SMART on FHIR in Healthcare: Everything You Need to Know

It’s hard to imagine a medical application that operates with electronic health records without SMART on FHIR. Don’t get me wrong, they do exist, but they aren’t easy to maintain, not to mention how painful and costly it is to integrate them with some custom EHR systems. Sustainability, interoperability, and security are the three pillars of modern healthcare, which explains how important and popular SMART on FHIR is nowadays.

So what is SMART on FHIR? The short answer is that SMART on FHIR is a set of open specifications that regulate the development of healthcare apps integrated with EHR systems . These specifications allow us to use plug-in applications and run them inside any EHR that complies with HIPAA. Continue reading and learn about the limitations, implementation, use cases, SMART on FHIR applications, SMART on FHIR app development, and the future of SMART on FHIR.

SMART and FHIR: a brief overview

Unintegrated siloed healthcare apps generate little value compared to those integrated with other digital solutions like clinical support or EHR systems. To make more use of healthcare data and improve healthcare outcomes, clinics, and healthcare service providers really need the EHR to travel freely between medical apps. This is where we first meet Fast Healthcare Interoperability Resources , also known as FHIR. To understand the value of SMART on FHIR, we should first learn what FHIR is.

So what is FHIR?

The FHIR standard defines the type and format of health data for digital solutions and apps that want to share this data. FHIR was developed by a non-profit organization called HL7, which specializes in creating standards for healthcare data interoperability. Here's how the FHIR API works:

1. An app needs to fetch patient vitals from electronic health records
2. It checks what kind of data is available
3. Looks which command it should send to request data from EHR
4. Figures which responses the app can receive to process them adequately

What is SMART?

SMART stands for Substitutable Medical Applications, Reusable Technologies and is a specification framework developed by data interoperability enthusiasts who recently started collaborating with FHIR/HL7. Before SMART on FHIR was a thing, vendors had to go and ask programmers to develop a new app to access EHR data since APIs they were using were closed.

So to overcome those complications, HL7 developed the first version of SMART. It happened in 2010 when smartphone innovations became a big thing. The creators were looking for ways of exchanging health data swiftly and securely. SMART allowed healthcare service providers to try out new apps programmed by various vendors and move on when the solutions failed to help them run operations well.

SMART was incorporated into the 21st Century Cures Act in 2016. IT SMART API is a universal API for ONC-certified health, but it is not compulsory for private businesses not affiliated with government apps. CMS lists SMART on FHIR as a mandatory standard for those health systems that accept Medicaid and Medicare.

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How do SMART and FHIR come together?

The birth of SMART on FHIR named a new era in healthcare solutions development. It accelerated the engineering process and simplified SMART on FHIR integration with EHR and medical software. But what does SMART on FHIR stand for? To be precise, it’s Substitutable Medical Applications, Reusable Technologies on Fast Healthcare Interoperability Resources. SMART relies on the way FHIR standardizes data and, at the same time, provides an additional authorization layer.

As of now, SMART on FHIR is an open and standardized means of exchanging data between EHR systems, data sources, and medical software. On the SMART side, there's an app gallery and a sandbox for testing.

So why do programmers love SMART on FHIR? First of all, it shares data in a predictable format which generates fewer bugs during data processing. Secondly, programmers work with concrete data objects, which accelerates the SMART on FHIR app development process.

Tech-wise, SMART on FHIR delivers many benefits, such as app reusability, big app gallery, and open standards. That is why SMART on FHIR is widely adopted. Let's take a closer look at the list of benefits.

1. SMART on FHIR has an ever-growing app gallery of providers and patients to choose from.
2. Apps that comply with SMART are reusable. For instance, one app can be repurposed with minimal effort.
3. SMART on FHIR has a large community of engineers and tech experts to ask for advice.
4. Programmers can improve their apps without ruining the way healthcare providers and patients access data. The technology simply disengages the protocols for accessing EHR from an app.

Now that we know that SMART on FHIR is a great tool for ensuring interoperability, we can move on to discovering the benefits SMART on FHIR integration generates for businesses, engineers, providers, patients, designers, and other parties involved.

SMART on FHIR benefits engineers

SMART significantly improves interoperability and saves development costs and duration. How so? The thing is that when a business wants to add another app that will be exchanging health data with the database, they need to request custom software development. Creating proprietary APIs is costly and takes some time. SMART resolves this issue by offering standardized plug-and-play connections.

In simple words, any EHR database that uses SMART on FHIR works seamlessly with any technology built with SMART. As a result, we receive impeccable interoperability and a wider variety of applications they can add.

“A bunch of popular EHR platforms such as Epic, Cerner, Allscripts, Meditech, and Intersystems support SMART on FHIR.”

This is partially why many healthcare service providers switch from legacy medical software to popular EHR providers.

The positive role of SMART on FHIR for providers and patients

Better interoperability grants access to a wider variety of applications businesses can add, test out, and adopt. For providers, this means that they won't be stuck with a solution that doesn't match their needs.

“SMART on FHIR allows healthcare providers to expand their business offerings without additional fuss.”

They can jump from one app to another until they deliver a perfect user experience.

Unknowingly, users, too, benefit from SMART on FHIR. Thanks to this technology, they can access their health data in a secure way. Moreover, patients of various age groups enjoy interacting with intuitively designed apps.

SMART on FHIR brings security benefits

Solutions built with SMART on FHIR technology allow us to grant and restrict access to data to responsible people. For instance, a patient and a doctor will see only the data they need to see.

The beauty of SMART on FHIR lies in the authorization and authentication layers that simplify granting access to data. On top of that, we have a single sign-in function. It guarantees that you can move freely between a bunch of apps that use PHI without being signed out.

SMART on FHIR improves the user experience

Switching between a couple of EHR platforms can be a challenging job, especially when they have different interfaces. SMART on FHIR allows accessing UI of other applications via their own EHR.

SMART on FHIR vs. FHIR alone

There’s a significant gap between FHIR alone and SMART on FHIR. For instance, SMART on FHIR has built-in authorization and authentication. The biggest difference, however, is that SMART on FHIR offers EHR UI integration that simplifies navigation between apps by uniting them under one user interface. So, for instance, when clinicians use a couple of integrated apps, they can access them through their EHR.

Features of health apps building with SMART on FHIR

The following is the list of SMART on FHIR application subtypes. Each of these apps uses SMART and FHIR standards and makes effective use of consolidated EHR data for data access and collection, health record access, clinical decision support, medication reconciliation, interoperability, security, and population management.

• Care coordination: These are apps for caregivers that help improve the process of care and/or patient outcomes, such as apps for oncology care teams, hospices, retirement home teams, and Alzheimer's and dementia caregivers. Apps can assist in communication, organization, medication tracking, and patient monitoring.
• Clinical research: Clinical research applications are designed to support and fast-track clinical trials through data collection, data consolidation, and study management. Examples are apps for online surveys used in clinical research studies, apps for collecting real-time data, and apps for management of clinical trials.
• Data visualization: Data visualization apps allow to visualize and analyze healthcare data like patient outcomes and treatment plans. These apps create charts, tables, interactive dashboards and help to get valuable insights.
• Disease management: These applications help manage chronic diseases through self-management tools, monitoring, and tracking. Disease management apps exist for all chronic diseases, including diabetes, asthma, heart disease, cancer, and mental health issues.
• Genomics: Such apps use genetic information to study individual health and genetic risk factors. These include health risk assessment apps, applications that analyze potential responses to medication, and research apps that analyze genetic risks in the general population.
• Medication: These applications allow individuals to manage their medication by tracking schedules, receiving notifications, and monitoring the process.
• Patient engagement, communication, and telehealth apps allow patients to engage and communicate with healthcare providers in real time and access health information.
• Population health: Such applications analyze large-scale patient data to predict and manage diseases. Examples are population health management platforms and data analytics apps.
• Risk calculation apps help to predict the risk of developing a specific disease, such as cardiovascular illnesses, type II diabetes, and various types of cancer based on data about the patient.
• Vaccine and passports applications allow patients to track and manage personal vaccination records and travel documentation.

Categories of SMART on FHIR applications, SMART App Gallery

How to develop a SMART on FHIR application?

The development of SMART on FHIR applications consists of multiple steps, including planning, security check, actual development, software testing , and deployment.

1. Decide which type of SMART on FHIR app you want to create

Before you even begin SMART on FHIR app development, decide which type of app you need. There are plenty of app types you can choose from:

• Mobile and web apps
• Patient-facing and healthcare provider-facing apps
• An integrated or stand-alone web app

With SMART on FHIR, you can focus on programming the main functionality since there's no need to write all interoperability functionality. The app development process using SMART on FHIR is quite quick due to its libraries that can be used for Python, Swift, JavaScript, Ruby, and many other programming languages.

There are also cloud services for the server-side that comply with SMART on FHIR. Some cloud technologies like Azure and Google are more standard-ready, while others may require more time and effort. For instance, AWS is gradually becoming a better fit for the development of SMART on FHIR apps

2. Ensure security on all levels

SMART on FHIR has integrated security specifications such as OAuth 2.0 and OpenID. With these technologies, system owners can grant permissions and manage access levels for people in their team and in TPAs alike.

They allow healthcare providers to skip authentication each time they switch between the integrated apps. Providers don't need to indicate passwords each time they log into third-party applications and EHR systems. What's more, oAuth OpenID in SMART on FHIR is compliant with the HIPAA standard .

3. Develop the app features with engineers based on the app type

Now that you know what your solution has to do for you, it's time to implement it with your engineers. And if you don't have one, you can collaborate with healthcare software development companies like Binariks. We have profound experience in creating HIPAA-compliant software with the application of SMART on FHIR and FHIR alone, depending on our client's needs.

Particular features of the app will depend on your type of app. Some apps access more large-scale population data, while others are more focused on individual patient data.

4. Run app testing with sandboxes

Why is it so important to test your medical solution? Firstly, because there are many data formats and you need to make sure they are adequately sent and received. The good news is that SMART offers its own sandboxes for testing app features.

Sandboxes have their own synthetic patient datasets for testing and emulating interaction between SMART on FHIR app and EHR interfaces. You can also test in EHR vendors' sandboxes. For example, Epic allows you to test your own app features with its sandbox.

5. Deploy your app

Now that the app development phase is finalized, you can deploy it and allow your employees, clients, and partners to download it from an app store. Since you've created a SMART on FHIR app, you can upload it to a specialized gallery, SMART App Gallery, with the rest of the healthcare providers.

The SMART App Gallery is a public platform that contains applications that use SMART on FHIR. Here, healthcare providers, patients, and other app developers can access and evaluate these apps. The goal of this gallery is not just to provide a standardized platform but also to accelerate the development and improve communication between involved stakeholders.

Top 8 SMART on FHIR apps you should know

There are around 58 SMART on FHIR apps in the store. Not much, but the number is growing. Each app serves a particular goal and can be repurposed to fill another gap. There are apps for practitioners, patients, healthcare service providers, and literally every party engaged in providing healthcare services. Let's take a closer look at the best SMART on FHIR apps.

1. BP Centiles

BP Centiles screenshot, SMART App Gallery

Boston Children's Hospital created an app that interprets children’s blood pressure readings for physicians. The thing is that physicians must take into consideration continually changing body sizes which may sometimes be quite a challenging task. On top of that, doing all of the required data entry takes a long time.

This app saves physicians time by computing both systolic and diastolic blood pressure percentiles and normalizing them by age, sex, and height. When the computing is done, BP Centiles employs visual clues so that doctors may quickly determine whether the readings are normal (represented by green), prehypertensive (represented by yellow), hypertensive (shown by red), or hypotensive (blue).

2. Duke PillBox

The latest DukeHealth app seeks to make it simpler for patients to manage complicated prescription regimens. About 50% of all treatments aren't properly followed, which costs the industry approximately $100 billion per year. Patients may drag and drop their medications and recommended amounts into the proper time slots using the interactive learning tool known as PillBox (i.e., morning, afternoon, or evening). The fact that every pill has a picture and there is a "hint" option available for those who are having trouble remembering their dosing regimen makes the app user-friendly.

Duke PillBox screenshot, SMART App Gallery

3. Cardiac Risk by Boston Children's Hospital

Boston Children's Hospital created the Cardiac Risk app that reads patient information to predict the 10-year cardiovascular risk of a person. It analyzes the family history of heart attacks, systolic blood pressure, and whether or not the patient smokes. The patient may change any of these metrics or vitals and see how it affects their risk score, which is one of the app's best features. A patient who smokes, for instance, might see how much their Reynolds Risk Score would decrease if they gave up.

Cardiac Risk App, SMART App Gallery

4. Propeller

Dignity Health, part of CommonSpirit Health, achieved a 54% reduction in asthma and COPD hospitalizations using the SMART on FHIR app, Propeller.

This innovative solution gathers real-time data from inhaler sensors, enabling doctors to anticipate respiratory events. Over time, Propeller learns about patients' breathing, flare-up triggers, and medication effectiveness. The app empowers patients with tools and reminders for managing respiratory health and medication use.

Developed by ResMed's subsidiary, Propeller Health aims to empower those with chronic respiratory diseases for a better life.

5. MedTrue

The MedTrue application seamlessly integrates medication data sources, enhancing medication reconciliation and adherence.

It embeds within the EMR and healthcare provider workflow, utilizing SMART on FHIR for compatibility across healthcare systems. This patient-verified medication list is accessible to both healthcare teams (facilitating point-of-care access through the EMR) and patients, offering a user-friendly interface for reporting medication details and adherence from the convenience of their homes.

Geisinger's Vice President of Enterprise Pharmacy, Mike Evans, emphasizes the application's significance in addressing medication list inaccuracies, potentially reducing errors (Source ).

6. Apple Health App

Apple's early adoption of FHIR and SMART on FHIR in 2018 set them as the standard for interoperability APIs, influencing the 21st Century Cures Act.

Launched in 2014, the Apple Health app organized personal health data. In 2018, Health Records, using SMART on FHIR, provided consistent records from 700+ providers. In September 2021, Apple added a feature allowing users to share health info, using SMART on FHIR to connect with vendors like Allscripts, Athenahealth, Cerner, CPSI, DrChrono, and Meditech Expanse.

With over 1 billion iPhone and 100 million Apple Watch users, Apple continues to lead in SMART on FHIR data sharing through the Health app.

7. SMART-PopHealth

The SMART Health IT team created SMART-PopHealth, a population health analytics app for payers and providers. It allows live data and metric sharing, displaying side-by-side comparisons of data from various sources on a single page.

Performance measure outcomes for the current and previous years are charted for easy comparison. This FHIR bulk data prototype includes a detailed reporting page with quality measure descriptions and a downloadable CSV dataset. Users can modify SQL queries using an in-browser editor to compute performance measure denominators, and results are shown on the reporting page data grid. The app is live, using a blend of synthetic and fully de-identified real-world data.

8. SMART Precision Cancer Medicine

Precision cancer medicine necessitates seamless access to genomic data and tools for clinical interpretation within the clinical workflow.

Recognizing the absence of such functionality in most EHR systems, Vanderbilt University Medical Center developed the EHR-agnostic clinico-genomic mobile app, SMART Precision Cancer Medicine. This prototype facilitates point-of-care conversations by visualizing real-time genomic information comparing a patient's somatic gene mutations to a population-level dataset.

Operating on FHIR Genomics DSTU2 specifications, the app efficiently displays a patient's genomic alterations against a distribution derived from thousands of patients. It provides context-specific links to external knowledge bases such as Gene Wiki, MyCancerGenome, and HemOnc.org.

SMART Precision Cancer Medicine, an open-source software, allows clinicians to present individual patient genomic profiles within the broader population spectrum of cancer somatic mutations. Compatible with any SMART on FHIR-enabled EHR, the app can evolve alongside external knowledge bases in future versions.

The role of experienced SMART on FHIR developers

Experienced SMART on FHIR developers are an asset because their presence helps to develop SMART on FHIR apps faster and more effectively. They have knowledge and expertise in navigating FHIR standards, SMART framework, and SMART on FHIR. They are also up to date with the latest advancements in standards and technology.

Here are some of the ways experienced developers can fast-track your application:

• They can choose a specific programming language and client that will cut development time
• They can seamlessly integrate complex functionality, such as the one related to large-scale population health management
• They can ensure interoperability easier than non-experienced developers
• They know the best test practices that work for your type of app and will choose right types of testing and testing automation tools

Issues with building health apps using SMART on FHIR

Despite the growing popularity of SMART on FHIR in healthcare app development, some healthcare app developers restrain from using it. Let's see why.

1. Insufficient documentation for SMART on FHIR implementations

SMART on FHIR has somewhat scarce documentation and not that many app developer forums. This leaves engineers with only a test-and-try approach to dealing with issues. Additionally, there aren't many EHR vendors supporting SMART on FHIR. However, those who do (Cerner, Epic, Intersystems, etc.) are quite popular. You can also learn more about the implementation of FHIR .

2. Not all vendors provide SMART on FHIR support

As of now, there’s a limited number of EHR providers that fully integrate with SMART on FHIR. Thus, it's not always possible to develop one app and integrate it with any EHR possible. Those EHR vendors who support the technology still have their own requirements for integration.

How Binariks can help you build a SMART on FHIR app

To create a HIPAA-compliant medical app with a convenient UX and a high-security level, you’ll need a company that has hands-on expertise, certifications, and expertise. Binariks has it all to develop SMART on FHIR. We help healthcare providers leverage technology and comply with all necessary standards by offering professional architecture and business analysis consulting, software development, and quality assurance expertise.

Recently, we helped a healthcare provider with a cloud platform for doctor referrals create a platform architecture enabling better interoperability. Our team of solution architects and business analysts tested Athenahealth, Epic, and Allscripts to conduct test integrations. As a result, they decided that it was best to implement an EHR system that supports SMART on FHIR:

Due to its support for SMART on FHIR, Epic was selected as the best EHR provider out of all of them. This choice helped the platform to smoothly interact with the features offered by numerous EHR providers.

In order to guarantee the security of patient health data transmitted over APIs, our client has embraced HL7 FHIR version 4.0.1 as the fundamental data interchange standard suggested by both the ONC and the Centers for Medicare & Medicaid Services (CMS).

Final thoughts

SMART on FHIR and healthcare go together like a hand in a glove. Considering the advantages and the fact that it is included in the Cures Act, developing SMART on FHIR apps is virtually required for every healthcare system. Major EHR providers, including Epic, Cerner, and Allscripts, already use SMART for this purpose.

However, at the time this article was written, there were only 102 apps available in the SMART app gallery, indicating that not many businesses have yet used the standard in their products. Therefore, SMART adoption might provide some tech businesses with a sales advantage.

Aside from requirements, early SMART acceptance might aid healthcare tech businesses in ensuring that their programs are eventually more generally used. Binariks will help you bring into life SMART on FHIR applications that serve your purpose.

Share your requirements with us, and we will assemble a team of tech specialists who will develop SMART on FHIR and cater to your needs.