Use of electronic medical data, digital imaging, and wireless communication in healthcare has significantly increased the speed and accuracy of providing care. These technologies have also dramatically changed the process, workflow, and tasks performed by many specialties within healthcare facilities. Radiologists represent one group of professionals whose tasks have been radically transformed over the past decade with the integration of medical informatics and related technology.

Photo archiving and communications systems (PACS) are now standard in most medical facilities. Compared to older image technologies, PACS captures numerous high-quality images from multiple modalities, making studies instantly available for radiologists' review, thus reducing the time from imaging to diagnosis and, ultimately, reducing the time to defining the course of care.

PACS also eliminated the need to manually hang films in the alternator or light box. The old work routine for radiologists required physical activity within the room as they moved about hanging, reading, and removing films. Radiologists' regular movements, combined with fewer images per study, helped counteract some of the negative ergonomic pressures on physicians' bodies. With the advent of PACS, however, the job has become more image-intense but less physical—almost static—because little movement is required beyond the scroll or click of a mouse.

Radiologists' work is now highly dependent upon multiple high-resolution, medical-grade monitors placed on a desk. It was assumed PACS would allow them to sit comfortably while reading cases for the duration of their shifts. Apart from providing a chair, desk, and phone, little thought went into the furnishings to optimize use of the new technologies.

“PACS are multimillion-dollar pieces of equipment,” says Mark Morita, marketing manager for Disruptive Technologies for GE Healthcare. “But in hospitals and clinics around the world, doctors' physical work environments and ergonomics aren't considered nearly as much as the technology itself.”

A painful lesson

A few years ago, Advanced Radiology Services, PC (ARS), a leading radiology practice in West Michigan, identified an increased risk of ergonomic injuries related to new technologies.

The company had nearly completed the migration, reading from monitors by 2003. A short time later, several radiologists developed repetitive stress injuries (RSIs) related to the integration of PACS and their subsequent decrease in physical activity. Many radiologists also reported significant pain and strains in the back, arms, and neck.

“In one way or another, nearly all of the 90 radiologists on the ARS staff faced increasing ergonomic challenges as digital technology swept through the radiology labs,” says James Paauwe, Advanced Radiology Service's chief information officer.

Knowing they were likely to see more of the same as its radiologists spent more time in relatively static postures, ARS turned to a neighboring Michigan company for help.

Nurture by Steelcase—located in Grand Rapids—responded by sending a research team to study the physical work environment at ARS and the technology and tasks performed by the company's radiologists. Nurture researchers eagerly tackled the radiologists' problems, using a systematic approach to identify and assess ARS' ergonomic challenges associated with the new radiology technology.

The Nurture study team—which included ergonomists, design researchers, industrial designers, and product engineers—quickly identified these individuals as “extreme” computer users; people who needed to achieve a level of deep focus to complete the task at hand. Both the onsite observations and hours of video ethnography showed significant ergonomic and workflow challenges posed to the radiologists (figure 1).

The Nurture study team identified the Advanced Radiology Services doctors as “extreme” computer users through onsite observations and hours of video ethnography, which showed significant ergonomic and workflow challenges posed to the radiologists.

The study team pored over data collected from in-depth doctor interviews and conducted live observations and video studies. The team then researched how these new technologies continued to change, predicting future trends. The team synthesized the research data and brainstormed how simple modifications might help improve the comfort of the radiologists' reading environment (figure 2).

The Nurture research team synthesized the research data and brainstormed how simple modifications might help improve the comfort of the radiologists' reading environment, as seen in these concept sketches.

“Working with ARS let us hypothesize what could be better ergonomically informed solutions for radiology reading work spaces,” says Jan Carlson, vice-president of Product Development and Marketing for Nurture by Steelcase. “We developed concepts into foam-core prototypes to gather additional feedback from the users (figure 3). Using the feedback from radiologists, we identified the concepts with the most merit, and developed them into full working solutions. The solutions were gradually installed in the ARS workplace, validating incremental change.”

Foam-core prototypes were built to help gather additional feedback from the users.

Multiple challenges, multiple solutions

Nurture's researchers assembled a thorough understanding of the obstacles to radiologists' maximum comfort and productivity.

Problem 1. The effect of the poor ergonomic design of the radiology tables and monitor mounting devices. One of the first things the researchers noted in the observation data was that many of the doctors would lean forward to be closer to the monitors. The monitors sat on heavy, nonadjustable stands positioned far back on the work surface. The radiologists' tendency to lean forward to compensate for the distance created other ergonomic challenges. The chair offered limited support, and the doctors were resting their forearms on the edge of the surface.

After evaluating the data, the team reconsidered the design of the basic work surface. The 30-inch-deep tables used by ARS doctors are typical in most offices and medical settings, but they pose a significant impediment when radiologists need to view monitors up close.

The situation was exacerbated by the fact that information technology specialists had installed the monitors to the back of the tables on nonadjustable arms. If doctors tried to pull their chairs forward to view the monitors while remaining seated, their chair arms usually interfered. If they adjusted their view by rising and leaning forward to get closer to the monitor, radiologists would often press against the hard edge of the table.

Another primary problem was the radiologists' inability to quickly adjust the depth, height, and viewing angles of the monitors.

“Instead of moving the monitors, the radiologists moved their bodies,” says Carlson. “Body movement and compensation is counter to what you want to see happen. Ideally, you'd like to have their bodies positioned in a comfortable, supported posture, making full use of the back of the chair while pulling the monitors toward themselves, not leaning on the hard edge of work surfaces.”

First, the team adjusted the geometry of the table's edge. Nurture scooped out a large portion of the frontal space, creating a deep curve that invited doctors to lean in close to the monitors. Improving upon that, they provided a swooping curve that tapers back at the corners to make the entire front of the worktable more user-friendly.

Next, in place of a hard and unforgiving surface, the designers covered the curve with urethane foam, reducing the compression of radiologists' hands and wrists, thereby mitigating soft-tissue injuries.

The team also attached the monitors to lightweight arms that could glide quickly and easily in any direction with a doctor's tug. This modification ensured radiologists could quickly find an ideal personalized setting, encouraging them to adjust the monitors to their comfort. The new monitor arms also feature pitch controls to adjust the angle of the monitor for viewing straight on or from an angle through bifocals.

Problem 2. The radiology table and chair in a given office were routinely used by different radiologists. Despite the differences in each radiologist's physical structure, few doctors bothered to adjust the equipment to their own specifications. The inability to quickly change table height posed a challenge. “The original tables could be raised or lowered only in increments of 1/32nd of an inch and moved at snail's pace,” says Carlson. As a result, radiologists rarely used the adjustability features of the tables.

One radiologist, Dr. Carol Bosanko, went so far as to keep a “hawk-like watch” on a single chair with a broken arm at a local hospital because it was the only one that she could use to read X-rays on a computer monitor. At 5'2", Bosanko needed more versatility. “I needed something adjustable so that I could be comfortable while reading,” she explains.

Nurture introduced a fully adjustable workstation to address the unique challenges of the specialized environment. Emphasizing speed and ease of use, these workstations quickly and easily adjust to user parameters.

ARS already had provided many of the workstations with new ergonomically sound chairs, but many radiologists couldn't take advantage of the chairs' features because they always had to lean forward to read the monitors. Also, most radiologists didn't bother making any of the individual adjustments the chairs offered, such as seat height and back angle.

The solution: a “passive ergonomic chair” was introduced to the radiologists' workstations. These chairs passively engage certain adjustable features—such as chair-back rigidity—by adjusting automatically to the height, weight, and other physical characteristics of each person who sits in them.

“We're learning that radiologists may want to have both types of chairs available,” says Carlson. “Those they can adjust, and those that are passively adjustable.”

Problem 3. Accustomed to the previous method of manually reading X-rays, radiologists had established personal physical and mental office routines that match the old process. These routines, still in place during the study, included a number of poor ergonomic practices that had never been addressed in radiologists' pre-PACS settings. For example, many radiologists continued to use the Dictaphone to record their observations and diagnoses. Subsequently, they felt strains from the constant use of shoulders and arms to handle their recording devices.

Another difficulty stemmed from the poor lighting situation in the reading rooms; many radiologists used the alternator as a reading light for paper documents because frequent changes in lighting put additional strain on their eyes. “The workstations didn't have enough storage. In a typical ARS work setting, the telephone and reference books were scattered around the room. But the radiologists were like air-traffic controllers, tethered to these monitors for everything they needed,” explains Carlson.

The Nurture team addressed workflow and spatial issues. The team designed shelves allowing placement of the most significant, widely used tools within a radiologist's reach on a shelf raised above the worktable. This ensured the workspace, itself, wasn't reduced. “We redesigned these work tools so that everything supports the radiologists' common work-flow processes,” said Carlson (figure 4).

Nurture redesigned the radiologists' workstations so that everything supports the radiologists' common work-flow processes.

The team also recommended the addition of Bluetooth earphones and headsets to the toolbox, making dictation observation less physically stressful. They developed ambient lighting to help radiologists keep their visual bearing during the frequent lighting changes from bright to dark as the doctors make medical observations and recommendations, often with the room door opening and closing during collaborative discussions.

Radiology research continues

“In working with Nurture we've been able to create multiple options for our doctors,” says ARS' Paauwe. “We don't just build a counter and say, ‘This is your spot.’ We wanted to achieve significant improvement in their work environments where they're stationed for half their lives, and we've already accomplished a lot.”

Nurture's team is already working with a major research university on documenting how more efficient and ergonomically sound radiology environments affect productivity, throughput, and accuracy. Nurture has already begun working on ergonomically sound radiology reading workstations that recognize and adjust automatically to each unique user with biorecognition software.

“We should be able to attach this cutting-edge technology to heights, light levels, and other particulars of the work area so that each doctor's individual preferences immediately and automatically snap into place,” Carlson says. “IT-related innovations in medicine usually start in the imaging department, so this is an area of great opportunity for radiological ergonomic improvements.” HD

Joyce Bromberg is the Director of Research for Nurture by Steelcase. She has 27 years of industry experience, the past 12 of which have concentrated on advanced concepts and user-centered research. She can be reached at