Solving the PACS Display Dilemma

Bruce Leavitt, MD, of Fletcher Allen Health Care, with a Sharp PN-445 monitorThere’s no quick or ‘right’ answer when it comes to PACS displays. Multiple solutions will work, but finding the right option takes time, homework and communication.

PACS, and PACS displays, are ubiquitous in hospitals and imaging centers across the country. While digital image management has become the norm, displays are a different story. There is no standard solution across or even within sites.

Radiologists are the primary PACS users, but even in radiology departments, it’s tough to find a standard display system. That’s because digital modalities — such as CT, MRI, CR and digital mammography — have specific display requirements. The conventional solution for interpreting radiology’s bread-and-butter studies is the high-resolution grayscale display system. But color modalities such as ultrasound and nuclear medicine studies require a color monitor. Similarly, advanced visualization software requires color.

Clinicians’ needs differ from radiologists. They are not the primary interpreters of images. Some, such as general practitioners, require a simple view that can be served by 1.3 or 2 megapixel monitors, but other specialists such as orthopedic surgeons depend heavily on images and need high-resolution solutions.

Size matters in the display world, too. The standard 21-inch system may suffice for the radiologist reading studies at his desk, but a standard system may not work for surgeons in the OR. The surgeon may not want to walk away from the table, and cart-mounted systems can be clumsy. Mega-displays can provide a solution.

Most sites employ a flexible, physician-centric approach to meet their PACS display needs. This month Health Imaging & IT tours several sites to see how they have tackled and solved the display dilemma across the enterprise.

The color world

Spectrum Health — Butterworth Campus in Grand Rapids, Mich., is a typical PACS site. The Grand Rapids hospital is a regional leader in healthcare; it’s designated as a Level 1 Trauma Center, houses a heart center and plans to open a new cancer care pavilion. The hospital has relied on PACS for digital image management for more than five years.

Last year, the radiology department decided to revisit display options as a group of its medical grade grayscale flat-panel display systems reached the end of their three year life cycle, says George Vallillee, manager of radiology medical informatics.

As in most hospitals, real estate, including office space, is at a premium at Spectrum Health. The radiology department decided to pilot a group of Barco Coronis 3 megapixel (MP) color luminance display systems. Physicians use the new systems in a dual-monitor configuration for traditional imaging studies and color modalities such as ultrasound. “Radiologists are infatuated with the new monitors,” says Vallillee.

The high-resolution color approach delivers several key benefits. For starters, the hospital has freed up valuable real estate and saved money as it was able to eliminate or redeploy a number of workstations dedicated to color interpretation. “This approach is more convenient, too,” says Vallillee. Radiologists no longer need to walk to a color station to read ultrasound studies, which translates into productivity improvements.

The color systems fit nicely with the hospital’s new thin-client 3D reconstruction software. 3D reconstruction requires a color system, and the thin-client model delivers 3D capabilities to all PACS workstations. “We’ve seen a productivity bump with the color displays and the thin-client system because radiologists can use the same workstation for all of their interpretations,” sums Vallillee.

The ability to eliminate or redeploy workstations and improve productivity is an economic plus, but the decision to deploy high-resolution color display systems is fiscally sound in other ways as well. “These monitors are a value proposition. From a pricing perspective, they are competitive with traditional grayscale monitors,” states Vallillee.

Thinking big

Deploying PACS and eliminating film in the radiology department is the first, and possibly easiest, step in the filmless process. Eliminating film across the enterprise, particularly in tricky areas such as the OR, represents an entirely different proposition.

Replacing the lightbox with a high-resolution grayscale monitor can eliminate film but does not necessarily meet surgeons’ needs as they still need to leave the table to review images. Cart-mounted displays can travel from room to room and enter the surgical field, but they can get in the way as typical ORs tend to be packed with critical equipment and personnel.

Like many sites, Burlington, Vt.-based Fletcher Allen Health Care struggled to find an OR-friendly display system in 2006. After considering the standard options, physicians asked about the viability of a large display that could be viewed at full fidelity from across the room. George Ebert, MD, vice chairman of radiology, investigated the new options and found that commercial grade plasma television sets don’t provide the resolution or sharpness necessary to view medical images. The next option is the high-fidelity LCD display. A 2 MP ‘1080p’ resolution system provides the resolution necessary for medical review. Ebert and his colleagues solved the OR image viewing dilemma after evaluating Sharp Electronics Corporation Sharp PN-445 45-inch monitors.

In addition to resolution, the Sharp system incorporates other features ideal for the surgical environment. The commercial grade system features multiple inputs, so Fletcher Allen Health Care can port in other inputs such as digital video or analog data. The Sharp monitors are encased in water-resistant protective housing that be scrubbed and sterilized if necessary.

After making the decision to deploy the Sharp monitors in its OR, the hospital decided to install the new systems on brackets. The monitors can be pulled up to two feet from the wall, turned 90 degrees in either direction and oriented vertically or horizontally. The upshot? The system is ideal for surgical image review, says Ebert.  

After the successful OR deployment, Fletcher Allen Health Care decided to invest in additional large monitors. The hospital equipped its conference rooms with Sharp PN-655 65-inch display system. “The monitors facilitate video-conferencing and provide the fidelity necessary for viewing clinical images like x-ray and pathology slides,” explains Ebert. The large systems can be used to demonstrate cases to residents or medical students. An OR conference room is similarly equipped, allowing multiple physicians to review the case without crowding around a small display system. 

Flexibility pays

ThedaCare in Appleton, Wis., is a community health system consisting of four hospitals including Appleton Medical Center, a regional leader in cardiac, cancer and orthopedic care. When the hospital deployed PACS three years ago, PACS Manager Jeff Ruhland embarked on a concerted effort to involve the 40 radiologists affiliated with the medical center in the medical display decision process.

The team evaluated multiple 2, 3 and 5 MP display solutions. “Although a group of radiologists lobbied for the 5 megapixel system, after side-by-side comparisons, 90 percent of the radiologists could not detect any visual difference between the two systems,” reports Ruhland.

The health system opted for Siemens Displays Technologies SMD-21300 3 MP grayscale monitor as its primary PACS display system. The site, however, has remained flexible in its approach to PACS displays. The Siemens monitors are paired with 2 MP color displays in a variety of configurations.

Some PACS workstations consist of four or five grayscale monitors with one color monitor. The four and five monitor arrangement is ideal for CR and DR interpretation, says Ruhland. Other workstations set up with two or three grayscale monitors and one color system are reserved for CT, MR and nuclear medicine study interpretation. The color monitor is used for multiplanar reconstruction (MPR) and the worklist.

The assortment of configurations is a successful strategy for ThedaCare, says Ruhland. The medical center decided early in the PACS deployment process to give radiologists what they wanted (within reason). One of the two radiology groups affiliated with the center wanted one screen dedicated to the worklist, which led to the three and five monitor configurations. The other radiology group did not request the additional worklist monitor, so the four monitor configuration suffices. 

ThedaCare also employed a user-centric approach to outfitting clinics and hospital departments with PACS displays. “We have a few standard options, and we meet with physicians to discuss their needs and show them the standard options,” explains Ruhland. In general, the image viewing and resolution needs of specialists and general practitioners diverge. The ER, ICU and orthopedic populations require high resolution systems and need 3 MP grayscale systems to review images. Other hospital floors are better served by 2 MP grayscale stations, and most physician offices can be outfitted with 1.3 or 2 MP color systems.


The right display is essential for PACS success; however, not all users require the same type of display systems. In radiology, the site should consider the type of study and radiologists’ preferences and build the solutions accordingly. A similar process works across the enterprise. Image-intense specialties like surgery and orthopedics typically require a solution similar to radiologists. Some areas, particularly the OR, have niche needs that should be addressed. Finding the right options can boost workflow, enhance physician satisfaction and streamline the transition to the filmless enterprise.


Finding the Right Fit
The wide assortment of display systems makes for a dizzying array of options for PACS workstations. Experience counts and can guide the novice through the display selection process. Insiders who have successfully navigated the PACS display process offer some tips for their colleagues.
  • Vendors can provide a significant amount of intelligence; look at all of the vendor offerings before making a decision, says George Vallillee, manager of medical informatics for Spectrum Health in Grand Rapids, Mich.
  • Find a physician champion who can lead discussions and facilitate consensus on monitors, configurations and resolution, says Jeff Ruhland, PACS manager at ThedaCare in Appleton, Wis.
  • Price counts, but don’t get too cheap. Avoid off-the-shelf consumer units, says George Ebert, MD, vice chairman of radiology at Fletcher Allen Health Care in Burlington, Vt. A well-priced consumer unit is not optimized for the medical environment and may lack necessary inputs and protective housing. It’s important to calculate total cost of ownership in the display decision, adds Vallillee. Factors such as productivity, convenience and flexibility should be considered. Don’t forget PACS administrator/IT workflow. Accessories like remote monitoring and QA tools can dramatically reduce hands-on display management time for staff.
  • After the systems are deployed, a few simple tricks can keep workstations humming and physicians happy. Keep a spare monitor at each site as a back up, says Ruhland. If a display goes down, the hospital won’t lose functionality. Consider a ‘hot swap’ in the contract, too. Vendors will ship a spare system within 24 hours with this option.