October 2016

Environmental Concerns
By Jeannette Sabatini
Radiology Today
Vol. 17 No. 10 P. 20

Ergonomic reading rooms can reduce radiologist burnout and improve productivity.

It's needless to say that a person who is comfortable while working will be more productive … or is it? According to ergonomic advocates/radiologists Eliot L. Siegel, MD, FSIIM, FACR, and John K. Mukai, MD, that point needs to be continually reinforced with administrators and others who oversee radiology reading rooms in hospitals and smaller facilities nationwide. Administrative professionals, they say, are ignoring the fact that radiologists are physically suffering as a result of poor ergonomics.

"The current situation could, in some cases, be considered abuse!" Mukai says.

Avoiding Burnout
Poor ergonomics were linked to repetitive strain injuries (RSIs), pain, discomfort, headaches, eye strain, and fatigue in the results of a 2014 study conducted by The MarkTech Group. Radiologists were found to be "especially susceptible" to RSIs, particularly of the neck, shoulders, back, wrists, and hands. Scientists at the Pennington Biomedical Research Center in Louisiana reported that "people who sit for most of the day are 54% more likely to die from heart attacks." Such a scenario is detrimental to the mental well-being and physical health of radiologists, as well as to the field of health care as a whole, since radiologists who are unable to work up to their potential due to an injury cannot make the contributions to the field that they are encouraged—and expected—to make.

"The Imaging 3.0 paradigm from the American College of Radiology urges radiologists to find ways to 'add value' to clinical care delivery, and an ergonomic reading environment is paramount to achieving these goals," says RedRick Technologies, Inc President Greg Patrick. "Reading rooms are where the value of the medical image is realized. Radiologists need to churn out loads of reports while staying comfortable, accurate, and unencumbered by repetitive stress disorders for their entire careers. [They] also must be able to increase their interactions with referring physicians and other specialists that rely upon imaging findings to deliver high-quality care."

Mike Graham, director of medical sales for imaging desk manufacturer Xybix Systems, Inc, agrees. "Radiologists have a lot of cases that they have to read, and they are going to burn out if they aren't taken care of," Graham says. "They really need to have good ergonomics."

"We need to get proactive about improving the situation," Mukai adds.
Good ergonomics help a person physically, cognitively, and organizationally, Siegel said in a presentation at June's Society for Imaging Informatics in Medicine (SIIM) meeting, referring to an International Ergonomics Association definition. According to that definition, ergonomics focus on the following:

• physically, on human responses to physical and physiological loads;
• cognitively, on mental processes such as perception, attention, cognition, motor control, and memory storage and retrieval, as they affect interactions among humans and other elements of a system; and
• organizationally, on sociotechnical systems, including their organizational structures, policies, and processes.

"Office ergonomics," Siegel explained, "applies science to workplace design to maximize productivity, while reducing operator fatigue and discomfort."

Getting Proactive
Siegel, a professor and vice chair of research informatics at the University of Maryland School of Medicine, an adjunct professor of computer science at the University of Maryland, and chief of imaging at the VA Maryland Health Care System in Baltimore, and Mukai, chief technical officer of Saint Vincent Radiological Associates in Worcester, Massachusetts, have concentrated their efforts on ergonomically improving the space in which radiologists work. They have created a workstation design laboratory with the goal of maximizing productivity while reducing stress, which they refer to as "RadFlowSpace." It features an up-to-eight-monitor configuration and a headset.

A special table was designed to allow radiologists to use eight monitors and remain comfortable. The multiplex monitor configuration allows users to have simultaneous access to information, such as EHRs, ancillary software, the internet, and administrative notes and do other activities, such as video chat and watch educational videos. The headset "helps to organize the space" because it integrates all of the devices, Mukai explains.

"The overarching goal [of RadFlowSpace] is comfort and minimizing repetitive stress injury with multiplexing speech and auditory functions, relative to the biggest horizon we can use without [needing] neck and/or back surgery," Mukai says, noting that he has had both kinds of surgery. Mukai and Siegel have posted many videos touting the benefits of RadFlowSpace on their new site, RadFlowSpace.com, and showcased it at SIIM. It will also be on display at the upcoming RSNA meeting. Mukai has a patent pending on the headset, while the monitor configuration is the "brainchild" of both radiologists.

David A. Bader, MD, FACR, president of Saint Vincent Radiological Associates and chief of radiology at Saint Vincent Hospital, also in Worcester, helped develop the RadFlowSpace system. "The quadruple aim of health care is lower cost, better outcomes, improved patient experience, and improved clinician experience. An ergonomically ideal radiologist workstation will help to achieve all of these goals; it is a win-win-win-win scenario," he says. "Asking a radiologist to do more with less or hiring additional staff to continue to work ineffectively will fail to meet every one of the quadruple aims of health care. In this scenario, the cost is higher, the quality is compromised, and the patient and clinician experience suffers."

Those who visit RadFlowSpace.com will be able to "walk" around virtual radiology workspaces of the future, yet the radiologists have a lot of tips for ergonomically improving reading rooms in today's real world. Smart choices in ambient and task lighting; floor and ceiling material; wall and partition coverings; heating, ventilation, and air conditioning; and sound control will "maximize productivity, reduce visual fatigue, and increase concentration," Siegel said in the SIIM presentation. Among his suggestions are the following:

• Use LED lighting. "Do not use fluorescent lighting. It can flicker, which can cause fatigue, even when imperceptible."
• Employ sound-absorbing materials (acoustic paneling and carpeting).
• Consider blue indirect lighting. "It has been shown to have a favorable effect on visual acuity and minimizes stress."
• Consider a sound-masking system that "generates 'noise' in the general frequency range of the human voice."
• Avoid suboptimal monitor brightness. "Suboptimal monitor brightness can cause decreased radiologist accuracy and increased radiologist fatigue. Contrast discrimination is optimal when levels of ambient light and computer monitor display are of similar intensity."

In addition, Mukai shared the following low-cost tips with Radiology Today:
• Install a nonporous, sound-deadening floor. "An old rug can be a dust source."
• Use HEPA filters to improve the conditions for those with a dust allergy.
• Open up the viewing room, "especially if you are in a teaching situation or high-demand clinical service situation."
• Use "click-lock Hotkey" so users do not have to hold the left mouse button down, which is "a sure cause of repetitive stress injury to the index finger."
• Raise the table height to stand and use a draftsman's chair to sit—also known as "perching." "You'll get the benefits of sitting and standing."
• Use as many monitors as the department can afford. "Monitors are cheap. Remote viewing of other computers is free. One can integrate multiple logons … these computers can be anywhere in the world."

Radiologists also stress less when their work environment makes it easier for them to meet the growing demands of their job. One of those demands is the need to collaborate with others. Partitions can be used to create spaces that are conducive to the collaborations, Siegel noted in his presentation. Describing a reading room that he helped revamp at the Baltimore VA Medical Center, Siegel said the plan made space for primary radiologist reading, group teaching and conferences, resident/fellow meetings, referring physician consultations, and patient consultations. The most logical design was found to be a hybrid of cubicles, which has "maximized flexibility," he added.

No Joke
Manufacturers are also looking for ways to improve ergonomics. "Today's radiologists are unhappy because they are uncomfortable; they end up with back and neck problems from sitting too long," Patrick says. "Our sit/stand PACS workstations and monitor mounting systems allow radiologists to change positions throughout the day in order to increase comfort and decrease risk of repetitive strain injury, which we know is prevalent in radiology." The workstations can be adjusted to accommodate a range of heights.

RedRick Technologies, Inc provides consulting services that help optimize reading room layout, design, acoustics, and lighting. Patrick adds: "We help design new ergonomic reading environments tailored to the way departments work." The company recently published a case study describing how it helped Juravinski Hospital and Cancer Centre in Hamilton, Ontario, Canada, redesign a reading room—with significant radiologist input—within its new CIBC Breast Assessment Centre. The original reading room was cramped and poorly lit, and the workstations lacked ergonomic adjustments. "The design of the workstations—which includes integrated back lighting—reduces eye strain and encourages good ergonomic practices, which minimizes the risk of back, neck, and wrist injuries to the radiologists as they read studies and offer their expertise."

"Twenty years ago, if someone said you could actually become injured sitting at a desk, it would've been a pretty big joke," Graham notes. "But today, it is a real deal." Radiologists also suffer from makeshift conditions, he says. "A lot of reading rooms are a disaster. I've seen monitors propped up with a reference material and a lot of millwork, which is not ergonomic."

"If everything is at the right angle and right height, you are going to feel better," Graham says, adding that Xybix Systems, Inc's dual-surface radiology desks allow users to independently adjust the focal depth and the heights of the monitors and keyboard. Adjustments can be made quickly. "If radiologists have to take 10 to 15 minutes to move this monitor and that monitor independently, they are not going to take the time to do it," he says. "They also are not going to bother to raise a table to stand, if the wires below the table will not raise with the table."

In addition to sit/stand imaging desks, Xybix Systems, Inc also offers workstations fitted with a treadmill or a stationary bike. "They get the circulation going. Users find that they are more alert," Graham says. "The whole idea is to get healthier in the workplace. It is a proactive approach." Xybix Systems, Inc has a team responsible for all aspects of the install.

"As imaging volumes expand, we are seeing a growth in the number of repetitive stress disorders in radiologists. Some radiologists are retiring early and many need to take a medical leave due to these issues," says Lynda Domogalla, vice president of product marketing at Barco, which makes monitors and medical displays. Barco's Coronis Uniti multimodality display, she says, "mirrors a human's natural field of vision and optimizes the reading workflow by reducing reflections, limiting head and eye movements, enhancing image sharpness, and reducing eye fatigue."

Providing further ergonomic aspects of the unit, Domogalla says: "Coronis Uniti allows users to bring multiple image types together [color and grayscale] and lay them out in a flexible way on the screen so they don't need to shift to look at multiple displays, and their eyes do not need to adjust focus as they scan across a display bezel. It has ambient lighting, and it includes some tools that help the radiologist see more of the fine details with less eye fatigue."

Comfort Isn't a Luxury
In addition, software and hardware peripherals have a role in an overall plan to keep reading rooms efficient and radiologists less stressed, notes Allan Noordvyk, executive director of research at McKesson Imaging and Workflow Solutions, which provided the PACS software for the SIIM demonstration. If a radiologist is stressed out and/or injured, care is impacted, he notes. "A distracted or harried radiologist may miss a subtle finding or communicate a diagnosis with less than optimal precision," Noordvyk states.

Diagnoses also can be delayed when a radiologist is in pain, and those delays "add up," Noordvyk points out. "The difference of 10% less radiologist efficiency for a single patient is typically minimal," he says. "But by the end of a radiologist's shift, that can add up to multiple patients whose studies had to be read by someone else later in the day or the next day, if there is no late shift."
When revamping a reading room, the best place to begin is to involve users, Mukai advises. "Improvements in workspace design have to be driven by the frontline, hardcore user; [it requires] the bottom-up approach. At the same time, the top-down development is also key," he says. "The paradigm shift is that everything should be user driven."

In order to stay on top of ergonomic concerns within the field and provide an outlet for those who have concerns, Siegel and Mukai have created a blog spot on RadFlowSpace.com. Visitors are encouraged to share stories and their ideas for a "workstation of the future."

Bader has concerns relating to what he sees as a lack of resources. "As a department chair and residency program director, I struggle for resources to create the optimal work environment for productivity, teaching, learning, and, most importantly, patient care. Radiologists are burning out with exponentially increasing data sets and demands for rapid and accurate reads along with value-added communication and consultation. Burnout comes quickly when the resources provided to the radiologists are insufficient to meet the demand," he says. "Radiology physician leaders and administrators need to be educated about, sensitive to, and advocates for the tremendous impact that ergonomic improvements can have on radiologist health and productivity."

Mukai encourages users to speak up: "We need to insist on comfort in the workspace. If we don't do that, we can't benefit from the rest of the improvements."

— Jeannette Sabatini is a freelance writer based in Malvern, Pennsylvania.