App store for EHRs may be reality in not so distant future
Kevin R.Dufendach, M.D., M.S., FAAP
Health IT Trends
Since Apple released its first iPhone in 2007, the smartphone has become a ubiquitous,
indispensable technology. Part of the rapid success of iOS and Android has been the
way the two platforms facilitate innovative development and delivery of integrated
On the front end, users can choose specific applications to meet their needs. On the
back end, each application is granted only limited access to data and system resources,
which helps ensure device security. SMART on FHIR seeks to bring similar technology
to health care, allowing innovators to create apps that run seamlessly and securely
in a variety of electronic health record (EHR) environments.
SMART on FHIR is an amalgamation of two primary technologies. SMART stands for substitutable
medical applications, reusable technologies, and FHIR stands for fast health care
SMART focuses on authorization (establishing what information an individual is allowed
to access) and authentication (establishing that individuals really are who they say
they are). To achieve this, SMART uses the OAuth standard, which is the same technology
behind a “Login with Facebook” or “Login with Google” button on a website. A SMART
application authenticates using existing credentials, such as a patient’s online portal
login or a provider’s active EHR session, to allow access to authorized EHR data.
However, obtaining access to the data is only half the problem, as individual EHR
systems speak a variety of internal languages. This is where FHIR becomes useful,
as it represents an open, common language that allows computers to exchange information.
FHIR specifies exactly where and how data should be communicated, and then SMART defines a set of “profiles” to ensure
apps know exactly what data elements should be included to ensure the data are useful. This combination is
what allows SMART on FHIR to provide an application programming interface (API) for
an EHR. For example, a developer can use the API to create a growth chart app that
retrieves a specific patient’s name, birthday, sex and all weight measurements and
displays them to the patient.
Another key to SMART is the concept of substitutability. A SMART app is intended to
give users options, much like you have when choosing a web browser. Most EHRs include
a growth chart application. But what other options do you have, besides asking your
understaffed information services team to create a custom design for you? SMART apps
seek to give users options through substitutability, whereby a user or institution
could choose an alternate application or feature through an EHR app store or repository.
Patients also have options when it comes to accessing their data through SMART on
FHIR apps. A patient or caregiver may want an app for viewing age-specific health
and safety recommendations, managing chronic disease, keeping track of medications
or accessing inpatient acute care data. In this case, the patient connects the app
to the EHR and uses his or her own existing credentials to log in. As long as the
appropriate APIs and authorization protocols are in place, the EHR doesn’t need to
know anything specific about the app that will be accessing the data. It just needs
to share the secret SMART on FHIR handshake.
Currently, SMART on FHIR is generating a large amount of excitement. Several EHR vendors
are supporting the API to varying degrees, and health care systems and commercial
companies are creating applications. A recent proof of concept demonstration at the
AMIA (American Medical Informatics Association) 2016 Annual Symposium displayed how
the technology could be used to access external clinical decision support recommendations
and display them natively in two separate vended EHR systems (http://cds-hooks.org/).
SMART Health IT hosts an App Gallery that includes live examples, such as the pediatric-focused
growth and bilirubin chart apps (https://apps.smarthealthit.org/).
Still, the technology is considered early or experimental. Providers as well as vendors
continue to work on some of the more complicated nuances of the system, including
how to incorporate write access (putting information into the EHR) through the SMART
on FHIR platform, how to distribute apps to various end users, and how to govern which
apps are safe and appropriate to include in a medical record. To this point, only
a few medical centers have implemented the necessary infrastructure and incorporated
apps into clinical care.
SMART on FHIR continues to gain momentum in the world of health information technology.
It has the potential to bring innovation, competition and collaboration into the health
care field for both patients and providers. As more medical systems implement the
necessary infrastructure, we likely will find ourselves interacting with an increasing
number of connected apps as we care for children.
Dr. Dufendach is a member of the AAP Council on Clinical Information Technology.