Why an Imaging Health Record Should be the Equal Counterpart of the Electronic Health Record

Scene from the movie Pacific Rim. Source: Warner Bros

In Guillermo Del Toro’s 2013 science fiction action movie Pacific Rim, humanity fights Kaiju, giant monsters coming from the Pacific, with equally giant robots called Jaegers. Each Jaeger is so mentally demanding that two pilots, connected by a neural bridge or “drift,” must be used to pilot it.

Health IT is no different. Our modern-day Kaiju is the Patient Health Record, massive, uncontrolled, complex. The Jaeger in this analogy represents our Health IT infrastructure, and the two-pilot system consists of the EHR (Electronic Health Record) and the IHR (Imaging Health Record). Only when these two systems are in absolute synchrony do we have a chance to manage the size and complexity of modern patient care.

Status Quo: EHR Remains the Hub

The EHR continues to garner disproportionate attention, budget, and strategic priority in health systems. Despite the increasing digitization and adoption of cloud-native toolsets, 2025 has done little to change the lopsided prioritization. Epic, Oracle, and MEDITECH continue to dominate, guiding health IT roadmaps with billion-dollar implementations.

Enterprise Imaging, even as its clinical significance grows and data volumes explode, remains an afterthought. Imaging projects must wait for the dust to settle on EHR implementations, years in the making, before they receive a budget or executive focus. Imaging IT continues to retrofit itself into workflows it wasn’t allowed to help create.

This is backwards.

Introducing the Imaging Health Record (IHR): Now More Urgent Than Ever

The Imaging Health Record (IHR) is not a theory; it’s a necessity. A radiology viewer strapped onto an EHR is not an IHR. A vendor-neutral archive lacking intelligent DICOM routing, AI orchestration, or correct workflow integration is also insufficient. In the future, healthcare delivery will depend on real-time, intelligent imaging workflows across radiology, pathology, dermatology, ophthalmology, point-of-care ultrasound (POCUS), and other specialties.

The IHR must:

Manage high-volume, high-complexity imaging data in real time.
Facilitate AI orchestration, 3D rendering, and multimodal comparison.
Route smartly based on clinical need, not modalities.
Interoperate cleanly with the EHR and other systems via DICOM, HL7, FHIR, and RESTful APIs
De-identify for research and facilitate hybrid on-prem/cloud architectures.
Facilitate scalable, secure access across internal and external user populations.

And most of all, it must stop being considered optional.

Europe Leads, U.S. Lags

We have seen gradual movement since the article was first penned. European nations, aided by centralized national health systems, are driving initiatives similar to the International Health Regulations (IHR). Scandinavian countries and parts of the NHS have begun to treat imaging as a first-class data citizen. Within the United States, however, EHR-centric investment models remain firmly entrenched.

Healthcare boards continue to blanch at multi-million-dollar imaging IT refreshes but nod in agreement at billion-dollar EHR deployments. Imaging remains in a cycle of delayed investments, all too frequently jury-rigged by teams forced to play MacGyver with dated infrastructure and tenuous integrations.

Photo of actor Richard Dean Anderson, who played MacGyver in the television series. Source: ABC

AI, Imaging, and the Widening Gap

The AI wave has exacerbated the mismatch. Introducing hundreds of imaging-focused AI algorithms targeting everything from lung nodules to diabetic retinopathy to whole-slide pathology into the clinical pipeline. Meanwhile, AI for EHRs focuses on administrative tasks (e.g., billing optimization, note summarization, scheduling).
The mismatch underscores the need for an IHR: a purposely designed ecosystem that can host, orchestrate, and audit imaging-focused AI at scale.

The mismatch underscores the need for an IHR: a purposely designed ecosystem that can host, orchestrate, and audit imaging-focused AI at scale.

The IHR and EHR Must Be Drift-Compatible

Together, and drift-compatible, the IHR and EHR can finally tame the patient health record. Integration is a two-way street. It’s a harmonized relationship where both domains enrich the other. Imaging data enriches diagnostic specificity, longitudinal tracking, and outcomes measurement. EHR context, meds, labs, notes, enriches interpretation, and AI model validity.

To serve as co-pilots in a Jaeger, the EHR and IHR must:

Be co-designed during digital transformation
Share governance and compliance frameworks
Coexist under enterprise security and observability needs
Provide one patient-centric experience for patients and clinicians alike

Where We Go From Here

The question in 2025 is not if an IHR is needed. That’s a certainty. The question is whether health systems will get past sunk-cost psychology and mature their governance models to oversee imaging and the EHR as parallel strategic imperatives.

Until that day, the IHR is fantasy, not for want of technology, but for want of will. Let’s change that.