Posted on: June 18, 2021

In the movie Field of Dreams, Ray Kinsella—played by Kevin Costner—hears voices telling him, “If you build it, they will come.” In the health information exchange (HIE) industry, we have heard voices for years telling us the same thing. But instead of a baseball diamond in the middle of a cornfield, the voices we hear are telling us to build “true” workflow integration between electronic health records (EHR) systems and HIEs.

The challenge has been the ability to integrate information into existing workflows in a meaningful, non-disruptive way. We have learned that, if we ask a provider to change their workflow, there is little chance they will do so willingly—no matter how readily available we make patient information in our system. In fact, Hixny participants’ responses to an annual statewide survey have consistently supported this notion in recent years.

We initially addressed this challenge by using web services to share standardized medical documents—known as Consolidated-Clinical Document Architecture (C-CDA)—with providers through their EHR. While this helps us get data from the HIE into EHRs, we still encounter barriers:

  • C-CDA files tend to be very large. They often contain vast amounts of historical data that is irrelevant to the provider.
  • Some of the most relevant and desirable data isn’t available in C-CDA because there are limitations on changing pre-set templates. And EHRs can’t recognize that data because it is considered non-standardized.
  • Retrieving C-CDA locks up the provider’s EHR until all data is returned from the HIE, and even then, the viewable format is often unsearchable.
  • C-CDAs are not branded, so providers have no idea that the information is provided by Hixny, not their own records, and they see no value in the HIE when asked.

Above all, however, the biggest barrier goes back to workflow: Using web services to share C-CDA integrates with the EHR, but not with the provider workflow. Providers are still required to click a “Get HIE Data” button to open a separate view of data from the HIE, when they are used to finding all the information they need within their EHR’s pre-populated tabs.


While we tried to understand how we could make C-CDA work better for providers and for us, a new technology was taking shape in the healthcare industry: SMART on FHIR. Two components tied together, SMART on FHIR allows developers to create a single application (app) that makes medical data available in a structured format within any EHR system.

  • Substitutable Medical Applications, Reusable Technologies (SMART) enables third-party apps to launch within an EHR and to seamlessly identify the user and the patient whose data is being accessed.
  • Fast Healthcare Interoperability Resources (FHIR) define the structure of the data and make discrete data elements available outside of documents, unlike C-CDA. FHIR technology allows providers fast access to the most relevant, actionable data while eliminating the EHR lock-up.

The emergence of SMART on FHIR technology created a potential alternative to C-CDA—one that truly integrates into a provider’s workflow with no added login screen, password entry, or “Get HIE Data” button. With SMART on FHIR, an HIE gets its own tab within the EHR interface, with its own app embedded on that tab, populating relevant information on the patient the provider is working with.

Beyond workflow integration, the combined technology presents a solution to each barrier created by C-CDA:

  • Apps are developed by an HIE, so the HIE has control over presentation of the data coming from their system—including the ability to display data graphically. No more sifting through irrelevant information.
  • The data is not necessarily pulled directly from the HIE into the EHR, but rather presented within the EHR by the embedded app. This provides the HIE with more flexibility because it can decide how the data is formatted and displayed, making relevant data more accessible to providers.
  • Retrieving information from the HIE doesn’t lock up the EHR while data is fetched. Providers can view information as it is found.
  • Apps can be branded so providers know which HIE is supplying the data and can follow links to the HIE’s support team or training materials. These apps foster instant buy-in for HIE value.

I am proud to say that at Hixny, with the support of our development team at XchangeWorx, we recently launched our first SMART on FHIR app, which is a snapshot of a patient’s record. In addition to relevant clinical health information—like lab results, allergies, and immunizations—this app prioritizes actionable care quality measures for providers. They can see at a glance if their patient needs a mammogram or colorectal cancer screening, for example, on a single tab within their EHR.

We took our time working on the app, knowing that if we wanted providers to use it, it was essential for the design to meet their needs. Without a truly integrated app, providers would revert to their usual pattern of gathering data outside of the HIE. And when COVID-19 took hold last year, we delayed launching the app so we could incorporate COVID-19 testing results into the snapshot. This year, we’ve already updated it to include COVID-19 vaccination status.

To date, the snapshot app has been successfully tested and approved by two major EHR vendors. We are speaking with others that support SMART on FHIR technology. One of our hospital clients has already integrated the app into their system and the results are promising:

  • More providers are accessing the data more frequently than they did before the app launched.
  • More than half of those access events include looking for data that is not available in C-CDA.
  • Use has increased by more than 10 times as compared to other integration methods—like the “Get HIE Data” button.

Ultimately, we successfully built an app that providers are using—and they’re using it because we are making their jobs easier and more efficient. They’re no longer searching through extensive documents to find information; they’re opening a tab that sits alongside the others they open every day.

Just like “Field of Dreams,” SMART on FHIR is a homerun for HIE and its users—because in the end, Ray Kinsella built the field, and they did come.

Hixny will be performing extended maintenance beginning Thursday, December 31 through Friday, January 1. During this time, all services
will be impacted and unavailable—including access to the provider portal.