AHA Responds to ASTP/ONC RFI on Diagnostic Imaging Interoperability

March 16, 2026

Thomas Keane, M.D., MBA
Assistant Secretary for Technology Policy
National Coordinator for Health Information Technology
U.S. Department of Health and Human Services
Mary E. Switzer Building
330 C Street SW
Washington, DC 20201

Submitted Electronically

RE: RIN 0955-AA11 Request for Information: Diagnostic Imaging Interoperability Standards and Certification

Dear Assistant Secretary Keane,

On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the American Hospital Association (AHA) appreciates the opportunity to provide comment on the Assistant Secretary for Health Information Technology (ASTP) Office of the National Coordinator for Health Information Technology (ONC) diagnostic imaging interoperability request for information.

Increased data interoperability in the health care ecosystem can support better continuity of care, more informed decision-making, enhanced patient safety and, ultimately, better patient outcomes. Timely access to secure, high-resolution images is often a critical component of diagnosis and early intervention and can improve outcomes and reduce costs. However, the seamless transfer of images has historically been hampered by siloes generated from proprietary systems, inconsistent formats and the lack of exchange frameworks.

The AHA applauds ASTP/ONC for seeking feedback on mechanisms to support the transition from physical media to electronic exchange and on ways the agency’s standards and certification criteria may be updated to better support the access, exchange and use of imaging data. In general, we support the evolution of standards as technology advances and urge the agency to develop reasonable glidepaths and timelines to support this transition. We also would encourage the agency to host listening sessions to capture feedback on current imaging workflows and functional requirements across radiology and specialty areas.

Background

Imaging data exist in multiple siloes, making it difficult for providers and patients to access imaging files in different care settings. Often, images are stored separately in picture archiving and communications systems (PACS) or vendor-neutral archiving systems (VNA) outside the electronic health record (EHR), where clinical notes are stored. This can make it difficult to complete patient matching activities and connect records longitudinally.

Variability in format types — some of which are proprietary — has led to cumbersome exchange, with providers often managing physical media, like compact discs (CDs) or poor quality printouts. This sometimes leads to redundant imaging orders because the printout image resolution is insufficient for interpretation, or hardware is not available to read physical media. Ultimately, this can drive increased costs and delay services. Also, file sizes for media, like 3-D videos, can be resource-intensive.

Imaging Standards and Certification Criteria

The AHA agrees with ASTP/ONC that integrating standards and establishing certification criteria for imaging interoperability could support the more timely exchange of imaging data. Different imaging workflows require varying standards, making integrated workflows complex. For example, for decades, the Digital Imaging and Communications in Medicine (DICOM) has been an international standard for storing, retrieving, printing, processing and displaying medical images. However, in the absence of certification standards, vendor adherence has varied, particularly when considering new artificial intelligence tools that augment image interpretation. This has also led to more costly implementation, as vendors have often charged “add-on” fees for DICOM features.

As mentioned above, clinical data is often stored in separate silos. Health Level 7 (HL7) standards can help support the exchange of clinical and administrative data. The evolution of HL7’s Fast Healthcare Interoperability Resources (FHIR) application programming interfaces (APIs) holds promise in supporting imaging and clinical standards integration. The AHA sees significant potential in expanding FHIR use, as this standard is more flexible than many other available frameworks. At the same time, transitioning to FHIR-based standards, particularly for imaging, will be complex. Migration to FHIR API standards is predicated on the technical capabilities and operational readiness of multiple stakeholders — EHR vendors, software developers and other providers such as hospitals and health systems. In terms of provider readiness, many rural and smaller hospitals do not have the resources to transition to FHIR-based API exchange. Furthermore, the effective functioning of FHIR-based APIs or any other technical standard relies on workflow changes that require testing to ensure they meet patient and provider needs. For these reasons, we urge ASTP/ONC to pursue realistic timelines and not set arbitrary dates for standards implementation. Alignment of incentives and infrastructure investment, for smaller and rural hospitals for example, will better support exchange of imaging data. We also encourage the agency to develop education and technical assistance to support imaging interoperability. This would support workflow redesign.

Lastly, we encourage the agency to conduct listening sessions to gather more detailed feedback on workflows and clinical requirements across specialty areas. The successful adoption of new imaging data exchange standards would require understanding the variations in file formats, file sizes and workflows across multiple clinical areas. We would especially encourage ASTP/ONC to include in listening sessions hospital and health system IT leaders and representatives from clinical specialties that rely heavily on diagnostic imaging. These include emergency medicine, cardiology, oncology, orthopedics, neurology, obstetrics and gynecology, and anesthesiology, that rely heavily on diagnostic imaging.

Again, we applaud ASTP/ONC’s ongoing work to ensure providers and patients have access to timely imaging data to better inform care delivery. We look forward to continuing to work with the agency to support the safe exchange of imaging data. Please contact me if you have questions, or feel free to have a member of your team contact Jennifer Holloman, AHA’s director of health IT policy, at jholloman@aha.org.

Sincerely,

/s/

Ashley Thompson
Senior Vice President
Public Policy Analysis and Development