There is no perfect FHIR server.
The FHIR standard is huge and there’s hidden complexity in the tall grass. No provider has implemented a full FHIR solution that meets all requirements.
The starting point when choosing a FHIR server is knowing what’s genuinely important to your project. You can then choose what trade-offs you can live with.
I’ve worked with Azure FHIR servers for three years. Here are my pros and cons.
The Pros
1. Versioning is Automatic
– Full resource version history out-of-the-box
– Configurable versioning by resource type
2. Health Data Services Workspaces
– Data segregation at the workspace level (HIPAA compliance)
– Multiple FHIR servers in one workspace (Dev, Staging, Production)
– DICOM servers in the same workspace
3. Same source code as OS project
– It’s built in public
– The OS project gets updated first, so you can test for breaking changes
– Easy to run a local Docker instance for Dev and testing
4. Infrastructure as code
– Part of the Azure portal and platform
– Terraform scripts for all FHIR setup and configurations
5. Lots of open source projects
– Middleware toolkit
– Data anonymization
– Smart-on-FHIR
– FHIR to Synapse data flow for analytics
– The FHIR server itself
6. Well integrated with Microsoft platform
– Power automate and Power BI drag and drop configuration
The Cons
1. Subscriptions not implemented
– A huge gap in functionality
– Ties implementers and users to Azure’s custom EventGrid
2. Limited number of operations exposed
– No $expand or other terminology operations
3. Smart-on-FHIR Integration is difficult
– Tightly integrated into the rest of the Azure Platform
4. No visibility into underlying database
– Common problem with managed cloud servers
Back to my earlier question: “what’s genuinely important to your project?”
Some of the Pros and Cons above might not matter to you or to your project. Some might be deal breakers.
Whatever FHIR server you choose it’s one you’ll have to live with for a long time.
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