Redesigning the Reading Room

Historically, radiology reading rooms have been undesigned spaces. A typical analog reading room was often simply a large sheetrocked room with fluorescent lights, that could be turned off for peering at the x-ray viewbox. Not so anymore, digital images have brought on new design theories for reading rooms - incorporating ergonomics, lighting, room design and furniture, acoustics and connectivity.

In the early days of the PACS era, a 'deploy it and reap the benefits' philosophy permeated the radiology business. "People thought you could take a computer, throw it on the desk and ask radiologists to sit and read for 10 or 11 hours a day," sums Ric McGill, PACS application manager for University of California Los Angeles Medical Center (UCLA). Environmental factors like lighting, ergonomics and acoustics play a much larger role in the practice of soft-copy reading. For example, comparison between less bright and higher luminance monitors link decreased productivity, decreased accuracy and increased fatigue levels with less bright monitors. Carpal and cubital tunnel syndromes are on the rise among radiologists as are complaints of shoulder, neck and back pain and eyestrain. Throw in the pressure to read more complex cases faster and higher overall image volume and you have the soft-copy conundrum.

Cutting-edge hospitals have revisited and redesigned radiology reading rooms - changing the environment to accommodate and facilitate digital workflow. The aim is to optimize the space for digital workflow and increase comfort, productivity and accuracy among radiologists.

Redesigning a soft-copy reading room is a multi-faceted and complex process. The pieces of the puzzle include lighting, ergonomics, acoustics, room design and spatial enclosures and network connectivity. The process is typically a redesign that reincarnates an analog room as a digital space rather than new construction of a digital reading room. But facilities report that the process is well worth the time and investment as the end result is a truer picture of the PACS environment - a fluid interface between the radiologist and technology that yields increased productivity and decreased discomfort, stress and injury.

Shedding Some Light

Lighting is one of the most critical issues in reading room design, says Bill Rostenberg, San Francisco-based principal with Anshen + Allen, an international architecture firm. Alan Hedge, PhD, director of the Human Factors and Ergonomics Laboratory at Cornell University (Ithaca, N.Y.), agrees. "The key to ergonomics is defining what the job involves. For radiologists, the job consists of pattern recognition with visual images. They have to clearly see images, [which means hospitals] really need to think carefully about lighting for the reading room," explains Hedge.

Many hospitals, however, give little thought to reading room lighting. One common misconception is that the reading room should be dark. Rostenberg points out, "The ideal is a consistent level between the monitor and background surface." The other common pitfall is to rely on traditional fluorescent lighting, which can create reflections and lead to eye strain, headaches and discomfort. Hedge says lighting warrants a level of attention similar to monitor calibration. If lighting isn't standardized, images can look different regardless of monitor quality or calibration efforts.

One starting point for lighting decisions is screen color. The key question to ask is what kinds of images are read in a particular room. Lighting needs differ for monochromatic and color PACS monitors; ideally, hospitals should separate grayscale and color reading areas, says Hedge. Grayscale image reading can be optimized with incandescent lamps with a reasonable amount of blue in the light because cool, blue light helps eyes fix on details. On the other hand, if blue light is selected for color reading of a 3D heart model, normal red blood flow can look more purple and obscure diagnosis. In color viewing rooms, the light source should match images on the screen. The color rendering index (CRI) of the light provides a starting point for light decisions. Bone images, which are more yellow, require more yellow in the light source, while blood images require more red. In general, warmer daylight or triphosphor lights work best in color reading rooms.

Wall color also comes into play. "The color of the light source should match the color of the walls, which should match the color of the screen. Everything should harmonize - not absorb or distort color," explains Hedge.

Other lighting rules of thumb include the 90-10 ratio. That is, in most rooms, 90 percent of light should come from indirect sources, and direct fixture should generate the final 10 percent. High-frequency electronic ballasts with dimmable, controllable lights enable radiologists to fine-tune lighting to meet their needs. Finally, standard clothing color recommendations can help further standardize images as images look different reflected against a white coat or dark shirt.

Ergonomics at a Glance

Digital radiology certainly improves the analog environment - with one exception. Analog reading is more comfortable for the radiologist; it facilitates movement. The radiologist can stand, move or walk as he or she interprets film images. The PACS environment with tethered mouse and monitor restricts movement, which increases the risk of injury. What's more, it can encourage abnormal postures that can result in strain and discomfort.

"Seating is a huge factor in reading room design," says UCLA's Ric McGill. "Build everything around the chair," he advises.

"The chair is the most neglected piece of office furniture, yet it is key for spinal alignment and reducing muscle stress and strain," adds Carolyn Coffin, ergonomic consultant with Sound Ergonomics.

It sounds simple, but the chair must fit the user. In the reading room, that often means chairs must be sized for multiple users. This includes the 6'5" neuroradiologist who weighs 310 pounds, the 5'0", 95 pound petite breast specialist and multiple docs in between. Even among individual users, height and needs change during the day. And the array of options on ergonomic chairs can be dizzying. "These chairs can have tons of bells and whistles, but users don't want to adjust every minute detail; they want to make a couple of adjustments and start reading," explains McGill. McGill's advice? Look for simplicity and function. The ideal chair incorporates:

• Lumbar support
• Seat back height adjustment
• Seat pan depth adjustment
• Arm height and width adjustment
• Possibly a separately adjustable headrest

When UCLA embarked on its reading room design, McGill and his colleagues did not ordain a single vendor or chair. Instead they presented radiologists with a number of approved options and used their input to purchase several different types of chairs for their reading rooms. Involving radiologists in design plans and furniture purchases is key, says Rick Alaimo, radiology administrator at Montefiore Medical Center (New York, N.Y.). Alaimo asked radiologists to participate in decisions and sign off on acceptable options to encourage acceptance and minimize complaints in the future. Other facilities, including Baltimore VA Medical Center, recommend that radiologists take chairs for a test drive of at least one week before committing to a purchase.

Other ergonomic furniture to incorporate in the reading room includes the table or desk. Rostenberg recommends that facilities steer clear of built-in casework. "An ergonomically adjustable and movable workstation table meets other needs," he explains.

The table should adjust to accommodate users of different heights. Some tables may be adjusted to allow radiologists to read in a standing position, if desired. Although switching postures during the workday is ergonomically-friendly, it is easiest to accommodate a single posture, says Hedge. Another option instead of desks that enable standing postures is to encourage radiologists to stand up for one or two minutes for every 20 minutes of reading. "If they follow that pattern, they will be able to read a lot longer without other adjustments," confirms Hedge.

Although many vendors sell tables with a handful of preset buttons, McGill recommends a dynamic system that allows for a wider variety of height options. A movable desk is more likely to accommodate the evolving practice of soft-copy reading. Equipment is changing, Rostenberg points out. Monitors have shrunk in size, and speech recognition is making inroads. "Hospitals want to be able to move furniture and reconfigure as technology changes," sums Rostenberg.

Montefiore Medical Center relies on specially designed carts for its radiology reading rooms. Nogah Haramati, MD, chief of radiology at Albert Einstein College of Medicine (New York, N.Y.) collaborated with AFC Industries in the design of soft-copy reading carts. The four-level, wheeled, motorized cart adjusts to meet the needs of radiologists of all sizes with various physical and vision requirements. Accessories like telephones, lamps, microphones and controls are placed within an arm's reach of users.

Another option in lieu of the movable, adjustable cart is to place a height and depth adjustable monitor mount on a stationary desk. This allows individual users to raise and lower the monitor so that their eyes remain level with the top of the monitor, which is the ergonomically-correct position. Depth adjustment allows individual users to maintain an arm's length from the monitor to meet their visual needs.

A final ergonomic factor comes down to the software. How many keystrokes and mouse clicks does it require to complete common tasks? Fewer clicks mean less pressure on the wrists and hands. Other ways to minimize the impact of repetitive mouse clicking include ergonomic mousepads, foot pedals, multimedia controllers, gamepads and voice command PACS software.

Can You Hear Me Now?

"The analog reading room is a very noisy environment," explains Alaimo. "Staff are walking in and out of the room for consults and placing film on viewboxes. PACS give you an opportunity to change that."

Acoustics matter. Background noise generated by computer workstations can have a detrimental distracting effect on reading and dictation tasks. The acoustic solutions tend to be fairly simple. UCLA Medical Center, for example, covered the panels separating individual reading stations with sound-absorbing material. "Carpeting in the reading room is important. It keeps sound from bouncing around," states McGill. Soundproofed walls minimize external noise, too.

Spatial Enclosures

"The traditional ballroom-style reading room that is necessary to enable efficient distribution in the film department is unnecessary with PACS. The digital environment does not require one central location for distribution," says Rostenberg. Private reading offices simplify lighting, furniture and acoustics questions as they can be tailored for one person. Radiologists, however, need to communicate and collaborate, which can make the spatial enclosure or room design one of the more perplexing items on the reading room agenda.

Eliot Siegel, MD, director of radiology at Baltimore VA Medical Center, explains, "There's a dichotomy. We want each radiologist to be able to control light, sound and temperature, but we also want to foster collaboration. How do you create a space that isolates radiologists yet does not stifle the potential for collaboration?"

Many facilities gravitate toward smaller two to four person reading rooms. The most efficient use of space occurs when the department locates two to four workstations along the perimeter of the room, says Rostenberg. The drawback with this configuration is that users have no control over light or sound. The inverse arrangement, two to four workstations clustered in the center of the room, allows the room to be divided into individual zones for lighting, acoustic and temperature control, and it leaves the perimeter of the room as a collaboration zone. UCLA relies on the central quad approach in its reading rooms. Partitions between the spaces create mini-office settings.

Wires, Wires Everywhere

One final reading room factor is cable management. Wires, it seems, can sprout up out of the very floor, creating a tripping hazard as well as a sense of disorganization that may not be conducive to productivity. Rostenberg uses the automobile as an analogy; in the car there is no distinction between the equipment and the environment. "There should be a similar goal for the reading room," he explains. And furniture vendors have made this task fairly simple by incorporating cable management functions in their products.

UCLA relies on a single, central ceiling-mounted conduit to power all four systems in its reading room quadrangles, thus eliminating all peripheral wires. "It's a good idea to leave an extra line to each workstation if you don't have wireless access in the reading room because more physicians want to use their laptops at their stations," recommends McGill.

Getting the Job Done

Although a reading room re-build may sound like an intense, time-consuming undertaking, the process can be fairly uncomplicated. Reading room warriors who have crossed over to the other side of the reading room offer a few words of wisdom.

• Plan ahead, says Alaimo of Montefiore. This means diagramming layout options prior to beginning any work.
• Anticipate power needs and keep IT in the loop, so that the re-interface can be scheduled to minimize downtime.
• Secure radiologists' buy-in by sharing plans with them and soliciting input.
• Keep new construction to a minimum. Montefiore Medical Center limited construction to areas where it was absolutely necessary. For example, the hospital relocated one door located mid-wall to provide wall space and minimize the impact of hall lighting.
• Contrary to popular misconceptions, redesigns require minimal displacement of radiologists. Modular furniture can be assembled in other rooms or even in parking lots and moved in 'just in time.'
• Work on one room at a time and segment large rooms into parts. Montefiore divided one 60 x 15 room into three parts, completing one section before moving to the next.
• Divide the tasks into discrete, logical pieces - power supply, cabling, painting and carpeting can be scheduled first, followed by furniture and equipment.
• Complete design work at night when possible.

Conclusion

The perfect (redesigned) soft-copy reading room can bring some significant benefits. Radiologists will be more comfortable, less prone to injury, and their productivity and accuracy may increase as well. The redesign process is multi-faceted with lighting and ergonomics as the top two items on the agenda. Although the project may be complicated it is a fairly low-cost investment.

ERGONOMICS FROM HEAD TO TOE

Ergonomics (er·go·nom·ics): the applied science of equipment design for the workplace with the intent of maximizing productivity by reducing fatigue and discomfort.

Ergonomics is not a new idea, says Carolyn Coffin, ergonomic consultant with Sound Ergonomics. The concept evolved in the 19th century. Henry Ford, father of the production line and productivity guru, took the idea to new heights in the early part of the 20th century. Fast forward a century or so. As radiology transitions from the analog environment to digital world of PACS and IT with a new emphasis on the workstation, repetitive stress injuries and discomfort have led to new focus on ergonomics in the radiology arena. Here's a quick look at how ergonomics pans out.

"The key to reducing the risk of injury and discomfort is to allow movement. In the PACS-mouse environment, the radiologist's movement is limited and the risk of injury is increased. The environment needs to be reconfigured to allow movement and reduce abnormal postures," explains Coffin.

• ears - Cover partition panels with sound-absorbing material to minimize noise. Carpet prevents sound from bouncing around.
• eyes - the radiologist's eyes should be level with the top of the monitor or no more than 10 degrees above or below the top of the monitor. A slight downward angle minimizes pressure. A height-adjustable desk or monitor mount meets this requirement. University of California Los Angeles Medical Center encourages radiologists to adhere to the 2-20 rule. Every 20 minutes, the radiologist should look away from the screen for two minutes to rest and refresh the eyes. The similarly termed 20-20-20 rule recommends looking away from the screen at an object 20 feet away for 20 seconds every 20 minutes. Windows should be covered or monitors should be positioned away from windows to eliminate glare on the screen. Dark, flat paint colors absorb light. A rheostat or dimmer switch can be placed at individual desks to allow radiologists to adjust lighting.
• back - The monitor should be about an arm's length away from the radiologist to eliminate leaning, which can cause shoulder discomfort or back injuries. Chairs should include lumbar support and multiple options for adjustment (back height, seat pan, arm height and width and head rest).
• legs - A waterfall type chair seat that slopes forward minimizes pressure on legs for long periods of sitting. The chair should be positioned so that the radiologist is in a slightly reclined positioned with feet flat on the floor.
• legs & back - It's ideal if the worker is not in one position all of the time. To encourage radiologists to sit and stand as they work, the desk should include height adjustment.
• arms & wrists - The radiologist should remain in the inner zone, avoiding the 'chicken wing' posture and not reaching more than 30 degrees from his or her body. A keyboard or mouse tray can facilitate this arrangement; the wrists should remain flat with the hands falling onto the keyboard and mouse. A negative keyboard tilt ups the odds of carpel tunnel syndrome.
• mind - Increased air flow or 'super-ventilated' reading rooms can increase comfort and alertness.

COST CONSIDERATIONS

It's not uncommon for hospitals to invest $1 million or more in imaging equipment and then seal the wallet. This stance may be penny wise and pound foolish. "It's a false savings to skimp on items that are relatively inexpensive compared to the cost of labor and technology," says Alan Hedge, PhD, director of the Human Factors and Ergonomics Laboratory at Cornell University in Ithaca, N.Y. Hedge estimates that an ergonomic makeover can be completed for less than $3,000. What's more, if the makeover is done right - with flexible furniture and partitions - it's a one time investment.

Ergonomics may not seem economical. "It can be difficult to sell the finance department on ergonomic chairs that can cost $800 or more," admits Ric McGill, PACS application manager for University of California Los Angeles Medical Center (UCLA). McGill's solution is to encourage penny pinchers to look at the big picture. Radiologists who are comfortable will stay longer; if each radiologist reads five extra cases per day, the extra revenue can add up quickly. Turnaround time may improve as well. UCLA has seen its turnaround time drop since redesigning reading rooms and implementing a new RIS and PACS, but can not separate the reading room impact from the technology impact.

Eliot Siegel, MD, director of radiology at Baltimore VA Medical Center, puts a similar spin on reading room economics - pointing to radiologists' salaries. "If radiologists gain even 1 percent on reading productivity, hospitals can recoup the cost of the new space in just a few weeks," he calculates.

No matter how the math is done, it all adds up. Reading room redesign is a smart investment.

LIGHTING READING ROOMS

Here's how a few reading room pioneers have handled lighting. "A combination of ambient [indirect] lighting that provides even consistent illumination but doesn't shine on the work surface and task lighting serves most sites well," explains Bill Rostenberg, San Francisco-based principal with Anshen + Allen, an international architecture firm.

• UCLA Medical Center - reading rooms have multiple recessed lights that can be adjusted at each workstation; small task LED lights on each table can be turned on for paperwork and other non-screen tasks
• Montefiore Medical Center - overhead lights remain off during work hours; accent lighting attached to carts provides primary reading light; each station features a maplight for tasks requiring additional light

A TALE OF TWO READING ROOMS

The Baltimore VA Medical Center (Baltimore, Md.) is one of the earliest and largest PACS installations in the U.S.; however, the PACS pioneer did not build a reading room to accommodate its filmless operation. Consequently, radiologists were condemned to digital reading in an analog room. With a decade of PACS experience under their collective belts, Baltimore VA is now completing a redesign of its reading rooms to be soft-copy savvy.

The Beginning

It was an ambitious plan. The Baltimore VA Medical Center was conceived as a high-tech operation that could support filmless radiology and a paperless electronic medical record. The filmless model was adopted late in the planning phase, and a rigid government design timeline prevented the radiology department from changing its large central reading room to a more PACS-friendly design. The medical center opened its doors in 1993 with an analog reading room for a digital department.

The Middle

Over the next decade, Eliot Siegel, MD, director of radiology, Bruce Reiner, MD, director of radiology research at VA Maryland Healthcare System, and their colleagues experienced the trials and tribulations of soft-copy reading in an analog room. They completed numerous studies and quantified their findings. They learned:<>

• The number of one-to-one, in-person consultations with clinicians dropped from 1 per 7.6 studies to less than 1 in 42.
• Radiologist efficiency is comparable in two-and four-monitor workstation configurations.
• The percent of radiologists complaining of a high level of fatigue drops from 50 percent to zero when room light matches monitor brightness.
• High levels of ambient light decrease diagnostic accuracy by 11 percent.
• As background fluorescent light levels in the reading room change from off to half on to completely on the use of window/level, workstation tools increases from 45 percent to 72 percent to 91 percent.

The End

Now, in partnership with GE Healthcare, the Baltimore VA radiology department is poised to unveil the gold standard of soft-copy reading rooms. "The rooms have been designed to meet three goals: function as clinical radiology reading rooms, serve as a virtual or in-person showroom and provide a laboratory to continue to research the impact of the environmental and ergonomic factors on radiologists' productivity, fatigue and stress," explains Siegel.

The medical center has built four distinct reading spaces that incorporate previous research on reading room environment conducted at the VA. Each room provides individual task and overhead lighting and allows radiologists to pipe in music or white noise to mask the impact of an adjacent MRI suite. Each space features a different combination of lighting, acoustic and ergonomic solutions.

For example, one room has a high-tech workstation with built-in sound, ventilation and temperature control. Others rely on different traditional ergonomic chair and desk solutions.

The rooms, however, are not the ultimate solution to soft-copy reading environment. Instead, they are more of a work-in-progress designed to spur a greater level of understanding about soft-copy room design and workflow. "The plan," explains Siegel "is to explore different technologies and arrangements and determine standards for radiology reading rooms." For example, it has been suggested that blue light increases visual acuity and has a calming effect on users. Siegel and his colleagues intend to test and prove or disprove the theory. They aim to answer other pressing reading room design questions as well.

• What is the impact of lighting on accuracy? Stress injuries? Fatigue?
• Does the deluxe, individualized workstation that allows individual users to control temperature, air circulation and light deliver added value?
• What are the benefits of self-correcting, remote monitoring flat-panel display systems?

Siegel says the message is not to fall in love with the hottest technology or look. A second, and equally important, message is that a soft-copy reading room that optimizes digital workflow can be built on a real budget, using real technology in a real space.

The new rooms have been built with semi-movable walls so that space can be reconfigured. "We wanted to create dynamic and flexible rooms that could be changed as we learn," explains Siegel. The most important lesson may be that reading room design is a series of compromises. For example, Siegel admits that the department still struggles with the best compromise between a space that facilitates collaboration yet allows individual control over light and sound. For now, the department has compromised on a hybrid approach. That is, the movable wall dividing two front areas into separate offices has been removed, creating one larger collaborative space. The downside in the 'collaborative area' is some degree of light and sound interference. The back part of the room features two distinct 'office' spaces divided by semi-movable walls with built-in sound attenuation. These spaces isolate light, sound, temperature and ventilation and provide individualized workspaces. "We're optimistic that this may be the best of both worlds," says Siegel.

Ultimately, the perfect soft-copy reading room may be a compromise that balances the needs of multiple users with a variety of ergonomic, lighting and acoustic solutions. For tired, aching radiologists, the end result may be no compromise at all - soft-copy reading is optimized, and radiologists are more comfortable, less fatigued and more productive and accurate.

The Saga Continues

Stay tuned as Siegel and his colleagues continue to study the soft-copy environment and share their results at upcoming trade shows like the 2005 Radiological Society of North America Society meeting and the Society for Computer Applications in Radiology in 2006. The Baltimore VA also aims to launch a website to enable virtual visits to their reading rooms.