smart on fhir aids interoperable app development

How SMART on FHIR Aids Interoperable App Development?

Healthcare app development is a massive global industry growing steadily. There are over 40,000 healthcare apps available on Apple’s App Store and Play Store for Android users. Moreover, the market for telemedicine apps is slated to grow to $18 billion within the next five years. As if that’s not enough, mobile medical app development bagged over $10 billion in funding in the last couple of years. To sum it up, mobile application development has become an integral part of the broader healthcare IT industry.

What is Smart on FHIR?

“Substitutable Medical Applications, Reusable Technologies” aka SMART is a standard framework to facilitate the development of interchangeable healthcare applications.

Initially, SMART aimed to establish a data standard that could enable a "build once, go anywhere" model. However, as Health Level Seven International's FHIR gained traction and support from the healthcare community, SMART shifted its focus. In late 2013, SMART began working to develop a standard that would complement and work in tandem with FHIR, which led to the creation of "SMART on FHIR." Instead of developing a data standard, SMART concentrated on formalizing the process for interacting with FHIR interfaces. This included defining how apps would be launched from the Electronic Health Record EHR and standardizing the security protocols used by third parties to exchange data with healthcare organizations' EHR systems.


  1. In many healthcare systems, patient information is spread across different EHRs and software used in various locations making it difficult for caregivers to view a patient's progress in one place.
  2. Caregivers may need to access different applications to get a complete view of a patient's treatment history or manually assemble workflows, which takes time and incurs costs
  3. SMART is an open-source, standards-based API that leverages the OAuth 2.0 standard to provide secure access to patient data in the EHRs. Hence, patient data can be assembled in a single view, allowing caregivers to see a patient's entire history without switching between applications.
  4. This unification of data opens possibilities for applications to display graphs and visualizations of patient progress.

How are SMART and FHIR Related?

  1. FHIR is a set model that standardizes clinical concepts stored in different EHR systems and other data siloes.
  2. It is like a security layer that sits on top of FHIR interfaces. It uses OAuth2.0 and OpenID Connect to give applications access to required data within an EHR or any other SMART on FHIR compliant repository.
  3. SMART defines how third-party apps launch within an EHR, how to determine which EHR user is interacting with the app, and what patient’s data is being accessed.
  4. Both FHIR and SMART are not platforms. They are a set of guidelines that tell us how to implement a certain technology and provide seamless data transfer. In other words, “FHIR standardizes data and SMART standardizes data access”.

What is it Like to Implement a SMART on FHIR app?

The process of implementation happens in the following steps:

  1. The specification is developed.
  2. EHR vendors implement the standards and specifications, albeit differently.
  3. The health systems – the customer of EHR vendors – install, update, and configure their systems to incorporate the standards.
  4. Applications are built on top of the health system’s specifications.

While seemingly simple, it’s important to note why this process makes the final step exceptionally difficult.

Once the vendor implements it, we’re onto step three—the health systems must install, update, and configure their systems to incorporate the standards. Many health systems use multiple EMRs/EHRs. Take, for example, a health system which uses both Epic and Cerner; their data center must install software to support FHIR and SMART on FHIR for both vendors. During installation, the health system can decide which pieces of FHIR they want to implement, and more importantly, which pieces they do not want.

The final step is apps building on top. By the time the apps start building, there’s been a lot of opportunity for deviation from the standard. An example where one can see this deviation is code sets for medications. When using the FHIR medication resource, Epic sites implement with the RXNorm standard; however, a Cerner implementation would use an internal Cerner ID. Moreover, it’s highly likely that two Cerner sites wouldn’t even be compatible with each other.

Why is SMART on FHIR Relevant Now?

  1. The 21st century cures act has called for the adoption of an FHIR API.
  2. Recent CMS and ONC rules have already made SMART on FHIR capabilities on EHR/provider/payer mandatory.
  3. The Office of the National Coordinator for Health Information Technology’s (ONC’s) Final Rule on Interoperability (Published in 2020) has later named SMART as a communication standard.
  4. Given the benefits and these recent regulations from the government, it is imperative that every major EHR vendor and other third-party organizations adopt SMART on FHIR. So, now you can choose to either stay with the crowd or become obsolete.

SMART on FHIR Interoperable Applications in use

Currently, there are more than 50 SMART on FHIR apps readily accessible. Unlike the App Store, where numerous apps may lack utility or functionality, nearly all the SMART on FHIR apps available today have a specific purpose. They serve various functions, such as aiding healthcare professionals in their daily tasks or providing educational resources to patients. In this guide, we will showcase some of the most impressive, practical, and innovative SMART on FHIR apps developed to date.

Without delay, let's present the top four outstanding SMART on FHIR applications:

  1. Pillbox

    DukeHealth has developed the Duke PillBox app to tackle the problem of medication non-adherence. With an average adherence rate of 50% for medications taken four times a day, this app simplifies the management of complex medication regimens. Patients can organize their medications by dragging and dropping them into the correct time slots, aided by visual representations of each pill. The app also provides hints to help patients remember their dosing schedule, aiming to improve adherence and enhance patient outcomes.

    Check app here.

  2. Cardiac Risk

    Boston Children's Hospital has created the Cardiac Risk app, which utilizes the Reynolds Risk Score to calculate an individual's 10-year cardiovascular risk. By considering factors such as family history of heart attacks, systolic blood pressure, and smoking status, the app estimates the risk level.

    An interesting feature of the app is its interactive nature. Users have the ability to modify any of these measurements or vitals and observe the impact on their risk score. For instance, a smoker can determine how quitting smoking would reduce their Reynolds Risk Score.

    Check app here.

  3. BP Centiles

    The BP Centiles app, developed by Boston Children's Hospital, simplifies the interpretation of blood pressure measurements for children. It calculates percentiles based on age, sex, and height, and uses color-coded visual cues to indicate normal, prehypertensive, hypertensive, or hypotensive readings. This saves clinicians time and helps them quickly assess a child's blood pressure status.

    Check app here.

  4. SMART Precision Care Medicine

    The SMART Precision Cancer app, created at Vanderbilt University Medical Center, supports clinicians in the field of precision cancer medicine. It addresses the growing complexity of tumor genetics by providing contextual information about a patient's specific cancer genome. With data integration from sources like My Cancer Genome, Gene Wiki, and, the app assists providers in managing the cognitive workload associated with this evolving field of research.

    Check app here.

RELATED: Unlocking Connected Health Potential through Interoperability

How Healthcare Providers and Vendors can Leverage SMART on FHIR

Healthcare providers and vendors can leverage SMART on FHIR in several ways, including:

  1. Building custom applications

    Healthcare providers and vendors can use SMART on FHIR to build custom applications that meet their specific needs. For example, they could create an application that aggregates patient data from multiple sources, such as EHRs, patient portals, and wearable devices, to provide a comprehensive view of a patient's health.

  2. Integrating with existing systems

    Healthcare providers and vendors can integrate their existing systems with FHIR-enabled systems using SMART on FHIR. This enables them to share data more easily and efficiently.

  3. Collaborating with other organizations

    Healthcare providers and vendors can collaborate with other organizations using SMART on FHIR. For example, they could create a shared application that allows patients to access their health data from multiple providers.

  4. Improving patient engagement

    Healthcare providers and vendors can use SMART on FHIR to create patient-facing applications that improve patient engagement. For example, they could create an application that enables patients to view their health data, schedule appointments, and communicate with their healthcare providers.


The future of the healthcare sector in the US is based on creating a highly interoperable and patient-centric ecosystem. Implementing SMART on FHIR at the right nodes of your system is a major step in the right direction. A healthcare interoperability solution expert can help you in this process.

Our healthcare IT team has the expertise and experience of working in the US healthcare ecosystem for more than a decade now. We can help you build applications compatible with SMART on FHIR, keeping in mind your requirements.

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