Diagnostic Imaging Interoperability Request for Information Shines a Spotlight on the Lack of Patient-Centered Longitudinal Health Records

On January 29, 2026, the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (“ASTP/ONC”) released the Draft United States Core Data for Interoperability Version 7 (“USCDI v7”) for public comment through Standards Bulletin 2026-1.

The very next day, ASTP/ONC also issued a Request for Information (“RFI”) seeking public input on the potential adoption of diagnostic imaging interoperability standards and certification criteria under the ONC Health IT Certification Program.

Both the RFI and USCDI updates arrive at a pivotal moment and invite stakeholders to reflect on where interoperability efforts in U.S. health IT policy have succeeded and where they may be falling short. They follow the publication in late December of the Health Data, Technology, and Interoperability: ASTP/ONC Deregulatory Actions to Unleash Prosperity (“HTI-5”) Proposed Rule. These developments are especially critical as the U.S. works to move beyond fragmented records toward truly comprehensive longitudinal health data to support individualized care, precision medicine and patient-centered care. Stakeholders should consider commenting by March and April for the RFI and USCDI, respectively, as described below; note that the due date for HTI-5 comments is February 28, 2026.

USCDI: Minimum Interoperability

USCDI establishes a policy-driven subset of data elements that certified health IT must be able to exchange and make accessible, largely to support the baseline required under the 21^st Century Cures Act. Draft USCDI v7 includes 29 proposed data elements (including, for example, diagnostic imaging reference, meaning the information that can be used to access a diagnostic imaging study, including an imaging study endpoint weblink, unique identifiers, and contextual information) and one significantly revised data element (tobacco use). Thirteen of the 30 proposed data elements are already largely supported for certified health IT. The full list is available in USCDIv.7.

Yet USCDI does not attempt to model the full breadth of clinical information generated during the course of care, nor is it designed to function as a comprehensive longitudinal patient health record. As a result, substantial portions of diagnostic, contextual, and workflow-derived clinical information remain outside its scope and locked in proprietary electronic health records (EHRs). Without a broader clinical data model, these efforts risk reinforcing a fragmented view of the patient record, one where compliance-defined subsets of data are interoperable, while the full clinical narrative remains locked in silos.

The Imaging RFI: Opportunity or Risk of Re-Siloing?

The newly issued imaging interoperability RFI identifies persistent challenges in the exchange and accessibility of diagnostic imaging across the healthcare ecosystem, including reliance on portable media, limited API support, and inconsistent metadata tagging, among other issues. Diagnostic imaging data (the underlying pixels/data of CT scans, MRIs, and X-rays) is typically captured and stored in specialized systems outside the EHR, such as a Picture Archiving and Communication System (“PACS”) or Vendor Neutral Archive (“VNA”). Conversely, the textual radiology report created by the radiologist is stored directly within the EHR (or the Radiology Information System (“RIS”), which integrates with the EHR).

While the RFI reflects an attempt to address these challenges, there is a policy risk if imaging interoperability is pursued primarily through additional certification criteria. Absent careful alignment with broader interoperability frameworks, such an approach could unintentionally deepen data silos rather than integrate imaging into longitudinal health records. The RFI asks for an alternative, which could be the adoption of standards and implementation mechanisms that integrate imaging into a unified clinical data layer, rather than erecting domain-specific boundaries that fragment information further.

HTI-5: A Broader Shift in Certification Strategy

As we noted in January, the Health Data, Technology, and Interoperability: ASTP/ONC Deregulatory Actions to Unleash Prosperity (“HTI-5”) Proposed Rule was published in late December. HTI-5 contemplates a fundamental recalibration of the ONC certification regime by:

• Streamlining certification by reducing burden on health IT developers by removing redundant or stagnant criteria. (ASTP/ONC Fact Sheet)
• Revising information blocking definitions and exceptions to support broader access, exchange, and use of electronic health information. (ASTP/ONC Fact Sheet)
• Advancing a foundation for Fast Healthcare Interoperability Resources (“FHIR”)-based APIs that support modern interoperability and AI-enabled solutions rather than prescriptive, checklist-driven criteria. (HHS.gov)

HTI-5 represents a policy pivot away from compliance-heavy certification boxes toward standards that promote flexible and API-driven interoperability. That shift aligns more closely with the original intent of ONC’s mission and recognizes that innovation often flourishes where standards enable, rather than mandate, behavior.

What Stakeholders Should Do Now

Practical steps forward include:

• Engaging in the public comment process to ensure policies support unified data exchange rather than domain-specific segmentation.
  • Written comments on USCDI v7 are due April 13, 2026, through the commenting feature on the USCDI data element pages. Depending on the comments submitted, ASTP/ONC plans to release the final version in July 2026.
  • Written comments on the RFI are due March 16, 2026, and will inform any future rulemaking aimed at improving how imaging data is accessed, exchanged, and used by healthcare providers and patients.
  • Note that the Health Data, Technology, and Interoperability: ASTP/ONC Deregulatory Actions to Unleash Prosperity (“HTI-5”) Proposed Rule remains open for comment through February 27, 2026.
• Encouraging ASTP/ONC to establish a voluntary pilot or demonstration program to evaluate end-to-end FHIR-based imaging exchange across unaffiliated systems. Such an initiative could assess workflow integration, usability, and readiness for secondary uses such as research queries or de-identified analytics, while aligning with HTI-5s deregulatory posture.
• Proposing innovation focused mechanisms such as challenge competitions coordinated with agencies including the Centers for Medicare and Medicaid Services (CMS), National Institutes of Health (NIH), or the Advanced Research Projects Agency for Health (ARPA-H), to incentivize development of tools that enable hospitals, health systems, and value-based care entities to build clinical data layers above core her infrastructure without reverting to silos.
• Encouraging ASTP/ONC to define success not only in terms of technical conformance, but also through measurable outcomes, such as reduced redundant imaging, faster cross-organizational access to studies, and diminished reliance on custom point-to-point interfaces.

For a deeper look at this topic, see our related client Insight.

If you are interested in submitting comments on these important matters, please contact one of our authors or the EBG attorney with whom you regularly work.

Epstein Becker Green Staff Attorney Ann W. Parks contributed to the preparation of this post.