Supporting Digital Workflow: Furniture, Carts & COWs

The little things in life (and healthcare) really do count. Nearly every solution in the digital hospital from PACS workstations to viewing stations and wireless systems rests on a table, desk or cart. And radiologists sit for hours at a time as they interpret images.

These supporting structures may be overlooked or under-financed in the all-encompassing digital plan. But they can make a world of difference by facilitating adoption of new solutions, improving workflow and enhancing safety.

Take for example Mary Washington Hospital in Fredericksburg, Va., where the right cart allowed the facility to implement barcoding technology and realize dramatic increases in patient safety, productivity and workflow. And Montefiore Medical Center (New York City) touts increased productivity among radiologists since implementing what it dubs the "world's first 100 percent ergonomic radiology department."

But finding (or creating) a solution can be a challenge. Mary Washington Hospital thought it had the solution with its initial foray into COWs (computers on wheels) - a lightweight, ergonomic COW with a notebook, scanner, IV pole and basket. But the cart incited a revolt among nurses. "The 11-inch screen was not a hit with our nurses, who are primarily in their 40s," explains Cecelia Ciarleglio, RN, information systems analyst. So the process began again. At Montefiore, Chief of Radiology Nogah Haramati, MD, and his colleagues invested a solid year in the development of its ergonomic reading room.

Tables & chairs - alleviating the pain

Digital workflow changes the practice of radiology in many ways. Although many changes are positive, there are potentially negative outcomes. Sitting in a standard office chair and interpreting images on a workstation on a conventional table can lead to a range of physical problems. The neck, back, shoulders and wrists are prone to pain and injury in a conventionally furnished digital environment.

A few years ago, stakeholders at Montefiore Medical Center decided the status quo would not suffice and assembled a team to investigate better options for its radiologists. The team included bone and musculoskeletal radiologists, spine rehabilitation physicians and engineers from AFC Industries. The first priority? A new and improved chair. After analyzing dozens of prototypes, the center opted for a chair with fully adjustable height, armrests and tilt.

The team followed a similar process for table selection, searching for a table that fit the chair. After cycling radiologists through multiple options, the center selected AFC Industries' ErgoTier Station. The horizontally and vertically adjustable table provides an optimal viewing arrangement for different radiologists, says Haramati. The surface is configured so that monitors can be placed in arc instead of a straight line for better viewing, continues Haramati.

While Montefiore Medical Center took the slow, team-oriented approach to furniture, Toseef Khan, MD, an independent radiologist with teleradiology provider Virtual Radiologic Consultants (VRC), took the opposite approach. "I saw VRC's Perfect Chair and ErgoPOD 500 Reading Station at the VRC office and knew they were right for me." He realized the right furniture would allow him to efficiently view images and prevent physical damage that might occur as a result of 10+ hours of daily reading. The semi-reclining Perfect Chair positions radiologists underneath the monitors, taking the pressure off of the back. The ErgoPOD Station provides a large surface for all of the 'stuff' of radiology - keyboards, mice and image interpretation tools.

Desert Radiologists, a five-office practice in Las Vegas, employed a middle of the road approach to equipping its sites for the digital world. The practice did not jump into an option, but it did not rebuild from the ground up either. Chief Operating Officer Jerry Hartman, RT, and two radiologists started the process at the Radiological Society of North America meeting in 2004, visiting a variety of vendors for brief demonstrations. After the show, Hartman completed online research and decided the Biomorph Desk led the field. Desert Radiologists purchased a single desk and Freedom Chair from Biomorph. Radiologists rotated through the new arrangement, allowing Hartman to determine whether or not his selection worked for the majority of radiologists.

After a short test drive, most radiologists agreed with Hartman's choice, so the COO took the next step - inviting a Biomorph designer to Las Vegas for a basic reading room design consultation. The designer helped Hartman determine which Biomorph desk model fit each reading room, and the practice eventually outfitted itself with several styles. Despite slight variations in size and style, each desk features electronic risers for easy adjustability and provides consistent end results - increased comfort and reduced fatigue.

Caritas St. Elizabeth's Medical Center in Brighton, Mass., employed a similar model as it converted to a digital reading environment. The radiology department contacted six vendors and provided each with a list of general and specific needs. For example, one reading room was slightly undersized, and the department required a three-workstation set-up for the area. In fact, the department used vendors' willingness to optimize its solutions to guide the selection process. St. Elizabeth's also thoroughly assessed quality of the tables and chairs under consideration, realizing that the administration would be resistant to replacing furniture in two to three years.

Another key part of the decision process was a plywood mock-up of the new space. "We wanted to make sure there was enough room and the arrangement worked," explains Jeffrey Mendel, MD, radiology department chair. The mock-up proved to be well-worth the time and effort. When Mendel saw radiologists placing books under monitors to raise them to a comfortable reading height, he realized the original plan - fixed height modular tables - was unacceptable. The department ultimately selected Redrick Technologies' Comfort View Workstation. In addition to the table, the company provided basic consulting and training services, helping the hospital optimize the wall color to light gray for minimal eye fatigue and assisting with placement of sound-absorbing panels. "The benefits are staggering. One radiologist who suffers from chronic neck pain is more comfortable with PACS than film reading," notes Mendel.  

Going mobile: Carts & COWs

Radiologists are among the most sedentary healthcare professionals. Their work entails hours of sitting, and thus they are best served by fixed site, adjustable, ergonomic tables and chairs. Other clinicians are constantly on the move. While wireless solutions promise to boost efficiency and enhance safety, the technology cannot be implemented without the proper supporting structures.

In 2001, Mary Washington Hospital became an early adopter of barcoding technology in its nursing units. At the time, there was a serious deficit of cart solutions designed for the hospital environment. The right cart needed to be beefy enough to hold medication and equipment including scanners, IV poles, batteries and needle boxes. On the other hand, nurses wanted a lightweight, ergonomic solution that could be easily maneuvered and could roll over floor strips and from carpet to vinyl flooring. Finally, the cart would need to support thin-client devices and untethered, wireless scanners, so that nurses could barcode from anywhere in a room.

Information Systems Analyst Ciarleglio created a list of the hospital's requirements and submitted it to seven vendors. The first prototype succeeded on the lightweight, ergonomic front, but failed in other aspects. The small, 11-inch screen was difficult to read, and the cart lacked a waste basket, so nurses carried trash in plastic bags. The hospital re-started the process with Lionville; the company customized its 800 Series medication cart with a storage bracket to integrate thin-client devices. The new cart eventually became Lionville's iCart/8 and features an adjustable monitor, auto-locking touchkey pad and articulating keyboard.

The right cart is certainly essential for facilitating wireless barcoding, but it is not the only ingredient for success. Ciarleglio lists other considerations:

  • Where will carts be plugged in for battery re-charging? Some sites designate 3 a.m. to 5 a.m. as re-charge time.
  • Where will carts be stored?
  • Is a secondary supporting solution warranted? Mary Washington Hospital complements the heavy-duty Lionville carts with NA Ware's mobile cart for quick charting or nursing documentation.
  • What is the maintenance plan? Mary Washington hospital purchased 12 extra carts, to enable a fast swap-out if a cart fails. "It takes us only 15 minutes to put a back-up on the road," brags Ciarleglio. "This is critical for sites considering mobile computing."

Mary Washington Hospital has realized significant benefits since deploying carts to facilitate barcoding technology and wireless charting. "Physicians can see in real-time whether or not a medication has been administered, which improves safety. We've revamped productivity and workflow among both pharmacists and nurses," says Ciarleglio. Carts also help to maximize the investment by increasing the longevity of equipment like scanners and batteries. A final benefit, says Ciarleglio, is retention of nurses. "If you make your users happy and show them the benefits of technology, they will want to stay at your site."

Children's Healthcare of Atlanta recently deployed 300 mobile carts from Flo Healthcare to allow clinicians to access it Epic Systems Corp. electronic medical record. The hospital aimed to replicate the portability of the pen and paper with electronic equipment. Small, lightweight thin-client computers are ideal for mobility, explains Ellen Hansen, director of clinical informatics. But thin-clients require a cart or wall mount; Children's Healthcare of Atlanta opted for carts because they provide the flexibility to document inside or outside of patient rooms.

The hospital surveyed 70 clinicians to create a list of essential cart features. Weight topped the clinician's list; other key features included ease of rolling, height adjustability and sturdiness. Hansen used clinicians' lists to drive the request for proposals (RFP).

The next step was a test drive of the top three carts. Children's placed carts from the top three vendors in every inpatient unit for 16 days; 800 clinicians assessed the carts with some surprising results. The intuitive favorite, a stable, durable cart with drawers, was bypassed in favor of smaller, more streamlined options. Hansen's staff reviewed warranties, service agreements and battery life and returned to Flo Healthcare, requesting a bit of customization based on staff input. The vendor agreed, increasing its cart's vertical adjustability and adding tilt to the keyboard for ergonomics.

As the selection process wound down, the hospital turned to the nitty-gritty. "We hired a consulting firm to locate storage areas, and they presented us with locations at the ends of halls and in rooms, but we decided not to go that route," says Hansen. "We believe the carts should be available and in use all the time." The hospital checked with the Joint Commission and local fire department to make sure that its plan was acceptable. Both organizations agreed - as long as carts were incorporated in fire drills and placed on one side of the hallway. The hospital also added additional power outlets at an adult-friendly 36-inch height to ensure that carts are easy to plug in.


Inevitably and particularly after a significant IT or PACS investment, the question of cost arises. Haramati lays those fears to rest. "Our furniture did not cost much more than traditional furniture. When you factor in a slight decrease in absenteeism, the furniture pays for itself."

Mendel spins the math in a different way. If a radiologist earning $250,000 annually can devote an additional 1 percent of his day to reading because he is not so uncomfortable that he must leave his station, the furniture pays for itself rather quickly.

"The problem is furniture is usually the last thing a department purchases when implementing PACS," says Mendel. His advice for those on a limited budget? "Buy good tables and chairs for the radiologists first. That investment can be shaved from the PACS purchase price if necessary as no vendor will lose a sale over a small fraction of the PACS price."


Supporting solutions - workstations, desks, chairs and carts - play a key role in building and effective, efficient digital environment. A wise choice certainly boosts the odds for a successful implementation, and it keeps staff healthy and happy. Selecting the right option takes time; both end-users and vendors should be involved in the process as solutions may require fine-tuning for optimal deployment. Experienced users offer some final advice for other facilities:

  • Understand the function and purpose of the product, says Hartman. For example, some desks are dual purpose and can serve as monitoring stations for the tech. Is that type of functionality needed? "Sites should fit function and performance," sums Hartman.
  • "Pilot, pilot, pilot. Try to think of everything, but realize you won't know certain things until the solution is in use," says Ciarleglio.
  • "Listen to other hospitals. We looked at computers in every room and computer cabinets, but when we talked with other sites about options, we realized it wouldn't work for use," explains Ciarleglio. At the same time, it's important to realize that a solution for another hospital may not work on home turf because of differences in workflow or architecture.

    And Ciarleglio sums, "Challenge the vendors to create a solution to meet your needs."