Push Button Population Health Data: Extending the HL7 FHIR Standard to Support Bulk Data Export

Activities such as managing population health, delivering value-based care, and conducting discovery science require access to large population data sets. The existing FHIR and SMART APIs work well for accessing small amounts of data, but large exports perform poorly, requiring an impractical number of API requests to be issued serially. By adding asynchronous primitives to FHIR and defining an export operation, the Bulk Data API enables secure integration of third-party, externally-hosted applications into diverse EHR and data warehouse environments.

On behalf of the ONC, The Boston Children’s Hospital Computational Health Informatics Program and SMART hosted a meeting in December 2017 to discuss standardizing bulk data exports from EHR systems and data warehouse environments. This meeting brought together key stakeholders from across health care, including the Director of the Office of the National Coordinator for Health Information Technology (ONC) and other members of the ONC staff, as well as representatives from payers, health systems, EHR vendors, and other health technology innovators.

A summary report is now available:

Also, get involved in the ongoing, early stage, FHIR Bulk Data API Project by reviewing the draft specification and joining the discussion group!

SMART at HIMSS 2018!

All times are PST. Session schedule may change – check back for updates.

  • Tuesday (3/6)

    • FHIR for Bulk Data
      Dan Gottlieb, Senior Technical Lead, SMART Health IT Project
      Learn about an exciting new effort by SMART and HL7 to bring the FHIR standard to bear on the challenges of bulk-data export.
      1:00 – 1:30pm | HL7 – Booth 5623
    • Sync for Science and the CMS Blue Button on FHIR API: Claims Data for Research
      Josh Mandel, Health IT Ecosystem Lead, Verily; David Kreda, Healthcare IT Designer and Consultant; Carly Medosch, Program Analyst, CMS
      2:00 – 3:00pm | CMS Booth #10110
    • SMART on FHIR: Building apps that integrate with clinical systems through open standards
      Dan Gottlieb, Senior Technical Lead, SMART Health IT Project; Josh Mandel, Health IT Ecosystem Lead, Verily
      Learn how SMART Health IT’s open source, standards-based technology platform enables innovators to create apps that run seamlessly and securely across the healthcare ecosystem.
      3:30 – 4:15pm | HIMSS Developer Innovation Lab (Hall G, Booth 9900-DL)
  • Wednesday (3/7)

    • Sync For Science Scientific Session
      Josh Mandel, Health IT Ecosystem Lead, Verily; David Kreda, Healthcare IT Designer and Consultant; Teresa Zayas Caban, Chief Scientist, ONC
      In this session, the Sync for Science team will sit down with the research community to talk through use cases, challenges, wish lists, and pragmatics of working with EHR data.
      10:00 – 10:45am | The Venetian, Room Zeno 4601
    • Argonaut Project Town Hall Meeting
      Micky Tripathi, President & CEO, MAeHC; Aneesh Chopra, President, CareJourney; Ryan Howells, Principal, Leavitt Partners; Josh Mandel, Health IT Ecosystem Lead, Verily; Dan Gottlieb, Senior Technical Lead, SMART Health IT Project
      The town hall will cover 1) Argonaut Project 2017 deliverables and 2018 work plan, 2) CARIN Alliance consumer directed exchange trust framework updates and TEFCA alignment, 3) SMART and ONC efforts to accelerate bulk data access via FHIR APIs.
      5:30pm – 6:30pm | Hall G, Booth 11955ET | RSVP Here
  • Thursday (3/8)

    • Sync For Science Demonstration
      Josh Mandel, Health IT Ecosystem Lead, Verily; David Kreda, Healthcare IT Designer and Consultant; Teresa Zayas Caban, Chief Scientist, ONC
      In this session we’ll review the consumer workflow, the underlying technologies and the regulatory environment that support Sync for Science, and describe upcoming extensions to support new data types.
      10:00 – 10:45am | The Venetian, Room Zeno 4601
    • CDS Hooks: Integrating decision support at the point of care
      Josh Mandel, Health IT Ecosystem Lead, Verily; David McCallie, Senior Vice President for Medical Informatics, Cerner
      We’ll review the technology, clinical use cases, standards development, and real-world implementation experience for the emerging CDS Hooks specification.
      11:40am – 12:10pm | HL7 – Booth 5623
    • FHIR for Bulk Data
      Dan Gottlieb, Senior Technical Lead, SMART Health IT Project
      Learn about an exciting new effort by SMART and HL7 to bring the FHIR standard to bear on the challenges of bulk-data export.
      1:00 – 1:30pm | Hall G, Booth 9900-DL

Response to ONC’s proposed Trusted Exchange Framework and Common Agreement

Next week is the final opportunity for public comment on the ONC’s proposed Trusted Exchange Framework and Common Agreement. I’ve prepared a set of comments and recommendations that focus on the scope and mechanics of individual access, including technical standards, security requirements, identity proofing, authentication, and authorization.

Given the importance of health data exchange to the SMART Health IT community, I’m sharing the full letter and 15 recommendations here in PDF.

Draft Model RFP Language for Purchasing Extensible Health IT

We’re updating our model RFP language to reflect the changes in the health IT landscape over the past few years, and drafted the version below for community input. Our goal is to finalize this in September – please review and post any suggestions or feedback to the SMART discussion group at https://groups.google.com/forum/#!forum/smart-on-fhir .

RFP Language for Purchasing Extensible HIT

SMART Platform (www.smarthealthit.org) is a project that lays the groundwork for a more flexible approach to sourcing health information technology tools. Like Apple and Android’s app stores, SMART creates the means for developers to create and for health systems and providers to easily deploy third-party applications in tandem with their existing electronic health record, data warehouse, or health information exchange platforms.

To deploy SMART-enabled applications, health systems must ensure that their existing health information technology infrastructure supports the SMART on FHIR API. The SMART on FHIR starter set detailed below lists the minimum requirements for supporting the API and SMART-enabled applications. You may wish to augment this list of minimum requirements with suggestions from the Add-On Functionality listed depending on the types of applications your organization wishes to deploy.

This document is intended as a resource for providers and health systems as they draft Request for Proposals (RFPs) and negotiate with their HIT vendors for added functionality. It has multiple authors from across the SMART team and its advisors. Feedback is welcome.

The vendor must support the SMART on FHIR platform, a vendor agnostic API that allows third-party developers to build external apps and services that integrate with the vended product.

At a minimum, the vendor product should include the following components in order to support SMART on FHIR and SMART-enabled applications:

Data Access

  • Provide automated, standards-based, read-only access through the FHIR API and FHIR data models (resources) to:
    • a well-defined set of real-time discrete data (including support for the API parameters and resources described in the Argonaut Implementation Guide)
    • free-text clinical notes

Data Manipulation

  • Write structured data from third-party apps back to the organization’s EHR and, where relevant, a data warehouse, using the FHIR REST API to communicate data including:
    • free-text clinical notes

Standards-Based App Authorization

  • Protect data and identity endpoints with standards-based authorization mechanisms (including the OAuth2 profiles described in the Argonaut Implementation Guide).
  • Provide access to data endpoints with an approach that does not require user intervention subsequent to the initial setup such as the method described in the draft SMART Backend Services Profile (http://docs.smarthealthit.org/authorization/backend-services/) Provide capability to restrict this access to a specified set of patients (roster).
  • Enable Health System to connect any any third‐party app of their choice that is conformant with the API without pre‐registering the app with HIT Vendor.
  • Enable patients to connect any third‐party app of their choice that is conformant with the API without pre‐registering the app with HIT Vendor through the OAuth Dynamic Registration protocol.
  • Provide OAuth refresh tokens with a duration of one year to patient and provider facing apps that support the SMART Client Secret profile.

Identity Management

  • Act as as standards-based Identity Provider using OpenID Connect. This ensures that users can authenticate to plug-in apps using single-sign-in via their existing EHR or patient portal credentials.
  • Act as a standards-based relying party to a customer-selected Identity Provider using OpenID Connect. This ensures that users can sign into the EHR or patient portal using an external, hospital-supplied single-sign-on account.

Workflow

  • Support standards-based embedding of external application UI (HTML5). This ensures that app developers can build Web apps, and these apps can run directly inside of the EHR.
  • Support the launch of external applications in the clinician’s workflow (this is not limited to the EHR, and should include non-EHR integrated tools such as smart phones and tablets). For example, a clinician that has opted to use a third-party-developed native iPad app to visualize a patient’s BMI over time can seamlessly use the application alongside the EHR via single-sign-on.
  • Support notifications to and from running applications. For example, an embedded app can notify the EHR when the user is “done” with it.

Add-On Functionality

The provider organization may also want to consider the following additions to its RFP depending on the types of applications it wishes to develop and run in the future.

Bulk Data Export

  • Provide automated access to bulk export of data (complete representation of all data in the MU Common Clinical data set as well as free text notes) using a method like the SMART Flat FHIR draft proposal (http://docs.smarthealthit.org/flat-fhir)

Data Manipulation

  • Write structured data from third-party apps back to the organization’s EHR and, where relevant, a data warehouse, using the FHIR REST API to communicate data including:
    • medication prescriptions
    • lab and diagnostic imaging orders
  • Support the dependent transactions necessary to ensure that actions completed by third-party applications using the API are valid in the EHR and data warehouse.

Context-Specific Service Hooks

  • Support the ability to call an external standards-based service in specific workflow steps, through the CDS Hooks specification, including:
    • opening a patient record
    • new prescriptions
    • new lab orders
    • new imaging studies

Intellectual Property

The IP of any app integrated through the SMART on FHIR API belongs to the author and not the vendor.

Custom SMART on FHIR Extension to a Proprietary API

Should a vendor neglect to provide SMART on FHIR natively, the client has the right to provide a custom extension to the vendor’s API. The ownership of the IP for the custom extension is negotiable between the client and the vendor, but the ownership of the app using the custom extension belongs to its author.

New Report On Connected Apps in Healthcare

In an evaluation developed in partnership with SMART and funded by the Office of the National Coordinator for Health Information Technology (ONC), KLAS Research spoke with clinical leaders at nearly 50 healthcare organizations about how they select and use clinical apps today, what they would like to see in the future, and the concerns they have around adopting apps.

Findings include:

  • Around half of the healthcare organizations interviewed use apps at the point-of-care.
  • Looking forward, many providers are interested in purchasing or developing apps around patient engagement, followed by EHR data visualization, diagnostic tools and decision support tools.
  • Usability is the most important factor healthcare organizations consider when purchasing an app, followed by cost, clinical impact and integration with existing systems.
  • Pilot programs and demos represent providers preferred way to evaluate apps, with peer recommendations, web content and video demonstrations also being popular.
  • Privacy and security is by far the biggest concern around adopting apps, although app credibility, concerns regarding ongoing maintenance, and the need for integration with existing systems are also high on the list.

The role of apps in healthcare is growing, with many organizations looking to third-party vendors to supply niche solutions that improve patient care and organizational efficiency.

Increasing adoption of the SMART and FHIR application programming interfaces (APIs) by EHR vendors and health systems is streamlining the process of connecting these apps to clinical systems, and strong regulatory support requiring APIs in certified health IT is expected to continue driving this trend. With app discovery tools, such as the SMART App Gallery, making it easier for healthcare providers to find and evaluate apps, there is a bright future for connected apps in healthcare.

View the full report, “Connected Apps in Healthcare 2017: A Look at Trends and Provider Attitudes in a Growing Market”

We’ll Be At HIMSS!

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  • Monday, February 20th
    • 1:00pm – 2:00pm / Quest Diagnostics Panel (room 203C)
    • 1:40pm – 2:10pm  / Introduction to SMART on FHIR at HL7 booth (#943)
    • 3:00pm – 3:30pm / SMART App Gallery 2.0 Beta Launch at Federal Health IT Pavilion (booth #230)
  • Tuesday, February 21st
    • 11:00am – 11:45am / HSPC Interoperability Showcase Demonstration (booth #9000)
    • 2:30pm – 4:30pm / Argonaut Roundtable (room 240ABC)
    • 4:20pm – 4:50pm / Introduction to SMART on FHIR at HL7 booth (#943)
  • Wednesday, February 22nd
    • 11:40am – 12:10pm / Introduction to SMART on FHIR at HL7 booth (#943)

21st Century Cures Act makes APIs in EHRs the law

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One aim of the 21st Century Cures Act recently passed by Congress is to make digital health data more accessible, emphasizing the use of APIs in healthcare to increase EHR interoperability and improve patient records matching. Aligning closely with the SMART Health IT focus on creating a app ecosystem for healthcare, the act states that a year from now, open APIs will be necessary for EHR system certification.


“… that the entity has in place data sharing programs or capabilities based on common data elements through such mechanisms as application programming interfaces without the requirement for vendor-specific interfaces;

[…] publish application programming interfaces and associated documentation, with respect to health information within such records, for search and indexing, semantic harmonization and vocabulary translation, and user interface applications; and

[…] demonstrate to the satisfaction of the Secretary that health information from such records are able to be exchanged, accessed, and used through the use of application programming interfaces without special effort, as authorized under applicable law.”


Read the full document at 21st Century Cures Act

Vital Directions for Health and Health Care

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About the Initiative

Guided by an 18-member steering committee, the National Academy of Medicine (NAM) has called on more than 100 leading researchers, scientists, and policy makers from across the United States to provide expert guidance on 19 priority focus areas for U.S. health policy. The resulting collection of discussion papers is organized around three overarching goals for the United States: better health and well-being; high-value health care; and strong science and technology.


“As the country orients toward alternative payment models, measuring individual health outcomes and disparities among vulnerable populations is crucial for driving innovation toward outcomes that matter most to individual lives.”

“Simply building APIs into EHR products so that data can be called by external applications will improve the current state. But the most important goal is that—as in an “app store”—an app written once will be able to run anywhere in the health care system and that a decision support service will be able to be created once and be called from any care point in the system. “


Read the Discussion Paper On Information Technology Interoperability and Use for Better Care and Evidence

https://nam.edu/wp-content/uploads/2016/09/Information-Technology-Interoperability-and-Use-for-Better-Care-and-Evidence.pdf

 

 

President Obama’s Cancer Panel Points to SMART On FHIR for Connected Health

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President Obama’s Cancer Panel defines connected health as “the use of technology to facilitate the efficient and effective collection, flow, and use of health information.” In their 2016 report to the President, the panel highlights the benefits of using the SMART On FHIR open-access API for development of health applications.


“The Precision Cancer Medicine (PCM) app was designed to present patients’ genomic test results to oncologists in real time as a component of clinical practice, as well as provide links to external knowledge bases that otherwise would be unavailable through the native EHR system. PCM was piloted at Vanderbilt University and integrated into that institution’s EHR system. However, because the app was developed based on an open-access API (Substitutable Medical Applications and Reusable Technology, or SMART) and uses the emerging HL7 Fast Healthcare Interoperability Resources standard, it could easily be deployed for other compatible EHR systems.”

“The Panel urges all stakeholders—health IT developers, healthcare organizations, healthcare providers, researchers, government agencies, and individuals—to collaborate in using connected health to reduce the burden of cancer through prevention and improve the experience of cancer care for patients and providers.”


Improving Cancer-Related Outcomes with Connected Health: A Report to the President of the United States from the President’s Cancer Panel. Bethesda (MD): President’s Cancer Panel; 2016.

A web-based version of this report is available at: https://PresCancerPanel.cancer.gov/report/connectedhealth

AMA and SMART Collaborate to Survey Physician Interest in EHR Connected Apps

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As part of a broader survey of 1,300 physicians covering digital health tools, the SMART Health IT Project and the American Medical Association collaborated on a set of questions to better understand how providers wish to discover, evaluate and purchase apps that connect with their EHR system.

One important finding for app creators is that 81% of physicians ranked integration with their EHR as a very important or important requirement for digital health tools. Additionally, more than half of the physicians indicated that they are extremely likely or very likely to purchase apps that extend their EHR system’s capabilities and securely integrate into the EHR workflow.

Download the full report at: https://www.ama-assn.org/sites/default/files/media-browser/specialty%20group/washington/ama-digital-health-report923.pdf