Monday, October 18, 2010

Screens for Pathologists: Portrait vs. Landscape

With the adoption of laboratory information systems and digital pathology, pathologists are increasingly reviewing and signing out pathology reports electronically. However, the majority of the pathologists still wish to review a draft or a final copy of their work on paper before sign-out. One of the major reasons cited for this duplication is the apparent ease of readability of a piece of paper compared to a screen, as an electronic page must be scrolled up and down to review all the information before sign-out.

Considering that the final output of a pathology report is an electronic representation that gets displayed in the electronic medical record or printed out on a portrait (taller than wider) orientation, it is surprising to observe that we are using landscape and now widescreen (i.e. wider than tall) monitors to draft and read pathology reports. There are several reasons for this mismatch (historical as well as lack of thought on workstation design) and little research has been done to see if the readability of electronic display can be improved.

For humans, it is easier to track objects moving sideways since our field of vision is more attuned to a horizontal spread, enhanced by an artificial reference or horizon (imagine watching horses galloping in a grassland at sunset). However, humans have historically preferred reading text arranged in small columns that wrap the text to the next line (reading a newspaper with text neatly arranged in short lines and long columns), and this is reflected in the almost universal adoption of a portrait format for forms used for textual information (from stone tablets to the modern A4 page).
In the 1970s, the modern computer monitor was derived from a modified television screen (a landscape display). We are now straddled with a convention wherein we are using an unsuitable display format for reading and writing large amounts of electronic textual information. This mismatch may be attributed to the preferences of early programmers who preferred to have more space for long lines of codes (landscape) and an absence of thoughts on design elements of a textual display device.
As a result, pathologists are now scrolling up and down to read different parts of an electronic pathology report and entering data into text fields without having the benefit of the viewing the complete page. Of course, we have the option of zooming out, but on a landscape monitor this renders text unreadable and just gives the rough outline of the document. This frustration often translates into several mouse-clicks and/or making a hard copy (duplication of work and not desirable in a green environment).
The manufacturers of common e-reading devices (e.g. Amazon Kindle, I-Pad and I-Phone) have adopted portrait as their default mode. It is easier to keep a mobile phone or e-reader upright and read down a column versus rotating it 90 degrees and then read text by moving across the screen. This reproduction of a ‘book’ format was hailed as a milestone in the e-publishing industry, but has been completely missed by the conventional computer users who type and read text on home and office computer screens.
Ironically, this mismatch can easily be addressed by rotating your screen 90 degrees, hitting ‘ctrl’+’alt’, and the right arrow key to adjust the video output. This converts the screen to a more logical portrait view on which a report can be entirely represented, text is easier to read and no visual ‘real estate’ is lost on the sides. A quick 5 minute trial (and allowing for a minute to adjust to new orientation) demonstrates the easy readability of a MS Word document, PDFs of medical literature and e-mails. For the surgical pathologist, it is easier to review the patient name, accession number, clinical history etc. while typing in the final diagnosis and reviewing the gross findings with this portrait display. The potential improvement in reading portrait electronic displays not only makes ergonomic sense, but could translate into some benefit in patient safety.  

Submitted by: Gaurav Sharma (


1. Manny said...

My 17" computer monitor is 10.5" high; I can see a whole 8.5 x 11 page in any orientation.

Therefore, the choice of reading on paper vs screen has less to do with size & origentation and more to do with resolution of the screen. My monitor is 72 dpi, my laser printer is 600dpi. It makes a huge difference when reading fonts size 10.

But, as usual, the solution to technological problems is more technology. Recent LCDs have a much better resolution; the iPhone4 has a whopping 325dpi, indistinguishable from a printed page. Build 17" monitors with this resolution and there will be no more paper.

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