Over the past several years, considerable research and development efforts by manufacturers have contributed to major advances in the technology underlying picture archiving and communications systems (PACS). These have been amplified by the initiatives of radiologists in the field, who have contributed greatly to improvements in software and hardware through field testing and through extensive cooperation with other users and vendors. As a result, the optimization of PACS technologies has been a continuous process.
One of the primary goals of that process, however, has received little attention and less intervention. Improving efficiency in radiology has been the stated goal of PACS since the earliest system implementations, but it cannot be achieved if the needs of radiologists are ignored. Clearly, their productivity depends, in part, on the speed with which they can retrieve images and prepare reports. Unless these technology-based abilities are accompanied by efforts to improve the physical factors affecting radiologists’ productivity, though, the full measure of efficiency that can be produced by PACS may never be gained by the organization that acquires it. On the other hand, enhancing the comfort of radiologists and decreasing the number of distractions that they must overcome can benefit both the individuals and the enterprise.
Since many radiology departments are now in the process of transition to filmless operation, they have an opportunity to make improvements to reading rooms at the least disruptive (and, perhaps, least costly) time. The nature of the necessary changes has been unclear, however, and little research that would provide guidance in making these alterations has been conducted. Previous investigations1 have, however, established that
- the number of image-enhancement tools needed by radiologists increases as ambient light levels rise (Figure 1),
- the level of fatigue that radiologists experience increases for the same reason, and
- the accuracy of image interpretation improves as ambient light levels are reduced (Figure 2).
The effects of ambient light on average reading time have not been found statistically significant.
SURVEYING PACS USERS
In order to clarify the elements of radiologist comfort, accuracy, and speed that are affected by the reading rooms in which they work, members of the filmless radiology departments at 10 institutions were surveyed by the author and Bruce I. Reiner, MD, for a paper presented at the Society for Computer App;lications in Radiology (SCAR) 2000 meeting. All of the radiologists had gained soft-copy experience through at least 3 years’ use of PACS, so they were considered likely to have noted the effects of changes in reading-room design. They were asked to describe any limitations placed on their productivity by the design of their current reading rooms, as well as to describe any improvements that they believed would allow them to become more efficient.
The radiologists surveyed used the products of several PACS vendors and were performing image interpretation at institutions in the United States, Korea, and England. They were asked to respond to questions concerning workstation ergonomics; their reading habits; the lighting, sound, and ventilation characteristics of their reading rooms; and their levels of experience as PACS users. In some instances, the response received from a facility was a composite representing the answers of the department’s radiologists. In other cases, several radiologists responded separately; for these facilities, a composite site profile was constructed in order to facilitate the analysis of replies. The composite for each institution was made part of a database so that the evaluation of results would be made easier.
Survey respondents indicated that their reading rooms had undergone little (if any) change since they had been used for the interpretation of film. The general design of these rooms remained the same as it had been in the film-based department, and the acoustic characteristics were typically unchanged. Lighting had not usually been modified. As a result, most radiology reading-room environments were not optimal settings for the soft-copy interpretation of imaging studies.
A number of sites, however, had made some minor changes in the interest of adapting their reading rooms to a filmless setting. These departments had installed dimmer switches in order to improve the control of ambient light, and some had painted their reading-room walls using dark colors in order to minimize glare. Monitor positions had also been changed, in some cases.
The radiologists surveyed agreed that three variables had the greatest effects on their productivity: ambient lighting, monitor brightness, and the number of monitors available. Specifically, efficiency was believed to increase with lower ambient light, increased monitor brightness, and a larger number of monitors per workstation. We found that two monitors were substantially better than one for conventional radiography but that four were not significantly more effective than two. Less important (but significant) factors were the temperature and layout of the reading room, its acoustic parameters, and the ergonomics of the reading chair and workstation.
Most respondents reported that overhead lighting was in use (rather than the indirect or portable lighting that they preferred), but dimming the overhead lights was possible in roughly half of the reading rooms. Temperature controls for individual workstations were not generally available, but most overall room temperatures could be changed. Distracting background noise typically came not from equipment, but from other radiologists and visiting clinicians.
The median reading time between breaks was 1.5 hours (although responses to this question varied widely), so workstation ergonomics are clearly important. The optimal working environment, respondents stated, allows radiologists to control lighting, ventilation, and noise levels. Comfortable seating is needed. Although most reading chairs had features that the radiologists surveyed found important (lumbar support, wheels, and the ability to swivel), they typically lacked armrests and the ability to recline, which respondents would have liked. The most commonly cited ways in which the responding radiologists believed that their productivity could be improved were the division of reading rooms into individual work sites and the improvement of access to radiology and hospital information systems at the PACS workstation.
In departments that implemented PACS more than 3 years ago, reading rooms often remain substantially unchanged since the days of film-based interpretation. As this situation does not promote efficiency or productivity, soft-copy reading environments should be improved. An effort to make the necessary changes is likely to enhance productivity and decrease fatigue among radiologists, but further research is still needed (especially where room design and workstation ergonomics are concerned).
In the interest of continuing research covering reading-room design, a reading laboratory has been set up at the Baltimore VA Medical Center. In addition, the survey project may be able to determine recent trends in reading-room design by expanding its scope to include sites where PACS implementation has taken place within the past 3 years.
See also: Reading Room Design Scenarios
This article has been excerpted from Optimization of Filmless Radiology Room Design: Survey Results of Experienced PACS Users, which he presented with Bruce I. Reiner, MD, VA Medical Health Care System; Michael Abiri, MD, Beth Israel Medical Center, New York; Anna Chacko, MD, Brooke Army Medical Center, San Antonio, Tex; Richard Morin, PhD, Mayo Clinic, Jacksonville, Fla; D.W. Ro, PhD, Georgetown University, Washington, DC; Kenneth M. Spicer, MD, Medical University of South Carolina, Charleston; Nicola Strickland, MD, Hammersmith Hospital, London; and Jeremy Young, MD, Medical University of South Carolina; at SCAR 2000 on June 3, 2000, in Philadelphia.
Eliot L. Siegel, MD, is director of imaging, Veterans Administration Maryland Health Care System, Baltimore, and associate professor, University of Maryland School of Medicine, Baltimore.