Survey Highlights FHIR Momentum, Ongoing Implementation Challenges

An international survey about the adoption of FHIR finds that over 70% of countries report active FHIR use for at least a few national use cases, and 54% expect a strong increase in adoption over the next three years. However, the survey also highlighted implementation challenges that continue to hamper the full realization of interoperable healthcare systems.

They survey was conducted by global health IT company Firely and HL7 International and involved input from 82 participants across 52 countries.

While FHIR is in use in most countries surveyed, only a minority have adopted it as their primary national exchange standard. Leaders include Israel, where FHIR is central to national interoperability strategy, and India, where it powers the Ayushman Bharat Digital Mission. The United States and Switzerland also stand out for mature regulation and ecosystem-wide support.

“FHIR is no longer just a promise—it’s becoming the backbone of modern healthcare data exchange,” said Ward Weistra, product lead at Firely, in a statement. “But this year’s findings show that global implementation is still highly uneven. Without stronger governance, funding, and version alignment, we risk fragmenting rather than unifying the digital health landscape.”

FHIR is mandated or recommended in 73% of countries with health data regulation—but fewer than half have defined compliance deadlines, and only 16% impose penalties for non-compliance. Saudi Arabia and Estonia are among the few enforcing national deadlines for FHIR integration.

The survey report noted that multiple FHIR versions (R4, R4B, R5) coexist within many national systems, complicating interoperability. Even among high-adoption countries, alignment around a common version remains a pressing issue.

REST APIs are widespread, but more advanced tooling—such as SMART on FHIR and CDS Hooks—remains limited to digitally mature ecosystems like the U.S. Several countries report continued reliance on legacy exchange mechanisms like HL7 Version 2 or Clinical Document Architecture (CDA), highlighting the need for capacity building.

“This survey highlights both the global enthusiasm for FHIR and the real-world hurdles that still stand in the way,” said Diego Kaminker, the deputy standards chief implementation officer at HL7 International, in a statement. “It’s a powerful reminder that adoption is only the first step. Implementation requires sustained investment, education, and alignment.”