The SMART Platform: early experience enabling substitutable applications for electronic health records

Abstract

Objective: The Substitutable Medical Applications, Reusable Technologies (SMART) Platforms project seeks to develop a health information technology platform with substitutable applications (apps) constructed around core services. The authors believe this is a promising approach to driving down healthcare costs, supporting standards evolution, accommodating differences in care workflow, fostering competition in the market, and accelerating innovation.

Materials and methods: The Office of the National Coordinator for Health Information Technology, through the Strategic Health IT Advanced Research Projects (SHARP) Program, funds the project. The SMART team has focused on enabling the property of substitutability through an app programming interface leveraging web standards, presenting predictable data payloads, and abstracting away many details of enterprise health information technology systems. Containers--health information technology systems, such as electronic health records (EHR), personally controlled health records, and health information exchanges that use the SMART app programming interface or a portion of it--marshal data sources and present data simply, reliably, and consistently to apps.

Results: The SMART team has completed the first phase of the project (a) defining an app programming interface, (b) developing containers, and (c) producing a set of charter apps that showcase the system capabilities. A focal point of this phase was the SMART Apps Challenge, publicized by the White House, using http://www.challenge.gov website, and generating 15 app submissions with diverse functionality.

Conclusion: Key strategic decisions must be made about the most effective market for further disseminating SMART: existing market-leading EHR vendors, new entrants into the EHR market, or other stakeholders such as health information exchanges.

Figure 1

‘Got Statins?’ is a complete SMART application (app) in 50 lines of HTML and JavaScript. The app includes an external SMART JavaScript library, then makes a call to obtain all medications for the in-context patient record. A list of drug names is created, and a loop checks each drug name against a list of known statin drugs. ‘Got Statins?’ is designed merely to illustrate the SMART API. A more robust approach would incorporate drug class data from a reference source such as NDF-RT.

Figure 2

Example of a SMART data payload.

Figure 3

At the center, a web browser window presents two principal components: (1) a white border region belongs to the SMART container, displaying a list of available applications (apps) as well as patient context; (2) a larger gray block belongs to a single ‘Cardiac Risk’ app. As illustrated, the ‘Cardiac Risk’ app can request data from the container directly inside the browser via SMART Connect; an app with a back-end component may request data with a server-to-server call via SMART REST. In either case, the SMART-enabled electronic medical record or personally controlled health record responds with the same SMART RDF data payload.

Figure 4

The ‘Cardiac Risk’ app, based on David McCandless' design (released under a Creative Commons license) shown running unmodified in (A) the SMART reference container, (B) the Indivo PCHR, and (C) the i2b2 analytic platform.

Figure 5

The envisioned SMART ecosystem. Health IT systems, such as electronic health records (EHR), personal health records (PCHR), and health information exchanges (HIE), that use the SMART application (app) programming interface (API) or a portion of it marshal data sources and present data simply, reliably, and consistently to apps. Apps are made available, under a business model to be specified, in one or more app exchanges. Administrators of individual SMART container installations (eg, vendors, chief information officers, practice leaders) can choose which apps are made available to their end users. End users can create a ‘dashboard’ of apps that they use in their workflow.