A Multi-society Effort Is Driving Imaging Interoperability Across Healthcare

Digital pathology is rapidly scaling, but many laboratories are discovering that simply digitizing glass slides is the easy part. The harder, and increasingly urgent, challenge is making those images interoperable across vendors, systems and institutions, in a way that supports enterprise imaging, AI and long‑term data reuse.

That problem, and a concrete strategy to solve it, was the focus of the recent Digital Pathology Association (DPA) webinar, “Advancing Imaging Interoperability Together: A DPA–CAP–SIIM Collaboration to Improve Standardized Workflow Adoption.” The session brought together leaders from the DPA, the College of American Pathologists (CAP) and the Society for Imaging Informatics in Medicine (SIIM) to report out on their joint DICOM toolkit effort and to outline what success should look like over the next one to three years.

From Radiology’s Experience to Pathology’s Moment

The webinar opened by situating digital pathology within a broader enterprise imaging arc. Moderator Jennifer Samboy, digital transformation leader at Philips and co‑chair of the DPA Education Committee, framed the goals of the session as threefold: to summarize key findings from a DICOM toolkit jointly developed by DPA, CAP and SIIM; to provide a deeper dive on why DICOM and imaging health information exchange standards matter; and to describe how DPA can accelerate cross‑organizational collaboration to advance interoperability for both clinical operations and innovation.

Radiology’s journey provides a powerful precedent. Alex Towbin, M.D., from Cincinnati Children’s Hospital and the upcoming president of SIIM, traced how radiology moved from proprietary, vendor‑specific formats in the 1980s to today’s mature, DICOM‑based ecosystem.

As he explained, early radiology systems produced electronic images, but each vendor used its own proprietary format, leaving organizations with “multiple scanners and no way to view it.” DICOM emerged as a way to solve exactly that problem: a standard file format and metadata model that would allow images from different modalities and vendors to be managed and viewed together.

Towbin emphasized that metadata is where “the real power” of DICOM lies. Beyond pixel data, structured tags about modality, study description, orientation and many other parameters support sophisticated routing, hanging protocols, AI workflows and multi‑modality viewing. Those same capabilities, he argued, are directly applicable to pathology.

Pathology “deserves to be in this place as well,” he said, alongside radiology, ophthalmology, endoscopy, point‑of‑care ultrasound and other image types in an enterprise imaging environment.

DICOM for Pathology: The “Shipping Container” for Images

Kevin Schap of CAP, Secretariat for DICOM Working Group 26 (WG-26) and a leader in IHE PaLM (Pathology and Laboratory Medicine), took the audience deeper into what DICOM means specifically for whole slide imaging.

Schap described DICOM as “a very detailed set of rules for how medical images are stored, described, transmitted and understood across systems.” While radiology has used DICOM for decades, pathology is a newer entrant, and it is facing many of the same issues radiology confronted decades ago: very large images, highly proprietary formats, and limited interoperability between vendors.

To make the concept more tangible, Schap borrowed an analogy: “You can think of DICOM like a shipping container for global trade. Before shipping containers, goods were transported in all kinds of inconsistent packaging, barrels, crates, sacks. It was inefficient, hard to track and difficult to move between ships, trucks and trains. So then came the standardized container, same size, the same structure, universally recognized. Now, any port truck or crane in the world knows exactly how to handle it.”

In the pathology context, DICOM doesn’t just carry the pixels; it carries the meaning — patient information, acquisition details, organ site, tissue type, stains and immunohistochemistry. Without standardized encoding of these elements, he argued, interpretation and secondary use become extremely difficult.

Schap also underscored why DICOM often feels “complicated,” and why that is acceptable and even necessary. It is not merely a file format, he said, but “a data model, it’s a communication protocol, it’s a workflow framework.” That complexity is the tradeoff for interoperability and future‑proofing in an environment of rapidly evolving modalities and AI tools.

Making Standards Actionable in Workflows

If DICOM defines how images and metadata are structured and exchanged, IHE (Integrating the Healthcare Enterprise) defines how that structure is actually used in real-world workflows.

Schap walked through how IHE develops profiles that stitch together standards such as DICOM, HL7 and SNOMED CT to support end‑to‑end processes. In digital pathology, that includes:

• Digital Pathology Image Acquisition (DPI): released, focused on creation, storage, display of DICOM files and the mapping of LIS metadata into images.
• Digital Pathology Ordering Workflow: in development, defining communication between order fillers, image managers and acquisition managers when new whole slide images are created.
• Digital Pathology Evidence Creation: focused on how AI‑derived measurements and annotations are associated with whole slide images, stored and accessed.

Schap noted that scanners will not natively know everything about a specimen; they must call back to the LIS for specimen type, site, stains and other attributes. IHE profiles specify how those calls and transactions should work, so that different vendors’ components can be mixed and matched without bespoke integrations.

Radiology’s Maturity and Pathology’s Gaps

The panel discussion shifted to the lessons pathology can learn from radiology, and to the practical barriers that still impede DICOM adoption.

Towbin highlighted two key radiology lessons: the limits of free‑text fields and the variability in how different specialties and vendors implement the standard. Many human‑facing fields, like procedure and series descriptions, are effectively “garbage” from an informatics standpoint because they are unstructured and institution‑specific. Yet he also noted that, with modern AI, this may become less of a problem as algorithms can ingest and interpret large, messy metadata sets in ways humans cannot.

He also emphasized that, in modern radiology, the use of DICOM is no longer debated: “Is this even a discussion amongst radiology departments whether you should be implementing a DICOM versus a non-DICOM compliance system in radiology? Is it even a question?” he was asked.

“No, no, it’s not,” Towbin replied. Radiologists, he added, generally do not know or need to know the technical details of DICOM. “The standard just means things work,” enabling teleradiology, second opinions and multi‑site workflows to “just work because it everyone’s using that standard.”

Barriers: Storage, Vendors, Incentives and Awareness

While the technical standards for pathology are now robust, especially Supplement 145 for whole slide imaging, real‑world adoption is uneven.

Mustafa Yousif, M.D., from the University of Michigan and co‑chair of DICOM Working Group 26, described Michigan’s enterprise implementation and the barriers they encountered. Storage was the first and most obvious challenge: single whole slide images can exceed 4 GB, and long‑term archival quickly reaches petabyte scale, far beyond what traditional radiology PACS were designed to handle. That has forced institutions to think in terms of hot/cold storage tiers and realistic retention strategies focused on diagnostic and tumor board time windows.

Yousif also pointed to an immature vendor ecosystem. Many digital pathology scanner vendors still treat DICOM as an optional output rather than a native format, and few supply robust DICOM viewers. That leaves clients struggling to validate images and metadata, and it feeds persistent myths such as the idea that there are “multiple versions” of pathology DICOM.

In reality, he stressed, “it is one DICOM standard … the pathology images and radiology images live under the same standard, use the same foundational metadata structure, and can really use as one standard when correctly implemented.”

Rajesh Dash, M.D., of Duke University and co‑chair of IHE PaLM, focused on economics and incentives. From the perspective of practice leaders, he said, digital pathology and standards‑based implementations must demonstrate a clear return on investment. At a national level, he pointed to precedents such as certified EHR incentives that accelerated adoption and suggested similar policy levers could help drive interoperable digital pathology.

Without such nudges, vendors have weak incentives to abandon proprietary formats that may be cheaper for them to maintain, even though they increase costs downstream for healthcare organizations, payers and ultimately patients.

A Toolkit, Connectathons and a Path to Success

One concrete output of the DPA–CAP–SIIM collaboration is a DICOM starter toolkit for pathology, based in part on a survey of pathologists. As Towbin reported, more than three‑quarters of respondents said such a toolkit would be helpful, with over half answering “yes” outright. The most requested components were:

• An overview of the DICOM standard and how it applies to pathology
• A step‑by‑step implementation guide
• Tools for converting proprietary formats to DICOM
• Workflow integration guidance and sample DICOM files

Schap suggested that, beyond education, the toolkit can arm organizations with specific questions to ask vendors during RFPs and negotiations, and can even signal to vendors what they will be expected to demonstrate. Several panelists also stressed the importance of IHE and DICOM Connectathons as real‑world proving grounds where multiple vendors test interoperability in common use cases.

Looking ahead one to three years, panelists converged on several measures of success:

• More vendors producing native DICOM output only, with robust conformance statements.
• Clearer, more detailed procurement requirements from hospitals that go beyond “do you support DICOM?” to “how do you support it?”
• Increased vendor participation, and successful testing, in IHE and DICOM Connectathons for digital pathology profiles.
• Wider use of standardized metadata fields critical for AI and patient care, including SNOMED CT‑based coding.

Moderator John Groth, M.D., of Endeavor Health and representing the DPA regulatory and standards task force, framed this as a “perfect time” to push, citing recent FDA signals around DICOM, emerging Advanced Research Projects Agency for Health (ARPA‑H) initiatives, and multi‑society efforts on interoperability and patient access. He characterized the current moment as one where “there are dozens of people across the spectrum specifically related to pathology that are meeting weekly in some capacity,” and where global collaboration is no longer aspirational but operational.

The webinar closed with an important reminder from the vendor side: a representative in the audience noted that this conversation is “equally important to us as the vendors who are trying to help you through this process as well,” underscoring that standardization will ultimately require coordinated action by professional societies, regulators, healthcare organizations and industry.

If radiology is any guide, the end state is not one where pathologists talk about DICOM every day, but one where, as Towbin put it, using DICOM is “not even a question.” The work described in this webinar aims to make that future a reality for digital pathology.