A guide to what each part of the book covers. The book moves from how DICOM began, through how it works and fails, to the systems and institutions around the image. Where a chapter uses an illustrative or composite scenario, the book says so at the start of that chapter.
A Note From the Author and How to Read This Book. Why the author wrote the book, the three composite figures, and which chapters give the spine of the argument for a reader with limited time.
Prologue: 4:17 AM. A CT scan finishes in a hospital basement in the early morning. The book introduces Robert Aldridge, an illustrative patient, and the unseen pipeline that must carry his images to a radiologist.
Chapter 1: Every Scanner Spoke Its Own Language. In the early 1980s, scanners from different manufacturers stored images in private formats, and a scan from one machine could not be used by another. How that problem shaped what came next.
Chapter 2: What DICOM Actually Is. A DICOM file looks like a ledger before it looks like a picture. What the file records, what it carries forward from people, and what it was never designed to establish.
Chapter 3: The Man Who Built the Pipes. Dale Kirchner, a composite PACS administrator whose highest achievement is that nobody knows his name.
Chapter 4: What the Router Decides. The DICOM router: middleware that compares the tags on an image with rules someone configured, then forwards, copies, or rewrites. It recognizes patterns; it does not understand the study.
Chapter 5: Disclosure Is Not a Promise. The conformance statement, and why conformance never meant that a product implements everything in the standard.
Chapter 6: The Message That Arrives Before the Patient Does. HL7 v2 messaging, which tells the scanner who is coming, and why every hospital negotiated its own version of the chain.
Chapter 7: Follow the Image. A constructed walkthrough, stage by stage, from acquisition to the radiologist’s screen. It is an illustration with no measured timings.
Chapter 8: Everything Was Compliant. Nothing Worked.. A composite scenario in which every system is compliant on paper and the pipeline still fails, and the difference between conformant and interoperable.
Chapter 9: Six Ways to Lose a Patient’s Name. A 2002 case in the Annals of Internal Medicine, and the points between ordering and image where a patient’s identity can fail.
Chapter 10: The Recall Nobody Notices. What the FDA’s public recall records show about imaging software failures, including a Class 2 recall of a PACS viewer that displayed an incorrect patient age.
Chapter 11: The Storm That Tested a Region’s Memory. What happened to hospital imaging archives when Hurricane Katrina struck in 2005, and what had been built to survive.
Chapter 12: The Radiologist Who Works While You Sleep. Overnight teleradiology, an illustrative read, and the history of the nighthawk model.
Chapter 13: Five Minutes, Two Scans, One Legal Question. A generalized illustration of a preliminary read and its consequences, and the real decided case Wilson v. Inthachak.
Chapter 14: Where the Infrastructure Isn’t. Building imaging pipelines where no network, archive, or reliable power exists, and the U.S. military’s three decades of work on the problem.
Chapter 15: The Scanner’s Second Life. The secondary market for refurbished scanners, and what it means when old equipment keeps working in another country.
Chapter 16: A Standard for Every Species. Veterinary imaging and the teleradiology industry that grew around DICOM-compliant equipment for animals.
Chapter 17: The Same Tumor, Measured Twice. How images are used in clinical trials to show that a drug works, and the FDA framework for imaging endpoints.
Chapter 18: What Radiology Got That Pathology Didn’t. Why radiology’s interoperability was not inevitable, seen through pathology and whole slide imaging.
Chapter 19: The Servers Nobody Locked. The 2019 investigation that found PACS servers exposed on the open internet, and what it showed about security.
Chapter 20: An Algorithm Is Not a Capability. Imaging AI, from the first FDA-authorized autonomous diagnostic system to the role DICOM plays in training data.
Chapter 21: What the Algorithm Actually Sends Back. How an AI finding gets back onto a radiologist’s screen in a standardized form, through DICOM structured reporting and related objects.
Chapter 22: The Shortage AI Was Supposed to Fix. The documented radiologist workforce gap, and how most AI devices reached the market.
Chapter 23: No Residency for This. Radiologists learn to read the image, but formal training in how it reached the screen is thin.
Chapter 24: The Code Behind the Scan. How a completed study turns into a payment through CPT coding, a system DICOM does not define.
Chapter 25: Friction, Not Refusal. An illustrative case of a mother trying to obtain her daughter’s brain MRI, and how access fails through small obstacles rather than one refusal.
Chapter 26: Preservation Is Not Access. Studies stored faithfully on media that can no longer be read, with the compact disc as the clearest example.
Chapter 27: The Same Standard, Different Rules. The same standard under different legal regimes, starting with Europe’s GDPR.
Chapter 28: The Image as Witness. What it takes for a medical image to be accepted as evidence in a courtroom.
Chapter 29: The Standard Beside the Standard. FHIR, Grahame Grieve, and how a newer standard sits beside DICOM.
Chapter 30: The Archive That Outlives the Vendor. Vendor neutral archives, and how lock-in moved from file formats to the archive itself.
Chapter 31: The Archive in the Cloud. An architecture rather than a set of products: what changes when images no longer live in one building.
Chapter 32: The Economy Beneath the Image. Who gets paid because DICOM exists, and the market built on the assumption of compatibility.
Chapter 33: What the Standard Couldn’t Fix, and Who Pays for It. The boundary of what a shared image standard can do, and the work that falls to everyone else.
Chapter 34: What a Reliable Pipeline Requires. Seven things that separate a pipeline that works from one that merely conforms, beginning with identity management.
Afterword: Thirty Years Inside the Pipeline. The author’s personal perspective on three decades in imaging.
Epilogue: The Best Infrastructure Is the One You Never Notice. The committee that has not stopped working, and why the best infrastructure goes unnoticed.
Technical Appendix, Notes, and Index. A reference for healthcare professionals, with a glossary, selected tags, and sources for every chapter.
Last updated October 2026.