SMART on FHIR: a standards-based, interoperable apps platform for electronic health records

Abstract

Objective: In early 2010, Harvard Medical School and Boston Children's Hospital began an interoperability project with the distinctive goal of developing a platform to enable medical applications to be written once and run unmodified across different healthcare IT systems. The project was called Substitutable Medical Applications and Reusable Technologies (SMART).

Methods: We adopted contemporary web standards for application programming interface transport, authorization, and user interface, and standard medical terminologies for coded data. In our initial design, we created our own openly licensed clinical data models to enforce consistency and simplicity. During the second half of 2013, we updated SMART to take advantage of the clinical data models and the application-programming interface described in a new, openly licensed Health Level Seven draft standard called Fast Health Interoperability Resources (FHIR). Signaling our adoption of the emerging FHIR standard, we called the new platform SMART on FHIR.

Results: We introduced the SMART on FHIR platform with a demonstration that included several commercial healthcare IT vendors and app developers showcasing prototypes at the Health Information Management Systems Society conference in February 2014. This established the feasibility of SMART on FHIR, while highlighting the need for commonly accepted pragmatic constraints on the base FHIR specification.

Conclusion: In this paper, we describe the creation of SMART on FHIR, relate the experience of the vendors and developers who built SMART on FHIR prototypes, and discuss some challenges in going from early industry prototyping to industry-wide production use.

Keywords: Electronic Health Records; HL7 FHIR; Information Storage and Retrieval; Interoperability; Software.

© The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association.

Figures

Figure 1:

AFHIR Observation Resource Definition for systolic blood pressure with example in JSON.

Figure 2:

SMART on FHIR use of OAuth2 for access delegation.

Figure 3:

ActiveMedication List app sample code with sample output.

Figure 4:

SMART on FHIR Apps at HIMSS14. (a) Bilirubin App by Intermountain Healthcare uses time of birth and serum bilirubin levels to monitor and flag risk for kernicterus; (b) Cardiac Risk App by SMART Health IT uses cholesterol lab, demographics, and other risk factors to estimate aggregate risks (concept by David McCandless and Stephanie Posovek),; (c) Meducation App by Polyglot Systems, Inc. uses a medication list to produce patient-friendly instructions in 12 languages; (d) Pediatric Blood Pressure Centiles App by SMART Health IT uses age, gender, height, and blood pressure data to graph trends and flag hypertension per NIH guidelines (specified and used by Boston Children’s Hospital clinicians); (e) Pediatric Growth Chart App by SMART Health IT uses gender, date of birth, available height, weight, head circumference, and body mass index data to plot growth against CDC, WHO, and disease-specific statistical norms; (f) VisualDx App by VisualDx, Inc. uses age, gender, problem list, and a medication list to provide diagnostic CDS (medication-induced disease and adverse events) and general differential diagnosis through visualization of disease. (Images courtesy of their respective authors.)