1 Introduction 9 mography (CT), MR, and positron emission tomography(PET) scans [2. while acknowledging that many factors are contributing to these high costs it is, however, important to separate out two issues: the healthcare cost savings generated as a result of imaging, in light of earlier diagnoses and quality of life; and the true cost of performing an imaging study (i.e, versus what is charged An"appropriate"process of care that disregards issues related to utilization review ind approvals required for imaging studies can be very effective for care of the patient as well as cost-effective. In one study performed by us for a self-insured employer group, we removed all of the requirements for(pre-)approval of imaging studies and allowed primary care physicians to order imaging based on their diagnostic hypothesis and the need of the patient. The imaging costs were instead capitated for the employer group. The number of cross-sectional images, particularly CT and MR, more than doubled and the number of projectional images decreased. However, the net effect was not only significant cost savings to the employer group but also much higher quality and satisfaction by patients [12]. A follow-up study further showed improved he (lowered incidence of chronic disease, decreased number of hospitalizations and emergency room visits, etc. ) continued high levels of patient satisfaction, and lowered expenditures within the cost-capitated imaging environment relative to a control group [4]. All of this is to suggest that it is not necessarily the overuse of imaging that is inherently costly, and that there are in fact cost-savings introduced through the un- restricted use of imaging. Of course, a capitated cost agreement with unfettered usage of imaging is not the norm. Unfortunately, the cost of imaging studies is rarely the true ost of performing the study. As an example, presently charges for a brain MR imaging study with and without contrast are in excess of $7, 000 at some institutions largely because of professional fees and attempts to recoup costs(e.g, from non paying and uninsured individuals). Yet in one internal study we conducted in the 1990s to understand the real cost of CTs and Mrs, it was concluded that the price of an MR study is no more than S200 and the price of a CT less than $120. These costs included technologists time, materials used (e.g, contrast) and the depreciation of the scanning machines over five years. Even adjusting for inflation and a moderate profes- sional fee, one can argue that the charges seen today for imaging largely outpace ne true cost of the exam. Hence, a current practical challenge for medical imo s informatics is to develop new paradigms of delivery that will encourage the use imaging throughout the healthcare environment while still being cost-effective A Historic Perspective and Moving Forward Medical imaging informatics is not new: aspects of this discipline have origins span- ning back over two or more decades [14]. As such, it is useful to consider this field's interdisciplinary evolution to understand its current challenges and future. Below, we consider four different eras of technical research and development. PACS: Capturing Images Electronically Concurrent to the progress being made with respect to CT and MR imaging, initial efforts to create an electronic repository for(digital) imaging in the 1980s led to the creation of picture archive and communication systems(PACS).[8, 11] provide some perspective on the early development of PACS, which focused on linking acquisition devices (ie, scanners), storage, intra-site dissemination of studies, and display tech- nologies(soft and hard copy). With the introduction of PACS, some of the physical limitations of film were overcome: images were now available anywhere within an1 Introduction 9 tomography (CT), MR, and positron emission tomography (PET) scans [2]. While acknowledging that many factors are contributing to these high costs it is, however, important to separate out two issues: the healthcare cost savings generated as a result of imaging, in light of earlier diagnoses and quality of life; and the true cost of performing an imaging study (i.e., versus what is charged). An “appropriate” process of care that disregards issues related to utilization review and approvals required for imaging studies can be very effective for care of the patient as well as cost-effective. In one study performed by us for a self-insured employer group, we removed all of the requirements for (pre-)approval of imaging studies and allowed primary care physicians to order imaging based on their diagnostic hypothesis and the need of the patient. The imaging costs were instead capitated for the employer group. The number of cross-sectional images, particularly CT and MR, more than doubled and the number of projectional images decreased. However, the net effect was not only significant cost savings to the employer group but also much higher quality and satisfaction by patients [12]. A follow-up study further showed improved health (lowered incidence of chronic disease, decreased number of hospitalizations and emergency room visits, etc.), continued high levels of patient satisfaction, and lowered expenditures within the cost-capitated imaging environment relative to a control group [4]. All of this is to suggest that it is not necessarily the overuse of imaging that is inherently costly, and that there are in fact cost-savings introduced through the un￾restricted use of imaging. Of course, a capitated cost agreement with unfettered usage of imaging is not the norm. Unfortunately, the cost of imaging studies is rarely the true cost of performing the study. As an example, presently charges for a brain MR imaging study with and without contrast are in excess of $7,000 at some institutions – largely because of professional fees and attempts to recoup costs (e.g., from non￾paying and uninsured individuals). Yet in one internal study we conducted in the 1990s to understand the real cost of CTs and MRs, it was concluded that the price of an MR study is no more than $200 and the price of a CT less than $120. These costs included technologists time, materials used (e.g., contrast) and the depreciation of the scanning machines over five years. Even adjusting for inflation and a moderate profes￾sional fee, one can argue that the charges seen today for imaging largely outpace the true cost of the exam. Hence, a current practical challenge for medical imaging informatics is to develop new paradigms of delivery that will encourage the use of imaging throughout the healthcare environment while still being cost-effective. A Historic Perspective and Moving Forward Medical imaging informatics is not new: aspects of this discipline have origins span￾ning back over two or more decades [14]. As such, it is useful to consider this field’s interdisciplinary evolution to understand its current challenges and future. Below, we consider four different eras of technical research and development. PACS: Capturing Images Electronically Concurrent to the progress being made with respect to CT and MR imaging, initial efforts to create an electronic repository for (digital) imaging in the 1980s led to the creation of picture archive and communication systems (PACS). [8, 11] provide some perspective on the early development of PACS, which focused on linking acquisition devices (i.e., scanners), storage, intra-site dissemination of studies, and display tech￾nologies (soft and hard copy). With the introduction of PACS, some of the physical limitations of film were overcome: images were now available anywhere within an