Electronic Health Reporter

Firely (www.fire.ly) and HL7 International (www.hl7.org) announce the global release of the 2025 State of FHIR survey report. The findings, based on expert input from 82 participants across 52 countries, provide a comprehensive look at the real-world adoption, implementation and regulation of HL7 Fast Healthcare Interoperability Resources (FHIR) — the world’s most widely used health data interoperability standard.

The survey, now in its third edition, reveals a clear surge in global momentum: 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. Yet, despite this progress, implementation challenges continue to hamper the full realization of interoperable healthcare systems.

“FHIR is no longer just a promise—it’s becoming the backbone of modern healthcare data exchange,” said Ward Weistra, product lead at Firely. “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.”

Survey Highlights – Progress Meets Complexity 

• Widespread adoption, limited scale: 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.

• Implementation guides underutilized: 79% of respondents report the existence of a national FHIR implementation guide, but just 20% say it is widely used. Countries such as Belgium and Brazil are actively funding and maintaining their national IGs to support hospitals and vendors in alignment.

• Regulation rising, enforcement lags: 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.

• Version fragmentation: 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.

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

Collaboration at the Heart of the Survey

The State of FHIR survey was conducted through a strategic partnership between Firely and HL7 International, the global standards body behind FHIR. Together, they engaged national FHIR leaders, HL7 affiliates, and digital health authorities to build a nuanced, qualitative understanding of adoption progress.

“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. “It’s a powerful reminder that adoption is only the first step. Implementation requires sustained investment, education, and alignment.”

Why This Matters

As healthcare systems modernize, FHIR offers the most scalable and standards-based path toward seamless data exchange—across providers, borders, and technologies. But without coordinated implementation, the benefits of interoperability remain out of reach for many.

This report sheds light on what’s working, what’s missing, and what’s next for digital health transformation. It offers a valuable resource for journalists, analysts, government stakeholders, and digital health professionals seeking to understand the state of play.