Hybrid rendering systems for medical imaging applications are provided. In some embodiments, an indication of a viewing mode is received at a medical image viewer from a user. The viewing mode is a diagnostic mode or a referential mode. A plurality of characteristics of the medical image viewer are determined. Based upon the viewing mode and the plurality of characteristics of the medical image viewer, a rendering mode is determined. The rendering mode is a server-side rendering mode or a client-side rendering mode. A request for medical imagery is sent. The request conforms to the rendering mode. The medical imagery is rendered according to the rendering mode. The requested medical imagery is displayed on the medical image viewer.