SMART on FHIR: Unlocking Digital Health

The first major innovation of recent was FHIR, a framework to allow real-time use of patient and provider data by external applications first published by Health Level Seven (HL7) International in February 2014. While it is hard enough to define a standard, it is even harder to entice broad and consistent adoption. By starting with practical use cases and a focus on implementer-driven evolution, it has managed to achieve integration across all the major EMR vendors through the Argonaut FHIR testing project. Today, the majority of US physicians use an EMR from a vendor supporting FHIR. Many, like Epic and Cerner, provide open documentation on how to leverage the interoperability features they have released.

Less heralded but potentially even more impactful than FHIR is the “Substitutable Medical Apps, Reusable Technology” framework, more commonly known as SMART. While often coupled with FHIR in the very formidable-sounding construction “SMART on FHIR”, the power of SMART is far greater than merely an authorization framework to allow FHIR-based data exchange. It signals a shift in a mindset from the EHR as a closed ecosystem to a framework where third-party applications can easily plug into and extend the functionality offered by the EMR, while still maintaining the familiar EMR as the core of the workflow.

SMART provides a standard mechanism for a third-party application to be embedded within the EMR, using single sign-on and context to create a seamless physician experience. These applications may choose to take advantage of FHIR, but they are not necessarily limited to the data that are contained in FHIR resources. Applications are free to source data in the most appropriate manner for their use case, be it HL7 v2.x, C-CDA, or even good-old-fashioned flat file dump, which is still the only way to retrieve many critical data that aren’t supported by HL7 standards. They can also extend their interactions with the EMR through proprietary mechanisms where appropriate, or plan for promising new proto-standards such as CDS Hooks. This allows health systems to add applications that bring exciting features without having to roll out “another system” to their overburdened physician base.

In addition to these innovations in the private sector, movement towards effective healthcare interoperability has been driven through government mandates stemming from the Meaningful Use provisions included as part of the 2009 American Reinvestment & Recovery Act (ARRA). The final rule for stage 3 requires patients to be able to access their information via an API.  While FHIR API’s are not explicitly named, they are currently the most widely adopted standard in HIT.

As app developers and integration geeks ourselves, we at Agathos are excited and optimistic not only about what all of this means for our ability to provide physicians easy access to transparent and fairly measured performance data, but also for these and other open standards to catalyze innovation in healthcare.