SMART on FHIR Apps: Building Secure Clinical Applications That Work Inside Any EHR

For decades, healthcare systems functioned on a closed, monolithic architecture. However, this is changing rapidly as the industry is shifting towards a modular, app-based ecosystem. 

The reason for this is that monolithic architecture limits how providers scale, integrate new technologies, and adapt to evolving regulations. More importantly, healthcare providers depend on what their vendor allows, forcing practices to adapt how they work rather than EHR adapting to their workflows.

But this changed with the standardization of FHIR R4. Moreover, regulations such as the 21st Century Cures Act also pushed for open data access, while to adapt to rapidly evolving technology, modular architectures become necessary.

At the center of this shift is the SMART on FHIR framework, which enabled seamless FHIR interoperability and brought the app store model to healthcare. Moreover, with these SMART on FHIR apps, organizations can build an application once and deploy it across multiple EHRs, without rebuilding integration each time.

However, many organizations still face challenges in developing scalable cross-EHR applications, as EHRs vary in how they are built and integrated. 

This is where SMART on FHIR app development becomes essential, as it speeds up development and enables healthcare app development that aligns with organizations’ clinical workflows.

In this guide, we will break down how SMART on FHIR works, how to build SMART on FHIR applications, and how to secure them to protect sensitive patient data.

What Are SMART on FHIR Apps?

Before we dive into how to build SMART on FHIR applications, let’s understand what SMART on FHIR apps are. In simple words, these apps are healthcare applications that use FHIR interoperability to access and interact with patient data across different EHRs and healthcare systems.

These apps are built on FHIR standards, enabling true interoperability without needing custom integrations for each new EHR. Moreover, the SMART on FHIR framework is like a bridge that connects the application with EHR systems.

At a high level, it defines how apps request data securely, verify users, and operate within clinical workflows, ensuring consistency across different EHR systems. This framework basically works on three components that make it possible to deploy SMART on FHIR apps across EHRs.

These components are:

• FHIR APIs: This works on REST APIs, giving standardized access to healthcare data through web-based requests.
• OAuth 2.0: With OAuth, data is stored and exchanged securely, ensuring that only authorized and authenticated users access it.
• SMART Scopes: This component decides how much data is exposed for an authorization level and controls the access of data to an application.

Additionally, there are three different types of SMART on FHIR applications based on use cases for giving a better user experience:

• Provider-facing apps: Clinical decision support, documentation tools
• Patient-facing apps: Patient portals, health tracking applications
• Backend services: Analytics platforms, population health tools

In short, these apps are based on the HL7 International SMART Health IT initiative. The goal of this initiative and apps is to standardize healthcare and ensure consistent data exchange across networks, implementing true interoperability.

Why Developers Choose the SMART on FHIR Framework?

As the healthcare ecosystem evolves and goes towards interoperability, developers are also moving away from traditional development models. They are increasingly using the SMART on FHIR framework and modular architecture, enabling a more standardized and efficient development approach.

The biggest advantage of using this framework is that developers don’t need to build custom integration with each new EHR. They can build once and deploy across multiple EHR systems, saving time and long-term maintenance effort.

Additionally, SMART on FHIR app development provides standardized data access. Meaning, developers don’t need to work with inconsistent formats or custom APIs, simplifying development and reducing integration complexity.

Another benefit of SMART on FHIR is for clinical workflows, as the apps can be directly implemented within the workflows. This improves usability and enables real-time data access. The result is higher adoption rates and better alignment with care delivery processes, improving productivity.

This approach even improves ROI as the development to deployment time is reduced significantly, reducing costs. Moreover, without multiple integration points, the maintenance costs are also reduced, and healthcare organizations can scale the EHR effortlessly without rebuilding the entire ecosystem.

In short, the SMART on FHIR approach shifts the vendor-dependent solutions to a platform-driven model supporting scalability, innovation, and interoperability.

How to Build SMART on FHIR Applications (FHIR App Development Flow)

Although it is efficient to build SMART on FHIR applications, it needs a structured approach that aligns with healthcare organizations’ needs. Moreover, FHIR app development is not a one-time integration, but a repeatable process built on FHIR and SMART standards.

The app development process starts by clearly defining the clinical use cases; without this clarity, the app development can’t be aligned with real workflows. For instance, decide whether you want to improve medication management or enable better patient engagement.

After defining the use cases, the apps must be registered with EHR to establish trust and enable secure interactions between the app and EHR. Then the next step is to configure the launch sequence.

Here, the developers either launch the apps within the EHR workflows or as a standalone application outside the EHR. Most importantly, the app must have security built into it using OAuth 2.0 for secure access and authentication.

Then the application communicates with FHIR APIs for retrieving and updating resources such as patient records, observations, and medications.

Finally, it must be tested in a sandbox environment to make sure that it works as intended and to validate interoperability and compliance before deploying it.

Security Architecture: Protecting Patient Data

As healthcare technology evolves and moves toward interoperability, the security risks are also increasing. That’s why embedding security measures into the EHR and SMART on FHIR apps architecture is essential. 

The SMART on FHIR framework makes sure of this by securing SMART on FHIR apps with the OAuth 2.0 standard at the core of this architecture. With this, it can manage authentication and authorization to verify users and set access levels.

Moreover, OpenID Connect makes it easier to establish user identities and access levels, allowing applications to differentiate between providers, patients, and administrators. Additionally, SMART scopes make sure to set least-privilege access by defining the scope of patient data to show limited data as per the user identity and permissions.

However, even after this, there are risks such as token misuse, over-scoping, and improper session handling. To mitigate these, organizations need to implement strict access controls, secure token management, and continuous monitoring.

When it comes to securing SMART on FHIR apps, it is about balancing interoperability and scalability without compromising data protection and security.

Deployment & Scaling Across EHR Systems

Building the SMART on FHIR app is only the first step, as after building it, ensuring it works consistently across multiple platforms is important. While the FHIR remains standard in various systems, the way they implement APIs, scopes, and workflows can be different, and that requires some major modification in FHIR apps, and these EHR differences are called EHR flavorings.

Moreover, some of the major EHR vendors even provide dedicated app stores, such as Epic App Orchard or Oracle Cerner Code, to support deployment. In these ecosystems, developers can register, test, and distribute applications, simplifying integration and adoption within their respective ecosystems.

Another important point is to ensure consistent performance across systems, and for that, the applications must be optimized for different environments. Along with this, they must be capable of handling varying API response behaviors and maintain reliability under different usage scenarios.

Most importantly, developers should align the application with the evolving regulatory requirements to maintain interoperability and compliance. This ensures that the application remains compliant with updated standards and future regulatory changes.

Challenges & Best Practices for FHIR App Development

While SMART on FHIR enables scalable and interoperable application development, real-world implementation comes with challenges that organizations must address strategically. Here are some of the most common challenges that developers face during development, and best practices to mitigate these challenges:

• EHR Variability & Inconsistent Implementation: The SMART on FHIR apps do not work at the same level in each EHR, as implementation of APIs, scopes, and workflows is different in each system. This impacts how applications behave and interact across platforms.

Best Practices: The best way to tackle this challenge is to design systems for cross-EHR compatibility from the first day of development. Also, use standardized profiles such as the US core to ensure consistent data understanding.

• Data Access & Scope Limitations: Applications may face restrictions in accessing data due to limited SMART scopes or incomplete API support, and not all required data may not be available across systems.

Best Practices: To overcome this hurdle, you need to define data requirements early and clearly. Use least-privilege access while optimizing API calls for efficiency.

• Workflow Integration Challenges: When the applications don’t align completely with clinical workflows, it slows down tasks for providers. Moreover, it also impacts usability and leads to low adoption rates and staff resistance.

Best Practices: To solve these issues, design apps that integrate seamlessly with EHR workflows and align with how providers work. Most importantly, focus on reducing clicks and match how each role works to improve usability and adoption rates.

Frequently Asked Questions