The Apple Health Integration Guide
Using Smile Digital Health to Power SMART on FHIR Data Sharing
WHITE PAPER
With health data on the iPhone, third-party
applications of the user’s choice can provide novel
insights into the user’s health that cut across
information silos.
Integrating with Apple Health is great for
organizations seeking to drive patient engagement.
Having data on their iPhone gives patients
frictionless access to their health records whenever
they need them. It can also increase awareness
and uptake of patient portals since users can self-
authenticate in the Health app with their existing
portal credentials.
Smile Digital Health has years of standards
governance and implementation experience as the
maintainers of HAPI FHIR, which is the reference
implementation of the FHIR specication in Java. It’s
also the most widely adopted stack globally for FHIR
implementations. Smile Digital Health leveraged
this experience to build out an enterprise grade
platform that provides an ideal integration enabler
for providers looking to accelerate and simplify data
sharing with Apple Health.
Apple’s Health application leverages
the latest interoperability standards
like SMART and FHIR to aggregate
health records from dierent
providers for secure viewing and
storage on the user’s iPhone.
1. Executive Summary
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2. New Opportunities for Patient Engagement
But even years after digitization, much of that data remains trapped in
single system silos, limiting its accessibility to patients.
Pressure is building from various stakeholders to nally put patient
health data, particularly EHRs, in the hands of patients. Government
regulators want to ensure compliance with interoperability legislation.
Providers want to improve outcomes and lower costs by integrating
patients into their own care team. Payers, seeking to alleviate rising
costs, want to increase patient activation and nd new opportunities to
connect with their clients.
What about the patients themselves? On the one hand, ballooning
deductibles and copayments are leaving patients on the hook for a
larger share of health care costs. These rising costs, along with the
recognition that they generally receive better care when more engaged,
are incentivizing patients to take greater ownership of their own health.
Unsurprisingly then, patients are increasingly demanding easy and
secure access to their EHRs.
However while patient portal use is generally on the rise, it varies
widely and remains far from universal. A majority of providers now
oer patient portals, but these usually only provide a narrow slice of
one’s overall health record. That information is frequently spread over
multiple provider portals, forcing the patient to jump from silo to silo.
This stands in stark contrast to the high-quality and convenient digital
customer experiences oered by industries like retail and travel.
These and other industries are raising consumers’ expectations—
expectations they bring with them whenever they have a digital
healthcare interaction.
Fortunately, a suite of new interoperability technologies has emerged
in recent years that nally lets providers put EHRs right into the hands
(and pockets) of their patients.
The rst of these, Health Level 7’s (HL7) Fast Healthcare Interoperability
Resources (FHIR) is a standard which provides both an application
programming interface (API) and a set of data models for describing
and accessing health data. It provides discrete and consistent data
and is the foundation upon which any interoperability solution is built.
FHIR has proven to be a practical standard for interoperability and
has gained endorsement and adoption from vendors, regulators and
providers, emerging as the global industry standard.
The advent of
electronic health
records (EHRs) was
supposed to make
it easier for providers
to connect patients
with their health data.
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The second, Substitutable Medical Applications and Reusable
Technologies (SMART) is a protocol for standardizing how applications
authenticate and integrate data from EHRs, patient portals, and health
information exchanges. SMART gives providers the ability to pick from
a growing ecosystem of interchangeable apps as their needs dictate,
without forcing all providers within one organization to use the same
apps. As such, SMART can be thought of as an app platform that works
with and on top of FHIR, giving rise to the term “SMART on FHIR”.
The nal piece of the puzzle is the Apple Health app. While originally
a tool for aggregating user data generated by the iPhone (like sleep
tracking or step counts), it made the leap to interoperability platform in
2018 with the addition of the health records feature. This update allows
patients to download their health records to their iPhone, using FHIR as
the underlying data standard and SMART for one-time authentication
using patient portal credentials.
Developers can now use Healthkit—Apple Health’s associated
developer API—to create third-party apps that securely make use of
patients health data. HealthKit is highly secure, giving users complete
control over data sharing permissions. All health data is protected by
an encrypted, direct connection when moving between the iPhone and
provider APIs. When the iPhone is protected by a password, Face ID or
Touch ID, any health data stored on the phone is encrypted-on-device.
In essence, Apple has turned the iPhone into a secure repository for
patient health data that users can access anytime and anywhere, much
like the Apple Wallet.
Providers know that increasing patient engagement is crucial for
improving long-term health outcomes, especially for the chronic
diseases which tend to drive the largest portion of healthcare costs.
Integration with Apple Health using SMART on FHIR gives providers a
unique opportunity to share EHR data with patients via the one device
that’s always on them.
2. New Opportunities for Patient Engagement
continued
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The core of Apple’s idea—to compile a complete record of each patient’s data on
one platform—isn’t new, but Apple’s innovative approach is. Additionally, timing is
a key factor in the success of any innovation, and Apple’s Health Records API has
come at a time when the market is primed for such a product and the technologies
exist to make it feasible. This wasn’t always the case.
Since the late 2000s, several attempts have been made to integrate patient health
data from dierent providers, including notable initiatives by large, global tech rms.
Ultimately, all of these failed to achieve signicant adoption.
Early eorts, especially those launched prior to 2010, were hampered by the dearth
of digital record systems at the time. They also lacked a viable mobile platform since
smartphones had yet to achieve widespread use. While these two factors were less
of an issue by the mid-2010s (as health records were digitized and smartphones
went mainstream), personal health platforms still struggled to optimize their
oerings for mobile and to integrate patient-generated data from outside clinical
EHRs (like wearables data).
These platforms were not entirely without success in the basic goal of connecting
users with their health data, but they weren’t able to attract and sustain large user
bases. One widely cited criticism was that most people didn’t know what to do with
the information in their health record. This underscores the fact that giving users
access to their data isn’t enough: to be truly useful, platforms need to help users
interpret their health data and then present them with actionable insights.
Patient portals, while not designed as interoperability platforms, can nevertheless
be considered part of a patient engagement solution. A majority of patients in the
US now have access to a patient portal via their healthcare provider and, as noted,
their use is trending upwards. This is encouraging, given that evidence suggests
portals can play an important role in patient engagement.
However, patient use of portals to access their health records is limited. One 2018
study showed that, while 52% of patients surveyed were given access to their health
record by their provider, only about half that number actually viewed their record
online. Those that did view their records tended to do so only once or twice a year.
Moreover, only a small minority chose to actually download their medical records.
Patient portals, while potentially useful, generally lack the kind of consistent, robust
engagement from patients that providers strive for. Perhaps the biggest strike
against them, however, is the limited scope of the information they provide, since
they’re generally tied to a single provider.
3. Existing Solutions
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4. Optimal Solution: Smile Digital Health as an Integration Platform
for SMART on FHIR Data Sharing With Apple Health
What can SMART on FHIR do?
The SMART and FHIR standards are both based on the idea that health
care data should be easy to transmit and interact with. Both leverage
API technology similar to that used by social media websites or ight
booking applications to standardize how query requests are handled
between clients and servers. This gives applications the ability to
access data in other applications quickly and easily. By using a stripped
down API design, FHIR gives developers the freedom to create plug-
and-play applications that can communicate with EHRs and supply
information directly into provider workows using tools they’re already
familiar with. This means developers can “build once and deploy many
times”; for clinicians, patients and providers it means compatibility with
more applications. By using an EHR or data warehouse that is SMART
compliant, providers can give patients and care teams access to an
ever-growing ecosystem of SMART-enabled applications to support
better patient engagement, better research, and better
health outcomes.
Unlike document-centric standards like C-CDA, FHIR breaks data down
to discrete elements and exposes these as services, meaning elements
like patients, medications, and diagnostics can be accessed and
modied using unique resource URLs. With FHIR, a clinician wanting to
access, for example, an immunization record, can search for that single
record instead of having to surface a whole case le.
As discussed, Apple Health leverages SMART on FHIR to enable
integration between EHR data from providers, the user’s iPhone,
and third-party apps. The upshot is that providers wishing to
share data with Apple Health must expose a SMART on FHIR app
for Apple to consume. Doing so will not just enable integration
with Apple Health; it also opens up access to the entire SMART
on FHIR ecosystem and confers a variety of other benets.
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SMART uses OAuth2, an open standard for
granting websites/apps access to information, for
authentication and integration. This is the same
technology used by Facebook, Google and others
to allow third-party apps/websites to authenticate
a new user’s identity using an existing prole, while
allowing the user to manage what the application/
website can do with that prole (e.g. logging into
Candy Crush with your Facebook prole and
allowing it to post your in-game achievements on
your Facebook wall).
SMART and FHIR both use Representational
State Transfer (RESTful) architecture, meaning all
necessary information needed to respond to a
query is contained within the query. Consequently,
any server can respond to such a query without
needing additional information, accelerating
the onboarding process for new data exchange
partners.
Why Apple Health is Dierent
In some ways, we’ve been here before. As we explored
in “Existing Solutions,” previous attempts at creating a
complete, patient-centric health record were ambitious
but ultimately failed to achieve widespread
adoption. Nevertheless these previous solutions,
along with current patient portals, were and
continue to be based on the laudable premise that
putting users in control of their own health data will
lead to stronger engagement and better outcomes,
especially when it comes to compliance with chronic
disease care plans.
Unlike previous eorts, however, Apple Health
benets from being very much in the right place at
the right time: oering a truly interoperable solution
based on the latest open standards and in full
control of a rich ecosystem and trusted platform
(the iPhone) that are deeply embedded in users’
lives. The iPhone, with its large and dedicated user
base, constitutes a great platform to scale the
adoption of the Apple health records feature.
The initial set up would involve searching for your
provider within the app, and then verifying your
identity by logging into the patient portal using
OAuth2.This establishes a trusted link between
your provider and the app, which can now securely
update your health record in the background and
send your phone notications when any changes
are made. After performing this set-up with all
providers, the app will aggregate dierent types of
health information like lab results, immunization
records, procedures, allergies and vitals from
multiple institutions on one screen on your iPhone.
Furthermore, as this set-up is ultimately mediated
by the user’s patient portal credentials, the Health
app can also help increase familiarity with provider
patient portals.
Where Smile Digital Health Fits In
Smile Digital Health, as the commercial
implementation for HAPI (the open source FHIR
API for Java), is the best choice for full FHIR stack
integration with Apple.
OAuth2, a prerequisite for SMART on FHIR, is
built into Smile Digital Health, leaving the door
open for future integration with any conformant
OAuth2 provider—not just Apple. It is OAuth2
(along with FHIR’s discrete date model) that enables
the granular user permissions mentioned in the
previous discussion of FHIR.
4. Optimal Solution: Smile Digital Health as an Integration Platform
for SMART on FHIR Data Sharing With Apple Health
continued
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Having the full FHIR stack means Smile Digital
Health provides a wider breadth of resources, a
greater depth of support, and a higher degree of
exibility for the immediate implementation of
future ideas. With the full FHIR stack opening up
access to the entire FHIR ecosystem, providers can
stay on the cutting edge of the newest innovations.
Implementation is also reliable and scalable: Smile
Digital Health maintains and is powered by HAPI
FHIR, the reference implementation of the FHIR
specication in Java and the most widely adopted
stack globally for FHIR implementations. By the
same token, Smile Digital Health is used by some
of the largest companies in the world in their
FHIR implementations to handle thousands of
transactions per second for tens of thousands of
concurrent users.
Beyond Apple Health
There is an abundance of apps available today
that allow users to enter or track their health
information, but these apps are often stand-alone
or siloed applications with their own repositories.
Should the popularity or usability of the app
fade, patient data associated with the app isn’t
recoverable or transferable. An Apple Health and
Smile Digital Health combination can oer users the
ability to persist healthcare data in a format that
can be accessed by both legacy and new apps. In
addition, Smile Digital Health can store healthcare
data from organizations like hospitals and clinics,
thus enabling and combining the patient’s self-
captured health data with their clinical data across
multiple providers.
4. Optimal Solution: Smile Digital Health as an Integration Platform
for SMART on FHIR Data Sharing With Apple Health
continued
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5. Leading Diagnostics Company Uses Smile to Accelerate Health
Records Integration
This leading diagnostics company is one of the largest clinical laboratory networks in the
world. As an early adopter of new interoperability solutions seeking to deepen patient
engagement and improve outcomes, they took the initiative in 2018 to make patient
health data accessible via Apple Health.
Their position was similar to many other healthcare organizations in that:
• They had a patient portal that users could sign into to view clinical data.
• All clinical data was stored in a non-FHIR database.
Smile Digital Health worked with this client to develop an integrated solution using Smile
Digital Health’s
core capabilities which could:
• Take FHIR queries and talk to the non-FHIR database, then return it back to the
application using FHIR.
• Support the SMART prole of OpenID connect (an authentication layer that sits
In essence, this client used Smile Digital Health
as a platform to accelerate their integration with
Apple Health. They knew that a custom build would
absorb time and resources while saddling them with
long term support costs. They also knew that since
Apple’s developer toolkit is FHIR- based, engaging
a vendor with a role in standards governance
would be a signicant advantage. By building on
the Smile Digital Health platform, whose modules
provided 2/3rds of the necessary features, they
saved valuable time and resources while ensuring
compliance with standards going forward. With
Smile Digital Health as an active technology partner,
this client was able to leverage Smile Digital Health’s
years of FHIR expertise to accelerate their learning
curve. Using only a small development team, around
25-35% of the size normally required, our client was
able to go-live with their Apple Health integration in
less than 6 months.
A key aspect of the partnership was Smile Digital
Health’s role in guiding the project via extensive
advice and training: a senior developer was
allocated to the project to provide on-demand
assistance during the development process. Our
client’s team found the upfront training provided by
Smile Digital Health during kicko particularly useful
as it helped address common pain points before
they came up.
By partnering with Smile Digital Health, our client
felt that the deployment process was faster,
required fewer resources, and was far less painful
for their development team. Overall, this new
patient centred service went to market quickly and
is fully integrated with Apple Health
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Smile Digital Health Architecture Overview
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In the rapidly shifting healthcare landscape,
combining the changes pioneered by consumer-
focused tech brands with a robust patient-centric
ethos will be essential to getting in front of the
coming disruption. Integration with Apple Health
helps you put patients rst through improved
engagement and interoperability.
At Smile Digital Health, our world-class team places
us at the leading edge of delivering new innovations
while also being available as a resource for
consultation and client support. As the commercial
implementation of HAPI FHIR, Smile Digital Health
ensures a solution that will be conformant with
any future standards changes. With a proven
track record of successful implementations and
standards governance, Smile Digital Health provides
a robust and exible solution for healthcare
providers looking to achieve seamless integration
with Apple Health.
Why Smile Digital Health?
Apple, iPhone, Apple Watch, HealthKit, Touch ID, Face ID and
Apple Wallet are trademarks of Apple Inc.
Any reference to or mention of Apple, iPhone, Apple Watch,
HealthKit, Face ID, Touch ID or Apple Wallet does not constitute
or imply the authorization, sponsorship, endorsement,
recommendation or approval of Apple, Inc.
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Smile Digital Health
622 College Street, Suite 401
Toronto, Ontario M6G 1B4, Canada
1 (877) 537-3343
www.smiledigitalhealth.com
Copyright © 2022 Smile CDR Inc. (doing business as Smile Digital
Health).
All product names, logos, and brands are the property of their
respective owners. All company, product and service names used are for
identication purposes only. The use of these names, logos, and brands
does not imply endorsement.
Why Smile Digital Health?
In the rapidly shifting healthcare landscape,
combining the changes pioneered by consumer-
focused tech brands with a robust patient-centric
ethos will be essential to getting in front of the
coming disruption. Integration with Apple Health
helps you put patients rst through improved
engagement and interoperability.
At Smile Digital Health, our world-class team
places us at the leading edge of delivering new
innovations while also being available as a
resource for consultation and client support. As
the commercial implementation of HAPI FHIR,
Smile Digital Health ensures a solution that
will be conformant with any future standards
changes. With a proven track record of successful
implementations and standards governance,
Smile Digital Health provides a robust and exible
solution for healthcare providers looking to
achieve seamless integration with Apple Health.
Apple, iPhone, Apple Watch, HealthKit, Touch ID, Face ID and
Apple Wallet are trademarks of Apple Inc.
Any reference to or mention of Apple, iPhone, Apple Watch,
HealthKit, Face ID, Touch ID or Apple Wallet does not constitute
or imply the authorization, sponsorship, endorsement,
recommendation or approval of Apple, Inc.
Smile Digital Health
622 College Street, Suite 401
Toronto, Ontario M6G 1B4, Canada
1 (877) 537-3343
www.smiledigitalhealth.com
Copyright © 2022 Smile CDR Inc. (doing business as Smile Digital
Health).
All product names, logos, and brands are the property of their
respective owners. All company, product and service names used are for
identication purposes only. The use of these names, logos, and brands
does not imply endorsement.
