By Dara O’Brien

The radiology reading room at Texas Children’s Hospital.  (Photo credit: Paul Kuntz)

The radiology reading room at Texas Children’s Hospital.
(Photo credit: Paul Kuntz)

It’s been twenty years since PACS revolutionized imaging interpretation. How has the reading room evolved around this groundbreaking technology—and what next-generation improvements are coming down the road? Axis spoke with three prominent radiologists for some in the trenches perspectives.

Form and Function

Edward Zaragoza, MD

Edward Zaragoza, MD

Edward Zaragoza, MD, clinical director of imaging informatics for UCLA Radiology in Santa Monica, Calif., was an early adopter of PACS technology who points out that digital integration has come with a price. “There was more physical activity associated with alternator reading style,” said Zaragoza. “The radiologist would be standing up, sitting down, moving sheets of film. Nowadays, you just sit at a computer screen and mouse around.”

Reading rooms like Zaragoza’s include a series of innovations to counterbalance the sedentary digital work style. Workstation design is key.

Many rooms at UCLA are equipped with Carl’s Tables from Anthro. The table’s flexibility–including an adjustable standing/sitting desktop and the ability to tilt, raise, or lower the monitor–was a key selling point for Zaragoza. “I’m a huge proponent of adjustable height stand-up tables,” said Zaragoza. “For any new environment that we open, that’s one of our standard requirements.”

Carl’s Table CT15 adjustable radiology desk from Anthro.

Carl’s Table CT15 adjustable radiology desk from Anthro.

Zaragoza also gave Carl’s Table high marks for its cable management recesses, which are critical in darkened reading rooms to avoid kicking and disconnecting cables, as well as its integrated lighting. “We turn off the lights and use the task lighting that’s built into the workstations,” said Zaragoza. “They sense ambient light in the room or light coming off the computer display, and adjust accordingly in real time.” Radiologists can take also advantage of the table’s integrated USB hub on the desktop for easy charging of mobile devices.

UCLA reading rooms use ergonomic chairs that can tilt back to transfer weight off of the spine and have adjustable arm rests. For those radiologists that prefer a standing work posture, padded footrests allow for cyclical redistribution of weight. Zaragoza has also explored alternative overhead microphone placement. “Something as simple as having better placement of the microphone can improve the quality of speech recognition, encourage better postural habits, and reduce collateral damages like cubital tunnel syndrome,” he said.

Looking ahead, Zaragoza is eager to see PACS technology adapted to incorporate expanded device integration for gains in ergonomic performance and productivity. “We are putting a lot of physical demands on the radiologist, and giving very little accommodation to the chronic stress damages that are happening as a result,” he observed.

Zaragoza pointed out that it is unusual to find a PACS interface that’s capable of accepting inputs from an advanced device, such as a joystick, toggle wheel, or customized multi-button mouse. “Radiologists are still using a standard desktop mouse to scroll and pan through not hundreds, but thousands of images,” he said. “If we had a button on the mouse that enabled us to advance to the next series, and another that would pop up the next comparison study, over the course of the day these tiny little process efficiencies could add up to an hour more reading time. Why can’t we do that?”

Zaragoza calls on vendors to develop computer interfaces that make their applications addressable from custom devices. “When I shop for my next-generation viewer, that’s going to be a requirement,” he said. “Some very large vendors have evolved their input devices very little in twenty years. They haven’t seen it as a need, and they’re going to be left at the wayside. Improving ergonomics needs to be a priority.”

One-Stop Shopping

George S. Bisset, MD

George S. Bisset, MD

George S. Bisset, MD, radiologist-in-chief at Texas Children’s Hospital in Houston, Texas, has determined that the reading room functions best when configured as a unified space, with no separation of subspecialties. He included the implementation of a single, centralized reading room as part of the negotiations when he accepted his current position.

“I wanted to create one-stop shopping for clinicians and technologists, so they could go to one place to find any radiologist,” Bisset explained. This “grand ballroom” concept required a ground-up reimagining, and careful planning up front.

A primary consideration was flexibility of the workstations. After testing models from a series of vendors, Bisset and his team chose to partner with RedRick Technologies. They moved forward with a design that took individual preferences into account, while still providing a uniform environment that could function as a shared workspace.

Texas Children’s Hospital partnered with RedRick Technologies to re-design its reading room. (Photo credit: Paul Kuntz)

Texas Children’s Hospital partnered with RedRick Technologies to re-design its reading room. (Photo credit: Paul Kuntz)

“Each station is designed exactly the same way, so you can sit at any of them,” said Bisset. “The radiologist can adjust the height of the workstation, the height and tilt of the monitor, and even the background lighting.” Comfortable, ergonomically efficient chairs were a must. A phone on a moveable arm is in easy reach. Room lighting is uniform, with no bright or dark spots.

With twenty-one workstations (soon to be twenty-two) in one location, sound design was a vital concern. “We were assured that we could create a relatively soundproof room, and we did,” said Bisset. “We wanted to make sure our radiologists could dictate in a quiet space, that they weren’t going to be interrupted by conversations in the next carrel.”

The radiologists’ offices are in close proximity to the reading room, so they can fit office time into the workday more easily. A centralized phone answering system, manned by a clerical team that sits outside the entrance to the room, limits interruptions and guides clinicians to the appropriate place.

The reading room at Texas Children’s Hospital is configured as a unified space, with no separation of subspecialties. (Photo credit: Paul Kuntz)

The reading room at Texas Children’s Hospital is configured as a unified space, with no separation of subspecialties. (Photo credit: Paul Kuntz)

In addition to providing ease of contact for clinicians, Bisset had other goals for the room’s redesign. He saw a need to enhance collaboration between radiologists, and offer more diverse educational opportunities for residents and fellows. “In other places that I’ve been, I’ve noticed that there’s no esprit de corps between the various subspecialists,” Bisset observed. “Now when I walk into the reading room, I see people talking to one another. It’s helped build camaraderie.”

Collaboration is further enabled by a separate but adjacent conference space. “If a clinician wants to talk to a radiologist, they don’t have to be right there at the view box, they can go outside,” said Bisset. A coffee bar has been installed, and white boards encourage discussion and the exchange of ideas.

How would Bisset like to see the reading room continue to evolve? He looks forward to having technology that facilitates instantaneous communication with clinicians. “When you see a significant finding, it would be great if you could hit a button and have face-to-face communication on your screen with the appropriate person,” he said.

A microphone with intuitive controls built directly into the workstation is also high on his wish list. “If you’re using structured reports, being able to move seamlessly from point to point would be a big step,” he said. “If it could check your report while you’re dictating it, and point out mistakes, that would be phenomenal.”

Clinical Perspective

Brian Petersen, MD

Brian Petersen, MD

Brian Petersen, MD, musculoskeletal radiologist at Inland Imaging, Spokane, Wash., approaches the reading room from a different perspective. When he served as chief of musculoskeletal (MSK) radiology at the University of Colorado, he stipulated that the facility move his MSK room from its location among a cluster of other radiology subspecialties and embed it within Orthopedics. “I was intent upon getting as close to the point of care as I possibly could,” Petersen said.

It was important to Petersen to be near the physicians with whom he would be working in order to increase opportunities for interaction. “I want as much information as possible, so I can be right most of the time,” he explained. “It turns out you’re right a whole lot more when you’re sitting next to the person for whom you’re interpreting the study. If you want to design a reading room for the most accurate interpretation and the greatest relationship, embed your reading room within those areas of clinical care that you serve.”

Primary considerations for the new reading room didn’t stop with proximity. When asked what kind of door he wanted for the room, Petersen told his administration that he wanted no door at all. “I didn’t want any barrier to interaction, physical, voice, or otherwise.” He found that his “open door” policy served as a gateway to extensive feedback from clinical colleagues. “When they came into my room, I immediately got a whole lot smarter,” he said.

The relocation and design of his reading room also stemmed from Petersen’s concern that the geographic separation of imaging interpretation from the point of care can insulate the radiologist from the repercussions of his or her read. “’Dictations are rendered and interpretations are made, but they aren’t correlated to the patient’s white blood cell count, or their blood pressure, or their vital signs, or where they hurt,” he said. “We need to be clinicians. We are MDs just like everybody else. We need to bring to bear as much clinical information as we possibly can, to render an impression that adds value to the patient care process.”

Petersen’s advocacy for on-site clinical interaction is reflected in his ideas for next-generation advancements. Like Bisset, he calls for the option for instant face-to-face communication with referring physicians. He includes screen-sharing capabilities in his scenario. “It’s a virtual personal interaction that you can do fairly easily,” said Petersen. “The referring physician just hits the consult button, and then we are speaking to each other, and when I point with a mouse, they see what I’m pointing to.”

It comes down to balancing the clarity and efficiency of advanced technologies with the investment and engagement of interpersonal communication.

“The reading room used to be a gathering place,” said Petersen. “With hard copy film, our clinical colleagues had to come to the radiologist and have that physical interaction,” he said. “And then PACS came along, so now we can send images over the airwaves. You can be anywhere and read and interpret studies. To be accurate and have clinical impact, I think that we have to come back to the model where we’re sitting next to each other.”

Embracing Innovation

As technology continues to transform the world of medical imaging, radiologists and administrators will continue to discover ways of embracing, enhancing, and incorporating the latest innovations. We welcome your comments regarding the modern reading room… and how it will evolve.

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Dara O’Brien is a contributing writer for AXIS.