Bulk FHIR Works. The Challenge Is Implementation.

If you've worked in federal healthcare IT, you've probably heard some version of this statement: "Bulk FHIR doesn't scale."

It's an understandable reaction. Large data exports can consume significant infrastructure resources, processing times can be long, and moving healthcare data at enterprise scale is never simple. But after supporting Bulk FHIR implementations across federal healthcare environments, our teams have found that the standard itself is rarely the problem.

More often, the challenge is implementation.

To better understand why, we spoke with three members of Element's healthcare interoperability team, FHIR Software Engineers Alex Dzeda, Parwinder Bhagat, and Mike Esposito. While their perspectives reflect their own experience, they also represent lessons our broader team has learned while designing, developing, and supporting Bulk FHIR solutions that securely exchange healthcare data at scale.

Compliance Isn't the Same as Optimization

Bulk FHIR has become a cornerstone of healthcare interoperability. It supports the secure, standardized exchange of large clinical and claims datasets across providers, payers, researchers, and government agencies. For organizations advancing healthcare modernization, it's an essential capability that supports analytics, care coordination, quality reporting, population health, and emerging AI-enabled solutions.

Yet many organizations still associate Bulk FHIR with slow exports and expensive infrastructure.

According to Alex, that's often because implementations stop at compliance.

"Bulk FHIR works. You just need to support Version 2."

It's a simple statement, but it highlights an important reality. Many certified EHR systems still primarily support the original Bulk FHIR implementation guide. While Version 1 introduced incremental exports through the optional _since parameter, support has been inconsistent across vendors.

The result is familiar to many healthcare organizations. Instead of retrieving only new or updated records, systems repeatedly export years of historical data. Processing requirements increase, infrastructure costs grow, and performance suffers. Eventually, the standard gets blamed for problems that stem from incomplete implementation rather than limitations of the technology itself.

Small Changes Can Have a Big Impact

Newer implementation guides introduce capabilities like _since, making incremental exports more consistent and efficient.

For organizations managing large healthcare environments, that improvement isn't just technical. It can reduce unnecessary data movement, lower infrastructure costs, improve processing times, and deliver more timely information to downstream systems.

Modernization doesn't always require replacing existing technology. Sometimes it simply means taking fuller advantage of capabilities that already exist.

What We've Learned from Real-World Implementations

Across Element, our healthcare interoperability teams have spent years designing, developing, and supporting Bulk FHIR solutions that process data for millions of patients. Working in production environments has reinforced a simple philosophy: interoperability should remove barriers, not create them.

As Mike explains,

"Our jobs basically come down to getting providers patient data at scale and with as little friction as possible. Bulk FHIR is how we do it."

Achieving that goal requires more than implementing an API. It requires thoughtful architecture that performs reliably under real-world conditions.

One example is using asynchronous, stream-oriented exports with NDJSON to minimize overhead while processing massive datasets. As Parwinder explains,

"It allows our customers to handle large datasets without breaking."

Organizations using these capabilities rely on large-scale healthcare data to identify gaps in care, monitor quality measures, support value-based care initiatives, perform population health analytics, and improve operational decision making. Experiences like these continue to reinforce what our teams see every day: Bulk FHIR is fully capable of operating at scale when implemented thoughtfully.

Bulk FHIR and Subscriptions Work Better Together

Another topic that frequently comes up in interoperability discussions is whether FHIR Subscriptions will eventually replace Bulk FHIR.

From our perspective, that's the wrong question.

Bulk FHIR and Subscriptions solve different problems. Bulk FHIR remains the most effective approach for moving large historical datasets and supporting population-level analytics. Subscriptions enable event-driven workflows by notifying systems when new information becomes available.

Modern healthcare systems increasingly need both capabilities. Together, they provide a foundation for efficient large-scale data exchange while enabling near real-time awareness of clinically important events.

The Goal Has Always Been Better Access to Data

Technical conversations about FHIR often begin with APIs, implementation guides, and certification requirements. They rarely end there because interoperability is ultimately about people.

For Parwinder, the long-term vision is "standardized and secure data portability, near real-time health insights, and eliminating system lock-in."

Mike frames the goal from the perspective of

the people using the technology every day.

"Anyone who needs access to a Medicare patient's data, and has permission to access it, should be able to with very little effort or frustration."

Those ideas reflect the broader mission that drives our healthcare interoperability work. Success isn't simply measured by passing certification or deploying another API. It's measured by reducing friction for providers, improving access to information, supporting better care decisions, and making it easier for healthcare organizations to exchange data securely and efficiently.

Bulk FHIR remains one of the industry's strongest tools for achieving those goals. As implementation guides continue to evolve, the greatest opportunity isn't replacing the standard. It's implementing it the way it was designed to be used and helping healthcare organizations realize its full potential.