By Malcolm Benitz, Medicom President, with a foreword by Michael Rosenberg, Medicom CEO

According to Forbes, diagnostic imaging accounts for roughly 90% of all data generated in healthcare. It’s the largest category of clinical information our system produces, and by far the most persistently siloed.

To address the system shortcomings, the Office of the National Coordinator for Health Information Technology (ONC), part of the Department of Health and Human Services (HHS), released a Request for Information (RFI) in January 2026 titled "Diagnostic Imaging Interoperability Standards and Certification." Imaging was included in a limited scope in the HTI-2 Proposed Rule, but was not included when ONC released the HTI-2’s Final Rule. With the appointment of Assistant Secretary Dr. Thomas Keane, an interventional radiologist, there is now a focus on applying the same standards that apply to EHRs to PACS, VNAs, and image-sharing and interoperability vendors.

The RFI is the clearest signal yet that the gap is closing between clinical systems that are held to certification standards under the ONC (e.g., EHR) and those that have been historically more of a wild west (imaging systems, including PACS, VNA, and image exchange). The RFI suggests that it’s time for an overdue shift from voluntary participation to a standardized, certified framework for imaging data. Essentially, it seeks to treat diagnostic images with the same level of interoperability and federal oversight as data found in an EHR.

Medicom believes that products should be built on standards so they can interoperate, and we’re grateful for the ONC’s leadership, which has shown deep dedication to closing the interoperability gap. We’re excited for the standards-based workflows we’ve developed for our clients to be better adopted across the industry, and can’t wait to see how that will help our users finally #ditchthedisk.

The public comment period for the RFI ended March 16, with more than 100 stakeholders, including Medicom, weighing in. HHS will now review the feedback to define future standards, specifically DICOMweb, FHIR, and SMART imaging-access specifications. What follows is a high-level summary of our RFI response and what it means for every organization operating in this space. - Michael Rosenberg, Medicom CEO & Founder

We Aren't Waiting for the Mandate

For many HIT vendors, this momentum creates a migration panic. They must now retrofit interoperability into legacy systems that were never meant to share data.

At Medicom, we built for this moment. These standards are available today, and it’s time for the industry to step up and embrace modern standards. 

While others are still solving for basic connectivity, we’ve already pivoted to active clinical execution. Our focus has moved from the simple exchange of files to the delivery of automated, point-of-care intelligence. We engineered our decentralized, vendor-agnostic architecture specifically to master this last mile of the provider workflow.

Let’s Ditch The Disk

A core pillar of the federal conversation is the strengthening of the Information Blocking Rule (45 CFR Part 171). To achieve the goal of a truly digital ecosystem, we must address the analog loopholes that still plague the industry and codify examples of prohibited interferences to eliminate ambiguity. The current exceptions leave a significant gray area for vendors and providers to circumvent adherence to this regulation. 

Requiring a patient or provider to rely on physical media when both parties possess the technical capability for electronic exchange must be recognized as a prohibited interference. Medicom believes that the ONC should follow through on the initial HTI-2 Proposed Rule that clarified it considered interference to require that access, exchange, or use of medical images occur by exchanging physical copies or copies on physical media when the actor and the requestor have the technical capability to access, exchange, or use the images through fully electronic means.

The regulatory framework does not explicitly prohibit physical media, so it persists because the ambiguity allows it. Consider a real-world example of how relying on manual data transfer affects care: When a patient is referred for a stroke evaluation and the referring institution defaults to a CD, the receiving team either waits or orders a repeat study. The first is a time delay. The second is unnecessary radiation exposure and cost. Neither outcome is acceptable when the technical capability to avoid it already exists.

By removing the excuses that allow vendors to obstruct data flow under the guise of technical limitations, we can finally #DitchTheDisk and move toward mandatory electronic liquidity.

The ONC also proposed relevant enhancements in HTI-2 and HTI-5 that should be finalized. The definition of prohibited interference needs to extend clearly to physical media requirements, to practices that induce requestors to narrow the scope of what they ask for, and to automated and modern AI-driven access workflows that the current language does not explicitly cover.

Bridging the Legacy Gap with FHIR ImagingStudy

Building with open standards is the only way to future-proof enterprise imaging. While much of the industry is still in a wait-and-see posture, at Medicom, this architecture is already live and performing.

DICOMweb enables web-based image retrieval without legacy on-premises infrastructure. The FHIR ImagingStudy resource makes imaging studies discoverable and actionable directly within the patient's longitudinal record inside the EHR workflow, not alongside it. SMART on FHIR and HTJ2K enable secure, high-performance image access on any device, including mobile. Together, these standards replace a fragmented, institution-bound model with one where imaging data behaves like any other clinical information: queryable, portable, and accessible where care is being delivered. 

ONC should also expand the United States Core Data for Interoperability to include imaging data elements, ensuring that every certified health IT system, not just those specialized imaging platforms, can natively discover and act on imaging studies.

Four-Point Patient Matching: Solving the Identity Crisis

A misidentified imaging study is not a data-quality problem; it’s a patient safety event, according to the Patient Identity Management Maturity Model (PIM3) for Imaging. When the wrong scan reaches a clinician making a treatment decision, the consequences can be severe and irreversible. That risk is built into the current standard: traditional imaging workflows rely on a limited demographic set. Within a single institution, that baseline may be manageable, but across a national exchange network, it’s not. The more organizations involved, the more likely multiple patients share those three attributes. As cross-organizational imaging exchange scales, which is exactly what this RFI is designed to accelerate, the probability of a mismatch scales with it.

In our formal response to HHS, we highlighted the necessity of a minimum four-point patient matching standard. By expanding required identity attributes, we help ensure that imaging is tied to the correct patient. The barrier to implementation is not technical, given that healthcare organizations already hold all five attributes for nearly every patient.

 Interoperability as Shared Infrastructure

The current fee structure around interoperability interfaces creates a problem that no certification mandate can fully solve on its own: if vendors are required to provide standards-based interfaces but can charge for access, the mandate becomes a toll road. Health systems and innovative third parties must pay to connect, allowing incumbents that have already integrated to maintain their advantage. The data stays siloed behind a paywall.

The economics of healthcare exchange must fundamentally change. Interoperability interfaces should be treated as shared infrastructure rather than optional, pay-to-integrate services. To support this, our industry should follow historical precedents used in other regulated sectors:

• Open Banking: CFPB Section 1033 prohibits fees for required consumer and developer interfaces, ensuring that consumers’ financial data belongs to them, not the bank.
• Telecommunications: The FCC limits cost recovery for phone number portability to ensure incumbents cannot impose fees that discourage competition.
• Energy and Securities: Regulators treat information systems as essential utilities with fair, non-discriminatory access to market data.

It is also worth being direct about something the industry rarely discusses: pricing model structure matters as much as pricing level. The policy framework should not only set a price ceiling, but also scrutinize how fees are structured, as certain models can create direct financial incentives to restrict data flow. If fees are to be applied similarly to other regulated spaces, there must be a thorough validation process to ensure those fees reflect true costs and are not inflated.

When the industry treats connectivity as a shared foundation rather than a profit center, we move the focus from moving pixels to delivering insights.

The Head-Start Advantage for Healthcare Organizations

Many health systems and vendors have already adopted modern imaging interoperability standards because the clinical and operational case was clear; for them, regulations are a validation rather than a disruption. 

The opportunity is significant. When imaging data becomes part of the longitudinal record, and prior studies arrive automatically, it allows clinicians to make decisions with the full picture while eliminating the costs associated with physical media and manual image requests. 

Systems that have made this transition describe it as a workflow transformation that offers a permanent competitive advantage. While modernization requires initial investment, organizations beginning now retain the latitude to implement on their own terms, whereas those who defer these decisions will soon face a compressed timeline as regulatory expectations tighten.

Meeting the Accelerating Implementation Horizon

The HHS timeline indicates that the transition toward mandatory electronic exchange is accelerating. The disk needs to go, and a policy with teeth makes it possible.

With more than six million clinical image transfers annually, Medicom has already built the high-density infrastructure required to meet the government’s objective to fully connect the healthcare ecosystem. Don’t wait for a regulatory deadline to modernize your imaging infrastructure. Get started with Medicom today to audit your current workflows and build a roadmap for an automated, compliant enterprise exchange.