This document describes a radiologist's experiment adding two additional monitors to reading workstations to improve workflow efficiency. The radiologist was able to add two 30-inch, 4 megapixel monitors, a video card, and free software to existing workstations for under $1,000. This doubled the screen real estate without increasing costs. In a trial period, radiologists reported major improvements to ergonomics, ability to compare multiple datasets simultaneously, and opening multiple applications at once. The radiologists estimated this setup could save 30 seconds per case and concluded it was a cost-effective way to improve efficiency without additional spending.

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QUESTION
How could a radiologist produce at twice the rate for half the cost of the
usual default hardware/software workstation?
ANSWER
A Six Monitor Workstation/paradigm shift in a busy imaging department.
WE WOULD LIKE TO SHARE OUR STORY WITH YOU
We were nagged by a visceral discomfort of the workflow. Here's our story
but go see the station itself.
Historical evolution of the monitor driven workstation:
Some radiologists at the transition to digital imaging erroneously assumed that
the digital workstation should approximate the analog eight panel world. It soon
became evident that with hundreds of images it was much better to roll the stack
on one monitor, not to mention avoiding a prohibitive monitor expense.
Current workflow dilemma:
The improvement in data throughput and display software has evolved not
towards sequencing a single static image on single stack but rather real time
fast-moving orthogonal simultaneous moving data . Review has become a near
cinematic comparative exercise. And, yet like the chest x-ray of old, there may
be three or four time points. Furthermore, aside from our basic PACS system,
there are evolving different specialty imaging applications such as coronary CT
angiography, CT/PET fusion imaging, nuclear medicine cardiac imaging, and
complex reconstructive real-time data analysis, dynamic and functional data
analysis fused on imaging data. Add to this the complex mix of multiple PACSs
outside our system from the cloud, part of the increasingly integrated healthcare
enterprise approach. Gone are the days of “when old films arrive an addendum
report will follow”. The 1000 images of a CT are the modern equivalent of a 2-
view CXR needing comparison to multiple prior readily available 1000 images
exams.
Problem:
There is limited capital for investment and IT support is predominantly to maintain
current systems. ”Make sure it doesn’t crash!” “Clean up that server!” The
radiologist can “drive” change to improve flow because we are driving. We suffer
with anti flow. In fact the response to the radiologist often is “if it ain’t broke don’t
fix it”. The latter is a crisis intervention paradigm and not a proactive process
improvement paradigm. We espouse the latter.
Sidelight:
There is a literature of "Flow". Flow states are those that develop out of a smooth
sense of progress. Most standard current hardware/software PACS models need
to be tweaked to support front end user and when sub optimally configured
become anti-flow.
THE OLD DAYS TIME IS MONEY CAN WE RECONFIGURE?
In the old days all we did was look.
Analysts understand that a missed detail or a second delay /click/window could
mean millions. Gamers understand as well and they would lose the game.
Do we not have a time sensitive mission-critical unique job? “Sometimes
custom designs, sizes, looks are called for to meet customer
requirements”.
HYPOTHESIS
Improve efficiency with an eye towards providing more real estate for
comparison of complex data sets at multiple time points in real time.
Without closing windows more monitors will improve flow if seamlessly
integrated.
Background Results/Conclusion
The Six Monitor Workstation-Twice the Flow for Half the Cost
John Mukai, M.D., David Bader, M.D. FACR, Alexander Rende, M.D.
St. Vincent Hospital, 123 Summer St, Worcester, MA 01608
TechnicalHardware:
1. Monitors: A pair of Four Megapixel 30 inch monitors (Yamakasi,
Korea). Under $400 each including cables. We found these comparable
to Dell 30 inch monitors costing $1000 each, (3x more than Yamakasi
monitors)
2. Video card: Nvidia GeForce 640 dual DVI. Needed for a pair of four
megapixel monitors. Under $100. GeForce 630 can be used for two
megapixel monitors (1920 x 1200).
3. Computer: the authors have done this on many different computers
and because of the low resource intensive methods (remote
administrator is like thin client, the heavy lifting is done by the remote
thick client) our configuration has worked on windows XP with four gig of
RAM and a standard workstation such as HP Z 600, originally windows
XP 32 bit then XP 64bit, and the most recent enterprise rollout Windows
7 64-bit with 16 gig of RAM on a Dell Precision T3610 .
4. Total cost: under $1,000.(Saves $5,000 not purchasing a second
PC). Saves $20K to $50 K due to decrease software license costs.
This is not only a cost effective expansion of real-estate, the global
department hardware and software budget decreases. There are very
few opportunities to spend less money and improve the work life of
a radiologist! We strongly believe this is one!
Procedure:
1. Install video card into second PCIE slot.
2. Attach cables Dual DVI cables included with monitors.
3. Launch Pacs application.
4. Total time under 15 minutes.
Additional free software required:
1. TURBOTOP. Freeware. This is a key item. Allows control of the
Windows in the foreground with the PET application defaulted to the
foreground. (For example stays on top of the main PACS application)
2. REMOTE ADMINISTRATOR SOFTWARE. (hospital enterprise
license) This this essentially enables the add-on monitors to be virtual
viewers to any other computer in the department our administrative
offices etc.
3. KATMOUSE -this is also freeware that allows toggling of the Z order
of overlapping imaging application data images .(Prevents the main app
from hogging the foreground )
Total cost of additional software: zero dollars.
RESULTS
The purpose of this endeavor was to do the following:
1. Develop a reasonable cost-effective hardware add-on to convert a 4 monitor
system to a 6 monitor system .
2. Experience the six monitor system over a 12 month trial to determine if there
is improved workflow.
Improvements:
1. Ergonomics. Standing and sitting options. Average 9/10.
2. Large data set multiple simultaneous time point comparisons. Average 7/10
3. View three more different imaging applications on one system: Average 9/10.
A thought exercise:
If there are half as many keyboards, mice clicks etc. conservatively assume we
could save 30 seconds sec/widget x 80 widgets/rad/day x 12 rad/ day working
an 8 hour shift = 8 rad hours/day saved or 1 full FTE/day of savings (either in
money or time which are equivalent).
Finally as workload goes up and reimbursement goes down, radiologist fatigue
and even burnout looms on the horizon. There is a tendency to call for more
FTE to saw the wood or process the widgets. Before that maneuver however
one needs to have the sharpest saw possible so that when the time comes
when more FTE is actually needed there is maximum bang for minimum buck.
Based on our preliminary experience and comparison we believe this system is
a much sharper saw. Also the sharpening is cost effective without the need for
as many specialty licenses/ thick clients saving at least $5000 per PC not
purchased not to mention saving on the license fee. Although this may be moot
if all apps move to thin client. Regardless this system will still be beneficial
relative to the ease of side by side comparison of all the data in the cloud.
CONCLUSION
1. Our hardware add-on is a simple and cost-effective method costing under
$1000, saving tens of thousands of dollars. Intsall takes 15 minutes without the
need for extreme IT skills.
2. There is markedly improved workflow. None of us would revert to a 4 monitor
system and to do so significantly impedes flow. We plan further substantiation
with appropriate volume, quality and turnaround time metrics on a larger scale.
3. Finally this method has the potential to save $20K to $50K department wide.
Thank you for your attention. Please visit the station for hands-on
demonstration.
Introduction
Our experience:
We have a busy multispecialty imaging practice in a very cost sensitive
environment. We experienced a rollout of an entire new PACS system
as a part of our hospital system national rollout. The configuration was
set at three monitors.
We modified the enterprise rollout to 4 monitors as we had been
experimenting with 4 or 5 with the previous vendor.
In parallel there was a growing PET and Cardiac CT volume. For
example, we were struggling with poor access to a single PET
workstation. Not only was it physically in a separate area, it needed a
separate mouse, desk and chair. One had to change workstations and
use 2 disparate systems.
Sidelight:
There is a literature on the psychology of "Flow". Flow states are those
that develop out of a smooth sense of progress. If anything our initial
systems were anti-flow.
Beta testing a simple cost-effective hardware solution:
We explored various inexpensive options hoping to spend no more than
$1000 to provide a 5th and 6th monitor. Our goal was to determine if a
simple robust solution was possible and if a preliminary test by a few
users warranted further rollout of same.