Introduction
SMART on FHIR1 was introduced in 2016 “to enable medical applications to be written once and run unmodified across different healthcare IT systems.” (Mandel et al. 2016)
To enable “write once, run anywhere” applications, SMART on FHIR uses FHIR along with common web technologies, such as OAuth 2 and OpenID Connect. Many EHRs–including those from Cerner, Epic, and MEDITECH–support SMART on FHIR applications. Researchers have successfully used SMART on FHIR applications across multiple EHRs (Wesley et al. 2021), though implementation differences may require additional work to resolve.
1 Research use cases
1.1 Integrating with an EHR
Researchers primarily use SMART on FHIR to integrate with an EHR. For example, several researchers have trialed new clinical decision support (CDS) systems using SMART on FHIR. They use SMART on FHIR to integrate their CDS tool into EHRs without modifying the EHRs and without creating unique versions for each EHR vendor.
Tarumi et al. (2021) used this approach to show that an AI-driven CDS could integrate with Epic via SMART on FHIR, and Curran et al. (2020) used this approach to prototype a CDS system for chronic disease management.
1.2 Adding data to an EHR workflow
Researchers also use SMART on FHIR to add data to EHR workflows. For example, a patient may use a web or smartphone app to report their outcomes data. A SMART on FHIR application can make this data accessible from an EHR (Wesley et al. 2021).
SMART on FHIR can also help researchers integrate data into an EHR that the EHR does not natively support. For example, Watkins and Eilbeck (2020) discuss how genetic testing could be better-integrated with EHRs using SMART on FHIR and CDS Hooks (see below).
1.3 Accessing bulk data
SMART on FHIR facilitated Bulk Data Access (see below) may provide a new way for researchers to access population-level data. A researcher may want to gather population data from multiple institutions that do not store their data using a shared common data model. However, if these EHRs use FHIR, they likely use the widely implemented US Core FHIR Implementation Guide. SMART on FHIR with Bulk Data Access would enable researchers to access the data as US Core-conforming FHIR resource instances across these institutions.
Note, SMART on FHIR used for Bulk Data Access is relatively new and has not yet appeared in peer-reviewed research publications.
1.4 SMART on FHIR app gallary
The SMART App Gallery lists a number of SMART on FHIR applications, which may provide additional ideas on how SMART on FHIR could be used for research.
2 Capabilities
SMART on FHIR pulls together existing standards to enable third-party applications to integrate with EHRs. These include:
Capability | Approach |
---|---|
Authorization | The OAuth 2 web standard enables third-party SMART on FHIR applications to access specific sets of data from an EHR. |
Authentication | The OpenID Connect web standard allows a SMART on FHIR application to tell the EHR who is using it (e.g., to allow a patient to access their own health data via SMART on FHIR). |
Data models | The standard set of FHIR resources are used to represent data. Additional customization can occur via FHIR profiles. |
Profiles | US Core Data Profiles or other FHIR Implementation Guides can be used to provide additional customization on top of the standard FHIR resources. |
Data access | Once a third-party application is authenticated and authorized, the standard FHIR REST API is used to exchange data. |
Data format | Data are formatted using the standard FHIR JSON or XML formats. |
EHR UI integration | third-party applications can be launched from within an EHR using SMART App Launch. |
EHR backend integration | third-party applications can launch in an EHR without an EHR user interacting directly with it using SMART Backend Services. |
4 Implementation considerations
If you have a research use case that is a good fit with SMART on FHIR, you will likely work with a software engineer and your institution’s IT experts to investigate integrating with the relevant EHR(s). If your institution has staff with experience integrating SMART on FHIR applications, consult with them early when developing your research approach.
SMART on FHIR applications that integrate with an EHR’s user interface via SMART App Launch are often web applications. SMART on FHIR applications that run without being triggered by user input in an EHR, including applications that use Bulk Data Access, are often backend services.
Integrating SMART on FHIR backend applications with EHRs is often less complex than integrating SMART on FHIR web applications. However, in both cases, there may be EHR-specific requirements including administrative approval.
Also, consider security and privacy early when developing your research approach. Take steps to ensure proper data storage and access as you would with any software that handles sensitive data. In addition to IRB approval, you may need approval related to privacy and information security. If your institution has not worked with SMART on FHIR before, it may not have a well-defined process for getting the appropriate approvals. In this case, it may be helpful to identify researchers from other institutions who have used SMART on FHIR in a similar context, and cite their work to demonstrate prior successful use of this technology when discussing with the IRB and decision-makers at your institution.
Please see SMART on FHIR Technical Details for more technical implementation on using SMART on FHIR and related standards.
References
Footnotes
SMART stands for Substitutable Medical Applications and Reusable Technologies.↩︎