第 16 課：FHIR 上的 SMART - OAuth2 和醫療應用

HL7 FHIR - 基礎到進階醫療資料標準

第 5 部分：整合、訊息傳遞與安全性

亞洲開發網

1. FHIR 上的 SMART 概述

智慧 FHIR 上的（可替代醫療應用程式、可重複使用技術）是一個框架，允許第三方醫療應用程式透過 OAuth 2.0 + FHIR 與 EHR/EMR 安全整合。

┌─────────────┐                    ┌─────────────┐
│  SMART App  │   OAuth 2.0 flow   │   EHR/EMR   │
│  (web/      │ ◀────────────────▶ │  (FHIR      │
│  mobile)    │   FHIR API calls   │   Server)   │
└─────────────┘                    └─────────────┘
       │                                  │
       │        ┌──────────────┐          │
       └───────▶│  Auth Server │◀─────────┘
                │  (OAuth 2.0) │
                └──────────────┘

2. 啟動類型

電子病歷發布

應用程式已打開 從電子病歷內部 — EHR 傳遞背景資訊（病人、遭遇）。

1. Bác sĩ click "Open App" trong EHR
2. EHR redirect → App với launch parameter
3. App → Authorization Server (authorize endpoint)
4. User đồng ý → Auth Server trả code
5. App đổi code → access_token + id_token
6. App gọi FHIR API với access_token

GET https://smart-app.example.com/launch
  ?iss=https://fhir-server.hospital.vn/fhir/r5
  &launch=xyz123

獨立啟動

應用程式運行 獨立的，自己找到FHIR伺服器並請求許可。

GET https://fhir-server.hospital.vn/fhir/r5/.well-known/smart-configuration

{
  "authorization_endpoint": "https://auth.hospital.vn/authorize",
  "token_endpoint": "https://auth.hospital.vn/token",
  "capabilities": [
    "launch-ehr",
    "launch-standalone",
    "client-public",
    "client-confidential-symmetric",
    "sso-openid-connect",
    "context-ehr-patient",
    "permission-v2"
  ],
  "scopes_supported": [
    "openid",
    "fhirUser",
    "launch",
    "launch/patient",
    "patient/*.rs",
    "user/*.cruds"
  ]
}

3. 臨床範圍（SMART v2）

SMART 範圍控制允許應用程式存取的內容：

# Scope format (v2):
# [context]/[resourceType].[cruds]

# Patient-level scopes (data của patient cụ thể)
patient/Patient.rs          # Read Patient + Search
patient/Observation.rs      # Read + Search Observations
patient/MedicationRequest.rs

# User-level scopes (theo quyền của user đang login)
user/Patient.cruds          # Full CRUD + Search on Patient
user/Encounter.rs
user/*.rs                   # Read + Search tất cả resources

# System-level scopes (backend services)
system/Patient.rs
system/*.rs

CRUD操作

人物	操作
c	創建
r	閱讀
你	更新
d	刪除
s	搜尋

4. OAuth 2.0 授權代碼流程

# Step 1: Authorization Request
GET https://auth.hospital.vn/authorize
  ?response_type=code
  &client_id=my-smart-app
  &redirect_uri=https://smart-app.example.com/callback
  &scope=launch/patient openid fhirUser patient/Patient.rs patient/Observation.rs
  &state=random-state-value
  &aud=https://fhir-server.hospital.vn/fhir/r5
  &code_challenge=E9Melhoa2OwvFrEMTJguCHaoeK1t8URWbuGJSstw-cM
  &code_challenge_method=S256

# Step 2: Token Exchange
POST https://auth.hospital.vn/token
Content-Type: application/x-www-form-urlencoded

grant_type=authorization_code
&code=auth-code-from-callback
&redirect_uri=https://smart-app.example.com/callback
&client_id=my-smart-app
&code_verifier=dBjftJeZ4CVP-mB92K27uhbUJU1p1r_wW1gFWFOEjXk

{
  "access_token": "eyJ...",
  "token_type": "Bearer",
  "expires_in": 3600,
  "scope": "launch/patient openid fhirUser patient/Patient.rs patient/Observation.rs",
  "id_token": "eyJ...",
  "patient": "patient-001",
  "encounter": "encounter-001",
  "fhirUser": "Practitioner/practitioner-001"
}

# Step 3: FHIR API Calls
GET https://fhir-server.hospital.vn/fhir/r5/Patient/patient-001
Authorization: Bearer eyJ...

5. SMART後端服務（系統到系統）

無需用戶互動——使用 客戶憑證 與 JWT 斷言。

POST https://auth.hospital.vn/token
Content-Type: application/x-www-form-urlencoded

grant_type=client_credentials
&scope=system/Patient.rs system/Observation.rs
&client_assertion_type=urn:ietf:params:oauth:client-assertion-type:jwt-bearer
&client_assertion=eyJ...signed_jwt...

6.CDS Hooks－臨床決策支持

CDS Hooks 允許應用程式配置 臨床建議 在 EHR 中做出決策時。

{
  "hookInstance": "uuid-001",
  "hook": "patient-view",
  "fhirServer": "https://fhir-server.hospital.vn/fhir/r5",
  "fhirAuthorization": {
    "access_token": "eyJ...",
    "token_type": "Bearer",
    "scope": "patient/Patient.rs patient/Observation.rs"
  },
  "context": {
    "userId": "Practitioner/practitioner-001",
    "patientId": "patient-001"
  }
}

CDS 回應（卡）

{
  "cards": [
    {
      "uuid": "card-001",
      "summary": "HbA1c cao — Cần điều chỉnh thuốc tiểu đường",
      "detail": "HbA1c gần nhất: 8.5% (2025-01-10). Mục tiêu: < 7%. Xem xét tăng liều Metformin hoặc thêm thuốc mới.",
      "indicator": "warning",
      "source": {
        "label": "Diabetes Management CDS",
        "url": "https://cds.hospital.vn"
      },
      "suggestions": [
        {
          "label": "Kê đơn Metformin 1000mg",
          "actions": [
            {
              "type": "create",
              "description": "Tạo MedicationRequest Metformin 1000mg",
              "resource": {
                "resourceType": "MedicationRequest",
                "status": "draft",
                "intent": "proposal"
              }
            }
          ]
        }
      ]
    }
  ]
}

七、總結

• FHIR 上的智能 — 適用於第三方健康應用程式的 OAuth 2.0 + FHIR

• 電子病歷發布 — 從 EHR 開啟應用程序，以取得可用的上下文

• 獨立啟動 — 應用程式獨立運行，自行要求權限

• 臨床範圍 — 具有 CRUDS 權限的病人/*、使用者/*、系統/*

• 後端服務 — 系統到系統，JWT 用戶端斷言

• CDS 掛鉤 — 護理點決策支持