Real World Performance of the 21st Century Cures Act Population Level Application Programming Interface

OBJECTIVE. To evaluate the real-world performance in delivering patient data on populations, of the SMART/HL7 Bulk FHIR Access API, required in Electronic Health Records (EHRs) under the 21st Century Cures Act Rule. MATERIALS AND METHODS. We used an open-source Bulk FHIR Testing Suite at five healthcare sites from April to September 2023, including four hospitals using EHRs certified for interoperability, and one Health Information Exchange (HIE) using a custom, standards-compliant API build. We measured export speeds, data sizes, and completeness across six types of FHIR resources. RESULTS. Among the certified platforms, Oracle Cerner led in speed, managing 5–16 million resources at over 8,000 resources/min. Three Epic sites exported a FHIR data subset, achieving 1–12 million resources at 1,555–2,500 resources/min. Notably, the HIE’s custom API outperformed, generating over 141 million resources at 12,000 resources/min. DISCUSSION. The HIE’s custom API showcased superior performance, endorsing the effectiveness of SMART/HL7 Bulk FHIR in enabling large-scale data exchange while underlining the need for optimization in existing EHR platforms. Agility and scalability are essential for diverse health, research, and public health use cases. CONCLUSION. To fully realize the interoperability goals of the 21st Century Cures Act, addressing the performance limitations of Bulk FHIR API is critical. It would be beneficial to include performance metrics in both certification and reporting processes.