Clinical evaluation on the wards and ED

I am interested in opinions on the monitor types utilised outside of Radiology to view xrays. While the RCR guidance implies that 2MP monitors are suitable for use for Clinical Review, our local medical physics expert has suggested that if clinicians are performing a clinical evaluation on the images then they should be doing this on a 3MP monitor for plain film. In the absence of real time reporting, the reality is that inpatient and ED xrays are all read initially by non-radiology clinicians and the official report often comes days later.

The issue of this is the significant increase in cost between 2MP and 3MP!

Interesting. We have the same discussion here for the last 10 years. We are an Orthopaedic specialist hospital, where about 40% of our examinations are not reported on by our radiologists.

Therefore a number of our Orthopaedic specialists argue they need diagnostic monitors.
As you say, costs is probably what is holding our IT department rolling out 3MP displays outside radiologist’s offices.

However, there is an important point to make: our radiologists work from darkened offices to optimise viewing conditions. The viewing condition in our clinics is far from ideal and benefits from expensive 3MP displays are somewhat negated when bright sunlight shines on the display.

Frank gives a very valid point. One other thing I would look for is whether the monitors, be they 2 or 3MP, are capable of and set to use the DICOM characteristic curve.

Commercial Interest Declared

Hopefully my lengthy experience in this market place can help :-).

3MP displays are usually recommended to users due to the size of the plain film x-ray to minimise zooming and image manipulation, saving time for the user and assisting to make a faster diagnosis/clinical decision. A further discussion point is brightness and contrast. If a user can see contrast easier, they need to make less manipulation of an image to see the anomaly quicker, therefore saving time of an expensive resource. You will likely still see an anomaly on a 2MP display, but you may have to manipulate the image a fraction more. If someone is reviewing an image, it is likely they know where and what they are looking for, so only need to manipulate an image to that point/area. However for junior or inexperienced users, to give complete satisfaction of the search, the entire image should be reviewed and continually focusing in on one area may lead to further bad practice.

As Frank has mentioned, areas outside of a Radiology reporting room are going to be bright and the main contributing factor to a lack of perceived image quality by users. If you give the users brighter, anti-glare screens, this will counter act the ambient light conditions they are likely struggling with but they must still be DICOM. Regular calibration of a display is also quite important to allow you keep a level of consistency required when working with medical images. Calibration is also recommended under the RCR-PACS 3rd edition for clinical review displays.

As someone who currently designs and supply’s Operating room imaging solutions, PACS images are often seen in such a bright environment and modalities often “produce images” users consider to be “diagnosing from”. I say the same thing to them, if the screen is bright enough, in-DICOM and conforming the GSDF, you would be OK. Surgeons often comment on the ability to see multiple images rather than say “this image is poor”. Originally the RCR set the recommendations for reporting in 2 tiers, “recommended” and “minimum”, below minimum, you are likely not to find what you are looking for. Closer you get to recommended, its easier to look for so consider the user and environment and how much you want to speed them up more than anything.

In the OR environment, we see a lot of trusts giving users separate screen solutions for multiple image viewing because we see video (endo) and PC images (PACS) in the same environment which are not the same. If you have a screen that can do both and is bright enough, then you have saved time and money (by the way, we do have such solutions).

Matt@EIZO

thank you all. We currently have 2MP monitors with a robust QA and calibration schedule and part of our ‘risk’ is that a 2MP monitor looks quite like a regular PC screen to an outside user. I quite often see users with xrays open on their normal PC screen and the EPR opened on the DICOM monitor.

Yep, I recognise that. Luckily our PACS viewer can be forced to open on a specific monitor.

Hi Frank, that is really interesting. Can I ask who your PACS vendor is? Is it the PACS or EHCR that is controlling that?