diff --git a/engine/src/androidTest/java/com/google/android/fhir/db/impl/DatabaseImplTest.kt b/engine/src/androidTest/java/com/google/android/fhir/db/impl/DatabaseImplTest.kt
index a5338bef1d..2e6055fd82 100644
--- a/engine/src/androidTest/java/com/google/android/fhir/db/impl/DatabaseImplTest.kt
+++ b/engine/src/androidTest/java/com/google/android/fhir/db/impl/DatabaseImplTest.kt
@@ -39,6 +39,7 @@ import com.google.android.fhir.search.getQuery
 import com.google.android.fhir.search.has
 import com.google.android.fhir.search.include
 import com.google.android.fhir.search.revInclude
+import com.google.android.fhir.sync.upload.LocalChangesFetchMode
 import com.google.android.fhir.testing.assertJsonArrayEqualsIgnoringOrder
 import com.google.android.fhir.testing.assertResourceEquals
 import com.google.android.fhir.testing.readFromFile
@@ -90,9 +91,9 @@ import org.junit.runners.Parameterized.Parameters
  * Integration tests for [DatabaseImpl]. There are written as integration tests as officially
  * recommend because:
  * * Different versions of android are shipped with different versions of SQLite. Integration tests
- * allow for better coverage on them.
+ *   allow for better coverage on them.
  * * Robolectric's SQLite implementation does not match Android, e.g.:
- * https://github.com/robolectric/robolectric/blob/master/shadows/framework/src/main/java/org/robolectric/shadows/ShadowSQLiteConnection.java#L97
+ *   https://github.com/robolectric/robolectric/blob/master/shadows/framework/src/main/java/org/robolectric/shadows/ShadowSQLiteConnection.java#L97
  */
 @MediumTest
 @RunWith(Parameterized::class)
@@ -267,7 +268,7 @@ class DatabaseImplTest {
       }
     assertThat(resourceNotFoundException.message)
       .isEqualTo(
-        "Resource not found with type ${TEST_PATIENT_1.resourceType.name} and id $TEST_PATIENT_1_ID!"
+        "Resource not found with type ${TEST_PATIENT_1.resourceType.name} and id $TEST_PATIENT_1_ID!",
       )
     assertThat(database.getLocalChanges(ResourceType.Patient, TEST_PATIENT_1_ID)).isEmpty()
   }
@@ -280,7 +281,7 @@ class DatabaseImplTest {
       }
     assertThat(resourceIllegalStateException.message)
       .isEqualTo(
-        "Resource with type ${TEST_PATIENT_1.resourceType.name} and id $TEST_PATIENT_1_ID has local changes, either sync with server or FORCE_PURGE required"
+        "Resource with type ${TEST_PATIENT_1.resourceType.name} and id $TEST_PATIENT_1_ID has local changes, either sync with server or FORCE_PURGE required",
       )
   }
 
@@ -326,7 +327,7 @@ class DatabaseImplTest {
       }
     assertThat(resourceNotFoundException.message)
       .isEqualTo(
-        "Resource not found with type ${TEST_PATIENT_1.resourceType.name} and id $TEST_PATIENT_2_ID!"
+        "Resource not found with type ${TEST_PATIENT_1.resourceType.name} and id $TEST_PATIENT_2_ID!",
       )
   }
 
@@ -336,12 +337,10 @@ class DatabaseImplTest {
       assertThrows(ResourceNotFoundException::class.java) {
         runBlocking { database.update(TEST_PATIENT_2) }
       }
-    /* ktlint-disable max-line-length */
     assertThat(resourceNotFoundException.message)
       .isEqualTo(
-        "Resource not found with type ${TEST_PATIENT_2.resourceType.name} and id $TEST_PATIENT_2_ID!"
-        /* ktlint-enable max-line-length */
-        )
+        "Resource not found with type ${TEST_PATIENT_2.resourceType.name} and id $TEST_PATIENT_2_ID!",
+      )
   }
 
   @Test
@@ -383,7 +382,7 @@ class DatabaseImplTest {
           HumanName().apply {
             family = "FamilyName"
             addGiven("FirstName")
-          }
+          },
         )
         meta =
           Meta().apply {
@@ -401,7 +400,7 @@ class DatabaseImplTest {
           HumanName().apply {
             family = "UpdatedFamilyName"
             addGiven("UpdatedFirstName")
-          }
+          },
         )
       }
     database.update(updatedPatient)
@@ -438,7 +437,7 @@ class DatabaseImplTest {
         database
           .getAllLocalChanges()
           .map { it }
-          .none { it.type == LocalChange.Type.DELETE && it.resourceId == "nonexistent_patient" }
+          .none { it.type == LocalChange.Type.DELETE && it.resourceId == "nonexistent_patient" },
       )
       .isTrue()
   }
@@ -512,7 +511,9 @@ class DatabaseImplTest {
         lastUpdated = Date()
       }
     database.insert(patient)
-    services.fhirEngine.syncUpload { it ->
+    // Delete the patient created in setup as we only want to upload the patient in this test
+    database.deleteUpdates(listOf(TEST_PATIENT_1))
+    services.fhirEngine.syncUpload(LocalChangesFetchMode.AllChanges) {
       it
         .first { it.resourceId == "remote-patient-3" }
         .let {
@@ -521,7 +522,7 @@ class DatabaseImplTest {
               Patient().apply {
                 id = it.resourceId
                 meta = remoteMeta
-              }
+              },
           )
         }
     }
@@ -538,7 +539,7 @@ class DatabaseImplTest {
         database
           .getAllLocalChanges()
           .map { it }
-          .none { it.resourceId in listOf(patient.logicalId, TEST_PATIENT_2_ID) }
+          .none { it.resourceId in listOf(patient.logicalId, TEST_PATIENT_2_ID) },
       )
       .isTrue()
   }
@@ -552,14 +553,14 @@ class DatabaseImplTest {
           HumanName().apply {
             addGiven("Jane")
             family = "Doe"
-          }
+          },
         )
       }
 
     database.insert(patient)
     val result =
       database.search<Patient>(
-        Search(ResourceType.Patient).apply { filter(Patient.GIVEN, { value = "Jane" }) }.getQuery()
+        Search(ResourceType.Patient).apply { filter(Patient.GIVEN, { value = "Jane" }) }.getQuery(),
       )
     assertThat(result.size).isEqualTo(1)
 
@@ -570,14 +571,14 @@ class DatabaseImplTest {
           HumanName().apply {
             addGiven("John")
             family = "Doe"
-          }
+          },
         )
       }
 
     database.insert(updatedPatient)
     val updatedResult =
       database.search<Patient>(
-        Search(ResourceType.Patient).apply { filter(Patient.GIVEN, { value = "Jane" }) }.getQuery()
+        Search(ResourceType.Patient).apply { filter(Patient.GIVEN, { value = "Jane" }) }.getQuery(),
       )
     assertThat(updatedResult.size).isEqualTo(0)
   }
@@ -591,14 +592,14 @@ class DatabaseImplTest {
           HumanName().apply {
             addGiven("Jane")
             family = "Doe"
-          }
+          },
         )
       }
 
     database.insertRemote(patient)
     val result =
       database.search<Patient>(
-        Search(ResourceType.Patient).apply { filter(Patient.GIVEN, { value = "Jane" }) }.getQuery()
+        Search(ResourceType.Patient).apply { filter(Patient.GIVEN, { value = "Jane" }) }.getQuery(),
       )
     assertThat(result.size).isEqualTo(1)
 
@@ -609,14 +610,14 @@ class DatabaseImplTest {
           HumanName().apply {
             addGiven("John")
             family = "Doe"
-          }
+          },
         )
       }
 
     database.insertRemote(updatedPatient)
     val updatedResult =
       database.search<Patient>(
-        Search(ResourceType.Patient).apply { filter(Patient.GIVEN, { value = "Jane" }) }.getQuery()
+        Search(ResourceType.Patient).apply { filter(Patient.GIVEN, { value = "Jane" }) }.getQuery(),
       )
     assertThat(updatedResult.size).isEqualTo(0)
   }
@@ -648,14 +649,14 @@ class DatabaseImplTest {
           HumanName().apply {
             addGiven("Jane")
             family = "Doe"
-          }
+          },
         )
       }
 
     database.insertRemote(patient)
     val result =
       database.search<Patient>(
-        Search(ResourceType.Patient).apply { filter(Patient.GIVEN, { value = "Jane" }) }.getQuery()
+        Search(ResourceType.Patient).apply { filter(Patient.GIVEN, { value = "Jane" }) }.getQuery(),
       )
     assertThat(result.size).isEqualTo(1)
 
@@ -666,14 +667,14 @@ class DatabaseImplTest {
           HumanName().apply {
             addGiven("John")
             family = "Doe"
-          }
+          },
         )
       }
 
     database.update(updatedPatient)
     val updatedResult =
       database.search<Patient>(
-        Search(ResourceType.Patient).apply { filter(Patient.GIVEN, { value = "Jane" }) }.getQuery()
+        Search(ResourceType.Patient).apply { filter(Patient.GIVEN, { value = "Jane" }) }.getQuery(),
       )
     assertThat(updatedResult.size).isEqualTo(0)
   }
@@ -694,20 +695,37 @@ class DatabaseImplTest {
     }
   }
 
+  @Test
+  fun getLocalChangesCount_noLocalChange_returnsZero() = runBlocking {
+    database.deleteUpdates(listOf(TEST_PATIENT_1))
+    assertThat(database.getLocalChangesCount()).isEqualTo(0)
+  }
+
+  @Test
+  fun getLocalChangesCount_oneLocalChange_returnsOne() = runBlocking {
+    assertThat(database.getLocalChangesCount()).isEqualTo(1)
+  }
+
+  @Test
+  fun getLocalChangesCount_twoLocalChange_returnsTwo() = runBlocking {
+    database.insert(TEST_PATIENT_2)
+    assertThat(database.getLocalChangesCount()).isEqualTo(2)
+  }
+
   @Test
   fun search_sortDescending_twoVeryCloseFloatingPointNumbers_orderedCorrectly() = runBlocking {
     val smallerId = "risk_assessment_1"
     val largerId = "risk_assessment_2"
     database.insert(
       riskAssessment(id = smallerId, probability = BigDecimal("0.3")),
-      riskAssessment(id = largerId, probability = BigDecimal("0.30000000001"))
+      riskAssessment(id = largerId, probability = BigDecimal("0.30000000001")),
     )
 
     val results =
       database.search<RiskAssessment>(
         Search(ResourceType.RiskAssessment)
           .apply { sort(RiskAssessment.PROBABILITY, Order.DESCENDING) }
-          .getQuery()
+          .getQuery(),
       )
 
     val ids = results.map { it.id }
@@ -723,7 +741,7 @@ class DatabaseImplTest {
         listOf(
           RiskAssessment.RiskAssessmentPredictionComponent().apply {
             setProbability(DecimalType(probability))
-          }
+          },
         )
     }
 
@@ -737,7 +755,7 @@ class DatabaseImplTest {
     database.insert(patient)
     val result =
       database.search<Patient>(
-        Search(ResourceType.Patient).apply { filter(Patient.GIVEN, { value = "eve" }) }.getQuery()
+        Search(ResourceType.Patient).apply { filter(Patient.GIVEN, { value = "eve" }) }.getQuery(),
       )
 
     assertThat(result.single().id).isEqualTo("Patient/${patient.id}")
@@ -753,7 +771,7 @@ class DatabaseImplTest {
     database.insert(patient)
     val result =
       database.search<Patient>(
-        Search(ResourceType.Patient).apply { filter(Patient.GIVEN, { value = "eve" }) }.getQuery()
+        Search(ResourceType.Patient).apply { filter(Patient.GIVEN, { value = "eve" }) }.getQuery(),
       )
 
     assertThat(result).isEmpty()
@@ -776,10 +794,10 @@ class DatabaseImplTest {
               {
                 value = "Eve"
                 modifier = StringFilterModifier.MATCHES_EXACTLY
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result.single().id).isEqualTo("Patient/${patient.id}")
@@ -802,10 +820,10 @@ class DatabaseImplTest {
               {
                 value = "Eve"
                 modifier = StringFilterModifier.MATCHES_EXACTLY
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result).isEmpty()
@@ -829,10 +847,10 @@ class DatabaseImplTest {
               {
                 value = "Eve"
                 modifier = StringFilterModifier.CONTAINS
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result.single().id).isEqualTo("Patient/${patient.id}")
@@ -855,10 +873,10 @@ class DatabaseImplTest {
               {
                 value = "eve"
                 modifier = StringFilterModifier.CONTAINS
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result).isEmpty()
@@ -870,7 +888,7 @@ class DatabaseImplTest {
       RiskAssessment().apply {
         id = "1"
         addPrediction(
-          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.5))
+          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.5)),
         )
       }
 
@@ -884,10 +902,10 @@ class DatabaseImplTest {
               {
                 prefix = ParamPrefixEnum.EQUAL
                 value = BigDecimal("100")
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result.single().id).isEqualTo("RiskAssessment/${riskAssessment.id}")
@@ -899,7 +917,7 @@ class DatabaseImplTest {
       RiskAssessment().apply {
         id = "1"
         addPrediction(
-          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(100.5))
+          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(100.5)),
         )
       }
 
@@ -913,10 +931,10 @@ class DatabaseImplTest {
               {
                 prefix = ParamPrefixEnum.EQUAL
                 value = BigDecimal("100")
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result).isEmpty()
@@ -928,7 +946,7 @@ class DatabaseImplTest {
       RiskAssessment().apply {
         id = "1"
         addPrediction(
-          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.0))
+          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.0)),
         )
       }
 
@@ -942,10 +960,10 @@ class DatabaseImplTest {
               {
                 prefix = ParamPrefixEnum.NOT_EQUAL
                 value = BigDecimal("100")
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("RiskAssessment/${riskAssessment.id}")
   }
@@ -956,7 +974,7 @@ class DatabaseImplTest {
       RiskAssessment().apply {
         id = "1"
         addPrediction(
-          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.5))
+          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.5)),
         )
       }
 
@@ -970,10 +988,10 @@ class DatabaseImplTest {
               {
                 prefix = ParamPrefixEnum.NOT_EQUAL
                 value = BigDecimal("100")
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result).isEmpty()
@@ -985,7 +1003,7 @@ class DatabaseImplTest {
       RiskAssessment().apply {
         id = "1"
         addPrediction(
-          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(100))
+          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(100)),
         )
       }
 
@@ -999,10 +1017,10 @@ class DatabaseImplTest {
               {
                 prefix = ParamPrefixEnum.GREATERTHAN
                 value = BigDecimal("99.5")
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result.single().id).isEqualTo("RiskAssessment/${riskAssessment.id}")
@@ -1014,7 +1032,7 @@ class DatabaseImplTest {
       RiskAssessment().apply {
         id = "1"
         addPrediction(
-          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.5))
+          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.5)),
         )
       }
 
@@ -1028,10 +1046,10 @@ class DatabaseImplTest {
               {
                 prefix = ParamPrefixEnum.GREATERTHAN
                 value = BigDecimal("99.5")
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result).isEmpty()
@@ -1043,7 +1061,7 @@ class DatabaseImplTest {
       RiskAssessment().apply {
         id = "1"
         addPrediction(
-          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.5))
+          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.5)),
         )
       }
 
@@ -1057,10 +1075,10 @@ class DatabaseImplTest {
               {
                 prefix = ParamPrefixEnum.GREATERTHAN_OR_EQUALS
                 value = BigDecimal("99.5")
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result.single().id).isEqualTo("RiskAssessment/${riskAssessment.id}")
@@ -1072,7 +1090,7 @@ class DatabaseImplTest {
       RiskAssessment().apply {
         id = "1"
         addPrediction(
-          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.0))
+          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.0)),
         )
       }
 
@@ -1086,10 +1104,10 @@ class DatabaseImplTest {
               {
                 prefix = ParamPrefixEnum.GREATERTHAN_OR_EQUALS
                 value = BigDecimal("99.5")
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result).isEmpty()
@@ -1101,7 +1119,7 @@ class DatabaseImplTest {
       RiskAssessment().apply {
         id = "1"
         addPrediction(
-          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.0))
+          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.0)),
         )
       }
 
@@ -1115,10 +1133,10 @@ class DatabaseImplTest {
               {
                 prefix = ParamPrefixEnum.LESSTHAN
                 value = BigDecimal("99.5")
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result.single().id).isEqualTo("RiskAssessment/${riskAssessment.id}")
@@ -1130,7 +1148,7 @@ class DatabaseImplTest {
       RiskAssessment().apply {
         id = "1"
         addPrediction(
-          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.5))
+          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.5)),
         )
       }
 
@@ -1144,10 +1162,10 @@ class DatabaseImplTest {
               {
                 prefix = ParamPrefixEnum.LESSTHAN
                 value = BigDecimal("99.5")
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result).isEmpty()
@@ -1159,7 +1177,7 @@ class DatabaseImplTest {
       RiskAssessment().apply {
         id = "1"
         addPrediction(
-          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.5))
+          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.5)),
         )
       }
 
@@ -1173,10 +1191,10 @@ class DatabaseImplTest {
               {
                 prefix = ParamPrefixEnum.LESSTHAN_OR_EQUALS
                 value = BigDecimal("99.5")
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("RiskAssessment/${riskAssessment.id}")
   }
@@ -1187,7 +1205,7 @@ class DatabaseImplTest {
       RiskAssessment().apply {
         id = "1"
         addPrediction(
-          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(100))
+          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(100)),
         )
       }
 
@@ -1201,10 +1219,10 @@ class DatabaseImplTest {
               {
                 prefix = ParamPrefixEnum.LESSTHAN_OR_EQUALS
                 value = BigDecimal("99.5")
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result).isEmpty()
@@ -1216,7 +1234,7 @@ class DatabaseImplTest {
       RiskAssessment().apply {
         id = "1"
         addPrediction(
-          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.0))
+          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.0)),
         )
       }
 
@@ -1230,10 +1248,10 @@ class DatabaseImplTest {
               {
                 prefix = ParamPrefixEnum.ENDS_BEFORE
                 value = BigDecimal("99.5")
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result.single().id).isEqualTo("RiskAssessment/${riskAssessment.id}")
@@ -1245,7 +1263,7 @@ class DatabaseImplTest {
       RiskAssessment().apply {
         id = "1"
         addPrediction(
-          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.5))
+          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.5)),
         )
       }
 
@@ -1259,10 +1277,10 @@ class DatabaseImplTest {
               {
                 prefix = ParamPrefixEnum.ENDS_BEFORE
                 value = BigDecimal("99.5")
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result).isEmpty()
@@ -1274,7 +1292,7 @@ class DatabaseImplTest {
       RiskAssessment().apply {
         id = "1"
         addPrediction(
-          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(100))
+          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(100)),
         )
       }
 
@@ -1288,10 +1306,10 @@ class DatabaseImplTest {
               {
                 prefix = ParamPrefixEnum.STARTS_AFTER
                 value = BigDecimal("99.5")
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result.single().id).isEqualTo("RiskAssessment/${riskAssessment.id}")
@@ -1303,7 +1321,7 @@ class DatabaseImplTest {
       RiskAssessment().apply {
         id = "1"
         addPrediction(
-          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.5))
+          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(99.5)),
         )
       }
 
@@ -1317,10 +1335,10 @@ class DatabaseImplTest {
               {
                 prefix = ParamPrefixEnum.STARTS_AFTER
                 value = BigDecimal("99.5")
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result).isEmpty()
@@ -1332,7 +1350,7 @@ class DatabaseImplTest {
       RiskAssessment().apply {
         id = "1"
         addPrediction(
-          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(93))
+          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(93)),
         )
       }
 
@@ -1346,10 +1364,10 @@ class DatabaseImplTest {
               {
                 prefix = ParamPrefixEnum.APPROXIMATE
                 value = BigDecimal("100")
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result.single().id).isEqualTo("RiskAssessment/${riskAssessment.id}")
@@ -1361,7 +1379,7 @@ class DatabaseImplTest {
       RiskAssessment().apply {
         id = "1"
         addPrediction(
-          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(120))
+          RiskAssessment.RiskAssessmentPredictionComponent().setProbability(DecimalType(120)),
         )
       }
 
@@ -1375,10 +1393,10 @@ class DatabaseImplTest {
               {
                 prefix = ParamPrefixEnum.APPROXIMATE
                 value = BigDecimal("100")
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result).isEmpty()
@@ -1402,10 +1420,10 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2013-03-14"))
                 prefix = ParamPrefixEnum.APPROXIMATE
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("Patient/1")
   }
@@ -1428,10 +1446,10 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2020-03-14"))
                 prefix = ParamPrefixEnum.APPROXIMATE
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result).isEmpty()
   }
@@ -1454,10 +1472,10 @@ class DatabaseImplTest {
               {
                 value = of(DateType("2013-03-14"))
                 prefix = ParamPrefixEnum.APPROXIMATE
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("Patient/1")
   }
@@ -1480,10 +1498,10 @@ class DatabaseImplTest {
               {
                 value = of(DateType("2020-03-14"))
                 prefix = ParamPrefixEnum.APPROXIMATE
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result).isEmpty()
   }
@@ -1505,10 +1523,10 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2013-03-14"))
                 prefix = ParamPrefixEnum.STARTS_AFTER
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("Patient/1")
   }
@@ -1530,10 +1548,10 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2013-03-14"))
                 prefix = ParamPrefixEnum.STARTS_AFTER
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result).isEmpty()
   }
@@ -1555,10 +1573,10 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2013-03-14"))
                 prefix = ParamPrefixEnum.ENDS_BEFORE
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("Patient/1")
   }
@@ -1580,10 +1598,10 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2013-03-14"))
                 prefix = ParamPrefixEnum.ENDS_BEFORE
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result).isEmpty()
   }
@@ -1605,10 +1623,10 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2013-03-14"))
                 prefix = ParamPrefixEnum.NOT_EQUAL
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("Patient/1")
   }
@@ -1630,10 +1648,10 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2013-03-14"))
                 prefix = ParamPrefixEnum.NOT_EQUAL
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result).isEmpty()
   }
@@ -1655,10 +1673,10 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2013-03-14"))
                 prefix = ParamPrefixEnum.EQUAL
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("Patient/1")
   }
@@ -1680,10 +1698,10 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2013-03-14"))
                 prefix = ParamPrefixEnum.EQUAL
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result).isEmpty()
   }
@@ -1705,10 +1723,10 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2013-03-14"))
                 prefix = ParamPrefixEnum.GREATERTHAN
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("Patient/1")
   }
@@ -1730,10 +1748,10 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2013-03-14"))
                 prefix = ParamPrefixEnum.GREATERTHAN
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result).isEmpty()
   }
@@ -1755,10 +1773,10 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2013-03-14"))
                 prefix = ParamPrefixEnum.GREATERTHAN_OR_EQUALS
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("Patient/1")
   }
@@ -1780,10 +1798,10 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2013-03-14"))
                 prefix = ParamPrefixEnum.GREATERTHAN_OR_EQUALS
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result).isEmpty()
   }
@@ -1805,10 +1823,10 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2013-03-14"))
                 prefix = ParamPrefixEnum.LESSTHAN
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("Patient/1")
   }
@@ -1830,10 +1848,10 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2013-03-14"))
                 prefix = ParamPrefixEnum.LESSTHAN
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result).isEmpty()
   }
@@ -1855,10 +1873,10 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2013-03-14"))
                 prefix = ParamPrefixEnum.LESSTHAN_OR_EQUALS
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("Patient/1")
   }
@@ -1880,10 +1898,10 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2013-03-14T00:00:00-00:00"))
                 prefix = ParamPrefixEnum.LESSTHAN_OR_EQUALS
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result).isEmpty()
   }
@@ -1912,10 +1930,10 @@ class DatabaseImplTest {
                 value = BigDecimal("5.403")
                 system = "http://unitsofmeasure.org"
                 unit = "g"
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("Observation/1")
   }
@@ -1944,10 +1962,10 @@ class DatabaseImplTest {
                 value = BigDecimal("5.403")
                 system = "http://unitsofmeasure.org"
                 unit = "g"
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result).isEmpty()
   }
@@ -1976,10 +1994,10 @@ class DatabaseImplTest {
                 value = BigDecimal("5.403")
                 system = "http://unitsofmeasure.org"
                 unit = "g"
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("Observation/1")
   }
@@ -2008,10 +2026,10 @@ class DatabaseImplTest {
                 value = BigDecimal("5.403")
                 system = "http://unitsofmeasure.org"
                 unit = "g"
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result).isEmpty()
   }
@@ -2040,10 +2058,10 @@ class DatabaseImplTest {
                 value = BigDecimal("5.403")
                 system = "http://unitsofmeasure.org"
                 unit = "g"
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("Observation/1")
   }
@@ -2072,10 +2090,10 @@ class DatabaseImplTest {
                 value = BigDecimal("5.403")
                 system = "http://unitsofmeasure.org"
                 unit = "g"
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result).isEmpty()
   }
@@ -2104,10 +2122,10 @@ class DatabaseImplTest {
                 value = BigDecimal("5.403")
                 system = "http://unitsofmeasure.org"
                 unit = "g"
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("Observation/1")
   }
@@ -2136,10 +2154,10 @@ class DatabaseImplTest {
                 value = BigDecimal("5.403")
                 system = "http://unitsofmeasure.org"
                 unit = "g"
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result).isEmpty()
   }
@@ -2168,10 +2186,10 @@ class DatabaseImplTest {
                 value = BigDecimal("5.403")
                 system = "http://unitsofmeasure.org"
                 unit = "g"
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("Observation/1")
   }
@@ -2200,10 +2218,10 @@ class DatabaseImplTest {
                 value = BigDecimal("5.403")
                 system = "http://unitsofmeasure.org"
                 unit = "g"
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result).isEmpty()
   }
@@ -2232,10 +2250,10 @@ class DatabaseImplTest {
                 value = BigDecimal("5.403")
                 system = "http://unitsofmeasure.org"
                 unit = "g"
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("Observation/1")
   }
@@ -2264,10 +2282,10 @@ class DatabaseImplTest {
                 value = BigDecimal("5.403")
                 system = "http://unitsofmeasure.org"
                 unit = "g"
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result).isEmpty()
   }
@@ -2296,10 +2314,10 @@ class DatabaseImplTest {
                 value = BigDecimal("5.403")
                 system = "http://unitsofmeasure.org"
                 unit = "g"
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("Observation/1")
   }
@@ -2328,10 +2346,10 @@ class DatabaseImplTest {
                 value = BigDecimal("5.403")
                 system = "http://unitsofmeasure.org"
                 unit = "g"
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result).isEmpty()
   }
@@ -2360,17 +2378,17 @@ class DatabaseImplTest {
                 value = BigDecimal("5403")
                 system = "http://unitsofmeasure.org"
                 unit = "mg"
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.single().id).isEqualTo("Observation/1")
   }
 
   @Test
   fun search_nameGivenDuplicate_deduplicatePatient() = runBlocking {
-    var patient: Patient = readFromFile(Patient::class.java, "/patient_name_given_duplicate.json")
+    val patient: Patient = readFromFile(Patient::class.java, "/patient_name_given_duplicate.json")
     database.insertRemote(patient)
     val result =
       database.search<Patient>(
@@ -2380,7 +2398,7 @@ class DatabaseImplTest {
             count = 100
             from = 0
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.filter { it.id == patient.id }).hasSize(1)
   }
@@ -2401,8 +2419,8 @@ class DatabaseImplTest {
             Coding(
               "http://hl7.org/fhir/sid/cvx",
               "140",
-              "Influenza, seasonal, injectable, preservative free"
-            )
+              "Influenza, seasonal, injectable, preservative free",
+            ),
           )
         status = Immunization.ImmunizationStatus.COMPLETED
       }
@@ -2420,10 +2438,10 @@ class DatabaseImplTest {
                       Coding(
                         "http://hl7.org/fhir/sid/cvx",
                         "140",
-                        "Influenza, seasonal, injectable, preservative free"
-                      )
+                        "Influenza, seasonal, injectable, preservative free",
+                      ),
                     )
-                }
+                },
               )
 
               // Follow Immunization.ImmunizationStatus
@@ -2431,7 +2449,7 @@ class DatabaseImplTest {
                 Immunization.STATUS,
                 {
                   value = of(Coding("http://hl7.org/fhir/event-status", "completed", "Body Weight"))
-                }
+                },
               )
             }
 
@@ -2440,10 +2458,10 @@ class DatabaseImplTest {
               {
                 modifier = StringFilterModifier.MATCHES_EXACTLY
                 value = "IN"
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.map { it.logicalId }).containsExactly("100").inOrder()
   }
@@ -2464,8 +2482,8 @@ class DatabaseImplTest {
         category =
           listOf(
             CodeableConcept(
-              Coding("http://snomed.info/sct", "698360004", "Diabetes self management plan")
-            )
+              Coding("http://snomed.info/sct", "698360004", "Diabetes self management plan"),
+            ),
           )
       }
     database.insert(patient, TEST_PATIENT_1, carePlan)
@@ -2479,13 +2497,17 @@ class DatabaseImplTest {
                 {
                   value =
                     of(
-                      Coding("http://snomed.info/sct", "698360004", "Diabetes self management plan")
+                      Coding(
+                        "http://snomed.info/sct",
+                        "698360004",
+                        "Diabetes self management plan",
+                      ),
                     )
-                }
+                },
               )
             }
           }
-          .getQuery()
+          .getQuery(),
       )
     assertThat(result.map { it.logicalId }).containsExactly("100").inOrder()
   }
@@ -2496,14 +2518,14 @@ class DatabaseImplTest {
       Patient().apply {
         id = "older-patient"
         birthDateElement = DateType("2020-12-12")
-      }
+      },
     )
 
     database.insert(
       Patient().apply {
         id = "younger-patient"
         birthDateElement = DateType("2020-12-13")
-      }
+      },
     )
 
     assertThat(
@@ -2511,9 +2533,9 @@ class DatabaseImplTest {
           .search<Patient>(
             Search(ResourceType.Patient)
               .apply { sort(Patient.BIRTHDATE, Order.DESCENDING) }
-              .getQuery()
+              .getQuery(),
           )
-          .map { it.id }
+          .map { it.id },
       )
       .containsExactly("Patient/younger-patient", "Patient/older-patient", "Patient/test_patient_1")
   }
@@ -2524,14 +2546,14 @@ class DatabaseImplTest {
       Patient().apply {
         id = "older-patient"
         birthDateElement = DateType("2020-12-12")
-      }
+      },
     )
 
     database.insert(
       Patient().apply {
         id = "younger-patient"
         birthDateElement = DateType("2020-12-13")
-      }
+      },
     )
 
     assertThat(
@@ -2539,9 +2561,9 @@ class DatabaseImplTest {
           .search<Patient>(
             Search(ResourceType.Patient)
               .apply { sort(Patient.BIRTHDATE, Order.ASCENDING) }
-              .getQuery()
+              .getQuery(),
           )
-          .map { it.id }
+          .map { it.id },
       )
       .containsExactly("Patient/test_patient_1", "Patient/older-patient", "Patient/younger-patient")
   }
@@ -2554,7 +2576,11 @@ class DatabaseImplTest {
           id = "immunization-1"
           vaccineCode =
             CodeableConcept(
-              Coding("http://id.who.int/icd11/mms", "XM1NL1", "COVID-19 vaccine, inactivated virus")
+              Coding(
+                "http://id.who.int/icd11/mms",
+                "XM1NL1",
+                "COVID-19 vaccine, inactivated virus",
+              ),
             )
           status = Immunization.ImmunizationStatus.COMPLETED
         },
@@ -2565,8 +2591,8 @@ class DatabaseImplTest {
               Coding(
                 "http://id.who.int/icd11/mms",
                 "XM5DF6",
-                "COVID-19 vaccine, live attenuated virus"
-              )
+                "COVID-19 vaccine, live attenuated virus",
+              ),
             )
           status = Immunization.ImmunizationStatus.COMPLETED
         },
@@ -2574,7 +2600,7 @@ class DatabaseImplTest {
           id = "immunization-3"
           vaccineCode =
             CodeableConcept(
-              Coding("http://id.who.int/icd11/mms", "XM6AT1", "COVID-19 vaccine, DNA based")
+              Coding("http://id.who.int/icd11/mms", "XM6AT1", "COVID-19 vaccine, DNA based"),
             )
           status = Immunization.ImmunizationStatus.COMPLETED
         },
@@ -2585,11 +2611,11 @@ class DatabaseImplTest {
               Coding(
                 "http://hl7.org/fhir/sid/cvx",
                 "140",
-                "Influenza, seasonal, injectable, preservative free"
-              )
+                "Influenza, seasonal, injectable, preservative free",
+              ),
             )
           status = Immunization.ImmunizationStatus.COMPLETED
-        }
+        },
       )
 
     database.insert(*resources.toTypedArray())
@@ -2606,8 +2632,8 @@ class DatabaseImplTest {
                     Coding(
                       "http://id.who.int/icd11/mms",
                       "XM1NL1",
-                      "COVID-19 vaccine, inactivated virus"
-                    )
+                      "COVID-19 vaccine, inactivated virus",
+                    ),
                   )
               },
               {
@@ -2616,14 +2642,14 @@ class DatabaseImplTest {
                     Coding(
                       "http://id.who.int/icd11/mms",
                       "XM5DF6",
-                      "COVID-19 vaccine, inactivated virus"
-                    )
+                      "COVID-19 vaccine, inactivated virus",
+                    ),
                   )
               },
-              operation = Operation.OR
+              operation = Operation.OR,
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result.map { it.vaccineCode.codingFirstRep.code })
@@ -2639,7 +2665,11 @@ class DatabaseImplTest {
           id = "immunization-1"
           vaccineCode =
             CodeableConcept(
-              Coding("http://id.who.int/icd11/mms", "XM1NL1", "COVID-19 vaccine, inactivated virus")
+              Coding(
+                "http://id.who.int/icd11/mms",
+                "XM1NL1",
+                "COVID-19 vaccine, inactivated virus",
+              ),
             )
           status = Immunization.ImmunizationStatus.COMPLETED
         },
@@ -2650,8 +2680,8 @@ class DatabaseImplTest {
               Coding(
                 "http://id.who.int/icd11/mms",
                 "XM5DF6",
-                "COVID-19 vaccine, live attenuated virus"
-              )
+                "COVID-19 vaccine, live attenuated virus",
+              ),
             )
           status = Immunization.ImmunizationStatus.COMPLETED
         },
@@ -2659,7 +2689,7 @@ class DatabaseImplTest {
           id = "immunization-3"
           vaccineCode =
             CodeableConcept(
-              Coding("http://id.who.int/icd11/mms", "XM6AT1", "COVID-19 vaccine, DNA based")
+              Coding("http://id.who.int/icd11/mms", "XM6AT1", "COVID-19 vaccine, DNA based"),
             )
           status = Immunization.ImmunizationStatus.COMPLETED
         },
@@ -2670,11 +2700,11 @@ class DatabaseImplTest {
               Coding(
                 "http://hl7.org/fhir/sid/cvx",
                 "140",
-                "Influenza, seasonal, injectable, preservative free"
-              )
+                "Influenza, seasonal, injectable, preservative free",
+              ),
             )
           status = Immunization.ImmunizationStatus.COMPLETED
-        }
+        },
       )
 
     database.insert(*resources.toTypedArray())
@@ -2685,16 +2715,16 @@ class DatabaseImplTest {
           .apply {
             filter(
               Immunization.VACCINE_CODE,
-              { value = of(Coding("http://id.who.int/icd11/mms", "XM1NL1", "")) }
+              { value = of(Coding("http://id.who.int/icd11/mms", "XM1NL1", "")) },
             )
 
             filter(
               Immunization.VACCINE_CODE,
-              { value = of(Coding("http://id.who.int/icd11/mms", "XM5DF6", "")) }
+              { value = of(Coding("http://id.who.int/icd11/mms", "XM5DF6", "")) },
             )
             operation = Operation.OR
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result.map { it.vaccineCode.codingFirstRep.code })
@@ -2712,7 +2742,7 @@ class DatabaseImplTest {
             HumanName().apply {
               addGiven("John")
               family = "Doe"
-            }
+            },
           )
         },
         Patient().apply {
@@ -2721,7 +2751,7 @@ class DatabaseImplTest {
             HumanName().apply {
               addGiven("Jane")
               family = "Doe"
-            }
+            },
           )
         },
         Patient().apply {
@@ -2730,7 +2760,7 @@ class DatabaseImplTest {
             HumanName().apply {
               addGiven("John")
               family = "Roe"
-            }
+            },
           )
         },
         Patient().apply {
@@ -2739,7 +2769,7 @@ class DatabaseImplTest {
             HumanName().apply {
               addGiven("Jane")
               family = "Roe"
-            }
+            },
           )
         },
         Patient().apply {
@@ -2748,9 +2778,9 @@ class DatabaseImplTest {
             HumanName().apply {
               addGiven("Rocky")
               family = "Balboa"
-            }
+            },
           )
-        }
+        },
       )
     database.insert(*resources.toTypedArray())
 
@@ -2768,7 +2798,7 @@ class DatabaseImplTest {
                 value = "Jane"
                 modifier = StringFilterModifier.MATCHES_EXACTLY
               },
-              operation = Operation.OR
+              operation = Operation.OR,
             )
 
             filter(
@@ -2781,12 +2811,12 @@ class DatabaseImplTest {
                 value = "Roe"
                 modifier = StringFilterModifier.MATCHES_EXACTLY
               },
-              operation = Operation.OR
+              operation = Operation.OR,
             )
 
             operation = Operation.AND
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result.map { it.nameFirstRep.nameAsSingleString })
@@ -2813,7 +2843,7 @@ class DatabaseImplTest {
           Identifier().apply {
             system = "https://custom-identifier-namespace"
             value = "OfficialIdentifier_DarcySmith_0001"
-          }
+          },
         )
 
         addName(
@@ -2823,14 +2853,14 @@ class DatabaseImplTest {
             addGiven("Darcy")
             gender = Enumerations.AdministrativeGender.FEMALE
             birthDateElement = DateType("1970-01-01")
-          }
+          },
         )
 
         addExtension(
           Extension().apply {
             url = "http://hl7.org/fhir/StructureDefinition/patient-mothersMaidenName"
             setValue(StringType("Marca"))
-          }
+          },
         )
       }
     // Get rid of the default service and create one with search params
@@ -2847,10 +2877,10 @@ class DatabaseImplTest {
               {
                 value = "Marca"
                 modifier = StringFilterModifier.MATCHES_EXACTLY
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result.map { it.nameFirstRep.nameAsSingleString }).contains("Darcy Smith")
@@ -2864,7 +2894,7 @@ class DatabaseImplTest {
           Identifier().apply {
             system = "https://custom-identifier-namespace"
             value = "OfficialIdentifier_DarcySmith_0001"
-          }
+          },
         )
 
         addName(
@@ -2874,14 +2904,14 @@ class DatabaseImplTest {
             addGiven("Darcy")
             gender = Enumerations.AdministrativeGender.FEMALE
             birthDateElement = DateType("1970-01-01")
-          }
+          },
         )
 
         addExtension(
           Extension().apply {
             url = "http://hl7.org/fhir/StructureDefinition/patient-mothersMaidenName"
             setValue(StringType("Marca"))
-          }
+          },
         )
       }
     val identifierPartialSearchParameter =
@@ -2908,10 +2938,10 @@ class DatabaseImplTest {
               {
                 value = "OfficialIdentifier_"
                 modifier = StringFilterModifier.STARTS_WITH
-              }
+              },
             )
           }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result.map { it.nameFirstRep.nameAsSingleString }).contains("Darcy Smith")
@@ -2922,21 +2952,21 @@ class DatabaseImplTest {
     database.insert(
       Patient().apply { id = "patient-test-001" },
       Patient().apply { id = "patient-test-002" },
-      Patient().apply { id = "patient-test-003" }
+      Patient().apply { id = "patient-test-003" },
     )
 
     database.update(
       Patient().apply {
         id = "patient-test-002"
         gender = Enumerations.AdministrativeGender.FEMALE
-      }
+      },
     )
 
     val result =
       database.search<Patient>(
         Search(ResourceType.Patient)
           .apply { sort(LOCAL_LAST_UPDATED_PARAM, Order.DESCENDING) }
-          .getQuery()
+          .getQuery(),
       )
 
     assertThat(result.map { it.logicalId })
@@ -2953,7 +2983,7 @@ class DatabaseImplTest {
           HumanName().apply {
             addGiven("James")
             family = "Gorden"
-          }
+          },
         )
         addGeneralPractitioner(Reference("Practitioner/gp-01"))
         addGeneralPractitioner(Reference("Practitioner/gp-02"))
@@ -2966,7 +2996,7 @@ class DatabaseImplTest {
           HumanName().apply {
             addGiven("James")
             family = "Bond"
-          }
+          },
         )
         addGeneralPractitioner(Reference("Practitioner/gp-02"))
         addGeneralPractitioner(Reference("Practitioner/gp-03"))
@@ -2980,7 +3010,7 @@ class DatabaseImplTest {
           HumanName().apply {
             family = "Practitioner-01"
             addGiven("General-01")
-          }
+          },
         )
         active = true
       }
@@ -2991,7 +3021,7 @@ class DatabaseImplTest {
           HumanName().apply {
             family = "Practitioner-02"
             addGiven("General-02")
-          }
+          },
         )
         active = false
       }
@@ -3002,7 +3032,7 @@ class DatabaseImplTest {
           HumanName().apply {
             family = "Practitioner-03"
             addGiven("General-03")
-          }
+          },
         )
         active = true
       }
@@ -3019,7 +3049,7 @@ class DatabaseImplTest {
             {
               value = "James"
               modifier = StringFilterModifier.MATCHES_EXACTLY
-            }
+            },
           )
 
           include<Practitioner>(Patient.GENERAL_PRACTITIONER) {
@@ -3034,14 +3064,14 @@ class DatabaseImplTest {
           SearchResult(
             patient01,
             included = mapOf(Patient.GENERAL_PRACTITIONER.paramName to listOf(gp01)),
-            revIncluded = null
+            revIncluded = null,
           ),
           SearchResult(
             patient02,
             included = mapOf(Patient.GENERAL_PRACTITIONER.paramName to listOf(gp03)),
-            revIncluded = null
-          )
-        )
+            revIncluded = null,
+          ),
+        ),
       )
   }
 
@@ -3054,7 +3084,7 @@ class DatabaseImplTest {
           HumanName().apply {
             addGiven("James")
             family = "Gorden"
-          }
+          },
         )
         addGeneralPractitioner(Reference("Practitioner/gp-01"))
       }
@@ -3066,7 +3096,7 @@ class DatabaseImplTest {
           HumanName().apply {
             addGiven("James")
             family = "Bond"
-          }
+          },
         )
         addGeneralPractitioner(Reference("Practitioner/gp-02"))
       }
@@ -3108,7 +3138,7 @@ class DatabaseImplTest {
             {
               value = "James"
               modifier = StringFilterModifier.MATCHES_EXACTLY
-            }
+            },
           )
           revInclude<Condition>(Condition.SUBJECT) {
             filter(Condition.CODE, { value = of(diabetesCodeableConcept) })
@@ -3125,15 +3155,15 @@ class DatabaseImplTest {
             patient01,
             included = null,
             revIncluded =
-              mapOf((ResourceType.Condition to Condition.SUBJECT.paramName) to listOf(con1))
+              mapOf((ResourceType.Condition to Condition.SUBJECT.paramName) to listOf(con1)),
           ),
           SearchResult(
             patient02,
             included = null,
             revIncluded =
-              mapOf((ResourceType.Condition to Condition.SUBJECT.paramName) to listOf(con3))
-          )
-        )
+              mapOf((ResourceType.Condition to Condition.SUBJECT.paramName) to listOf(con3)),
+          ),
+        ),
       )
   }
 
@@ -3154,7 +3184,7 @@ class DatabaseImplTest {
             HumanName().apply {
               addGiven("James")
               family = "Gorden"
-            }
+            },
           )
           addGeneralPractitioner(Reference("Practitioner/gp-01"))
           addGeneralPractitioner(Reference("Practitioner/gp-02"))
@@ -3167,7 +3197,7 @@ class DatabaseImplTest {
             HumanName().apply {
               addGiven("James")
               family = "Bond"
-            }
+            },
           )
           addGeneralPractitioner(Reference("Practitioner/gp-01"))
           addGeneralPractitioner(Reference("Practitioner/gp-02"))
@@ -3180,13 +3210,13 @@ class DatabaseImplTest {
             HumanName().apply {
               addGiven("James")
               family = "Doe"
-            }
+            },
           )
           addGeneralPractitioner(Reference("Practitioner/gp-01"))
           addGeneralPractitioner(Reference("Practitioner/gp-02"))
           addGeneralPractitioner(Reference("Practitioner/gp-03"))
           managingOrganization = Reference("Organization/org-03")
-        }
+        },
       )
 
     val practitioners =
@@ -3197,7 +3227,7 @@ class DatabaseImplTest {
             HumanName().apply {
               family = "Practitioner-01"
               addGiven("General-01")
-            }
+            },
           )
           active = true
         },
@@ -3207,7 +3237,7 @@ class DatabaseImplTest {
             HumanName().apply {
               family = "Practitioner-02"
               addGiven("General-02")
-            }
+            },
           )
           active = true
         },
@@ -3217,10 +3247,10 @@ class DatabaseImplTest {
             HumanName().apply {
               family = "Practitioner-03"
               addGiven("General-03")
-            }
+            },
           )
           active = false
-        }
+        },
       )
 
     val organizations =
@@ -3239,7 +3269,7 @@ class DatabaseImplTest {
           id = "org-03"
           name = "Organization-03"
           active = false
-        }
+        },
       )
 
     val conditions =
@@ -3373,7 +3403,7 @@ class DatabaseImplTest {
               start = DateType(2022, 2, 1).value
               end = DateType(2022, 11, 1).value
             }
-        }
+        },
       )
     // 3 Patients.
     // Each has 3 conditions, only 2 should match
@@ -3394,7 +3424,7 @@ class DatabaseImplTest {
             {
               value = "James"
               modifier = StringFilterModifier.MATCHES_EXACTLY
-            }
+            },
           )
 
           include<Practitioner>(Patient.GENERAL_PRACTITIONER) {
@@ -3404,7 +3434,7 @@ class DatabaseImplTest {
               {
                 value = "Practitioner"
                 modifier = StringFilterModifier.STARTS_WITH
-              }
+              },
             )
             operation = Operation.AND
           }
@@ -3414,7 +3444,7 @@ class DatabaseImplTest {
               {
                 value = "Organization"
                 modifier = StringFilterModifier.STARTS_WITH
-              }
+              },
             )
             filter(Practitioner.ACTIVE, { value = of(true) })
             operation = Operation.AND
@@ -3431,7 +3461,7 @@ class DatabaseImplTest {
               {
                 value = of(DateTimeType("2023-01-01"))
                 prefix = ParamPrefixEnum.GREATERTHAN_OR_EQUALS
-              }
+              },
             )
           }
         }
@@ -3450,21 +3480,21 @@ class DatabaseImplTest {
               Pair(ResourceType.Condition, "subject") to
                 listOf(resources["con-01-pa-01"]!!, resources["con-03-pa-01"]!!),
               Pair(ResourceType.Encounter, "subject") to
-                listOf(resources["en-01-pa-01"]!!, resources["en-02-pa-01"]!!)
-            )
+                listOf(resources["en-01-pa-01"]!!, resources["en-02-pa-01"]!!),
+            ),
           ),
           SearchResult(
             resources["pa-02"]!!,
             mapOf(
               "general-practitioner" to listOf(resources["gp-01"]!!, resources["gp-02"]!!),
-              "organization" to listOf(resources["org-02"]!!)
+              "organization" to listOf(resources["org-02"]!!),
             ),
             mapOf(
               Pair(ResourceType.Condition, "subject") to
                 listOf(resources["con-01-pa-02"]!!, resources["con-03-pa-02"]!!),
               Pair(ResourceType.Encounter, "subject") to
-                listOf(resources["en-01-pa-02"]!!, resources["en-02-pa-02"]!!)
-            )
+                listOf(resources["en-01-pa-02"]!!, resources["en-02-pa-02"]!!),
+            ),
           ),
           SearchResult(
             resources["pa-03"]!!,
@@ -3475,10 +3505,10 @@ class DatabaseImplTest {
               Pair(ResourceType.Condition, "subject") to
                 listOf(resources["con-01-pa-03"]!!, resources["con-03-pa-03"]!!),
               Pair(ResourceType.Encounter, "subject") to
-                listOf(resources["en-01-pa-03"]!!, resources["en-02-pa-03"]!!)
-            )
-          )
-        )
+                listOf(resources["en-01-pa-03"]!!, resources["en-02-pa-03"]!!),
+            ),
+          ),
+        ),
       )
   }
 
diff --git a/engine/src/main/java/com/google/android/fhir/FhirEngine.kt b/engine/src/main/java/com/google/android/fhir/FhirEngine.kt
index 59a2a1322e..0b9a31b4fb 100644
--- a/engine/src/main/java/com/google/android/fhir/FhirEngine.kt
+++ b/engine/src/main/java/com/google/android/fhir/FhirEngine.kt
@@ -19,6 +19,7 @@ package com.google.android.fhir
 import com.google.android.fhir.db.ResourceNotFoundException
 import com.google.android.fhir.search.Search
 import com.google.android.fhir.sync.ConflictResolver
+import com.google.android.fhir.sync.upload.LocalChangesFetchMode
 import java.time.OffsetDateTime
 import kotlinx.coroutines.flow.Flow
 import org.hl7.fhir.r4.model.Resource
@@ -53,7 +54,8 @@ interface FhirEngine {
    * api caller should [Flow.collect] it.
    */
   suspend fun syncUpload(
-    upload: (suspend (List<LocalChange>) -> Flow<Pair<LocalChangeToken, Resource>>)
+    localChangesFetchMode: LocalChangesFetchMode,
+    upload: (suspend (List<LocalChange>) -> Flow<Pair<LocalChangeToken, Resource>>),
   )
 
   /**
@@ -62,7 +64,7 @@ interface FhirEngine {
    */
   suspend fun syncDownload(
     conflictResolver: ConflictResolver,
-    download: suspend () -> Flow<List<Resource>>
+    download: suspend () -> Flow<List<Resource>>,
   )
 
   /**
@@ -87,29 +89,32 @@ interface FhirEngine {
    * Retrieves a list of [LocalChange]s for [Resource] with given type and id, which can be used to
    * purge resource from database. If there is no local change for given [resourceType] and
    * [Resource.id], return an empty list.
+   *
    * @param type The [ResourceType]
    * @param id The resource id [Resource.id]
    * @return [List]<[LocalChange]> A list of local changes for given [resourceType] and
-   * [Resource.id] . If there is no local change for given [resourceType] and [Resource.id], return
-   * an empty list.
+   *   [Resource.id] . If there is no local change for given [resourceType] and [Resource.id],
+   *   return an empty list.
    */
   suspend fun getLocalChanges(type: ResourceType, id: String): List<LocalChange>
 
   /**
    * Purges a resource from the database based on resource type and id without any deletion of data
    * from the server.
+   *
    * @param type The [ResourceType]
    * @param id The resource id [Resource.id]
    * @param isLocalPurge default value is false here resource will not be deleted from
-   * LocalChangeEntity table but it will throw IllegalStateException("Resource has local changes
-   * either sync with server or FORCE_PURGE required") if local change exists. If true this API will
-   * delete resource entry from LocalChangeEntity table.
+   *   LocalChangeEntity table but it will throw IllegalStateException("Resource has local changes
+   *   either sync with server or FORCE_PURGE required") if local change exists. If true this API
+   *   will delete resource entry from LocalChangeEntity table.
    */
   suspend fun purge(type: ResourceType, id: String, forcePurge: Boolean = false)
 }
 
 /**
  * Returns a FHIR resource of type [R] with [id] from the local storage.
+ *
  * @param <R> The resource type which should be a subtype of [Resource].
  * @throws ResourceNotFoundException if the resource is not found
  */
@@ -120,6 +125,7 @@ suspend inline fun <reified R : Resource> FhirEngine.get(id: String): R {
 
 /**
  * Deletes a FHIR resource of type [R] with [id] from the local storage.
+ *
  * @param <R> The resource type which should be a subtype of [Resource].
  */
 suspend inline fun <reified R : Resource> FhirEngine.delete(id: String) {
@@ -138,7 +144,7 @@ data class SearchResult<R : Resource>(
   /** Matching referenced resources as per the [Search.include] criteria in the query. */
   val included: Map<SearchParamName, List<Resource>>?,
   /** Matching referenced resources as per the [Search.revInclude] criteria in the query. */
-  val revIncluded: Map<Pair<ResourceType, SearchParamName>, List<Resource>>?
+  val revIncluded: Map<Pair<ResourceType, SearchParamName>, List<Resource>>?,
 ) {
   override fun equals(other: Any?) =
     other is SearchResult<*> &&
@@ -155,7 +161,7 @@ data class SearchResult<R : Resource>(
 
   private fun equalsShallow(
     first: Map<SearchParamName, List<Resource>>?,
-    second: Map<SearchParamName, List<Resource>>?
+    second: Map<SearchParamName, List<Resource>>?,
   ) =
     if (first != null && second != null && first.size == second.size) {
       first.entries.asSequence().zip(second.entries.asSequence()).all { (x, y) ->
@@ -168,7 +174,7 @@ data class SearchResult<R : Resource>(
   @JvmName("equalsShallowRevInclude")
   private fun equalsShallow(
     first: Map<Pair<ResourceType, SearchParamName>, List<Resource>>?,
-    second: Map<Pair<ResourceType, SearchParamName>, List<Resource>>?
+    second: Map<Pair<ResourceType, SearchParamName>, List<Resource>>?,
   ) =
     if (first != null && second != null && first.size == second.size) {
       first.entries.asSequence().zip(second.entries.asSequence()).all { (x, y) ->
diff --git a/engine/src/main/java/com/google/android/fhir/db/Database.kt b/engine/src/main/java/com/google/android/fhir/db/Database.kt
index b2cb416fcb..cbbc840b64 100644
--- a/engine/src/main/java/com/google/android/fhir/db/Database.kt
+++ b/engine/src/main/java/com/google/android/fhir/db/Database.kt
@@ -58,7 +58,7 @@ internal interface Database {
     resourceId: String,
     resourceType: ResourceType,
     versionId: String,
-    lastUpdated: Instant
+    lastUpdated: Instant,
   )
 
   /**
@@ -105,6 +105,9 @@ internal interface Database {
    */
   suspend fun getAllLocalChanges(): List<LocalChange>
 
+  /** Retrieves the count of [LocalChange]s stored in the database. */
+  suspend fun getLocalChangesCount(): Int
+
   /** Remove the [LocalChangeEntity] s with given ids. Call this after a successful sync. */
   suspend fun deleteUpdates(token: LocalChangeToken)
 
@@ -127,23 +130,25 @@ internal interface Database {
    * Retrieve a list of [LocalChange] for [Resource] with given type and id, which can be used to
    * purge resource from database. If there is no local change for given [resourceType] and
    * [Resource.id], return an empty list.
+   *
    * @param type The [ResourceType]
    * @param id The resource id [Resource.id]
    * @return [List]<[LocalChange]> A list of local changes for given [resourceType] and
-   * [Resource.id] . If there is no local change for given [resourceType] and [Resource.id], return
-   * empty list.
+   *   [Resource.id] . If there is no local change for given [resourceType] and [Resource.id],
+   *   return empty list.
    */
   suspend fun getLocalChanges(type: ResourceType, id: String): List<LocalChange>
 
   /**
    * Purge resource from database based on resource type and id without any deletion of data from
    * the server.
+   *
    * @param type The [ResourceType]
    * @param id The resource id [Resource.id]
    * @param isLocalPurge default value is false here resource will not be deleted from
-   * LocalChangeEntity table but it will throw IllegalStateException("Resource has local changes
-   * either sync with server or FORCE_PURGE required") if local change exists. If true this API will
-   * delete resource entry from LocalChangeEntity table.
+   *   LocalChangeEntity table but it will throw IllegalStateException("Resource has local changes
+   *   either sync with server or FORCE_PURGE required") if local change exists. If true this API
+   *   will delete resource entry from LocalChangeEntity table.
    */
   suspend fun purge(type: ResourceType, id: String, forcePurge: Boolean = false)
 }
diff --git a/engine/src/main/java/com/google/android/fhir/db/impl/DatabaseImpl.kt b/engine/src/main/java/com/google/android/fhir/db/impl/DatabaseImpl.kt
index 8da36f8bce..8ca9fff23c 100644
--- a/engine/src/main/java/com/google/android/fhir/db/impl/DatabaseImpl.kt
+++ b/engine/src/main/java/com/google/android/fhir/db/impl/DatabaseImpl.kt
@@ -46,7 +46,7 @@ internal class DatabaseImpl(
   private val context: Context,
   private val iParser: IParser,
   databaseConfig: DatabaseConfig,
-  private val resourceIndexer: ResourceIndexer
+  private val resourceIndexer: ResourceIndexer,
 ) : com.google.android.fhir.db.Database {
 
   val db: ResourceDatabase
@@ -88,8 +88,10 @@ internal class DatabaseImpl(
             openHelperFactory {
               SQLCipherSupportHelper(
                 it,
-                databaseErrorStrategy = databaseConfig.databaseErrorStrategy
-              ) { DatabaseEncryptionKeyProvider.getOrCreatePassphrase(DATABASE_PASSPHRASE_NAME) }
+                databaseErrorStrategy = databaseConfig.databaseErrorStrategy,
+              ) {
+                DatabaseEncryptionKeyProvider.getOrCreatePassphrase(DATABASE_PASSPHRASE_NAME)
+              }
             }
           }
 
@@ -115,7 +117,7 @@ internal class DatabaseImpl(
           val timeOfLocalChange = Instant.now()
           localChangeDao.addInsert(it, timeOfLocalChange)
           resourceDao.insertLocalResource(it, timeOfLocalChange)
-        }
+        },
       )
     }
     return logicalIds
@@ -140,14 +142,14 @@ internal class DatabaseImpl(
     resourceId: String,
     resourceType: ResourceType,
     versionId: String,
-    lastUpdated: Instant
+    lastUpdated: Instant,
   ) {
     db.withTransaction {
       resourceDao.updateAndIndexRemoteVersionIdAndLastUpdate(
         resourceId,
         resourceType,
         versionId,
-        lastUpdated
+        lastUpdated,
       )
     }
   }
@@ -174,12 +176,13 @@ internal class DatabaseImpl(
           null
         }
       val rowsDeleted = resourceDao.deleteResource(resourceId = id, resourceType = type)
-      if (rowsDeleted > 0)
+      if (rowsDeleted > 0) {
         localChangeDao.addDelete(
           resourceId = id,
           resourceType = type,
-          remoteVersionId = remoteVersionId
+          remoteVersionId = remoteVersionId,
         )
+      }
     }
   }
 
@@ -200,7 +203,7 @@ internal class DatabaseImpl(
           IndexedIdAndResource(
             it.matchingIndex,
             it.idOfBaseResourceOnWhichThisMatchedInc ?: it.idOfBaseResourceOnWhichThisMatchedRev!!,
-            iParser.parseResource(it.serializedResource) as Resource
+            iParser.parseResource(it.serializedResource) as Resource,
           )
         }
     }
@@ -216,6 +219,10 @@ internal class DatabaseImpl(
     return db.withTransaction { localChangeDao.getAllLocalChanges().map { it.toLocalChange() } }
   }
 
+  override suspend fun getLocalChangesCount(): Int {
+    return db.withTransaction { localChangeDao.getLocalChangesCount() }
+  }
+
   override suspend fun deleteUpdates(token: LocalChangeToken) {
     db.withTransaction { localChangeDao.discardLocalChanges(token) }
   }
@@ -265,12 +272,12 @@ internal class DatabaseImpl(
         if (forcePurge) {
           resourceDao.deleteResource(resourceId = id, resourceType = type)
           localChangeDao.discardLocalChanges(
-            token = LocalChangeToken(localChangeEntityList.map { it.id })
+            token = LocalChangeToken(localChangeEntityList.map { it.id }),
           )
         } else {
           // local change is available but FORCE_PURGE = false then throw exception
           throw IllegalStateException(
-            "Resource with type $type and id $id has local changes, either sync with server or FORCE_PURGE required"
+            "Resource with type $type and id $id has local changes, either sync with server or FORCE_PURGE required",
           )
         }
       }
@@ -301,5 +308,5 @@ internal class DatabaseImpl(
 data class DatabaseConfig(
   val inMemory: Boolean,
   val enableEncryption: Boolean,
-  val databaseErrorStrategy: DatabaseErrorStrategy
+  val databaseErrorStrategy: DatabaseErrorStrategy,
 )
diff --git a/engine/src/main/java/com/google/android/fhir/db/impl/dao/LocalChangeDao.kt b/engine/src/main/java/com/google/android/fhir/db/impl/dao/LocalChangeDao.kt
index f8c9524439..d69684a9bd 100644
--- a/engine/src/main/java/com/google/android/fhir/db/impl/dao/LocalChangeDao.kt
+++ b/engine/src/main/java/com/google/android/fhir/db/impl/dao/LocalChangeDao.kt
@@ -64,8 +64,8 @@ internal abstract class LocalChangeDao {
         timestamp = timeOfLocalChange,
         type = Type.INSERT,
         payload = resourceString,
-        versionId = resource.versionId
-      )
+        versionId = resource.versionId,
+      ),
     )
   }
 
@@ -73,11 +73,12 @@ internal abstract class LocalChangeDao {
     val resourceId = resource.logicalId
     val resourceType = resource.resourceType
 
-    if (!localChangeIsEmpty(resourceId, resourceType) &&
+    if (
+      !localChangeIsEmpty(resourceId, resourceType) &&
         lastChangeType(resourceId, resourceType)!! == Type.DELETE
     ) {
       throw InvalidLocalChangeException(
-        "Unexpected DELETE when updating $resourceType/$resourceId. UPDATE failed."
+        "Unexpected DELETE when updating $resourceType/$resourceId. UPDATE failed.",
       )
     }
     val jsonDiff =
@@ -85,7 +86,7 @@ internal abstract class LocalChangeDao {
     if (jsonDiff.length() == 0) {
       Timber.i(
         "New resource ${resource.resourceType}/${resource.id} is same as old resource. " +
-          "Not inserting UPDATE LocalChange."
+          "Not inserting UPDATE LocalChange.",
       )
       return
     }
@@ -97,8 +98,8 @@ internal abstract class LocalChangeDao {
         timestamp = timeOfLocalChange,
         type = Type.UPDATE,
         payload = jsonDiff.toString(),
-        versionId = oldEntity.versionId
-      )
+        versionId = oldEntity.versionId,
+      ),
     )
   }
 
@@ -111,8 +112,8 @@ internal abstract class LocalChangeDao {
         timestamp = Date().toInstant(),
         type = Type.DELETE,
         payload = "",
-        versionId = remoteVersionId
-      )
+        versionId = remoteVersionId,
+      ),
     )
   }
 
@@ -124,7 +125,7 @@ internal abstract class LocalChangeDao {
         AND resourceType = :resourceType 
         ORDER BY id ASC
         LIMIT 1
-    """
+    """,
   )
   abstract suspend fun lastChangeType(resourceId: String, resourceType: ResourceType): Type?
 
@@ -135,7 +136,7 @@ internal abstract class LocalChangeDao {
         WHERE resourceId = :resourceId 
         AND resourceType = :resourceType
         LIMIT 1
-    """
+    """,
   )
   abstract suspend fun countLastChange(resourceId: String, resourceType: ResourceType): Int
 
@@ -146,15 +147,23 @@ internal abstract class LocalChangeDao {
     """
         SELECT *
         FROM LocalChangeEntity
-        ORDER BY LocalChangeEntity.id ASC"""
+        ORDER BY LocalChangeEntity.id ASC""",
   )
   abstract suspend fun getAllLocalChanges(): List<LocalChangeEntity>
 
+  @Query(
+    """
+        SELECT COUNT(*)
+        FROM LocalChangeEntity
+        """,
+  )
+  abstract suspend fun getLocalChangesCount(): Int
+
   @Query(
     """
         DELETE FROM LocalChangeEntity
         WHERE LocalChangeEntity.id = (:id)
-    """
+    """,
   )
   abstract suspend fun discardLocalChanges(id: Long)
 
@@ -168,7 +177,7 @@ internal abstract class LocalChangeDao {
         DELETE FROM LocalChangeEntity
         WHERE resourceId = (:resourceId)
         AND resourceType = :resourceType
-    """
+    """,
   )
   abstract suspend fun discardLocalChanges(resourceId: String, resourceType: ResourceType)
 
@@ -181,11 +190,11 @@ internal abstract class LocalChangeDao {
         SELECT *
         FROM LocalChangeEntity
         WHERE resourceId = :resourceId AND resourceType = :resourceType
-    """
+    """,
   )
   abstract suspend fun getLocalChanges(
     resourceType: ResourceType,
-    resourceId: String
+    resourceId: String,
   ): List<LocalChangeEntity>
 
   class InvalidLocalChangeException(message: String?) : Exception(message)
@@ -197,8 +206,8 @@ internal fun diff(parser: IParser, source: Resource, target: Resource): JSONArra
   return getFilteredJSONArray(
     JsonDiff.asJson(
       objectMapper.readValue(parser.encodeResourceToString(source), JsonNode::class.java),
-      objectMapper.readValue(parser.encodeResourceToString(target), JsonNode::class.java)
-    )
+      objectMapper.readValue(parser.encodeResourceToString(target), JsonNode::class.java),
+    ),
   )
 }
 
@@ -210,12 +219,14 @@ internal fun diff(parser: IParser, source: Resource, target: Resource): JSONArra
  * and causes the issue with server update.
  *
  * An unfiltered JSON Array for family name update looks like
+ *
  * ```
  * [{"op":"remove","path":"/meta"}, {"op":"remove","path":"/text"},
  * {"op":"replace","path":"/name/0/family","value":"Nucleus"}]
  * ```
  *
  * A filtered JSON Array for family name update looks like
+ *
  * ```
  * [{"op":"replace","path":"/name/0/family","value":"Nucleus"}]
  * ```
@@ -226,6 +237,8 @@ private fun getFilteredJSONArray(jsonDiff: JsonNode) =
     return@with JSONArray(
       (0 until length())
         .map { optJSONObject(it) }
-        .filterNot { jsonObject -> ignorePaths.any { jsonObject.optString("path").startsWith(it) } }
+        .filterNot { jsonObject ->
+          ignorePaths.any { jsonObject.optString("path").startsWith(it) }
+        },
     )
   }
diff --git a/engine/src/main/java/com/google/android/fhir/impl/FhirEngineImpl.kt b/engine/src/main/java/com/google/android/fhir/impl/FhirEngineImpl.kt
index 4c93efec9f..adf2611487 100644
--- a/engine/src/main/java/com/google/android/fhir/impl/FhirEngineImpl.kt
+++ b/engine/src/main/java/com/google/android/fhir/impl/FhirEngineImpl.kt
@@ -30,6 +30,8 @@ import com.google.android.fhir.search.execute
 import com.google.android.fhir.sync.ConflictResolver
 import com.google.android.fhir.sync.Resolved
 import com.google.android.fhir.sync.upload.DefaultResourceConsolidator
+import com.google.android.fhir.sync.upload.LocalChangeFetcherFactory
+import com.google.android.fhir.sync.upload.LocalChangesFetchMode
 import java.time.OffsetDateTime
 import kotlinx.coroutines.flow.Flow
 import org.hl7.fhir.r4.model.Resource
@@ -122,12 +124,15 @@ internal class FhirEngineImpl(private val database: Database, private val contex
       .intersect(database.getAllLocalChanges().map { it.resourceId }.toSet())
 
   override suspend fun syncUpload(
+    localChangesFetchMode: LocalChangesFetchMode,
     upload: suspend (List<LocalChange>) -> Flow<Pair<LocalChangeToken, Resource>>,
   ) {
     val resourceConsolidator = DefaultResourceConsolidator(database)
-    val localChanges = database.getAllLocalChanges()
-    if (localChanges.isNotEmpty()) {
-      upload(localChanges).collect { resourceConsolidator.consolidate(it.first, it.second) }
+    val localChangeFetcher = LocalChangeFetcherFactory.byMode(localChangesFetchMode, database)
+    while (localChangeFetcher.hasNext()) {
+      upload(localChangeFetcher.next()).collect {
+        resourceConsolidator.consolidate(it.first, it.second)
+      }
     }
   }
 }
diff --git a/engine/src/main/java/com/google/android/fhir/sync/FhirSynchronizer.kt b/engine/src/main/java/com/google/android/fhir/sync/FhirSynchronizer.kt
index c58857dfbb..f2f6de79b0 100644
--- a/engine/src/main/java/com/google/android/fhir/sync/FhirSynchronizer.kt
+++ b/engine/src/main/java/com/google/android/fhir/sync/FhirSynchronizer.kt
@@ -21,6 +21,7 @@ import com.google.android.fhir.DatastoreUtil
 import com.google.android.fhir.FhirEngine
 import com.google.android.fhir.sync.download.DownloadState
 import com.google.android.fhir.sync.download.Downloader
+import com.google.android.fhir.sync.upload.LocalChangesFetchMode
 import com.google.android.fhir.sync.upload.UploadState
 import com.google.android.fhir.sync.upload.Uploader
 import java.time.OffsetDateTime
@@ -129,7 +130,8 @@ internal class FhirSynchronizer(
 
   private suspend fun upload(): SyncResult {
     val exceptions = mutableListOf<ResourceSyncException>()
-    fhirEngine.syncUpload { list ->
+    val localChangesFetchMode = LocalChangesFetchMode.AllChanges
+    fhirEngine.syncUpload(localChangesFetchMode) { list ->
       flow {
         uploader.upload(list).collect { result ->
           when (result) {
diff --git a/engine/src/main/java/com/google/android/fhir/sync/upload/LocalChangeFetcher.kt b/engine/src/main/java/com/google/android/fhir/sync/upload/LocalChangeFetcher.kt
new file mode 100644
index 0000000000..34f8eee4d4
--- /dev/null
+++ b/engine/src/main/java/com/google/android/fhir/sync/upload/LocalChangeFetcher.kt
@@ -0,0 +1,93 @@
+/*
+ * Copyright 2023 Google LLC
+ *
+ * Licensed under the Apache License, Version 2.0 (the "License");
+ * you may not use this file except in compliance with the License.
+ * You may obtain a copy of the License at
+ *
+ *       http://www.apache.org/licenses/LICENSE-2.0
+ *
+ * Unless required by applicable law or agreed to in writing, software
+ * distributed under the License is distributed on an "AS IS" BASIS,
+ * WITHOUT WARRANTIES OR CONDITIONS OF ANY KIND, either express or implied.
+ * See the License for the specific language governing permissions and
+ * limitations under the License.
+ */
+
+package com.google.android.fhir.sync.upload
+
+import com.google.android.fhir.LocalChange
+import com.google.android.fhir.db.Database
+import kotlin.properties.Delegates
+
+/**
+ * Fetches local changes.
+ *
+ * This interface provides methods to check for the existence of further changes, retrieve the next
+ * batch of changes, and get the progress of fetched changes.
+ *
+ * It is marked as internal to keep [Database] unexposed to clients
+ */
+internal interface LocalChangeFetcher {
+
+  /** Represents the initial total number of local changes to upload. */
+  val total: Int
+
+  /** Checks if there are more local changes to be fetched. */
+  suspend fun hasNext(): Boolean
+
+  /** Retrieves the next batch of local changes. */
+  suspend fun next(): List<LocalChange>
+
+  /**
+   * Returns [FetchProgress], which contains the remaining changes left to upload and the initial
+   * total to upload.
+   */
+  suspend fun getProgress(): FetchProgress
+}
+
+data class FetchProgress(
+  val remaining: Int,
+  val initialTotal: Int,
+)
+
+internal class AllChangesLocalChangeFetcher(
+  private val database: Database,
+) : LocalChangeFetcher {
+
+  override var total by Delegates.notNull<Int>()
+
+  suspend fun initTotalCount() {
+    total = database.getLocalChangesCount()
+  }
+
+  override suspend fun hasNext(): Boolean = database.getLocalChangesCount().isNotZero()
+
+  override suspend fun next(): List<LocalChange> = database.getAllLocalChanges()
+
+  override suspend fun getProgress(): FetchProgress =
+    FetchProgress(database.getLocalChangesCount(), total)
+}
+
+/** Represents the mode in which local changes should be fetched. */
+sealed class LocalChangesFetchMode {
+  object AllChanges : LocalChangesFetchMode()
+
+  object PerResource : LocalChangesFetchMode()
+
+  object EarliestChange : LocalChangesFetchMode()
+}
+
+internal object LocalChangeFetcherFactory {
+  suspend fun byMode(
+    mode: LocalChangesFetchMode,
+    database: Database,
+  ): LocalChangeFetcher =
+    when (mode) {
+      is LocalChangesFetchMode.AllChanges ->
+        AllChangesLocalChangeFetcher(database).apply { initTotalCount() }
+      else -> throw NotImplementedError("$mode is not implemented yet.")
+    }
+}
+
+private fun Int.isNotZero() = this != 0
diff --git a/engine/src/main/java/com/google/android/fhir/testing/Utilities.kt b/engine/src/main/java/com/google/android/fhir/testing/Utilities.kt
index 6b7a27ae57..ebd90ab6dc 100644
--- a/engine/src/main/java/com/google/android/fhir/testing/Utilities.kt
+++ b/engine/src/main/java/com/google/android/fhir/testing/Utilities.kt
@@ -33,6 +33,7 @@ import com.google.android.fhir.sync.DownloadRequest
 import com.google.android.fhir.sync.DownloadWorkManager
 import com.google.android.fhir.sync.UploadRequest
 import com.google.android.fhir.sync.UrlDownloadRequest
+import com.google.android.fhir.sync.upload.LocalChangesFetchMode
 import com.google.common.truth.Truth.assertThat
 import java.net.SocketTimeoutException
 import java.time.Instant
@@ -111,7 +112,7 @@ object TestDataSourceImpl : DataSource {
 }
 
 open class TestDownloadManagerImpl(
-  private val queries: List<String> = listOf("Patient?address-city=NAIROBI")
+  private val queries: List<String> = listOf("Patient?address-city=NAIROBI"),
 ) : DownloadWorkManager {
   private val urls = LinkedList(queries)
 
@@ -147,17 +148,17 @@ object TestFhirEngineImpl : FhirEngine {
   }
 
   override suspend fun syncUpload(
-    upload: suspend (List<LocalChange>) -> Flow<Pair<LocalChangeToken, Resource>>
-  ) {
-    upload(getLocalChanges(ResourceType.Patient, "123")).collect()
-  }
+    localChangesFetchMode: LocalChangesFetchMode,
+    upload: suspend (List<LocalChange>) -> Flow<Pair<LocalChangeToken, Resource>>,
+  ) = upload(getLocalChanges(ResourceType.Patient, "123")).collect()
 
   override suspend fun syncDownload(
     conflictResolver: ConflictResolver,
-    download: suspend () -> Flow<List<Resource>>
+    download: suspend () -> Flow<List<Resource>>,
   ) {
     download().collect()
   }
+
   override suspend fun count(search: Search): Long {
     return 0
   }
@@ -176,8 +177,8 @@ object TestFhirEngineImpl : FhirEngine {
         payload = "{ 'resourceType' : 'Patient', 'id' : '123' }",
         token = LocalChangeToken(listOf()),
         type = LocalChange.Type.INSERT,
-        timestamp = Instant.now()
-      )
+        timestamp = Instant.now(),
+      ),
     )
   }
 
diff --git a/engine/src/test/java/com/google/android/fhir/impl/FhirEngineImplTest.kt b/engine/src/test/java/com/google/android/fhir/impl/FhirEngineImplTest.kt
index d19d1b8dfc..fbf400007e 100644
--- a/engine/src/test/java/com/google/android/fhir/impl/FhirEngineImplTest.kt
+++ b/engine/src/test/java/com/google/android/fhir/impl/FhirEngineImplTest.kt
@@ -29,6 +29,7 @@ import com.google.android.fhir.search.LOCAL_LAST_UPDATED_PARAM
 import com.google.android.fhir.search.search
 import com.google.android.fhir.sync.AcceptLocalConflictResolver
 import com.google.android.fhir.sync.AcceptRemoteConflictResolver
+import com.google.android.fhir.sync.upload.LocalChangesFetchMode
 import com.google.android.fhir.testing.assertResourceEquals
 import com.google.android.fhir.testing.assertResourceNotEquals
 import com.google.android.fhir.testing.readFromFile
@@ -85,7 +86,7 @@ class FhirEngineImplTest {
           HumanName().apply {
             family = "FamilyName"
             addGiven("GivenName")
-          }
+          },
         )
       }
     val ids = fhirEngine.create(patient.copy())
@@ -101,7 +102,7 @@ class FhirEngineImplTest {
       }
     assertThat(exception.message)
       .isEqualTo(
-        "Resource not found with type ${TEST_PATIENT_2.resourceType.name} and id $TEST_PATIENT_2_ID!"
+        "Resource not found with type ${TEST_PATIENT_2.resourceType.name} and id $TEST_PATIENT_2_ID!",
       )
   }
 
@@ -160,7 +161,7 @@ class FhirEngineImplTest {
       }
     assertThat(resourceNotFoundException.message)
       .isEqualTo(
-        "Resource not found with type ${ResourceType.Patient.name} and id nonexistent_patient!"
+        "Resource not found with type ${ResourceType.Patient.name} and id nonexistent_patient!",
       )
   }
 
@@ -175,7 +176,7 @@ class FhirEngineImplTest {
       listOf(
         buildPatient("3", "C", Enumerations.AdministrativeGender.FEMALE),
         buildPatient("2", "B", Enumerations.AdministrativeGender.FEMALE),
-        buildPatient("1", "A", Enumerations.AdministrativeGender.MALE)
+        buildPatient("1", "A", Enumerations.AdministrativeGender.MALE),
       )
 
     fhirEngine.create(*patients.toTypedArray())
@@ -184,7 +185,7 @@ class FhirEngineImplTest {
 
     assertThat(result.size).isEqualTo(2)
     assertThat(
-        result.all { (it.resource as Patient).gender == Enumerations.AdministrativeGender.FEMALE }
+        result.all { (it.resource as Patient).gender == Enumerations.AdministrativeGender.FEMALE },
       )
       .isTrue()
   }
@@ -195,7 +196,7 @@ class FhirEngineImplTest {
       listOf(
         buildPatient("3", "C", Enumerations.AdministrativeGender.FEMALE),
         buildPatient("2", "B", Enumerations.AdministrativeGender.FEMALE),
-        buildPatient("1", "A", Enumerations.AdministrativeGender.MALE)
+        buildPatient("1", "A", Enumerations.AdministrativeGender.MALE),
       )
 
     fhirEngine.create(*patients.toTypedArray())
@@ -212,7 +213,7 @@ class FhirEngineImplTest {
       listOf(
         buildPatient("3", "C", Enumerations.AdministrativeGender.FEMALE),
         buildPatient("2", "B", Enumerations.AdministrativeGender.FEMALE),
-        buildPatient("1", "A", Enumerations.AdministrativeGender.MALE)
+        buildPatient("1", "A", Enumerations.AdministrativeGender.MALE),
       )
 
     fhirEngine.create(*patients.toTypedArray())
@@ -258,7 +259,7 @@ class FhirEngineImplTest {
         },
         buildPatient("2", "Patient2", Enumerations.AdministrativeGender.FEMALE).apply {
           meta = Meta().setTag(mutableListOf(Coding("http://d-tree.org/", "Tag2", "Tag 2")))
-        }
+        },
       )
 
     fhirEngine.create(*patients.toTypedArray())
@@ -279,15 +280,15 @@ class FhirEngineImplTest {
               .setProfile(
                 mutableListOf(
                   CanonicalType(
-                    "http://fhir.org/STU3/StructureDefinition/Example-Patient-Profile-1"
-                  )
-                )
+                    "http://fhir.org/STU3/StructureDefinition/Example-Patient-Profile-1",
+                  ),
+                ),
               )
         },
         buildPatient("4", "C", Enumerations.AdministrativeGender.FEMALE).apply {
           meta =
             Meta().setProfile(mutableListOf(CanonicalType("http://d-tree.org/Diabetes-Patient")))
-        }
+        },
       )
 
     fhirEngine.create(*patients.toTypedArray())
@@ -295,7 +296,7 @@ class FhirEngineImplTest {
     val result =
       fhirEngine
         .search(
-          "Patient?_profile=http://fhir.org/STU3/StructureDefinition/Example-Patient-Profile-1"
+          "Patient?_profile=http://fhir.org/STU3/StructureDefinition/Example-Patient-Profile-1",
         )
         .map { it.resource as Patient }
 
@@ -305,7 +306,7 @@ class FhirEngineImplTest {
           patient.meta.profile.all {
             it.value.equals("http://fhir.org/STU3/StructureDefinition/Example-Patient-Profile-1")
           }
-        }
+        },
       )
       .isTrue()
   }
@@ -313,7 +314,7 @@ class FhirEngineImplTest {
   @Test
   fun syncUpload_uploadLocalChange() = runBlocking {
     val localChanges = mutableListOf<LocalChange>()
-    fhirEngine.syncUpload {
+    fhirEngine.syncUpload(LocalChangesFetchMode.AllChanges) {
       flow {
         localChanges.addAll(it)
         emit(LocalChangeToken(it.flatMap { it.token.ids }) to TEST_PATIENT_1)
@@ -321,7 +322,6 @@ class FhirEngineImplTest {
     }
 
     assertThat(localChanges).hasSize(1)
-    // val localChange = localChanges[0].localChange
     with(localChanges[0]) {
       assertThat(this.resourceType).isEqualTo(ResourceType.Patient.toString())
       assertThat(this.resourceId).isEqualTo(TEST_PATIENT_1.id)
@@ -340,7 +340,7 @@ class FhirEngineImplTest {
   private fun buildPatient(
     patientId: String,
     name: String,
-    patientGender: Enumerations.AdministrativeGender
+    patientGender: Enumerations.AdministrativeGender,
   ) =
     Patient().apply {
       id = patientId
@@ -414,7 +414,7 @@ class FhirEngineImplTest {
       assertThat(get(0).payload).isEqualTo(patientString)
     }
     assertResourceEquals(patient, fhirEngine.get(ResourceType.Patient, patient.logicalId))
-    // clear databse
+    // clear database
     runBlocking(Dispatchers.IO) { fhirEngine.clearDatabase() }
     // assert that previously present resource not available after clearing database
     assertThat(fhirEngine.getLocalChanges(patient.resourceType, patient.logicalId)).isEmpty()
@@ -436,7 +436,7 @@ class FhirEngineImplTest {
       }
     assertThat(resourceNotFoundException.message)
       .isEqualTo(
-        "Resource not found with type ${TEST_PATIENT_1.resourceType.name} and id $TEST_PATIENT_1_ID!"
+        "Resource not found with type ${TEST_PATIENT_1.resourceType.name} and id $TEST_PATIENT_1_ID!",
       )
     assertThat(fhirEngine.getLocalChanges(ResourceType.Patient, TEST_PATIENT_1_ID)).isEmpty()
   }
@@ -450,7 +450,7 @@ class FhirEngineImplTest {
         }
       assertThat(resourceIllegalStateException.message)
         .isEqualTo(
-          "Resource with type ${TEST_PATIENT_1.resourceType.name} and id $TEST_PATIENT_1_ID has local changes, either sync with server or FORCE_PURGE required"
+          "Resource with type ${TEST_PATIENT_1.resourceType.name} and id $TEST_PATIENT_1_ID has local changes, either sync with server or FORCE_PURGE required",
         )
     }
 
@@ -462,9 +462,10 @@ class FhirEngineImplTest {
       }
     assertThat(resourceNotFoundException.message)
       .isEqualTo(
-        "Resource not found with type ${TEST_PATIENT_1.resourceType.name} and id nonexistent_patient!"
+        "Resource not found with type ${TEST_PATIENT_1.resourceType.name} and id nonexistent_patient!",
       )
   }
+
   fun syncDownload_conflictResolution_acceptRemote_shouldHaveNoLocalChangeAnymore() = runBlocking {
     val originalPatient =
       Patient().apply {
@@ -478,7 +479,7 @@ class FhirEngineImplTest {
           HumanName().apply {
             family = "Stark"
             addGiven("Tony")
-          }
+          },
         )
       }
     fhirEngine.syncDownload(AcceptRemoteConflictResolver) { flowOf((listOf((originalPatient)))) }
@@ -500,7 +501,7 @@ class FhirEngineImplTest {
     fhirEngine.syncDownload(AcceptRemoteConflictResolver) { flowOf((listOf(remoteChange))) }
 
     assertThat(
-        services.database.getAllLocalChanges().filter { it.resourceId == "Patient/original-001" }
+        services.database.getAllLocalChanges().filter { it.resourceId == "Patient/original-001" },
       )
       .isEmpty()
     assertResourceEquals(fhirEngine.get<Patient>("original-001"), remoteChange)
@@ -521,7 +522,7 @@ class FhirEngineImplTest {
             HumanName().apply {
               family = "Stark"
               addGiven("Tony")
-            }
+            },
           )
         }
       fhirEngine.syncDownload(AcceptLocalConflictResolver) { flowOf((listOf((originalPatient)))) }
@@ -535,7 +536,7 @@ class FhirEngineImplTest {
             Address().apply {
               city = "Malibu"
               state = "California"
-            }
+            },
           )
         }
       fhirEngine.update(localChange)
@@ -555,7 +556,7 @@ class FhirEngineImplTest {
       val localChangeDiff =
         """[{"op":"remove","path":"\/address\/0\/country"},{"op":"add","path":"\/address\/0\/city","value":"Malibu"},{"op":"add","path":"\/address\/-","value":{"city":"Malibu","state":"California"}}]"""
       assertThat(
-          services.database.getAllLocalChanges().first { it.resourceId == "original-002" }.payload
+          services.database.getAllLocalChanges().first { it.resourceId == "original-002" }.payload,
         )
         .isEqualTo(localChangeDiff)
       assertResourceEquals(fhirEngine.get<Patient>("original-002"), localChange)
@@ -575,7 +576,7 @@ class FhirEngineImplTest {
           {
             value = of(DateTimeType(Date.from(localChangeTimestamp)))
             prefix = ParamPrefixEnum.EQUAL
-          }
+          },
         )
       }
 
@@ -597,7 +598,7 @@ class FhirEngineImplTest {
             HumanName().apply {
               addGiven("John")
               family = "Doe"
-            }
+            },
           )
         }
       fhirEngine.update(patientUpdate)
@@ -611,7 +612,7 @@ class FhirEngineImplTest {
             {
               value = of(DateTimeType(Date.from(localChangeTimestampWhenUpdated)))
               prefix = ParamPrefixEnum.EQUAL
-            }
+            },
           )
         }
 
diff --git a/engine/src/test/java/com/google/android/fhir/sync/upload/AllChangesLocalChangeFetcherTest.kt b/engine/src/test/java/com/google/android/fhir/sync/upload/AllChangesLocalChangeFetcherTest.kt
new file mode 100644
index 0000000000..b14637f446
--- /dev/null
+++ b/engine/src/test/java/com/google/android/fhir/sync/upload/AllChangesLocalChangeFetcherTest.kt
@@ -0,0 +1,97 @@
+/*
+ * Copyright 2023 Google LLC
+ *
+ * Licensed under the Apache License, Version 2.0 (the "License");
+ * you may not use this file except in compliance with the License.
+ * You may obtain a copy of the License at
+ *
+ *       http://www.apache.org/licenses/LICENSE-2.0
+ *
+ * Unless required by applicable law or agreed to in writing, software
+ * distributed under the License is distributed on an "AS IS" BASIS,
+ * WITHOUT WARRANTIES OR CONDITIONS OF ANY KIND, either express or implied.
+ * See the License for the specific language governing permissions and
+ * limitations under the License.
+ */
+
+package com.google.android.fhir.sync.upload
+
+import androidx.test.core.app.ApplicationProvider
+import com.google.android.fhir.FhirServices
+import com.google.common.truth.Truth.assertThat
+import java.util.Date
+import kotlinx.coroutines.test.runTest
+import org.hl7.fhir.r4.model.Enumerations
+import org.hl7.fhir.r4.model.Meta
+import org.hl7.fhir.r4.model.Patient
+import org.junit.Before
+import org.junit.Test
+import org.junit.runner.RunWith
+import org.robolectric.RobolectricTestRunner
+
+@RunWith(RobolectricTestRunner::class)
+class AllChangesLocalChangeFetcherTest {
+  private val services =
+    FhirServices.builder(ApplicationProvider.getApplicationContext()).inMemory().build()
+  private val database = services.database
+  private lateinit var fetcher: AllChangesLocalChangeFetcher
+
+  @Before
+  fun setup() = runTest {
+    database.insert(TEST_PATIENT_1, TEST_PATIENT_2)
+    fetcher = AllChangesLocalChangeFetcher(database).apply { initTotalCount() }
+  }
+
+  @Test
+  fun `next returns all the localChanges`() = runTest {
+    val localChanges = fetcher.next()
+    assertThat(fetcher.next().size).isEqualTo(2)
+    assertThat(localChanges.map { it.resourceId })
+      .containsExactly(TEST_PATIENT_1_ID, TEST_PATIENT_2_ID)
+  }
+
+  @Test
+  fun `hasNext returns true when there are local changes`() = runTest {
+    assertThat(fetcher.hasNext()).isTrue()
+  }
+
+  @Test
+  fun `hasNext returns false when there are no local changes`() = runTest {
+    database.deleteUpdates(listOf(TEST_PATIENT_1, TEST_PATIENT_2))
+    assertThat(fetcher.hasNext()).isFalse()
+  }
+
+  @Test
+  fun `getProgress when all local changes are removed`() = runTest {
+    database.deleteUpdates(listOf(TEST_PATIENT_1, TEST_PATIENT_2))
+    assertThat(fetcher.getProgress()).isEqualTo(FetchProgress(0, 2))
+  }
+
+  @Test
+  fun `getProgress when half the local changes are removed`() = runTest {
+    database.deleteUpdates(listOf(TEST_PATIENT_1))
+    assertThat(fetcher.getProgress()).isEqualTo(FetchProgress(1, 2))
+  }
+
+  @Test
+  fun `getProgress when none of the local changes are removed`() = runTest {
+    assertThat(fetcher.getProgress()).isEqualTo(FetchProgress(2, 2))
+  }
+
+  companion object {
+    private const val TEST_PATIENT_1_ID = "test_patient_1"
+    private var TEST_PATIENT_1 =
+      Patient().apply {
+        id = TEST_PATIENT_1_ID
+        gender = Enumerations.AdministrativeGender.MALE
+      }
+
+    private const val TEST_PATIENT_2_ID = "test_patient_2"
+    private var TEST_PATIENT_2 =
+      Patient().apply {
+        id = TEST_PATIENT_2_ID
+        gender = Enumerations.AdministrativeGender.MALE
+        meta = Meta().apply { lastUpdated = Date() }
+      }
+  }
+}