FHIR Server Performance Benchmark Released: Comparative Analysis of Four Major Types

Details

Health Samurai released an open-source FHIR server performance benchmark on June 29, 2026. This benchmark compares four major FHIR servers—Aidbox, HAPI FHIR, Medplum, and Microsoft FHIR Server—on identical hardware. Key metrics evaluated include CRUD workload (requests per second), search throughput across various data families (string, date, etc.), and storage footprint using a 1,000-patient Synthea load. The analysis revealed significant performance disparities among the servers. For instance, while Aidbox led in overall CRUD processing, Medplum showed strong performance in searching, indicating specialized strengths. Furthermore, the storage footprint varied by over 5x, which is attributed primarily to differing indexing strategies (write-time vs. default). Crucially, the benchmark emphasizes reproducibility: the harness and configurations are fully open source. The system also runs daily automated tests, allowing for rapid detection of regressions following vendor updates. This report serves as a technical resource for selecting FHIR servers, providing critical data points for large-scale system design planning.