Transition to a hybrid teleradiology model with a new plug-and-play workstation concept

INTRODUCTION The radiology department at Ng Teng Fong General Hospital, Singapore, operates on a conventional on-site working model, similar to that of most hospital infrastructures in Singapore. It is fitted with 46 desktop workstations serving both staff radiologists and trainees, and utilises the GE Healthcare Radiology Information System — Picture Archiving and Communication System (RIS–PACS). While this work model has served us well since the hospital’s inception in 2015, certain limitations became evident following the coronavirus disease 2019 (COVID-19) pandemic. Although not a new concept, the hybrid teleradiology model has seen increased adoption since the COVID-19 pandemic.[1,2] We believe that this approach offers flexibility by enabling remote work when possible, while also mitigating some of the possible drawbacks of a fully remote teleradiology setup. With our current workstations approaching the end of their life cycle, we have chosen to trial new workstation hardware to facilitate our transition to a hybrid model. Our research on teleradiology and hybrid setups revealed a general theme.[3,4,5] In most centres, each radiologist is issued with a separate set of desktops, monitors and peripherals to enable remote work. In Singapore, the general guideline is to provide radiologists with a separate desktop or laptop with a dedicated graphic card to facilitate teleradiology. We found the current setup to be costly, as two sets of computers, in addition to the monitor and peripherals, must be procured for each radiologist. To better manage costs, we propose replacing the desktop with a single portable laptop that will serve as the main workstation for both on-site and remote work using a plug-and-play (PnP) system. THE CONCEPT At our hospital, radiologists are provided with laptops for administrative work and review of radiology studies off-site. To date, we are unaware of any other institutions in Singapore that utilise laptops as dedicated radiology workstations. We postulate several reasons for this and detail how we can overcome some of the limitations of laptops. One limitation is the perception that laptops are inferior to desktops. We concur that there will always be a performance gap between laptops and desktops due to the physical size constraint of the former. However, based on our prior experience, current generation laptops have the capability to run our required programs. Additionally, the performance of laptops can be comparable to desktops if they are equipped with components such as a dedicated graphic card and multicore central procession unit (CPU) — this was confirmed by our IT vendors during discussion about hardware requirements. The other main limitation of using laptops is the limited number of connection ports. The small screen size and lack of Digital Imaging and Communications in Medicine (DICOM) calibration on laptop screens preclude laptops from being used for image interpretation. As such, laptops will have to be connected to medical-grade monitors for image interpretation. Most laptops on the market offer only a single display output, which is not sufficient, especially for large-format monitors or multi-monitor setups Additionally, the need for multiple essential peripherals, such as a mouse, keyboard and dictation device, limits the practicality of laptops as workstations. A simple workaround solution involves the use of aftermarket devices such as universal serial bus (USB) hubs and docks, which can expand the functionality of a single USB port. Of particular interest is the recent availability of Thunderbolt™ 4 docks, which can connect to multiple monitors and peripherals while providing power to the laptop. Having considered the limitations and workaround solutions, we conceptualised a hybrid PnP workstation system using laptops and docks with the following key criteria: (a) the laptop should be equipped with a dedicated workstation-grade graphics processing unit (GPU) that is capable of 4K output; (b) the laptop should have at least one Thunderbolt™ 4-certified port; (c) the dock should be Thunderbolt™ 4 certified; (d) the dock should have at least two display output ports that support the DisplayPort interface; and (e) the dock must have at least three USB type A ports for peripherals and an RJ45 port for connecting to the hospital network. The other specifications, such as the screen dimension, random access memory (RAM) and hard disk, were secondary considerations that were factored in after considering our budget and RIS-PACS requirements. The final specifications of the laptop used in our setup are detailed below, and the complete setup is shown in Figure 1.Figure 1: Photograph shows the new workstation concept — (1) laptop is connected to (2) Thunderbolt™ 4 dock, which is connected to (3) peripherals and (4) monitors..Laptop specifications: (a) model: HP Z-Book Fury G8 Mobile workstation; (b) CPU: Intel (R) Xeon (R) W-11955 CPU @ 2.60 GHz; (c) GPU: NVIDIA RTX A3000; (d) RAM: 32 GB ram; (e) hard disk: 1 TB solid state drive; and (f) screen dimensions: 17.3 inch, 3840 × 2160 resolution. Dock specifications: model – Dell Thunderbolt™ 4 Dock WD22TB4 that has the following connections: (a) two USB-C ports, (b) three USB-A ports, (c) two DisplayPort 1.4, (d) one HDMI 2.0 port; and (e) Gigabit Ethernet RJ45. After confirming the compatibility of these components, two radiologists were each provided with (a) one laptop, (b) two sets of peripherals (mouse, keyboard, dictaphone), (c) two sets of docks, and (d) two sets of monitors to enable a hybrid teleradiology setup. The docks are permanently connected to the monitors and peripherals in both the on-site and remote workspaces. When switching between on-site and remote work, the radiologist would need to transport the laptop between locations and connect it to the dock to achieve full workstation functionality [Figure 2]. After testing this setup for 6 months, the radiologists found no difference in performance when compared to a traditional desktop-based workstation.Figure 2: Photograph shows the Thunderbolt™ 4 dock connections — (1) DisplayPort connections to diagnostic monitor; (2) HDMI connection to generic work monitor; (3) USB connections to peripherals (mouse, keyboard, dictaphone); (4) RJ45 connection to local network; (5) Thunderbolt™ 4 connection to laptop; and (6) power supply connection for Thunderbolt™ 4 dock.The key to our setup is the Thunderbolt™ 4 connection standard, which was introduced by Intel in 2020. To receive the Thunderbolt™ 4 certification, specific hardware specifications must be met — support for two 4K monitors, 40 GB/s data transfer speed over cables of up to 2 m in length and at least one port supporting 100 W laptop charging — all of which are crucial to our new workstation concept. With this fairly new dock technology, our radiologists can switch between on-site and home reporting seamlessly without having to reconnect all the cables for the monitors and peripherals each time. In addition, we also found several added advantages when testing this workstation concept. ADVANTAGES Cost saving and reduced redundancy Traditionally, laptops with specifications similar to desktops are costly. However, we found that the cost of a single laptop is almost half that of a desktop. We postulate that the cost of these laptops is lower because they come prebuilt from the manufacturer, whereas desktops are custom-built according to the submitted hardware specification. Another added advantage of using laptops is reduced redundancy. In the conventional hybrid setup, the desktop at the remote workspace cannot be utilised by anyone else when the radiologist is working on-site, making it redundant. Conversely, with our proposed workstation setup, the single laptop provided to each radiologist is constantly utilised for on-site or remote work. When the radiologist is working remotely, the on-site hardware can be utilised by other radiologists simply by connecting their laptops to the docks. In addition, the laptop can be transported to another physical location in the hospital for other work functions such as multidisciplinary meetings, omitting the need for a dedicated computer to be installed in these locations. All these culminate in cost saving. Even with the additional need for Thunderbolt™ 4 docks, we found that the overall cost of our setup is much lower than purchasing two desktops for each radiologist. We also anticipate long-term cost savings, as only one working laptop per radiologist requires maintenance. Workflow benefits There are other benefits of switching to laptops as the primary workstations. First, the additional monitor on the laptop enables the radiologists to enhance their productivity by completing tasks, such as checking emails, preparing presentations, looking up references and attending video conferences, without having to minimise the RIS-PACS window [Figure 3].Figure 3: Photograph shows the hybrid teleradiology setup with the laptop screen used as an additional monitor.The screen and keyboard that comes with the laptop also provide added flexibility to our remote setup. This is particularly useful for radiologists who have limited space at home as the laptop can be used as a standalone reporting station, omitting the use of a separate monitor and keyboard [Figure 4].Figure 4: Photograph shows the space-saving configuration with the laptop used as a standalone reporting station without an additional monitor and keyboard.POTENTIAL DRAWBACKS While our hybrid setup offers many benefits, there are also potential drawbacks that warrant attention. Transporting the laptop between places carries the risk of loss and theft. This is an important factor to consider, as a radiologist’s workstation has access to sensitive patient data. As per our hospital IT governance, all new workstation laptops are set up in the same manner as other hospital computers, requiring secured logins and encrypted connection to access the hospital network. We have also put in place protocols in the event of loss or theft, which involve notifying the head of department, IT department and the police. The longevity of laptops as radiology workstations has yet to be proven. Unlike desktops, the components of a laptop cannot be replaced as easily. The dock also adds another point of failure to this setup. Transporting the laptop between places also theoretically increases the risk of damage. To mitigate this risk, each radiologist is advised to only transport the laptop home only when scheduled for remote work. As with our previous workstations, securing sufficient warranty coverage from our vendor remains a top priority. Ultimately, we felt that these drawbacks are worthwhile trade-offs for enabling a flexible hybrid teleradiology system that can be set up with a relatively conservative budget. CONCLUSION Our new hybrid workstation concept offers an elegant solution for hybrid teleradiology, with numerous advantages. Although there are some potential drawbacks, they can be mitigated with proper precautions and protocols. We hope that other radiology departments considering a hybrid teleradiology model will benefit from our experience. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.