Somewhere in a place you have never heard of - in a hospital in rural Senegal, a clinic in Peru or a radiology department in the heart of Brussels - a doctor is looking at a medical scan. There is a reasonable chance that scan is being served by software built in Liège.
Orthanc is a free, open-source DICOM server for medical imaging. It was initiated in 2011 by Sébastien Jodogne at the University Hospital of Liège, with its first public release on July 19, 2012. Since then it has become one of the most widely deployed medical imaging tools in the world, running in hospitals, research institutions, and clinics across dozens of countries. The Orthanc Team, a Belgian consultancy run by Alain Mazy and Benoît Crickboom, handles community support, plugin development, and deployment for hospitals and software companies worldwide. Sébastien Jodogne continues development from his research lab at UCLouvain. They deliberately keep it small: focused on development and documentation, without the overhead of enterprise support contracts and shareholder obligations.
This is Belgian talent at its best.
There is already an open standard
Medical imaging has an open standard. DICOM (Digital Imaging and Communications in Medicine) has governed how medical images are stored, transferred, and displayed for decades. Every MRI scanner, CT machine, and digital X-ray system nominally speaks DICOM, which means medical images should be portable and interoperable across systems and vendors.
The reality is more nuanced. Most commercial PACS (Picture Archiving and Communication System) systems adhere reasonably closely to the DICOM standard, and typically extend it in ways that still allow data to be extracted. Additional results from diagnostic tools or AI helpers are generally stored as separate blocks that do not break the underlying data. Migration is rarely trivial, but it is usually possible.
Open-source implementations like Orthanc stick to the standard as it was intended: fully inspectable, fully portable, with no licensing fees tied to storage volume and no vendor lock-in baked in. When Orthanc introduced its implementation of DICOMweb (the web-based extension of the DICOM standard) it served as a reference that pushed other PACS vendors to follow. Not all do so to the same extent, but the baseline certainly shifted.
Where Orthanc fits in practice
Orthanc is not a drop-in replacement for the large commercial PACS systems that most hospitals run and it also doesn’t have that ambition. Those systems carry a price tag of multiple hundreds of thousands and even up to a million euros per year and bundle in diagnostic viewers, AI tooling, dictation, and regulatory-grade device certification that open-source software cannot easily replicate.
What Orthanc does exceptionally well is everything around that core: research environments, smaller services like veterinary practices, and, most relevantly for policy: the exchange of imaging data between facilities. Hospitals routinely need to send scans to other hospitals, import studies from external sources, or make images accessible across departmental boundaries. That exchange layer is exactly where open standards matter most. Orthanc functions as a bridge: connecting internal hospital networks to external systems and ensuring that a patient’s data stays tied to that patient, even when it carries different identifiers across different systems and ecosystems.
Belgian public health and its imaging infrastructure
Many Belgian hospitals are public institutions with significant public governance. Municipalities frequently hold board positions, and the sector operates under federal and regional health frameworks. Public money funds a large share of Belgian healthcare, which raises a fair question: what standards govern the infrastructure that money is paying for?
There is currently no requirement in Belgian health policy that medical imaging infrastructure (including the exchange layer between facilities) be based on open standards. The fact that an open-standard, open-source tool exists for exactly this purpose, built in Belgium and deployed in research and clinical settings worldwide, does not currently factor into procurement policy.
What a policy shift would change
Belgian health policy (at federal level through RIZIV/INAMI, or at regional level through the Flemish and Wallonian health authorities) could formally favour genuine open-standard compliance in medical imaging procurement, particularly for interoperability and data exchange. The European Interoperability Framework already pushes in this direction for public sector software. The EU’s Interoperable Europe Act creates obligations around open standards in public digital infrastructure. Medical imaging fits that logic directly.
Hospitals evaluating procurement for their exchange infrastructure would need to show that their chosen solution is genuinely open-standard compliant: auditable, portable, and readable by any DICOM-compliant system. That would put Orthanc and similar tools on the table and generate the kind of sustainable usage that supports continued development, allowing all hospitals to benefit from the progress, not only the ones who can afford premium vendor contracts.
There is a wider dimension to this. For hospitals in low-income countries, a commercial PACS license running into hundreds of thousands of euros per year is simply out of reach. For them, a solution like Orthanc is often the only option available. A Belgian policy shift that generates sustainable usage and supports continued development also sustains infrastructure that clinical teams in Africa, Asia, and Latin America rely on. That is a concrete form of global solidarity, at no additional cost.
The same logic applies closer to home. Veterinarians, dentists, and other independent practitioners all work with medical imaging but rarely have the budget or the infrastructure for a full commercial PACS. For smaller practices, Orthanc is a practical and affordable solution. Supporting its continued development is also supporting those practitioners, and the patients they serve.
Why Belgium is well placed here
The Digital Public Goods Alliance recognised Orthanc as a digital public good in 2023. It is production infrastructure used in hospitals across Africa, Asia, Latin America, and Europe, built and maintained in Belgium.
Favouring open standards in this domain benefits Belgian hospitals directly: less vendor dependency, better data portability, lower long-term procurement costs. And it gives other health ministries a working template. Belgium already has the proof of concept and the policy levers, and its influence in European institutions is disproportionate to its size.
Strengthening Orthanc and their implementation of the DICOM standard will also enable medical imaging experts to grow their professional skills inside our country.
For policymakers
Medical imaging infrastructure rarely surfaces in ministerial briefings. It sits between IT procurement and clinical operations, and it tends to get overlooked. But radiology underpins diagnosis across virtually every medical speciality, and how imaging data is stored and exchanged is a choice that gets harder to reverse the longer it goes unexamined.
Belgium already has a working, globally deployed, open-source implementation of the relevant standard, built and maintained by Belgians. That is a good starting point.
Orthanc is available at orthanc-server.com. For institutional support or deployment services, contact the Orthanc Team at orthanc.team. To support the project’s open-source community work: opencollective.com/orthanc.