Many factors, including disproportionate growth rates and exciting new technologies, have focused attention on cardiovascular imaging. However, critical examination of the field reveals a surprisingly weak evidence base and inconsistent systematic attention to quality improvement. Remedies span research and practice. The optimal clinical continuum of care begins with ensuring a proper match between the diagnostic test and the individual's clinical question, and progresses to include image acquisition, image interpretation, and results reporting. Better research methodologies are needed to more tightly link imaging use to improved outcomes in non-biased community populations. To accomplish these lofty goals, alignment across stakeholders is needed to ensure the necessary human and capital investment in research and systems of care.