MedCity Influencers, Health IT

From HITECH to SMART-on-FHIR: Where does the healthcare app ecosystem stand?

SMART-on-FHIR is the inflection point for driving the shift to value-based care. The reason: It offers another pathway to integration in which user experiences, not just discrete data, are shared across systems, enabling lightning quick implementation.


A little over a decade ago, fewer than 10% of hospitals were using electronic health records (EHRs). But then healthcare officially moved into the digital age when the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law, ushering in widespread and rapid adoption of EHRs in hospitals across the country.

While EHRs today are ubiquitous and contain more patient data than ever before, these systems can often create information silos. Such technological barriers can make it difficult to share data with stakeholders, from patients and providers to payers and the research community.

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These limitations are no longer acceptable. Healthcare providers expect the same ease of use and interoperability in healthcare applications that they experience with online banking or online shopping. And as our industry moves away from the fee-for-service status quo, healthcare services can be improved if providers have all the data they need at their fingertips, which in turn helps them make more informed decisions and deliver better care and greater value and outcomes to patients.

Breaking down these silos requires EHRs to interoperate with each other and a host of diverse applications created by innovators in healthcare. The first step toward this goal was the 2011 introduction of Fast Interoperable Health Resources (FHIR), a data standard that defines the structure of health data in transit. FHIR ensures EHRs and third-party applications can speak the same language, such that health data can flow freely and securely between EHRs and other digital solutions. Around the same time came Substitutable Medical Applications, Reusable Technologies (SMART). With a $15 million grant from the Office of the National Coordinator for Health Information Technology (ONC), SMART fostered development of a standard framework that enabled development of interchangeable healthcare applications. This innovation paved the way for the EHR app marketplaces we know today.

The two standards were brought together to create SMART-on-FHIR, an open, free, standards-based application programming interface (API) that makes it easier to develop applications that can run anywhere within the healthcare system. In essence, what FHIR is to data integration, SMART is to workflow integration. SMART-on-FHIR then enables creation of third-party apps for a variety of use cases that clinicians can launch within their existing EHR workflow. These apps will work with the EHRs, allowing single sign on and eliminating the need to toggle between tabs, windows or extra portals.

In fact, two recent federal rules are mandating these standards to further advance adoption of value-based care:

SMART-on-FHIR is the inflection point for driving the shift to value-based care. The reason: It offers another pathway to integration in which user experiences, not just discrete data, are shared across systems, enabling lightning quick implementation. The reality of a fast and painless integration gives health systems the flexibility to pick, trial and adopt the right solution for them, rather than being saddled with the sunk cost of a lengthy and expensive implementation phase. The maintenance of the user experience is further centralized by the application, offloading health system IT staff from the burdensome task of managing several systems. Lastly, the agility of the FHIR specification and the built-in adherence to it breaks the pattern of data silos that are too often found when specialty applications get involved. Finally we have a fully integrated mechanism for democratizing innovation within the healthcare record.

Supporting the value-Based care evolution with SMART-on-FHIR

SMART-on-FHIR will ultimately be the catalyst for growth in the healthcare app market. In “The Ecosystem of Apps and Software integrated with Certified Health Information Technology,” published in Journal of the American Medical Informatics Association, ONC reports that in 2021, there was a 20% year-over-year increase in the number of apps that integrate with certified EHRs. About 38% of the apps were for clinical uses, including performing automated tasks, population health, telehealth and clinical decision support. Other apps, the research noted, focused on care management, patient engagement and research.

Between rules mandating integration and access to healthcare information, and technological innovation in use cases, it’s my prediction that we’ll begin to see numerous new apps that support the value-based care evolution, and help reduce costs for patients, providers and payers alike. These apps will further address aspects of healthcare, such as remote monitoring of patients, precision medicine, integration of personal fitness trackers with EHRs, monitoring medication adherence, managing patients with chronic diseases, and collecting patient-reported outcomes, to name just a few.

Apps can also be valuable to the research community, giving them greater access to more patient population data when delving into cures for diseases or uncovering possibilities to match patients to clinical trials that could improve their quality of life or result in development of life-saving treatments. I see a special opportunity for applications that support clinical studies, as they can connect a single web application to multiple centers through SMART-on-FHIR. This gives EHR users access to a unified experience, data set, patient set, and database, framed into their individual EHR through SMART-on-FHIR, and automatically reading and writing data through FHIR integration.

There is so much data being generated today in healthcare, and it will only continue to grow exponentially from here. SMART-on-FHIR is the spark our industry needs to heat up in the app ecosystem, which will be important to support innovative use cases in value-based care long into the future.

Photo: DrAfter123, Getty Images

Dan Bonistalli is the Director of Product at Rimidi, a leading clinical management platform designed to optimize clinical workflows, enhance patient experiences and achieve quality objectives. Dan holds a B.S. in Biomedical Engineering and a Master’s degree in Medical Device Product Development. His background and experience includes supporting national health IT systems with leading Electronic Health Records company, Epic, as well as early-stage medical device conceptualization, design and commercialization with the Global Center for Medical Innovation at Georgia Tech. Dan has a passion for using data to help tell a patient’s story and improve clinical care.

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