RESUMEN
While in the last decade there has been significant technical infrastructure development to support standards-based image exchange through organizations like Integrating the Healthcare Enterprise, Carequality, DICOM, and HL7 FHIR, the human operationalization of such infrastructure using centralized, intuitive, standards-based applications remains the cornerstone of effective and reliable electronic image exchange. Image libraries managing the highly transactional and often uncertain inflows and outflows of images have a unique perspective on the challenges of image exchange. This manuscript will summarize frequent collaboration and communication, release of information, staffing, technology, information localization, and analytics difficulties for image exchange from the perspective of the image library staff managing the transactions.