From care gaps to EHR-embedded clinical impact

We work across five disciplines that usually sit in separate teams: medical education, clinical workflow redesign, EHR optimization, SMART on FHIR development, and clinical-impact evaluation. This is the public reference for how we do it, grounded in open standards.

Four layers, one continuum

A tool changes care only when clinicians adopt it, so we cover all four layers.

01

Clinical workflow design

Map how care is delivered, role by role, before changing anything.

02

EHR optimization

The native vendor toolkit. Usually the lowest-friction way to change behavior at the point of care.

03

SMART on FHIR applications

Vendor-neutral apps that do what native tools cannot: live calculation, multi-source synthesis, custom interfaces.

04

Implementation science

Methods for planning adoption and measuring whether it lasts.

Layer 2 · EHR optimization

Start with the lowest-friction tool that solves the problem

Many clinical-workflow problems can be solved inside the EHR's native toolkit before anyone writes code. In Epic, that toolkit looks like this.

SmartPhrases (.phrases)

Reusable text blocks expanded by a dot-prefixed token. They standardize documentation.

SmartText

Pre-configured template content that pre-populates a note.

SmartLists / SmartLinks / SmartForms

Pick-lists, dynamic chart data pulls, and structured input inside the note.

SmartSets

Modular bundles of orders plus documentation that standardize a care pathway.

Order Sets

Grouped, pre-built orders aligned to a clinical scenario.

Best Practice Advisories (BPAs)

Point-of-care alerts and reminders driven by patient data. A native form of decision support.

Physician Builder

Epic's certification track that grants clinicians build access (CLN150 basic, CLN155 orders and CDS).

Epic, SmartPhrase, SmartSet, BPA, and Physician Builder are proprietary to Epic Systems. HMHCP references them descriptively and is not affiliated with or certified by Epic. Oracle Health (Cerner) and MEDITECH expose analogous capabilities through their own tooling and FHIR APIs.

Layer 3 · SMART on FHIR

When native tools are not enough, extend the EHR

A SMART on FHIR app handles what native tools cannot: live calculation, multi-resource synthesis, a custom interface, a registry. It runs vendor-neutral on open standards.

How a SMART app launches

Built on OAuth 2.0. The current SMART App Launch IG (v2.2.0) requires PKCE for every app, public or confidential.
EHR launch: the EHR passes context from an active session. Standalone launch: the app requests context during authorization.
Scopes are resource-prefixed (patient/, user/, system/) with launch context and identity scopes layered on top.

A worked example

A .ASTHMAFOLLOWUP SmartPhrase produces a standard note. A SMART app goes further: it pulls FeNO, eosinophils, and exacerbation history, applies guideline-driven biologic-eligibility logic, and proposes a note recommendation for the clinician to confirm. The app supports the decision; the clinician makes it.

For registries, quality measurement, and population health, SMART Backend Services run server-to-server with no user in the loop.

Layer 3 · Decision support

Decision support that meets the clinician in the workflow

CDS Hooks (v2.0.1) is a vendor-neutral way to surface decision support as Cards at defined moments in the workflow, built on FHIR R4 and maintained by HL7.

A Card carries a summary, an indicator (info, warning, or critical), a source, and optional suggestions and links. A discovery endpoint at {baseURL}/cds-services advertises the available services and their prefetch templates. A Card can launch a SMART app, so the two standards can be used together.

Illustrative use cases: suggest a biologic referral, prompt CRSwNP screening, flag an EoE evaluation, or surface an asthma action plan, each at a defined point in the encounter.

Standard hooks

patient-view
order-select
order-sign
order-dispatch
medication-refill
appointment-book
encounter-start
encounter-discharge

FHIR R4 and US Core

SMART on FHIR and CDS Hooks both build on HL7 FHIR R4. US Core is the US baseline profile set (Patient, Observation, Condition, MedicationRequest, Encounter, and more) that underpins ONC-certified API access. It advances annually with USCDI, so build to the current published release rather than a frozen version.

Layer 4 · Implementation science

Why tools succeed or fail

We use the frameworks below to design for adoption and to measure whether it happened.

CFIR (2022)

Consolidated Framework for Implementation Research. Five domains: Innovation, Outer Setting, Inner Setting, Individuals, and Implementation Process. Explains why a tool is or is not adopted in a given setting.

RE-AIM

Reach, Effectiveness, Adoption, Implementation, Maintenance. Evaluates whether a tool reaches its population and sustains its effect.

Proctor outcomes

Eight measurable implementation outcomes: acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability.

Audit and feedback

An evidence-based behavior-change mechanism for sustaining guideline adherence over time.

The tool ladder and the pipeline

Choose the lowest rung that solves the problem. Then follow a pipeline that continues past deployment to measurement and publication.

The tool ladder

1SmartPhrases / dot phrases: documentation standardization
2SmartText / SmartLinks: pull structured data into the note
3SmartSets / Order Sets: standardize care pathways
4BPAs / alerts: point-of-care reminders
5CDS Hooks: vendor-neutral decision-support cards
6SMART on FHIR apps: embedded tools with UI, analytics, registries
7Backend FHIR services: registries, quality measurement, population health

The pipeline

Clinical gap and needs assessment
Workflow mapping across physicians, nurses, APPs, pharmacists, and care coordinators
EHR build-option selection
Vendor and site engagement
Prototype design
Clinical governance review
Privacy and security review
Pilot
Adoption measurement
Clinical-impact evaluation
Publication and dissemination package

Where these disciplines connect

Education, EHR build, and app development are usually run as separate tracks. We cover all three and finish with measurement and publication. The standards are public; we connect them and measure the result.

The playbook, as a PDF

A version of this reference with citations, formatted for print and sharing. We email a secure link.

EHR Workflow + SMART on FHIR Playbook

Eleven pages: the four build layers, the native EHR toolkit, SMART on FHIR, CDS Hooks, FHIR R4 and US Core, implementation science, and the HMHCP delivery pipeline.