A significant proportion of diagnostic medical procedures are used in response to public or private policy rather than in response to an individual patient-physician interaction. We have studied the system whereby such policies are developed and implemented in the case of employment-related chest and lumbar spine roentgenograms, which were found to account for about 11% of the total use of diagnostic radiographs in the state of Michigan. We observed that factors influencing formulation of policy are diverse and largely nonmedical, organizational policies developed in similar environments are often very dissimilar and are highly subject to external influence, and perceptions of policy success and examination utility are typically subjective and uncertain. It is concluded that considerable opportunity exists to enhance the efficacy of such radiographic examinations through leverage provided by their policy-driven nature.