- Kenneth Mandl, MD, and Isaac Kohane, MD, PhD, both big players in creating SMART on FHIR, a major interoperability project, have recently recounted key details to the project and its successes in a paper published in the Journal of the American Medical Informatics Association.
This paper first explained the project, stating that the Substitutable Medical Applications and Reusable Technologies (SMART) project aimed to create a platform on which developers could make healthcare applications that could run interoperably across different health IT systems.
To make such an initiative effective, the SMART team would have to garner enough momentum and vendor interest to make a difference on interoperability in the health IT industry.
Using a new set of web standards, SMART workers developed a method by which developers could adopt a standard set of app models that would work across the different health IT systems.
“We adopted contemporary web standards for application programming interface transport, authorization, and user interface, and standard medical terminologies for coded data,” the paper explained. “In our initial design, we created our own openly licensed clinical data models to enforce consistency and simplicity.”
Combining with HL7’s Fast Health Interoperability Resources, a project which “focused on providing an [application programming interface] for healthcare that was ‘simple and easy to implement and manage,’” strengthened SMART by leveraging other industry knowledge.
The SMART on FHIR team saw the results of its labor at the Healthcare Informatics Management Systems Society (HIMSS) 2014 conference when four health IT and EHR vendors reported how SMART on FHIR worked with their systems.
“In January 2014, in preparation for HIMSS14, four corporate exhibitors, Cerner Corporation, Intermountain Healthcare, Hewlett-Packard Company (on behalf of the Veterans Administration), and Harris Corporation, produced prototype implementations of SMART on FHIR on their respective test systems,” the paper’s authors wrote.
Implementation of these SMART on FHIR apps took each vendor approximately two months, and resulted in a diverse set of apps that could be used on any health IT platform. Through showing all four of the vendor-developed apps, along with six original apps from SMART on FHIR, the team saw that it could gain enough vendor interest in their platform.
“We created SMART on FHIR as a technical and market experiment to test whether standards-based data models could gain sufficient EHR vendor interest to influence the trajectory of the industry,” the team reported. “HIMSS14 served as early evidence of the success of this experiment, demonstrating substitutability using a small set of data profiles.”
Despite their reported success, the SMART on FHIR team also identified a few key issues with the platform. These issues include constraining resources, leaving open all data fields and coding options, curbing semantic fragmentation, and data validation within apps and systems.
These issues, as well as the preliminary support around SMART on FHIR seen at HIMSS14, led the team to identify several learned lessons regarding the platform:
- Prospective ecosystem participants must see something real before they engage in productive discussions.
- Successful community building benefits from multiple channels of engagement around specific, shared goals with tangible results. Active collaboration among SMART, app developers, EHR vendors, and Healthcare Services Platform Coalition enabled us to build critical mass around a technology demonstration at HIMSS14.
- Properly designed data and authentication APIs can successfully shield health IT app developers from complexity in integrating with proprietary vendor systems.
- Granular data access, as opposed to document-oriented access, provides a well-suited model to support apps that integrate into workflow at the point of care.
- A solution that permits incremental implementation of resources and profiles provides vendors an efficient onramp to begin app platform implementation.
Going forward, the SMART on FHIR team recognizes that it will continue to have to garner vendor enthusiasm around the initiative.
“First, a critical mass of vendors must complete production level implementations to anchor the effort,” the authors concluded. “Second, vendors and providers will have to extend their business and operational models to embrace a healthcare ‘app economy.’”