Innovations in care delivery models, physician workflow, artificial intelligence, big data analytics, learning health system, and precision medicine need a nimble, rapidly evolving set of open technologies to support an evolving ecosystem. The SMART Health IT project run out of the Boston Children’s Hospital Computational Health Informatics Program, advances that ecosystem. Our best known invention is the SMART on FHIR application programming interface (API) which enables an app written once to run anywhere in the healthcare system. But many more SMART team innovations are beginning to take hold at the national and international levels.

SMART By Any Other Name

Many projects and products incorporate the SMART on FHIR and SMART Flat FHIR APIs, including:

SMART Origins

Over a ten year period, through our sustained focus on open and free specifications, with strong attention to privacy, security, and regulatory requirements, SMART innovations are becoming standardized and regulated across certified health information technology.

SMART Health IT is the interface between healthcare data and innovation. 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 up quality and down price. SMART supports an “App Store for Health” model.

In 2009, in a New England Journal of Medicine article, we introduced to the world, the idea of an API to promote an apps-based 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.

SMART HealthIT was initially funded by the Office of the National Coordinator for Health Information Technology, through the Strategic Health IT Advanced Research Projects (SHARP) Program with a $15M grant. The SMART team focused on enabling the property of substitutability through an application programming interface (API) leveraging web standards, presenting predictable data payloads, and abstracting away many details of enterprise health information technology systems. Containers—health information technology systems, such as electronic health records, personal health records, and health information exchanges that use the SMART API or a portion of it—marshal data sources and present data simply, reliably, and consistently to apps. 

In 2012 we again convened 100 stakeholders at the 2012 Harvard ITdotHealth II 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 draft health data standard.  Though co-development and close collaboration, SMART and FHIR have evolved together. SMART enables FHIR to work as an apps platform. Many refer to that synergy as “SMART on FHIR.”

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

The SMART team successfully lobbied for an API requirement in the 21st Century Cures Act. Major HHS rules out of CMS and the ONC are implementing the Cures provisions and making SMART the law of the land.

Major SMART Extensions

We did not stop innovating with the original SMART on FHIR API, but are continually extending the SMART ecosystem. Here are a few projects. 

CDS Hooks. In 2015, we launched the CDS Hooks project to trigger third party decision support services. We explored the CDS opportunity at ITdotHealth 3: Getting SMARTer. All EHR vendors have worked through the Argonaut process to implement hooks in their products, and CDS Hooks is specifically referenced in the 21st Century Cures Act of 2016.

SMART App Gallery and Sandbox. We created the SMART Sandbox, containing de-identified data to support app development and demonstration. In 2016, we were federally funded to create the SMART App Gallery, which runs on the Sandbox. In addition to scores of SMART Apps listed in the gallery, major development efforts use the SMART Sandbox, including Apple Health, and Google Health. Many other projects have replicated the SMART Sandbox and Gallery, including the Epic App Orchard, Cerner App Gallery, Allscripts Application Store, and HSPC.

21st Century Cures. The SMART Team ,successfully lobbied for language in the 2016  21st Century Cures Act that requires a universal API for health information technology, providing access to all elements of a patient’s record, with no special effort.. We also strongly advocated for provisions in the proposed rule that would specifically define SMART as the universal API and so foster a robust marketplace by eliminating prohibitively expensive fees. The 2017 ITdotHealth 4: SMART Decisions meeting focused on setting an agenda for the Office of the National Coordinator of Health Information Technology to ensure that EHR make all elements of a patient’s record accessible across the SMART API “without special effort”.

SMART Flat FHIR/Bulk Data Export. In 2017, the SMART team was asked by the National Coordinator of Health Information Technology to design a standard and suite of tools for export of large population datasets from electronic health record systems, and to standardize it in partnership with HL7. The SMART Bulk Data standard has been balloted into HL7 and is widely used by CMS to provision data, including in its Data to Point of Care program.

SMART Markers is a standards based software framework for creating health system integrated apps for patient generated health data, including, patient reported outcomes (PROs), PROMIS® instruments, smartphone based activity tests and sensor data. Building upon the SMART on FHIR API, SMART Markers encapsulates the functionality needed for rapid deployment of both patient- and practitioner-facing PGHD apps.