How to Build FHIR-Native Custom EHR Systems

Data exchange has become the core of healthcare software systems, and especially EHR systems, which have found themselves in the middle of almost every healthcare system that needs to deal with.

Have a look at this: according to a recent survey by the Office of the National Coordinator for Health IT, almost 90% of the US hospitals allow their patients to access their information through APIs. These are fairly recent stats; prior to this, almost 7 out of 10 hospitals were using standards-based APIs such as FHIR, according to a different report by ONC Healthcare IT.

This clearly highlights the shift that is taking place in the healthcare landscape, moving toward seamless and standardized data exchange. Now, simply adding FHIR APIs to your EHR architecture is not enough, and many have even tried it.

And naturally, healthcare practices turned to custom EHR software development for building their FHIR-native EHR.

With FHIR being the foundation of the data models rather than just having an integration layer, it can make your system compatible enough to exchange data with most of the healthcare systems in the ecosystem, seamlessly.

On that note, let’s explore the intricacies of FHIR-native EHR development and answer the question, ‘How to build an EHR using FHIR standards?’

So, without further ado, let’s get started!

What is a FHIR-Native EHR & Why Build One?

Let’s start with the basic understanding of FHIR-native EHR. In basic terms, unlike a traditional EHR that stores data in its own proprietary format, this EHR system uses FHIR, a FHIR-provided standardized format, to store, share, and manage healthcare information.

Here, a FHIR-native EHR uses the FHIR resources as its primary data model, which is also used for communication with other healthcare software systems. Due to this, the application’s data, APIs, and workflows are designed for FHIR from the first day, and that makes your EHR system FHIR-native and not FHIR-compliant. Have a look at this table to understand the difference.

Some of the major benefits of FHIR-native electronic health records are that they reduce the data mapping efforts between systems and simplify integration with hospitals, labs, pharmacies, and other payer platforms.

On top of that, it makes onboarding new partners faster, supports standardized APIs for third-party applications, and reduces long-term maintenance caused by custom interfaces.

With FHIR-native EHR development, your practice can support faster product development, easier scalability, better support for patient-facing apps, improved readiness for AI, and easier integration with SMART on FHIR applications.

Planning Your FHIR-Native EHR Architecture

FHIR-native EHR development is not built by simply implementing FHIR APIs. It is a well-thought-out process that works around clinical workflows, data architecture, interoperability, security, and future scalability.

The things that you finalize during the planning stage can set the stage for your systems to easily integrate with other healthcare apps, adapt to regulatory changes, and support new features over time.

Here are a few things that you have to consider while planning your FHIR-native EHR architecture.

Defining Business & Clinical Requirements

The first thing that you have to do is get your business goals right. Know what you want to achieve with this EHR, which users will be using this first, define clinical workflows, address specialty needs, and compliance requirements that your EHR system must support.

Here are some of the key deliverables in this stage:

• Business requirements document
• User personas and workflow maps
• Functional and compliance requirements
• Feature prioritization roadmap

Selecting FHIR Resources & Data Models

Once your requirements are defined, it is time to choose the right FHIR resources, profiles, and terminology standards to represent your clinical and administrative data.

Here are some of the key deliverables involved in this stage:

• FHIR resource mapping
• Data model blueprint
• FHIR profiles and extensions
• Terminology standards (SNOMED CT, LOINC, ICD-10)

Designing a Modular & Scalable Architecture

After your FHIR EHR resources are defined, you move on to the next stage, where you define a modular architecture that separates core EHR functions into scalable and maintainable components.

Some of the key deliverables involved in this stage are:

• High-level system architecture
• Module and service definitions
• Data flow diagrams
• Scalability strategy

Planning Interoperability from the Beginning

The last thing in requirement gathering is planning interoperability for your EHR system, basically FHIR-native EHR development. In this, you identify the system you want to integrate with and define the standards and APIs required for the seamless data exchange.

Here are some of the key deliverables involved in this:

• Integration requirements
• FHIR API strategy
• Authentication plan
• Integration roadmap

Building the Core Components of a FHIR-Native EHR

The next step is implementing the core building blocks of a FHIR-native EHR. This step involves selecting the right FHIR server to enable SMART on FHIR applications. Every component should be designed to support standardized data exchange, security, scalability, and long-term interoperability.

Let’s cover some of the intricacies involved in this:

Choosing the Right FHIR Server

The first thing that you have to do is find the right FHIR server for your EHR. Choose the FHIR server that aligns with your deployment, scalability, security, and compliance requirements. This will serve as the foundation for storing, managing, and exchanging FHIR resources.

Some of the key considerations in this are:

• Open-source vs. commercial FHIR servers
• Cloud-native or on-premise deployment
• Performance and scalability
• Security and compliance support
• Compatibility with existing infrastructure

Structure FHIR Resources & Data Models

Designing your data model in this is also crucial. It should be designed around standardized FHIR resources and healthcare terminologies to ensure consistent data representation and easier interoperability.

Some of the key considerations in this are:

• Map workflows to appropriate FHIR resources
• Use standard FHIR profiles wherever possible
• Create extensions only when necessary
• Adopt standard terminologies (SNOMED CT, LOINC, ICD-10, RxNorm)

Build FHIR APIs & SMART on FHIR

After the structures and data models are defined, it is time to build FHIR APIs and SMART on FHIR. Developing these secure and standards-based APIs that allow internal modules and third-party applications to access healthcare data using FHIR specifications.

Key considerations involved in this are:

• Implement RESTful FHIR APIs
• Support SMART on FHIR authentication
• Enable secure third-party app integration
• Design APIs for future extensibility

Integrate External Healthcare Systems

After building, connect your EHR with external healthcare applications that allow seamless exchange of patient information across the care ecosystem.

Here are the key considerations involved in this:

• Integrate laboratories and imaging systems
• Connect pharmacies and payer platforms
• Support patient portals and mobile apps
• Bridge legacy systems using HL7 or middleware when required

Design for Scalability & Future Growth

Build an architecture that can support increasing users, data volumes, integrations, and evolving interoperability requirements without major redesigns.

Key considerations involved in this are:

• Adopt modular services
• Use an API-first architecture
• Plan for cloud scalability
• Support future FHIR versions and AI-enabled capabilities

Developing, Testing & Deploying a FHIR-Native EHR

After developing the core components, your FHIR-native EHR system is almost ready. After this, you need to validate system security, interoperability, performance, and reliability. Thorough testing and a well-planned development strategy need to be in place so that your FHIR-native EHR can securely exchange healthcare data, handle production workloads, and comply with industry standards.

Refer to the table below to know the steps and other intricacies involved in this:

Best Practices for Long-Term Success

For long-term success of your FHIR-native EHR development, here are some of the best practices that you can adopt.

• Support Evolving FHIR Standards: Regularly update your EHR to align with the latest FHIR releases and implementation guides. Staying current helps maintain compatibility with new healthcare technologies and regulatory requirements.

• Build an Extensible Healthcare Ecosystem: Design your platform to easily accommodate new modules, third-party applications, AI capabilities, and emerging healthcare services without major architectural changes.

• Maintain Interoperability Across Partners: Continuously monitor and validate integrations with EHRs, laboratories, pharmacies, payers, and other healthcare systems to ensure consistent and reliable data exchange.

• Plan for Continuous Improvement: Adopt a continuous improvement strategy by monitoring system performance, gathering user feedback, strengthening security, and introducing new features to meet evolving clinical and business needs.

Frequently Asked Questions