Open-source medical imaging annotation tools are popular among practitioners in the healthcare industry due to their cost-effectiveness and ease of use. These tools, such as MITK Workbench, ITK-Snap, 3D Slicer, HOROS, OsiriX, and OHIF Viewer, offer a range of features for annotating medical images and videos, including segmentation, labeling, and collaboration capabilities. However, using open-source tools also has its downsides, including scaling limitations, security concerns, and hidden costs that can become apparent as the volume of annotations increases. As teams progress through their data annotation journey, they often graduate to commercial, proprietary tools that offer more advanced features, better security standards, and scalability. Encord is a leading annotation platform in medical AI that offers a powerful, automated DICOM annotation suite with fully auditable data and labeling protocols, enabling teams to achieve significant efficiency gains and compliance milestones.