Reading is Fundamental: Making Image Viewing More Efficient

hiit040306.jpgThe impetus for re-designing a radiology reading station varies by institution and preference of the radiologists who use them. Upgrades in technology or PACS configurations may necessitate some changes, while ergonomic principles may lend urgency to the task as personnel recognize that their environment is causing them harm. Sometimes a revision of the philosophy of how a radiology department should function lies at the heart of dramatic shifts in the way radiologists read studies.

Shawn McKenzie, MPA, CRA, who serves as president and CEO of McKenzie Stephenson in Rockland, Calif., gained both a clinical and IT background as the director of imaging for many years. As a consultant to imaging departments and healthcare systems, he observes a number of driving forces in the re-design of reading cockpits. Among them are increased integration of applications, stand-alone IT platforms with built-in voice recognition capabilities, and increased emphasis on ergonomics as vendors work to provide smooth department workflow.

In the future, McKenzie believes there will be continued attention to physical ergonomics of the workspace, but in addition he predicts that “social ergonomics” will rise in importance. He suggests that just as in academic facilities radiology reading spaces must accommodate group viewing, the same paradigm will move into small community hospitals so that referring physicians will be welcomed into the reading area for increased interaction with radiologists in collaborative image review.

In this configuration, radiology would serve as the hub in the wheel of patient care. He envisions specialists and primary-care physicians entering the radiology domain and the radiologist sitting in the “hot seat” to read with them. In higher traffic areas such as the ICU, the radiology reading station is placed on the unit. The challenge is finding real estate on the patient care units.

Finally, McKenzie envisions greater use of biometrics for one-step log-on activities using the clinicians’ thumbprints or retinal scans or perhaps badge proximity for authentication purposes. While those systems are in use at some institutions, he believes they will become more widespread. Clinicians often complain about multiple log-on passwords that they must remember to access important clinical data. (For more on single sign-on software, see "Single Sign-on: One Authentication for All Applications.")

While his ideas reflect anticipated changes in the future, in today’s world, there are healthcare systems that have already instituted major changes to their radiology reading stations.

Medical University of South Carolina, Charleston, S.C.

Jay Crawford, MHA, who serves as radiology informatics manager at MUSC describes a multiphase project that involved renovation of the radiology informatics area, a re-engineering of the file room and an expansion in the primary reading room. The department switched from analog to digital in 1990 and went completely filmless in 1996 when they installed CR units. They began with an Agfa IMPAX mini-PACS for ultrasound and nuclear medicine and then obtained the funding to improve the rest of the department by 1996.

A major overhaul was necessitated when they recognized that they had just gone from a film reading room with a row of alternators to a row of desks with monitors for digital reads. The walls were painted a deep eggplant (nearly black) and the lighting was inadequate.

“Just the addition of five workstations meant the thermal load was tremendous, so we put in a cold spot air conditioning station that was very noisy,” Crawford relates. They realized that there were numerous deficiencies in the environment, and they also needed to expand the utilization of the workstations, so a re-vamp was imperative.

In the new reading room, they placed a mix of 2 megapixel (MP) and 3 megapixel (MP) Barco Coronis high-brightness active matrix LCD monitors placed into different configurations based on the types of images being reviewed. The new department features a total of eight, three-monitor computer stations, with appropriate lighting based on current radiology standards, central air conditioning and a reading room that is nearly triple the size of the old one.

“We have places where we primarily read CT and MRI, versus places where we read CR radiographic images … those are on the 3 MP portrait configuration. CT or MRI [images] are read on the 2 MP [display] in a landscape configuration where they can look at several slices at once. We try to match the monitor resolution to the acquisition matrix of the modality that [the radiologists] are reviewing.”

They paid close attention to workspace height in relation to monitor height, and looked for furniture options that would allow their radiologists to change positions from seated to standing for reading images. To that end, they purchased L-shaped tables with a lot of work surface from AFC Industries. The monitors are placed on an electric boom, so that they can be adjusted for height.

Finally, because they are an academic health center, MUSC configured their reading spaces so that several people could work together at the same desk. They’ve been rewarded with excellent reaction by the radiologists who find that both the ergonomics and collaborative activities have greatly improved.

New York University Medical Center, New York, N.Y.

Chris Petillo, director of PACS in the NYU Information Technologies division, describes the challenges and solutions they employed in designing their reading stations. Although they’re not quite 100 percent digital, they’re working towards that goal. Each day, they add 1,000 cases to the PACS.

“One of the major problems we had at NYU was real estate for PACS,” says Petillo. Since their physicians came from many other institutions, and were accustomed to two-, three- or four-monitor reading stations, NYU had to make decisions about conformity between all of their reading cockpits. In each station, they placed dual dome portrait configuration monitors from Siemens Display that were high-grade (1536 X 2048) CRT because it would be appropriate for reading whatever images needed to be read, given the high resolution. The two-monitor arrangement allowed them to distribute more workstations throughout the medical center.

Because of the need for efficient reading of a series of x-ray studies, they worked with Siemens to design a layout for the images. They concluded that having small thumbnail images on both monitors, which could easily be enlarged to full size with a single function key, would address the needs of those reading x-ray studies.

“Typically, the way we draw our CT layouts is to draw one fairly large size series in the center of the monitor and then smaller thumbnail series around the sides. But in our med center, the center series is usually the “money” series. That is the one the radiologist really wants to see first. Then they want to see the second series. Instead of making them drag and drop every single time, we created these displays that automatically place the second series that works fairly well.”

A software design considered a works-in-progress with Siemens will provide a way to more efficiently read their CT or MR layouts using DICOM series description.

Mercy Medical Imaging, Des Moines, Iowa

This 900-bed acute care facility with the busiest emergency department in the state logs 250,000 imaging studies a year. To keep things running smoothly, Mercy implemented a Kodak PACS, including web tools in clinical review stations, and in the physician offices for their “heavy hitters,” says Susan A. Johnson, BS, RT (CV), PACS administrator and operations director.

“When we went live on PACS, we basically gutted the [area] where the reading rooms were. We made individual cubicles for each radiologist, got rid of all of the fluorescent lighting and placed wall sconces with candescent light in the internal hallways,” she says. To make sure that radiologists could read both sitting and standing, they will be installing brackets to hold the monitors that allow a 26-inch variance. “So if they’re sitting, they can read in that position, and they can lift both monitors up as a unit and stand for awhile.”

In the radiology department, the cubicles support departmental workflow so they have a neuro cubicle, one where musculoskeletal reads are accomplished and one for nuclear medicine.

Next they made sure that they placed reading stations throughout the institution. By using high-definition Dell 21-inch, flat-panel monitors with 1 gigabyte of memory each, they could afford to place monitors at each end of every floor, in every OR suite as well as in the physicians’ lounge. This approach meant that physicians no longer had a reason to request films.

Johnson explains that they feel it is very important for their PACS team to support more efficient reading with face-to-face encounters, but they also have remote access to the workstations so they can dial in to troubleshoot when physicians are experiencing problems, and the PACS team can re-boot computers remotely.


Radiology reading stations must be efficient and support the heavy — and increasing — workload endured by most radiologists and other specialists. With attention to ergonomic principles and care in designing the software that supports tasks to be accomplished, radiology cockpits can greatly enhance the work environment.