diff --git a/packages/subscriptions-nextjs/.eslintrc.cjs b/packages/subscriptions-nextjs/.eslintrc.cjs
new file mode 100644
index 00000000..bc73447a
--- /dev/null
+++ b/packages/subscriptions-nextjs/.eslintrc.cjs
@@ -0,0 +1,14 @@
+/**
+ * @type {import("eslint").Linter.Config}
+ */
+module.exports = {
+  extends: "@bonfhir/eslint-config",
+  overrides: [
+    {
+      files: ["**/{.*,*.config}.{cjs,js,mjs,ts}"],
+      env: {
+        node: true,
+      },
+    },
+  ],
+};
diff --git a/packages/subscriptions-nextjs/.prettierignore b/packages/subscriptions-nextjs/.prettierignore
new file mode 100644
index 00000000..849ddff3
--- /dev/null
+++ b/packages/subscriptions-nextjs/.prettierignore
@@ -0,0 +1 @@
+dist/
diff --git a/packages/subscriptions-nextjs/CHANGELOG.md b/packages/subscriptions-nextjs/CHANGELOG.md
new file mode 100644
index 00000000..e4d87c4d
--- /dev/null
+++ b/packages/subscriptions-nextjs/CHANGELOG.md
@@ -0,0 +1,4 @@
+# Change Log
+
+All notable changes to this project will be documented in this file.
+See [Conventional Commits](https://conventionalcommits.org) for commit guidelines.
diff --git a/packages/subscriptions-nextjs/README.md b/packages/subscriptions-nextjs/README.md
new file mode 100644
index 00000000..27687bf0
--- /dev/null
+++ b/packages/subscriptions-nextjs/README.md
@@ -0,0 +1,3 @@
+# Bonfhir Subscriptions NextJS Adapter
+
+See https://bonfhir.dev/packages/integrations/subscriptions-nextjs for more information.
diff --git a/packages/subscriptions-nextjs/package.js b/packages/subscriptions-nextjs/package.js
new file mode 100644
index 00000000..7209a9ea
--- /dev/null
+++ b/packages/subscriptions-nextjs/package.js
@@ -0,0 +1,99 @@
+/**
+ * This script is a helper to create the final NPM package.
+ */
+
+import { existsSync } from "fs";
+import {
+  copyFile,
+  readdir,
+  readFile,
+  rename,
+  unlink,
+  writeFile,
+} from "fs/promises";
+import { exec } from "node:child_process";
+import { promisify } from "node:util";
+import { dirname, join } from "path";
+import { fileURLToPath } from "url";
+
+const execAsync = promisify(exec);
+
+(async () => {
+  const rootPackageDirectory = dirname(fileURLToPath(import.meta.url));
+  const distDirectory = join(rootPackageDirectory, "dist");
+
+  // Copy package.json while stripping unwanted information
+  const packageJson = JSON.parse(
+    await readFile(join(rootPackageDirectory, "package.json"), "utf8")
+  );
+  delete packageJson.scripts;
+  delete packageJson.packageManager;
+  delete packageJson.devDependencies;
+  delete packageJson.prettier;
+
+  packageJson.exports = {};
+  for (const packageRootDirName of (
+    await readdir(distDirectory, { withFileTypes: true })
+  )
+    .filter((dirent) => dirent.isDirectory())
+    .map((dirent) => dirent.name)) {
+    packageJson.exports[`./${packageRootDirName}`] = {
+      types: `./${packageRootDirName}/index.d.ts`,
+      require: `./${packageRootDirName}/index.cjs`,
+      import: `./${packageRootDirName}/index.js`,
+      default: `./${packageRootDirName}/index.js`,
+    };
+  }
+
+  await writeFile(
+    join(distDirectory, "package.json"),
+    JSON.stringify(packageJson),
+    "utf8"
+  );
+
+  // Copy README.md
+  await copyFile(
+    join(rootPackageDirectory, "README.md"),
+    join(distDirectory, "README.md")
+  );
+
+  // Copy CHANGELOG.md
+  await copyFile(
+    join(rootPackageDirectory, "CHANGELOG.md"),
+    join(distDirectory, "CHANGELOG.md")
+  );
+
+  // Delete TypeScript build info
+  try {
+    await unlink(join(distDirectory, "tsconfig.build.tsbuildinfo"));
+  } catch {
+    // Ignore the error if the file does not exists.
+  }
+
+  // eslint-disable-next-line no-undef
+  const npmCommand = process.argv[2] || "pack";
+  // eslint-disable-next-line no-undef
+  const npmCommandOptions = process.argv.slice(3).join(" ");
+
+  // Run npm in the dist directory
+  const result = await execAsync(`npm ${npmCommand} ${npmCommandOptions}`, {
+    cwd: distDirectory,
+    maxBuffer: 1024 * 1000 * 10,
+  });
+
+  // eslint-disable-next-line no-undef
+  console.log(result.stdout);
+  // eslint-disable-next-line no-undef
+  console.error(result.stderr);
+
+  // Copy the package back to root if was produced
+  const packageFilename = `${packageJson.name
+    .replace("@", "")
+    .replace("/", "-")}-${packageJson.version}.tgz`;
+  if (existsSync(join(distDirectory, packageFilename))) {
+    await rename(
+      join(distDirectory, packageFilename),
+      join(rootPackageDirectory, packageFilename)
+    );
+  }
+})();
diff --git a/packages/subscriptions-nextjs/package.json b/packages/subscriptions-nextjs/package.json
new file mode 100644
index 00000000..6e2a3777
--- /dev/null
+++ b/packages/subscriptions-nextjs/package.json
@@ -0,0 +1,39 @@
+{
+  "name": "@bonfhir/subscriptions-nextjs",
+  "description": "NextJS adapter for bonfhir subscriptions.",
+  "version": "0.1.0",
+  "repository": "https://github.com/bonfhir/bonfhir.git",
+  "license": "APACHE-2.0",
+  "type": "module",
+  "scripts": {
+    "build": "yarn clean && tsup r4b/index.ts --format esm,cjs --out-dir dist/r4b --shims --dts --tsconfig tsconfig.build.json",
+    "check": "prettier --check ./**/*.ts && eslint ./**/*.ts && tsc --noEmit",
+    "clean": "rimraf dist/",
+    "format": "prettier --loglevel warn --write ./**/*.ts && eslint --fix ./**/*.ts",
+    "package:create": "yarn build && node package.js pack",
+    "package:publish": "yarn build && node package.js publish"
+  },
+  "packageManager": "yarn@3.3.1",
+  "devDependencies": {
+    "@bonfhir/codegen": "^1.0.0-alpha.5",
+    "@bonfhir/eslint-config": "^1.1.0-alpha.1",
+    "@bonfhir/prettier-config": "^1.0.1-alpha.1",
+    "@bonfhir/typescript-config": "^1.0.1-alpha.2",
+    "@types/fhir": "^0.0.35",
+    "@types/node": "^18.15.3",
+    "@types/react": "^18.0.15",
+    "@types/react-dom": "^18.0.6",
+    "eslint": "^8.36.0",
+    "jest": "^29.5.0",
+    "prettier": "^2.8.4",
+    "rimraf": "^4.4.0",
+    "tsup": "^6.7.0",
+    "typescript": "^5.0.3"
+  },
+  "dependencies": {
+    "@bonfhir/core": "^1.0.0-alpha.16",
+    "@bonfhir/subscriptions": "^0.1.0-alpha.7",
+    "next": "latest"
+  },
+  "prettier": "@bonfhir/prettier-config"
+}
diff --git a/packages/subscriptions-nextjs/r4b/index.ts b/packages/subscriptions-nextjs/r4b/index.ts
new file mode 100644
index 00000000..758c3c68
--- /dev/null
+++ b/packages/subscriptions-nextjs/r4b/index.ts
@@ -0,0 +1 @@
+export * from "./middleware";
diff --git a/packages/subscriptions-nextjs/r4b/middleware.ts b/packages/subscriptions-nextjs/r4b/middleware.ts
new file mode 100644
index 00000000..06ff8a77
--- /dev/null
+++ b/packages/subscriptions-nextjs/r4b/middleware.ts
@@ -0,0 +1,187 @@
+import { FhirRestfulClient } from "@bonfhir/core/r4b";
+import {
+  AuditEventConfiguration,
+  createErrorAuditEvent,
+  errorToString,
+  FhirSubscription,
+  registerSubscriptions,
+  SubscriptionLogger,
+} from "@bonfhir/subscriptions/r4b";
+
+import { Subscription } from "fhir/r4";
+import { NextRequest, NextResponse } from "next/server";
+
+export interface FhirSubscriptionsConfig {
+  /**
+   * The {@link FhirRestfulClient} to use to register subscriptions.
+   * If this is a function, it is invoked prior to every handler invocation as well.
+   */
+  fhirClient:
+    | FhirRestfulClient
+    | (() => FhirRestfulClient | Promise<FhirRestfulClient>);
+
+  /** The subscriptions handlers to register. */
+  // eslint-disable-next-line @typescript-eslint/no-explicit-any
+  subscriptions: FhirSubscription<any>[];
+
+  /** The API base URL */
+  baseUrl: string | URL | null | undefined;
+
+  /**
+   * Indicates how to register the subscriptions:
+   *  - during startup
+   *  - when a specific endpoint is invoked
+   *  - or disable registration
+   */
+  register: "startup" | "endpoint" | "off";
+
+  /**
+   * The registration endpoint to use. Defaults to /fhir/register-subscriptions.
+   */
+  registerEndpoint?: string | null | undefined;
+
+  /**
+   * The name of the security header used. Defaults to "X-Subscription-Auth"
+   */
+  securityHeader?: string | null | undefined;
+
+  /** A secret shared between the API and the FHIR subscription use to secure the endpoint. */
+  webhookSecret: string;
+
+  /** The subscription payload, a.k.a. MIME type. Defaults to application/fhir+json */
+  payload?: Subscription["channel"]["payload"] | null | undefined;
+
+  /** Logger to use. Defaults to console. */
+  logger?: SubscriptionLogger | null | undefined;
+
+  /**
+   * If set, will automatically create AuditEvent using this as a source / reference.
+   * Alternatively, you can build the AuditEvents yourself.
+   */
+  // eslint-disable-next-line @typescript-eslint/no-explicit-any
+  auditEvent?: AuditEventConfiguration | null | undefined;
+}
+
+/**
+ * Register subscriptions and routes to webhooks handlers.
+ */
+export async function fhirSubscriptions(
+  config: FhirSubscriptionsConfig
+): Promise<(request: NextRequest) => Promise<NextResponse>> {
+  const logger = config.logger ?? console;
+
+  const fhirClient =
+    typeof config.fhirClient === "function"
+      ? await config.fhirClient()
+      : config.fhirClient;
+
+  if (config.register === "startup") {
+    await registerSubscriptions({
+      baseUrl: config.baseUrl,
+      fhirClient,
+      logger,
+      subscriptions: config.subscriptions,
+      webhookSecret: config.webhookSecret,
+      securityHeader: config.securityHeader,
+      auditEvent: config.auditEvent,
+      payload: config.payload,
+    });
+  }
+
+  const securityHeader = config.securityHeader || "X-Subscription-Auth";
+
+  function verifySecurityHeader(request: NextRequest): boolean {
+    return (
+      request.headers.has(securityHeader) &&
+      request.headers.get(securityHeader) === config.webhookSecret
+    );
+  }
+
+  async function fhirMiddleware(request: NextRequest): Promise<NextResponse> {
+    if (config.register === "endpoint") {
+      if (!verifySecurityHeader(request)) {
+        logger?.warn(`Received unauthorized request for ${request.url}.`);
+        return new NextResponse(null, {
+          status: 401,
+        });
+      }
+      if (
+        request.method === "POST" &&
+        request.nextUrl.pathname ===
+          (config.registerEndpoint || "/fhir/register-subscriptions")
+      ) {
+        try {
+          await registerSubscriptions({
+            baseUrl: config.baseUrl,
+            fhirClient,
+            logger,
+            subscriptions: config.subscriptions,
+            webhookSecret: config.webhookSecret,
+            auditEvent: config.auditEvent,
+            payload: config.payload,
+          });
+          return new NextResponse(null, { status: 204 });
+        } catch (error) {
+          return new NextResponse(`Error: ${error}`, { status: 500 });
+        }
+      }
+    }
+
+    const subscription = config.subscriptions.find(
+      (sub) => `${sub.endpoint}` === request.nextUrl.pathname
+    );
+
+    if (subscription) {
+      if (!verifySecurityHeader(request)) {
+        logger?.warn(`Received unauthorized request for ${request.url}.`);
+        return new NextResponse(null, {
+          status: 401,
+        });
+      }
+
+      // eslint-disable-next-line @typescript-eslint/no-explicit-any
+      const resource = await request.json();
+      try {
+        const result = await subscription.handler({
+          fhirClient:
+            typeof config.fhirClient === "function"
+              ? await config.fhirClient()
+              : config.fhirClient,
+          resource,
+          logger,
+        });
+
+        if (result == null) {
+          return new NextResponse(null, {
+            status: 204,
+          });
+        } else {
+          return new NextResponse(JSON.stringify(result), {
+            status: 200,
+          });
+        }
+      } catch (error) {
+        logger.error(error);
+        if (config.auditEvent) {
+          try {
+            await createErrorAuditEvent({
+              auditEvent: config.auditEvent,
+              error,
+              fhirClient,
+              relatedResource: resource,
+            });
+          } catch (auditEventError) {
+            logger.error(auditEventError);
+          }
+        }
+        return new NextResponse(errorToString(error), {
+          status: 500,
+        });
+      }
+    }
+
+    return NextResponse.next();
+  }
+
+  return fhirMiddleware;
+}
diff --git a/packages/subscriptions-nextjs/tsconfig.build.json b/packages/subscriptions-nextjs/tsconfig.build.json
new file mode 100644
index 00000000..480c70ff
--- /dev/null
+++ b/packages/subscriptions-nextjs/tsconfig.build.json
@@ -0,0 +1,8 @@
+{
+  "extends": "./tsconfig.json",
+  "exclude": ["**/*.test.ts", "**/__fixtures__"],
+  "compilerOptions": {
+    "incremental": false,
+    "outDir": "dist"
+  }
+}
diff --git a/packages/subscriptions-nextjs/tsconfig.json b/packages/subscriptions-nextjs/tsconfig.json
new file mode 100644
index 00000000..76f85f11
--- /dev/null
+++ b/packages/subscriptions-nextjs/tsconfig.json
@@ -0,0 +1,7 @@
+{
+  "extends": "@bonfhir/typescript-config/tsconfig.json",
+  "include": ["**/*.ts"],
+  "compilerOptions": {
+    "rootDir": "."
+  }
+}
diff --git a/samples/sample-api-nextjs/.eslintrc.cjs b/samples/sample-api-nextjs/.eslintrc.cjs
new file mode 100644
index 00000000..de604f66
--- /dev/null
+++ b/samples/sample-api-nextjs/.eslintrc.cjs
@@ -0,0 +1,14 @@
+/**
+ * @type {import("eslint").Linter.Config}
+ */
+module.exports = {
+  extends: "@bonfhir/eslint-config",
+  overrides: [
+    {
+      files: ["**/{.*,*.config}.{cjs,js,mjs,ts,tsx}"],
+      env: {
+        node: true,
+      },
+    },
+  ],
+};
diff --git a/samples/sample-api-nextjs/.gitignore b/samples/sample-api-nextjs/.gitignore
new file mode 100644
index 00000000..8f322f0d
--- /dev/null
+++ b/samples/sample-api-nextjs/.gitignore
@@ -0,0 +1,35 @@
+# See https://help.github.com/articles/ignoring-files/ for more about ignoring files.
+
+# dependencies
+/node_modules
+/.pnp
+.pnp.js
+
+# testing
+/coverage
+
+# next.js
+/.next/
+/out/
+
+# production
+/build
+
+# misc
+.DS_Store
+*.pem
+
+# debug
+npm-debug.log*
+yarn-debug.log*
+yarn-error.log*
+
+# local env files
+.env*.local
+
+# vercel
+.vercel
+
+# typescript
+*.tsbuildinfo
+next-env.d.ts
diff --git a/samples/sample-api-nextjs/.prettierignore b/samples/sample-api-nextjs/.prettierignore
new file mode 100644
index 00000000..849ddff3
--- /dev/null
+++ b/samples/sample-api-nextjs/.prettierignore
@@ -0,0 +1 @@
+dist/
diff --git a/samples/sample-api-nextjs/middleware.ts b/samples/sample-api-nextjs/middleware.ts
new file mode 100644
index 00000000..2a33774f
--- /dev/null
+++ b/samples/sample-api-nextjs/middleware.ts
@@ -0,0 +1,41 @@
+import { NextRequest } from "next/server";
+
+import { fhirSubscriptions } from "@bonfhir/subscriptions-nextjs/r4b";
+import { MedplumClient } from "@medplum/core";
+
+import { buildFhirRestfulClientAdapter } from "@bonfhir/medplum/r4b";
+import { communicationRequests } from "./requests/communication-requests";
+
+// Limit the middleware to paths starting with `/fhir/`
+export const config = {
+  matcher: ["/fhir/:function*"],
+};
+
+const initializeSubscriptionMiddleware = async () =>
+  fhirSubscriptions({
+    baseUrl: process.env.BASE_URL || "http://devcontainer:3001",
+    fhirClient: async () => {
+      const medplum = new MedplumClient({
+        baseUrl: process.env.MEDPLUM_SERVER_URL!,
+        fetch: fetch,
+      });
+
+      await medplum.startClientLogin(
+        process.env.MEDPLUM_CLIENT_ID!,
+        process.env.MEDPLUM_CLIENT_SECRET!
+      );
+
+      return buildFhirRestfulClientAdapter(medplum);
+    },
+    register: "startup",
+    subscriptions: [communicationRequests],
+    webhookSecret: "thewebhooksecret",
+    auditEvent: "Sample API",
+  });
+
+const subscriptionMiddleware = initializeSubscriptionMiddleware();
+
+export async function middleware(request: NextRequest) {
+  const subs = await subscriptionMiddleware;
+  return subs(request);
+}
diff --git a/samples/sample-api-nextjs/package.json b/samples/sample-api-nextjs/package.json
new file mode 100644
index 00000000..c66bf9e7
--- /dev/null
+++ b/samples/sample-api-nextjs/package.json
@@ -0,0 +1,41 @@
+{
+  "name": "@bonfhir/sample-api-nextjs",
+  "description": "Bonfhir Sample api",
+  "version": "0.1.0-alpha.1",
+  "private": true,
+  "repository": "https://github.com/bonfhir/bonfhir.git",
+  "license": "APACHE-2.0",
+  "scripts": {
+    "dev": "next -p 4000",
+    "build": "next build",
+    "start": "next start"
+  },
+  "dependencies": {
+    "@bonfhir/core": "^1.0.0-alpha.8",
+    "@bonfhir/medplum": "^1.0.0-alpha.9",
+    "@bonfhir/subscriptions": "^0.1.0-alpha.2",
+    "@bonfhir/subscriptions-nextjs": "0.1.0",
+    "@medplum/core": "2.0.14",
+    "next": "latest",
+    "react": "^18.2.0",
+    "react-dom": "^18.2.0",
+    "swr": "^2.0.0"
+  },
+  "devDependencies": {
+    "@bonfhir/eslint-config": "^1.1.0-alpha.0",
+    "@bonfhir/prettier-config": "^1.0.0",
+    "@bonfhir/typescript-config": "^1.0.1-alpha.0",
+    "@swc/core": "^1.3.41",
+    "@swc/jest": "^0.2.24",
+    "@types/fhir": "^0.0.35",
+    "@types/node": "^18.0.3",
+    "@types/react": "^18.0.15",
+    "@types/react-dom": "^18.0.6",
+    "prettier": "^2.8.4",
+    "rimraf": "^4.4.0",
+    "ts-node": "^10.9.1",
+    "typescript": "^5.0.3"
+  },
+  "packageManager": "yarn@3.3.1",
+  "prettier": "@bonfhir/prettier-config"
+}
diff --git a/samples/sample-api-nextjs/pages/index.tsx b/samples/sample-api-nextjs/pages/index.tsx
new file mode 100644
index 00000000..4972e2f9
--- /dev/null
+++ b/samples/sample-api-nextjs/pages/index.tsx
@@ -0,0 +1,3 @@
+export default function Index() {
+  return <h1>Sample NextJS API for Bonfhir</h1>;
+}
diff --git a/samples/sample-api-nextjs/requests/communication-requests.ts b/samples/sample-api-nextjs/requests/communication-requests.ts
new file mode 100644
index 00000000..c45672f2
--- /dev/null
+++ b/samples/sample-api-nextjs/requests/communication-requests.ts
@@ -0,0 +1,11 @@
+import { FhirSubscription } from "@bonfhir/subscriptions/r4b";
+import { CommunicationRequest } from "fhir/r4";
+
+export const communicationRequests: FhirSubscription<CommunicationRequest> = {
+  criteria: "CommunicationRequest",
+  reason: "Send communication requests",
+  endpoint: "/fhir/communication-requests",
+  async handler({ resource, logger }) {
+    logger?.info(resource);
+  },
+};
diff --git a/samples/sample-api-nextjs/tsconfig.json b/samples/sample-api-nextjs/tsconfig.json
new file mode 100644
index 00000000..85e3f0f4
--- /dev/null
+++ b/samples/sample-api-nextjs/tsconfig.json
@@ -0,0 +1,24 @@
+{
+  "extends": "@bonfhir/typescript-config/tsconfig.json",
+  "compilerOptions": {
+    "rootDir": ".",
+    "lib": [
+      "dom",
+      "dom.iterable",
+      "esnext"
+    ],
+    "allowJs": true,
+    "noEmit": true,
+    "module": "esnext",
+    "isolatedModules": true,
+    "jsx": "preserve"
+  },
+  "include": [
+    "next-env.d.ts",
+    "**/*.ts",
+    "**/*.tsx"
+  ],
+  "exclude": [
+    "node_modules"
+  ]
+}
diff --git a/yarn.lock b/yarn.lock
index b7021bbf..24624e3e 100644
--- a/yarn.lock
+++ b/yarn.lock
@@ -2298,6 +2298,35 @@ __metadata:
   languageName: unknown
   linkType: soft
 
+"@bonfhir/sample-api-nextjs@workspace:samples/sample-api-nextjs":
+  version: 0.0.0-use.local
+  resolution: "@bonfhir/sample-api-nextjs@workspace:samples/sample-api-nextjs"
+  dependencies:
+    "@bonfhir/core": ^1.0.0-alpha.8
+    "@bonfhir/eslint-config": ^1.1.0-alpha.0
+    "@bonfhir/medplum": ^1.0.0-alpha.9
+    "@bonfhir/prettier-config": ^1.0.0
+    "@bonfhir/subscriptions": ^0.1.0-alpha.2
+    "@bonfhir/subscriptions-nextjs": 0.1.0
+    "@bonfhir/typescript-config": ^1.0.1-alpha.0
+    "@medplum/core": 2.0.14
+    "@swc/core": ^1.3.41
+    "@swc/jest": ^0.2.24
+    "@types/fhir": ^0.0.35
+    "@types/node": ^18.0.3
+    "@types/react": ^18.0.15
+    "@types/react-dom": ^18.0.6
+    next: latest
+    prettier: ^2.8.4
+    react: ^18.2.0
+    react-dom: ^18.2.0
+    rimraf: ^4.4.0
+    swr: ^2.0.0
+    ts-node: ^10.9.1
+    typescript: ^5.0.3
+  languageName: unknown
+  linkType: soft
+
 "@bonfhir/subscriptions-koa@^0.1.0-alpha.1, @bonfhir/subscriptions-koa@workspace:packages/subscriptions-koa":
   version: 0.0.0-use.local
   resolution: "@bonfhir/subscriptions-koa@workspace:packages/subscriptions-koa"
@@ -2326,6 +2355,30 @@ __metadata:
   languageName: unknown
   linkType: soft
 
+"@bonfhir/subscriptions-nextjs@0.1.0, @bonfhir/subscriptions-nextjs@workspace:packages/subscriptions-nextjs":
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