Getting Smart About FHIR

What does healthcare interoperability look like?

Advances in health tech have boomed over the last 50 years, however, not being able to access patient data from past visits at other facilities remains a huge barrier to patient care and research. Not to mention it is directly related to an enormous amount of wasted time, resources and money! (Ever have a routine lab draw done at one location, only to be transferred to another location to see a specialist and have to repeat the same lab draw?! That’s because doctors don’t have access to those previous lab results!) In the realm of joint replacements, repeat lab testing or imaging to determine readiness for surgery is a classic example of healthcare waste that could be eliminated with interoperability.

So, what are FHIR and SMART on FHIR?

If you are on a path to understand how to implement healthcare interoperability you are probably seeing the terms FHIR and SMART on FHIR pop up. FHIR stands for Fast Healthcare Interoperability Resources. It is a standard that defines how healthcare information can be exchanged between different computer systems independent of how that data is stored within those systems. FHIR acts as the language or coding mechanism for an EHR so that data sharing from one EHR will translate into the same language on a different EHR. A lot of health systems and EHR companies have already implemented FHIR into their EHR structure because it significantly lowers the barriers for creating integrations between systems.

FHIR breaks down healthcare data into categories such as patients, lab results, insurance claims, etc. These categorial subsets represent a FHIR Resource: each of these resources have defined data elements, constraints on those elements and relationships to other data/resources. This combination makes up a patient record that can be transmitted from one system to another.

Even though the “language” of data transfers became accessible in 2014 with FHIR, there were no rules or regulations as to how this new ease of data transfers could be utilized. The 21st Century Cures Act, that was passed in 2016 called for the adoption of a universal API that would allow “individuals to securely and easily access structured electronic health information using smartphone applications.” This was no small project. Two main projects came about from the Cures Act: the development of SMART, and TEFCA as an outline of regulatory/compliance steps (check out the bottom of the blog for more insight on TEFCA).

Wait… what is an API again?

An application programming interface (API) is a way for two or more computer programs to communicate with each other. It is a type of software interface, offering a service to other pieces of software (think of an API like wires in a circuit, connecting one thing to the next).

Today, most EHRs operate as a standalone application, using their own proprietary API to access data. As a result, it is impossible to access data from one EHR in a different EHR unless software companies build custom connections between systems. Not only is this costly, but it limits providers from accessing data in different systems (cue the need for repeat lab testing and imaging). Even if you were to have an API connection built, the data transfer could still be very difficult or impossible unless every EHR is using the same language. If EHR A uses the term “BP”, but EHR B uses the term “blood pressure”, when system A goes looking for the letters “BP” in system B it will come up with zero results.

What is SMART?

The Substitutable Medical Applications and Reusable Technologies (SMART) platform helps solve interoperability challenges by standardizing the workflow of accessing healthcare data in disparate systems. SMART is an open-source, standards based API that leverages OAuth 2.0 standards to provide secure access to EHRs. The SMART platform utilizes FHIR as the data model thus giving you SMART on FHIR! Together, these two standards contain everything necessary to build applications that will work anywhere across the universal healthcare system.
Today, most EHRs use proprietary APIs to access data. As a result, software companies have to build custom connections between systems to access medical data. Not only is this costly, but it also hinders healthcare providers from accessing data in different systems that will allow them to efficiently make care decisions for their patients. Utilizing SMART on FHIR simplifies development. Developers can develop one integration based on SMART/FHIR standards and it will work with any EHR database that also uses these standards.

What is driving the use of SMART on FHIR?

The 21st Century Cures Act, that was passed in 2016 called for the adoption of a universal API that would allow “individuals to securely and easily access structured electronic health information using smartphone applications.” The Office of the National Coordinator (ONC) for Health Information Technology’s Final Rule on Interoperability identified SMART as that universal API. The Centers For Medicare and Medicaid Services (CMS) also named SMART on FHIR as the preferred technical standard for any healthcare system that accepts Medicare or Medicaid. Adopting SMART on FHIR is a priority for any healthcare system. For this reason, major EHR players are already using SMART on FHIR.

What is TEFCA?

In January, 2022, the U.S. Department of Health and Human Services published the Trusted Exchange Framework, Common Agreement (TEFCA) – Version 1, and Qualified Health Information Network (QHIN) Technical Framework. The overall goal of the TEFCA is to establish a universal floor for interoperability across the country. The Common Agreement will establish the infrastructure model and governing approach for users in different networks to securely share basic clinical information with each other—all under commonly agreed-to expectations and rules, and regardless of which network they happen to be in.

In 2023, CommonWell Health Alliance, eHealth Exchange, Epic, Health Gorilla, Kno2 and KONZA National Network will participate in the “network of networks” and begin the interoperability process of exchanging data between each of their health systems.