Integrating a Patient Engagement App into an Electronic Health Record-Enabled Workflow Using Interoperability Standards

David F. Lobach, Aziz Boxwala, Nitu Kashyap, Krysta Heaney-Huls, Andrew B. Chiao, Thomas Rafter, Edwin A. Lomotan, Michael I. Harrison, Chris Dymek, James Swiger, Prashila Dullabh

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


Background  Patient use of mobile health applications is increasing. To promote patient-centered care, data from these apps must be integrated into clinician workflows within the electronic health record (EHR). Health Level 7 Fast Healthcare Interoperability Resources (FHIR) offers a standards-based application programming interface (API) that may support such integration. Objective  We aimed to use interoperability standards to integrate a patient mobile application (coronavirus 2019 [COVID-19] Tracker) with an EHR. The COVID-19 Tracker engages patients by sending introductory and reminder text messages, collecting vital signs and symptom data from COVID-19 patients, and providing actionable guidance if concerning issues are identified. This case report explored the use of FHIR APIs to integrate the app into EHR-enabled clinical workflows. Methods  The authors used notes from project meetings and from semistructured discussions among the application development team to track the design and implementation processes. Seven points of integration between the application and the EHR were identified, and approaches using FHIR to perform these integrations were delineated. Results  Although this clinical decision support integration project benefited from its standards-based approach, many challenges were encountered. These were due to (1) partial implementation of the FHIR standard in the EHR, particularly, components needed for patient engagement applications; (2) limited experience with the adoption of FHIR standards; and (3) gaps in the current FHIR standard. Alternative approaches, often not based on interoperability standards, were developed to overcome these limitations. Conclusion  Despite the challenges encountered due to the early stages of FHIR development and adoption, FHIR standards provide a promising mechanism for overcoming longstanding barriers and facilitating the integration of patient engagement apps with EHRs. To accelerate the integration of apps into clinical workflows, additional components of the FHIR standard must be implemented within the EHR and other clinical systems. Continued expansion of available FHIR resources will help with tighter workflow integration.

Original languageEnglish
Pages (from-to)1163-1171
Number of pages9
JournalApplied Clinical Informatics
Issue number5
StatePublished - Oct 2022
Externally publishedYes

Bibliographical note

Publisher Copyright:
© 2022 Georg Thieme Verlag. All rights reserved.


We developed the COVID-19 Tracker application (COVID-19 Tracker) for clinicians to remotely monitor patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A requirement from the intended clinical users of this application at the initial clinical site was that it must integrate into their existing EHR-based workflow. Since we wanted to make the application widely available and easy to integrate with EHRs, we decided to use interoperability standards. The informaticians (A.B., D.L., and N.K.) chose to use Health Level 7 (HL7)'s Fast Healthcare Interoperability Resources (FHIR) standard because it provides application programming interfaces (APIs) commonly used in contemporary software systems. FHIR-based APIs exchange data in the form of objects known as resources. Prior work by others has described integrating patient apps with EHRs using the HL7 CDA standard. This case report describes our design for integration using FHIR, the challenges encountered when implementing this design at the clinical site, and the lessons we learned. This project was undertaken as part of the Patient-Centered Outcomes Research Clinical Decision Support: Current State and Future Directions project funded by the Agency for Healthcare Research and Quality to advance research, development, and implementation of patient-centered clinical decision support (CDS) solutions.

FundersFunder number
Agency for Healthcare Research and Quality
National Center for Advancing Translational SciencesUL1TR001863


    • clinical decision support
    • interoperability standards
    • patient-generated health data


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