IT Guidance Documents

Picture archiving and

communication systems
(PACS) and guidelines on
diagnostic display devices
Second edition

Board of the Faculty of Clinical Radiology

The Royal College of Radiologists

This guidance forms part of a series on the developments in information technology in radiology. This is a
fast-moving field and developments are occurring rapidly. Consequently, this guidance will be updated
regularly and readers should check regularly that they are using the most up-to-date guidance available.

These guidelines are aimed at simplifying the essentials relating to medical display devices (including picture
archiving and communication system [PACS] monitors), and deal with the issues of spatial and contrast
resolutions, and provide a recommended basic specification table. These guidelines should be read in conjunction
1
with those on the ergonomics of a PACS workstation to appreciate the importance particularly of ambient lighting
conditions on digital display devices. This document replaces BFCR(08)7 Picture archiving and communication
systems (PACS) and guidelines on diagnostic display devices, which has been withdrawn.
1.

Classification of display devices

1.1

Medical display devices can be classified as either primary (diagnostic) or secondary (review). Primary
display devices are used for the interpretation of medical images. Secondary display devices are used for
reviewing medical images, usually in conjunction with the report. It is recommended that all primary display
devices undergo acceptance testing and regular performance review.

1.2

Specialist medical liquid crystal display (LCD) devices should be distinguished from common-off-the-shelf
(COTS) LCD devices. Medical displays offer improved pixel resolution: a 2048 x 1536 pixel display is
typical for a medical display, whereas COTS displays are rarely available with resolutions greater than
1920 x 1200. Medical displays can also offer improved performance in terms of luminance level, uniformity
and constancy, contrast ratio, viewing angles and compliance with the Digital Imaging and
Communications in Medicine (DICOM) Greyscale Standard Display Function (GSDF). Advanced
management features available with medical displays include remote quality assurance and automatic
quality assurance (QA) report generation.

1.3

Specialist medical LCD devices are preferred to COTS devices for primary diagnosis. Lower diagnostic
performance has been demonstrated on appropriately calibrated COTS devices compared to specialist
2
medical LCD displays.

2.

Spatial resolution

2.1

When first viewing a digital radiographic image, the image data should be interpolated to display the image
fully within the maximum available screen area since it is recognised that pattern recognition of nonspatially limited abnormalities can be overlooked if the image is not viewed as a whole. There is insufficient
evidence to quantify the clinical risks associated with viewing images interpolated below their acquisition
resolution, but it has been shown that any risk can be minimised by a process of systematic magnification.

2.2

On a medical imaging workstation, magnification should be achieved by using the software zoom, pan and
magnification tools, as closer visual inspection will not overcome the effects of image interpolation. Ideally,
images should be magnified to their acquisition resolution or to a whole number magnification factor
greater (for example, x2 or x3) to avoid the risk of introducing artefacts due to image interpolation. For
example, when an image is too large to be displayed fully on screen, it should be displayed at its
acquisition resolution (1:1 pixel matching) and the image panned around the screen until the whole of the
image has been viewed. Alternatively, the magnifying glass tool can be used to systematically magnify
areas of the image to reveal the full image detail. Studies suggest that there is little reduction in the
diagnostic power of using these techniques when compared to displaying the whole image at 1:1 on higher
resolution screens, but there is an increase in the time taken to make a report.

2.3

When viewing multiple images, it is recommended that serial images are compared directly, side-by-side,
to highlight any difference in appearance. Smaller images, such as those obtained in cross-sectional
imaging, can be displayed fully side-by-side on a single screen. Larger images, such as from projection
radiography (CR and DR), should ideally be viewed on separate displays to optimise the ratio of the display
resolution to the acquisition resolution.

2.4

At normal viewing distances, the psychophysical performance of the human eye imposes a limit on the
perceived resolution. It has been calculated that at a 60 cm viewing distance, human visual performance is
well matched to a screen with 0.25 mm pixels (pixel pitch). This is equivalent to a native screen resolution
of 1280 x 1024 (~1.3 MP) on a 42 cm (~17) display, or 1600 x 1200 (~1.9 MP) on a 50 cm (~20) display.
Higher resolution display devices enable the user to view the image in greater detail by closer inspection of
the screen, but a similar effect can be achieved with software zoom, pan and magnification tools. High
fidelity dual screen displays (3 MP) are recommended in radiology and other areas where large numbers
of radiographic images are reported, to reduce reporting times and thereby optimise department workflow.

2.5

Medical displays achieve their higher resolution by the use of a smaller pixel pitch, with most display
devices for primary diagnosis being limited to a size of approximately 54 cm (22). COTS devices tend to
use a larger minimum pixel pitch and high pixel counts are achieved primarily by increasing the physical
size of the screen. The use of very large displays (>70 cm/27) may make achieving adequate ergonomics
difficult, particularly when used in a portrait configuration, or when multiple display devices are used on a
single workstation.
3

2.6

Display devices, especially COTS displays, are increasingly available in wide aspect ratios (AR) (for
example, 16:9) as opposed to the older aspect ratios (4:3 and 5:4). When comparing the resolution of
devices with different aspect ratios, the pixel count may be misleading, as the limiting factor is the absolute
number of pixels in the limiting direction. Wide aspect ratios may not be as well suited to most radiographic
images with squarer AR. However, a wide monitor with the same number of pixel rows provides a greater
screen area, so may help workflow by permitting the display of more images side by side.

3.

Contrast resolution

3.1

The contrast resolution of a display system depends on a number of factors, including the maximum and
minimum luminance of the display device, the characteristic (luminance response) curve of the display
device, the greyscale bit depth, the background ambient illumination, and the use of application software
windowing tools (see below). A useful concept is the just noticeable difference (JND) index. Each JND
index step corresponds to a perceivable difference in grey scale resolution. In medical image viewing, it is
desirable to optimise the number of JND index steps available.

3.2

The contrast ratio of a display system is defined as the ratio of the maximum to minimum luminance that
the device is capable of displaying. In general, the higher the contrast ratio of a display device, the higher
the number of JND index steps that can be perceived, and the better the contrast resolution. High fidelity
medical grade monochrome LCD monitors are brighter than COTS LCD displays, achieving maximum
luminance values >500 cd/m2, and contrast ratios >800:1. Higher display luminance is useful in
maintaining visible contrast in the presence of ambient illumination. There is some evidence that high
brightness display devices with maximum luminance >500 cd/m2 can cause fatigue and impair contrast
resolution by their effect on the adaptation level of the human visual system, and the optimum operating
level may vary between users. It is common for medical LCDs to be specified with maximum luminance
significantly higher than the recommended level. This is advantageous in prolonging the life of the display,

as the luminance of the light source declines with aging. LCD contrast ratio can deteriorate significantly at
oblique viewing angles, and it is recommended that all reporting is performed with the user perpendicular
to the screen.

3.3

The characteristic curve of a display device is a plot of the measured luminance response for each step in
the digital driving level (DDL) of the display system. The human visual system has a non-linear response to
contrast resolution, with the effect that it is more difficult to perceive contrast differences at low illumination.
To compensate for this, a standard curve of luminance versus JND index has been defined within the
3
DICOM Greyscale Standard Display Function (GSDF). Devices calibrated according to the GSDF are said
to be perceptually linear in response, and optimised to human visual performance.

3.4

The greyscale bit depth of a display device is the number of levels of grey that can be represented by the
digital driving level (DDL) of the display device. An 8-bit (per pixel) greyscale display device can represent
256 levels of grey, while a 10-bit device can represent up to 1024 total levels. For colour monitors
displaying monochrome images, 24-bit and 32-bit colours are equivalent to 8-bit greyscale. Whether a user
is able to perceive all the greyscale bit-depth levels that are represented depends on the maximum
luminance, contrast ratio, and calibration of the display device to the GSDF (see above). In practice, a user
will typically only see a fraction of the 256 levels of grey represented by a non-calibrated 8-bit display
device as the luminance difference between each step in the DDL will not correspond to a perceivable
difference in greyscale contrast (JND index step). By comparison, high contrast 10-bit calibrated display
devices are capable of displaying >500 perceivable shades of grey (JND index steps).
[Current operating system software has limited support for handling 10-bit greyscale data. Display of 10-bit
data requires the image display application to be written such that it communicates directly with a 10-bit
capable graphics card, and that there is a 10-bit capable connection between the graphics card and display
device. Even with an 8-bit greyscale input, a 10-bit display device can outperform an 8-bit display device by
ensuring all 256 input greyscale levels are represented as perceivable differences in greyscale to the end
user.]

3.5

Application software windowing tools control the number of simultaneous greyscale values in an image that
are presented for display. A DICOM image can encode up to 16 bits greyscale per pixel, but only a fraction
of these are shown at any time. By changing the centre (level) and range (width) of the greyscale values
presented, it should be possible to demonstrate all the greyscale data represented in the image. The
minimum specification of a display device in terms of contrast resolution parameters is therefore somewhat
arbitrary, and depends on how the windowing tools are used during normal workflow. High fidelity display
devices are recommended in radiology and other areas where large numbers of images are reported to
reduce requirements for windowing images, and thus assist in reporting workflow.

The luminance of the light source can be reduced electronically to reach the recommended value, but once the light source has degraded and
is unable to maintain the recommended luminance, the display has reached the end of its working life.
4

Use of colour displays

4.1

Historically, the performance of colour display technology was insufficient to meet the recommended
greyscale performance targets for primary diagnosis. Advances in technology have led to the development
of colour display devices that are capable of achieving these standards. Previously, this may have required
a segregation of reporting work: dedicated workstations with high performance monochrome displays for
high-throughput reporting of projection radiography, and workstations with colour displays for reporting of
nuclear medicine or other advanced modality imaging.

4.2

The accurate reproduction of colour images is technically complex and beyond the scope of this document.
Unlike the multiple national standards for medical display greyscale luminance and contrast, there are not
yet similar standards for colour medical image reproduction. However, commonly used (display and
graphics) industry standards for colour calibration and response are incompatible with the DICOM
monochrome luminance response meaning that a display cannot be calibrated to both standards

simultaneously . In the context of current radiology practice, where foreseeable use of colour is limited to
false-colour images and/or coloured annotations, the risk associated with incorrect colour rendering is likely
to be lower than that obtained by incorrect greyscale rendering.

Modern computer operating system software (eg, Windows 7 and Mac OS X) provide a solution by the use of International Color Consortium
(ICC) profiles, which inform the system software of the display devices colour response. Colour management capable software can process
image colour data, so that the data sent to the display is corrected for the displays response function, and hence should provide near-optimal
display regardless of the monitors calibration (provided that the monitors response is known, or has been measured). Alternative softwareindependent solutions to this problem have included display devices that automatically detect monochrome and coloured images, and apply the
appropriate calibration to their respective screen regions. Where non-standard solutions such as this are used, their performance should be
verified as part of acceptance testing.
5

5.

Recommended specification

5.1

Table 1 shows the PACS and Imaging Informatics Group minimum and recommended specification for
primary diagnostic display devices used for clinical image interpretation. This guidance applies to all
workstations where CR, DR, fluoroscopy, ultrasound, CT, MR, nuclear medicine and PET images are
viewed (excluding mammography).

Table 1. Minimum and recommended specification for primary diagnostic display devices used for clinical
image interpretation
Minimuma

Recommendeda

Screen resolutionb
(Native pixel array)

1280 x 1024c
(~1.3 megapixels)

1500 x 2000d
(~3 megapixels)

Screen size
(viewable diagonal)

42 cm (~17)

50 cm (~20)

Maximum luminancee

>170 cd/m2f

500 cd/m2g

Luminance contrast ratio

(maximum/minimum)

250:1f,h

500:1

Greyscale calibration

Within 10% GSDFh

Calibrated to GSDFe

Greyscale bit depth

8-bit greyscale
(24-bit colour)i

10-bit greyscale

Video display interface

Digital
(Analogue not recommended for new
installations)

Digital (eg, DVI, displayport)

Pixel defectsj
ISO 13406-2 classification

Class 2
(2 per million)

Class 1
(0 defects)

Notes
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

The minimum and recommended specifications for diagnostic display devices are only appropriate if clinical image viewing is performed
according to image viewing guidelines. All diagnostic image interpretation should be performed on DICOM images, making use of the application
software zoom, pan, magnification and windowing tools to optimise spatial and contrast resolution.
LCD devices should be run at their native resolution to ensure there is a 1:1 match between screen pixels and screen resolution, and therefore
no loss of image quality due to screen interpolation. Displays should be configured such that the correct aspect ratio is maintained to avoid
distortion of the image; this will automatically be the case is a 1:1 pixel match configuration is used.
Where the majority of reporting performed on a diagnostic workstation is of cross-sectional imaging, lower resolution landscape style displays
(1.3 megapixels) are considered adequate, providing larger (e.g. direct radiographic) images are interpreted with the aid of systematic
magnification.
High fidelity (3 megapixels) portrait style displays are recommended in radiology and other areas where large numbers of plain radiographic
images are reported to reduce requirements for systematic magnification, and thus reduce image interpretation and reporting times.
Display devices may be set initially to operate at a fraction of the maximum luminance in the manufacturers specification. This can be adjusted to
compensate for the decline in performance of the back-light over time while maintaining greyscale calibration.
American Association of Physicists in Medicine TG18 recommendation.4
High luminance displays can increase the number of perceivable greyscale levels (JND index steps) but may have a detrimental effect in user
performance through fatigue and the human visual adaptation response. The optimum operating luminance level may vary between users.
Institute of Physics and Engineering in Medicine 91 recommendation.5
24-bit and 32-bit colours are equivalent to 8-bit monochrome greyscale. Colour display devices are recommended for displaying colour images,
but they generally perform less well than monochrome display devices in terms of maximum luminance and contrast ratio.
The number of permissible pixel defects per million is defined by the ISO 13406-2 standard. Class 1 panels should have no defects. Class 2
panels should be replaced if they have >2 whole pixel defects per million. Appropriate use of application software zoom, pan and magnification
tools can negate the effect of pixel defects in clinical practice.

Approved by the Board of the Faculty of Clinical Radiology: 15 June 2012

References
1. The Royal College of Radiologists. Ergonomics. London: The Royal College of Radiologists, 2012.
2. Krupinski E. Medical grade vs off-the-shelf color displays: influence on observer performance and visual
search. J Digit Imaging 2009; 22(4): 363368.
3. DICOM Standard Status. 3.14. Grayscale Standard Display Function. http://www.dclunie.com/dicomstatus/status.html (last accessed 27/11/12)
4. American Association of Physicists in Medicine. Assessment of display performance for medical imaging
systems. http://www.aapm.org/pubs/reports/OR_03.pdf (last accessed 27/11/12)
5. Institute of Physics and Engineering in Medicine. Report 91. Recommended Standards for the Routine
Performance Testing of Diagnostic X-Ray Imaging Systems. London: IPEM, 2005.
http://www.ipem.ac.uk/publications/ipemreports/Pages/RecommendedStandardsfortheRoutinePerformance
TestingofDiagnosticX-RayImagingSystems.aspx (last accessed 27/11/12)

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Citation details:
The Royal College of Radiologists. Picture archiving and communication systems (PACS) and
guidelines on diagnostic display devices. London: The Royal College of Radiologists, 2012.
Ref No. BFCR(12)16 The Royal College of Radiologists, November 2012
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