My Experience Cracking the HL7 FHIR Certifications (R4 & Foundation)
Introduction
Gaining proficiency in Fast Healthcare Interoperability Resources (#FHIR) has been high on my list of professional goals ever since I joined Verily in April 2022. Though, aside from just learning it, I wanted a way to measure whether I actually understood the material. After a bit of browsing for FHIR resources (pun intended), I came across Health Level Seven International's certifications and saw that one existed for HL7 FHIR R4 Proficiency and knew that I'd sit for the exam at some point in the future. Further, HL7 introduced a new set of FHIR certifications in 2024, including a new 'Foundation' certification that replaces HL7 FHIR R4 Proficiency which will retire in December 2024. Of course, I also added that to my list of professional goals.
As of last month, I sat for and passed both exams and received the certifications. In this article, I want to describe my experience preparing for and taking the two exams.
Background
For a bit of context, my actual journey in learning FHIR began in 2018 when I was still at Mayo Clinic and deep in the weeds of optimizing our Health Level Seven International (#HL7) v2 interface messages sent by our labs to ensure semantic interoperability of discrete microbiology cultures to enable clinical decision support. Given my interests in healthcare interoperability, I kept seeing FHIR everywhere and was eventually sold on its potential during my 2019 - 2020 stint at the Assistant Secretary for Technology Policy (formerly the Office of the National Coordinator for Health IT or #ONC) when usage of FHIR R4 was embedded into regulations that fulfilled the 21st Century Cures Act. Six years later, I'm still quite bullish on FHIR and want to share as much as I can about it in hopes that others will join me in tackling global healthcare interoperability.
Btw, my final MPH capstone project at Johns Hopkins Bloomberg School of Public Health was about how the 21st Century Cures Act could reduce clinician burden within the electronic health record (EHR). This body of work established the foundation for a lot of my perspectives of how impactful FHIR can be in solving some of our most complex issues in healthcare and I linked it above for others who are interested in learning more.
Anyways, I digress so let's jump right into preparing for the FHIR certification exams.
Preparation
To give a big picture of how I prepared:
Initial prep (first few months in 2022) using official courses from HL7
Experience prep (2022 - 2024) primarily through my job
Certification prep (Feb 28, 2024 - May 1, 2024)
I'll expand on each of these below.
Initial prep (first few months in 2022)
Time is money and I strongly value solutions that can enable me to be more efficient with my time. Because of that, my preparation for these certifications began two years earlier through Health Level Seven International's formal training courses:
I took the fundamentals course first, followed by FHIR fundamentals next. Although I already had working experience with v2 and C-CDA, I figured the former would provide a more formal training pathway for me to get an introduction to FHIR, but also further strengthen my knowledge in the other two standards. Well, it did, and it also gave me the bonus of becoming much more confident with XML. The latter, was also excellent in that it provided an amazing introduction to FHIR, but additionally helped make a lot of the concepts click because it had hands on learning. Certainly, it helped me gain a lot more confidence in using integrated development environments (IDEs), working with JSON and application programming interfaces (#APIs). We used Postman quite a bit in the course as a FHIR client and interacted with public FHIR servers. To this day, Postman is still my go-to for learning and interacting with APIs in general.
From a preparation perspective, I'd strongly recommend HL7 FHIR Fundamentals to anyone interested in an introductory course to learning more about FHIR. However, a cautionary warning to those who don't come from a technical background since it assumes you have a baseline knowledge of XML and JSON along with some other computer science concepts. I had to do a lot of learning outside the classroom to supplement my gaps as I'm a pharmacist by training, but keep in mind I also had about 10 years of informatics experience at this point with knowledge of HL7 v2 and C-CDA standards. Not saying it's impossible or even challenging, just a warning that it can be frustrating. At least initially.
Experience prep (2022 - 2024)
The next set of preparation was simply via work experience. I started working on FHIR projects pretty quickly when I started at Verily. I won't go too much into detail here, but want to call out that the data modeling work really helped me better understand FHIR. I've worked with a quite a few resources since I first started that span financial (e.g. claim, coverage), clinical (e.g. observation, medication-related resources, ServiceRequest), terminologies (e.g. codesystem, valuesets), decision making (e.g. PlanDefinition, ActivityDefinition), amongst others that have given me a breadth of experience in how FHIR can be used.
I'd strongly encourage anyone that is preparing for these certifications, especially the new FHIR Foundation, to look for opportunities that allow hands-on, implementation work because it'll be an invaluable way to prepare for that exam. Conversely, if you're planning on taking FHIR R4 Proficiency, which will be retired in Dec 2024 and replaced by FHIR Foundation, I don't think experience is as beneficial. Granted, it helps, just not as much as simply memorizing the entire FHIR specification.
Certification prep (Feb 28, 2024 - May 1, 2024)
After two years of working with FHIR, I thought it was time to actually sit for the FHIR R4 Proficiency Exam. I split this out into its own section because there's a difference between learning the material vs. being assessed on the material. To expand on the latter, you don't only prepare by learning the material in more depth, but rather, you need how to take the exam itself. Things like the test format and strategies. This section will detail how I approached this and will hopefully be the most insightful in passing both FHIR R4 Proficiency and FHIR Foundation. I'll break this section into the following:
Comprehensive HL7 FHIR Proficiency Exam Preparation Course (no longer available as of 7/2024)
Review of each FHIR Resource
Quizlet flashcards
Exam checklist for both exams
Practice tests
Other resources
Comprehensive HL7 FHIR Proficiency Exam Preparation Course
Unfortunately, this is no longer available as the last class was offered June 13 - July 11, 2024. I imagine this is because it was targeted towards the FHIR R4 Proficiency Exam which will be retired in December 2024. I would guess that HL7 will release a new exam preparation course for FHIR Foundation once the exam is available to the public sometime later this month during the August 2024 WGM. Ironically, I thought this course was kind of average, if not slightly below average for the FHIR R4 Proficiency Exam, but was much more helpful for the FHIR Foundation exam as the livestreams provided very valuable knowledge in how to implement FHIR, which was more helpful to know for the Foundation exam and my day to day work.
Since this is no longer offered, there's not much folks can do. However, my main recommendation would be to take the new FHIR Foundation Exam Preparation Course when HL7 offers it (this isn't confirmed, it's just a guess).
Review of each FHIR Resource
This was an exercise suggested in the Comprehensive HL7 FHIR Proficiency Exam Preparation Course which, in my opinion, was overkill for FHIR R4, but strongly recommended for FHIR Foundation. This is also a lot easier for individuals who have domain expertise as the main goal is to create a mental model of how healthcare concepts map to FHIR resources. For example, if you're modeling vital signs, you'll probably need Observations. If you're modeling a patient's diagnosis, it's probably Conditions. It's usually quite straightforward, but it'll also depend on the use cases.
The way I prepared for this was to simply read every single FHIR resource. The course instructor suggested to only read the introduction and the Scope and Usage sections, which aren't too bad, but I just read the entire thing since I use this for work too. Thing is, I vastly underestimated how long that would take, but I certainly think it's well worth it if you're trying to also understand FHIR better. From a ROI perspective on the exam, I'd say it was probably a 6/10 as I think my time could have been spent elsewhere if the goal was to simply pass the exam. Otherwise, 8/10 overall ROI as I think it helped me grasp some of the concepts better. Especially the resources I've never used or used infrequently.
Btw, I live streamed this entire section over the course of 7 days in case you wanted to see how I did this.
Quizlet Flashcards
Don't quote me on this, but I believe I've read in a few places that research supports recall as the best method of internalizing information. From experience, I agree. Simply reading something won't help you learn the material. You must find a way to assess your knowledge - quizzes and exams are the best in my opinion. Because of that, I created Quizlet flashcards for every resource in how they were used from doing the 7 days of live streams, but also captured a bunch of sections that they reviewed in the course that I thought would be helpful to quiz myself on. I'll expand on it in the next section, but most of those things were just the topics within the checklist for the exam.
For anyone studying, I'd strongly recommend some way of assessing your understanding be it through Quizlet (not sponsored) or some other tool. I thought it was extremely valuable in making sure I had a firm understanding of the concepts to pass the exam.
Exam checklist for both exams
If you want to pass the exam, you must read the checklist. It not only covers the topics that will be covered on the exam, but the test format and suggested resources. Below are links to the official checklists for both exams:
You can read through both of these yourself, and again, I strongly suggest this as a must read as I view it as a pre-req for passing the exam. The only additional things I'll add to both from my experience:
For FHIR R4 Proficiency Exam: There is no such thing as enough reading. The best preparation here is probably just reading the entire FHIR spec over and over again. Obviously using the study guide to help you prioritize, but the exam will ask extremely nitpicky questions that is pure memorization. You either know it or you don't.
For FHIR Foundation Exam: Heed the recommendations mentioned in the study guide: 6-months experience using FHIR, understanding of basic concepts of XML/JSON, and understanding basic concepts of RESTful APIs. If you don't feel comfortable about these topics, you won't pass. Be sure you do before taking the exam!
Practice tests
Underpinning my comments above about assessing your knowledge, I'm a huge fan of practice tests. Especially ones that are offered via the organization that administers the exam. For me, I used the 2-hour practice exam that came with the now retired Comprehensive HL7 FHIR Proficiency Exam Preparation Course. It was quite helpful - especially since the questions were not easy. The mini assessments in the course and the practice exam really helped me understand what the questions would look like and the level of complexity they would be. In lieu of that course, HL7 offers a very short, practice exam for $20, which, was pretty much a subset of the one offered in the Comprehensive HL7 FHIR Proficiency Exam Preparation Course and a waste of money if you took that already. However, since it's no longer offered, I'd strongly encourage taking their practice exam for $20. It helps with recall.
Other resources
I write this article standing on the shoulders of giants. There have been many before me that have written about their experiences taking the FHIR R4 Proficiency Exam and I want to highlight some of the key resources I also used in supplementing my initial interest and preparation for the proficiency exam.
HL7 FHIR R4 Certification: A guide to self-study path by Janaka Peiris
Pointers to crack "HL7 R4 FHIR Proficiency Exam" by Surabhi G.
FHIR Profiency Certification at Firely DevDays 2020 by Virginia Lorenzi
Thanks for being trailblazers in this space and providing some insight into how others can also follow in your footsteps.
Taking the exam
In this section, I'll describe my experience taking both exams to give an idea of what it may be like. Note that HL7 prohibits discussing the contents of the test with others, so I'm keeping this section intentionally ambiguous when it comes to content. Review the official study checklists from HL7 if you want to learn more about the content.
FHIR R4 Proficiency Exam
If you didn't already read the study guide, this is taken directly from it:
Total questions: 50
Question format: multiple choice, multi-select, and true/false
Duration: 2 hours
Passing: 70% (35 / 50 questions)
My experience taking the exam wasn't the most pleasant. I had prepared a fresh cup of coffee and wasn't allowed to drink it during my examination. In fact, the live proctor paused my exam to ask me to remove the cup of coffee from my desk and also had me scan around the room to check to see for anything else that should not be around me during the exam. Nothing was, but I really wanted my cup of coffee since the exam was 8 AM in the morning and I love my coffee.
In any case, I finished the exam pretty quickly (~1 hour), but didn't feel very good about the exam since there were so many questions that I had to guess on. It was quite apparent the exam is a proficiency Exam in that you had to do pure memorization of the FHIR specification. Given how large the spec is, I thought the exam was a bit too nitpicky on what they wanted candidates to memorize, and more importantly, a poor assessment/tool of FHIR knowledge. Even if it was a proficiency exam. Although I dislike the exam, I don't think it's a terrible idea to take it as part of your prep for the FHIR Foundation exam.
As for my result, I barely passed as I scored a 70% (35/50). I did well on the terminology sections (100%), which I'd expect for individuals with domain expertise, and quite poorly on other sections like FHIR Licensing (0%) and APIs (57%).
FHIR Foundation Pilot Exam
My experience taking the foundation exam pilot was much better. I thought the exam did an amazing job of assessing ones FHIR knowledge as I felt it was much more practical and applicable to actual FHIR work. I really enjoyed the exam experience. Similar to above, if you haven't already read the exam checklist, a few call outs:
Total questions: 125
Question format: multiple choice
Duration: 3.5 hours
Passing: 60% (75 / 125 questions)
As opposed to the FHIR R4 Proficiency Exam, you really had to have a bit more experience working with FHIR to really do well on this exam. I won't go into the details obviously, but having a firm grasp of the concepts in their checklist will go a long way - especially their recommendation section.
As for my result, I did a lot better here and received a 82%. I can't recall if I spent the entire time on the exam (I don't think I did), but I believe I spent the majority of the time on it - probably 3 hours. I employed my typical test strategy of skipping questions that I didn't know until the very end so I didn't waste time anywhere and could cover as many questions as possible to ensure I could score the most points on questions I was confident on. It worked well, but I also had a decent amount of questions I skipped at the end (~15-20) that I spent a solid 1+ hour on re-reviewing at the end. Below is a more high level breakdown of how I scored:
Reflection
As I mentioned earlier, I am quite bullish on FHIR and think it will be a key in tackling some of healthcares most complex issues. Not just in interoperability either. There is so much hype around artificial intelligence (#AI) currently, but think about how those AI models are trained: high-quality data. Especially for those large language model (#LLM)-based foundation models that are used for inference in any use case. You need heterogenous data from many different EHR systems to enable that and I think FHIR is one of the key ingredients to solving that aspect. In short, to enable robust foundation models in healthcare, we likely will need FHIR to solve the data aggregation aspect across disparate information systems in healthcare.
In any case, I'm excited to be part of the inaugural cohort of individuals certified in HL7 FHIR Foundation. Fun fact, based on a 2024 presentation from Firely DevDays, 107 individuals took the pilot exam in April 2024 and 72 individuals ended up passing resulting in a 67% pass rate.
If you're interested in learning more about FHIR, or healthcare informatics concepts in general, be sure to check out my personal contributions to the community via: OpenClinTech where I post a lot of free and accessible resources, usually in the form of YouTube videos to empower others interested in solving healthcare interoperability. To learn more about me or my projects, you can check out my personal website at https://www.briankfung.com/.
Best of luck on your FHIR journeys!