Beyond PACS: How Imaging Infrastructure Is Evolving in 2026

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AI concept image of 3 Apple monitors showing a chest x-ray to depict a PACS workstation.

Radiology’s transition from film to digital created a wide-open opportunity for the growth of PACS (Picture Archival Communication Systems).  PACS quickly became a “must have” technology for image viewing, sharing, and storage, as well as the gravitational center of imaging operations.  Alongside PACS, RIS (Radiology Information System) became its sidekick, but was equally important, as it handled imaging’s operational workflows. 

If the viewer worked and images were flowing from the modalities to the PACS archives, radiology functioned and everyone was happy. As time went on, imaging demands began to change and the market started to shift.  Radiology was no longer operating as a siloed department.  Increasing demands on imaging started to overwhelm radiology and following the COVID-19 pandemic, staffing shortages at both the technologist and radiologist levels emerged.  Today, multi-site operations are normal, modality output has increased dramatically, subspecialties rely on imaging services, and the demands for speed, security, and collaboration have grown exponentially.

We’re entering an era where modern PACS platforms must replace legacy outdated systems. This is driven by new care models, staff limitations, and increasing imaging volumes.  Today’s new platforms are cloud-native, interoperable by design, and orchestrated to keep work moving to reduce daily workflow burdens.

Why Legacy PACS is…a Legacy

Radiology continues to evolve and some organizations are discovering that their legacy PACS of yesterday is holding them back.  Two forces are prompting this:

  1. Growing imaging volumes – Recent analyses shows imaging volume rising significantly over time, with workload pressures becoming unevenly distributed across radiologists. For example, reporting based on Journal of the American College of Radiology findings highlighted roughly 31% growth in imaging exam caseloads since 2018 and that the busiest radiologists are reading substantially more than they were several years ago.
  2. Workforce scaling is not matching demand – Staffing challenges continue to persist with skilled radiology technologists, while fewer radiologists are graduating. Supply and demand challenges in medical imaging are not in balance.  A 2025 article in RSNA’s journal Radiology describes a growing radiologist shortage and notes that demand for imaging is outpacing growth in the radiologist pipeline.


Put simply: more studies and fewer available skilled radiologists’ means that organizations must be creative to keep up with today’s growing imaging demands.  Systems and workflows must be faster, elevate efficiency to cut unnecessary costs, and streamline operations.  Fewer mouse clicks, inefficient handoffs, unnecessary delays, workflow bottlenecks, and less IT overhead are just some of the areas where improved efficiency helps organizations do more with less.

Legacy PACS struggle with modern initiatives because they were built to handle the imaging demands of the past and those that have evolved are refreshes to existing technology stacks but still lack the ability to handle the demands required today:

  • Single-site operations (or loosely connected multi-site setups)
  • Legacy architectures that are challenging to cost effectively scale
  • Thicker clients dependent on dedicated workstations and older infrastructure dependencies
  • Limitations for modern system interoperability
  • Workflow logic spread across multiple systems and manual processes
  • Fragmented system designs
  • Cloud-enabled vs cloud-native design

Following the approach of the past doesn’t just slow down operations and delay report generation, it increases operational risk.

Modern PACS Platforms are the Operating Models of the Future

A modern PACS platform focuses on the entire imaging ecosystem, not just the viewer and archive. All specialty reading workflows, highly efficient worklists, complex and just-in-time image routing, peer-to-peer clinician and clinician to radiologist collaboration, fast and accurate reporting, life-cycle data management, and enterprise access from anywhere all work together as a single coordinated system.

This enhanced strategy is more a “platform modernization” rather than a “PACS replacement.” The goal is to reduce workflow and operational challenges while enabling true change management that improves efficiency and enables better patient outcomes, all without rebuilding the environment every time volumes increase, or service models shift.

What’s Changing in the Platform Era?

Modern Radiology PACS platforms are built around a platform architecture that is designed to keep imaging operations moving at scale, not necessarily a viewer first approach as was common in the past.  A well-designed viewer is still important for efficient radiologist work, but it’s one small piece of the puzzle. For instance, you need:

  • Elastic scalability to handle dynamic growth (especially true with cloud architecture)
  • Unified yet tailored experiences for radiologists across multiple locations
  • Enhanced integrations between various information systems, AI algorithms, and other connected specialty solutions (via APIs, web services, HL7, FHIR, and other standards-based exchange mechanisms)
  • AI enabled workflow intelligence that moves cases to the right person at the right time while continually balancing workloads and exam complexity
  • Enterprise-ready access for clinicians, patients, and other downstream systems

The result: fewer silos, streamlined tools, improved system integrations, and less “human in the middle” workflows, all aimed at keeping efficiency running at the highest level.

Interoperability: Turns “Systems” Into an Ecosystem

Interoperability can no longer be an afterthought with today’s modern systems. It’s a survival requirement to move medicine at the speed clinicians think, especially as care becomes more distributed and organizations push for tighter alignment between imaging, EHR workflows, AI, and patient access.

There are two interoperability building blocks that are important to understand:

  • DICOMweb – is the web-based extension of DICOM that enables RESTful, HTTP-based access to imaging objects. The DICOM standard (Part 18) explicitly defines these web services for managing and distributing DICOM objects using web protocols.
  • FHIR – enables structured clinical data exchange and is increasingly used to represent and reference imaging context (e.g., ImagingStudy) within broader healthcare workflows.

On the policy and program side, the push toward nationwide interoperability continues to mature through the U.S. Core Data for Interoperability (USCDI) foundation and standards work led by federal health IT stakeholders, prompting one to assume modern systems will only continue to improve in overall interoperability capabilities.

Why This Matters

When organizations replace a legacy PACS, a common trap is requiring features and workflows one has grown comfortable and accustomed to in the past.  When replacing legacy solutions, focus on identifying and correcting your biggest challenge areas. Research how to improve those issues, then find solutions that can help achieve your end goals.  Additionally, modern solutions should be highly adaptable to address workflows and operational demands of the future.  Falling back into siloed tech stacks and disjointed workflows will not serve your organization well as you continue to grow.

Interoperability becomes a differentiator in new replacements because it affects:

  • How easily AI can be integrated into your reading workflow without further burdening radiologists
  • How imaging data and results can be shared seamlessly and efficiently across facilities
  • How quickly new partners or service lines can be onboarded
  • How resilient you prepare your organization against vendor lock-in over time

RSNA emphasized interoperability’s role in enabling value from advanced tools like AI, pointing to standards such as DICOM and HL7 as foundational to exchanging and analyzing imaging data. The bottom line is if your imaging environment cannot cleanly exchange data, you’ll spend your modernization budget on integration workarounds instead of reaping the benefits of operational gains.

Workflow Orchestration: “Do More with Less”

How do you turn chaos into clarity in your imaging environment?  Defining interoperability as how data moves, workflow orchestration would be defined as how work moves.

Workflow orchestration is a critical requirement in any new system architecture. Attend any imaging conference and its clear workflow orchestration is a sought-after capability.  Why it is so important:

  • Radiologists are asked to read more, faster, with higher complexity
  • Coverage models are becoming increasingly hybrid (on-site + remote + geographically diverse)
  • Subspecialty reads require smarter routing ensuring the right exam gets to the best qualified radiologist
  • Operational variability (backlogs, stat cases, downtime events) can’t be “handled manually” at scale

In practice, workflow orchestration is the layer that actively manages how imaging work actually flows, from order to acquisition, reporting, and finally, results distribution. This is accomplished by applying rules, priorities, and automations across systems, sites, and teams while using AI to adjust workflows real-time as bottlenecks are encountered.

Instead of radiologists and technologists compensating for system gaps, orchestration ensures the system compensates for operational complexity automatically, with minimal intervention. This ensures the work gets to where it needs to go, when it needs to get there, and follow-up happens as needed.

Capabilities include:

  • Intelligent worklist prioritization (urgent cases surface reliably)
  • Rules-based routing across sites, subspecialties, geographic locations, authorized insurance carriers, and subspecialty expertise
  • Shared worklists across distributed teams
  • Integration of AI outputs into the same reading workflow (not a separate app or a manual workflow that needs to be invoked)
  • Operational visibility (where delays happen, where bottlenecks form)

These capabilities define how work, well…works.

These concepts are increasingly visible across enterprise imaging messaging, including RSNA communications describing how “intelligent workflow orchestration” helps urgent cases rise to the top and supports consistent access across reading locations (While vendor messaging shouldn’t be your only input, it’s notable that orchestration has become a core theme precisely because the operational need is universal.)

The most important point for leaders is orchestration isn’t a “nice-to-have feature.” It’s a requirement to fix structural problems of increased exam volume and staffing shortages. 

So…is it “The End of PACS”?

Let’s be perfectly clear; PACS is not going away – it’s evolving to keep up with our expanding demands.  But legacy PACS, as a standalone, departmental focused system is fading fast, and it’s being replaced by a new generation of thinking and software development that focuses on optimal workflow challenges than features and functions:

  • Interoperability makes imaging data available when and where it’s needed.
  • Workflow orchestration ensures reading work is distributed intelligently despite resource constraints.
  • Platform architecture reduces system sprawl and supports modernization without constant reinvention.

And that’s the real shift: the future isn’t a better PACS, it’s better imaging workflow at the enterprise level.

What to Ask During PACS Modernization or Replacement

If you’re planning a PACS modernization project, here are some questions that may assist you in cutting through the noise:

  1. How will the platform exchange imaging data using modern standards (DICOMweb/FHIR) and integrate with EHR(s) and other downstream systems?
  2. How does workflow orchestration work across sites, subspecialties, and coverage models and what capabilities are included vs. what capabilities are not included?
  3. Can the platform scale operationally as volume grows, without adding proportional IT burden?  If the solution offers a cloud architecture, explain how costs are incurred when volume expands plus long-term storage tiers.
  4. Does the solution reduce clicks and manual handoffs throughout the workflow process?
  5. Will your solution support future workflow models (distributed reading, AI augmentation, enterprise imaging) without major re-architecture? If complete enterprise imaging is available, please elaborate on all the capabilities, workflows, and other tools available for the primary “ology” service lines (pathology, oncology, cardiology, dermatology, ophthalmology, wound care, POCUS, surgical video, etc.)

Where InsiteOne Fits into This Evolution

When radiology leaders talk about “platform evolution,” they’re describing the exact problems modern architectures are built to solve: interoperability, workflow efficiency, scalability, resilience, and reduced system sprawl.  If you’re evaluating PACS modernization, start by mapping your current workflow reality (not just a feature wish list) – where cases queue, where handoffs happen, and where people compensate for system gaps.  Then brainstorm about future workflows you need that alleviate your current bottlenecks.  That blueprint will tell you if your next move is a replacement, a platform shift, or an orchestration-first strategy.

InsiteOne’s approach aligns to this shift by emphasizing our cloud-native imaging platform, vendor-neutral data strategies, and workflow-centered design. Your clinical teams can then modernize operations without forcing radiology and IT to carry the burden of fragile integrations and manual processes.

Want to learn more about how a modern imaging platform from InsiteOne could transform your operational workflows?  Reach out to us today and let’s start a conversation to map the future of your imaging ecosystem!

For more information on how InsiteOne can provide a tailored solution to meet your organization’s Imaging IT needs, contact us today at 866.467.4831 or visit us here.