In United States, FHIR is a main standard for exchanging healthcare data. It is widely used across the healthcare ecosystem, with strong adoption among providers, payers, vendors, and government agencies.

The most common version is FHIR R4, which is heavily used. Some organizations still work with older versions like DSTU2 or are starting to explore R4B and R5. R6 is not yet in use.

Looking ahead, we expect continued strong growth in FHIR adoption. New regulations and ongoing pilot projects will keep pushing FHIR further into everyday healthcare data exchange.

Rules and Support

The United States has clear rules for electronic health data exchange:

  • Regulations mandate the use of standards, and FHIR is specifically required.
  • There are deadlines for compliance.
  • Fines can apply if organizations miss those deadlines.
  • Government funding is available to support FHIR adoption.
  • The U.S. uses a layered approach to enforcement, such as tying compliance to program participation and payments.

You can learn more about federal FHIR plans here: Federal FHIR Action Plan. Agencies like CMS (Centers for Medicare & Medicaid Services) and ASTP (Assistant Secretary for Technology Policy) provide several regulations to promote FHIR adoption.

National Setup

Several national organizations share responsibility for health data standards:

  • ASTP, CMS, CDC, FDA, NLM, and NIH all act as stewards of national standards.
  • The base FHIR implementation guide is US Core, and it is widely used. You can find it here: US Core STU6.1.
  • There is no national FHIR terminology server, and none is currently planned.

Active Use Cases

FHIR specifications are being developed in the United States for a wide range of use cases, including:

  • Prescriptions and pharmacy
  • Referrals and continuity of care
  • Provider directories
  • Public health reporting
  • Terminology
  • Diagnostic orders and reports
  • Consent
  • Clinical decision support
  • Document exchange
  • Imaging and genomics
  • Immunizations
  • Clinical registries
  • Patient access
  • Scheduling
  • Allergy intolerance
  • Invoice and claim

US Core complies with the International Patient Access (IPA) specification. A newer guide, US PCS, aligns with the International Patient Summary (IPS).

The United States also has approved participants in the FHIR Community Process (FCP), and we expect approved FCP specifications within the next 2–3 years.

Who's Using FHIR

A broad set of stakeholders is adopting FHIR:

  • Care providers
  • Payers and insurers
  • EHR system vendors
  • Diagnostic system vendors (imaging and lab)
  • App developers
  • Clinical registries
  • Government agencies
  • Researchers

The main drivers for adoption include:

  • Regulation and grants
  • Improving health outcomes
  • Improving care workflows
  • Patient data access
  • Innovation

When it comes to how FHIR is used, the FHIR REST API is the dominant exchange mechanism. SMART on FHIR (a standard for launching healthcare apps) and CDS Hooks (a way to trigger clinical decision support) are also widely applied. FHIR Shorthand, a tool for authoring profiles, sees strong use as well. FHIR Documents, Bulk Data, and Subscriptions are used to a moderate extent. FHIR Messaging is rarely used.

Both open source and proprietary FHIR software are in use, with a fairly balanced mix.

Successes and Challenges

FHIR has delivered real benefits in the United States, including:

  • Lower costs
  • Improved healthcare outcomes
  • Better access to information
  • Improved care workflows

Concrete success stories include:

  • Patients gaining access to their own health data
  • Providers deploying low-cost SMART on FHIR applications
  • Use of Bulk FHIR for large-scale data exchange

The main challenges include:

  • High investment costs
  • Unclear benefits for some stakeholders
  • A lack of FHIR knowledge in parts of the industry

Looking forward, one anticipated use case is "killing the clipboard" through SMART Health Links, which would let patients share their health information more easily.

Future Plans

Last year, the United States made more progress than expected on FHIR adoption. Key achievements included:

  • New regulations requiring standards in electronic health data exchange
  • Development of new FHIR standards for specific use cases
  • Launch of pilot projects with healthcare stakeholders
  • Expanded adoption across the ecosystem

In the coming year, we expect:

  • More new regulations
  • More FHIR standards for specific use cases
  • More pilot projects
  • Continued expansion of FHIR adoption

Respondents are satisfied to very satisfied with the current adoption rate. They strongly agree that within the next three years, FHIR adoption will lead to cost savings, better care coordination, and a stronger digital health ecosystem.

Contributors

  • Bret Marquard, US Realm (Chair and vice chair)
  • One additional respondent chose to remain anonymous

The above summary is based on the answers to the State of FHIR Survey 2026, organized by Firely and HL7 International.

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