SMART uses for public health

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What is SMART

SMART stands for Sustainable Medical Applications, Reusable Technologies. [1] SMART is an API—an application programming interface that leverages the emerging FHIR standards to define health data resources, REST to access them, and oAUTH for authentication. This platform allows developers to write an app once and have it run on any vendors EHR without custom programming or development. It was created in a collaboration between the US government and teams from Boston Children’s Hospital Computational Health Informatics Program and the Harvard Medical School Department for Biomedical Informatics.

Benefits of SMART

The rapidly changing and complex health care landscape requires short cycle, nimble innovation of novel solutions to health care challenges. Vendor developed EHR’s, with their long development cycles and unwieldy proprietary platforms , do not allow for the rapid development and deployment of useful, malleable and swappable applications to meet regional and national needs in a time frame that is responsive enough to meet the public good or private imperatives. Use of SMART programming is particularly useful to address public health imperatives such as disease outbreaks and preparations for mass gatherings.

SMART's potential uses during the Ebola crisis

The recent Ebola crisis in the US highlighted the deficiencies in our current EHR infrastructure to rapidly respond on a national level in a coordinated fashion to public health threats. [2] When Thomas Duncan presented to a Texas hospital complaining of flu like symptoms after recently arriving from Liberia, his travel history was recorded in the hospital EHR. There was some question in the aftermath of his misdiagnosis if the travel history obtained by the nurses was , in fact, viewable by the provider seeing Mr. Duncan in the emergency department on that day. There was an initial flurry of accusations and speculation that the EHR screens may not have been designed to promulgate the travel history from one part of the chart to another.[3] Those speculations later proved to be unfounded. But following that incident, every hospital in the country gathered swat teams of EHR builders to add more explicit database elements and design surveys screens and alerts to implement more rigorous and highly conspicuous mandatory questioning of all patients on their travel history and presenting symptoms.

As highlighted by Mandl, the EHR's should have been nimble enough to be rapidly adapted to accommodate a nationally standardized travel and symptom questionnaire tailored to the emerging public health threat posed by the Ebola outbreak. Using SMART, the "CDC or another innovator could release a single app and affect the point of care nationwide."

Additional Public Health Uses for SMART

Most recently, Middle Eastern Respiratory Syndrome has reemerged, becoming the latest in a series of travel related zoonosis to threaten the health of US citizens. In the absence of SMART API's or other such plug and play strategies, most US institutions will again be faced with having to reconvene teams to perform custom builds to trigger appropriate screening and alerting for this reemerging threat.

Natural disasters and Mass Gathering preparations could be also be managed using SMART apps to collate information about hospital admissions and event related injuries. Additionally, using SMART apps designed to sift local content through national standards can drive down antibiotic over prescribing as in the case of streptococcal pharyngitis. SMART supports the vision of a learning healthcare system [4] by disseminating standardized, generalizable, easily digestible but locally applicable frameworks to screen for and manage disease in individuals or populations.

References

  1. What is SMART. Accessed 7/30/2015. http://smarthealthit.org/about//>
  2. Mandl KD. Ebola in the United States: EHRs as a public health tool at the point of care. JAMA. 2014;312(23):2499-2500.>
  3. McCann E. Missed ebola diagnosis leads to debate. http://www.healthcareitnews.com/news/epic-pushes-back-against-ebola-ehr-blame-shifting. Updated 2014. Accessed July 30, 2015.>
  4. 1. Friedman CP, Wong AK, Blumenthal D. Achieving a nationwide learning health system. Sci Transl Med. 2010;2(57).>


Submitted by Karen Pinsky