Optimal soft-copy reading rooms have a Feng Shui all their own. If the design follows certain principles that balance ergonomics and ambience, the result is a workspace that improves workflow as well as satisfaction for radiologists and referring clinicians.

"Replacing alternators with monitors does not a modern reading room make," said Paul Nagy Ph.D., director of the radiology informatics laboratory at the Medical College of Wisconsin (MCW), Milwaukee. "It's ironic that most people install PACS to increase productivity but ignore the changes that must be made to achieve it."

Good design for soft-copy reading takes into account the five "E"s: economics, environment, equipment, ergonomics, and ease of use. Developed by Nagy and PACS pioneers Dr. Eliot Siegel and Dr. Bruce Reiner of the VA Maryland Health Care System, these five tenets provide a framework for design of functional reading rooms (Figure 1).

Putting the five "E"s into practice may be easier for some than for others. While some sites have the luxury of building new soft-copy environments from the ground up, others must take their old film-based rooms and adapt them. And retrofitting has its pitfalls.

Conventional rooms have limitations that range from inadequate lighting to poor location of reading workstations and light boxes, excessive reflection and glare, minimal sound insulation, and overcrowding.

"The biggest challenge has been retrofitting space designed for alternators," said David Melson, manager of PACS and imaging applications at the Mallinckrodt Institute of Radiology. "In one area, we opened a new center for advanced medicine and were able to make filmless operations part of the design, specifying countertops, lighting, and ergonomic issues in advance. But in the rest of the facility, we've made do the best we can."

The typical reading station at Mallinckrodt includes both a PACS and a PC with access to ancillary applications such as electronic patient records, e-mail and the Internet, and voice recognition. Other stations also have a Dictaphone.

"Just getting the space for all of this-two computers and three to five monitors-and designing it in a way that is not too challenging ergonomically has been difficult," Melson said.

The challenge is familiar to Dr. Lucy Glenn, chief of radiology at Virgina Mason Medical Center in Seattle. The facility, which includes a downtown campus with hospital and outpatient clinic as well as six satellite facilities in a ring around the metropolitan area, is still making the transition to filmless operation.

"We're in the midst of redoing all our reading rooms so they're more in line with soft-copy ergonomics," Glenn said. "The difficulty is in standardizing all the workstations so that each is consistent."

Until recently, few guidelines existed for architects of filmless reading rooms. For many facilities, design is an intangible that is rarely a budget line item. That's a mistake, according to Nagy.

"Most PACS budgets have a set amount for the vendor, who is not being paid to consider ergonomics, furniture, or reading room design," he said. "It's up to the hospital to carve out a sliver of the budget for design and internal cosmetic changes and to actively protect it."

TRADING SPACES

Digital image and distribution technologies create opportunities for unconventional thinking when it comes to where and how radiologists work. Some sites have eschewed the traditional ballroom setup for reading, instead setting up satellite areas within the radiology department and beyond. Other facilities are migrating toward a hybrid solution: centralized areas for reading that are focused on specific areas of expertise.

Such is the case at Mallinckrodt. The university's PACS network links two hospitals on the north and south campus.

"Instead of staffing radiologists at both sites, we can be more efficient by moving all of the images to the radiologist, rather than the radiologist to the images," Melson said. "And we can offer the services of our super-subspecialists to Barnes West County Hospital as well. Referring physicians can send their patients there and have the world-renowned knee expert read their images much more quickly than in the past."

The centralized areas of reading expertise span 10 categories from bone-joint to neuroradiology. Clinicians can access images from their own desktops using a Web-based distribution service and then contact the relevant expert reading area for additional consultation with a radiologist.

At MCW, Nagy opted to keep the existing film-reading ballroom and transform it for soft-copy interpretation. His logic had to do with the collegial nature of the facility. The department wanted to maintain a large central area where radiologists could work together along with residents and fellows. The decision didn't come easily, however, as the way the ballroom had been used in the past colored perceptions of how it might be used in future.

"With alternators in the ballroom, it was a complete disaster, like a train station," he said. "People moved in and out with film, and physicians congregated in the center of the room having loud discussions. I don't know how any work got done."

But Nagy and other administrators persuaded radiologists that digital imaging could transform the ballroom into a useful area for soft-copy reading once the alternators were removed. The new design created 15 workstations as linked hubs radiating from the center of the room (Figure 2). Each workstation includes two monitors and enough room to accommodate two to three radiologists. Ergonomic chairs with customizable settings have mesh backs to enhance air circulation and maximize comfort.

Since an estimated 25% of radiologists' reading time is spent in on-the-spot consultations, the new room also includes an alcove housing a 42-inch plasma screen mounted on the wall of an adjacent workstation that can accommodate up to 15 people. The alcove and screen provide an opportunity for radiologists to consult with referring physicians without disturbing readers.

For image consultation or grand rounds conducted for larger groups, the university has installed a DICOM-compliant projection display in its conference room. The theater-style, rear projection system from Barco is designed to render image quality similar to gray-scale diagnostic monitors even when viewed in ambient light environments. The rear projection display, like others on the MCW network, is linked to sensors that permit remote calibration and quality checks.

"It's useful to have the sensor on the screen, so even though we are in the conference room, we can calibrate the display and have the exact same lookup tables as on a regular monitor," Nagy said. "We're not fighting windows and levels."

CULTURE SHOCK

Reading room design changes can spark more than productivity boosts. MCW's new design has led to an unexpected cultural change. Unlike the chaotic environment of the old film reading room, the new area has a more professional ambience. Consults among radiologists and visitors are conducted sotto voce instead of at maximum volume.

Another change is the contact point between radiologists and referring physicians in the room. In the old environment, open work areas made any radiologist fair game when a referrer came to call. In the new setup, workstations are inverted and only one faces the entry door.

Whoever loses the coin toss-or the on-duty resident-assumes the hot seat for the day, providing assistance, direction, and interpretation as needed.

"I've seen the body specialists do this-they kind of put up a sacrificial lamb to work at that station," Nagy said. "So instead of everyone being constantly interrupted, you have one person who is the point radiologist for the room. The others are more productive knowing that they can just bang out cases, and the person sitting at the main consultation booth knows what to expect as well. It's a new organizational dynamic."

SPECIAL ENVIRONMENTS

With the advent of digital image display and distribution, image reading no longer ends in the radiology department. The ability to access images across the medical campus means considering the demands of soft-copy image reading in clinical areas such as the operating room and intensive care.

Cramped space, sterile fields, and bright lighting are just a few of the special considerations to be taken into account when designing workstations for the operating room. A pilot program at Ohio State University tackled some of these problems by installing dual flat-panel monitors in six operating rooms. The CPU tower, keyboard, and mouse are mounted on a frame on the wall, and images are pushed to the OR by a Web server linked to the department PACS. Initial response by surgeons has been positive (J Digital Imag 2002;15[supp 11]:137-139).

As is increasingly the case in radiology reading areas, a flat-panel or liquid crystal display is the monitor of choice in the OR. Three-megapixel monochrome LCDs mounted on an adjustable boom arm provide plenty of pixel density for the OR environment (SCAR News, Winter 2002:1-2). The displays can also be customized by handles with sterile covers so that surgeons and assistants can position them as needed.

In the operating rooms at Virginia Mason, surgeons read images from a mobile 19-inch flat-panel monitor on a pole designed for the purpose, Glenn said. The display is located right outside the sterile field near the operating table.

Mallinckrodt is still looking for the right OR solution, but first it plans to test out different approaches to soft-copy display in the interventional radiology suite, Melson said.

"The interventional suites are very similar to an operating room environment," he said. "We're now trying to determine the best place for a monitor: Should it be mounted on a boot above the patient or on a wall and to the side? While there is clearly demand to provide images to the OR, that has been slated for later in the filmless transition."

FIGURE 1. The five "E"s of elegant room design. (Provided by P. Nagy)

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