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This guide focuses on developer integrations, especially U.S. patient access. ONC’s developer resources are a useful U.S. starting point, but implementation details and legal responsibilities depend on the platform, deployment, parties, data, and jurisdiction.
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1. Define the workflow before choosing an API
Write down who will use the app, how they reach it, what information it needs, and what it will do with that information. A patient portal, a clinician-facing app launched inside an EHR, and a backend service have different access and authorization needs.
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- Clinician-facing: A user may launch the app from an EHR with patient or encounter context. Establish which context the platform passes and what scopes are appropriate.
- Backend integration: A service may operate without an interactive user at each request. Check whether the platform supports a backend authorization pattern, such as SMART Backend Services, and what registration and operational controls it requires.
For each workflow, specify the data classes and actions: for example, reading a patient’s medications, retrieving observations, exporting records, or writing data. Do not assume that a general “record access” permission covers every resource or operation.
2. Understand what FHIR and SMART each provide
FHIR: a shared foundation, not a universal data promise
FHIR is a health-data standard used for exchanging information through APIs. An implementation guide and its profiles add constraints and expectations for a particular use case or ecosystem. Before building against a resource, identify the FHIR release and profiles the target platform supports, then check which resources, operations, and fields it actually makes available.
SMART on FHIR: application launch and authorization patterns
SMART on FHIR builds application access and authorization patterns around FHIR-based systems. Depending on the implementation, relevant details include OAuth or OpenID behavior, requested scopes, launch mode, and context such as a patient or user. Google Cloud Healthcare API documentation describes its own SMART implementation, including OAuth 2.0/OpenID, scopes, patient launch context, and a standalone launch sequence. Those details illustrate one product’s behavior; they are not a guarantee about every EHR.
Rank #2
FHIR and SMART are related but distinct: an API can use FHIR without offering the same SMART launch options as another platform, and SMART support does not establish that all desired FHIR resources or operations are available.
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3. Verify each platform’s implementation
Use the following checklist for every EHR, payer, or health-data service in scope. Treat platform documentation and access terms as authoritative for that particular integration, and confirm them again before release because support and policies can change.
Rank #3
| Area | Questions to resolve |
|---|---|
| Standards | Which FHIR release and implementation guides apply? Which profiles and terminology expectations are required? |
| Data and operations | Which resources, data classes, search parameters, and read, write, or export operations are supported? Are there restrictions by access mode? |
| Workflow | Is the app patient-facing, clinician-facing, launched from an EHR, standalone, or backend? What user or patient context is available? |
| Authorization | Which OAuth/OpenID flow and scopes are supported? How are clients registered, tokens validated, and launch context supplied? |
| Developer access | Is there a sandbox, test account, synthetic data, sample app, SDK, or approval process? Does the test environment match production behavior? |
| Operations | What are the documented expectations for monitoring, audit, error handling, support, and production access? |
| Geography and responsibilities | Which jurisdiction applies, and what duties arise from this product’s relationships, data, contracts, and deployment? |
Examples of different developer entry points
These examples illustrate the variety of integration paths; they are not a ranking or an apples-to-apples capability comparison.
- Greenway Health: Its developer platform describes APIs for clinical data in Intergy and Prime Suite and SMART on FHIR for FHIR API authentication. Confirm the details for the specific product and access path.
- Oracle Health: Its SMART overview describes registering, updating, and deleting SMART applications through its code console. Check the current registration process and supported implementation.
- Apple Health Records: Apple’s technical requirements page names supported EHR systems and describes SMART on FHIR OAuth and patient credentials for authentication against FHIR endpoints. It also points organizations without a FHIR endpoint to implementation guides. Check the current requirements for the relevant locale and system.
- Payer APIs: Anthem’s portal describes FHIR R4 and SMART on FHIR conformance; Aetna’s describes FHIR-based exchange for registered participants and third-party applications. Confirm eligibility, specifications, and access terms with the payer.
- Australia’s My Health Record: The Digital Health Implementer Hub documents its FHIR Gateway and related security and implementation guidance. Requirements in this national system should not be assumed to apply in other jurisdictions.
- Cloud and platform services: Google Cloud and Salesforce publish healthcare API documentation describing their own products and deployment behavior. Evaluate those services against the same workflow and platform checks as any other option.
4. Implement in a testable sequence
- Document the use case. Record the user type, launch point, needed data, required actions, and whether access is interactive or backend.
- Select the standards path. Use the implementation guide and FHIR release relevant to the target ecosystem. The SMART developer resources list FHIR, US Core profiles, SMART App Launch, SMART Backend Services, and the Bulk Data API as distinct standards or data-access resources. Verify actual support with the target platform.
- Confirm registration and authorization. Determine whether the app is launched from an EHR or independently; identify the supported OAuth/OpenID flow, scopes, context, client registration, and token-validation requirements. Implement the target’s documented behavior rather than relying on a generic SMART example.
- Build against an appropriate test environment. Use the platform’s sandbox and synthetic or otherwise approved test data before connecting to production records. SMART’s developer resources list a SMART App Launcher, Bulk Data Server, vendor sandboxes, and Synthea synthetic-data resources. Verify each environment’s supported version, registration rules, and data constraints.
- Exercise failure and boundary cases. Test denied or expired authorization, missing context, unavailable resources, incomplete records, and API errors. Ensure the app handles those results without presenting absent or inaccessible data as a complete health record.
- Review privacy and security for the deployment. Identify the parties, data flows, access controls, and applicable responsibilities before production. Use relevant regulator guidance and qualified counsel where needed; the correct legal analysis depends on the specific product and relationship.
5. Design privacy and security into the release
ONC’s developer resources emphasize that health API implementation and management require attention to privacy and security, and that patients should be able to get, check, and use their information. ONC also links HIPAA resources, including a Security Risk Assessment tool designed to help healthcare providers conduct a Security Rule risk assessment. The tool is not, by itself, a determination of an app developer’s legal status or obligations.
Rank #4
Assess the actual product, parties, data, contracts, and jurisdiction rather than assuming that one rule applies to every health app. Use the regulator guidance relevant to the deployment and obtain qualified legal advice when the applicable duties are uncertain.
6. Make the integration decision against the real requirement
Compare platforms only after turning the use case into specific acceptance criteria. A vendor’s standards label alone cannot establish whether it supports the resources, workflow, authorization, or access terms the app needs. The available platform descriptions do not support naming a universal best solution.
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