Optimizing vancomycin dosing in Cerner’s PowerChart with DoseMeRx SMART-on-FHIR

What is SMART on FHIR?

SMART is an open, standards based technology platform that allows developers to easily and securely develop applications for EHRs. Two main services the SMART platform provides are authentication and authorization – this controls which applications are allowed to run inside the EHR, and what data they can access. It is built on top of another open standard, FHIR, which defines a common language for EHR providers to exchange patient and clinician data.

The result of is SMART-on-FHIR: a standard for development and integration of healthcare applications that works across any EHR system. This gives both developers and care providers more options and the flexibility to evaluate different solutions. This flexibility allows hospitals to find the SMART application that best improves their workflow, or that is optimized for their specific needs. EHR systems are designed to be applicable across the entire hospital workflow; each clinical area, however, has different requirements. SMART lets app developers provide solutions for specific care problems.

How is SMART on FHIR changing the landscape of healthcare?

Prior to SMART and FHIR, EHRs could expose data by the HL7 standard. The HL7 standard is cumbersome and did not provide adequate methods for exposing patient data, making integrating with developers and other tools something that needed to be configured on a site by site basis. This left little room for trialing different solutions, and a large barrier for developers, EHR providers and hospitals to collaborate. Now, with the ability to easily install any application developed on top of SMART-on-FHIR, healthcare providers can quickly try a number of potential solutions, and choose the one best suited for their use case.

What is DoseMeRx and why integrate with SMART-on-FHIR?

DoseMeRx is a unique decision support software designed to guide dose optimization. These dose recommendations are based on clinically validated pharmacokinetic drug models, patient characteristics, drug concentrations and genotypes.

By building integration for SMART enabled EHRs, hospitals and clinicians can seamlessly use DoseMeRx to optimize dose recommendations based on their existing patient history. DoseMeRx provides the drug models and algorithms, and the patient data and drug concentrations are pulled directly from the hospital’s EHR. You can even simulate the results of different doses and/or therapeutic targets to find the optimal dose regimen in seconds inside your everyday working environment without leaving the patient profile.

Initial Concept and Validation of DoseMeRx SMART application

The process from initial concept to deployment will vary from EHR vendor to vendor. DoseMeRx has validated integrations in both the Cerner and Epic app stores.

This chart below gives a basic overview of the Cerner process. The workflow is as follows:

Developer submits an application proof of concept.
Cerner reviews the application. If required, the development team meets with Cerner’s integration team.
If the application is approved, it is listed in the Cerner app store. If validation fails, the Cerner team provides feedback so the development team can make the required changes.

Figure 1: Cerner Integration Process

Cerner provide a basic tutorial to help you make your first SMART application, which reads data from their code sandbox – the same one you use during development. After building a basic prototype, we submitted it to Cerner for validation.

The concept of DoseMeRx inside of PowerChart was given the go ahead by the team at Cerner after one meeting, and the initial implementation using the code sandbox took around three months. While this may seem like a long time, building your application on top of SMART enabled EHR has a lot of benefits, including:

The data is stored and maintained within Cerner’s data warehouse. The entire application runs inside of Cerner’s HIPAA compliant EHR environment.
The application is served over secure protocols, so both healthcare providers and patients can be confident in the integrity of their data.
No need for healthcare providers to do integrations manually – the developers and the EHR providers, using the SMART-on-FHIR standard, handle the complexity.
No need to update software manually – SMART applications are automatically updated when the developers release new versions.

SMART-on-FHIR is effectively the layer between the EHR and third party applications. This images shows how SMART-on-FHIR fits in with DoseMeRx.

Figure 2: DoseMeRx and SMART-on-FHIR workflow

Going Live with DoseMeRx in PowerChart

After validation and competing the DoseMeRx SMART-on-FHIR integration, the next step was working with hospitals who expressed interest in optimizing their vancomycin dosing. Most recently, we integrated and went live with a leading health system based in Florida. Once a client decides to start using DoseMeRx, it takes just weeks for Cerner to complete the full integration. This requires little to no resources from the hospital – DoseMeRx’s development team and Cerner take care of everything. More information about this is available in Cerner’s FAQ page.

During this time, we sent a team to Florida to work closely with the clinicians and pharmacists that would be using DoseMeRx. This gave us the opportunity to tweak our SMART application, as well as vigorously test the integration and performance of the application.

Workflows and dosing strategies vary from hospital to hospital, and naturally this presented some customizations that we underwent for our integration.

Initial training: We pride ourselves on a great user experience, including training and 24/7 support. Several of our team members conducted on-site training sessions.
Performance: The test data sets were generally simpler, smaller, and more focused on suspected edge-cases than some of the real patient data the clinicians were using. In addition to this, we went from a small amount of traffic to a large amount of clinicians constantly simulating doses. Specifically, long term patients often have accumulated a large amount of data, presented by FHIR as MedicationAdministrations and ResponseObservations. We lowered our load times significantly, down to just seconds, by only requesting a smaller subset of required data.

Cerner DoseMeRx PowerChart — *Figure 4: DoseMeRx Cerner PowerChart*

What have we learnt from going live with DoseMeRx in PowerChart?

Integrating DoseMeRx with Cerner’s SMART-on-FHIR implementation was an exciting experience, and we learned a lot:

Test with real data: Once your application is validated, move to testing with real data as soon as possible, especially on the cases likely to be challenging. These cases include any instance within the EMR where users can enter free-form data, patients with a large amount of data, or a very complex dosing regime.
Cerner provide excellent support and resources: We were able to call and talk to the actual engineers implementing the endpoints we required, and their advice was instrumental to our success.
Work with the right healthcare providers: The hospital we worked with is on the cutting edge of technology and always looking for new ways to improve patient outcomes. Their feedback during the integration and throughout the training was a major part of why our SMART-on-FHIR integration has been so successful. Their project team superbly managed all of the moving parts to not only ensure that DoseMeRx was successfully deployed, but to also ensure that change management occurred appropriately and all staff were comfortable and confident in using DoseMeRx.
Learn the FHIR specification: Read the vendor’s implementation carefully. FHIR is a specification, so naturally it is up for interpretation. Vendors choose which part(s) they want to implement and have flexibility over how some patient data is represented. An example is the effective time of a MedicationAdministration, which can either be represented as a dateTime or a period, whichever is most appropriate for the given drug.

About the author

Lachlan Miller, Full Stack Developer, DoseMe

Lachlan’s background is in software development, for which he earned a degree in Software Engineering from the Queensland University of Technology in 2016. Since then, he has worked on various web applications, ranging from the payroll, marketing and social media industries. The wide range of industries he has worked in are a reflection of his passion for learning and personal development. In his free time he enjoys a good work out, contributing to open source projects and learning foreign languages. If you have any questions you would like to ask Lachlan about SMART-on-FHIR, please reach out to him at lachlan.miller@doseme-rx.com.

Interested in evaluating DoseMeRx for your hospital?

If you are interested to discuss DoseMeRx and our SMART-on-FHIR integrations, please get in touch. You can also access all DoseMeRx’s features and drug models free for 14-days using our web-based platform. Start your free trial now →