What is SMART on FHIR Apps? - Ushering in a new era of standards based interoperable health app platform

The current healthcare scenario expects a seamless omnichannel or a “digital front door” which is essential in order to deliver the personalized, value-based healthcare. In practice, however, implementing this digital front door strategy is challenging for most healthcare systems, due to the fragmented nature of healthcare information.

The birth of SMART on FHIR era 

Thousands of healthcare apps exist and can be easily downloaded but getting them to work with an existing backend system is not easy as apps come with their proprietary databases, data models, and interfaces. Each new app deployed immediately becomes a legacy product, creating silos of data throughout the organization each connected to the main database with individual integrations. 

While FHIR revolutionized the exchange of data in real time with its incremental structure and RESTful architecture, it had few limitations as well. FHIR only defined the data models, ontologies, and the method to exchange the information with a FHIR server but did not define the security mechanism to access the data. 

To close this gap the SMART Health IT project was developed which created the SMART app platform. The SMART Health IT Project was launched with an idea. The idea was to have a universal API (application programming interface) transform electronic health records (EHRs) into platforms for substitutable applications. Substituting applications gives providers the freedom to try out different technology solutions and to pick what works best for them.

SMART is an acronym for Substitutable Medical Applications and Reusable Technologies and is a platform which promises to solve these data fragmentation challenges by standardizing how patient data is accessed and shared. SMART framework has now become a standard to facilitate the development of interchangeable healthcare applications compatible with any healthcare organization, regardless of EHR.

The SMART app platform builds on the existing FHIR standard, hence known as “SMART on FHIR”.

In the SMART on FHIR framework SMART handles the application side while FHIR is all about the data. Together, the SMART on FHIR creates a complete framework to build healthcare applications that runs across any healthcare system with a seamless user experience for the clinicians, in a secure manner, without having to create custom, non-standard applications.

Any technology built with SMART works with any EHR database using SMART. As a result, healthcare technology becomes interchangeable, allowing health systems and patients to access data on the applications that best suit their needs, rather than only the ones that work with the EHR database they use.

Following are some of the highlights:

• FHIR standardizes data, while SMART standardizes data access.
• FHIR standardizes the representation of clinical concepts such as allergies and medications in any clinical application such as an EHR.
• SMART standardizes the process through which a third-party application could plug into a clinical application and access that clinical information. It provides a security layer that sits on top of FHIR interfaces, giving approved applications access to the data within an EHR or any other SMART on FHIR compliant repository using OAuth2.0 and OpenID Connect.
• SMART provides open-source tools and libraries for developers that make it easier to use SMART standards during application development as well as a free sandbox that helps developers test their apps before deployment
• SMART provides an application gallery that displays all of the existing healthcare applications that currently uses SMART on FHIR's platform.

Components

SMART constrains FHIR with “SMART based” profiles and adds standard authorization and authentication technologies (OAuth 2.0 and OpenID Connect) as well as EHR UI integration patterns to provide an open health app platform. The deep integration permits the inclusion of SMART-enabled HTML apps directly into the clinical workflow as a plug-and-play” solution.

Following are the components:

1. Authorization

OAuth2 is a Web standard for authorization. Its key function is to enable an end user such as a patient or a clinician to approve a third-party app to access a specific set of data from a clinical application such as an EHR. SMART on FHIR specifies how apps obtain authorization tokens transmitted via OAuth 2 technology. The scope of access tokens is kept narrow so that, an app working with a patient record requests a limited data access that is only valid for querying that patient's data. 

2. Authentication

OpenID Connect is a Web standard for authentication. It allows end users to sign into apps using external identity providers. OpenID Connect provides the ability to sign in to the app without the need to open a new account each time an app is opened. Once logged in the users can then switch between different health apps that share PHI data without signing in individually into every single app. These apps will work with the EHRs eliminating the need to toggle between tabs, windows, or extra portals.

3. UX integration

UX integration of SMART on FHIR puts the user experience of an app inside the clinician’s workflow such as EHR. The app would be already aware of the context within the workflow such as the patient record. UX integration will embed an app within an EHR such that it already knows about the patient context. If there is a growth chart app running with the patient record open, the growth chart app would know the patient in context.

4. Implementation

Launching an app outside the EHR such as the Home screen of a mobile device: Standalone launch

In this workflow user launches an app in the device and the connection process begins. The EHR will need to sign in and authorize the user. Post signing in, the EHR will display an authorization screen in which it seeks the user’s permission to access the data. Upon getting approval the user will be redirected to the app which gets some information that it can use to access the desired data, namely an access token, user ID token, and information about the context like the patient record that is currently opened in the EHR. With this information it begins to interact with the FHIR API in the EHR system. It sends a request to fetch the demographics or the lab results of the patient in context. The FHIR API will then respond with the appropriate FHIR Resources back to the app.