SMART on FHIR: Unleashing the Potential of Health Data

Dive into the transformative role of SMART on FHIR in achieving seamless healthcare data exchange. This article unpacks how the SMART platform and FHIR standard synergize to bolster interoperability, offering insights into the architecture, benefits for healthcare entities, and popular apps harnessing its capabilities.

The integration of SMART on FHIR technology into healthcare systems has become increasingly critical, with a consensus among healthcare executives highlighting data interoperability as a paramount priority. Recognizing this need, our team has focused on enhancing the capabilities of the Kodjin FHIR Server by implementing SMART on FHIR support. This implementation addresses the challenges presented by the fragmented digital healthcare landscape, facilitating a smoother and more secure exchange of clinical data across different systems.

SMART on FHIR empowers developers to craft and deploy medical applications capable of seamless interaction with health records through a well-defined authorization flow. This flow is meticulously designed to ensure the security of patient data while prioritizing user consent and privacy.

Below, we will explain how SMART works with FHIR, illustrate a SMART on FHIR architecture with the authorization flow example, and talk about the value healthcare organizations gain from leveraging these standards.

What is SMART on FHIR?

SMART on FHIR in healthcare is a set of open standards and specifications that work in conjunction to provide means by which healthcare IT professionals can create and seamlessly integrate healthcare apps

SMART on FHIR framework stands for and combines:

  • FHIR (Fast Healthcare Interoperability Resource) is an open specification developed by the HL7 that standardizes how healthcare information is represented, stored, and exchanged between different clinical data systems.
  • The SMART (Substitutable Medical Applications and Reusable Technologies) platform standardizes authorization and authentication to enable third-party applications to connect to healthcare systems (primarily EHRs). SMART was born to enable “interchangeable healthcare applications,” meaning any developer could create a healthcare app that would integrate and work with any healthcare organization. The aim was to make it especially easy for providers to try out different solutions and find the one that fits their needs best. The platform acts as a security layer built on top of FHIR-based systems.

Together, SMART on FHIR offers a robust and flexible framework for developers and healthcare providers. It enables the development of apps that can be easily integrated into existing healthcare systems.

“The goal of SMART is audacious and can be expressed concisely: an innovative app developer can write an app once, and expect that it will run anywhere in the healthcare system,” said Kenneth D. Mandl, MD, MPH Chair of the SMART Advisory Committee

Some of the SMART on FHIR applications:

  • Access to a standardized format of patient data.
  • Improved patient engagement through personalized apps.
  • Enhanced data analytics and decision support tools.
  • Streamlined clinical workflows.
  • Increased interoperability among different health IT systems.

The SMART on FHIR framework is increasingly becoming a key component in modern healthcare informatics, promoting better health data exchange and utilization.

How does SMART on FHIR architecture work?

To best understand how SMART on FHIR works and its many advantages, we’ll describe the authorization process that SMART-compliant FHIR servers adhere to.

SMART on FHIR architecture implements the OAuth2.0 with OpenID Connect, a widely-used authorization and identity management protocol. It’s familiar to many users, as the same protocol allows you to use «Login with Google» or «Login with Facebook» on various websites or applications. In the context of SMART on FHIR in healthcare, however, the role of Google or Facebook as the authorization server is taken by SMART-compliant authorization servers such as Keycloak or Okta, for example.

To describe the authorization flow, let’s say there’s a mobile app that wants to access patient information to display a historical heart rate graph. When a user installs this app and wants to sign up, they are redirected to the authorization server with a login screen that asks them to approve the necessary permissions called scopes.

SMART on FHIR scopes are used to delegate specific access rights to third-party applications. There are patient-specific, user-specific, and system-specific level scopes that can be granted various permissions such as .read, .write, and .* (SMART on FHIR version 1.0.0)  or *.cruds (SMART on FHIR version 2.0.0).

(It’s important to note that scopes are app permissions, meaning a user might have write permissions, but if the app does not, it cannot write any data on the user’s behalf.)

If the login is successful, the authorization server provides a temporary authorization token that can be used by the mobile app to request an access token. The access token is an encrypted and digitally signed piece of information containing crucial information in an FHIR-compliant format, such as who the token was issued by, its expiration date, scope, etc.

The mobile FHIR app sends the access token to the FHIR server, which then validates it through the authorization server. If the operation is successful, the app is granted permission to read the requested information and display it to the user.

The following diagram demonstrates the necessary steps in the SMART on FHIR authorization process:

The diagram demonstrates the necessary steps in the SMART on FHIR authorization process

The authorization process we described also involves user authorization, but it’s not always necessary for SMART apps to involve a user in the access permission process. It’s also possible to set up non-interactive user processes. However, the main principles of SMART on FHIR remain the same.

The Benefits of Smart on FHIR Protocols

Now that we’ve learned what the SMART on FHIR framework is and how it works, let’s talk about the advantages it brings to hospitals, clinicians, healthcare developers, and patients:

  • Streamlined Development: SMART on FHIR considerably reduces the costs and time of new app development and integrations. Developers can better focus on building useful applications instead of being preoccupied with implementations since instead of developing new software for EHR systems, users or implementers can choose from a catalog of published solutions and use them in their solution. These can be all kinds of clinical calculators, for example.
  • Secure and Efficient Data Sharing: Thanks to the SMART authorization and authentication flows, sharing data between various healthcare systems and applications can be done in a fast and secure manner. The standard oAuth 2.0 protocol as implemented by OIDC brings to FHIR a technology widely used in the web application industry. This means that system developers and integrators do not need to develop customized or proprietary tools to ensure secure connections when solving EHR interoperability issues. That is why SMART on FHIR authentication is considered the best in this regard.
  • Simplified EHR Integration: Electronic Health Record (EHR) systems are central to modern healthcare, facilitating the management and exchange of patient information. However, integrating different EHR systems or adding new functionalities often presents significant challenges, including compatibility issues, complex data formats, and stringent security requirements. SMART on FHIR addresses these issues head-on, simplifying the integration process and enhancing the ability to share healthcare data across varied systems.
  • Enabling Substitutability: The main idea behind SMART on FHIR integration is to provide “substitutability,” as such EHR systems can phase out legacy applications that have become obsolete without losing any underlying data.
  • Enhanced Patient Care: Since SMART on FHIR standardized the implementation of apps, clinicians have a better choice of applications available to them that support administrative and clinical workflow instead of being limited by implementation costs and time. This allows them to provide better care. Patients also benefit from this, as their entire medical history can be made available just a couple of clicks away.

Use Cases of SMART

The SMART on FHIR framework enables a wide range of use cases, each designed to enhance different aspects of healthcare delivery and patient care. From supporting clinicians with advanced decision-making tools to empowering patients with access to their own health data, the applications of SMART extend across the healthcare continuum. Here’s a closer look at some of the key areas where SMART is making an impact:

  • Clinical Decision Support: SMART on FHIR applications can provide real-time, evidence-based recommendations to clinicians within their workflow, helping improve the quality of care and patient outcomes.
  • Patient Engagement and Education: By accessing their health records through patient-facing apps, individuals can better understand and manage their health conditions, leading to increased patient engagement and satisfaction.
  • Population Health Management: SMART on FHIR applications can analyze data across a patient population to identify trends, risk factors, and opportunities for preventive care, supporting efforts to improve public health outcomes.
  • Research and Data Analysis: Researchers can use apps to access large datasets for analysis, facilitating medical research and the development of new treatments and interventions.
  • Telehealth and Remote Monitoring: Enables the development of apps that support remote care delivery and patient monitoring, expanding access to healthcare services and reducing the need for in-person visits.
  • Personalized Medicine: By integrating genomic data and other personalized health information, apps can support tailored treatment plans that are optimized for individual patient characteristics.

What about SMART on FHIR app development?

SMART on FHIR offers a range of benefits to software developers in the healthcare industry. Typically when a healthcare organization wants to integrate another application to extend their EHR system capabilities, a lot of time and money need to be spent on custom development. But with SMART on FHIR support, which offers standardized plug-and-play connections, EHR can work seamlessly with any app built with SMART. This significantly reduces the time and costs of integrating third-party apps with EHR systems.

Furthermore, SMART decouples the protocols for accessing EHRs from a piece of software itself. This means that healthcare IT developers can improve their products and services without worrying about how it will impact the way patients and providers access their data. As a result, this ensures a faster development of healthcare applications, which further improves the quality of the entire marketplace.

SMART also simplifies app development by eliminating the need to build custom connections to each EHR database. Developers can now develop their apps once using SMART, and those apps will work with any EHR databases built with SMART. This broadens the reach of their SMART on FHIR applications to a wider audience of health organizations and consumers, making them more useful and beneficial.

Overall, SMART on FHIR applications provides a standardized platform for accessing and exchanging patient health data.

Popular SMART on FHIR apps

There are many SMART on FHIR apps available that are used by healthcare providers, patients, and researchers. Here are some popular examples:

Growth Chart

An example of the Growth Chart App interface.
Source: https://apps.smarthealthit.org/app/growth-chart

A collaboration between SMART, Fjord service design consultancy, Interopion software development group, and clinicians resulted in the development of the Growth Chart app. This app features a streamlined, high-performance interface that presents a child’s growth over time with minimal clicks required.

The data in the app can be represented in three ways: charts, tables, and the Parental View, which is designed for individuals without extensive medical knowledge, such as parents of the child.

The charts view is the most intricate, offering a unique set of features:

  • It can display multiple charts in an organized manner, regardless of the data type.
  • It includes time navigation and zoom capabilities, allowing users to explore different segments of the data.
  • It can display three types of data simultaneously, including patient measurements and up to two additional datasets, enabling comparison to statistical averages.
  • It features an interactive selection function, enabling users to click on the canvas to select a point in time and view details of records near that time. Users can also compare other points with the current selection by moving the mouse over them.

CommonHealth

Commonhealth app interface
Source: https://www.commonhealth.org/

Another example of SMART on FHIR applications is the Commons Project, a nonprofit public trust committed to protecting privacy developed the CommonHealth app. This platform enables individuals to collect and manage their personal health data and share it with trusted health services, organizations, and apps.

CommonHealth supports digital vaccine records in the form of SMART Health Cards, and is linked to over 700 data sources (including reputable healthcare institutions such as Mayo Clinic, Cleveland Clinic, and New York-Presbyterian). Once a healthcare provider is connected to CommonHealth, users can opt to share their health records and data with apps and services verified by CommonHealth for security and reliability.

CommonHealth provides users with several key benefits:

  • Convenient access to health information: With CommonHealth, users can access their health information anytime, anywhere, and share it with trusted individuals.
  • Comprehensive health information management: Users can import health data from multiple providers and gain a holistic view of their health information. CommonHealth helps patients and the care team understand the patient’s health better.
  • Data privacy and control: Users are in charge of their data with CommonHealth. Personal data is stored solely on the user’s device, not in the cloud. CommonHealth does not sell, use, or share your data for marketing or advertising purposes without consent.

Cardiac Risk

Example of the Cardiac Risk SMART app interface showing patient information and cardiac risk prediction.
Source: https://apps.smarthealthit.org/app/cardiac-risk

The SMART Cardiac Risk app is a tool designed to simplify the calculation and reporting of the widely-used Reynolds Risk Score. With its intuitive and patient-friendly interface, this app presents relevant patient vitals and lab measurements, along with the calculated Reynolds Risk Score and a succinct, easy-to-understand explanation of each result.

The SMART Cardiac Risk app also offers simulation capabilities, allowing clinicians or patients to make changes to one or more of the patient’s vitals or lab results to see how their current Reynolds Risk Score could be improved.

What is the Future of SMART on FHIR?

The future of SMART on FHIR in healthcare looks promising. The SMART team has successfully lobbied for language in the 21st Century Cures Act that requires a universal API for health information technology, providing access to all elements of a patient’s record with no special effort. Now for ONC-certified health IT, SMART’s API is now a requirement, and health systems that accept Medicare or Medicaid must also adopt SMART.

In addition, the SMART ecosystem is continually expanding with the development of new projects. CDS Hooks, launched in 2015, allows for third-party decision support services to be triggered. The Sandbox, federally funded in 2016, provides de-identified data to support app development and demonstration.

The team has also designed a standard and suite of tools for the export of large population datasets from electronic health record systems – SMART Flat FHIR/Bulk Data Export.

Moreover, SMART Markers, a standards-based software framework for creating health system-integrated apps for patient-generated health data, is encapsulating the functionality needed for rapid deployment of both patient- and practitioner-facing PGHD apps.

Overall, the continued development and adoption of SMART on FHIR in healthcare bodes well for increased interoperability, improved patient outcomes, and a more efficient and effective healthcare system.

Takeaway

The integration of SMART on FHIR is essential for modern healthcare organizations seeking enhanced data interoperability and streamlined patient care processes.

Our Kodjin FHIR server excels in offering convenience and ease-of-use for integrating SMART on FHIR applications. With our specialized FHIR development services, we provide a straightforward path for healthcare organizations to leverage the power of FHIR standards, ensuring seamless data exchange and improved clinical decision-making.

Kodjin’s out-of-the-box support for SMART-on-FHIR allows you to integrate any apps necessary, enabling your organization to focus on what matters most – delivering exceptional patient care instead of development.

FAQ

What is Smart on FHIR?

Smart on FHIR is a technology that enables seamless communication, bulk data export and data exchange between healthcare systems.

How does Smart on FHIR facilitate healthcare interoperability?

Smart on FHIR provides a standard framework for applications to access and exchange health information in a secure and efficient manner, thereby improving healthcare interoperability.

What types of healthcare organizations can benefit from Smart on FHIR?

Smart on FHIR can benefit a wide range of healthcare organizations, including hospitals, clinics, research institutions, and health IT companies.

Is Smart on FHIR widely adopted in the healthcare industry?

Yes, Smart on FHIR is gaining traction in the healthcare industry and is being adopted by healthcare organizations and health IT vendors worldwide.

Post author

Stanislav Ostrovskiy

Partner, Business Development at Edenlab

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