Project Background

The SMART North Community of Practice

The SMART North COP was established to develop implementation guidance for SMART on FHIR implementers in Canada. More information about SMART North and communication forums can be found here.

Purpose

As a step toward establishing a shared foundation for Canadian application developers, this IG will bring together information from a range of different sources to facilitate sharing and reuse of existing system capabilities.

Information sources drawn upon as a basis for this IG include:

• The International Patient Access Specification which provides app implementers a shared set FHIR profiles with the SMART App Launch specification to support clinician-facing applications and backend access to patient records.
• The Canadian Baseline FHIR Profiles developed by the Canadian FHIR community that define basic interoperability expectations for human-patient systems in the Canadian space.
• Experience of implementers of the Ontario eReferral SMART Integration as part of the Ontario eServices program.

International Patient Access (IPA)

The IPA specification describes how an application acting on behalf of a patient can access information about the patient from a clinical records system using a FHIR R4 based API where the clinical records system may be supporting a clinical care provider (e.g., a hospital or a general practitioner), a health data exchange, or other system managing patient records, including a national health record system.

Example Scenario

Salma Kahil uses a personal health record app to track her health and assemble her records from multiple healthcare providers. Her healthcare providers support the International Patient Access API, and Salma’s health record app provides a user-friendly IPA application to provide safe, quick, and reliable access to data. Because retrieving and updating her medical information from her healthcare providers is secure, fast, and simple, Salma is a more informed and engaged patient.

Ontario eReferral Contextual Launch

The Ontario eServices program is working to replace fax based referral processes with digital referrals. A key enabler of this change is giving clinicians who wish to initiate referrals an efficient way to:

• Access information about available services
• Select a provider
• Complete necessary referral forms
• Transmit the information to another provider

Existing EMR systems used in the province do not have these capabilities.

To address this gap, the Ontario eReferral SMART Integration defines a way for EMR systems to perform a user interface level integration with Referral Management Systems that provide these capabilities by providing a way for the EMR to:

• Launch the app
• Securely sign the user into the app
• Authorize the app and user to access information from the EMR to populate required referral forms / add attachments

Need for the SMART North specification and Canadian Baseline profiles

Although the Ontario eReferral SMART Integration has been implemented by several vendors, the ability to populate referral forms is limited by the absence of a shared, agreed upon set of FHIR profiles and operations to access information needed to populate referral forms and/or provide supporting information as binary attachments.

Additional Use Cases

BC Contextual Launch [coming soon!]

Key differences between the IPA and Ontario eReferral use cases

Both the eReferral and IPA use cases build upon different SMART App Launch with different requirements:

• International Patient Access focuses on Patient use of a standalone SMART App and uses the standalone launch.
• Ontario eReferral assumes that the Referral Management System SMART App will be launched from the EMR and is based on the EHR launch

SMART Actors

Actors relevant to the scope of this IG are defined by both the International Patient Access Specification and the Ontario eReferral SMART Integration:

IPA Requestor (or SMART App)

An application that initiates a data access request to retrieve patient data. It can be thought of as the client in a client-server interaction. The terms “app”, “patient app”, “client” or “SMART app“ may be used interchangeably throughout this guide and are not meant to limit this actor to patient or provider apps.

IPA Responder (or SMART Server)

A product that responds to the data access request providing patient data. It can be thought of as the server in a client-server interaction. The terms “server”, “IPA FHIR server”, “SMART app“, “EHR”, “EMR”, or “POS system“ are used interchangeably throughout this guide and are not meant to limit this actor to electronic health record systems. HIEs, care coordination platforms, population health systems, etc., can use the same technology. Consider these terms a short-hand notation for an “interoperable healthcare platform”.

SMART on FHIR Authorization Server

A product that responds to authentication and authorization requests as defined in the SMART App Launch specification. It can be thought of as the server in a client-server interaction. The terms “Authorization server” and “OAuth2.0 server” are used interchangeably throughout this guide. In the Ontario eReferral SMART Integration this is referenced as a component of the SMART Server along with the FHIR endpoint.

IPA Sequence Diagram

The sequence diagram in the figure below outlines a successful interaction between a patient and an IPA server to query and retrieve the patient’s clinical data:

How to read this guide

Relationship to other FHIR IGs

Credits

This SMART North Implementation Guide is a work product of the SMART North Working Group. This working group is composed of a dedicated group of Canadian stakeholders and technology vendors with the objective of establishing a standards-based SMART application approach.

Implementation Guide Contributors:

• Russell Buchanon (eCE)
• Paula Lee (eCE)
• Kobika Pararasasingam (eCE)
• Matt Wellhauser (eCE)