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As most terminologies are not natively distributed using FHIR resources, converters are needed. Large-scale FHIR projects, especially those with a national or even an international scope, define enormous numbers of value sets and reference many large and complex code systems, which must be regularly updated in TS and other systems. This necessitates a flexible, scalable and efficient provision of these artifacts. This work aims to develop a comprehensive, extensible and accessible toolkit for FHIR terminology conversion, making it possible for terminology authors, FHIR profilers and other actors to provide standardized TS for large-scale terminological artifacts.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Implementation<\/jats:title>\n                    <jats:p>\n                      Based on the prevalent HL7 FHIR Shorthand (FSH) specification, a converter toolkit, called\n                      <jats:italic>BabelFSH<\/jats:italic>\n                      , was created that utilizes an adaptable plugin architecture to separate the definition of content from that of the needed declarative metadata. The development process was guided by formalized design goals.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>All eight design goals were addressed by BabelFSH. Validation of the systems\u2019 performance and completeness was exemplarily demonstrated using Alpha-ID-SE, an important terminology used for diagnosis coding especially of rare diseases within Germany. The tool is now used extensively within the content delivery pipeline for a central FHIR TS with a national scope within the German Medical Informatics Initiative and Network University Medicine and demonstrates adequate usability for FHIR developers.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>The first development focus was geared towards the requirements of the central research FHIR TS for the federated FHIR infrastructure in Germany, and has proven to be very useful towards that goal. Opportunities for further improvement were identified in the validation process especially, as the validation messages are currently imprecise at times. The design of the application lends itself to the implementation of further use cases, such as direct connectivity to legacy systems for catalog conversion to FHIR.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>\n                      The developed\n                      <jats:italic>BabelFSH<\/jats:italic>\n                      tool is a novel, powerful and open-source approach to making heterogenous sources of terminological knowledge accessible as FHIR resources, thus aiding semantic interoperability in healthcare in general.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s13326-025-00343-4","type":"journal-article","created":{"date-parts":[[2025,11,29]],"date-time":"2025-11-29T20:25:43Z","timestamp":1764447943000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["BabelFSH\u2014a toolkit for an effective HL7 FHIR-based terminology provision"],"prefix":"10.1186","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9902-6459","authenticated-orcid":false,"given":"Joshua","family":"Wiedekopf","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9775-0657","authenticated-orcid":false,"given":"Tessa","family":"Ohlsen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6685-4429","authenticated-orcid":false,"given":"Ann-Kristin","family":"Kock-Schoppenhauer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3274-8422","authenticated-orcid":false,"given":"Josef","family":"Ingenerf","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,11,29]]},"reference":[{"key":"343_CR1","first-page":"p312","volume":"Stat, 114\u2013255","author":"US Public Law","year":"2016","unstructured":"US Public Law. 21st Century Cures Act. 130 Stat 1033. 2016;Stat, 114\u2013255:p312.","journal-title":"130 Stat 1033"},{"key":"343_CR2","doi-asserted-by":"publisher","first-page":"13","DOI":"10.1016\/j.annemergmed.2021.08.002","volume":"79","author":"M Vijayaraghavan","year":"2022","unstructured":"Vijayaraghavan M, Genes N, Darrow BJ, Rucker DW. 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No personally identifiable data from the usability study is archived.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"As part of the Medical Informatics Initiative, all authors are responsible for the provision and development of FHIR-based terminological services to the MII across Germany, and have substantial experience in working with medical terminologies and FHIR terminological services. They are active in the development of the FHIR standard and national adaptations through HL7 Germany, and in the working groups of the German Association for Medical Informatics, Biometry and Epidemiology (GMDS).","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Authors\u2019 information"}},{"value":"The authors declare no competing interests.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"19"}}