Your Images Do Not Travel: Why Sending a Radiograph Is Still Hard

Federal regulators came close to requiring that medical and dental images be portable. It has happened more than once. Each time, the requirement got weaker or went away.

That history is the real answer to why a practice still burns a CD, emails a screenshot, or hands the patient a folder and hopes it reaches the specialist. It is not that nobody built the technology. It has existed for decades, and the ADA has published guidance on using it in dentistry for years. It is that nothing has ever required a vendor to use it.

The requirement that was written, weakened, and deleted

Here is the sequence, from the government's own record.

In 2012, the federal health information technology office proposed an imaging criterion for certified systems, and proposed requiring certified records to let images be downloaded and sent to a third party. By the time the final rule was published that year, the imaging criterion had been adopted without the DICOM standard behind it, on the stated view that requiring an imaging standard was unnecessary. The download and transmit requirement was removed as well, citing complexity and burden raised by commenters.

In 2015, the imaging criterion was removed entirely, because the incentive-program objective behind it had gone away.

In 2024, new certification requirements to support image access and exchange were proposed again. In December 2025, those proposals were withdrawn.

In January 2026, the office published a request for information asking how diagnostic image exchange should work, which is where the matter sits. Certified health information technology today carries no imaging requirement at all.

The government's own description, in that request, is blunter than anything a vendor would write:

"In some cases, organizations' vendors use proprietary formats that impede exchange and external access by 'outside' providers. In other cases, outside providers are denied access to full-resolution [DICOM] files, and are instead given access to low resolution, incomplete, or inferior (e.g., encapsulated PDF) images through web-based viewers... Ultimately, the burden to 'exchange' these images is placed on the patient or their caregiver."

What that leaves sitting in your operatory

The ADA filed a ten-page response in March 2026. It is worth reading if you buy imaging equipment, because it describes the daily experience of a dental practice with unusual precision.

On who does the carrying, the ADA wrote that without robust patient portals, "patients frequently serve as intermediaries, transporting CDs, emails, or paperwork between care locations, because automated workflows are not available across systems."

On what survives the trip: images "are often transmitted as screenshots, PDFs, or secondary captures, stripping essential metadata (acquisition parameters, exposure, timestamps), and compromising diagnostic value." The consequence the ADA names is not inconvenience. It is repeat imaging, which means additional radiation for a real person, delay, and avoidable cost.

There is a quieter version of the same problem. Many systems store images at a lower bit depth than they were captured at, which reduces grayscale resolution and can hide subtle pathology, and vendors apply their own sharpening and noise reduction without documenting it. A receiving system usually cannot tell whether it is looking at the original, an enhanced version, or a degraded one.

For most owners, though, the sharpest sentence is the one about claims. Because federal attachment standards were never finalized, images still move to payers by mail, fax, clearinghouse, or portal. The ADA put it this way: "Dentists must navigate multiple payer-specific workflows and proprietary transmission channels for sending required images; each workflow has different file requirements, formats, and proprietary portals." The result is longer payment cycles and more denials for insufficient imaging documentation. If one person in your office knows which payer wants what, in which format, through which portal, that knowledge is worth more than most of the software you pay for.

And there is no dental equivalent of what hospitals use. The ADA said so directly: unlike the picture archiving systems used by health systems, "dental imaging platforms have no consistent external access mechanism."

"We support DICOM" can mean several different things

DICOM is the standard for medical and dental imaging. The ADA runs the dentistry working group inside the DICOM standards organization and has published dental DICOM guidance for years. So when a vendor says they support it, that is technically true far more often than it is useful. The phrase covers at least four different capabilities, and a practice needs to know which ones it is getting.

Can you get a full-fidelity export, or a picture of one? A true DICOM export carries acquisition parameters, exposure, and timestamps with it. A secondary capture is a screenshot in a DICOM wrapper, stripped of the information that makes it diagnostically useful.

Can another system retrieve it, or can a person only look at it? A portal where an outside dentist views your image in a browser is not the same as their system pulling it into their patient's record. One is a viewer. The other is exchange.

Can you get your archive out? Practices carry years of images in vendor-specific formats. Converting them often produces secondary captures, and some original data cannot be recovered at all. This gets discovered during a system change, which is the worst possible time.

Will they put it in writing? The ADA was pointed about why this persists: imaging vendors "frequently use proprietary formats as a means of customer retention." It compared the pattern to the information-blocking behavior federal law already addressed for medical records, noting that dental imaging "has not received equivalent policy attention."

The ADA has a dental DICOM standard in development, numbered 1114, and has asked federal regulators to adopt it with conformance criteria and testing behind it. That would help. It has not happened yet, and in this particular story, a standard nobody is required to meet has a long history of changing nothing.

What to do while the rules catch up

Test it before you need it. Pick a specialist you refer to often, send a real case the way you normally would, and ask what actually showed up on their end. Full resolution or a compressed picture. Their system or a link in a browser. That one exchange will tell you more than any product sheet.

Then write down what you learn, per referral partner and per payer, somewhere other than one person's memory. The requirements will not become uniform soon. The practices that handle this well are not the ones with better software. They are the ones where the requirements are documented and anyone at the desk can follow them.

And when you are buying, ask about the exit before the features. What comes out, in what format, at what fidelity, and what happens to the archive if you leave. A vendor who answers that plainly is telling you how they intend to treat you.

That is a standard we hold ourselves to. AiroDental does not move your images, and we will say so rather than imply otherwise. What we do is answer the phone and keep the schedule accurate, with live integrations that read and write to Dentrix, Dentrix Ascend, Open Dental, and CareStack, and we will tell you exactly what each one reads and writes before you sign anything. There is nothing to sign, as it happens. No contracts and no onboarding fee.

The images will travel eventually. Somebody has to require it first.

Deren Flesher, DDS. Founder, AiroDental.