X-Ray Reading Room Next Generation

www.appliedradiology.com APPLIED RADIOLOGY©� 11April 2002

In the current era of dwindling reim-bursement, undersupply of diag-nostic radiologists, and increasing

volume of studies, imaging depart-ments are asking radiologists to inter-pret more studies than ever before. Theuse of picture archival and communica-tion systems (PACS) has resulted in

improved departmental efficiency inmost cases, especially when associatedwith the re-engineering of departmen-tal workflow. Technological develop-ment, such as improved networkinfrastructure and speed, faster work-stations with more reliable and brightermonitors, improved image presenta-tion and navigation software, imageenhancement, computer-aided diagno-sis, and integrated speech recognitionhave received a good deal of attentionin the research community as candi-dates for improved radiologist effi-ciency and productivity.

However, surprisingly little atten-tion has been paid to the potential ofimprovements in radiology readingroom design as a means to enhance

the performance of radiologists.1

Experience and research performed atour facility, the Baltimore VA MedicalCenter, suggest that relatively smallinvestments in room design and work-station ergonomics can result in majorgains in productivity and accuracywith a concomitant decrease in radiol-ogist fatigue.

The Baltimore VA Medical Centeropened in 1993 as a replacement facil-ity for an older hospital previouslylocated in the northern part of the city.Although the hospital was designedoriginally as a high-technology replace-ment medical center with an emphasison the infrastructure to support digitalimaging and a paperless electronicmedical record, the concept of filmless

Radiology reading room design:The next generation

Eliot Siegel, MD and Bruce Reiner, MD

Dr. Siegel is the Director of Imagingat the VA Maryland Healthcare Sys-tem (VAMHCS) and an AssociateProfessor at the University of Mary-land School of Medicine; Dr. Reineris the Director of Radiology Researchat VAMHCS and an Associate Profes-sor at the University of MarylandSchool of Medicine, Baltimore, MD.

12 � APPLIED RADIOLOGY© www.appliedradiology.com April 2002

operation came relatively late in theplanning phase for the facility. Thegovernment rules concerning hospitaldesign and construction precluded“last-minute” changes to the depart-mental or reading room design, despitethe fact that we knew that we werepurchasing an enterprise-wide PACSfor a conventionally designed depart-ment. This resulted in the need to place5 four-monitor diagnostic imagingworkstations in a reading room thatwas originally intended for film.

Our PACS has been in operation foralmost 9 years and radiologists have beenreading using soft-copy interpretation forthe past 8.5 years. This means that wehave the dubious distinction of havingmore experience not only with soft-copyinterpretation but also with the conse-quences of a poor PACS reading roomdesign than any other facility in the UnitedStates. Our experience has allowed us toshare with visitors and others how to and,perhaps more importantly, how not todesign a filmless reading room.

Room layoutThe initial design for the radiologist

reading room called for a single largereading area with workstations forfour or five radiologists to interpretprimarily the conventional radi-ographic studies performed in thedepartment. The room was locatedadjacent to a large area designated asthe “file room.” This design was mod-eled after most “general read” areas inother imaging departments (figure 1).A large central reading room is typi-cally necessary in a film-based envi-ronment to accommodate not only theradiologists interpreting films but alsothe film room carts brought withbatches of studies to be interpretedand the many clinicians who “round”in the radiology reading room usinglight boxes or film alternators. No par-titions were used to isolate the radiol-ogists from each other since glarefrom overhead lights or adjacent viewboxes is typically not a problem in aconventional reading room.

However, in a filmless, soft-copyreading environment, a large centralreading room for general radiographyis no longer necessary. Radiologistscan read from any location in thedepartment or potentially anywhere inthe hospital (or outpatient center),since images are available or can beretrieved to any location on the PACSnetwork. The other traditional reasonfor a large central reading area was toserve as a central location for radi-ographic consultations with the clini-cians. However, as shown in figure 2,the consultation rate for general radi-ographic examinations fell from 1consultation per 7.6 examinations to 1in 42 (and has continued to decreasesince we published the study).2

In our department, this dramaticdecrease in one-on-one, in-personconsultations has also altered therequirements for a central congregat-ing place for clinicians and consulta-tions. This change has also beenconfirmed by other facilities with

FIGURE 1. The reading room at the Baltimore VA Medical Center was designed originallyfor a conventional, film-based operation. It serves as a “poster child” for an improperlydesigned filmless reading environment.

45

40

35

30

25

20

15

10

5

0

42.1

7.5

Studies Per Consult

Baltimore '93 FilmBaltimore '96 Filmless

FIGURE 2. The easy access to PACS workstations throughout the hospital has resulted in adramatic decrease in the frequency of “in-person” clinician consultations in radiology from 1 in 7.5 to 1 in 42.1 for conventional radiography.


filmless imaging departments. As thenumber of consultations has decreased,there is even less need for a large, cen-tralized reading room. In a soft-copyreading environment, consultations aremuch more likely to take place viaphone, e-mail, annotation of images byradiologists, or via fast report turnaroundtimes. Fortunately, report turnaround hasdropped considerably, to the point wherestudies from the ER, for example, areoften interpreted prior to the patientreturning to the emergency room fromthe radiology department. Consequently,the radiology report itself, rather than an“in-person” consultation, becomes themeans of communication of the imagingfindings. Room partitions may be

unwieldy for clinician traffic in a conventional radiology department, butthey can be very helpful in reducingunwanted glare and noise in a filmlessroom since clinicians visit less often.

Our current reading room environ-ment is still a hybrid that features bothlight boxes for film and PACS work-stations for soft-copy interpretationfor each radiologist. This is despitethe fact that old films from our ownhospital are never reviewed now thatwe have been filmless for almost 9years, and the fact that films from out-side institutions are infrequently sub-mitted for evaluation. Our new roomdesign will include only a single view-box to be shared by all radiologists.

Although we originally utilizedfour-monitor workstations to emulatefilm alternators more closely, and ourradiologists who interpret conven-tional radiographic images prefer fourmonitors, our research has demon-strated that the use of two-monitorworkstations results in comparableradiologist efficiency when comparedwith a four-monitor configuration(figure 3).

Room lightingBackground room lighting, which

was thought to be relatively unimpor-tant in the original design for a film-based reading area, becomes criticallyimportant in a soft-copy environment.This is due to the very low levels oflight associated with a typical high-resolution 5 megapixel (2,000 by2,500 pixel) PACS monitor, which hasan output typically in the range of 60to 70 foot-lamberts. This figure isapproximately 1/10 of the light that isassociated with conventional light-boxes, which can range between 500and 1,000 foot lamberts. We have per-formed studies previously that havedocumented the importance of anoptimal balance between monitorlight and background ambient roomlighting.3 Decreased radiologist pro-ductivity (increased interpretationtimes), decreased accuracy, andincreased fatigue levels were seenwhen using monitors that were lessbright when compared with those withhigher luminance. Other studies per-formed in our reading room have docu-mented that ambient room lighting isalso very important in radiologist per-formance. For example, the use of win-dow/level workstation tools increasedfrom 45% to 72% to 91% as the back-ground light levels in our reading roomchanged from off, to half on, to com-pletely on (using overhead fluorescentlights). Fatigue levels increased dra-matically as background light levelsincreased as well (figure 4). As was thecase with decreased monitor lumi-

100

80

60

40

20

0

Number of Monitors

Seconds123

FIGURE 3. Radiologist interpretation times dropped substantially when using two ratherthan one monitor, but there was only a minimal improvement when using four monitors.

70%

60%

50%

40%

30%

20%

10%

0%

Off Half On Full On

Low Fatigue

Medium Fatigue

High Fatigue

FIGURE 4. Fatigue levels increased significantly as the ambient room light levels increasedfrom off, to half-on, to full-on.


nance, higher ambient light levelswere also associated with significantlydecreased interpretation accuracy.These studies underscore the impor-tance of striking a balance betweenambient room lighting and monitorbrightness. The use of newer genera-tion, higher brightness, active-matrixLCD displays is likely to permit radi-ologists to once again increase thebackground lighting levels in readingrooms, freeing radiologists (as was thecase decades ago with developmentsin fluoroscopy equipment) from theconstraint of reading “in the dark.”

The lighting in our radiology readingroom currently uses overhead indus-trial-type fluorescent fixtures that arecomparable in brightness to the filmviewboxes. These lights have on/offswitches located near the entrance tothe room and cannot be dimmed orindividually controlled by the radiolo-gists. Additional lighting is provided byconventional light boxes that were orig-inally intended for film display prior tothe implementation of the PACS. Theradiologists place old films, often hungupside down or sideways, on the lightboxes, which results in a modicum oflight for the radiologists. But this solu-tion is a very poor substitute for ade-quate individual task lighting. Thesuboptimal brightness of the earlyPACS monitors, coupled with the lackof true task lighting in our readingroom, has resulted in an increase in thenumber of complaints of eyestrain andfatigue comparison with that expectedin a film-based environment. Other fac-tors that might have contributed to theincreased fatigue are monitor flicker,small cursor size, and the more activerole required for image manipulation.

In order to improve ambient light-ing, it is important to remember fourprimary objectives in the radiologyreading environment: 1) general illu-mination levels for computer tasks, 2) illumination for reading tasks usinglocalized light sources, 3) balance ofbrightness levels in the user’s field of

view, and 4) control of monitor reflec-tion. In order to accomplish theseobjectives, a combination of indirectoverhead lighting and local task light-ing, using dimmable sources, can beused to provide maximum flexibilityfor each radiologist. Moveable parti-tions can be helpful to further fine-tunethe control of local and general lighting(as well as to reduce ambient noise lev-els). A number of sites have repaintedthe walls of the reading room with darkcolors in an attempt to further reducereflected light from the walls. We arenot aware of any studies that suggest aspecific color or color combination toreduce fatigue and improve productiv-ity in a radiology reading room.

Temperature and ventilationThe contribution of improved air

conditioning and individual tempera-ture and ventilation controls is typi-cally underestimated in the design offilmless radiology reading environ-ments. Improved air handling is espe-cially important, in some cases, due tothe high heat output of high-resolutioncomputer monitors and workstations

and because of the greater sensitivity ofthe PACS equipment to temperatureand humidity than film and film-basedviewboxes. Radiologists who arealready subject to increased fatigue as aresult of the transition to soft-copyinterpretation may be even more vul-nerable to the effects of increased heatand poor ventilation. When the Balti-more VA PACS first became opera-tional in the summer of 1993, wequickly discovered that the readingroom air conditioning and ventilationsystems were overwhelmed, and tem-peratures exceeded 100 degreesFahrenheit when the door to the read-ing area was closed. Monitor lifeexpectancy at that time (due to a com-bination of increased temperature andinherently unreliable first-generationPACS monitors) was a surprisinglyshort 3 months and radiologists’ coffeebreak frequency and duration soareduntil additional air conditioning capac-ity was installed. Our experienceunderscores the importance of ade-quate planning for air conditioning andventilation in the reading rooms. Ourplans for the new, redesigned reading

FIGURE 5. Dr. Abe Obuchowski, Director of Neuroradiology at the Baltimore VA MedicalCenter, must have access to the PACS workstation, digital dictation, the electronic medicalrecord, the Internet and Intranet, e-mail, and Microsoft Office (Redmond, WA) programs.


room include not only better individualcontrol of local and general lighting,but also individual ventilation controlssimilar to those available in most auto-mobiles. We believe that a smallexpenditure in improved air handlingwill result in improvements in produc-tivity and decreased fatigue, althoughwe have not yet rigorously tested thisin our laboratory or reading room.

SoundAnother key factor that was not con-

sidered in the initial reading roomdesign was the impact of ambient noise.After we made the transition to a soft-copy department, we quickly learnedthat computer workstations generate agood deal of background noise that canbe distracting during image interpreta-tion and dictation. Although one-on-one consultations have decreasedconsiderably, telephone communica-tions with clinicians have increased. Ina single, large reading space withoutcarpeting or other sound-absorbing par-titions, we believe background noisecan have an adverse effect on radiolo-gist fatigue and productivity. We plan to

attempt to quantify the effect of back-ground noise on radiologist perfor-mance in future studies. The recent,partial introduction of speech-recogni-tion systems in our department hasmade us much more aware of distract-ing background sounds such as a noisyventilation fan, the phone, overheadhospital paging system, or other radiol-ogists dictating in the same room, all ofwhich can decrease the accuracy ofthese systems. We believe that the useof acoustic dampening materials, suchas carpets and sound-absorbing panels,will ameliorate some of these problems.The impact of background music, whitenoise, or even active sound cancellationhas not been documented adequately inthe radiology literature and these areconsequently interesting avenues offuture research in our laboratory.

Integration of information systemsand ergonomic workstation design

As the hospital moves toward anelectronic medical record and radiolo-gists become increasingly reliant oncomputer information systems andother electronic systems, it becomes

increasingly evident that these sys-tems must be integrated. Radiologistsat the Baltimore VA currently requireaccess to the PACS workstation, theInternet and Intranet, a speech-recog-nition or digital-dictation system, thehospital “paperless” electronic med-ical record, e-mail, office software(such as word processing), and thetelephone (figure 5). These functionsshould be able to run on a single multi-tasking workstation that should bedesigned to allow easy access to all ofthe features on demand.

Despite the fact that our corporatecounterparts have documented theimportance of optimizing theergonomic design of the workstationuser, the radiology literature has paidscant attention to the importance ofthis in reading room design. The radi-ologist’s chair, workstation table, key-board, mouse, and monitors should bedesigned to maximize comfort andefficiency. The architectural literaturemakes specific recommendations con-cerning optimal viewing angle anddistance for computer monitors.1 Alarge body of literature exists regard-ing airplane cockpit design thatclearly documents the importance ofergonomic factors.

Other reading environments within and outside the radiology department

In addition to the main readingroom, which is used primarily for theinterpretation of conventional radi-ographs (computed radiography, digi-tal radiography, and fluoroscopy), theBaltimore VA has soft-copy readingareas in other locations in the depart-ment, such as angiography, neuroradi-ology, cross-sectional imaging, andnuclear medicine. Each of these loca-tions has its own unique challengeswith regard to lighting and sounddepending on its proximity to otherworking areas in the department, oftenwith limited ability to control roomlighting, noise, and ventilation.

FIGURE 6. Dr. Thomas Stair, Emergency Room physician, is pictured with a PACS worksta-tion located in a typical physician workroom with poorly designed overhead fluorescentlights, cramped space, and an inadequate chair and table.


As we move outside the imagingdepartment to workstations located inthe emergency department, the inten-sive care units, and the operatingrooms, it becomes apparent that theseenvironments are even more difficultto control (figure 6). For example, oneof our PACS workstations is located inthe admitting area of the emergencydepartment where lighting and soundare clearly impossible to control as istrue, of course, of the operating roomsand the intensive care units. In theseareas, restricted physical access tothese workstations, which will be man-dated under the HIPAA regulations,will require additional technologicdevelopments such as a radiofre-quency-controlled identification cardthat can automatically sign users ontoand off of a PACS workstation in a rel-atively “public” location. We have per-formed a study that has documentedlarge variations in background sound(both average and instantaneous) in thenumerous areas throughout the hospi-

tal that have PACS workstations. Assome radiology departments are con-sidering relocating from the imagingdepartment to a more distributed modelwith radiologists located in the traumaareas or intensive care units, thesebackground sound and lighting con-cerns become more important.

ConclusionThe transition from a film-based to a

soft-copy, filmless environment pre-sents us with the opportunity toredesign not only our workflow, butalso our reading environments. In ouropinion, this redesign is likely to resultin substantial improvements in radiolo-gist performance resulting in reductionof fatigue, increased productivity,increased diagnostic accuracy, and pos-sibly increased job satisfaction. Sur-prisingly, this opportunity has receivedlittle attention in the diagnostic imagingliterature and presents the radiologyresearch community with fertilegrounds for future investigation. AR

AcknowledgmentThe Baltimore VA Medical Center

Department of Diagnostic Imaginggratefully acknowledges the partialsupport of our work by General Elec-tric Medical Systems (Milwaukee,WI) who have provided us with aresearch grant to design and imple-ment a second-generation PACS read-ing room to test the impact of variousenvironmental factors such as light-ing, acoustics, ventilation, optimiza-tion of workstation ergonomics, andalternative display devices.

REFERENCES1. Rostenberg B. The Architecture of Imaging.Chicago: American Hospital Publishing, Inc.; 1995.2. Reiner B, Siegel E, Protopapas Z, et al. Impactof filmless radiology on frequency of clinician con-sultations with radiologists. AJR Am JRoentgenol. 1999;173:1169-1172.3. Reiner B, Siegel E, Hooper F, et al. Variation ofmonitor luminance on radiologist productivity inthe interpretation of skeletal radiographs using apicture archiving and communication system. JDigital Imaging. 1997;10(3 Suppl 1):176.

Documents

X-Ray Reading Room Next Generation