HL7 FHIR Adoption and Interoperability Maturity in Sri Lanka: A Mixed-Methods National Baseline Assessment

1. Introduction

Interoperability is a fundamental requirement for digital health transformation [1], enabling the secure and seamless exchange of health information across disparate systems and supporting continuity of care through longitudinal patient records. As countries increasingly invest in digital health infrastructure, the adoption of internationally recognized health data standards has become essential for reducing fragmentation, improving data quality, and facilitating integrated healthcare delivery. [2,3,4] Among the available interoperability standards, Health Level Seven (HL7) Fast Healthcare Interoperability Resources (FHIR) has emerged as the leading global framework for health information exchange [5,6]. Leveraging modern web technologies and a modular resource-based architecture, FHIR enables standardized, scalable, and interoperable data exchange across diverse healthcare settings [7].

Globally, FHIR has been adopted to support national health information exchanges, electronic health records, patient-facing applications, clinical decision support systems, and broader digital public infrastructure initiatives. Its growing adoption reflects increasing recognition that interoperability is critical for achieving Universal Health Coverage (UHC), strengthening health system resilience, and supporting data-driven healthcare delivery. International organizations, including the World Health Organization (WHO), have emphasized the importance of open standards and interoperable digital ecosystems as key enablers of national digital health transformation. [8] Yet the evidence base on FHIR implementation remains heavily concentrated in high-income settings, and systematic assessments of adoption maturity in low- and middle-income countries (LMICs), particularly within the WHO South-East Asia Region are scarce. Importantly, national endorsement of an interoperability standard does not automatically translate into operational interoperability. Countries may develop policies, implementation guides, and proof-of-concept demonstrations while still lacking the institutional mechanisms required for scale, including conformance testing, terminology governance, vendor certification, procurement alignment, workforce capacity, and sustainable financing. Understanding this transition from standard adoption to implementation at scale is especially important for LMICs, where digital health programs often depend on project-based financing and small pools of specialized technical expertise. This gap limits the ability of national policymakers and regional partners to benchmark progress, prioritize investment, and learn from comparable health systems.

Sri Lanka has identified interoperability as a strategic priority within its digital health agenda and has progressively positioned HL7 FHIR as the national standard for health information exchange. This commitment was first articulated in the National Digital Health Guidelines and Standards (NDHGS) Version 2.0, published in 2020, which referenced FHIR data structures as a foundational component for developing a National Electronic Health Record (NEHR). [9] Building upon this foundation, the Sri Lanka Digital Health Blueprint formally designated HL7 FHIR Release 4 (R4) as the preferred interoperability standard underpinning the National Electronic Health Record and the proposed Digital Health Platform (DHP). [10,11] Together, these initiatives aim to establish a patient-centric, longitudinal health record capable of supporting integrated care across public and private healthcare providers.

To operationalize this vision, Sri Lanka has established governance mechanisms including the National eHealth Steering Committee, the National Digital Health Technical Advisory Committee, and the Technical Working Group for Digital Health Interoperability and the National Electronic Health Record. The country has also invested in national FHIR profiling activities, development of the SL Core and NEHR FHIR Implementation Guides, and multiple national FHIR Connectathons that have demonstrated successful data exchange between major electronic medical record systems and a prototype NEHR environment. Capacity-building initiatives supported by international partners such as HL7 International, the Asia eHealth Information Network (AeHIN), eSHIFT, and Jembi Health Systems have further contributed to strengthening local expertise and implementation capacity.

Despite these advances, the maturity of FHIR adoption across Sri Lanka’s health system remains uncertain. While several pilot implementations and interoperability demonstrations have shown technical feasibility, there is limited evidence regarding the extent of institutional readiness, governance capacity, workforce preparedness, infrastructure maturity, and sustainability required for nationwide implementation. Furthermore, barriers to scaling FHIR adoption across public, private, and academic sectors have not been systematically documented. Understanding these factors is essential for informing future investments, strengthening implementation strategies, and ensuring alignment with global interoperability best practices.

This study aimed to assess the current landscape of HL7 FHIR adoption in Sri Lanka and evaluate national interoperability maturity using internationally recognized assessment frameworks. Specifically, the assessment aimed to (i) map existing FHIR implementations and interoperability initiatives across sectors, (ii) assess the maturity of national FHIR artefacts and broader maturity of interoperability, (iii) identify key technical, operational, and systemic barriers influencing adoption, and (iv) benchmark Sri Lanka’s progress against selected countries with established FHIR ecosystems. To our knowledge, among the first systematic, framework-based assessment of national FHIR interoperability maturity conducted in a South Asian LMIC. The findings provide a baseline assessment of Sri Lanka’s interoperability landscape and identify strategic priorities for advancing sustainable, standards-based digital health transformation.

2. Methods

2.1. Study Design

A mixed-methods baseline assessment was conducted to evaluate the current state of HL7 Fast Healthcare Interoperability Resources (FHIR) adoption and interoperability maturity within Sri Lanka’s digital health ecosystem. Data collection took place between September and November 2025. The assessment aimed to characterize the national FHIR landscape, identify implementation barriers and enabling factors, document existing interoperability initiatives, and assess the maturity of FHIR adoption across public, private, and academic sectors. To achieve these objectives, the study combined multiple data collection and analysis methods, including a desk review, rapid literature review, technical review of national FHIR Implementation Guides (IGs), key informant interviews, stakeholder surveys, and interoperability maturity assessments. Findings from all sources were subsequently triangulated to enhance the reliability, validity, and comprehensiveness of the assessment. The assessment was led by the Health Informatics Society of Sri Lanka in collaboration with the Ministry of Health and with support from the WHO Regional Office for South-East Asia. We conceptualized the study as a mixed-methods national case study and baseline maturity assessment. Qualitative and quantitative data were collected concurrently and integrated during interpretation. The assessment combined document-based evidence, stakeholder perceptions, technical artefact review, and structured maturity scoring to examine both the technical readiness of FHIR artefacts and the wider institutional readiness required for national implementation. Because the study combined elements of implementation research, health-system assessment, and technical standards review, no single reporting guideline was fully applicable; however, reporting was informed by principles from mixed-methods and qualitative health research, including transparent description of sampling, data sources, analysis, triangulation, and limitations.

2.2. Desk Review

A systematic desk review was undertaken to establish the policy, governance, technical, and implementation context for FHIR adoption in Sri Lanka. National policy and strategic documents reviewed included the National Digital Health Guidelines and Standards (NDHGS) Version 2.0 (2020) and the Sri Lanka Digital Health Blueprint (2023), both of which provide the strategic direction for national interoperability initiatives. Additional materials reviewed included technical reports, evaluation frameworks from national FHIR Connectathons conducted between 2023 and 2024, presentations from FHIR profiling workshops, organizational governance documents, human resource policies, data privacy frameworks, ICT infrastructure reports, budget documents, and other system-specific technical documentation.

Documents were eligible for inclusion if they described national digital health policy, interoperability standards, FHIR implementation, governance arrangements, health information system architecture, Connectathon testing, data protection, procurement, financing, workforce capacity, or implementation status relevant to Sri Lanka’s digital health ecosystem. Documents were excluded if they were superseded by more recent versions, were unrelated to health data exchange, or did not contain information relevant to interoperability governance, technical architecture, implementation, or maturity. For each document, the assessment team extracted information on document type, issuing institution, year of publication, relevance to FHIR adoption, implementation status, governance implications, technical artefacts described, and evidence of operational deployment.

Particular attention was given to the review of the two national FHIR Implementation Guides: the SL Core Implementation Guide and the National Electronic Health Record (NEHR) FHIR Implementation Guide. These documents were examined to assess their scope, technical completeness, alignment with international FHIR standards, and readiness for implementation. Reports and technical artifacts associated with the three national FHIR Connectathons were also analyzed to understand implementation progress, interoperability testing outcomes, and emerging technical challenges. Most technical documentation related to FHIR profiling and Connectathon activities was obtained through repositories maintained by the Ministry of Health and associated digital health programs.

2.3. Rapid Literature Review

In addition to the desk review, a rapid literature review was conducted to identify international examples of FHIR adoption, implementation best practices, and lessons learned from comparable health system contexts. The literature search was conducted using the PubMed database and focused on studies describing implemented FHIR use cases at national or regional levels. Eligible publications included studies that documented implementation experiences, technical architectures, outcomes, challenges, and best practices associated with FHIR adoption. The review was intended to provide a global benchmark against which Sri Lanka’s progress could be contextualized. The rapid literature review was designed to contextualize Sri Lanka’s experience against international FHIR implementation practice rather than to provide a comprehensive systematic review. Searches were conducted in PubMed using combinations of the terms “FHIR”, “HL7 FHIR”, “interoperability”, “implementation guide”, “national health information exchange”, “electronic health record”, “digital health architecture”, “conformance testing”, and “health information system interoperability”. Eligible sources included peer-reviewed articles and selected institutional reports describing national or regional FHIR implementation, governance, technical architecture, conformance testing, implementation barriers, or maturity assessment. Findings from the literature review were used to inform benchmarking domains and the interpretation of Sri Lanka’s maturity, but were not pooled quantitatively.

2.3. Key Informant Interviews

To complement documentary evidence and capture experiential knowledge not available in published sources, semi-structured key informant interviews were conducted with purposively selected stakeholders involved in digital health implementation, governance, and interoperability initiatives in Sri Lanka. Eighteen stakeholders were invited and interviewed. Participants were selected to ensure representation across multiple sectors and stakeholder groups relevant to FHIR adoption.

Interview participants included senior Ministry of Health officials responsible for policy and planning, information technology officers and system managers overseeing health information systems, health informaticians involved in FHIR profiling and implementation activities, members of the National Technical Working Group for Digital Health Interoperability and the National Electronic Health Record, electronic medical record (EMR) vendors operating within both curative and preventive healthcare settings, representatives from development partners supporting digital health initiatives, and private-sector healthcare providers and digital health implementers.

A semi-structured interview guide was developed to ensure consistency across interviews while allowing flexibility to explore context-specific experiences and perspectives. Interviews explored participants’ understanding of FHIR, current interoperability initiatives, implementation challenges, governance arrangements, workforce capacity, technical infrastructure, lessons learned from existing pilots, vendor incentives, legal and regulatory considerations, and perceived priorities for scaling adoption. Interviews were conducted in professional settings using a semi-structured format. Interview notes were anonymized before analysis and organized using a framework aligned with the study objectives: technical maturity, institutional readiness, implementation barriers, enabling factors, and strategic priorities. Qualitative data were coded using a hybrid deductive and inductive approach. Initial deductive categories were derived from the FHIR maturity and MEASURE interoperability maturity frameworks, while inductive codes captured emergent issues raised by stakeholders. Codes were subsequently grouped into technical, operational, and systemic themes. Disagreements in interpretation were resolved through discussion within the assessment team, and findings were triangulated with documentary evidence, survey responses, and technical review findings.

2.4. Stakeholder Survey and International Benchmarking

A stakeholder survey was conducted to assess perceptions of Sri Lanka’s FHIR maturity and to benchmark national progress against selected countries with established FHIR adoption initiatives. The benchmarking exercise was based on domains assessed in the 2025 HL7–Firely State of FHIR Survey, which evaluated national-level FHIR adoption across several countries, including the United States, Australia, Israel, and Singapore. [12] The comparator countries were selected because they represent relatively mature FHIR ecosystems with publicly visible implementation guides, governance arrangements, and production use cases.

The adapted benchmarking survey was used for descriptive comparison only. Because Sri Lanka was not part of the original HL7–Firely survey sample and because the local survey used purposive sampling of national stakeholders, scores were not treated as statistically comparable with the original international cohort. Benchmarking results were therefore interpreted qualitatively across domains such as governance, implementation-guide maturity, production deployment, vendor ecosystem, testing infrastructure, and community engagement.

The questionnaire was distributed electronically through Google Forms to all stakeholders who participated in the key informant interviews. Of the 18 stakeholders invited, 16 completed the survey, resulting in a response rate of 88.9%. Respondents represented diverse professional backgrounds, including health informatics specialists, EMR vendors, public health practitioners, healthcare administrators, and representatives from both public and private sectors. Participants possessed prior knowledge and experience related to digital health interoperability, with an average of 6.4 years of professional experience in digital health and interoperability-related fields.

2.5. Technical Review of FHIR Implementation Guides

A structured technical review was conducted for the two nationally endorsed FHIR Implementation Guides: the SL Core Implementation Guide and the NEHR FHIR Implementation Guide. The review examined profiled resources, extensions, value sets, code systems, cardinality constraints, terminology bindings, and conformance with HL7 FHIR guidance. Particular attention was given to the extent of localization, adherence to international profiling principles, incorporation of international terminologies, and alignment with global implementation guides such as the International Patient Summary (IPS). The review also assessed evidence generated through national FHIR Connectathons to determine the practical implementation maturity of profiled artifacts. Connectathon evaluation reports were analyzed to identify the degree of interoperability achieved between participating systems and to assess implementation readiness using established maturity criteria.

2.6. Interoperability Maturity Assessment

Interoperability maturity was assessed using two complementary frameworks that collectively evaluated both technical and organizational dimensions of interoperability.

First, the HL7 FHIR Maturity Model (FMM) was used to assess the maturity of national FHIR artifacts and implementation guides. The model evaluates the progression of FHIR resources and profiles through successive stages of maturity, ranging from draft status to normative standards, based on implementation evidence, interoperability testing, and production deployment. The FHIR Maturity Model was originally developed to assess the maturity of FHIR resources and artefacts based on implementation evidence and stability. In this assessment, FMM was applied pragmatically to national FHIR profiles and implementation guides to estimate their readiness for broader adoption. Because national implementation guides did not map perfectly onto the original FMM criteria, FMM findings were interpreted as indicative rather than definitive and were triangulated with Connectathon evidence, implementation status, and stakeholder feedback.

Second, the Health Information Systems Interoperability Maturity Toolkit developed by MEASURE Evaluation [13] was used to assess broader ecosystem readiness. This framework evaluates interoperability across three domains: Leadership and Governance, Human Resources, and Technology, each scored across multiple subdomains on a five-level scale ranging from nascent (Level 1) to optimized (Level 5).

Evidence collected through document review, interviews, and surveys was systematically mapped against the toolkit’s predefined maturity criteria. Maturity scores were assigned across multiple subdomains, including governance structures, interoperability policies, technical standards, workforce capacity, financial sustainability, enterprise architecture, data management, infrastructure, and system integration. Final maturity scores were determined through consensus-based review by the assessment team. Maturity scoring was conducted at the subdomain level before assigning overall domain scores. Subdomain scores reflected the highest level for which documentary or stakeholder evidence was available. Where evidence suggested partial achievement of the next level, a “+” notation was used to indicate transition toward the next maturity level; however, “+” scores were not treated as separate numerical categories in calculating overall maturity. Overall domain scores were assigned conservatively and reflected the lowest maturity level at which core functions were consistently present across the ecosystem, rather than isolated examples of higher performance. This conservative approach was used because national interoperability requires system-wide capability, not only high-performing subcomponents.

2.7. Data Triangulation and Analysis

Qualitative data from interviews and open-ended survey responses were analysed using thematic analysis, with codes organized into technical, operational, and systemic domains. Candidate barriers and recommendations derived from this analysis were subsequently validated through a structured stakeholder consensus exercise using the Nominal Group Technique. Participating health informaticians and EMR developers scored each item using Likert scales (1 = strongly disagree to 5 = strongly agree) and time-bound prioritization, and consensus was reached through facilitated discussion. Findings from the desk review, literature review, key informant interviews, stakeholder survey, technical review of implementation guides, and maturity assessments were then synthesized using a triangulation approach. This process enabled cross-validation of findings across data sources and facilitated identification of areas of convergence, divergence, and complementarity.

Triangulation was used to develop a comprehensive understanding of FHIR adoption in Sri Lanka, map implementation progress across public, private, and academic sectors, assess alignment with international standards and best practices, and identify barriers and enabling factors influencing adoption. The approach also enabled identification of sector-specific challenges and contextual nuances relevant to future capacity-building efforts, governance strengthening, and interoperability policy development. Through integrating multiple sources of evidence, the assessment aimed to provide a robust and holistic representation of Sri Lanka’s current interoperability landscape and readiness for scaling FHIR adoption nationwide.

2.8. Ethics

This assessment involved professional stakeholders participating in their institutional or technical capacities and did not involve patients, clinical intervention, personal health information, or patient-identifiable data. Participants were informed of the purpose of the assessment before interviews and surveys and provided informed consent for participation. Responses were anonymized during analysis and are reported in aggregate. The assessment was classified as a programmatic, non-clinical health-system assessment rather than human-subject clinical research; therefore, formal ethics committee review was not required under applicable national guidance. No individual-level patient or service-user data were accessed.

3. Results

3.1. Current Landscape of FHIR Adoption in Sri Lanka

Sri Lanka has formally adopted HL7 Fast Healthcare Interoperability Resources (FHIR) Release 4 (R4) as the national interoperability standard through the National Digital Health Guidelines and Standards (NDHGS) Version 2.0 and the Sri Lanka Digital Health Blueprint. These policy instruments position FHIR as the foundational standard for health information exchange across the public and private health sectors and establish interoperability as a core component of the country's digital health transformation agenda.

National governance for interoperability is coordinated through the National eHealth Steering Committee, the National Digital Health Technical Advisory Committee, and the Technical Working Group for Digital Health Interoperability and National Electronic Health Record (NEHR). Two national FHIR Implementation Guides have been developed and Published: the SL Core Implementation Guide and the National Electronic Health Record (NEHR) FHIR Implementation Guide, which is based on the International Patient Summary (IPS) framework.

Three national FHIR Connectathons conducted between 2023 and 2024 demonstrated successful FHIR-based data exchange between major public-sector electronic medical record (EMR) systems and the NEHR environment. Participating systems included HHIMS-ICTA, HHIMS-LRH, OpenMRS, OpenSRP, and CloudHIMS. Large volumes of FHIR bundles were exchanged during Connectathon testing; however, production-level message volumes were not independently verified, demonstrating the technical feasibility of interoperability using nationally defined profiles.

Several pilot implementations have further demonstrated practical use of FHIR. These include the Diabetic Compass project, which uses a FHIR-native OpenSRP mobile application to capture non-communicable disease screening data and exchange information with DHIS2-based analytics platforms, and prototype patient and clinician portals that retrieve longitudinal health records from the NEHR. Despite these achievements, the NEHR remains at proof-of-concept stage and has not yet transitioned to production-grade deployment. Similarly, the Digital Health Platform (DHP), envisioned as the national interoperability backbone, remains under development.

Public-sector adoption has progressed more rapidly than private-sector implementation. Several government-supported health information systems have demonstrated FHIR-enabled data exchange in connectathon settings, whereas private-sector adoption remains limited to exploratory pilots and isolated implementations.

3.2. Participant Characteristics

Of the 18 stakeholders invited, 16 completed the survey (response rate 88.9%). Respondents represented health informatics, EMR vendors, curative and preventive health services, and both public and private institutions, and reported an average of 6.4 years of professional experience in digital health. This distribution ensured that perceptions of national maturity reflected both implementation and governance perspectives across sectors.

3.3. Technical Maturity of FHIR Artefacts

The HL7 FHIR Maturity Model (FMM) was applied to systematically audit the real-world implementation depth of national profiles, specifically the localized “SL Core” and “LK NEHR” implementation guides. The assessment revealed that all national FHIR artefacts currently operate at FMM Level 1, indicating they are substantially complete and ready for implementation. Although national Connectathons successfully demonstrated data exchange across major electronic medical record (EMR) systems, no profile has been tested against the 80% core data element threshold required to achieve FMM Level 2. In the most advanced testing, profiles were exercised against approximately 37.5% of core data elements across four participating EMRs, falling short of the threshold for FMM Level 2 and indicating that demonstrated interoperability, while genuine, remains partial in scope. The FMM Level 1 rating should therefore be interpreted as evidence that national artefacts are substantially specified and have undergone early implementation testing, but not yet as evidence of broad ecosystem readiness. Progression to higher maturity levels will require repeated testing across a wider range of systems, clearer versioning and maintenance processes, validation against defined conformance criteria, and evidence of production use beyond Connectathon settings.

3.4. Institutional Readiness and Interoperability Maturity

Using the MEASURE Health Information Systems Interoperability Maturity Toolkit, overall interoperability maturity was scored at a nascent stage (Level 1) across all three primary domains: Leadership and Governance, Human Resources, and Technology.

Leadership and Governance: Subdomains such as governance structure for HIS and financial resource mobilization performed well (Level 3+), but compliance with standards, monitoring and evaluation, and business continuity remained nascent at Level 1.

Human Resources: There was strong evidence of capacity development (Level 3+), yet this was offset by a minimal foundational policy to support the workforce.

Technology: While national HIS enterprise architecture, operations and maintenance, communication networks and hardware are emerging (Level 2+), technical standards, data management, and HIS subsystem integration remain at Level 1. The full subdomain scoring is summarized in Table 1.

3.5. Operational, Systemic, and Institutional Barriers to FHIR Adoption

The absence of clear economic incentives emerged as the most frequently cited systemic barrier to widespread adoption. Stakeholder validation identified an unclear return on investment (ROI) for vendors, unsustainable donor-driven funding models, and public procurement processes that fail to mandate or financially reward FHIR compliance as critical constraints. Consequently, adoption is largely driven by government pilot programs rather than market demand. Operationally, the ecosystem is hindered by a critically small skilled workforce, emigration of trained personnel, and a lack of structured health data interoperability curricula or career pathways. Furthermore, governance structures lack an active, multi-stakeholder national FHIR working group that incorporates the private, academic, and vendor communities. As a result of these gaps, adoption is highly asymmetric; the public curative sector is substantially ahead of the private sector, preventive health, and research domains.

A total of twenty-one barriers to FHIR adoption were identified and validated through document review, stakeholder interviews, survey findings, and triangulation. These barriers were grouped into three major categories: technical, operational, and systemic challenges (Table 2).

3.6. Global Benchmarking and Engagement

When benchmarked against the United States, Australia, Israel, and Singapore, Sri Lanka had lower descriptive maturity across most benchmarking domains. This reflects the country's early stage of adoption, reliance on draft artefacts, limited production implementations, and the absence of a dedicated national governance structure. Comparator countries combined multiple published, versioned, and maintained implementation guides with large-scale production deployments, centralized governance (for example, through ONC and HL7 accelerators in the United States, ADHA in Australia, and MOH/IHiS in Singapore), mature vendor ecosystems, and national conformance-testing platforms. By contrast, Sri Lanka has two nationally published but still-draft implementation guides, predominantly pilot or proof-of-concept deployments, heterogeneous infrastructure, and no national sandbox for pre-integration testing. However, metrics on global engagement highlight emerging regional leadership; Sri Lanka provided the largest national cohort among 16 participating countries for the 2023 AeHIN HL7 FHIR Proficiency Training, contributed facilitators to international courses, and hosted the 2024 OpenHIE Community Meeting.

Table 3. Benchmarking Sri Lanka with comparator countries on major domains.

Benchmarking domain	Sri Lanka	Comparator countries	Interpretation
National FHIR policy	Present	Present	FHIR adoption is highlighted in the NDHGS and the Sri Lanka Digital Health Blueprint
Published national IGs	Present, draft/early maturity	Published, versioned, maintained	Sri Lanka needs an IG versioning and maintenance process
Production deployments	Limited/pilot	Multiple production deployments	Sri Lanka remains in the early stages
National sandbox/validator	Not yet established	Present in mature ecosystems	Critical infrastructure gap
Vendor certification	Not established	Present or emerging	Procurement and certification gap
Workforce ecosystem	Small expert pool	Larger professional ecosystem	Capacity and retention gap
International engagement	Strong regional engagement	Strong global engagement	Sri Lanka has leadership potential

Table 3. Benchmarking Sri Lanka with comparator countries on major domains.

Benchmarking domain	Sri Lanka	Comparator countries	Interpretation
National FHIR policy	Present	Present	FHIR adoption is highlighted in the NDHGS and the Sri Lanka Digital Health Blueprint
Published national IGs	Present, draft/early maturity	Published, versioned, maintained	Sri Lanka needs an IG versioning and maintenance process
Production deployments	Limited/pilot	Multiple production deployments	Sri Lanka remains in the early stages
National sandbox/validator	Not yet established	Present in mature ecosystems	Critical infrastructure gap
Vendor certification	Not established	Present or emerging	Procurement and certification gap
Workforce ecosystem	Small expert pool	Larger professional ecosystem	Capacity and retention gap
International engagement	Strong regional engagement	Strong global engagement	Sri Lanka has leadership potential

Because the adapted Sri Lanka survey was not administered as part of the original HL7–Firely international survey, benchmarking findings should be interpreted descriptively rather than statistically. The comparison indicates relative maturity across broad domains, not a direct ranking. Sri Lanka’s lower maturity reflects limited production deployment, early-stage implementation guides, absence of a national sandbox or validator, and limited vendor certification mechanisms, rather than lack of policy commitment or international engagement.

3.7. Strategic Priorities for Sustainable Scaling

To transition from nascent, pilot-driven initiatives to production-scale, ecosystem-wide interoperability, coordinated action is required across three mutually reinforcing pillars:

1. Participatory Governance: Transitioning from concentrated authority within the Ministry of Health to a multi-stakeholder governance model with distributed technical stewardship.

2. Technical Infrastructure: Establishing a robust developer ecosystem equipped with a national sandbox, validator, and developer tooling.

3. Workforce and Talent Retention: Creating sustained workforce capacity anchored in academic institutions, alongside competitive career pathways that incentivize talent to remain in the country.

Crucially, economic and public procurement incentives must be aligned to financially reward FHIR compliance beyond basic regulatory mandates. Finally, Sri Lanka is advised to actively engage with the Community of Interoperability Lab (COIL) and pursue formal HL7 Affiliate status to solidify its emerging role as a regional leader in digital health standards.

Building on stakeholder validation using the Nominal Group Technique, twenty-two specific recommendations were prioritized across short-term (6–12 months), medium-term (1–3 years), and long-term (3–5 years) horizons (Table 4). In the short term, priorities centred on establishing a national FHIR sandbox and interoperability laboratory, formalizing a National FHIR Technical Working Group, refining and versioning the national implementation guides, and launching structured training programs. Medium-term priorities included a centralized national terminology and validation service, vendor incentive and certification mechanisms, embedding FHIR compliance in procurement, and monitoring-and-evaluation dashboards. Long-term priorities emphasized regulatory mandates, integration of FHIR into academic curricula, legal and consent-framework reform, and sustainable domestic financing.

To operationalize participatory governance, a multi-tier national FHIR governance model was proposed. A National FHIR Technical Working Group would serve as the apex decision-making body chaired by the Ministry of Health and including the Ministry of Digital Economy, public and private providers, vendors, academia, and health-informatics experts responsible for national strategy, roadmap approval, ratification of implementation guides, and alignment with HL7/FHIR standards. Four specialized working groups would operationalize core functions: (i) Architecture and Standards; (ii) Terminology Governance; (iii) Implementation Guide and Compliance; and (iv) Security, Privacy and Policy. This structure would report through the existing national committees for digital health interoperability, the National Digital Health Technical Advisory Committee, and the National eHealth Steering Committee, ensuring accountability while distributing technical stewardship across sectors.

Sustaining adoption will also require an active community of practice. Recommended measures include national FHIR webinars, hands-on workshops and Connectathons, shared collaboration tooling (for example, FHIR Zulip channels, Confluence spaces, and GitHub repositories), formal participation in the HL7 FHIR Community Process to publish national IGs to the global registry, and continued engagement in HL7 Connectathons, DevDays, and regional interoperability forums.

4. Discussion

This study demonstrates that Sri Lanka has established a strong policy and governance foundation for FHIR adoption, positioning interoperability as a central component of its national digital health strategy. The development of national FHIR Implementation Guides, establishment of dedicated governance structures, and successful completion of multiple national Connectathons illustrate significant progress toward standards-based health information exchange. These achievements indicate that the technical feasibility of FHIR-enabled interoperability has been demonstrated across several public-sector health information systems.

Despite these advances, the findings reveal a substantial gap between policy commitment and ecosystem-wide implementation. While FHIR artefacts were assessed as substantially complete and ready for implementation, all national profiles remain at FMM Level 1, and overall interoperability maturity across governance, human resources, and technology domains remains nascent. This suggests that Sri Lanka's interoperability challenge is no longer primarily one of standards selection, but rather of operationalization, institutionalization, and scale. Importantly, the barriers identified were largely socio-technical rather than purely technological. Stakeholders consistently highlighted limited workforce capacity, dependence on a small pool of experts, insufficient incentives for vendors, donor-dependent financing, and the absence of robust compliance and monitoring mechanisms.

Global benchmarking further suggests that Sri Lanka is at an early but promising stage of FHIR adoption. Unlike countries such as the United States, Australia, Singapore, and Israel, where FHIR has matured through large-scale production deployments and institutionalized governance structures, Sri Lanka's implementation remains concentrated in pilot and proof-of-concept environments. Nevertheless, the country's active participation in regional and global interoperability initiatives, combined with its strong policy alignment with international standards, provides a solid platform for future advancement.

The pattern observed in Sri Lanka, which is a rapid policy adoption outpacing operational maturity, with economic incentives cited as the dominant barrier mirrors experiences reported across other low- and middle-income countries pursuing standards-based interoperability. This convergence suggests that the strategic priorities identified here, particularly participatory governance, national sandbox and validator infrastructure, balanced incentives, and sustained workforce development, are likely transferable to other member states of the WHO South-East Asia Region. Positioning these findings within a regional frame may help development partners and ministries of health avoid the common trap of treating interoperability as a one-time technical procurement rather than an enduring institutional capability.

Moving forward, achieving national-scale interoperability will require a shift from pilot-driven implementation toward sustained ecosystem development. Priorities include operationalizing national interoperability infrastructure, strengthening compliance and conformance mechanisms, expanding workforce development pathways, establishing multi-stakeholder governance arrangements, and embedding interoperability requirements within procurement and regulatory frameworks. Collectively, these actions will be essential for translating Sri Lanka's strong foundational investments into a sustainable and interoperable national digital health ecosystem.

Principal findings

This study found that Sri Lanka has established important foundations for standards-based interoperability, including formal policy endorsement of HL7 FHIR R4, national Implementation Guides, governance committees, Connectathon-based testing, and early pilot implementations. However, the assessment also shows a clear gap between policy adoption and ecosystem-wide operational maturity. National FHIR artefacts remain at an early maturity level, production implementation is limited, and broader interoperability readiness remains constrained across governance, workforce, technology, financing, procurement, and conformance-testing functions.

Interpretation

The central finding is that Sri Lanka’s interoperability challenge is no longer primarily the selection of a technical standard. Instead, the next phase requires institutional mechanisms that convert standards into routine practice. These include permanent standards governance, transparent Implementation Guide maintenance, national terminology services, developer sandboxes, conformance-testing infrastructure, vendor certification, procurement requirements, and sustained workforce pathways. The barriers identified in this study were therefore predominantly socio-technical rather than purely technical. This distinction is important because technical artefacts alone cannot create national interoperability unless they are embedded within financing, governance, regulatory, and operational systems.

Comparison with more mature FHIR ecosystems

Compared with more mature FHIR ecosystems, Sri Lanka has strong policy alignment and visible regional engagement but fewer production deployments, limited testing infrastructure, a smaller vendor and developer ecosystem, and less institutionalized conformance governance. This pattern is consistent with the experience of countries that have moved from early standard adoption to implementation at scale: progress depends not only on publishing implementation guides but also on maintaining them, testing them, requiring them in procurement, supporting vendors to implement them, and monitoring conformance over time.

Policy and implementation implications

The findings suggest that Sri Lanka’s immediate priority should be to establish the institutional and technical infrastructure required for implementation at scale. Short-term priorities include formalizing a multi-stakeholder National FHIR Technical Working Group, creating a national FHIR sandbox and validator, publishing versioned Implementation Guides, and expanding practical training. Medium-term priorities include terminology governance, vendor certification, procurement alignment, and interoperability monitoring indicators. Long-term priorities include sustainable domestic financing, legal and consent-framework clarification, and integration of interoperability competencies into academic and professional training pathways.

Regional relevance

Sri Lanka’s experience offers useful lessons for other low- and middle-income countries in the WHO South-East Asia Region that are adopting digital health standards. The findings suggest that national FHIR adoption should be treated as a long-term ecosystem-building process rather than a one-time technical procurement. Countries pursuing similar reforms may benefit from sequencing investments across governance, technical infrastructure, workforce development, procurement, and regulation, while also participating in regional communities of practice to share implementation guides, testing tools, and capacity-building resources.

4.1. Strengths and Limitations

This study has several strengths. It applied two complementary, internationally recognized maturity frameworks and triangulated evidence across desk review, technical review, interviews, and a benchmarked survey, with stakeholder validation of findings using a structured consensus method. To our knowledge, it is the first framework-based national FHIR maturity assessment in a South Asian LMIC, providing a reproducible baseline against which future progress can be measured.

Several limitations should be considered when interpreting the findings. First, the assessment relied on purposive sampling of stakeholders already engaged in digital health, which may overrepresent more digitally mature actors and underrepresent private-sector, provincial, and preventive-health perspectives. Second, the benchmarking survey had a modest sample size (n=16) and used an adapted instrument, limiting direct statistical comparison with the original State of FHIR Survey cohort. Third, self-reported maturity is subject to response bias, particularly where FHIR adoption may be conflated with broader NEHR or Connectathon participation. Fourth, production-level metrics such as message volumes, payload quality, and downstream clinical impact were not independently verified. Fifth, given the rapid evolution of national programs, the findings represent a point-in-time baseline that may not reflect subsequent developments. Sixth, the assessment focused primarily on stakeholders involved in digital health governance, standards development, and implementation; it did not systematically include frontline clinicians, patients, or service users who may experience interoperability gaps differently. Seventh, the study did not include independent technical validation of all systems against national profiles or live production testing; therefore, technical maturity findings should be interpreted as a baseline assessment rather than a certification of conformance. Eighth, because some respondents were directly involved in national FHIR activities, findings may be subject to optimism, role-based, or social desirability bias. Finally, the study did not assess implementation costs, cost-effectiveness, or clinical outcomes associated with FHIR-enabled exchange, which should be priorities for future research.

5. Conclusion

Sri Lanka has made meaningful early progress in adopting HL7 FHIR as a national interoperability standard, with policy endorsement, Implementation Guides, Connectathons, and pilot implementations demonstrating the feasibility of structured data exchange. However, national interoperability maturity remains at an early stage, constrained primarily by socio-technical rather than purely technical factors. The next phase requires a shift from standard adoption and proof-of-concept testing toward sustained ecosystem implementation. This will require participatory governance, national conformance-testing infrastructure, terminology services, workforce development, procurement alignment, sustainable financing, and regulatory clarity. Sri Lanka’s experience illustrates a broader lesson for LMICs: adopting FHIR is necessary but insufficient unless countries also build the institutions, incentives, and infrastructure required to make interoperability routine, testable, and sustainable.