Health IT Trends
by Kevin R. Dufendach, M.D., M.S., FAAP
Since Apple released its first iPhone in 2007, the
smartphone has become a ubiquitous, indispensable
technology. Part of the rapid success of iOS and Android has been the way the two platforms facilitate innovative development and delivery of integrated apps.
On the front end, users can choose specific applications to meet their needs. On the back end, each
application is granted only limited access to data and
system resources, which helps ensure device security.
SMART on FHIR seeks to bring similar technology
to health care, allowing innovators to create apps that
run seamlessly and securely in a variety of electronic
health record (EHR) environments.
SMART on FHIR is an amalgamation of two primary technologies. SMART stands for substitutable
medical applications, reusable technologies, and FHIR
stands for fast health care interoperability resources.
App store for EHRs may be reality in not so distant future
SMART focuses on authorization (establishing what
information an individual is allowed to access) and
authentication (establishing that individuals really are
who they say they are). To achieve this, SMART uses
the OAuth standard, which is the same technology behind a “Login with Facebook” or “Login with Google”
button on a website. A SMART application authenticates using existing credentials, such as a patient’s
online portal login or a provider’s active EHR session,
to allow access to authorized EHR data.
However, obtaining access to the data is only half the
problem, as individual EHR systems speak a variety of
internal languages. This is where FHIR becomes useful,
as it represents an open, common language that allows
computers to exchange information. FHIR specifies
exactly where and how data should be communicated,
and then SMART defines a set of “profiles” to ensure
apps know exactly what data elements should be in-
cluded to ensure the data are useful. This combination
is what allows SMART on FHIR to provide an ap-
plication programming interface (API) for an EHR.
For example, a developer can use the API to create
a growth chart app that retrieves a specific patient’s
name, birthday, sex and all weight measurements and
displays them to the patient.
Another key to SMART is the concept of substitutability. A SMART app is intended to give users options,
much like you have when choosing a web browser.
Most EHRs include a growth chart application. But
what other options do you have, besides asking your
understaffed information services team to create a custom design for you? SMART apps seek to give users
options through substitutability, whereby a user or
institution could choose an alternate application or
feature through an EHR app store or repository.
Patients also have options when it comes to accessing
their data through SMART on FHIR apps. A patient
or caregiver may want an app for viewing age-specific
health and safety recommendations, managing chronic
disease, keeping track of medications or accessing inpatient acute care data. In this case, the patient connects
the app to the EHR and uses his or her own existing
credentials to log in. As long as the appropriate APIs
and authorization protocols are in place, the EHR
doesn’t need to know anything specific about the app
that will be accessing the data. It just needs to share
the secret SMART on FHIR handshake.
Currently, SMART on FHIR is generating a large
amount of excitement. Several EHR vendors are supporting the API to varying degrees, and health care
systems and commercial companies are creating applications. A recent proof of concept demonstration
at the AMIA (American Medical Informatics Association) 2016 Annual Symposium displayed how the
technology could be used to access external clinical
decision support recommendations and display them
natively in two separate vended EHR systems (http://
SMART Health IT hosts an App Gallery that includes
live examples, such as the pediatric-focused growth and
bilirubin chart apps ( https://apps.smarthealthit.org/).
Still, the technology is considered early or experimental. Providers as well as vendors continue to work
on some of the more complicated nuances of the system, including how to incorporate write access (
putting information into the EHR) through the SMART
on FHIR platform, how to distribute apps to various
end users, and how to govern which apps are safe and
appropriate to include in a medical record. To this
point, only a few medical centers have implemented
the necessary infrastructure and incorporated apps into
SMART on FHIR continues to gain momentum in
the world of health information technology. It has the
potential to bring innovation, competition and collaboration into the health care field for both patients
and providers. As more medical systems implement the
necessary infrastructure, we likely will find ourselves interacting with an increasing number of
connected apps as we care for children.
Dr. Dufendach is a member of the AAP
Council on Clinical Information Technology.
Two free apps created by the Tobacco Control
Research Branch at the National Cancer Institute
aim to help teens and adults quit smoking.
QuitSTART is geared toward teens, while
QuitGuide is for adults. Both were developed
with input from smoking cessation experts and
After teens provide information about their
smoking history, the quitSTART app gives them
personalized tips, inspiration and challenges to
help them become smoke-free. The app allows
teens to monitor progress and earn badges for
smoke-free milestones and other achievements;
play games to distract themselves from cravings;
and share progress on social media.
QuitGuide offers numerous ways for adults to
track smoking behaviors, see recurring patterns
and build the skills to stay smoke-free. The app
allows smokers to record their cravings by time of
day and location. They also can input moods and
triggers. After time, users can recognize patterns
to their smoking behavior.
Users begin by selecting a target quit date and
identifying reasons for quitting. Push notifications provide tips and inspirational messages
throughout the day to help beat cravings. Statistics provide users with details such as minutes
and money saved by not smoking.
QuitSTART is available for Apple devices at
http://apple.co/2nSWbjh and Android devices
QuitGuide is available for Apple devices at
http://apple.co/2oBHoId and Android devices
at http://bit.ly/2nAOFqG. However, advanced
functionality is available only for Apple users at
More tips and support to quit smoking are
available at www.smokefree.gov and https://teen.
If you would like to share a first-hand experience
using technology, such as software, program, app,
widget, etc., to improve patient care or practice
management, email submissions of 250 words or
less to Vanessa Short at firstname.lastname@example.org.
Apps help teens, adults kick the habit
from the AAP Division of Quality