Planning for the radiology department of the future requires more than technical knowledge or impressive design skills. Today, architects, physicians, and management personnel who intend to survive our chaotic environment are challenging every basic health care planning tenet. Nowhere is this more evident than in radiology, due to the overarching driver of change: digital technologies, with particular emphasis on picture archiving and communications systems (PACS). While outpatient and inpatient departments have evolved due to incredible changes in tools and techniques, one fundamental planning criterion today is that radiology reading environments will be organized differently due to the impact of PACS.
Historically, radiology departments and the spaces where radiologists read films were designed around basic determinants: space needed; number of rooms required; and room location. That model works if planning is facility focused without regard to strategic improvements.
A more current model considers very different determinants: work process; relationship between design and process; and flexibility to accommodate future needs. In this version, architectural process is an essential tool, a common thread that links all of the new digital imperatives. Any attempt to redefine the way radiologists and radiology support staff work must include an architectural component intent on facilitating and responding to change.
Because it enables the movement of information, not people, digital technology will have a profound impact on reading-room design. Digital images force boundaries to be eroded and reshaped, thereby challenging our basic assumptions about the best place for the radiologist to work, as well as issues regarding the placement and organization of radiological departments and technology. Digital imaging not only enables the management of information from a variety of sites, but also encourages access to the radiologist throughout the entire integrated health care system. Carefully planned and located, the PACS reading room supports patient-focus initiatives that empower not only the patient, but also families, radiologists, and staff.
Health care architects and their radiology clients must ask an important new question when planning any new PACS reading environment. Are we providing radiologists, as well as support staff, with the reading environments they need to work effectively?
The PACS Reading Room
Clearly, the days of burying radiology in the windowless depths of hospitals, painted dark and with limited lighting, have passed. In a film-based era, radiology departments evolved with scattered reading rooms, housing rows of light boxes and alternators, generally located near basic groupings of compatible imaging modalities. Again, the inability to move information meant that it was much more convenient to marry the radiologist to specific areas. As the need for radiologists grew with increased volumes at many hospitals, and radiologists became subspecialized, more reading rooms were added, creating confusion, duplication, and inefficiency.
Today, imaging is at the heart of the health care system, and the PACS-based reading environment is a critical component, mandating not only a strong functional and operationally efficient location, but also a location for being the best possible place for patient care.
Digital technologies, including PACS and teleradiology, mandate the creation of central information hubs, the radiologist reading room of the future. Because data is easily moved, the radiologist can be located more convenient to staff and referring physicians, enabling more radiologist involvement with patients and other specialists. A centralized, common reading area promotes collaboration and communication among radiologists. Today, in radiology as in other consultative businesses, group and team settings are becoming increasingly more important. Some new solutions successfully combine individual and team spaces (Figure 1 and Figure 2).
The concept of a completely digital PACS reading environment is very difficult to achieve today, and definitely will not occur overnight. What everyone is dealing with, some more aggressively than others, is the transition from film-based, hard-copy reading, to filmless, soft-copy reading. The reasons for a transition are clear. Few, if any, can afford the cost or withstand the system shock associated with an overnight PACS renovation. Analog imaging equipment will likely be repl..aced and upgraded to digital over a period of time. A certain amount of film review will always be required, for comparison or referral, which must also be phased out over a reasonable time, if ever.
Three specific reading-room design elements must be analyzed within each unique radiological setting: physical space demands, lighting, and ergonomics.
determining Physical Space
The majority of PACS reading spaces will be accomplished through renovation of existing spaces implemented over time versus immediate new construction. The opportunity to create an all-new digital department is on everyone’s wish list, but most projects will consist of difficult, phased renovation. Radiology reading spaces will consist of three types of workstations and all will likely be required during the transition: fully digital stations, film-based stations, and hybrid combination stations. In this scenario, individual work spaces will actually become larger than traditional reading cubicles. Those hybrid reading stations accommodate multiple film illumination, digital monitors for viewing images, and, most often, a separate computer workstation for information management and network communications. Shared workstations for manipulation of data and consults are often planned, as are conference and office spaces. Most departments in a transition mode will also include a separate teleradiology station within the team space. In reality, a state-of-the-art PACS reading room will require more space, not less, and consist of a variety of reading stations, which can be converted over time to a more fully digital environment (Figure 3).
- Program 125-sq-ft area minimum each for a hybrid reading station.
- Work surfaces should be 18-20 in deep — no more and no less.
- Consider adjustable, demountable furniture systems for reading.
- Select nonreflective finishes for walls and work surfaces.
- Use sound-absorbing materials for design details, including ceilings.
The single largest problem area in any reading room is related to lighting: glare, reflection, and inability to control lighting levels. This becomes even more of a problem in a PACS environment. Fortunately, through careful, deliberate planning, most of these problems can be avoided, without painting the walls black, eliminating any light fixtures, or building tiny reading closets. Many lighting innovations, used throughout the general building industry, provide excellent solutions for radiology reading environments. Examples include specially designed diffusers that provide controlled lighting patterns, indirect light fixtures that reflect light up instead of directly down onto screens, and lighting controls that provide dimming and preset lighting levels based on the work being accomplished and its location in the room.
- Avoid film illuminators at right angles to computer monitors.
- Avoid film illuminators in the direct view or peripheral field of view.
- Avoid placing light fixture or film illuminator directly behind a computer monitor.
- Do not use a film illuminator to light the room.
- Visit showrooms, retail spaces, and conference or meeting spaces to see how lighting is handled in other visually critical business settings.
Ergonomic design is very important, particularly within the hybrid reading environment providing both film-based and monitor screen viewing in a common workstation. It does not take an expert designer to realize that functional, useable spaces enhance job performance and satisfaction. Ergonomic design has been adopted by the medical imaging technology manufacturers for some time, directly benefiting patients. Now, these same types of design innovations must be part of PACS implementation design.
- Place frequently used devices within easy reach.
- Place the primary viewing device, film illuminator, or monitor screen at the optimal eye level height. Do not place these items based on an existing work surface height that happens to be there.
- When film illuminators and monitor screens are combined in one setting, place the illuminators above the monitors, with the surface face of the illuminators aligned with the monitors.
- Place control systems for lighting, electrical devices, phones, intercoms, and dictation where they ought to be for the work to be done efficiently, not somewhere because it always is done that way. Example: Why are light switches always on walls?
- Read up on human design factors and design standards with ANSI (American National Standards Institute) publications.
Redefining the design of a radiology reading environment requires the planning team to establish new rules and strategies. Before beginning any project, set time aside at an initial meeting, in order to identify those special rules and strategies that will help ensure project success. Every project will be different, due to scope, area, budget, or other determinants.However, consider these examples, which will apply to most projects:
- Design is a tool that advances strategy and creates lasting value.
- Planning should not be so transparent that it becomes easy to forget the details or miss the big picture.
- There is no one model for what the radiology reading environment should be.
- Thinking about digital is not enough — accomplish digital. The plan may be more important than the purchase.
- Planning should be based on supporting work process, not tradition or status.
- Create a radiology master plan that considers physical improvements, information infrastructure, and technology implementation.
No matter how the puzzle pieces are assembled, take advantage of the new digital technologies to rethink operational strategy, imaging management, and information delivery. Planning a state-of-the-art PACS reading room is more than design; it is the opportunity to reinvent.
Morris A. Stein is a founding partner and president of The Stein-Cox Group, a Phoenix-based architectural firm specializing in health care facilities, with emphasis on imaging, cardiovascular disease, and cancer treatment.