EHR development in the FHIR era favors specific strategies. Seven that ship in 2026.
1. FHIR-native storage from day one. Skip proprietary + facade duplication.
**2. SMART on FHIR for all auth.**
3. Reference implementations first. Use LHC-Forms, Inferno, etc.
4. Declarative over imperative. StructureMap, ConceptMap.
5. Conformance testing in CI.
6. Terminology as subsystem.
7. Metrics from day one.
Investment sequence
1. Foundation (server + terminology + auth). 2. Core resources. 3. Integration surface. 4. Conformance testing. 5. Production hardening.
Common complexity accumulators to avoid
1. Custom internal + FHIR facade. 2. Custom auth vs. SMART. 3. Custom form renderer. 4. Manual conformance. 5. Terminology in code. 6. No metrics. 7. Bulk data as afterthought.
Team composition
1. Technical lead. 2. FHIR engineers (3-5). 3. DevOps (1-2). 4. Terminology admin (0.5). 5. Clinical informaticist (1).
Success signals
1. Inferno passing. 2. $validate pass rate >97%. 3. Reference integrity >99%. 4. Bulk export operational. 5. Auth end-to-end.
Timeline
1. 6 months: foundation. 2. 12 months: core + integration. 3. 18 months: CMS-0057. 4. 24+ months: full Da Vinci.
EHR development strategies in FHIR era are well-understood. Sites adopting the seven above ship 30-50% faster.
