Journey of FHIR: Global Insights and Impact from the ‘State of FHIR’ Surveys

Survey Participation

The latest survey shows a significant increase in participation in 2025 compared to the survey over the years. This growing participation emphasizes the increasing global interest and engagement with FHIR standard. While the surveys are qualitative rather than quantitative due to the modest number of responses, they offer valuable insights into the global trajectory of FHIR adoption.

Current State of FHIR Adoption: On the Rise, but with Caution and Context

The general sentiment on FHIR adoption has been consistent across the world (82 – 82% overall) pointing towards a strong increase in the rate of FHIR adoption in the coming years. In 2024, 84% of respondents (32 of 38) expected an increase, a percentage consistent with 2023 findings. The 2025 survey saw nearly half of respondents (67 of 82) expecting a strong increase, representing a substantial uplift from the previous year.

Regarding the current use of FHIR to exchange healthcare data, the majority of countries report using FHIR for “a few use cases”. This trend has been consistent, with 66% of respondents in 2024 and 71% in 2025 indicating use for a few cases. Lithuania and Switzerland notably reported FHIR as their main standard in 2024.

State of FHIR Version in Use

When it comes to FHIR versions in use, there’s a clear shift towards newer releases in terms of use that is showcased by the above graphic. Some insights derived from the survey results are as follows:

• DSTU2: Not widely used, with 25 of 38 respondents in 2024 and 36 of 61 in 2025 reporting no use at all. Only Uganda reported it as their main standard in 2025.
• STU3: Half of respondents (19 of 38 in 2024, 27 of 62 in 2025) reported not using STU3 at all. The Netherlands consistently reported using STU3 as their main standard in both 2024 and 2025.
• R4: In 2024, the majority of respondents (22 of 38) said they were using R4 as their main standard. While still the most used, this proportion decreased slightly in 2025, with 31 of 78 respondents (40%) reporting R4 as their main standard.
• R4B: This was a new question in the 2025 survey. Most respondents (25 of 60) are not using R4B at all, with Latvia and Singapore being the only countries to report it as their main standard.
• R5: In both 2024 and 2025, a significant portion of respondents (12 of 38 and 25 of 67 respectively) reported not using R5 at all. Estonia consistently reported R5 as their main standard in both years.
• R6 (pre-release): The majority of respondents in both 2024 (24 of 38) and 2025 (38 of 57) reported not using R6 (pre-release) at all, with many indicating they “don’t know” if it’s in use.

Regulatory Imperative: Mandates and Capital Allocation

Regulation plays a crucial role in driving FHIR adoption. The majority of countries have regulations in place that mandate the use of standards in electronic health data exchange: 27 of 32 in 2023, 31 of 38 in 2024, and 64 of 82 in 2025.

A notable trend is the increasing mention of FHIR within these regulations. In 2023, 15 of 27 relevant respondents stated FHIR was mandated or advised. This rose to 20 of 31 in 2024 (65%), and further to 47 of 64 in 2025 (73%), indicating a growing legal and policy recognition of FHIR. Countries like Argentina, Belgium, Brazil, France, Germany, India, Israel, Italy, Japan, Lithuania, Netherlands, Philippines, Switzerland, Taiwan, and the United States reported FHIR being mandated in 2024.

Compliance deadlines for these regulations vary widely, with nearly half of respondents in 2024 (15 of 31) stating no deadline, but a higher proportion (29 of 63) reporting deadlines in 2025. Deadlines cited ranged from 2008 to 2026, with examples like Colombia (2025-12-31), Estonia (2008-09-01), France (2025-07-01), Germany (various dates, e.g., 2025-01-01), Netherlands (2026-01-01), and the United States (2025-12-31). Despite the regulations, fines for non-compliance are not widely imposed. In 2024, the majority (18 of 31) reported no fines, and this trend continued in 2025, with 41 of 64 respondents indicating no fines. Slovenia and Germany were among the few countries reporting fines.

Federal Capital Investment to drive FHIR adoption

Government funds to stimulate FHIR adoption are available in many countries like Belgium, Finland, France, Germany, India, Israel, Italy, Japan, Lithuania, Netherlands, New Zealand, Norway, Philippines, Switzerland, Taiwan, Thailand, and the United States have reported such funds. Examples include the Ayushman Bharat Digital Mission (ABDM) in India, the Wegiz law in the Netherlands, and various grants and programs in the United States. Israel’s Ministry of Health and Innovation Authority have funded FHIR implementation programs and projects.

National Standards Development: Building Blocks for Interoperability

The establishment of national standards organisations responsible for health data exchange is prevalent. The surveys show an increase in the number of such organisations over the years, affirming their existence. Examples include the Australian Digital Health Agency, Canada Health Infoway, InteropSanté & Agence du Numérique en Santé (France), gematik (Germany), Nictiz (Netherlands), HISO (New Zealand), and the Office of the National Coordinator for Health IT (United States).

The majority of countries confirm the existence of a national FHIR data model or base/core FHIR implementation guide (IG). Many of these are still under development or used in a limited set of use cases. Notable examples include:

• USCDI + US Core in the United States.
• BR-Core in Brazil.
• IL CORE in Israel.
• NZ Base IG in New Zealand.
• Basisprofil-DE-R4 in Germany.
• FHIR-FR-Core in France.

A significant portion of countries are developing FHIR standards for more specific use cases. These often derive from the national FHIR data model. The most common use cases for which FHIR specifications are being developed that were reported in the 2025 survey, include:

• Prescriptions/Pharmacy
• Terminology
• Diagnostic orders/Reports
• Document exchange
• Referrals/Continuity of care
• Immunizations

International specifications heavily influence national FHIR specifications, with International Patient Summary (IPS) being the most common basis (42 respondents in 2025) followed by European Implementation Guides (26 respondents).

The availability of a national FHIR terminology server is a key focus. In 2025, roughly half of respondents (39 of 79) reported a national FHIR terminology server in production or development, while another 27 reported one in planning.

FHIR Implementation: Stakeholders, Drivers, and Tools

EHR vendors consistently remain the main parties adopting FHIR, cited by 30 of 38 respondents in 2024 and 60 of 82 in 2025. App developers and care providers also play significant roles, with care providers notably increasing their adoption in 2025.

The primary drivers for FHIR adoption are consistently identified as Innovation and Regulation and grants, both mentioned by 23 respondents in 2024 and 52 in 2025. Improved care workflows and improved health outcomes are also important drivers.

Various FHIR features and techniques are being applied:

• FHIR Rest API is widely used, with many countries reporting it as their main standard.
• FHIR Documents and FHIR Messaging are also commonly applied.
• SMART on FHIR is widely adopted in the United States and Italy, with Japan, New Zealand, Australia, and Canada also making progress.
• CDS Hooks are used in Estonia, Japan, Argentina, Switzerland, and the United States.
• CQL on FHIR sees use in Estonia, France, Germany, and the United States.
• FHIR Bulk Data is used in Luxembourg, Germany, and the United States, among others.
• Subscriptions and FHIRcast are less widely adopted, but are in use in some countries like New Zealand and the United States.
• FHIR Questionnaires and SDC are being adopted in countries like the Philippines, Germany, New Zealand, Switzerland, Australia, Belgium, France, Italy, Japan, and the United Kingdom.
• FHIR Shorthand is also seeing adoption, notably in Belgium, Estonia, France, Germany, Italy, New Zealand, Philippines, Switzerland, and the United States.

Awareness of patient advocacy for healthcare data availability is mixed, with the majority of respondents (24 of 38 in 2024, 24 of 38 in 2025) not being aware of such groups. Among those who are aware, patient advocacy groups are increasingly paying attention to health data standards (9 of 14 in 2024, increasing from 5 of 9 in 2023).

Successful FHIR use cases are widely reported, with 29 of 38 respondents in 2024 and 63 of 82 in 2025 aware of successful implementations. The main achievement is consistently “Improved access to information” (26 of 29 in 2024, 56 of 63 in 2025). “Improved healthcare outcomes” and “lowered cost” are also cited, though less frequently.

Specific successful use cases include:

• ePrescription in Argentina, Canada, Germany, and Chile.
• International Patient Summary (IPS) in Argentina, Cyprus, and New Zealand.
• National Health Data Repository (NHDR) initiatives in Brazil and the Philippines.
• Patient access to health records via apps in the United States, Finland, and India.
• Centralized medication services/lists in Norway, Sweden, and Finland.
• Communicable disease reporting (e.g., CH ELM in Switzerland).
• eHealth4u Project in Cyprus.
• National Clinical Terminology Service in Australia.
• National Chronic Disease Management System in Turkey.
• Ukrainian National E-Health system, noted as one of the world’s largest HL7 FHIR-based projects in production, serving over 36.5 million patients.

However, significant challenges to FHIR adoption persist:

• Lack of FHIR knowledge is the most frequently cited barrier (29 of 38 in 2024, 59 of 82 in 2025).
• High investment cost (18 in 2024, 33 in 2025).
• Unclear benefits (14 in 2024, 35 in 2025).
• Unclear regulations (13 in 2024, 33 in 2025).
• Changes in political direction (newly highlighted in 2025 with 34 respondents).
• Other challenges include HR shortage, legacy system migration, terminology challenges, resistance to change, and lack of overall digitization of healthcare beyond administrative functions.

Looking forward, countries anticipate further developments in use cases such as:

• Patient Summaries (IPS), e-Requesting, and Chronic Condition Management Plans in Australia.
• National medication lists in Finland.
• Seamless claims processes in India.
• Medication prescription and dispense and diagnostic reports in Italy.
• Electronic claims on FHIR in the Philippines.
• Image sharing, SMART Health Links, and Bulk FHIR in the United States.
• EHDS-driven standards are widely anticipated across Europe.

Regarding open source versus proprietary FHIR software, the 2025 survey found a mixed landscape, with responses reporting “Exclusively open source” and “Exclusively proprietary,” and the majority falling towards the proprietary side of the middle ground.

Notable Achievements and Future Outlook

The 2025 survey introduced new questions to gauge recent progress and future expectations.

• Few major achievements in the last year include the launch of pilot projects (42 respondents), expanded adoption of FHIR (39 respondents), and the development of new FHIR standards for specific use cases (37 respondents). Australia notably launched Sparked-A National FHIR Accelerator in August 2023, significantly increasing FHIR adoption.
• Regarding satisfaction with the FHIR adoption rate, most respondents (35) reported being Neutral, with the remaining responses leaning slightly towards dissatisfaction.
• For next steps in the coming year, respondents most frequently expect expanded adoption of FHIR (61 respondents), development of new FHIR standards for specific use cases (53 respondents), and launch of pilot projects (44 respondents).
• Majority of respondents (51 of 81) agree or strongly aligned with the hypothesis that within the next three years, their country will reap the benefits of FHIR adoption, leading to significant cost savings, enhanced care coordination, and a more robust digital health ecosystem.

In Conclusion

The global journey of FHIR adoption is characterised by steady growth, driven by a combination of innovation and increasingly specific regulatory mandates. Certain challenges like a lack of FHIR knowledge and investment costs persist, but the community’s commitment to developing national standards, implementing diverse use cases, and collaborating internationally indicates a strong and optimistic trajectory towards a more interoperable and digitally mature healthcare landscape.

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