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🏥 Building a Modern, Interoperable Application for Hospitals

or, what I learned over the last five years building an app for hospitalists

Building a clinical app 1 and getting healthcare providers on-board is hard. This guide should help.

In this series you’ll learn how to compose a healthcare application out of familiar, modern web technologies: patients / physicians authenticate via OAuth, clinical data is fetched as JSON over a RESTful API, and you can deliver an HTML5 user-interface.

As for why: this is the guide I wish I’d had when my company, HealthTensor, set out to build a digital health app for hospitals back in 2017. We had experience developing web and mobile apps, but a clinical app? Back then we had no idea where to even begin and as a result our first hospital integration took well over a year to complete. Fast-forward several years to 2021: with a better understanding of the process we can now integrate with new hospitals in well under a month.

Contents

This guide is organized as a series of four posts, each of which walks through a component of building a clinical app. The content is targeted at early-stage clinical application developers and integration managers, or for anyone curious about developing an application for healthcare providers.

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Below is an overview of the parts; each will be linked to as it’s written.

Part 1: Building a relationship with the health provider and EHR

For your app to be used, the first step is to develop a relationship with a healthcare provider and their electronic health record (EHR)2 so you can deliver your application physicians. This is both the least technical and most difficult part of going from zero-to-one with a hospital app because that you need to take a demo or idea to a healthcare provider and prove value. Once the provider is onboard they’ll require you to complete a security review3 and have a plan for testing and deploying application. In parallel to completing the healthcare provider’s requirements you can register your application with the EHR’s SMART platform and work through their security review.

Part 1 covers developing the clinical relationship and planning the timeline. Note: Part 1 will be linked here when available.

Part 2: The application platform: SMART on FHIR

Next I’ll explain how to work with SMART on FHIR4 to handle the technical side of clinical integration. We’ll work through how to register your application with the EHR, authenticate on behalf of patients or physicians (OAuth), and fetch clinical data (JSON over a RESTful API). By the end of this part you should understand what it takes to build a backend-only hospital application.

Part 2 covers how to use SMART on FHIR for authentication and clinical data fetching. Note: Part 2 will be linked here when available.

Part 3: Developing a web-application in the EHR

The third part covers how to deliver a user-interface to a patient or physician. As a composable web-based standard SMART on FHIR allows you to build your front-end using any technology which can speak HTTP, e.g. web, mobile, and desktop apps are possible. I’ll specifically explain how to build a web-app for healthcare practitioners that can be loaded from a patient’s record in the EHR at the point-of-care.

Part 3 explores building a user-interface for clinical apps. Note: Part 3 will be linked here when available.

Part 4: Getting the most out of clinical integrations

In the final part of the series you’ll see how to get the most out of a hospital integration. As a new standard SMART on FHIR still has some rough edges for common workflows. It lacks “hooks” for new clinical data, bulk data fetching, and complex queries across multiple references. I don’t have clean solutions, but I can offer some workarounds with their tradeoffs.

Fortunately there are solutions to these issues in the works. Developing technologies like CDS hooks, SMART/HL7 bulk data access, and a GraphQL API will fill in the gaps, and each continues the trend of leveraging industry-standards to solve real problems with clinical integration.

Part 4 gets into shortcomings with SMART on FHIR, how to overcome them, and developing standards. Note: Part 4 will be linked here when available.

Conclusion

For many reasons, some of them good, the healthcare industry is hard to build for. New standards have drastically lowered the technical bar to contribution, and I hope this guide has helped you understand what tools are available. That being said, I’ll leave the business, medical, security, and bureaucratic challenges up to you.

I can’t promise a response, but you can continue the conversation over email: [email protected]

Footnotes:

1

The term clinical app covers a huge range of products and requirements. I’ll focus on developing software applications that 1) are web-based, 2) requires up-to-date clinical data, and 3) are used by healthcare practitioners at the point-of-care in hospitals. This likely won’t fit your exact requirements but is super customizable. For example, the front-end might be implemented as a desktop or mobile application. Or, patients can authenticate you to access data on their behalf instead of healthcare practitioners.

2

The Electronic Health Record (EHR) is the system of record for a hopsital’s digital data and the platform clinical workflows are built on. While SMART on FHIR is specified as a standard, it’s implemented, hosted, and managed on the hospital’s behalf by the individual EHRs. In other words, the EHRs are key stakeholders throughout clinical integration. More on wikipedia.

3

While security isn’t emphasized in this introduction, it’s an absolutely critical component of clinical integration. From a business and legal perspective your stack must comply to HIPAA as well as any additional requirements set by the healthcare provider. Fall short of that you are legally liable for breaches and no one will do business with you. More importantly, from an ethical perspective you are being entrusted with individuals’ private information and are responsible for protecting that information. I’ll touch on this more in Part 1, but HIPAA compliance is a massive topic that is better covered elsewhere.

4

SMART on FHIR is a relatively young but disruptive healthcare standard designed to facilitate building clinical applications. Since its inception at Brigham-Young in 2010 it’s grown into a standard supported by all major EHRs. Apple’s HealthKit, for example, uses SMART on FHIR to give patients access to their clinical information.

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