As imaging studies have morphed from analog to digital, many departments responded merely by replacing lightboxes with computer screens in the same reading room space configurations. This approach has yielded widespread radiologist and technologist complaints of eyestrain and neck, back and wrist pain.

"As time goes on, I see radiologists who are so affected by ergonomic issues that it threatens whether or not they can actually continue working as radiologists," says Eliot Siegel, MD, professor and vice chairman of diagnostic radiology at the University of Maryland and chief of imaging for the Veterans Administration Maryland Health Systems. "Even amongst radiologists who are not experiencing these problemsÃ?¢?Ã?¦given the onslaught of additional images and additional volume of imaging, how can we cope and still maintain our productivity and proficiency without increasing our stress levels? How do we minimize injuries to ourselves and maximize efficiency?"

Siegel's group and others have engaged in addressing ergonomic issues for a number of years, inspired by research of experts outside the realm of radiology including Alan Hedge at Cornell University. Siegel cites as an example Hedge's 20-20-20 rule which suggests that a person working at a computer workstation should stand up or at least stop every 20 minutes to gaze at least 20 feet away for at least 20 seconds to minimize eye strain.

Susan Murphey, BS, RDMS, RDCS, CECD, director of operations for Sound Ergonomics, and her experienced team provide education and consultation not only in the realm of sonography, but they have begun addressing the issues that arise in the PACS environment as well.

"As more departments transition to filmless, the work activity becomes minimized to sitting in front of a PACS workstation for eight to 10 hours a day," says Murphey.  "Anytime you decrease your movement, you'll affect your muscles."  If reading activities shift from a workflow that requires movement around the department and elsewhere to sitting in front of a computer for long periods of time and the reading area has not been set up with ergonomics in mind, the radiologists, technologists and others will definitely feel the result.

Besides the problematic restricted workspace, Siegel notes that many radiologists are using ergonomically incorrect sitting or standing positions for reading images because they should be looking slightly down instead of looking slightly up at monitors to reduce neck strain.

There are several core principles that lie at the heart of ergonomic design of reading rooms.

Foundations of ergonomics

As the science of proper body mechanics and postural alignment that not only identifies risk factors but also seeks to reduce incidence of injury, ergonomics is based on principles that encompass the entirety of the environment under consideration. Such issues as lighting, adjustability of workstations, noise control, air quality and reduction of repetitive motions comprise the key elements to consider in reading room design.

Alan Hedge, PhD, professor of ergonomics at Cornell University and research professor in the department of biomedical and chemical engineering at Syracuse University in New York, urges radiology professionals to consult with experts in ergonomics as they design digital reading rooms. Decisions are made in purchasing millions of dollars worth of equipment based on the capabilities of the system without regard to how and where it will be used. Considering that the quality of the diagnostic outcome is primarily a function of the radiologist and not the capabilities of the equipment, it is easy to create a dysfunctional system if ergonomics principles are ignored.

Lighting: Hedge suggests that since the job of the radiologist involves close inspection of imaging studies, that if environmental lighting is designed improperly, the outcome will fail while causing problems for the radiology staff. Lighting includes providing the correct spectrum coupled with appropriate lighting levels and direction of the source to avoid glare on a computer screen. Because an imaging study may require reading the image from a monitor while referring to a paper requisition or medical record, some type of supplemental task lighting often proves essential.

Since a busy radiology department may include practitioners of all age ranges, the amount and types of light must be adjustable. Actually, a 30-year-old radiologist usually requires about half as much light as his colleagues in their 60s.

Adjustability: In fact, adjustability serves as a key consideration to reduce fatigue and decrease opportunities for injury. Because the best scenario includes having the radiologist or technologist spending part of his or her time standing and part sitting, the ability to adjust the reading site up and down is important.

"You need to think about adjustability of the [work] surfaces," says Hedge. "It's not just the height of the table, because when you stand up, the distance between your eyes and hands is different than when you sit. When you stand, you need to not only change the height of the table; you need to change the height of the screens as well. Otherwise, if you're leaning, you'll create neck and shoulder strain."

Lawrence Schwartz, MD, department of radiology, Memorial Sloan-Kettering Cancer Center in New York, raises another issue of adjustability that involves the number of staff who may be using any given reading station.

The general position of the body, height of the monitor, table and chair, combined with the radiologist's interaction with a number of monitors and input devices, the size of the table, as well as placement of the wrist and elbow relative to equipment all play a vital role in effective and safe workflow.  Since in many work sites there may be numerous personnel who work at each workstation, all components must be adjustable to the specifics of every member of the staff. While some professionals may be taller than six feet, others may be much shorter, and the flexibility of the system becomes critically important from an ergonomic perspective.

Schwartz says they have installed both the ErgoTier and DualTier tables from AFC Industries in their radiology suite, to provide the adjustability and flexibility they require in this academic setting. They found that larger table areas helped to accommodate the numerous input devices - from keyboards, at least one mouse, several monitors, a telephone and barcode device.

"Monitor placement, the height of the monitor relative to the radiologist or technologist with the position of the neck and back and the general overall height of the system is important," says Schwartz.  "With improper positioning, there is increased eye, neck and back strain."

All devices must be positioned in such a way that the person can work in what is called a "neutral posture," according to Hedge who explains that the upper arms should be relaxed against the body, with lower arms no higher than a 90-degree angle to the elbow and preferably a bit lower than that, and both hands and wrists straight out ahead, not bent up or down or to either side.
Murphey concurs with the recommendation to work in a neutral posture, and reminds clinicians that it is very important to take the time to correct the situation if you experience any discomfort by adjusting the height of the chair and table, and shifting to an alternative position whenever possible.

Noise: Many radiology departments have adopted voice recognition systems to facilitate report generation for imaging studies. This addition increases the importance of room acoustics. A flasher on the phone rather than a ring will help to decrease some of the room noise, and acoustic shielding will decrease the ambient noise level.

Hedge notes that anywhere air goes, sound goes. For maximum sound absorption, material that offers an uneven surface shape breaks up the sound waves. Considering the inside of a sound recording studio that is lined with "egg crate" foam demonstrates one solution to sound problems. Acoustic shielding addresses these issues when multiple people work in one area.

Siegel explains that older reading rooms were not designed to address issues of sound. He suggests sound-absorbing materials be placed on walls and floors and acoustic tiles on the ceiling. His group is conducting experiments to determine whether having music or nature sounds in the background may help to reduce stress and fatigue.

Repetitive motion: "The computer mouse was designed not for continuous use, but for occasional use as a pointing device," says Siegel.  "Now radiologists, as they are reading CT and MR, are using the mouse as a navigation device. Instead of looking at static images on the screen, we're navigating through three-dimensional and more complex images."  
Since the mouse was not designed for these sophisticated procedures, the radiologist is required to engage in repetitive motion continuously, thus placing additional stress on his or her hands and wrists.

Room temperature: Steven Horii, MD, professor of radiology, University of Pennsylvania Medical Center in Philadelphia, explains that although temperature requirements are unchanged from past years, much of the computer equipment in use creates additional heat in the modern digital reading room. If engineers and architectures have not incorporated those realities, problems could develop.

Evolving room designs

Several experts in ergonomics with an interest in radiology have begun devising solutions to the stressors that have been identified.

Horii raises the issue that with film, there were few changes in technology for years other than improvements in the film and the screens used. However, with digital technology, there could be hardware turnover at fairly frequent intervals. "Having an open design with appropriate generalized lighting and carts for workstations with task lighting means you can reconfigure reading rooms as needed," he says.

Paul Nagy, PhD, director of informatics research at the University of Maryland, recently moved from the Medical College of Wisconsin and Froedert Memorial Hospital where he and Thomas Hanson, applications specialist, worked to re-design an existing "ballroom" style reading room where all of the reading stations were placed against a wall.

They placed 16 workstations in one very large room, with most of the workstations in the center of the room pointing out, configured as inverted pods. They paid special attention to the workflow of collaboration, because as an academic facility, they utilize teams for reading studies.

While they had one workstation facing a door for consultation purposes, they closed the door to a busy hallway and opened another to a less traveled hallway to avoid light and noise pollution. They used frosted tip incandescent lights to provide a glow for lower ambient light, and they utilized walls with a high STL (Sound Transmission Loss) to reduce the overall noise level.
"We found that if there is one conversation any place in the room, it can be heard and be distracting," explains Nagy. "But when there are two or more conversations, they tend to cancel each other out." Anecdotally, they found the slight "din" to be beneficial because in this humming professional environment, radiologists became more productive.

Osman Ratib, MD, PhD, FAHA, formerly with UCLA Medical Center and now professor and chief of nuclear medicine of the department of radiology at the University Hospital of Geneva, was brought to  UCLA to help deploy digital imaging enterprise-wide into a new medical center. He appreciated the opportunity to collaborate with the architects to incorporate ergonomic principles into their new site. They addressed issues of lighting, noise, and adjustability of the workspace as the architects configured their four workstations separated by two partitions into the middle of the large room. Each workspace is rotated to be placed at a 90-degree angle to each of the others enabling all cables to emerge from the middle of the room.
Originally they designed their own worktables but then found that there were many companies that had developed lighter and more sophisticated furniture. Now they use commercial systems from Anthro Corp. and others. They have one workspace designed completely with "off the shelf" furniture with motorized tables and arm rests.

Table it

John Hanada, systems manager for the department of radiology at the University of Oregon Health Sciences, describes their use of Carl's Table, where one advantage they have identified is the fact that the tabletop work surface is independent of the monitors, which are mounted on arms. This means that the radiologists are able to angle the table to support their arms and wrists in a neutral position. Besides this capability, the entire system raises to enable a radiologist reading in a standing position.

"The work surface area is made of a material so that things don't slide off, even if you have the table deeply angled," says Hanada. They appreciated the fact that Carl's Table features adjustable task lights for reading papers. "They also put a sensor on the system so that when the image changes and the background is brighter, it automatically adjusts the background light."

Virtual Radiology Consultants (VRC) employs radiologists who read studies via teleradiology systems in their homes or at centralized locations in Minnesota and Hawaii. They have designed an ErgoPod system with a "Perfect Chair" to provide maximum comfort, follow ergonomic principles and enable their radiologists to work effectively without strain. The Perfect Chair utilizes memory foam that is temperature sensitive and moulds to the person. Some of their radiologists read in a full reclining position for part of their eight to 10 hour day.

Sean Casey, MD, who is CEO of VRC is a practicing radiologist as well, and uses the system in his office.  "What I found from my long reading sessions is that it was good to have my legs elevated," says Casey.  "When you look at the ErgoPod setup, those monitors are able to angulate so that I can keep them the appropriate distance from my eyes." In addition, the table rises to accommodate a standing position.

James Turner, MD, consulting radiologist for VRC who reads images from his home in Denver, describes his office configuration as similar to Casey's, although he has his monitors in a landscape rather than a portrait configuration.
Turner says that before using this set up, he would be able to read 100 studies a day with about 50 to 70 of those cross-sectional studies. Using his current arrangement, he can read 120 CT, MR or ultrasound cross-sectional studies in a 10-hour shift with less fatigue.

VRC is in the process of developing the VR Grip, which is a pod that the radiologist's hand rests upon with buttons to change windowing, accomplish measurements and perform many other important reading functions without requiring mouse movements.
"When we're using the VR Grip, we don't have to look down to navigate through the PACS as we would if we were using a keyboard, nor do we have to make a lot of mouse clicks or take our eyes off the image," says Casey.

Conclusion

Gone are the days when a digital reading room can just be designed as an instant replay of the area where film studies were read. With ergonomic issues moving to the forefront of consideration to protect the radiologist and other staff from injury, careful thought and planning must direct reading room design.