The Architecture

of Medical Imaging
Designing Healthcare Facilities for
Advanced Radiological Diagnostic
and Therapeutic Techniques

Bill Rostenberg, FAIA, FACHA,

Principal and Director of Research
Anshen + Allen
Steven C. Horii, MD, FACR, FSCAR,
Clinical Director of Medical Informatics Group
Professor of Radiology
University of Pennsylvania
This presentation is based on The Architecture of Medical Imaging (John Wiley, and Sons 2006)
Written by todays presenters
AIA Young Architects Forum, February 2008

Presentation Outline
1. Overview

2. Imaging Techniques

3. Design and Planning

Considerations

4. Convergence of
Surgery and Imaging

Overview

Early X-Ray
Circa 1900:
The first x-ray department at
Boston Childrens Hospital
was limited in its function
because it was not equipped
with electricity.
It was obliged to obtain its
power from the Opera House nearby.

Photo: Stevens, E. F. The American Hospital of the Twentieth Century;

Architectural Record Publishing Company; 1918

A wire was run from the Opera House to the Hospital,

but when there was no music there was no current.
No opera, no X-rays! *
* Eisenberg, R. L. Radiology: An Illustrated History. Mosby-Year Book, 1992

Milestones in Medical Imaging

ACR MRI Safety2002,2004,2007
CR, 1984

Nobel Prize
for MRI 2003

EBT 1982

Direct
Radiography 1999+
Multidetector
CT 1996
PET/CT 1996

PACS, 1982
Fluoroscopy
1896
X-Ray
Discovery
1885

1880

PET, 1953

DSA 1979

Clinical
MRI, 1981

1st Filmless hosp.

1994

MRI 1973
Cardiac
Catheterization, Automatic Film
Processor ,1942
1929

1925
1900

CT 1972

I-MRI,1994

US 1966
SPECT
1963

DICOM, 1993

1950

PACS Development
1990s

1975

2020
2000
Molecular Medicine

Early Medical Imaging

Information and Communications

Advanced Medical Imaging

Resource Shortage Drivers

The Staffing Crisis will
continue at many levels:
radiology nurse
radiology technologist
radiologists
PACS specialists

New types of personnel are

evolving in the procedural
environment:
Image-guidance radiologists
Surgical Imaging Technologists
Surgical IT Managers
Non-surgical Interventionalists

Communications Drivers
Digital image
acquisition and
transmission

The PACS Concept

Digital pathology,
pharmacy, lab,
etc.
Digital supply
management /
billing
Artificial
intelligence / CAD

...transferred
electronically...

Images &
Information
acquired
digitally...

...made
available to
a variety of
review
stations...

...stored digitally...

Productivity Drivers

Collaboration Drivers
Advanced technology .

Image courtesy of Brigham and Womens

Hospital

. can accelerate or disrupt collaboration.

Recruiting, Retention & Market Drivers

Imaging Techniques

Radiography

Patient Corridor

Staff Core

Conventional x-rays
Analogous to casting shadows, but
with much stronger light
Radiographs are essentially shadowgrams
Bones, soft tissues, and air attenuate
the x-ray beam differently this is the
basis for radiographs

Digital radiography
Replaces film
with a digital
detector
Separates the
capture,
and storage functions

image
display,

Fluoroscopy
Early fluoroscopy
Used a fluorescent/
phosphorescent screen
place of film
Allowed viewing of moving
structures
Very high radiation exposure

Modern fluoroscopy
Uses an image
intensifier or
digital detector
Much lower
radiation
exposure

in

Mammography
Conventional Film
Basically radiography but with very
high-resolution film/screen system
Proven to reduce breast cancer
deaths

Digital
Similar to digital radiography, but
uses a high-resolution digital detector
High resolution is needed because
important findings are often very
small

Computed Tomography
Staff Core

A major revolution in radiology

Patient Corridor

Abdominal CT

Allowed for the first cross-sectional

imaging of the body in living humans
(and animals)
CT is an x-ray technique and
depends on the different attenuation
of tissues
In cross-sectional imaging, the great
advantage for the physician is that
the overlap of structures on
radiographs is eliminated
The newest CT machines can
generate many slices (up to 256)
per rotation, as a result, scan times
have fallen by an order of magnitude

Interventional Radiology and Cardiology

Largely use fluoroscopic
techniques
Viewing and recording motion are
critical
To achieve the views that the
radiologists and cardiologists
need, the equipment has to be
able to move in many directions
and angles
Cardiologists usually need higher
frame rates (more images per
second) because of the rapid
motion of the heart and cardiac
valves

Ultrasound
Relies on sound, not x-rays
Sound is reflected differently from
different tissues
Typically done in real-time mode
so moving structures are easily
imaged
Limitations are bone and gas
through which ultrasound does not
pass
The lack of radiation means the
technique can be used on children
and fetuses
The newest systems allow for 3and 4-dimensional imaging (4D =
3D + time)

Magnetic Resonance Imaging

Taking your protons out for a
spin
Uses the magnetic properties of
the nuclei of some atoms
The atoms are lined up with a
strong magnetic field
The atoms are hit with a radio
pulse
As the atoms return to their
starting state, they give off a radio
signal that signal varies with the
atom and the environment of the
atom
The signal is detected and results
in the MR image

Nuclear Medicine
Typically a functional imaging
technique
Radioactive isotopes are attached to
molecules of interest
The molecules can be targeted to
particular cellular or organ functions;
for example, radioactive iodine which is
avidly taken up by the thyroid gland
The radiation emitted by the
molecules is detected
Isotopes that give off positrons can be
used to generate cross-sectional
images

Images courtesy of:

http://www.med.harvard.edu/JPNM/chetan/

Hybrid Imaging
Combination imaging
methods
PET-CT: combines nuclear
medicine positron imaging (a
cross-sectional technique that is
good at functional imaging) with
CT (good at anatomic imaging)
The machine has a single patient
table with PET and CT gantries
around it

PET-MRI
The newest hybrid imaging:
combines PET and MRI

Image Management - PACS, IMACS

Digital image management
systems:
Replace film and paper-based
management
Acquire images digitally
Display images on computerbased workstations
Store images in servers
Manage images, patient
information, reports, scheduling,
and billing information
Manage workflow get
information where needed when
needed

Trends
Plain film procedures (R&F)
being replaced by advanced
cross-sectional imaging (CT,MR)
Increasing demand today for
intensive air, power, data, and
structural capacities
Need to provide additional
infrastructure capacities for future
equipment and procedures
Hybrid modalities (PET/CT,
PET/MR, PET/OR/MR) require
more space and infrastructure
Greater horizontal & vertical
space required

Questions??

Design and Planning

Considerations

Workflow
Radiologist
Technologist
Patient
Information
Equipment / Supplies

INPATIENT
OUTPATIENT
PATIENT RECORD
MEDICAL IMAGE
TECHNOLOGIST
RADIOLOGIST

= IMPACT OF DIGITAL IMAGE MANAGEMENT

STORE IMAGE

MD CONSULT

READ IMAGE

QA IMAGE

PROCESS IMAGE

ACQUIRE IMAGE

DRESS / TOILET

INTERVIEW

BUSINESS OFF.

WAIT / HOLD

RECEPTION

Flow Type

Location

Workflow Analysis

Traditional Film-based Department

MRI

Radiology
ED

Lab

CT

Angiography

Dark
Room

R/F
R/F
R/F

The Digital Department

OR
M/S

Images to/from
Med/Surge
Floors

IMAGING

ICU

Images to/from
ED, OR & ICU

Images to/from
Technology Dock
HC
Enterprise

ED

Tech
Dock

Images to/from
Entire Enterprise

Intradepartmental Relationships
Outpatient Circulation
Routine Outpatient

Work Core
Special
Interventional

IP
Hold

Routine
Inpatient

Inpatient Circulation
Elevators/
Emergence Entry

OP
Wait

Recep

Concept Diagram
Routine / Short
Duration

FRONT

CT

Chest Room
Mammography
General Radiography

Outpatient

MRI
Nuclear Medicine

Inpatient

Special Fluoroscopy
Interventional Radiology

Complex / Long Duration

BACK

Planning Typologies
Exam
Exam /
Supt

Exam

Exam

Exam

Exam

Exam

Supt
Exam /
Supt

Exam

Exam

Staff
Work
Core

Exam

Exam

Single
Corridor

Double
Corridor

Modality Pod

Expansion

Flexibility
Vertical Elements at Perimeter

2008 Anshen+Allen

Flexibility
Geographically-distributed Tele/data Closets

2008 Anshen+Allen

Traditional Film-based Department

Circa: 1990 (and earlier)
5

1 Central Dark Room

2 Central Film File Room

1
4

2
3

3 Central Tech Work Core

4 Ball Room Reading Area

5 Minimal Prep / Holding

Hybrid Department

US

CT

(Film / Digital)
Circa: 1995
Rad

1 Non-Equipped Dark Room

RF

Rad

3
MR

2 Large Image Archive

in Basement

11
RF

3 Tech Work Core for Daylight or Digital Processing

4

4 Reading in Individual Offices

5 More Prep / Holding

Admin

Digital Department
Circa: 2002 (and beyond)
NM

1 No Dark Room
2 Decentralized
Modality Clusters

3 Remote Virtual Archive

4 Reading
Anywhere
5 Extensive
Prep / Holding

RAD/RF

US

MRI

3
5

CT

Imaging Environments that Improve

Outcomes and Safety

Radiation
Safety

MRI Safety

Handed vs.
Mirrored
Rooms

Environments
that Improve
Diagnostic
Interpretation

Radiation Safety

Architect

Radiation Health
Physicist

Equipment Planning
Consultant

Equipment Vendors

Health Safety
Compliance Officer

Image, courtesy of: Scott Jenkins, EDI Design

Radiation Barrier Basics

Radiation Barrier Basics

Solid end of barrier

should be min. 18
wide

18

Barrier should
protect staff & door
opening

Radiation Barrier Basics

Solid end of barrier

should be min. 18
wide
Shielded window
should provide
unobstructed view
of patient and
room

18

Barrier should
protect staff & door
opening

Equipment Orientation

Door
Scan
Room

Control

Door
Scan
Room

Control

Door
Scan
Room

Control

Equipment Orientation
CT orthogonal with
scan room
Door

CT diagonal, away
from door

Control

Scan
Room

Direct radiation
through doorway.
Marginal visibility
into scanner

Door

CT diagonal, toward
door

Control

Scan
Room

Minimal direct
radiation through
doorway. Poor
visibility into scanner

Door

Control

Scan
Room

Direct radiation
through doorway.
Good visibility into
scanner

Location of Door Openings

Control Window

Control Window

Control Window

Staff Door

Good visibility into scanner.

Good radiation protection
Good access from control into scanner room
Good patient access onto scanner

Staff Door
Patient Door

Patient Door

Patient Door

Staff Door

MRI Safety
In the future, much of pediatric imaging will transition
from ionizing radiation techniques (general x-ray, CT,
etc) to MRI due to concerns about potential hazards of
radiation exposure.

MRI hazards are among the top 10 healthcare concerns

leading to errors and adverse events1
1

The Quality Letter for Healthcare Leaders, April 2003, Lippincott Williams and Wilkins

MRI Design Variables Influencing Safety

RF Interactions
Tissue Heating

Magnetic Interactions
Translational Attraction
(projectile)
Torque

Emergency Egress
Restricted Access
Cryogen Safety
Image, courtesy of: Scott Jenkins, EDI Design

Landmark Accident (2001)

Incident: July 27, 2001,

Westchester (NY) Medical Center
Source: The Journal News June 1, 2002

ACR MRI Safety Guidelines- 2002, 2004, 2007

ZONE 1: Unrestricted
[outside MR suite]
ZONE 2: Restricted to supervision
by MR personnel
[reception, waiting, toilets, dressing]
ZONE 3: Highly restricted area
where serious injury can occur
[control room, computer room]

Source: The Journal News June 1, 2002

ZONE 4: Most highly restricted

where all non-MR personnel must
be in direct visual supervision of
Level 2 MR staff at ALL times
[MR scanner room]

MRI Safety Planning Implications

MRI suite with
3 scanners
1

Imaging Department
Future 4th Scanner
2008 Anshen+Allen

MRI Safety Planning Implications

MRI suite with
3 scanners
1

Imaging Department
Future 4th Scanner
2008 Anshen+Allen

ZONE 1

MRI Safety Planning Implications

MRI suite with
3 scanners

ZONE 2

Imaging Department
Future 4th Scanner
2008 Anshen+Allen

ZONE 1

MRI Safety Planning Implications

MRI suite with
3 scanners

ZONE 2

Imaging Department
Future 4th Scanner
2008 Anshen+Allen

ZONE 1

ZONE 3

MRI Safety Planning Implications

MRI suite with
3 scanners

ZONE 2

ZONE 4
3

Imaging Department
Future 4th Scanner
2008 Anshen+Allen

ZONE 1

ZONE 3

MRI Safety Planning Implications

Secure MRI
suite
boundary
(Zones 3 & 4)

2008 Anshen+Allen

MRI Safety Planning Implications

Secure MRI
suite
boundary
(Zones 3 & 4)
Secure MRI
suite door

2008 Anshen+Allen

MRI Safety Planning Implications

Secure MRI
suite
boundary
(Zones 3 & 4)
Secure MRI
suite door

Through-traffic
does not enter
MRI suite

2008 Anshen+Allen

MRI Safety Planning Implications

2008 Anshen+Allen

MRI Safety Planning Implications

One Tech can
see 2 MRI
rooms

2008 Anshen+Allen

MRI Safety Planning Implications

One Tech can
see 2 MRI
rooms

Both Techs
can see
entrance to
Security
Vestibule

2008 Anshen+Allen

MRI Safety Planning Implications

One Tech can
see 2 MRI
rooms

Both Techs
can see
entrance to
Security
Vestibule
Securitycontrolled
Corridor
2008 Anshen+Allen

Direction of Door Swing Into Scan Room

During a quench,
cryogenic gas fills
the scan room and
depletes 02

Direction of Door Swing Into Scan Room

During a quench,
cryogenic gas fills
the scan room and
depletes 02

If the door swings in,

increased room
pressure can make it
difficult to exit quickly.

Direction of Door Swing Into Scan Room

During a quench,
cryogenic gas fills
the scan room and
depletes 02

If the door swings in,

increased room
pressure can make it
difficult to exit quickly.

If the door swings out it

will be easier to exit.

Handed vs. Mirrored Rooms

Handed Inpatient Rooms

Designed for safety

because everything is
in the same place

Do providers get
disoriented (which
patient)?

Need to provide
distinguishing visible
landmarks

Where is the
evidence?

Handed X-ray Rooms

Designed for safety

because everything is
in the same place

Do providers get
disoriented (which
patient)?

Need to provide
distinguishing visible
landmarks

Where is the
evidence?

Mirrored X-ray Rooms

Designed for safety

because one
technologist can
supervise multiple
rooms

Staff travel distances

tend to be shorter than
with handed rooms

Where is the evidence?

Mirrored CT Rooms

Mirrored MRI Rooms

Visibility from one

shared control room

Restricted access
vestibule

Shared electronics
room

Emergency
resuscitation area

Evidence for Better Reading Room Design

Improperly designed reading environments contribute to:

Reduced radiologist accuracy

(misdiagnoses)

Reduced radiologist productivity

Increased workplace injuries

(inefficiency)

(hands, neck, eyes, headaches)

Non-designed Film Reading Room

Typically, the reading room is not designed

Often specified as an office work space, with
inappropriate lighting, materials and finishes
Reading activities appear to be misunderstood

Transition from Film to Soft Copy

Reading activities become more intense

3D & 4D images; reading is more interactive
Room design becomes more critical

Reading Room Design Elements

Enclosure
Lighting
Ergonomics
Acoustics
Connectivity

Enclosure
Design for both privacy and collaboration
Flexibility for both individual and group reading

Lighting

Avoid high luminance sources in the

peripheral field of view

Position the workstation & monitor to minimize

reflective glare

Ergonomics
Optimal Viewing Distance = 24 to 36

Optimal
Viewing Angle =

100 to 200

Use furniture
adjustments to
avoid excessive
near-point viewing

Configure workstations for multiple users

Acoustics
Confine conversations within the
work area...

Keep distracting noises

outside the work area ...

... with acoustic ceiling, floor, and wall finishes.

Reading Room Design Interventions

Avoid Built-in Casework;

Use Adjustable Computer Furniture

Select Neutral Non-reflective Materials

& Finishes
Install Sound-dampening Materials
Provide Adequate Ceiling Height
& Adjustable Ventilation

Reading Room Prototype

Reading Room Prototype COTS

(Commercially off-the-shelf)

1200

Questions??

Convergence of Imaging
and Surgery

Does Form Follow Function?

Surgical and
interventional radiology
procedures have
changed dramatically in
recent decades and in
many ways are
converging
Why do the designs of
surgical suites and
interventional suites
remain so different?

Surgery Has Become Less Invasive

Minimal surgical incisions
Redefinition of
Sterile Field
Increased reliance on
image guidance
Many surgical
procedures similar to
interventional radiology
and interventional
cardiology

IR Has Become More Interventional

Historic IR room
utilization: 60-70% =
diagnostic procedures
Many diagnostic IR
procedures now
replaced by lessinvasive modalities
(CTA, MRA, SPECT,
PET, Hybrids, etc.)
Future IR room
utilization will focus on
more interventional
procedures

IR Requires a Surgical-like Environment

Surgical-quality Heating,
Ventilation and Air
Conditioning (HVAC)
requirements
Surgical-like restricted
workflow requirements
Increased Prep /
Recovery needs

2008 Anshen+Allen

Surgery Relies on Image Guidance

Design Implications
Operating Rooms often
have sub-optimal
lighting conditions
Surgeons may need to view
& interact w/ medical images
from a distance
As image guidance become
more complex new personnel
(radiology techs, IT specialists,
etc.) will need to paticipate in
procedures without entering
the OR

PACS and Image Guidance in the OR

Design Implications

Green theatrical gels placed over ambient lighting tubes

Information Technology in the OR

Design Implications

MRI in the OR
Design Implications

MAGNET
TYPES
Stationary

ROOM
TYPES

Pivoting

Single Room

Traveling

Dual Room

Portable

Many Rooms

MRI in the OR
Design Implications
Design for MRI safety
(ACR safety guidelines)
Locate MRI for either
scrubbed or
street clothes access
Protect against RF and/or
magnetic interactions
with adjacent occupants
Increase structural, air
and cooling capacities

ORs With Control Rooms

2008 Anshen+Allen

ORs With Control Rooms

2008 Anshen+Allen

ORs With Control Rooms

Support Team

Patient

Scrubbed Team

Supplies

Sub-sterile
Control Room
2008 Anshen+Allen

The Integrated Interventional Suite

Definition: The consolidation of various interventional services
within a common area and operated as an integrated
program.

Endoscopy

IR / Cath

Surgery

2006 Anshen+Allen

Level 2
Recovery
Shared prep/
recovery

PACU
Intake/
Prep

The Integrated Interventional Suite

Challenges:
Collective vision to
minimize turf battles
Differing protocol for
infection control in Surgery,
Interventional Radiology and
Interventional Cardiology

Kingdom
of
Surgery

Kingdom
of
Imaging

Kingdom
of
Cardiology

Contiguous space for

multiple services
Cross-training for some
support staff
Cost of excess
infrastructure capacity for
future areas of change
Lower middle image, courtesy of: Center for Integration of Medicine and Innovative Technology / Massachusetts General Hospital - Operating Room of the Future
(ORF) Reuben Mezrich, MD, PhD; Nat Sims, MD

The Integrated Interventional Suite

Level 2 IR: 2; EP: 1 Cath Labs: 2; Shell: 1

Endo

IR / CCL /
EP / Shell

ORs

Pre- Op /
Post-Op

2008 Anshen+Allen Associated Architects for Palomar Pomerado Health

ORs: 12;

Endo: 3;

Prep / PACU beds: 53 (2.5:1)

The Integrated Interventional Suite

Approach: Flexible Planning Modules

2008 Anshen+Allen Associated Architects for Palomar Pomerado Health

Universal Procedure Rooms

Design Considerations:
Room Size:

Room Configuration:

<600 NSF; 600-750 NSF;

> 750 NSF
Square; rectangular;
handed vs. mirrored

Universal vs. Dedicated:

A question of flexibility

Table Orientation:

Parallel; perpendicular;
diagonal to corridor

Orientation of patients head:

Head to corridor; feet to

corridor; head to side

Room zoning and workflow:

Sterile; circulation;
anesthesia;
documentation zones

The Integrated Interventional Suite

Approach: Flexible Planning Modules

2008 Anshen+Allen Associated Architects for Palomar Pomerado Health

The Integrated Interventional Suite

Approach: Surgery - Clean Core / IR - Staff Core

2008 Anshen+Allen Associated Architects for Palomar Pomerado Health

The Integrated Interventional Suite

Approach: Collaborative Cath/IR Staff Core

2008 Anshen+Allen

2008 Anshen+Allen

The Integrated Interventional Suite

Approach: Virtual Red Line

EP

IR

CATH

IR

CATH

IR

OR

OR

OR

OR

OR

OR

OR

OR

OR

OR

OR

OR

2008 Anshen+Allen Associated Architects for Palomar Pomerado Health

The Integrated Interventional Suite

Approach: Flexible Pre-op / PACU

2008 Anshen+Allen Associated Architects for Palomar Pomerado Health

The Integrated Interventional Suite

Approach: Flexible Pre-op / PACU

2008 Anshen+Allen Associated Architects for Palomar Pomerado Health

Questions??