Ever since the enterprise EHR came into being 40 years ago (i.e. EHR systems), there has been a need to customize, adjust, improve, or extend the out-of-the-box functionality to better suit the clinicians, administrators, and patients that rely on them. However, innovation comes only as fast as the EHR vendors can accommodate it; and only when a request from one client proves to be successful is that feature rolled out to other clients in their upgrade cycles. The newest ideas exist alongside the EHR, rarely within it. Invariably, this leads to double-entry, disjointed workflow, and in many cases, abandonment as it just isn’t worth the effort to work outside of the EHR.

In recent years, users of EHR systems have banded together to offer an alternative to the EHR vendors’ product cycles: SMART on FHIR. The combination of two separate efforts, SMART on FHIR promises to open both the data and workflow silos within the EHR, allowing innovators and users to unlock the powerful utility of the EHR.

 What is SMART on FHIR?

HL7’s Fast Healthcare Interoperability Records (FHIR) and the Harvard-based SMART Platforms Project started as two very different initiatives. However, after they both demonstrated their products at the annual HIMSS conference in 2014, a natural partnership between the two EHR programs seemed to make sense. Since then, they’ve become something of a package deal, working to “app-ify” EHRs across the United States.

SMART (Substitutable Medical Apps, Reusable Technologies) specifies how external applications can be launched from within an EHR. It is not restricted to just opening the app, SMART also describes how the external app will understand which EHR user is interacting with the system and which patient’s data should be loaded.

FHIR describes a common interface for accessing EHR data and workflow. EHR systems that support FHIR expose API endpoints for many clinical data types to trusted applications.


Image source: SMART Health IT http://smarthealthit.org/smart-on-fhir/

With the combination of SMART and FHIR, users can choose what extensions make sense for them, launch from within the context of the EHR, and have the data they need seamlessly available in the app and fed back into the EHR as appropriate. For the developers/innovators, the interface from the EHR to the external software is the same, regardless of vendor. This means that the external software can be built once and run anywhere.

What SMART on FHIR isn’t

While the promise of SMART on FHIR is great, it is not the silver bullet. Both the EHR vendors and the innovators hoping to integrate with their systems have significant hurdles to clear to make the technology fully successful.

EHR vendors, especially, face challenges. Both sets of standards need to be built into their systems and rolled out to clients. EHRs are complex systems. These sorts of initiatives require significant engineering, testing, and change management. It will be difficult for vendors to keep up with the still-evolving standard and match the hype of what is possible.

The innovators face significant technical challenges, too. In addition to building their apps to suit what pieces of FHIR are implemented in the EHR, they are also responsible for guaranteeing the security of their solutions. SMART and FHIR include security for identifying the apps and users connecting, but do not dictate how the apps themselves handle the data. HIPAA compliance and user security requirements need to be built into each app.

Will it work?

Tackling interoperability and workflow management is no easy game, especially with many interested parties pushing for many different types solutions. However, we’d bank on SMART on FHIR as arguably the closest we’ve come in the U.S. to creating a streamlined, interoperable option for accessing the EHR. That’s pretty impressive.



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Julliette Ehlert is senior manager of technology at Medullan, a digital health consultancy that improves the user experience through human-centered technology solutions. Ehlert specializes in architecture and development best practices, with emphasis on continuous integration and delivery. She has over 15 years of experience in enterprise application architecture and development, with over a decade focused in healthcare IT.

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