Why FHIR Alone is not Enough
Part 1 - Presenting the Problem
Fast Healthcare Interoperability Resources (FHIR) has rapidly become the centerpiece to healthcare data exchange efforts. With its modern web-based architecture and standardized resources, FHIR offers a promising framework for improving how health information is shared. But despite its popularity, potential, and broad adoption, FHIR alone cannot fully address the challenges of data interoperability. True interoperability, the seamless and meaningful exchange of health information, requires more than a technical specification for data formatting and transmission.
It also requires consistent and well-managed usage of healthcare terminology, something FHIR does not enforce. A terminology server like TermHub, which acts as a centralized library for managing terminologies, is essential. It provides consistent handling of code systems, maps, value sets, versioning, and overall semantic alignment across FHIR systems. Without it, even properly structured data can be misunderstood or misused.
In this post, we'll explore why FHIR is not enough and highlight the additional components needed to enable effective, scalable interoperability in real-world healthcare settings. In the next post, we will provide examples where the meaning of the data is lost by assuming FHIR will "solve it all." The third post will introduce a more practical solution: normalizing all incoming data to a consistent internal model which can be done via West Coast Informatics’ AutoMap Solution.
Can Two FHIR Systems Misunderstand Each Other?
FHIR provides a standardized way to structure and transmit data. It can be thought of as the grammar of healthcare data exchange. However, true interoperability also requires semantic understanding. Different systems may use different terminologies, value sets, and clinical models even within FHIR resources.
For example, one EHR might code a diagnosis using SNOMEDCT, while another uses ICD10CM.
A "condition" resource in FHIR might have different meanings across contexts unless the underlying terminology bindings are explicitly standardized.
Without semantic interoperability, two systems can "talk" using FHIR but still misunderstand each other.
How Do FHIR Profiles Impact Interoperability?
FHIR is highly flexible by design, allowing for profiles (customized constraints on FHIR resources). While this flexibility helps tailor FHIR to different use cases, it also fragments the standard.
Different organizations create their own FHIR profiles, making it difficult for one system to interpret another’s data.
Without harmonization, we risk creating "FHIR silos" or systems using the same framework but incompatible implementations. For example, the US Core implementation guide is a kind of standard for US healthcare but would not facilitate exchange of data with any entity outside of the US.
Even with the same base FHIR standard, the lack of consistent implementation guides and profile governance can undermine interoperability.
Does FHIR Solve Data Quality and Governance Challenges?
Interoperability isn't just about moving data. It's also about trusting and using the data effectively.
FHIR doesn't enforce data quality standards (e.g., consistency, completeness, accuracy).
Nor does it address governance frameworks which define who owns the data, how it's used, and how consent is managed.
It also doesn't resolve workflow integration challenges as clinicians still face fragmented user experiences even if data is technically interoperable.
Until these issues are addressed, FHIR-compliant systems might exchange bad or incomplete data, which can harm care rather than improve it.
Does FHIR APIs Guarantee Interoperability?
FHIR uses RESTful APIs, making data access more efficient, but APIs are just pipes sending data from one location to another. What's inside the pipe, how it's interpreted, and how it's used still matters.
APIs don’t ensure that data is timely, relevant, or actionable.
Integration into clinical workflows, decision support, and longitudinal patient views often require layers of logic beyond what FHIR provides.
FHIR APIs are necessary, but not sufficient for clinical-grade interoperability.
Does FHIR Replace Collaboration in Healthcare Data Exchange?
Finally, achieving interoperability requires more than technology. It requires alignment across stakeholders, including:
Payers, providers, health IT vendors, patients, and regulators
Policy frameworks, such as United States Core Data for Interoperability (USCDI), that mandate standard adoption and data exchange practices
Incentives and business models that reward sharing, not hoarding, of data
FHIR is a key part of this puzzle. Governance, collaboration, and policy enforcement are still necessary to ensure it’s used effectively and consistently.
What Does FHIR Need to Deliver True Interoperability?
To unlock true interoperability, FHIR must be more than just a data exchange framework. It must be part of a coordinated ecosystem. This means pairing FHIR with:
Shared terminologies and semantic models (for example, SNOMED CT, LOINC, RxNorm) to ensure that clinical concepts are consistently understood across systems.
Standardized FHIR implementation guides and profiles (such as US Core or the International Patient Summary) to promote uniform structure, required fields, and terminology bindings.
Strong data governance and stewardship to maintain data integrity, accountability, and alignment with regulatory and ethical standards.
Clinical workflow integration to ensure data flows naturally into decision-making processes and enhances rather than disrupts care delivery.
Policy frameworks and incentives for data sharing, which encourage adoption, standardization, and collaboration among stakeholders.
Together, these elements bridge the gap between technical interoperability and meaningful interoperability, where data is not just exchanged but is accurate, timely, and usable in real clinical and administrative contexts.
What Policies Are Needed to Ensure FHIR Drives Real Interoperability?
While each of these components is essential, their existence alone is not enough for there must be mechanisms to ensure they are actually adopted and applied. Without meaningful incentives or regulatory enforcement, healthcare organizations have little motivation to align with shared terminologies, standardized FHIR profiles, or robust governance practices. The burden of interoperability often falls on those consuming data, rather than those producing it. To shift this dynamic, policies must hold data creators accountable for the quality and usability of the data they generate. This could include tying compliance to reimbursement, certification, or participation in value-based care programs. True interoperability depends not just on having the right tools and standards, but on creating the systemic pressure and support necessary to drive consistent, real-world adoption.
FHIR is an essential building block in the future of healthcare data exchange. But like any tool, it works best when used in the context of a broader strategy. Without semantic alignment, consistent implementation, high-quality data, strong governance, and collaborative policy, FHIR cannot deliver on its full promise.
To achieve meaningful, system-wide interoperability, we must look beyond APIs and resource structures to the entire ecosystem of standards, practices, and relationships that make health data truly useful.
Ultimately, it is not just about sending data. It is about making that data understandable, trusted, and actionable. To get there, the industry must align around more than technology. It must embrace the full ecosystem required to make FHIR work as intended.