Increased FHIR Adoption Requires a New Testing Strategy, Sponsored by Drummond Group

It wasn’t long ago that Health Level 7 (HL7©) Fast Healthcare Interoperability Resource (FHIR©) was seen as a neat utility for basic data sharing. A sleek new way to fetch a patient’s allergies or lab results from an EHR without wrangling complex legacy formats. Early on, many treated FHIR APIs as sidekicks to the main electronic health record, useful for one-off data pulls or satisfying a regulatory checkbox. But fast forward a decade and FHIR has graduated from sidekick to critical infrastructure.

Today, those APIs are the conduits for prior authorizations, patient access tools, and care coordination workflows that health care depends on daily. Insurers are using FHIR to automate prior auth decisions that once took weeks. Patients are tapping FHIR-powered apps to access claims and clinical data instantaneously. Care teams are coordinating across hospitals via FHIR-based referrals and alerts.

In short, what began as a simple data exchange mechanism is now the lifeblood of an API-first healthcare ecosystem driving real-time decisions and patient care. This transformation raises an urgent question: Has our approach to certification kept pace with FHIR’s coming of age?

When APIs were experimental, a basic compliance test or a quick integration test might have sufficed. But now that dynamic workflows ride on these connections, the old “test it once and forget it” mentality is showing its limitations. Traditional certification models are struggling to keep up. Too often, an organization will pass a one-time conformance test or shine in a brief demo, only to discover blind spots months later in production. Real-world interoperability is more complex depending on the use case and the variety of endpoints, and many integration issues only surface after the official testing is over.

That’s why it is more important than ever for health care organizations to reevaluate their approach to FHIR testing and certification. This shift is not only about preventing failures; it is also about enhancing performance. By adopting a more adaptive, real-world testing strategy, organizations can reduce integration issues, accelerate deployments, and achieve stronger returns on their technology investments.

The Limits of Traditional Certification Testing

Why do interoperability issues persist? To understand the challenge, it’s helpful to look at how interoperability testing has traditionally been approached in health care. Consider Connectathons. These events have long provided a valuable proving ground where developers demonstrate their systems’ ability to exchange data.

However, by design, Connectathons are time-bound and focused in their scope. A single event might concentrate on one implementation guide, such as a patient access API or a Da Vinci prior authorization workflow, leaving many other potential interactions unexplored. Given the constraints, participants often focus on validating core “happy path” scenarios, while more complex or less common edge cases remain untested.

Similarly, formal certification processes like ONC Health IT Certification provide essential assurance that software meets specific technical criteria at a given point in time. This snapshot of compliance is a critical milestone, but it doesn’t always account for what happens after certification, as software updates roll out or new integration partners come online.

For example, in response to regulations like the CMS Interoperability and Patient Access Final Rule, health plans across the country are implementing FHIR APIs to support patient data exchange. Similarly, ONC-certified EHRs are now required to include FHIR-based APIs. But while certification confirms that these APIs meet specific standards at a moment in time, things can quickly change in practice. As new partners are added, security updates are applied, or new features are introduced, unexpected interoperability issues often arise. These real-world challenges can create gaps between what was certified and how technology performs in everyday use.

It’s like wiring up an entire industry in parallel, without a shared blueprint or coordinated test plan. While the intention is interoperability, the reality is that most systems are going live without the level of testing and certification needed to ensure they’ll work together reliably. The result is a fragmented rollout, where small inconsistencies between implementations can lead to major breakdowns in real-world data exchange.

The challenge of ensuring real-world interoperability gets even more complicated when you consider that FHIR is constantly evolving. With multiple versions now in use, it introduces a new set of compatibility issues that need closer attention, forcing the question: Can today’s testing and certification models keep pace with the rapid evolution of FHIR?

The Hidden Risks of FHIR Version Drift

FHIR is a moving target, and that creates real-world challenges. The standard continues to evolve at a steady pace. FHIR R4, the first normative version, became the foundation for many U.S. certification programs and is still the basis for the ONC’s current certification criteria. In 2023, FHIR R5 followed with over 100 new resources, improved workflow capabilities, and stronger security features. Now, FHIR R6 is already in development (could possibly arrive as soon as 2026) and aims to optimize resource definitions, reduce variability, and enhance backward compatibility.

Each of these versions brings meaningful improvements but also increased complexity for implementers. Systems must adapt to new capabilities, updated resource definitions, and changes in conformance expectations. In many real-world environments, older and newer versions coexist, requiring interfaces that can dynamically interpret and translate between versions. This demands more than static documentation. It requires dynamic version handling, flexible implementation logic, and robust regression testing.

Consider this: if your API is certified on R4 but your data-sharing partner has moved to R5, are your systems still compatible? If one side relies on an implementation guide built for R4 and the other builds on R5 conventions, will they exchange data correctly or fail silently? These are not hypothetical edge cases. They are already happening in the market.

The reality is that a static certification and one time testing earned two years ago cannot assure interoperability today, especially as vendors issue updates, switch IGs, or adopt newer tooling. Version drift is real, and without deliberate version management and ongoing validation, certified systems can quickly fall out of sync.

In short. FHIR’s release cycle is measured in years, but industry adoption is accelerating in months.

A Turning Point for Interoperability Assurance

If all this sounds like a tall order, the good news is the industry is waking up to the challenge. There’s a growing recognition among health IT developers, health care providers, EHR vendors, payers, and even regulators that we must shift from static, point-in-time certification to a regime of real-world, continuous validation.

The market appetite for more rigorous assurance is evident. Vendors know that a botched integration or a go-live failure is costly, not just in dollars, but in reputation. Providers and health plans, too, are now asking tougher questions of their IT suppliers: “Can you prove not just that you passed a test last year, but that your system works today with the systems I use?”

Forward-thinking organizations aren’t waiting for regulators to mandate this. They’re seeking it out to de-risk their deployments.

The final rules from CMS and ASTP/ONC are starting to point in the right direction, yet they don’t fully address the day-to-day reality that technology and partnerships can evolve faster than the law.

As a result, the industry is taking matters into its own hands, looking for solutions that provide ongoing confidence. This shift reflects a growing recognition that continuous assurance is no longer optional. To maintain trust, reduce risk, and stay competitive, both vendors and health care providers should invest in tools and processes that go beyond compliance to deliver consistent, real-world performance.

New Approach to Real World Testing

In this context, many organizations are rethinking the role of certification in the FHIR era. Alongside point-in-time conformance tests, they are adopting living testbeds where systems are exercised against one another on a regular cadence. FHIRplace is one example of this approach: a shared, production-simulated environment where participants connect their software and run end-to-end scenarios that mirror real workflows.

Used this way, FHIRplace functions less like a one-off exam and more like ongoing practice. Teams can rerun the same scenarios as versions, implementation guides, and policies evolve; observe differences in behavior; and address issues before they affect production. The emphasis shifts from “passing a test” to maintaining operational reliability over time, complementing formal certification rather than replacing it.

This move toward continuous, collaborative testing is as much organizational as technical. It encourages common test data, transparent issue tracking, and predictable release routines across partners. The practical outcome is fewer surprises after go-live and steadier interoperability as systems change.

Getting Ahead Pays Off: The ROI of Continuous FHIR Testing

For years, testing and certification were treated as sunk costs, an obligatory expense to clear a regulatory hurdle or gain market entry. But for organizations that have embraced continuous, real-world validation, the story is changing. What used to be a compliance burden is now becoming a competitive asset, one with tangible returns.

Reducing Post-Go-Live Failures

Think about the typical cost of failure in this space. A FHIR API that passes lab testing but breaks down during a client implementation can stall a project for weeks. Engineers are pulled off roadmap work to troubleshoot urgent issues. Clients grow frustrated and may reconsider the partnership. Meanwhile, reputational damage quickly and quietly spreads. Fixing these problems post-go-live is not just expensive; it is disruptive.

Now imagine a vendor that integrates continuous interoperability testing directly into their development process. Developers test as they build, catching bugs early when fixes are faster and less expensive. They gain real-time insight into how their software performs and interacts with other systems. By the time they are ready to deploy, they can move forward with confidence, knowing their product not only works well but is also interoperable with others in the marketplace. Partner onboarding is more efficient, and support teams spend less time resolving misunderstandings because those issues were already addressed in shared testing environments.

Unlocking New Market Opportunities

There is also the opportunity cost of waiting. In a market where stakeholders are increasingly demanding proof, not just claims, of interoperability, being early to adopt continuous validation unlocks deals that others cannot close. RFPs are beginning to ask about participation in real-world testing programs or structured test events. Being able to say, “Yes, we’re part of an independently validated network,” removes friction from sales cycles. It signals trustworthiness in a measurable way.

Driving Internal Efficiency and Product Quality

And then there is internal efficiency. Development teams that adopt a cadence of external testing start to align their release schedules around those quality gates. They improve regression testing. They anticipate edge cases earlier. That is not just about avoiding failure, it is about building better software, faster.

In this light, continuous testing becomes less about checking boxes and more about reducing risk, increasing quality while lowering the associated costs, and accelerating revenue. It is not a “nice to have.” It is a strategic investment with a clear return.

The Path Forward for FHIR Certification and Interoperability

In summary, FHIR testing is no longer just a one-time checkpoint. It is becoming a foundational part of delivering reliable, high-quality health IT. The industry is shifting away from static checklists and occasional integration testing and moving toward a model of continuous assurance. The good news is that organizations adopting this approach through continuous validation and evolving certification models are better positioned to deliver on the promise of FHIR and an API-first ecosystem. The technology, the standards, and the industry mindset are all moving in the same direction. This is not a quick fix, but a long-term journey toward stronger, more consistent interoperability.