As a “dinosaur” who trained in the days of actual film-based imaging studies, which could so easily get lost, I can remember the sense of possibility we felt about a new “silver bullet” called “PACS.” The bright future it promised was one where films never went astray and care was immeasurably improved by the reliable availability of the prior studies. Why then, as the specialty that prides itself on being at the intersection of technology and patient care and which has innovation in its DNA, has radiology settled for so much less when it comes to the sharing of images? Twenty-five years after, I crafted my first RFP for a PACS system; we are largely dependent on an obsolete medium, CDs, when we need to access images from outside our own institutions. In many instances, we collectively shrug our shoulders, and we perform and interpret current imaging without the important context provided by antecedent studies because it feels just too hard to do otherwise. We need to do better. Our patients certainly deserve better.

Our patients deserve better because our failure to adopt modern pathways for transferring images is not just embarrassing for us tech-avid radiologists. When we fail to leverage the information afforded by comparison with prior imaging we will increase the number of studies from which we generate additional cost and worry related to management of incidental findings. Worse than that, we will potentially fail to identify subtle changes that might represent an opportunity to diagnose disease at an earlier more treatable stage.

Let us not be too hard on the individual radiologist. Our US medical system is composed in the main of entities that compete with one another and for whom there is little natural incentive to facilitate transfer of care to one another. Performance metrics that promote rapid turnaround of interpretations are well intentioned but likely to dissuade many from spending the extra time to track down prior imaging. The information technology leaders of large health systems are challenged daily by potential cyber terrorists while managing the demands of multiple platforms and systems. Facilitating the capability to send and receive images electronically often with little advance notice is unlikely to make it to the top of the priority list if only a single radiologist is advocating for change. It will take collective initiative to move us forward.

I served as the Chair of the American College of Radiology’s Board of Chancellors from 2018 to 2020. As a leader in organized radiology and a passionate advocate for patient-centered imaging care, I felt compelled to do something. The good news seemed to be that there were others who felt the same way. Working with the ACR’s Commission on Informatics, I assembled an informal group around this initiative which we called “Ditch the Disk”. Dr. Ashwini Zenooz, a radiologist who had worked in leadership in large complex systems like the Veterans Administration, agreed to steward the effort.

It felt important to keep the barriers to entry for this collective effort extremely low. By the time this initiative launched in 2018, there were longstanding efforts to create standards for image transfer, several vendors for whom this was their primary business and a clear recognition of the issue at the national regulatory level. There were even some examples of regional image sharing networks. Yet we still had not made meaningful progress, and individual patients continued to undergo unnecessary and inappropriate imaging on our watch.

We needed an approach to problem solving that could engage all of the stakeholders and push past the logjam. This fit well with my own leadership style which to quote EU Commissioner for Competition, Margrethe Vestager, aspires to be “low on protocol, high on substance.” But lack of structure and governance can make for evanescence rather than a sustainable impact. Three years later, have we accomplished anything of substance?

We have definitely made progress. The informal “Ditch the Disk” effort served its purpose in raising awareness and building stakeholder engagement and consensus. Now this effort is not only contained within the workplan of the ACR’s Commission on Informatics, but we also have broadened the coalition of stakeholders to include the Commissions on Quality and Safety and Patient and Family Centered Care in order to leverage their expertise and unique perspectives. We have developed an active trainee advocacy group that uses social media to raise awareness, and we have built meaningful, albeit vendor neutral, relationships with the companies who are engaged in image sharing as either their core business or an important component thereof. We are in the process of developing a set of cross-association multistakeholder strategies for effecting broad adoption of interinstitutional image exchange within the next few years. Regulatory policy has, in recent years, trended towards reduction in barriers to information sharing and ACR’s influencing agenda with policy makers has supported that goal.

There is clearly much more work to do. The COVID-19 pandemic taught us that we could change rapidly and in ways we did not think possible: witness the rapid shift to telehealth. Providers were able to pivot because they already had the technology. They had not previously shifted because reimbursement and regulation prevented it. And for me that is the takeaway. As someone who has worked extensively within the reimbursement policy and regulation space, I am likely biased in thinking that we will not be able to “Ditch the Disk” for good until we are prohibited from using CDs at all. But the work that we have done to raise awareness, build consensus, and influence policy will be the important foundation on which we will build.