SMART on FHIR

SMART on FHIR is a standard that enables healthcare applications to securely access patient data across different EHR systems. It builds upon OAuth 2.0 and OpenID Connect to provide healthcare-specific authentication and authorization.

Overview

SMART on FHIR is an open standard developed by the SMART Health IT project in collaboration with HL7. It allows third-party applications to launch from within EHR systems or standalone, while maintaining consistent security and user experience across different healthcare platforms.

Key Features:

EHR Integration: Applications can launch directly from within EHR systems
Standardized Scopes: Healthcare-specific permissions using FHIR resource types
Patient Context: Applications receive context about which patient's data to access
User Context: Applications know which user (patient, practitioner) is authenticated
Interoperability: Same app works across different EHR vendors (Epic, Cerner, etc.)

SMART Launch Flows

SMART on FHIR supports two primary launch patterns:

1. EHR Launch (Contextual Launch)

EHR Launch is not yet supported in Haste Health

This feature is not yet supported in Haste Health. The following is for informational purposes only.

The application is launched from within an EHR system, automatically receiving context about the patient and user.

Launch URL Format:

https://app.example.com/launch?
  iss=https://api.haste.health/w/{tenant}/{project}/api/v1/fhir/r4
  &launch=eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9...

Authorization Request:

GET /w/{tenant}/{project}/api/v1/oidc/auth/authorize?
  response_type=code&
  client_id=smart-app-id&
  redirect_uri=https://app.example.com/callback&
  scope=launch patient/*.read&
  state=random-state&
  aud=https://api.haste.health/w/{tenant}/{project}/api/v1/fhir/r4&
  launch=eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9...

2. Standalone Launch

The application launches independently, and the user selects which patient's data to access.

SMART Scopes

SMART on FHIR defines a structured scope syntax that combines permissions with FHIR resource types.

Scope Syntax

<context>/<resource>.<permission>

Components:

Context: Who is accessing the data (patient, user, system)
Resource: FHIR resource type (Patient, Observation, etc.) or * for all
Permission: Access level (read, write, or * for both)

Scope Categories

1. Clinical Scopes (Patient Context)

Access data for the currently selected patient:

Scope	Description
`patient/*.read`	Read all patient compartment resources
`patient/*.write`	Write all patient compartment resources
`patient/.`	Full read/write access to patient compartment
`patient/Patient.read`	Read Patient demographics
`patient/Observation.read`	Read Observations (labs, vitals, etc.)
`patient/Condition.read`	Read Conditions (diagnoses)
`patient/MedicationRequest.read`	Read medication orders
`patient/AllergyIntolerance.read`	Read allergies
`patient/Immunization.read`	Read immunization history
`patient/DiagnosticReport.read`	Read diagnostic reports
`patient/Procedure.read`	Read procedures
`patient/DocumentReference.read`	Read clinical documents
`patient/CarePlan.read`	Read care plans
`patient/Goal.read`	Read patient goals
`patient/Encounter.read`	Read encounter history

2. User-Level Scopes

Access data across all patients the user has access to:

Scope	Description
`user/*.read`	Read all resources the user can access
`user/*.write`	Write all resources the user can access
`user/.`	Full read/write access for the user
`user/Patient.read`	Read all patients user can access
`user/Observation.read`	Read all observations user can access
`user/Practitioner.read`	Read practitioner information
`user/Organization.read`	Read organization information

3. System-Level Scopes

Access for backend services (Client Credentials flow):

Scope	Description
`system/*.read`	Read all resources (backend access)
`system/*.write`	Write all resources (backend access)
`system/.`	Full read/write system access
`system/Patient.read`	Read all patients (no user context)
`system/Observation.read`	Read all observations (no user context)

4. Launch Scopes

Control launch context and behavior:

Scope	Description
`launch`	Required for EHR launch flow
`launch/patient`	Request patient picker for standalone launch
`launch/encounter`	Request encounter context
`online_access`	Request refresh token for long-term access
`offline_access`	Request refresh token for offline/background access

5. OpenID Connect Scopes

Standard OIDC scopes for user identity:

Scope	Description
`openid`	Required for OIDC authentication
`profile`	User's name, picture, etc.
`email`	User's email address
`fhirUser`	FHIR resource representing the user (Patient, Practitioner, etc.)

Token Response with Context

When using SMART on FHIR, the token response includes additional context information:

{
  "access_token": "eyJhbGciOiJSUzI1NiIsInR5cCI6IkpXVCJ9...",
  "token_type": "Bearer",
  "expires_in": 3600,
  "scope": "patient/Patient.read patient/Observation.read",
  "patient": "Patient/123",
  "encounter": "Encounter/456",
  "refresh_token": "eyJhbGciOiJSUzI1NiIsInR5cCI6IkpXVCJ9...",
  "id_token": "eyJhbGciOiJSUzI1NiIsInR5cCI6IkpXVCJ9..."
}

Context Parameters:

Parameter	Description	Example
`patient`	FHIR Patient resource ID	`Patient/123`
`encounter`	Current encounter context	`Encounter/456`
`fhirUser`	FHIR resource for authenticated user	`Practitioner/789` or `Patient/123`
`tenant`	Tenant identifier (if multi-tenant)	`org-acme-health`
`need_patient_banner`	Whether to show patient banner	`true`
`intent`	Launch intent (reconcile-medications, etc.)	`reconcile-medications`

SMART Configuration Discovery

Applications discover SMART capabilities via the .well-known endpoint:

Request:

GET /.well-known/smart-configuration HTTP/1.1
Host: api.haste.health

Response:

{
  "issuer": "https://api.haste.health",
  "authorization_endpoint": "https://api.haste.health/w/{tenant}/{project}/api/v1/oidc/auth/authorize",
  "token_endpoint": "https://api.haste.health/w/{tenant}/{project}/api/v1/oidc/auth/token",
  "token_endpoint_auth_methods_supported": [
    "client_secret_basic",
    "client_secret_post",
    "private_key_jwt"
  ],
  "registration_endpoint": "https://api.haste.health/w/{tenant}/{project}/api/v1/oidc/auth/register",
  "scopes_supported": [
    "openid",
    "profile",
    "email",
    "fhirUser",
    "launch",
    "launch/patient",
    "launch/encounter",
    "online_access",
    "offline_access",
    "patient/*.read",
    "patient/*.write",
    "user/*.read",
    "user/*.write",
    "system/*.read",
    "system/*.write"
  ],
  "response_types_supported": [
    "code"
  ],
  "capabilities": [
    "launch-ehr",
    "launch-standalone",
    "client-public",
    "client-confidential-symmetric",
    "context-ehr-patient",
    "context-ehr-encounter",
    "context-standalone-patient",
    "context-standalone-encounter",
    "permission-offline",
    "permission-patient",
    "permission-user",
    "permission-v2"
  ],
  "code_challenge_methods_supported": [
    "S256"
  ],
  "grant_types_supported": [
    "authorization_code",
    "refresh_token",
    "client_credentials"
  ]
}

SMART Capabilities

Supported Capabilities

Haste Health supports the following SMART capabilities:

Capability	Description	Supported
`launch-standalone`	Supports standalone launch	✅ Yes
`client-public`	Supports public clients (no secret)	✅ Yes
`client-confidential-symmetric`	Supports confidential clients with secret	✅ Yes
`context-standalone-patient`	Patient picker in standalone launch	✅ Yes
`permission-offline`	Supports offline_access scope	✅ Yes
`permission-patient`	Supports patient/* scopes	✅ Yes
`permission-user`	Supports user/* scopes	✅ Yes
`permission-v2`	SMART v2 scope syntax	✅ Yes

Common Use Cases

Patient Portal

// Patient viewing their own data
scope: 'openid profile patient/Patient.read patient/Observation.read patient/Condition.read patient/MedicationRequest.read online_access'

Clinical Decision Support

// CDS app launched from EHR
scope: 'launch patient/Patient.read patient/Observation.read patient/Condition.read patient/MedicationRequest.read patient/AllergyIntolerance.read'

Population Health

// Analytics dashboard for clinicians
scope: 'openid profile user/Patient.read user/Observation.read user/Condition.read user/Encounter.read'

Research Data Export

// Backend system for de-identified data
scope: 'system/Patient.read system/Observation.read system/Condition.read system/Procedure.read'

Overview​

SMART Launch Flows​

1. EHR Launch (Contextual Launch)​

2. Standalone Launch​

SMART Scopes​

Scope Syntax​

Scope Categories​

1. Clinical Scopes (Patient Context)​

2. User-Level Scopes​

3. System-Level Scopes​

4. Launch Scopes​

5. OpenID Connect Scopes​

Token Response with Context​

SMART Configuration Discovery​

SMART Capabilities​

Supported Capabilities​

Common Use Cases​

Patient Portal​

Clinical Decision Support​

Population Health​

Research Data Export​

Resources​