1Children’s Hospital Informatics Program at Harvard-MIT Health Sciences and Technology, Boston, Massachusetts, USA 2Center for Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA 3Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA 4Partners HealthCare Systems, Information Systems, Charlestown, Massachusetts, USA 5Laboratory of Computer Science, Massachusetts General Hospital, Boston, Massachusetts, USA 6School of Biomedical Informatics, Department of Internal Medicine, The University of Texas Health Science Center, Houston, Texas, USA 7SMART Platforms Project, Center for Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA 8Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA 9Mozilla, Mountain View, California, USA Correspondence to Dr Kenneth D Mandl, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA; kenneth_mandl@harvard.edu KDM and JCM contributed equally to this work. Received 3 October 2011 Accepted 12 February 2012 Published Online First 17 March 2012 This paper is freely available online under the BMJ Journals unlocked scheme, see http:// jamia.bmj.com/site/about/ unlocked.xhtml Research and applications The SMART Platform: early experience enabling substitutable applications for electronic health records Kenneth D Mandl,1,2 Joshua C Mandel,1,3 Shawn N Murphy,4,5 Elmer Victor Bernstam,6 Rachel L Ramoni,1,2 David A Kreda,7 J Michael McCoy,8 Ben Adida,9 Isaac S Kohane1,2 ABSTRACT Objective The Substitutable Medical Applications, Reusable Technologies (SMART) Platforms project seeks to develop a health information technology platform with substitutable applications (apps) constructed around core services. The authors believe this is a promising approach to driving down healthcare costs, supporting standards evolution, accommodating differences in care workﬂow, fostering competition in the market, and accelerating innovation. Materials and methods The Ofﬁce of the National Coordinator for Health Information Technology, through the Strategic Health IT Advanced Research Projects (SHARP) Program, funds the project. The SMART team has focused on enabling the property of substitutability through an app programming interface leveraging web standards, presenting predictable data payloads, and abstracting away many details of enterprise health information technology systems. Containersdhealth information technology systems, such as electronic health records (EHR), personally controlled health records, and health information exchanges that use the SMART app programming interface or a portion of itdmarshal data sources and present data simply, reliably, and consistently to apps. Results The SMART team has completed the ﬁrst phase of the project (a) deﬁning an app programming interface, (b) developing containers, and (c) producing a set of charter apps that showcase the system capabilities. A focal point of this phase was the SMART Apps Challenge, publicized by the White House, using http:// www.challenge.gov website, and generating 15 app submissions with diverse functionality. Conclusion Key strategic decisions must be made about the most effective market for further disseminating SMART: existing market-leading EHR vendors, new entrants into the EHR market, or other stakeholders such as health information exchanges. BACKGROUND AND SIGNIFICANCE The structure, function, and cost of the US healthcare system are under ever-increasing scru- tiny. But for the system to adapt to the impact of an aging population, growing expenditures, and a diminishing primary care workforce, innovation in medical practice will have to be supported by information technology (IT) that enables rather than hinders experimentation and innovation. The proprietary electronic health record (EHR) offerings currently on the market tend to be architected monolithically, making modiﬁcation difﬁcult for hospitals and physician practices. In 2009, we proposed that EHRs instead should be designed as platforms supporting a selection of ‘substitutable’ modular third party applications (apps).1 We drew an analogy with mobile phone plat- forms such as iPhone and Android, which lower the barrier to app development by providing a software platform with a published interface to a set of core services such as camera, address book, geo-location, and cell and wireless networks. The platform functionally separates the core system from the apps, and the apps are substitutable. Thus, for example, a consumer can download a calendar reminder system, reject it, and replace it with another one. Through substitutable apps, the iPhone and Android platforms now support myriad capabilities that the original platform designers never imagined. A platform with substitutable apps constructed around core services is a promising approach to driving down healthcare technology costs, supporting standards evolution, accommodating differences in care workﬂow, fostering competition in the market, and accelerating innovation. With the cost of switching kept low, the platform enables a physician using an EHR, a Chief Infor- mation Ofﬁcer running a hospital IT infrastructure, or a patient using a personally controlled health record (PCHR) to readily discard an under- performing app and install a better one. Competi- tion on quality, cost, and usability is enabled, and the pace of innovation increases. This model stands in stark contrast with the largely monolithic and slow-to-evolve health information systems that have been designed and implemented to date, where one size has to ﬁt most providers, custom- ization is arduous and expensive, and only the few established EHR vendor developers can innovate. The principle of substitutability is the central focus of the Substitutable Medical Applications, Reusable Technologies (SMART) Platforms project. By deﬁning an app programming interface (API) that consistently presents well-speciﬁed data, we seek to (a) enable purchasers, users, and adminis- trators of platform-based systems to be able to install and subsequently substitute apps from different vendors without software programming and (b) create a broad market for app developers J Am Med Inform Assoc 2012;19:597e603. doi:10.1136/amiajnl-2011-000622 597