About SMART

What is SMART?

Innovations in care delivery models, physician workflow, predictive medicine, big data analytics, learning health system, and precision medicine need a nimble, rapidly evolving façade on top of the existing infrastructure. SMART provides that capability.

Technically, SMART is an API—an application programming interface that provides a health app interface based on open standards, leveraging HL7 FHIR ((Fast Healthcare Interoperability Resources), OAuth2, and OpenID Connect. FHIR provides a detailed set of “core” data models, but leaves many fields optional and vocabularies under- constrained, in order to support diverse requirements across varied regions and use cases. But to enable substitutable health apps as well as third-party application services, developers need stronger contracts. To this end, SMART on FHIR applies a set of “profiles” that provide developers with expectations about the vocabularies that will be used to express medications, problems, labs, and other clinical data.

Key features include:

  1. Developers work directly with concrete data types such as allergy, prescription, or condition, not abstract types such as entity, actor, or role
  2. SMART specifications are ‘opinionated,’ making up-front choices about how data are represented so that developers know what to expect. For instance, every problem in a SMART record is associated with a SNOMED CT disorder code
  3. SMART defines a limited set of broadly applicable data types, rather than permitting a proliferation of interface-specific definitions.

The goal of the original SMART on FHIR API is audacious and can be expressed concisely: an innovative app developer can write an app once and expect that it will run anywhere in the health care system. Further, that one app should be readily substitutable for another. When apps are substitutable, they compete with each other which drives quality up and price down. SMART supports an “App Store for Health” model.

Today, the SMART on FHIR API is built into major EHR products, has been used by Apple to connect its health app to hundreds of healthcare systems, and is used for apps launch in the on the Microsoft Azure product.

The developer community has already become activated as demonstrated by our ever-growing SMART Apps Gallery. SMART enables an app developer to readily access the underlying health system data without needing specialized knowledge about the configuration the HIT will connect to, or even which EHR it will run on.

SMART Origins

SMART Health IT was initially funded by The Office of the National Coordinator for Health Information Technology, through the Strategic Health IT Advanced Research Projects (SHARP) Program project with a $15M grant.

We first introduced the idea of a health information technology platform in a paper in the New England Journal of Medicine, called “No Small Change for the Health Information Economy,” Working with Clayton Christensen and informatics leaders from diverse settings, we defined “Ten Principles for Fostering Development of an ‘iPhone-like’ Platform for Healthcare Information Technology.” With that foundation, we brought together 100 leaders in Health IT across government, industry and academia to an invited meeting at Harvard Medical School at the beginning of the first term of the Obama Administration.

In 2012 we again convened 100 stakeholders at the 2012 Harvard ITdotHealth 2 meeting. There, we found strong endorsement to move forward on formation of the SMART Advisory Committee to catalyze uptake, collaboration, and health system experimentation.

In late 2013 we found tremendous synergy with FHIR, the emerging health data standard from HL7. Through co-development and close collaboration, SMART and FHIR have evolved together to enable the ‘SMART on FHIR’ apps platform.

At the HIMSS 2014 Annual Conference in Orlando, Florida, we witnessed an unexpected phenomenon that let us know we were really onto something. Four vendors presented prototype implementations of SMART on FHIR. The prototypes included three EHR systems and one federated query system that combined data from multiple EHR systems to support third-party app integration. Moreover, the vendors implemented the SMART on FHIR API in under two months – in one case under one month – thereby turning them into platforms that exposed semantically uniform data to third-party apps in real-time. Despite very different underlying architectures, all four vendors were able to run the same clinical apps inside, or on top of, their EHR systems.

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