FHIR maturity and adoption around the world 

If you’ve ever wondered how FHIR is progressing around the world, we’ve had the same thought. So HL7 International and Firely collaborated to conduct a landmark survey to better understand FHIR maturity and FHIR adoption across the world – and to identify any barriers. As Firely’s data modelling product manager, it fell to me to create the survey and collaborate with HL7 to circulate it in countries where FHIR has a foothold.

As well as providing useful insights about FHIR in specific countries, it provides confirmation that FHIR is the way forward – whether organizations and implementers need that assurance themselves, or to inform and convince stakeholders. To keep the global FHIR community informed and engaged, Diego Kaminker (HL7 Fellow) and I shared the key findings at FHIR DevDays 2023 and at the HL7 Working Group Meeting in Phoenix in September 2023.

What we did and how we did it

The link to our online survey was sent in April 2023 to all HL7 affiliates and other known national standards developers across the globe. We hoped to engage at least one knowledgeable source from each country. In the event, a total of 32 responses were received from 24 countries, with two responses each from Brazil, Peru, and Canada, three from New Zealand and four from Germany. 13 respondents were from HL7 affiliates and 19 were from other organizations.

How firm are the figures?

Many of the questions were open-ended and responses in the same country were not always consistent. Given the relatively small sample, our conclusions are qualitative rather than quantitative.

FHIR is here to stay

Almost all respondents expected the rate of FHIR adoption to increase in their countries. Nearly half expected a strong increase. No-one expected FHIR adoption to decrease. Chile reported the highest rate of FHIR adoption. Most respondents said FHIR is being used for a few use cases. Only Cyprus, Mexico, and Slovakia reported that FHIR is not yet in use.

Carrot or stick?

Twenty-seven respondents reported regulations in place for the use of standards in electronic health data exchange. More than half of those said FHIR is mandated or advised but most had no deadline in place and no fines for non-compliance. Fifteen respondents said their countries have funds available to stimulate the adoption of FHIR.

Who is adopting FHIR and why?

The largest groups adopting FHIR were: EHR vendors (20 respondents), app developers (19 respondents) and care providers (17 respondents). Single mentions included health information systems, jurisdictional assets/repositories, national services, eHealth agencies, researchers, and individual companies and hospitals.

When given multiple-choice options about the main drivers for FHIR adoption, 23 respondents selected innovation and 20 selected regulation and grants. There were single mentions for improved data analytics and reporting, and FHIR being easy to implement. Half of the respondents were aware of patient advocacy for healthcare data availability, with two-thirds of the patient advocacy groups specifically paying attention to health data standards.

Successful FHIR use cases

Twenty-six respondents knew of successful FHIR use cases in their countries, and 25 of those said the main achievement was improved access to information. Eight mentioned ‘lowered cost’ and eight said ‘improved healthcare outcomes’.

FHIR adoption challenges

Nearly everyone (29 respondents) said lack of FHIR knowledge is the biggest challenge
for FHIR adoption. Sixteen respondents also noted unclear regulations, 13 said high investment cost, and 12 mentioned unclear benefits.

“Almost all considered lack of FHIR knowledge to be the biggest barrier to FHIR adoption.”

Respondents also mentioned: competing short-term priorities, multiplicity of health systems, variability in clinical practices and vendor solutions, basic technological infrastructure (hardware and software), resistance to change, existing working interfaces, legacy, inconsistent use of FHIR by different organizations, and lack of experienced implementers.

Standards organizations and national FHIR data models

Nearly all respondents (29 of 32) said their country has a national organization for standards in electronic health data exchange and nearly as many confirmed the existence of a national FHIR data model. Four said it was widely used, eight said it applied to a limited set of use cases, 13 (11 countries) said one is under development. The remaining six (five countries) reported a model does not yet exist. At least ten national core profiles are hosted – or due to be hosted – on Firely’s Simplifier.

Standards organizations and national FHIR data models

Two insights stand out:

• Innovation is the biggest driver for FHIR adoption, even greater than the impetus from regulation and grants
• The single greatest barrier to FHIR adoption is a lack of FHIR knowledge

Highlights from the responses:

• Cyprus: FHIR likely to be legally adopted as main interoperability standard for the national EHR system.
• Germany: multiple FHIR specs, some compatibility issues.
• Netherlands: biggest challenge is keeping international compatibility.
• New Zealand: a good mixture of public and private sector implementations.
• United Kingdom: the release of UK Core should encourage more FHIR adoption.
• United States: too much activity to keep track of!

100% FHIR-based solutions

As one of the initiators of FHIR, Firely believes the survey results are a valuable guide to its current progress. Sharing global information is one of the best ways to confirm the benefits of FHIR and stimulate adoption of the standard.

The full report can now be downloaded from the HL7 website. We welcome your feedback on everything we do, so please send your comments and questions to info@fire.ly, or get in touch via our Contact page.