The State of FHIR in 2026: Analyzing global adoption and the emerging role of AI 

Since 2023, HL7 International and Firely have partnered to conduct a yearly survey of national experts to track the evolution of the HL7 FHIR standard. Now in its fourth edition, the 2026 State of FHIR survey provides a comprehensive overview of how FHIR is maturing as a global infrastructure for healthcare data exchange.

Having recently transitioned into the role of Product Lead for Simplifier, I dived into the latest findings to identify the primary developments in regulation, implementation maturity and the impact of emerging technologies.

The 2026 survey results are based on 101 responses from 63 unique countries. This represents a significant increase in participation compared to 2025, which saw 82 responses from 52 countries.

The geographic reach of the survey now spans five continents, including new contributions from regions in Africa and the Pacific that were not previously represented. This growth suggests that FHIR has transitioned from an experimental framework used by early adopters into a foundational component of national digital health strategies. 

The AI paradox in interoperability 

A new topic for 2026 is the impact of Artificial Intelligence (AI) and Machine Learning (ML) on FHIR efforts. The survey identified what can be described as an “AI paradox.” While AI is often discussed as a technology that could potentially interpret unstructured data and thus bypass the need for rigorous data standardization, the experts surveyed strongly disagreed with this premise.

A total of 72% of respondents rejected the idea that AI reduces the importance of investing in FHIR or structured data. Instead, the majority view structured data as an essential foundation for successful AI. This is reflected in the finding that 41% of respondents believe AI is actually helping FHIR and structured data efforts. The most cited positive impact was an increased interest in FHIR as a foundation for AI, followed by the use of AI to accelerate mapping and transformation to FHIR.

Qualitative feedback from jurisdictions like Colombia and France suggests that AI is being used to facilitate data capture at the source and to improve the quality of data mappings. However, respondents remain cautious about hallucinations and the need for human oversight, particularly regarding clinical coding. The consensus is that AI acts as an amplifier for FHIR implementation rather than a distractor.

Regulatory trends and enforcement

The maturation of policy is evident in how FHIR is treated within national legislation. Of the countries that have regulation in place for electronic health data standards, 80% now specifically mandate or advise the use of FHIR. This is an increase from 74% in 2025 and 56% in the initial 2023 survey.

However, a gap remains between the existence of mandates and their enforcement. While 37 respondents reported that their regulations include compliance deadlines, up from 29 in 2025, the use of financial penalties is still uncommon. Only 11 respondents reported the existence of fines for non-compliance.

This suggests that while governments are becoming more prescriptive about which standards to use, they are still relying primarily on administrative policy and procurement conditions rather than strict legal penalties to ensure adoption.

Implementation maturity and version adoption

The extent of FHIR use continues to deepen. 80% of respondents shared that FHIR is used for at least a few national use cases, and those identifying FHIR as their main standard for data exchange has risen to 20% in 2026, compared to 13% in 2025.

Use case development is currently led by prescriptions and pharmacy with 42 mentions, terminology with 37 and diagnostic orders or reports with 34. Infrastructure is also maturing, with 55% of respondents reporting a national terminology server either in production or under development.

The version landscape remains dominated by FHIR R4, which is identified as the main standard by 36% of respondents. This figure has declined steadily from 58% in 2024 and 40% in 2025. Conversely, adoption of FHIR R5 is accelerating with eight countries, including Estonia, Kenya, Poland and the Czech Republic, now identifying R5 as their primary version.

A couple of things are happening here. Some countries are moving up to newer versions, and new entrants to the survey are starting on a mix of versions. Both pull R4’s overall share down, for different reasons, so the decline reads as the field broadening rather than mature programs stepping back.

This diversity highlights a persistent challenge for global interoperability, as organizations must manage the coexistence of multiple versions even within a single national system.

Persistent bottlenecks: the knowledge gap 

Despite the progress in adoption and regulation, the biggest challenge to FHIR implementation remains unchanged. A lack of FHIR knowledge was cited by 76 respondents as the dominant bottleneck, an increase from 59 mentions in 2025. This knowledge gap was cited more often than high investment costs (48), unclear regulations (46), or unclear benefits (39).

This indicates that while the technology and policy frameworks are largely in place, the capacity of the workforce to implement these standards is not keeping pace. Experts in various countries, including Togo and Tonga, noted that a lack of technical expertise prevents them from maintaining and monitoring FHIR-based systems effectively. Even in more digitally mature ecosystems like the Netherlands, respondents highlighted that a lack of education and misaligned statements by influencers continue to slow progress.

A wide field of adopters

The 2026 data shows a broad mix of stakeholders involved in FHIR adoption. For the first time, government agencies were tracked as their own category, and they came in at the top: named by 76 respondents. That’s not a surprise given that governments are often the ones setting the regulatory conditions that drive adoption in the first place. EHR system vendors follow closely at 68, with app developers (55) and care providers (44) behind them.

Turning to adoption drivers, regulation and grants break a two-year tie with innovation to take the top spot in 2026, with FHIR mandates up 24% since 2023. Innovation comes in second, which makes sense alongside EHR vendors and app developers sitting second and third among adopter groups. Both are industries where competitive pressure makes continuous innovation important.

The FHIR Community Process (FCP)

The 2026 survey introduced another new field of interest regarding the FHIR Community Process (FCP), a governance framework designed to move localized FHIR projects toward recognized global standards. Current findings suggest that FCP activity is in its early stages. Approximately one-third of respondents reported no known FCP activity in their country, while 29 respondents indicated that organizations are exploring becoming FCP participants.

Despite this slow start, expectations for the near future are high. When asked where their country would be in two to three years, the number of respondents expecting to have approved FCP specifications rose to 16, while 19 expected to have approved FCP participants.

Organizations in jurisdictions such as Australia, Israel and Switzerland are already positioning themselves within this framework to ensure that their national implementation guides meet the technical and transparency requirements for global certification.

Conclusion and outlook

The results of the 2026 State of FHIR survey confirm that FHIR has established itself as the global infrastructure for health data exchange. The transition of leadership toward government agencies and the increasing specificity of regulatory mandates suggest that the industry is moving from pilot projects toward systemic implementation.

The emergence of R5 and the formalization of the FHIR Community Process indicate a growing focus on technical rigor and long-term sustainability. Perhaps most significantly, the rejection of the idea that AI replaces the need for standards proves that structured, interoperable data remains a critical asset in digital health.

As we look toward the next three years, optimism remains high. 74% of respondents anticipate that their countries will reap significant benefits from FHIR adoption by 2029, including cost savings and enhanced care coordination.

To realize this vision, the community must focus on addressing the primary bottleneck identified in this survey: the global FHIR knowledge gap. Technology and regulation are necessary components, but sustained investment in education and governance will be the determining factors in whether these national digital health strategies succeed.

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