PACS Reading Room Design

Paul Nagy, Eliot Siegel, Thomas Hanson, Laura Kreiner, Ken Johnson, and Bruce Reiner

RADIOLOGISTS WILL CONTINUE to spendmore and more of their time interpreting

images in front of a computer monitor. As a result,everything possible should be done to make thiswork area comfortable and efficient to minimizefatigue and maximize radiologist productivity.This area should be designed to make radiologistsfeel that they are in the “game” rather than thepenalty box.

In this current era of declining reimbursement,undersupply of diagnostic radiologists, and withthe increasing volume and complexity of studies,radiologists are being asked to interpret morestudies, faster than ever before. The use of picturearchival and communication systems (PACS) has,in most cases, resulted in improved departmentalefficiency, especially when associated with re-engineering of departmental workflow. Technolog-ical developments such as improvements in net-work infrastructure, commercial off-the-shelfworkstations with more reliable and brighter mon-itors, improved image presentation and navigationsoftware, image enhancement, computer-aided di-agnosis, and integrated speech recognition havereceived a good deal of attention in the researchcommunity as candidates for improving radiologistefficiency and productivity. However, surprisinglylittle attention has been paid to the potential formodifications in radiology reading room design toenhance radiologist performance, either in theimaging literature or in the design or redesign ofradiology reading environments. Based on ourexperience, relatively small investments in roomdesign and workstation ergonomics can have amajor impact on productivity and accuracy with aconcomitant decrease in radiologist fatigue.

The requirements for an optimal room design fora digital, filmless department are very differentfrom those of a conventional film-based depart-ment.1,2 The film-based reading room design had toaccommodate a very different pattern of workflowthat included frequent interruptions from referring

physicians constantly searching for films of theirpatients, technologists, and/or clerks coming in andout to hang films for interpretation, bulky and verynoisy alternators that take up a good deal of space,and all or nothing lighting from bright fluorescentoverhead lights. A digital environment offers thepotential of freedom from many of the constraintsimposed by the analog film-based paradigm. Thereis, however, very little experience with the designof a digital departmental by hospital administra-tors, architects, radiology administrators, or radi-ologists. Departments that do not have direct ex-perience with a filmless environment may have aparticularly difficult time anticipating the manyunique opportunities and constraints associatedwith a digital department and filmless readingenvironment.

One of the major potential advantages of aPACS is its ability to decrease the amount of spacerequired for image interpretation as well as filmstorage. The prohibitive cost of space and thedifficulty finding expansion space in an existingdepartment are often overlooked and the benefitsof a digital department understated as is the flexi-bility and freedom obtained by not having to betethered to a film file room. PACS makes it easierfor a department to add modalities, and otherwiseexpand operations, without the same overheadtypically required to absorb additional film roomtraffic. The potential to create new areas for addi-tional computed tomography (CT) or magneticresonance imaging (MRI) scanners for examplemay be of enormous importance to an imagingdepartment.

Many imaging departments have succumbed tothe temptation to simply swap out the alternatorsfor PACS workstations or worse yet to stuff theworkstations next to existing film alternators. Thetransition to a PACS offers an excellent opportu-nity for a department to step back and reevaluate itsassumptions about the layout of the entire depart-ment, especially the image interpretation areas.

The ultimate goal of achieving the best possiblereading room design requires a careful balance of 2seemingly diametrically opposed concepts. Thefirst concept is productivity. The ideal environmentfor maximum productivity might, at first blush,seem to be one that isolates the radiologist fromcontact with the outside world so he/she can be as

From the Medical College of Wisconsin, Milwaukee, WI.Address reprint requests to Paul Nagy, PhD, Medical Col-

lege of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee,WI 53226.

© 2003 Elsevier Inc. All rights reserved.0037-198X/03/3803-0006$30.00/0doi:10.1016/S0037-198X(03)00049-X

244 Seminars in Roentgenology, Vol 38, No 3 (July), 2003: pp 244-255

productive as possible (maximize the number ofrelative value units per hour). The second basicgoal, however, is to achieve a high level ofaccessibility for collaboration and consultationwith radiology and clinical personnel. This goal toimprove accessibility is particularly important be-cause of the tendency for the consultation rate todecrease after the transition to filmless operationbecause of the universal enterprise-wide access toimages outside the radiology department. For ex-ample, there was a reduction of 82% in the“in-person” consultation rate at the Baltimore VAMedical Center (VAMC) for general radiographyand a 44% reduction for the cross-sectional imag-ing section after making the transition to filmlessoperation (Fig 1).3 Surveys at the BaltimoreVAMC indicated that clinicians attributed this tothe improved accessibility of current and compar-ison studies provided by PACS workstations thathad become available in clinical areas and officesthroughout the hospital.

Unfortunately, despite improved electronicmeans of communication and report turnaroundtimes, most radiologists believe that the report andimages alone cannot satisfactorily substitute for anin person consultation with a radiologist. Theradiologist adds substantial value when he/she areconsidered and appreciated as an integral as part ofthe “patient care team.”

The struggle between the need to maximizeaccessibility as well as productivity is epitomizedin the reading room design. PACS, because of the“any image anywhere at any time” concept frees usfrom the constraints of a centralized reading room.However, there is the tradeoff between radiologistswanting to work independently and wanting tocollaborate with their colleagues. Radiologists in-terpreting radiology examinations in their officescan become isolated from clinicians or other radi-

ologists. Radiologists located outside the radiologydepartment in clinical areas are at risk of becomingisolated from their radiology colleagues and thetechnologists. A shared reading room in the imag-ing department could be an optimal compromise.The goal is to make the radiologists as accessibleas possible to each other and clinicians but alsoallow them to work with a minimum of distractionsin a comfortable environment.

LESSONS LEARNED DURING THE PAST10 YEARS AT THE BALTIMOREVA

WITH BAD ROOM DESIGN

The Baltimore VAMC has the dual distinctionof being the first filmless department and hospitalin the United States as well as having the mostexperience with how not to design a filmlessradiology reading room. Despite the fact that thehospital and radiology department were designedfor digital rather than conventional imaging, thereading room was specified during the late 1980sbefore the idea to operate in a completely digitalmode was formulated. Unfortunately, the depart-ment was unable to make any subsequent modifi-cations to that original design once the decisionwas made because of federal construction regula-tions. During the past 10 years, we have identifieda number of deficiencies in the design, planning,and implementation of our reading room. Thefollowing is our list of top 10 mistakes.

Insufficient Planning

Although the planning for the PACS itself wasconsiderable including technology assessment,vendor discussions, cost analysis, and other activ-ities, very little thought was given to addressing thephysical environment in which this multimilliondollar technology would be used, especially theradiologist reading room. A relatively smallamount of time spent planning for the readingroom environment would have paid major divi-dends in productivity and radiologist comfort aswell as accessibility during the past 10 years.4

Room Design Similar to that of a ConventionalFilm-Based Department

One of the most common mistakes made bynovice PACS users is to try to emulate a film-basedsystem with a PACS including similar room designand similar expectations for image presentationand image characteristics.5 The transition to afilmless department offers the potential to substan-

Fig 1. The number of “in-person” consultations for gen-

eral radiography dropped by 82% from one per 7.5 cases to 1

per 42.1 cases between 1993 (film based) and 1996 (filmless).

245PACS READING ROOM DESIGN

tially improve workflow, the reading environment,and image quality. Our design was a single largereading room with workstations for 5 radiologistsin a single large reading area. This design wastypical for a film-based reading room optimized forfilm alternators and a central cart filled with films.This large room was also necessary in a film-baseddepartment for the numerous clinicians who cameto review their studies.

This conventional design proved to be unneces-sary and counterproductive. The ability to interpretany studies on any workstation obviated the needfor access to a central “cart” of images. Thedramatic drop in “in-person” consultations becauseof workstations distributed throughout the enter-prise made this large central design even lessnecessary. A much better room layout would havebeen to create partitions that would facilitate easyaccess to consultation among radiologists and withclinicians but would create sound and light isolatedreading areas to maximize productivity and mini-mize distractions.

WORKSTATION AND MONITOR LAYOUT

The layout of the workstations and monitorswithin each radiologist reading area was alsosuboptimal for a digital reading environment. An8-panel lightbox was placed on the wall adjacent toeach workstation for review of old films or outsidestudies. Although these were used occasionallyduring the initial transition to filmless operation toread prior films (the decision was made not todigitize old films onto the PACS because of logis-tic constraints) radiologists found that they couldhave easily tolerated a single-panel lightbox for oldand outside films. Although we elected to equipeach workstation with 4 monitors, a study per-formed at our facility suggests that radiologistimage interpretation times, even for conventionalradiographic studies, are similar for either 2- or4-monitor configurations (Fig 2). The use of 2rather than 4 monitors would have a major impacton space, noise, and heat generation as well asresult in substantial savings because most of thecost of a workstation is typically strongly depend-ing on the number of monitors. Recent advances inactive matrix liquid crystal display (LCD) technol-ogy has resulted in high-quality 3 megapixel dis-plays that rival traditional 5 megapixel cathode raytube (CRT) monitors. Studies performed at theBaltimore VAMC have not found any clinicaldifference in diagnostic accuracy when comparing

these 2 types of monitors and we have suggestedthat it is likely that active matrix LCD monitors areacceptable for primary diagnosis in general radi-ography. Other electronic devices such as dictationequipment, telephones, and personal computers foraccess to the electronic medical record (EMR) andthe Internet were initially placed in inconvenientlocations at the Baltimore VAMC. These should allbe placed within easy reach of the radiologistwithout the need to move his/her chair.

Room Lighting

According to our experience, the most importantfactor in radiologist performance in a reading roomis adequate lighting, both monitor brightness, andambient (background room lighting). This was anarea that was implemented particularly poorly atthe Baltimore VAMC. Our reading room has onlyoverhead, nondimmable industrial type fluorescentlighting. The light can be turned full on (bothswitches up), half on (one switch up), or off. Theradiologists keep the overhead lights off during theday and use the old lightboxes with a single panelwith a film on it for local and room lighting. Theonly staff members that use the overhead lights arethe housekeeping staff who uses them when clean-ing the room. These overhead lights may beacceptable for film-based departments in whichconventional viewboxes and alternators use lightsources that are 500- to 1,000-ft lamberts but theyare not acceptable in a softcopy environment suchas that at the Baltimore VAMC where the monitorsare set to a luminance of only 65-ft lamberts.

Studies performed at the Baltimore VAMC havefound that suboptimal monitor brightness results inincreased radiology reading times, decreased radi-ologist accuracy, and increased radiologist fatigue.Ambient room lighting is another critical factor in

Fig 2. There is a major improvement in radiologist inter-

pretation time for general radiographic studies when compar-

ing a single monitor to a dual monitor configuration. The

improvement is negligible when comparing a dual with a

4-monitor workstation.

246 NAGY ET AL

radiologist performance. One study performed atthe Baltimore VAMC found that there was a majorchange in the percentage of cases in which radiol-ogists modified an image using the window/leveltool depending on whether overhead fluorescentlights were turned off (45%), half on (72%), or fullon (window/level required in 91% of cases). Thishas major implications for radiologist interpreta-tion times and fatigue and probably stress levels aswell. Perhaps even more concerning is the fact thatinterpretation accuracy was also found to varydepending on ambient light levels from 85% accu-racy for clinically significant findings with thelights off (compared with an expert panel), 79%with the lights half on, and 74% with the overheadfluorescent lights turned fully on. We have learnedthat contrast discrimination for radiology interpre-tation studies is optimal when levels of ambientlight and the brightness of the computer monitordisplay are of similar intensity.

The use of softcopy monitors improved radiol-ogist productivity by 40% but this was accompa-nied by increasing complaints of fatigue and eye-strain when using the computer workstations.Increased radiologist fatigue was multifactorial inetiology; decreased monitor brightness (in compar-ison to a film lightbox), monitor flicker, smallcursor size, a more active role required for imagemanipulation, and lower ambient room light wereall believed to be important contributors to fatigue.Radiologists also reported visual fatigue and eye-strain, also probably related in part to monitorflicker and relatively low monitor luminance. Ad-ditional factors that contributed to radiologist fa-tigue included glare from other workstations andfrom the lightboxes used as a surrogate source ofroom lighting.

Environmental Controls

The room design at the Baltimore VAMC alsowas inadequate to meet the demanding environ-mental challenges posed by a digital environment.There was only a single thermostat in the roomlocated at a distance from the reading stations.There was limited ductwork located in the cornersof the room and dissipation of heat from thecomputers and monitors was very poor. In fact,room temperatures climbed over 100° F during thesummer of 1993 when PACS was first installedbecause of the tremendous amount of heat gener-ated by the 20 high-resolution monitors and 8 largecomputers and major work was required to recon-

figure the air conditioning units. During this pe-riod, computer monitor life expectancy was partic-ularly short, averaging less than 3 months.

Lack of Integration of Information Systems

The lack of integration of information systemssuch as the digital dictation system, PACS work-station, electronic medical workstation, and Inter-net PC and phone created an unnecessarily bulkyand unwieldy workplace for the radiologists. ThePACS vendor and hospital IT department havebeen reluctant to allow our workstations to operatemultiple programs simultaneously, despite the ma-jor savings in space and complexity that thisintegration would bring.

Noise

We did not make any special plans for noisecontrol for the Baltimore VAMC reading room.This also turned out to be problematic because ofthe noise from the fans within the computers andthe noise made by the high-resolution monitorsthemselves. No acoustic dampening materials wereused, and no sound reducing panels or barrierswere setup between the radiologists prompting oneof the radiologists to put up a sign beseeching hiscolleagues for “quiet.” The sensitivity to noisesfrom other radiologists, electronic equipment, de-partmental overhead paging systems, clinicians,and ventilation systems becomes especially criticalwith the introduction of speech recognition sys-tems, which typically try to interpret backgroundsounds as words that can significantly affectspeech recognition speed and accuracy.

Ergonomics

Ergonomic considerations were not adequatelytaken into consideration in the room design at theBVAMC. The workstation keyboards and monitorsare fixed in a suboptimal location and are not easilyadjustable. The chairs selected for the room lackadequate arm and lumbar support. These factorshave been shown in the industrial literature tocontribute to eyestrain, fatigue, low back pain, andoccupational repetitive stress disorders in employ-ees who use computer workstations. At the Amer-ican Roentgen Ray Society meeting in 2001, Reusset al reported four cases of cubital tunnel syndromeand one case of carpal tunnel syndrome in radiol-ogists in their department associated with the useof computer workstations.

247PACS READING ROOM DESIGN

Lack of Attention to Other Reading Rooms

Other departmental reading rooms such as thenuclear medicine, angiography, neuroradiology,and body imaging areas in the department havesimilar and in many cases even greater designlimitations. These areas have unique challengessuch as higher clinician traffic, more frequent needto communicate with technologists, and difficultyadjusting room lighting because of surroundingequipment or patients.

Workstation Environments Outside the RadiologyDepartment

Perhaps the greatest challenge in the healthcareenterprise is primary or secondary interpretation ofimaging studies made by clinicians or radiologistsin areas that are exceptionally difficult to controlsuch as the operating room, emergency room, andintensive care units. Workstations in the operatingroom have been a tremendous challenge and rep-resent another area that could be improved greatly.Relatively small changes such as the use of anarticulating arm for a flat-panel monitor to replacea CRT monitor against the wall and the use ofremote controls to advance to the next image orstudy would result in a major improvement accord-ing to our surgeons. Cramped space and limitedcontrol over lighting have both represented majorchallenges in the intensive care units and emer-gency room.

USER CENTERED DESIGN

When redesigning a reading room to move fromthe analog environment to the digital realm, itseems appropriate to ask an architect to lay out thenew room and fit in as many workstations aspossible into the space. With this approach to thedesign, the potential for a dissatisfactory environ-ment is high unless specific user requirements areaddressed. Most architects and hospital plant op-erations do not understand the unique requirementsof reading room design. To determine what theseuser requirements are, a process is needed thatcombines both the engineering skills of the archi-tect and a fair amount of user psychology. Aprocess that is gaining in popularity with softwaredevelopers and other design disciplines is user-centered design (UCD). UCD is an iterative pro-cess that involves working with the end users of aproduct from beginning to end of a new designcreation. This is an industry standard design pro-

cess used throughout the usability engineeringcommunity.

The 3 phases of a UCD project are as follows:1. Phase 1: Analysis—what do users like and

dislike about their current product or design? For areading room design project, interviews that arescripted with open-ended questions regarding thedesign and use of the current reading room. A userdemographic questionnaire is also distributed aswell as a questionnaire to capture the user’s viewsof the current reading room design. Finally, obser-vations of the users at work are conducted.

2. Phase 2: Design—from the information gath-ered in phase 1, design concepts are developed.This process involves collating and analyzing theresults of the demographic survey to arrive at asummary of the information from end users. Theinterview dialogs and observation reports are sum-marized and categorized. Examples of the catego-ries for the reading room are lighting, chairs, andaccessories (pointing devices) and physical roomlayout.

3. Phase 3: Evaluation—this phase can be themost fun and most frustrating for designers. In thisphase, a mockup of the design is created andtested. A mockup of a reading room workstationcan be built and evaluated by the users. Many referto this as “user testing” but in actuality, this phaseis “usability testing.” It is the design that is tested,not the user.

PHASE I ANALYSIS

The starting point for any User Centered Designproject is to gather information on the true endusers of the product. The Medical College ofWisconsin/Froedtert Memorial Lutheran recentlyconducted a UCD project to redesign the readingroom. A typical starting point to gather this data isto user a demographic survey form written specif-ically to gather the makeup of the user group.Pertinent demographic information may includethe age group of the user population, self-rankedcomputer skill level, likes, and dislikes of certaininput devices. Users are more willing to participateand complete the survey if it is simple and concise.Try to keep the demographic survey to the lengthof a single page (Table 1).

A short demographic and needs assessmentsurvey is conducted starting with collecting data onhow the users feel about the current (analog) roomdesign and how it relates to assisting or interferingwith their work. The collection tool for this data is

248 NAGY ET AL

also a simple survey that allows users to completethe form in a timely manner. Users are asked torank a series of attributes on a Lickert scale from 1to 7, with 1 being “poor,” in their opinion and 7being “excellent.” A 7-point Lickert scale is usedbecause many users will not use the ranking of 1 or7, leaving in essence a 5-point scale for ranking asshown in Figure 3. The information gathered willgive the designer the users’ view of what theylike/dislike about the current reading room designand will also spark an open dialogue of what theyfeel should be included in the new design. Thesesurveys also act as a good change management toolfor radiologists who have reservations aboutswitching from a film-based environment to asoftcopy one. Most radiologists will have someconcerns, and this is a good forum to capture andaddress those concerns. One-on-one interviewswith the users are conducted with a set of open-ended questions to prompt the user to speak freelyabout their concerns and suggestions for the newdesign. Through these dialogs, the designer canuncover elements that may not have been consid-ered if UCD was not used. The final step in theanalysis phase of UCD is to summarize the find-ings from the data collection. Summing the demo-graphic information will give the designer anoverview of the average end user; for example, “a52 year old, right-handed male, physician withintermediate computer skills.” Similarly, a sum-mary of the users’ views on the current roomdesign is produced from the questionnaire. Notestaken during the interview sessions are transcribedand summarized. The comments were consoli-

dated, where there was overlap, and summarizedby the design team.

Below is some of the output from the one-on-one interviews with the radiologists conducted atthe Medical College of Wisconsin/Froedtert Me-

Table 1. Interview Script—Prompting Questions

1. How long is the typical reading session?2. How often do you stand to read the films?3. How do you typically sit relative to the board? (Lean back, close to screen, standing).4. How many people typically will sit at one workstation? How do you tend to arrange the different people? (Radiologist,

referring physician, residents, medical students).5. Do you prefer the films to be prehung? What do you like or dislike about this (is it often done right)?6. Do you ever get headaches? Feel eyestrain? Back or neck pain? Wrist pain?7. Do you feel there is a noise problem? How would you remedy this?8. Do you feel the room is adequate for teaching purposes?9. What are the percentages of your time spent on the following: Hanging films, reviewing, consulting, dictating.

10. Do you have a preference in the style of the chair? (Armrests, high back).11. Do you currently feel there is enough desk space?12. Would you be willing to learn to use a modified keyboard or mouse?13. How does the current reading room feel with regards to space? (Too close, would be comfortable with closer).14. How often do you consult with referring physician or colleagues?15. Should referring physicians still have separate room for reviewing films?16. How should conferencing between radiologist and referring physician occur when films are online?17. Where should the sentence summary written on the jacket go in a filmless world?18. How do you feel your work will change with softcopy reading?19. What would you consider to be the most important factor in designing a new reading room?

Fig 3. Reading preference survey to understand the defi-

ciencies of the current design and explore the potential of a

filmless environment.

249PACS READING ROOM DESIGN

morial Lutheran Hospital. The questions were tocapture the opinions of the current design of thereading room and their thoughts and ideas for thenew “filmless” reading room design. The interviewresponses were broken down into 5 main catego-ries: room layout, “pod” or workstation design,accessories, chairs, and environment.

Reading Room Layout

In general, the reading room design needs toprovide both privacy and accessibility. It is neces-sary to create space in which radiologists canperform their work with minimal noise and inter-ruptions and at the same time be available forconsultation by their colleagues and clinicians.Separate areas need to be created that allow clini-cians to access patient examinations without inter-rupting the radiologists.

Pod Design

Workstation areas (pods) should be designed toaccommodate 2 to 3 people directly in front of thedesk area and an additional 2 to 3 people behindthem. Not all workstations need a large screensystem for teaching and conferencing, but eachwork group should have one. A challenge in thedesign will be the idea of providing privacy and, atthe same time, accessibility. All respondents be-lieve that view boxes are needed for “old” filmsand films from outside facilities. CT and MR staffmembers are comfortable with a 2-monitor work-station, whereas chest and orthopedic staff mem-bers asked for up to 4 monitors.

Accessories

Accessories include keyboards, a mouse, andtrackballs needed for work performance. It wasexpressed that a mouse or trackball is needed as

well as a keyboard. Additional types of pointingdevices are worth investigating. Phones are neededat each workstation as well as access to phonenumbers. Storage space for books and journalsshould be included. Placement of the monitors,mouse, and keyboard will be driven by the resultsof the usability testing of the pod mockup.

Environment

Comments regarding the overall environment ofthe current reading room state that it is not darkenough, too noisy, and the temperature fluctuatestoo much. Also, lighting needs to be planned thatwill not cause glare on the workstation monitors.

PHASE II DESIGN

Following the user analysis and gathering theirinput on the design of the current reading room andtheir desires for consideration in the new design, anIshikawa cause and effect or “fishbone” problemanalysis diagram is constructed. The goal of theproject (the “fish head”) is to construct an ergo-nomically elegant and functional reading room.The major categories that will affect the outcomeof the design (the “fish bones”) are based on theuser analysis. The analysis from the reading roomdesign project at the Medical College of Wiscon-sin/Froedtert Memorial Lutheran Hospital yieldedthe attribute categories of equipment, environment,economics, ergonomics, and ease of use. Eachcategory is further broken down into the compo-nents that can be designed and controlled toachieve the primary goal. The design team nextchallenge is to develop several designs that canthen be tested in phase III (evaluation). Whendesigning, the team should consider the data avail-able from other studies including the current trendsin seating, lighting and ergonomics (Fig 4).

Fig 4. Ishikawa fishbone of

factors that affect the reading

room environment.

250 NAGY ET AL

Ergonomics

Important considerations in redesigning thereading room are the overall ergonomics. Appro-priate desk height is required for physical com-fort. If possible, the work surface should beadjustable to accommodate the individual heightrequirements. Specifically for the intended usergroup, high-quality, ergonomically designedchairs are especially important. The chairsshould be adjustable in many directions, con-structed of a rip and strain-resistant fabric, andhave large wheels that can easily roll overcarpeting. Varying seat heights and back depthswill also be important in accommodating themany users. A good chair allows the user tocomfortably rest his or her feet on the floor, withthe thighs fully supported and approximatelyparallel to the floor. The user’s back should becomfortably supported, and the angle formed bythe thighs and the torso should be betweenroughly 90° and 105°. Tilting back should beeasy but not too easy, and the chair shouldpermit frequent posture changes. The top of themonitor should line up with the top of the headso there is no strain in the neck when looking upor down. We found that we could also raise themonitors higher because some people tend tolean back in their chair and their line of sightangles upward. It was agreed by consensus thatthe keyboards should not be in pull out drawersbut instead be placed on top of the table at anergonomic height. Pullout keyboards can bumppeople in their knees and push them away fromthe monitors and the desktop.

Following is a brief compiled list of ergonomicbest practices.

1. Screen positioned at arm’s length2. Wrists straight3. Wrist support4. All dictation controls within easy reach5. Shoulders relaxed6. Ears, shoulders, and hips lined up vertically7. Elbows bent at 90°8. Stand up workstations can provide a break

from sedentary reading stations; this can help withusers with back problems

9. Foot rest if chair is too high10. Meshed chairs provide better aeration to the

back11. Good lumbar support in the chairs12. Adjustable arm rests and seat height

Environment

Lighting. Another important consideration inthe new design is lighting. The room should be litindirectly with shaded lights mounted above andbehind workstation. The use of “up” lighting willaid in reducing eyestrain and potential glare on thereading surface. This lighting design can workexceptionally well with high ceilings. One of thechallenges in designing a room to be dark butadequately lit for common tasks is to “accommo-date the low general luminance for computer workwhile simultaneously attenuating other light.” Neu-tral-colored fabrics will help to minimize reflectiveglare. The typical high resolution 5-megapixelPACS monitor has an output between 60- and 70-ftlamberts, which is approximately one tenth of thelight cast from typical lightboxes. The best sourceof lighting is one that is indirect and coupled withadditional task lighting. Good practices includetrying to avoid monitors from opposing one an-other to reduce glare as well as trying to avoidhaving monitors oppose open doors where hallwaylight will also create glare. The low level indirectlighting should be dimmable, flicker free, and asclose to the natural spectrum of sunlight as possi-ble. Higher-end fluorescent lighting with magneticballasts can be dimmable, flicker free, and have acolor rendering index (CRI) in the low to mid 90s.The CRI is a relative index describing how closethe spectrum of the light matches the spectrum ofsunlight. High CRI fluorescent lights are also usedin photography and for painters. Incandescentlights provide good coloration but also create anunwanted amount of heat.

Sound protection. Radiologists have becomeacclimated to the chaos of the traditional readingroom environment with rumbling alternators, therustling of film jackets, and the constant foot trafficof film transport. With few physical barriers, thesound of one conversation or dictation is carriedthroughout the room. The only mechanism thatcurrently helps to minimize this is the noise beingdrowned out by the sound created by the alterna-tors. With the alternators no longer present in thefilmless environment, it is imperative that parti-tions, along with sound-absorbing materials beused in the design. The walls in the design shouldnot only block but also absorb some of the sound inthe room.

Even though a normal conversation (65 dB) isonly half as loud as a ringing telephone (73 dB) ora quarter as loud as a copy machine (81dB), the

251PACS READING ROOM DESIGN

“information content” of normal conversationmakes it much more distracting than the muchlouder equipment noise in the open-plan office.The information content also carries a long, longway; even with carpet and a very sound absorbentceiling, a conversation held in open space can beeasily understood 32 ft away.

This is where workstation panels become anexcellent solution. The panels and hang-on storageelements serve to bend the sound waves comingfrom adjacent work areas. A bent wave has a muchlower probability of reaching the ear and thusbeing heard. Another good alternative is to con-sider is the use of noise cancellation headsets thatcan provide better dictation quality as well asreduce hand strain from repetitive tasks; however,headsets can be uncomfortable after a few hours ofwear and they may be distracting to radiologistsand counterproductive to dictation and communi-cation. A third option for reducing the crossoversound within the reading room is through the useof sound-masking devices. A sound-masking de-vice is actually a white noise generator that soundslike an air conditioner that will make conversationunintelligible outside of a short distance and pro-viding acoustic privacy. They have been shown tobe effective of reducing the overall sound level ina room and making people more productive. Thesesound-masking devices are also sold as ways toensure patient confidentiality.

Temperature. Keeping the room temperaturecomfortable is important to maintaining good pro-ductivity. Contributors to the temperature are thecomputers, incandescent lighting, the number ofpeople in the room, and especially medical-gradehigh-intensity CRT monitors. Ventilation can dis-sipate heat but can also create noise. Make sure allventilation has suitable filtration because monitorsand computers can be sensitive to dust buildup.

Accessibility. Simply arranging desks to re-place the alternators would be a waste of valuablespace and current technology. The new designshould allow for better lighting and ventilationwhile accommodating the general desire to have amore private reading area and maintaining theability to consult with colleagues. A modulardesign is the solution to the PACS-reading roomredesign. Avoid exposed workstations that areadjacent to high-traffic areas without partitioning.Motion in the peripheral field of view is distract-ing. With alternators, this is usually not a problembecause they are against a wall and large. Consider

the use of screens or partitions. Walkways betweenworkstation need to be wide enough space to walkthrough for wheelchair accessibility. The use ofconventional doors presents issues of fire safety,light pollution, security, privacy, and accessibility.Radiologists typically need quick and easy accessto the areas that contain the various imagingmodalities.

Equipment

Chairs. Selecting task seating is one of themost critical decisions in terms of health, comfort,and productivity at a workstation. The human bodydid not evolve to live in chairs. Chair sitting isgood for literate, focused, detail work, but toomuch of it is bad for your spine, your calves, yourarms, shoulders, and your neck. Significant effortshave been made by numerous companies in devel-oping the ideal chair for working extended hours atcomputer workstations (Herman Miller, Zeeland,MI; Steelcase, Grand Rapids, MI); however, whichone (or ones) are the best choice for you dependson a number of factors. One of the most significantissues to consider is the complexity in adjusting thechair. Although some chairs are ideal when theyare properly adjusted, in a busy reading area inwhich many individuals are working, these maynot be the right choice. A good chair should havelumbar support and a mesh fabric to provideaeration to the back.

Computers. Personal computers should be outof view but accessible for periodic maintenance ortroubleshooting. Computers can be considerablynoisy. The use of high RPM SCSI hard drives orthe use of smaller diameter higher speed fans willcreate whining sounds. Consider using larger,slower, quiet-bearing fans, and quiet hard drives inthe personal computers to reduce the noise levelscoming from the computer. To compensate for theperformance degradation, consider using additionsolid state random access memory that is faster andmakes no noise.

Monitors. The general preference is for 3 mon-itors, 2 for reading with as little button clutter aspossible and 1 for worklist and informationsources.6 Computer access is desired to otherinformation systems within the hospital as well asfor academic functions such as literature searching.

Viewboxes. One or 2 viewboxes to view priorsand outside studies that are film based should belocated at each workstation.

Telephone and dictation station. Each work-

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station needs to be equipped with a phone anddictation system. Incoming telephone calls aregrouped to several telephones for each area withinradiology.

Slave monitors. Several departments employthe use of slave monitors to see what is going on inthe modality. We were able to discontinue the useof slave monitors by getting the PACS to conduct“in-progress” viewing of images. As images areacquired, they are streamed to the workstation forin-line reading. This was able to cut down theclutter and distractions of the reading room design.If the reading room is not locked down or staffed24 hours 7 days a week, then these monitors alsopresent privacy concerns.

Economics

Make sure that the reading room is not anoversight of the PACS budget. Even if there is aline item for the reading room, there is also thePACS budget squeeze. Although the reading roomis usually a small line item in the PACS budget,any cost overruns in the infrastructure or thevendor costs can squeeze it. This can be attributedto the fact that the reading room design is notconsidered as critical as upgrading the networkinfrastructure or getting the PACS functionallyintegrated. Make sure the reading room has achampion on the committee in charge of thebudget.

Ease of Use

The workspace should be designed to be smallenough to create a semiprivate feeling while filmsare being read but also open enough to accommo-date the larger teaching groups and encourageconsultations. The desktop should be large enoughto have room for all of the necessary equipment butat the same time keeping those things within reachto minimize strain caused from constant reaching.The workspace covers 120° orientation that pro-vides the feeling of cockpit and automaticallycreates a more open atmosphere compared with asomewhat cramped 90° corner cubicle worksta-tion. The room is designed so that each station willbe appropriate for teaching; however, for thoselarger groups, plasma screens will be available forprojecting the images in a more accessible manner.Appropriate signs can be added to the designedsystem to indicate which types of images arecurrently being read at which station.

PHASE III EVALUATION

Phase III of a UCD project is challenging andfrustrating. The goal of the evaluation is to deter-mine what is right and what is wrong with thedesign before it is “cast into stone.” A simple andcost-effective method to conduct usability testingis to build a prototype of the design(s) for users toevaluate. Is it important to note that usabilitytesting is not user testing; it is the design that istested, not the user! Design mockups can bequickly built from simple materials such as card-board and foam core. A simple mockup lends itselfto honest feedback from the users. If a prototypehas too much of a “finished” look, users will tendto not be as critical for fear of hurting the design-er’s feelings (Fig 5).

Once a prototype is built, usability test sessionscan be planned. The designers decide what featuresof the design are in need of feedback. A set of testscenarios or tasks is developed for use in each testsession. Usability tasks and scenarios should bephrased as open questions to avoid “leading” theuser to a specific answer. For example, instead ofasking a user “do you think placing the keyboardon the desktop is better than using a pull-outdrawer” the question should be phrased “show mewhere you would like to have the keyboardplaced.” Documenting, and if possible videotaping,the usability sessions is essential for evaluating theuser feedback.

Design issues will usually reveal themselveswithin the first few usability sessions. And, with aprototype made of simple materials, changes caneasily be incorporated for future sessions (Fig 6).The data collected during the usability testing issummarized and analyzed. From the analysis, ofwhat works and what does not, the prototype is

Fig 5. Picture of mockup testing to determine layout of the

workstation preferences.

253PACS READING ROOM DESIGN

modified and the design retested. Usability testingand evaluation is complete when the design isaccepted by the users. In practice, time and costalso play a vital role in determining the conclusionof the testing phase.

THE FINAL DESIGN

This section will focus on the reading roomdesign project at the Medical College of Wiscon-sin/Froedtert Memorial Lutheran Hospital, whichis an academic teaching hospital located in Mil-waukee, WI. The academic and teaching aspects ofthe institution change some of the priorities thataffect the design, but the process should be appli-cable to private practice groups as well. The basisfor our solution was looking at current best prac-tices around the industry. Dr Osman Ratib, UCLA,came up with the concept of the inverted cubedesign.7 This design challenges normal assump-tions about placement of workstations in a room. Ina traditional reading area, the workstations oralternators line the walls. This is a poor utilizationof space because it is more likely that alternatorswill be facing one another and causing glarereflections. This also “pushes” all the cliniciansinto the center of the room where it is more likelyto cause a distraction where everyone can hearwhat everyone else is saying. The novel concept isputting the workstations in the center of the roomand facing those outward. This will add privacy for

each workstation as well as breakup the flow oftraffic in the room and minimize workstationsbeing opposed to one another. We took the in-verted cube design and tried to integrate thatconcept with a single large room as opposed tomany small reading rooms. By using the inverteddesign, we were able to comfortably place 14workstations into our reading room design,whereas only 10 would have fit using a “hug thewall” design (Fig 7).

Key Points From Reading Room Layout

A room of 3 standing workstations next to thefilm room for clinicians. This will become theentrance to the reading room from the back corri-dor. This clinician review room is to give imme-diate access of images to clinicians who comedown to the department who do not need to consultwith a radiologist. Although access to images isavailable across the enterprise, it is still expectedthat some clinicians will come down for older filmsand access to images.

An alcove that can accommodate up to 15people with a telescoping arm to shield the groupfrom the rest of the room. A 42-inch plasma screenis mounted on the wall as a slave monitor to amonitor on both workstations that it is adjacent to.The plasma screen can provide a larger viewingfactor for people who are standing back at 5 to 10ft away. Workstations in the center of the roompointing outward break up the flow of traffic in theroom pushing the flow to the sides of the room asopposed to congregating in the center.

Openness and Privacy

The workstations are all in the same room soclinicians know where to go to find the radiolo-gists. At the same time, the workstations havewalls and many workstations are quite secludedfrom the traffic in the reading room and should beconducive to getting work done, exposing the mostfrequently visited areas to be closest to the doorsand readily accessible to clinicians. Areas identi-fied as being high-traffic consultation stations werechosen for covering areas such as the intensivecare units.

The use of modular workstations minimizes thedisruption of reading services during the construc-tion phase. No walls were knocked down orconstructed that would have wreaked havoc on thereading environment. This makes the process fasterand less painful to the radiologists. Modular work-

Fig 6. Picture of testing room. A layout of the Herman

Miller Resolve product with a mock dictation station. This

layout was used for final usability testing. Shown above is a

light-diffusing canopy and to the right are light boxes hanging

on side partition.

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stations can be assembled onsite quickly withoutthe overhead of normal construction projects. Ca-bling for power, lighting, communications, anddata were dropped from the ceiling into conduitsdown power poles that could serve each of theworkstations that are located in the center of theroom.

CONCLUSION

The medical imaging community can derivetremendous benefit from studying and applying

techniques used in industry to the challenges ofradiology room design. This, when combined withthe last 10 years of experience with suboptimalPACS reading room environments should allow usto revolutionize this underemphasized but criticalaspect of our medical practice. Studies and surveysperformed at our institutions suggest the potentialfor major gains in productivity, accuracy, comfort,and potentially job satisfaction that can beachieved with a well-planned and implementedradiology room design process.

REFERENCES

1. Siegel E: Designing command central. Imaging Econ 20002. Siegel E, Reiner B: Radiology reading room design. The

next generation. Available at: www.imagingeconomics.com/library/200007-08.asp. Accessed June 1, 2003.

3. Reiner B, Siegel E, Protopapas Z, et al: Impact of filmlessradiology on frequency of clinician consultations with radiolo-gists. Am J Roentgenol 173:1169-1172, 1999

4. Siegel E, Reiner B, Abiri M, et al: The filmless radiologyreading room: A survey of established picture archiving andcommunication system sites. J Digital Imaging 12:22-23, 2000(Suppl 1)

5. Rostenberg B: Reading rooms should be designed toaccommodate future change. Available at: www.dimag.com/db_area/archvies/2002/0202.rosenberg.di.pacs.shtml. AccessedJune 1, 2003

6. Bennett W, Vaswani KK, Mendiola JA, et al: PACS moni-tors: An evolution of radiologists’ viewing techniques. J DigitalImaging 15:171-174, 2002 (suppl 1)

7. Ratib O, Valentino D, McCoy M, et al: Computer-aideddesign and modeling of workstations for radiology readingrooms for the new millennium. Radiographics 20:1807-1816,2000

Fig 7. Reading room layout.

255PACS READING ROOM DESIGN