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HL7 has matured even more now. The linear evolution from HL7 v2 to HL7 v3 did not win the day. Most are now moving to https://www.hl7.org/fhir/

Main issue is with HL7 is not technical. From a business point of view, the incentive to cooperate with other systems via HL7 means another reason for a department to adopt a system other than yours.

Ruby makes working with things like HL7 super easy. Check out the super extensible HL7 ruby parser I wrote here: https://github.com/sufyanadam/simple_hl7_parser. It currently focuses on parsing ORU messages but can be easily extended to support any HL7 segment. Feel free to submit a PR :)

Yes and no. I spoke with an Epic engineer recently and he confirmed that Epic is still a front-end to HL7 databases. With that said, many PACS are adopting the WADO standard (https://www.research.ibm.com/haifa/projects/software/wado/), which provides a REST interface to radiology images. It makes it a lot easier to retrieve images for analysis, albeit you'd still have to implement DICOM/HL7 if you want to make a usable product.