A key question for any organization starting to work with FHIR is which server provider to use.
10 years ago the answer would have been “build your own.” Back then managed FHIR servers were barely making an impression and “off-the-shelf” providers were just getting started.
That’s all changed.
Microsoft, AWS and Google Cloud each provide managed servers as “out-of-the-box” solutions, as do smaller providers such as Health Samurai, Medplum and others.
InterSystems are big players across Europe and the US and companies like Smile and Firely provide fully featured servers that you can install and manage yourself.
Who provides your FHIR server?
This was one of the questions I asked in last year’s FHIR survey, and it threw up a few surprises.
Here are the results:
- 33% — Microsoft Azure
- 28% — We built our own
- 19% — Smile
- 11% — InterSystems
- 8% — Health Samurai Aidbox
- 8% — Firely
- 14% — Other
The question was multi-choice. Some organizations use more than one server provider which accounts for the percentage total being greater than 100%. I would have liked to dig into this a little more but the simple Q&A format didn’t allow for that.
Here are the key takeaways.
1. Microsoft Azure dominates
Their servers integrate tightly with the rest of the Microsoft Azure ecosystem, making them an easy purchase for any large company already invested in Microsoft. They’re active in the FHIR community and lead the way when it comes to helping organizations build large FHIR based solutions using a number of open source projects they maintain.
2. 28% said they built their own server
I’ve spoken to a number of companies who leverage open source FHIR servers from IBM, HAPI and Firely, customizing them into a server that they maintain themselves. This doesn’t get talked about much but these are not small companies and they deal with serious amounts of data.
While it’s rare these days for organizations to build their own FHIR façade from scratch, these OS server projects are a well trodden path to achieving the same goal.
3. InterSystems ranked higher than I expected
This should not have come as a surprise. Their marketing efforts are far more low-key than many of the other providers on the list. This can lead to a false understanding of their size and position in the server market — a cautionary lesson. In many European countries InterSystems FHIR servers dominate the market.
4. Firely and Smile combined add up to 27%
This suggests that “managed” cloud servers are not the only answer. There is a use case for commercial grade servers that an organization can install and manage themselves. I wonder at the long term lifespan of these servers as the push to Cloud is only getting stronger, but I could be wrong here.
5. The absence of AWS and Google Cloud
This was a big surprise to me. I know a number of organizations who use AWS servers and would have expected a stronger showing. It may be that the response size was too small to accurately capture their use or it may be that their users are fewer than their brand name suggests.
6. Other providers accounted for 14%
The number of server providers is growing, with new companies popping up in the space every year. Smaller companies like Medplum, Oystehr, Kodjin and others made an appearance here. Investing in a startup for your FHIR server feels risky to me, but one of the advantages of tying yourself to these companies is that you have an opportunity to influence their product direction and development — something that is unlikely to happen with Microsoft or AWS.
What lessons can be drawn from this?
The key lesson for me is that there is a healthy diversity in the FHIR server market. No one server company or approach has a monopoly. Cloud providers often try to claim that cloud has “won” and every organization will be using cloud servers in the future. But the answers given by the companies who responded to my survey suggest otherwise.
In conclusion, if you’re looking to invest in a FHIR server, there are a host of available options you should investigate.
- Managed servers from the “Big 3” cloud providers (Azure, AWS, Google)
- “Off-the-shelf” servers that you manage yourself
- Open Source servers that you can own and tailor to your specific requirements
- Servers built by smaller companies and startups
Here’s a link to my list of 20 FHIR Server Providers. Every company or project I mentioned above is on this list. You should investigate each one before making a decision.
[Metadata about the survey and the list of questions is here.]
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