On March 16, 2026, the LTPAC HIT Collaborative submitted comments to ASTP/ONC in response to the RFI on Diagnostic Imaging Interoperability Standards and Certification. Our comments highlight a critical structural distinction that federal imaging policy must recognize: LTPAC providers do not operate integrated radiology departments. Instead, they access diagnostic imaging — portable X-ray, mobile ultrasound, echocardiography, teleradiology — as external ancillary services through contracted vendors, creating a fundamentally different workflow than the hospital-centric PACS/VNA model that most interoperability policy assumes. Today, imaging results in LTPAC settings still arrive primarily via CDs, fax, and paper reports, creating care coordination gaps, duplicative testing, delayed diagnoses, and significant administrative burden for already resource-constrained facilities.

The Importance of Standards Addressing Three-Way Communication:
A central theme of our comments is the "three-way communication challenge" — the triangulation of information flow between ordering physicians with their own EHRs, LTPAC facilities with facility-based EHRs, and ancillary imaging service providers with their own systems. This model closely parallels the pharmacy e-prescribing workflow that has been successfully addressed through NCPDP SCRIPT standards, where prescriptions, medication administration records, and clinical updates flow among physicians, pharmacies, and LTPAC facilities. Federal policy must apply the same level of focus, standards adoption, and certification requirements to diagnostic imaging that has been applied to pharmacy and laboratory services — treating imaging as the critical ancillary service it is in LTPAC care delivery.

Recommendations:
Our recommendations to ASTP/ONC include adopting FHIR ImagingStudy and DICOMweb standards to enable lightweight imaging references that accommodate LTPAC bandwidth constraints; expanding USCDI to include diagnostic imaging data elements including structured radiology reports and quantitative parameters; developing certification criteria specifically for LTPAC EHR systems as receiving systems in imaging workflows; extending information blocking requirements to prevent hospitals and imaging centers from withholding imaging data from LTPAC care coordinators; supporting PACIO Project development of LTPAC-specific imaging FHIR implementation guides; and providing dedicated grant funding and technical assistance to address the 15-year technology investment gap created by LTPAC exclusion from HITECH Act incentive programs. Imaging interoperability that serves all Americans — including those in our nation's nursing homes, home health programs, and hospices — must be built on policies that reflect how care is actually delivered.

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Read the full comment letter below

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