Integrating the Healthcare Enterprise (IHE) has recently published a new integration profile for sharing documents
between multiple enterprises. The Cross-Enterprise Document Sharing Integration Profile (XDS) lays the basic
framework for deploying regional and national Electronic Health Record (EHR). This profile proposes an architecture
based on a central Registry that holds metadata information describing published Documents residing in one or multiple
Documents Repositories. As medical images constitute important information of the patient health record, it is logical to
extend the XDS Integration Profile to include images. However, including images in the EHR presents many
challenges. The complete image set is very large; it is useful for radiologists and other specialists such as surgeons and
orthopedists. The imaging report, on the other hand, is widely needed and its broad accessibility is vital for achieving
optimal patient care. Moreover, a subset of relevant images may also be of wide interest along with the report.
Therefore, IHE recently published a new integration profile for sharing images and imaging reports between multiple
enterprises. This new profile, the Cross-Enterprise Document Sharing for Imaging (XDS-I), is based on the XDS
architecture. The XDS-I integration solution that is published as part of the IHE Technical Framework is the result of an
extensive investigation effort of several design solutions. This paper presents and discusses the design challenges and
the rationales behind the design decisions of the IHE XDS-I Integration Profile, for a better understanding and
appreciation of the final published solution.