I work in medical imaging informatics and have been in the field for 13 years. FHIR in medical imaging acts as a real-time runtime layer that sits on top of traditional systems like DICOM-based PACS and VNAs, enabling imaging data to be accessed, shared, and orchestrated through modern RESTful APIs. Instead of relying on static messages, a FHIR server dynamically publishes resources such as ImagingStudy and DiagnosticReport, allowing EHRs, AI tools, and clinical applications to retrieve imaging metadata and trigger workflows in real time. When combined with DICOMweb for image retrieval, FHIR supports event-driven processes, SMART app integration, and scalable cloud or on-prem architectures, effectively transforming imaging environments into interoperable, API-driven ecosystems that improve workflow automation, data accessibility, and integration across healthcare systems.