App Platform for Healthcare - SMART Health...

DanGottliebJune2017

AppPlatformforHealthcare

KLASConnectedAppsReporthttp://SmartHealthIT.org/apps-report

“…wehadthiswonderfulpopulationhealthtool,butwecouldn’tgetthe[EHR]systemtointerfacewithit,sowehadtoenterinformationbyhand.Wejusthadtogiveuponthatbecausewecouldn’tphysicallykeepup.”

- Physician,KLASInterview

SMARTCoreFocus

HealthcareApps ClinicalSystems(EHRs,PatientPortals,DataWarehouses)

SMART:UXIntegrationAuthorizationSingleSign-OnClinicalData

Why?

• Users:• Appchoice(substitutability)

• Developers:• Lowbarrierstoentry(openstandards,largecommunity)

• Singleappcanruninsystemsbydifferentvendors

• Singleappcanrunindifferentcontexts(e.g.EHRandPatientPortal)

ModernEHRsbecomeaplatform!

• UserandPatientManagement

• Workflowandcoreservices

• Datapersistence

• Regulatorycompliance

• Apps

TheSMARTPlatform

Opensourcetoolsandresources

Standardsbasedtechnologystack

Publicappgallery

Industrysupport

Standardsbasedtechnology

SMARTOAuthAuthorization&LaunchContext

SMARTOpenIDConnectSingleSignOn

FHIRAPI

FHIRResources(SMART/ArgonautProfiles)

Newtakeonhealthcaredatastandardsfocusedonmodernwebstandardsandimplementability

• FastHealthcareInteroperabilityResources• Draft→WorkingStandardfromHL7(readytouse!)• LicensedunderCreativeCommons- “Norightsreserved”• Clearandextensivedocumentationwithexamples• Encouragestheuseofpunsandpoorclipart

Whatis?




FHIRAPI


FHIRResourcesDatamodelsrepresentingdiscreteclinicalandadministrativeunits(patient,practitioner,allergy,medicationorder,etc.)

• Currentlyaround100havebeendefined• Eachresourceincludesnarrativetext“lowestcommondenominatordataexchange”

• Developerreadabledataformat (JSONorXML)• CanreferenceotherresourcesbytheirURL(moreonthatlater)• Don’tincludethekitchensink

“Weonlyincludedataelementsifweareconfidentthatmostnormalimplementationsusingthatresourcewillmakeuseoftheelement”– GrahameGrieve(FHIRProductDirector)

• But,supportextensionsforfaucets,etc.

https://www.hl7.org/fhir/resourcelist.html

PatientResourceExample




FHIRAPI


FHIR API

• Multiplereferenceimplementations• BasedonRepresentationalStateTransfer(REST)• EveryFHIRResourcelivesataURLoftheform:

http://fhir-open-api.smarthealthit.org/Patient/1032702

• Resourcescanhaveversionstoo(iftheserversupportsit)!http://server/Patient/123/_history/2

Server ResourceType Id

https://www.hl7.org/fhir/http.html

FHIRSearchAPI• EachFHIRResourcedefinesasetofsearchparameters

• TheseparameterscanbepassedintheURLtolimitwhichResourcesarereturnedbytheserver

http://fhir-open-api.smarthealthit.org/Patient?gender=male

• ResourcesarereturnedasaFHIRBundle– anarrayofresultswithsomemetadata• Thebundlemaycontainasubsetofresultswithlinkstoadditionalpagesof

resources(e.g.1-50of300)

OtherAPIFeatures

• Create,updateanddeleteresources• UsesstandardHTTPmethodsPOST(create),PUT(update)andDELETE(logicaldelete)

• JSONorXMLhttp://fhir-open-api.smarthealthit.org/Patient/1032702?_format=xml

http://fhir-open-api.smarthealthit.org/Patient/1032702?_format=json

• Conformancestatements• TerminologyBindings(required/extensible/preferred/example)• Batch/Transaction• Profiles




FHIRAPI


• BasedonOAuthstandard

• Twolaunchworkflows

• EHR/PortalLaunch– userpicksanappfromwithinEHR(EHRcanpassalongcontextlikeencounterandpatient)

• StandaloneLaunch– userlaunchesappandpicksanEHRserver(canrunfrommobiledevices)

SMARTAuthorization

http://docs.smarthealthit.org/authorization/

App EHR

EHRLaunch

1b.Dataaccessrequested(scopes)

3a.FHIRAPIrequest(withauth token)

3b.FHIRresources

3.DisplayData

2a.Auth tokenfordataaccess/useridentity/context(currentpatient,encounter)/

extras(stylesheet,etc.)

1.ChooseApp(fromregisteredapps)

2.AuthorizeAccess(limiteddata)

1a.Launchinformation(serverURL,token)

App EHR

StandaloneLaunch

1a.Dataaccessrequested(scopes)

1.ChooseEHRorPortal

2.Login,authorizeaccessandchooseapatient(ifnecessary)

3.DisplayData

2a.Auth tokenfordataaccess/useridentity/context(currentpatient,encounter)/

extras(stylesheet,etc.)

3a.FHIRAPIrequest(withauth token)

3b.FHIRresources

SMARTAuthorizationScopes

• Scopesconveywhataccessanappneedspatient/Immunization.read

• Examples:• Simpleapp:patient/Patient.read,patient/Observation.read• Complexapp:patient/*.read• ePrescribing app:patient/MedicationOrder.write• Populationheathapp:user/*.read

AccessType FHIRResource Permission

http://docs.smarthealthit.org/authorization/scopes-and-launch-context/

Opensourcedevelopmenttools&resources

• SoftwareLibraries• SandboxesforDevelopmentandTesting• SampleApps• Tutorials&Tools

SoftwareLibrariesforDevelopers

PublicSandboxesforTesting

• Over1,500samplepatientscomprising145,000FHIRresources

• PROdatabasedonNHSpreandpostsurgerysurveys

• De-identifiedlongitudinalmedicalrecords

SampleClinicalData

OpenSourceSampleApps

ToolsandTutorials

http://docs.smarthealthit.org

• EHRVendors• Government• HealthcareInstitutions• ExtensionofSMART

Industrysupport

ArgonautProjectGroupofEHRvendorsandhospitalsdrivingsupportforSMARTandFHIRintheUnitedStates

• ArgonautImplementationGuide• SecurityandAuthorization(SMART)• DataelementqueryoftheONCCommonClinicalDataSet• Documentqueryofstaticdocuments• USProviderDirectory

• NextSteps• Implementationguideforschedulingclinicalservices• ImplementationguideforCDSHooks(including:launchanappfromaCDSHookresponsecard)

https://www.healthit.gov/buzz-blog/health-innovation/nih-and-onc-launch-the-sync-for-science-pilot/https://www.youtube.com/watch?v=0FeQHlpIIXk&feature=youtu.be

SyncforSciencehttp://syncfor.scienceGoal:helpingpatientsshareEHRdatawithresearchers• PMIisoneearlyS4S"customer"(researchstudy).Therewillbelotsmore,ifwe'resuccessful.• Approach:SMART,FHIR,Argonaut,andMU3APIcertificationrequirements• Collaborators:Government(NIH,ONC,OSTP),EHRvendors(Allscripts,athenahealth,Cerner,drchrono,eClinicalWorks,Epic,McKesson)• Timeline:Deployingto~10providersitesandtestingwithrealpatients2017

HealthcareInstitutions

“OnOctober9,2015Isuccessfullyloggedintoourproductionsystemforthefirsttimetoview realpatientdata inaFHIRapp!I'dlovetosharescreenshotswithyou,buttheycontain realpatientdata,soIcan't!Letmesaythatagain: realpatientdata,viaFHIR,withinMaestroCare,ourEpic-basedEHR.”

RickyBloomfieldJr,MDDirectorofMobileTechnologyStrategyhttp://www.rickybloomfield.com/2015/10/dukes-on-fhir-for-real-this-time.html

Makeiteasytoincorporateexternaladviceintoclinicalworkflows

• Approach:UseFHIRandSMART-definedAPIcalls("hooks”)• Collaborators:athenahealth Allscripts,Cerner,andEpicparticipatinginConnectathon tracks.• Responsetypes(“CDSCards”):• Information(directdisplaytoclinician)• Suggestion(proposedactiontoimpactworkflow)• Applink(SMARTappthat’srelevantnow)

CDSHookshttp://cds-hooks.org

CDSHooksCDSHooksspecificationisa“workinprogress”

• Argonautprojectfor2017• EHRadoption/securitymodel/appintegration

• AlignmentwithHL7CDSWorkingGroup• Newhookdefinitionsandusecases• Performanceassessment• Asynchronousdelivery

• SMARTAppGalleryofferasingleplacetofindandlearnaboutSMARTandFHIRapps

• Vendorandlicenseneutral• NotrestrictedtoasingleEHRplatform• Hostscommercialandopensourceapps

• Manywaystonavigateapps

• Manywaystolearnaboutapps

Publicappgallery

https://www.healthit.gov/buzz-blog/from-the-onc-desk/foundation-discovering-clinical-health-applications/

SMARTAppGalleryhttps://apps.SmartHealthIT.org

MeducationandtheSMARTPlatformBackground● Tryingtoworkwithhospitalsforyears,butblockedbyEHRintegrationchallenges● Difficulttofindsupportivewebservicesandworkflowintegrationpoints● Securitychallenges(authorization,authentication)

WhatChanged:● MajorEMRvendorssupportingFHIRandSMARTapps

Result● Integrationsinprogressacrossmultiplehospitalsystemsandclinics● IntegrationswithCerner,Epic,Athena

“WithouttheSMARTplatformandEHRvendors’adoptionofSMARTonFHIR,wewouldbeyearsawayfrombringingthebenefitsofMeducation topatients.--- Nowwe’re

there!” LoriMcLean,CEOPolyglot

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