SMART integrations in the health IT

In the pre-COVID-19 era, there were mainly two ways of transmitting our healthcare information to the doctor’s office – it was either using non-secure communication (phone, e-mail, etc.) or in person. Due to the healthcare crisis, we had to reduce unnecessary contact, leaving us only with the first option – communicating our personal, private, confidential, intimate health information via phone or e-mail. However, not only is this the least secure way of communication in terms of healthcare interoperability and structured data, but it’s also the least usable, reliable and dependable. Words can be misinterpreted, lines cut off, other people may be listening in & tracking our condition, emotions and actual feelings may come across different from what they really are at the moment.

Security and privacy aspects which we believe are crucial for the quality of patient care are at the bottom of the list. In times when the health crisis is driving the world, we can not let healthcare take the bullet and deteriorate in characteristics critical for the quality of care. Suppose progress made in health IT was mostly drawn back under the pretense that patient health data is too sensitive. In that case, it seems as if this doesn’t matter anymore – Viber, SMS, Facebook, e-mail – anything goes, as long as the personal distance is ensured.

It’s no secret that the crisis took the healthcare IT segment by surprise. Even with the pitfalls described above, people were forced to use other means of interacting with the doctor’s office when not given a proper alternative. However, it’s the times like this that should shed light on what’s really important and in which direction the healthcare IT segment needs to evolve – standardisation of data, security of information and interoperability of systems.

What is SMART and SMART on FHIR?

SMART Health IT is an open, standards-based technology platform that enables innovators to create apps that seamlessly and securely run across the healthcare system. Using an electronic health record (EHR) system or data warehouse that supports the SMART standard, patients, doctors, and healthcare practitioners can draw on this framework to improve clinical care, research, and public health. There is no better way to leverage health standards and deliver new value than adopting interoperability. This way, the existing health data and services can be used in an end-to-end, seamless care process, regardless of vendor system borders, departments, organisations. Even established health IT ecosystems are gradually embracing this mantra.

When you include FHIR in this whole picture, you’re no longer talking just about contextual launches of applications within other systems but also using a standard approach to exchanging clinical data. Having a SMART framework around you can support you with the access control and provide you with an open API and standards to achieve full interoperability. FHIR helps you to integrate with Electronic Health Records, portals, Health Information Exchanges and other Health IT systems using a set of open specifications and guidelines.

A Cerner standardised and guided approach to SMART Health IT

The Cerner EHR platform, Millennium? uses the standards mentioned above and therefore offers you the ability to integrate with it using a standardised and guided approach. Utilising Cerner Ignite APIs? for Millennium enables external applications to be embedded in the EHR workflow. These APIs are Cerner’s implementation of SMART Health IT and the HL7? Fast Healthcare Interoperability Resources (FHIR?) standard.

Looking past the buzzwords and keywords, Cerner, with this implementation, provides a data platform that enables you to retrieve data using FHIR standard wrapped around the SMART on FHIR framework, therefore handling both access control and data exchange. Both integrations with their identity provider and the FHIR server are straightforward as they’re both using widely adopted standards (Open ID Connect, FHIR) and specifics or restrictions that may exist are very well documented. Even if one stumbles upon a problem, Cerner offers very well responsive Google groups where they assist you to help you proceed.

About the integration

On paper, any of our solutions should have been fully compatible with Cerner’s system, as we too not only use FHIR standard but have it deeply embedded in our core solution. To test the compatibility in practice and start the process of listing our application in Cerner’s App Gallery, we’ve decided to integrate with the Cerner EHR platform, Millennium. The first order of business was to register our solutions in the Application Gallery – an apple store or play store like platform containing all available applications compatible with Cerner’s framework.

When registering, you need to provide a couple of specifics, such as application type (system, patient or provider), access required to FHIR Resources (as per SMART specification) and own OpenID specifics for successful IdP integration.

Open sandbox enabling standard integration in no-time

Integration with the open sandbox was as straightforward as merely pointing our FHIR Integrator component to the FHIR server provided by Cerner, and just like that, we’ve established the connection to their Patient, Binary and DocumentReference database. This was a validation to us that the FHIR Integration alone won’t present any challenges and another justification that having a fully compatible solution with the widely adopted standards really was a step in the right direction. In a matter of minutes, we were able to support many vital use cases of our Vitaly solution for coordinated care – from document listing, patient searching, identifiers and demographics exchange, and others. In terms of technical integration, this means:

• PDQ and PIX (Patient FHIR Resource, search and read; exchanging demographics as well as identifiers; read-only)
• Document listing and retrieving (DocumentReference search, read, Binary read)

A secure environment powered by a seamless experience

Having the clinical use case and functionalities of our solutions mainly covered, we’ve decided to proceed with the secure environment. This meant integrating with the Identity Provider surrounded by the SMART framework for invoking provider applications and obtaining context from patient-facing applications. The secure environment allowed us to differentiate between different applications and access rights that designated users usually have when interacting with the EHR. 

Vitaly Coordinated care solution was integrated as a provider-facing app that can be opened in context from within a third-party EHR. As mentioned, SMART App Launch guidelines are used to achieve that, and it means that our solution – when invoked – is given a context for launching (for example, patient id or encounter ID), which we forward to the Cerners’ IdP to obtain the right access token for continuing in this context. Access token obtained ensures that the practitioner only has rights within the context and nothing more. Furthermore, when our solution is opened from within the EHR in this way, it is immediately set up in the patient’s context that the professional was viewing in his own EHR software, achieving a straightforward and seamless experience.

The patient access was set up as a standalone application, meaning anyone could access it by going directly to our solution and log in within Cerner’s IdP. Upon login, our solution again obtains the patient identifier of the logged-in user (context). The FHIR server, on the other side, makes sure that access control is strictly and consistently enforced, preventing the leaking of data between different patients.

Architecture

Below you can see a high-level overview of our architecture. The red parts are those that – once integrated with Cerner’s workflow mentioned above – are responsible for exchanging data between both systems. 

An integrated solution for secure clinical information exchange between different systems

We at Parsek are constantly expanding our product portfolio as well as technical expertise. While we’ve already proven to be a compatible vendor on various IHE integrations, we were yet to validate third-party integrations with FHIR compatible systems. Cerner supports FHIR as a mean of transporting clinical information between systems and has a SMART on FHIR framework built around its solution, ensuring both interoperability and security while leveraging open standards, making integrations fast, seamless and efficient.