 that he describes as the latest upgrade to the 2180.  He considers that both offer a nice bright background similar to lightboxes. They are automatically calibrated and produce the critical colors that their radiologists require. The SpectraView technology is optimized for digital picture review and analysis, and it allows crisp clear delineation of anatomic structures of CT and MR as well as a concentrated area for molecular images, according to Levering.

“We have two major studies going on right now that deal with PET/CT fused images. We see about 80 percent of the cases from our sites with combined hybrid scanners, and we fuse the PET and the CT,” Levering says.

On the radar screen

Once all of the basics are covered, Siegel describes other factors that remain important issues for the future, most specifically the notion of personalizing space for each individual radiologist. Because the Baltimore VA doesn’t have the capability to provide each staff member with his or her own space to read images, they created a flexible work environment.

Adjustable furniture is key as it can easily be configured to meet the height requirements of an individual reader, and address their preference for working in either a seated or standing position. Many of the tables and chairs on the market offer that capability.

Temperature and ventilation must be considered. Siegel says that radiologists who may be experiencing fatigue due to other factors in soft-copy reads may prove vulnerable to the effects of increased heat and poor ventilation. With equipment emitting heat as well as the people in a room, they discovered that temperatures could exceed 100 degrees when the door to a reading room was closed. 

The Baltimore VA department has five reading stations in the room, with three of them using modular furniture that does not extend to the ceiling, which provides the collaborative setting their staff prefer. To view a virtual tour of the reading room that was designed in collaboration with GE Healthcare and Baltimore VA Medical Center, visit: http://www.rsna.org/Publications/rsnanews/upload/GE_Reading_Room.swf

Overhead lighting was changed from fluorescent lamps to adjustable candescent, to reduce glare and eliminate flicker, and they use the Leaf Personal Light from Herman Miller that employs innovative LED technology as energy-efficient and adjustable individual task lighting. Individual task lighting helps to reduce fatigue.

Besides their background noise system and walls, floors and ceiling noise abatement design, another sound-related product they find beneficial is Babble by Sonare Technologies that they use to meet HIPAA requirements for privacy. With a footprint approximately the size of a tape dispenser, this system is only turned on when needed. As the user speaks, the person on the other end of the phone hears normal conversation, but the Babble system projects the speaker’s voice as a gentle hum scrambled so that others cannot understand the words being spoken. Since it can be turned on and off with the touch of a button, it is only used when sensitive information is being imparted.

And to further individualize space, they have ordered a product similar to digital frames so that each physician can have his or her own personal photos displayed in the reading area when they are there. “It may sound hokey, but I think there are psychologic benefits when people feel like they are in a nice calm, relaxed space,” says Siegel. The whole idea of having a customized desktop is to make it feel as much as possible as a radiologist’s own workspace rather than someone else’s workspace.


Five key points you need to know
If you haven’t seen it, be sure to check out “Digital Eye for the Analog Guy,” a film produced by (and starring) staff at the Baltimore VA Hospital (along with GE and EMC) that offers five key points for designing an optimum reading environment.
  • For optimal performance, maintain room temperature between 68 and 75 degrees. Ideal humidity is 40 to 60 percent. Install individual temperature and ventilation controls.
  • Sit at least 25 inches away from the monitor as the resting point of vergence is the distance where eyes naturally converge, relaxed in total darkness. The stress of convergence contributes more to visual discomfort than stress of accommodation.
  • Ideally sound levels should be maintained at less than 65 decibels.
  • Research at Baltimore VA found that the optimal number of monitors for general radiography is two. There was a major improvement in reading time going from one to two monitor workstation, but very little difference when going from two to much more expensive four.
  • To avoid eye fatigue, follow the 20-20-20 rule by looking at an object that is 20 feet away for 20 seconds every 20 minutes. Check visual acuity routinely.

To view “Digital Eye for the Analog Guy,” go to http://www.rsna.org/Publications/rsnanews/extras.cfm