Chapter 31 Future Directions and Future Research in Health Informa.docx

Chapter 31 Future Directions and Future Research in Health
Informatics
Nancy Staggers
Ramona Nelson
David E. Jones
Health informatics can be described as an interprofessional
discipline that is grounded in the present while planning for the
future.
Objectives
At the completion of this chapter the reader will be prepared to:
1.Explore major trends and their implications for future
developments in healthcare, health informatics, and informatics
research
2.Analyze techniques and challenges of planning for future
directions and trends
3.Apply futurology methodologies in identifying trends and
possible, probable, and preferred futures
4.Describe the field of nanotechnology and its subdisciplines,
the role of informatics in nanotechnology, and implications for
healthcare
5.Analyze the advantages and disadvantages of
nanotechnology in health and health informatics
Key Terms
Backcasting, 499
Cytotoxicity, 505
Data visualization, 502
Extrapolation, 497
Futures research, 495
Nanofabrication, 503
Nanoinformatics, 505
Nanomedicine, 504

Nanotechnology, 502
Trend analysis, 497
Abstract
This chapter expands on the future directions sections included
in the individual chapters to provide broad guidance about the
future of informatics. First, healthcare trends in society are
outlined. Second, futures studies or futurology (methods to
analyze probable future directions in any field) is discussed.
Third, an overview of potential future directions in informatics
are discussed, including the following informatics trends: (1)
patient engagement, consumerism, and informatics; (2)
electronic health records (EHRs) 2.0; (3) usability and
improving the user health information technology (health IT)
experience; (4) big data and data visualization; and (5)
nanotechnology and nanoinformatics. The last trend is discussed
in more detail as an example of the major influence each of
these trends will likely have on the future of healthcare and
society as a whole. The organization and depth of the
nanotechnology-related content also provides a guide for
readers to develop similar material in informatics areas of
specific interest.
Introduction
Informatics will play a large role in the future of healthcare.
Which informatics trends will prevail and in what depth is
unclear. In each of the chapters in this book authors outlined
expanding areas of influence, from knowledge discovery to the
epatient, from cloud computing to standards integration with
public health data sharing, and from initial EHR installations to
mobile health. In this chapter unequivocal healthcare trends are
listed, followed by methods that readers may use to predict
likely trends in the future. These techniques are called
futurology or futures research methods. Subsequently, five
major trends are discussed: (1) patient engagement,
consumerism, and informatics; (2) EHRs 2.0; (3) usability and
improving the user experience for health IT; (4) big data and
data visualization; and (5) nanotechnology and nanoinformatics.

Special attention is given to nanotechnology and
nanoinformatics.
The purpose of informatics is to provide support for clinical
care, public health, and other practices. Thus to understand the
future of health informatics, major health trends need to be
acknowledged. Examples of unequivocal trends in society
include:
•Rising healthcare costs. In the U.S. alone, costs are expected
to nearly double to $4.5 trillion by 2019, up from $2.5 trillion
in 2009.1
•Aging populations. By 2050 the global population of those
aged 60 years or older will be more than 2 billion.2
•Increase in patients with chronic diseases. By 2030 chronic
diseases will be the leading cause of deaths worldwide.3
Diabetes rates alone will increase by 2.8% to 4.4%.4
•Predicted shortage of healthcare providers. By 2025 the U.S.
will have a shortage of an estimated 260,000 registered nurses5
and 124,000 physicians.6
•Health insurance reform. Several health reform measures are
scheduled to take effect in 2014, according to the provisions of
the Patient Protection and Affordable Care Act signed into law
on March 10, 2010.7
These trends clearly have implications for informatics support
in the future but how does one determine or perhaps even create
future trends? Futures research or futurology, the methods used
to determine future trends in any field, may help to answer this
question.
Futures Research or Futurology
discipline that is grounded in the present while planning for the
future. Health informatics specialists are selecting and
implementing today's healthcare information systems, thereby
creating the foundation for the systems of tomorrow. By
reviewing current trends and predictions, as well as employing

tools for predicting and managing the future, health informatics
specialists can prepare for their leadership role in planning for
the effective and innovative healthcare information systems of
the future. This section introduces the reader to levels of change
that can be anticipated in future trends. By analyzing
methodologies and tools for predicting, planning for, and
managing the future, health informatics specialists are
introduced to the kind of leadership roles they will play in
planning future healthcare information systems. With a better
understanding of the potential future, informatics professionals
can make better current decisions.
Defining Futures Research or Futurology
Futures research is the rational and systematic study of the
future with the goal of identifying possible, probable, and
preferable futures. The formal study of the future goes by a
number of names, including foresight and futures studies,
strategic foresight, prospective studies, prognostic studies, and
futurology. Using a research approach to formally study the
future began after World War II. Since that time a number of
institutes, foundations, and professional associations were
established supporting the field of futures studies. Examples of
these are included in Box 31-1. However, from the beginning,
this field of study aroused skepticism. Today researchers and
corporate strategists may use numerous concepts, theories,
principles, and methods that are based on the field of futures
research but they may not associate these methods with the field
of futurology.8 A number of educational programs related to
futures studies now use the various futurology terms to describe
their programs. Box 31-2 includes examples of educational
programs related to this field. Despite the initial skepticism
about the topic, today the futures studies techniques are
accepted, educational programs are available, and these methods
can be very useful for informaticists.
The focus of futures studies has evolved over time. Initially,
futures studies tended to focus on a longer time horizon of at
least 10 years. Today researchers are typically studying the

world anywhere from 5 to 50 years from now.9 This creates an
overlap of futures studies with traditional forecasting and
planning disciplines that examine political, economic, and
market trends on a 1- to 5-year horizon.
Health informatics can use traditional forecasting and planning
methods in combination with futures studies methods as well as
futures studies. Strategic planning in health informatics
typically focuses on projects 1 to 3 years in the future.
Institutional long-range planning tends to focus on 5 to 10 years
in the future. For example, vendor contracts for major
healthcare informatics systems often cover a 5- to 10-year
period spanning both strategic and long-range planning.
However, there are some differences between forecasting and
futures studies.
First, forecasters focus on incremental changes from existing
trends while futurists focus on systemic, transformational
change. Second, futurists do not offer a single prediction.
Rather, they describe alternative, possible, and preferable
futures, keeping in mind that the future will be created, in most
part, by decisions made today. The technical, political, and
sociocultural infrastructure being built today will have a major
impact on the choices of tomorrow. Both types of change are
key to planning health informatics products.10 Understanding
the impact of future trends and using this information for
planning begins by understanding the degree and scope of
change that occurs over time.
Box 31-1 Futures Studies: Selected Associations, Institutes, and
Foundations
• Acceleration Studies Foundation,
http://accelerating.org/index.html
• Copenhagen Institute for Future Studies, www.cifs.dk/en/
• Foresight Canada, www.foresightcanada.ca/
• Fullerton and Cypress Colleges, and School of Continuing
Education: Center for the Future, http://fcfutures.fullcoll.edu
• The Arlington Institute, www.arlingtoninstitute.org

• Association of Professional Futurists, www.profuturists.org
• The Club of Rome, www.clubofrome.org
• The Futurist, www.wfs.org/futurist/about-futurist
• Institute for the Future, www.iftf.org/home
• The Millennium Project, www.millennium-project.org
• World Future Society, www.wfs.org/node/920
• World Futures Studies Federation (WFSF), www.wfsf.org
Box 31-2 Selected University Programs in Futures Studies
• EBS Business School: Institute for Futures Studies and
Knowledge Management, www.ebs.edu/11866.html?&L=1
• Regent University: School of Business & Leadership,
www.regent.edu/acad/global/degree_programs/masters/strategic
_foresight/home.cfm
• TamKang University: Graduate Institute of Futures Studies,
http://future.tku.edu.tw/en/1-4.htm
• University of Advanced Technology,
http://majors.uat.edu/Emerging-Tech
• University of Hawaii: Hawaii Research Center for Futures
Studies, www.futures.hawaii.edu/academic-offerings.html
• University of Houston: College of Technology,
www.houstonfutures.org/program.html
• University of Stellenbosch: Institute for Futures Research,
www.ifr.sun.ac.za/Home
• University of Turku: Finland Futures Research Centre
(FFRC), www.utu.fi/en/units/ffrc/Pages/home.aspx/
Future Directions and Level of Change
The 1890 United States census count was finished months ahead
of schedule and far under budget by using a punch card
counting machine. This technology continued to be used by the
U.S. Census Bureau well into the 1950s because the problem to
be solved remained basically unchanged. Each decade, the
Census Bureau was challenged to count the number of people in
the population and certain characteristics about the population.

Over the decades the population characteristics to be counted
changed but the need to count these data remained the same.
In the 1950s the Census Bureau introduced new technology in
the form of computers and magnetic computer tape. The basic
problem remained the same but new technology offered more
efficient and effective methods for solving that problem. The
Census Bureau's introduction of new technology is an example
of a first-level change. With a first-level change a new
technology solves a problem in a more efficient or effective
manner.
For example, replacing a typewriter with a word processer is an
example of a first-level change. One is still producing a
document but the technology makes the process more effective
and efficient. Another example is the use of Bar Code
Medication Administration (BCMA) methods. Scanning a bar
code before administering medication can make the process of
administering medication safer. However, scanning bar codes
does not change the basic role or responsibility of healthcare
providers. Within the levels of change, first level change is the
least disruptive and the most comfortable level of change. In
many ways requests that new technology be designed to fit the
work-flow of healthcare providers is, in reality, a request, or
perhaps a demand, for first-level change only. In fact, if the
equipment and related procedures do not support the current
roles and responsibilities of the healthcare providers, they
quickly develop workarounds to meet their requirements that the
degree of change be limited to a first-level change.
A second-level change involves changing how a specific
outcome is achieved. For example, historically the peer review
process used by professional journals involved sending a
submitted manuscript to a limited number of selected experts
for an anonymous opinion. The goal was to ensure that only the
highest quality articles were published. The process of review
and revision could take several weeks or months. In addition,
with a limited number of experts screening what is published,
some degree of professional censorship existed. Articles

representing a paradigm shift in thinking risked being rejected
as not on target by a limited set of reviewers. Today,
professional online journals, where all readers can comment on
material, are changing who is involved and how the peer review
process is completed, with comments from readers assuming a
more important role than in the past. Similarly, patient groups
within social media applications are changing how patients
learn about their health problems. Groups of patients help each
other to read and interpret the latest research to create a whole
new level of health literacy within these groups. Social media
interactions not only change the process for achieving an
outcome, but also change the relationships between the
participants. For example, as patients become organized and
knowledgeable, they take a more active role in their own care
and move from the role of patients needing education about
their diseases into more of a colleague role, sharing new and
innovative findings with healthcare providers.
The scope of change at this level creates both excitement and
anxiety within professional groups and among individual
healthcare providers. The scope of practice, policies,
procedures, and established professional customs, such as
professional boundaries, are challenged and resistance to this
challenge can be expected. For example, in healthcare the goals
of improved health for individuals, families, groups, and
communities have not changed but technology is changing the
roles and responsibilities related to how these goals might be
achieved.
A third-level change alters the process and can also refocus the
goal. For example, a hyperlinked multimedia journal, with a
process for adding reader comments and linking to related
publications, may change not only the definition of an expert,
but also the historical gold standard for review of new
information and knowledge. Another example can be seen in the
use of knowledge discovery and data mining with big data to
discover clusters and relationships, as opposed to using a theory
and hypothesis to develop a traditional clinical trial, thereby

redefining (or at least expanding) the concept of research.
Third-level change involves changes at the societal and
institutional level, typically occurring over long periods of
time. For instance, the evolving role of the nurse from a
handmaiden for the physician to a leader in healthcare delivery
can be seen as a third-level change.
Today, innovations in healthcare and computer technology are
interactively creating first-, second-, and third-level changes,
creating the future of healthcare within a society that is also
undergoing change at all levels. Informatics experts are among
the key leaders managing and guiding these change processes
within healthcare. However, they face a number of challenges in
achieving these goals.
The Challenge of Anticipating Future Directions
In 1970 Alvin Toffler published the book Future Shock.11 One
of the themes in the book was “what happens to people when
they are overwhelmed by change. It is about how we adapt or
fail to adapt to the future.”11(p1) Interestingly, Future Shock
was written long before the widespread use of personal
computers or the Internet. Today innovations in practice and
technology are changing healthcare delivery at an ever-
increasing speed. As Toffler identified many decades ago in a
slower-paced world, for many the degree and speed of change is
overwhelming. This includes people in healthcare in the midst
of a knowledge explosion who must do more than just adjust to
overwhelming change.
While there are no research methods for predicting the future
with absolute certainty, techniques can be used to rationally
predict future directions and trends. A historical example of this
is the publication of the book Megatrends by John Naisbitt in
1982, well before the general population was even aware of the
Internet or the potential of owning a computer. Megatrends are
trends that affect all aspects of society. The 10 trends identified
by Naisbitt are listed in Box 31-3. These trends, identified many
years ago, continue to have a major influence on health
informatics today.

While health informatics specialists clearly recognize the
importance of planning and the long-term implications of
building today's healthcare information systems, there are
immediate challenges in thinking about the future. First, present
issues are often more pressing and take a higher priority over
tasks that can wait for another day. This type of thinking is
sometimes referred to as “putting out fires.” For example, a
health informatics specialist may spend an afternoon answering
users' questions but as the number of communications increases,
the notes documenting these calls can become increasingly
sparse. Trends and patterns that could be used as a basis for a
new education and training program, or for upgrading functions
in the current healthcare informatics system, can be lost in the
pressing demands of the moment.
Box 31-3 Naisbitt's Megatrends for the 1980s
Industrial society → Information society
Forced technology → High tech/High touch
National economy → World economy
Short term → Long term
Centralized → Decentralized
Institutional help → Self-help
Representative democracy → Participatory democracy
Hierarchies → Networking
North → South
Either/Or → Multiple options
Second, small rates of growth often seem insignificant.
However, major trends start from small, persistent rates of
growth. This is especially true when dealing with exponential
growth. A few years ago very few patients asked for copies of
their health reports and a very small percentage of those
patients would have considered accessing their healthcare data
via the Internet. In August 2012 the Veterans Health
Administration (VHA) reported that the one millionth patient
had used the Blue Button application to download data from his

or her personal health record (PHR).12
Third, there are intellectual, imaginative, and emotional limits
to the amount of change that individuals and organizations can
anticipate. The imagined future is built on assumptions
developed in the past and therefore includes gaps and
misinterpretations. Future predications can seem vague and the
farther one looks into the future, the more disconnect there is
between the present and the significance of the future. For
example, nurses educated in small diploma schools 50 years ago
usually called a physician to restart an intravenous (IV). Nurses
from that time period would have struggled to anticipate the
high levels of responsibility common in today's staff nursing
role.
Approaches for Predicting
Qualitative and quantitative methods are used in traditional
forecasting and planning as well as by futurists to foresee,
manage, and create the future. The use of established research
methods separates these researchers from soothsayers. Multiple
methods used in concert are needed to identify and address
future challenges. Selected examples of these methods are
presented here. In addition, Box 31-4 includes resources for
exploring a number of other methodologies used in this field of
study.
Trend Analysis and Extrapolation
Trend analysis involves looking at historical data and
identifying trends over time in those data. For example, a log of
help desk calls may demonstrate that over the past 2 months
there has been an increasing number of calls from clinical
managers and department heads concerning the institution's
newly introduced budget software. The new software offers a
number of options and levels of analysis that were not used in
the past and it is more robust and complex. Initially there were
several calls from three managers who work in the same
division. However, these managers are now making very few
calls. Instead, the majority of the calls are coming from a
different division. Extrapolation consists of extending these

historical data into the future. For example, if the trend line is
sloping upward, one would continue this line at the same degree
of slope into future time periods. Needless to say, this historical
upward trend line will not continue forever. Eventually the
growth will start to slow and an S curve will develop. With an S
curve the growth is slow initially but then becomes very rapid.
Once the event begins to reach its natural limit the rate of
growth slows again.
A potential example of this pattern is the future use of PHRs by
the general public. Initially only a small number of people were
using this resource. Google, an early entrant in PHR
development, withdrew from this market because of lack of
interest by the general public. However, the current Blue Button
data from the VHA suggests that the use of PHRs may be at the
beginning of an S curve, with the possibility of very rapid
growth in the next few years. The expected patterns of growth
can be used to plan educational programming as well as support
services. The need for these services can be expected to grow
and then level off.
While trend analysis and extrapolation demonstrate using
quantitative methods to foresee the future, qualitative methods
FIG 31-1 MappyHealth home page.
(Copyright Mappyhealth.org.)
are also important. One example of qualitative methods is
content analysis.
Box 31-4 Futures Studies Methodologies Resources
• Methods and Approaches of Futures Studies,
http://crab.rutgers.edu/~goertzel/futuristmethods.htm
• World Future Society:
• Methods, www.wfs.org/methods
• Methodologies Forum, www.wfs.org/method.htm
• Futures Research Methodology Version 3.0,
www.millennium-project.org/millennium/FRM-V3.html
• Five Views of the Future: A Strategic Analysis Framework,

www.tfi.com/pubs/w/pdf/5views_wp.pdf
• Methodologies for Studying Change and the Future,
www.csudh.edu/global_options/IntroFS.HTML#FSMethodols
Content Analysis
Content analysis was the major research approach used to
identify the trends in the book Megatrends. 13 Content analysis
within the futures research realm involves reviewing a number
of information resources and noting what topics are discussed,
what is being said about these topics, and what topics are not
discussed. A current example of this type of analysis can be
seen in the application MappyHealth (www.mappyhealth.com).
MappyHealth uses an automated process to search Twitter posts,
looking for trends related to a specific list of diseases. A
screenshot showing the types of data being tracked is provided
in Figure 31-1. The assumptions made in identifying resources,
topics, and trends to monitor can have a major impact on
determining the forecasts produced. For example, the initial
version of MappyHealth was limited to a list of specific
diseases. This is one of the reasons why it is important that
informatics specialists review several different resources from
several different perspectives to analyze trends.
Scenarios
Scenarios involve asking individuals to envision possible
futures within a certain context. For example, people may be
asked to describe the EHR one might expect to see 10 to 15
years in the future. This can be done as a group process or
individually. Participants should be encouraged to envision
scenarios that are multifaceted and holistic, internally
consistent, and free of personal bias. Elements in the scenario
should not be contradictory or improbable. A well-constructed
scenario may suggest events and conditions not presently being
considered.
The following three major approaches can be used to construct a
scenario:

1.The Delphi method can be used to elicit expert forecasts for
a specific time frame. A combination or synthesis of opinions is
used to develop the scenario.
2.Experts develop scenarios that reflect the viewpoint of
their disciplines. These are modified and combined to produce
an overall scenario.
3.A cross-impact technique is used to test the effect of one
aspect of the scenario on all of its contributing parts.
The creation of scenarios can be used in concert with
backcasting.
Backcasting
With backcasting one envisions a desired future end point and
then works backward to determine what activities and policies
would be required to achieve that future. Backcasting involves
the following six steps:
1.Determine goals or the desired future state
2.Specify objectives and constraints
3.Describe the present system
4.Specify exogenous variables
5.Undertake scenario analysis
6.Undertake impact analysis
The end result of backcasting is to develop alternative images
of the future, thoroughly analyzed as to their feasibility and
consequences.14
With the rapid changes in informatics, the use of futures
research methods is likely to increase. For the first generation
of EHRs and data warehouses, informatics specialists have
concentrated more on initial implementations than on
forecasting future needs. For the next generations of health IT
products, futurology can more readily be incorporated in the
health informaticist's suite of skills.
Application of Futures Research
The health informatics specialist uses methodologies and

strategies from futures studies in two primary ways. First is
foreseeing or predicting future trends and directions. For
example, in the 1970s and 1980s much of healthcare was
financed via fee-for-service funding approaches. Health
information systems were designed to capture charges but not to
measure the cost of care. A number of items, including nursing
and other services, are included in the patient's charge for a
hospital room. In a fee-for-service approach, the contribution of
each of these items to the total cost was irrelevant. Cost and
charges did not need to correlate. The charge could be whatever
the market would bear.
The introduction of the prospective payment system in the
1980s and managed care in the 1990s required that healthcare
institutions capture costs rather than just charges. Existing
information systems were totally ineffective in capturing costs.
The ability to predict these kinds of major changes in healthcare
delivery could be a significant advantage to vendors and
healthcare institutions alike. By predicting the potential costs
and benefits, one is better prepared to manage these events.
Cost–benefit analysis is an example of using futures studies for
management.
Creating the future is the second way in which health
informatics specialists use futures studies methods. By thinking
of possible futures scenarios, the informatics specialist can
work toward creating the environment in which these futures
might be possible. By using the work of futurists, as well as
applying futures studies tools, it is feasible to imagine possible
future trends and directions and thereby work to create
preferable future directions.
The Future of Informatics
Health informatics is and will remain a dynamic and complex
field. Thus accurately predicting precise directions for the
future of health informatics is inherently uncertain. An informal
survey of health informatics experts at Medical Informatics
Europe 2012 and NI2012 resulted in the following interesting
list of projected topics with little overlap (listed in no particular

order):
•Robotics
•Cloud computing and “drops from clouds”
•Big data, analytics, and meta-analytics
•Data visualization and information synthesis
•Usability, participatory design, and usability labs
•Augmented reality
•Interprofessional collaboration and cooperation within
facilities, across diverse fields inside and outside of
informatics, including their implications
•Process modeling with biomedical engineering
•Risk analysis
•eHealth indicators for countries and across nations
•Modularized health informatics systems (available functions
or applications versus whole systems)
•Mobile devices for health applications (mhealth)
•Evaluation studies on the impacts of health informatics
products
•Personal health, patient-centered health system and
applications (moving away from a provider-centered health
system), and their implications for informatics
•Ontologies and interoperability, version 2.0
•Health reform and how informatics supports it
•Data reuse for policy-making and decision making
•Theoretical and model-based informatics
•Research-based healthcare using informatics tools
•Increased emphasis on guidelines and protocols to improve
care
•EHRs 2.0, redesigned and rethought
•Research and scholarly outlets limited by vendor-support
EHRs
•Policy and education role for informaticists15
Formal literature does not provide consensus about emerging or
future directions for informatics. Most recently, authors wrote

about the future of academic biomedical informatics in 201215;
a nursing informatics research agenda for 2008 to 201816;
medical informatics past, present, and future in 201017;
harnessing information and communication technologies for
nurses worldwide in 200818; informatics directions from an IT
consulting firm (Table 31-1); and an agenda for nursing
informatics in 2006.19 Within informatics and nursing, major
past efforts internationally have centered on terminology
development.20 Beyond that, a consensus of themes is not
apparent across articles and little collaboration to develop
future directions across disciplines is evident.
TABLE 31-1 Trends in Healthcare Important to Health IT
TREND
DESCRIPTION
Wellness first
Focus on wellness versus illness
ePower to the patient
Patients take on a larger, more active role in managing their
wellness and health
Earlier detection
Earlier detection maximizes options for successful treatment,
leading to a speedier return to good health
High-tech healing
New technologies can significantly boost outcomes and quality
of life
Resources: more but different
Solving the healthcare resource puzzle requires new players and
new care models
Global healthcare ecosystem emerges

More information, more connected, leads to better care and
better research.
Adapted from Forum LE. The Future of Healthcare: It's Health,
Then Care. Falls Church, VA: Computer Sciences Corporation
(CSC); 2010.
Outside the field of healthcare, contemporary issues of The
Futurist (www.wfs.org/futurist) list its annual outlook on trends
for society. Trends pertinent to healthcare include the
following:
•New leader skills. These will be shaped by those with social
networking, content management, data mining, and data
meaning skills. New job titles include Chief Content Officer
and Chief Data Scientist.21
•Nanotechnology products. Buckypaper is composed of
industrial-grade carbon nanotubes and is 100 times stronger
than steel per unit of weight. It conducts electricity like copper
and disperses heat like steel or brass.22
•Nanorobots or nanobots. These carry molecule-sized
elements, can detect cancer, and are being developed by
researchers at Harvard University.23
•Full-body firewalls. These are necessary to prevent hackers
from tampering with wireless medical devices and internal drug
delivery systems. Researchers at Purdue and Princeton
universities are developing a medical monitor (MedMon)
designed to identify potentially malicious activity.24
•Ubiquitous computing environments. Workplaces will
become ubiquitous computing environments that include
computing capabilities and connectivity.25
•Image-driven communication. Graphics and images will be
more heavily relied on for communication, allowing faster
comprehension and possibly new ways of thinking but at the
cost of eloquence and precision.26
•Living data. Connectivity will expand to millions of things
and sensors will gather more data that will be processed by
more computers. Data may become too big, so channeling the

power of data will become important.27
•The intelligent “cloud.” This will become not just a place to
store data but will evolve into an active resource providing
analysis and contextual advice.28
Due to the lack of consensus on trends, this chapter weaves
threads from available publications, chapter authors' thoughts,
and other current informatics perspectives into the following
five major themes:
•Consumerism and informatics
•EHRs 2.0
•Usability and improving the user experience for health IT
•Big data and data visualization
•Nanotechnology and nanoinformatics
A substantial part of the chapter is devoted to nanotechnology
and nanoinformatics because the topic is likely new to most
readers. Also, given its potential impact on society and funding
largess in the billions of dollars worldwide, nanotechnology is
currently underemphasized in health education and health
informatics.
Consumerism and Informatics
A shift is occurring away from provider-centric care toward
patient-centered or consumer-centered care.19,21,29 Through
current informatics tools, consumers are being supported as they
assume more responsibility for their own care, especially those
consumers with chronic diseases. The importance of this shift is
underscored in several chapters of this book: Chapter 8
(telehealth), Chapter 9 (home health), Chapter 13 (the evolving
epatient), Chapter 14 (social media and social networking), and
Chapter 15 (PHRs). This future direction is clear and will only
grow over time. For example, the design of tailored, mhealth
(mobile health) PHRs could include the following:
•Theory-based studies on the impact of consumer health IT

products
•The integration of consumer and provider health IT products
to increase care collaboration
EHRs 2.0
Clearly, the billions of dollars in Health Information
Technology for Economic and Clinical Health (HITECH) Act
funding directed at healthcare provider incentives will drive
development of future EHRs and correlated topics of
interoperability and impact. The HITECH Act funding will
continue to increase the number of implemented EHRs,
especially among eligible professionals and ambulatory
practices, the main target for the HITECH Act funds. What is
less clear is how these systems will affect the quality of care
and the practice of healthcare. There has been a rush to
implement EHRs and attend to Meaningful Use to receive
financial incentives. Healthcare providers and sites could easily
experience detrimental impacts to workflow and patient care,
especially initially, instead of the projected benefits of EHRs.
The HITECH Act did not include funding for research to assess
EHR impacts,15 so this kind of evaluative research constitutes a
future direction for informatics practice as well as needed
informatics research. In fact, Shortliffe15 claims that future
academics in informatics will find this kind of research one of
the only research avenues available to them for EHR-related
activities.
Clinicians are disgruntled with the current offerings from EHR
vendors. In an editorial for The New England Journal of
Medicine, Mandl and Kohane argue that EHR vendors propagate
a myth of complexity that precludes innovation and a myth that
EHRs are different than more flexible and robust consumer
technology.30 With most sites using vendor-supported EHRs,
this kind of impatience from users will likely drive important
changes for EHR offerings. One change might be that vendors
no longer are full-service providers of EHRs. Instead, they may
become smaller service and application providers, allowing

sites to pick and choose best options among vendors, including
nontraditional vendors such as Google or Microsoft.
Newer infrastructure, such as cloud computing, middleware, and
mobile applications, could allow more robust integration efforts
at the healthcare provider and consumer end of computing.
Consumer demand may force EHR vendors to incorporate newer
tools in their offerings, such as more robust clinical
documentation tools with integrated graphics and drawing
capabilities and even a basic spell-checker, which is currently
lacking in today's EHRs. Mandl and Kohane indicate that
disruptive technologies for EHRs are needed to displace the
current model of EHRs. This suggests another future direction
for EHRs.
Interoperability efforts will continue, especially in the U.S.,
where the diversity of products and EHR components has
caused the nation to lag behind others in creating integrated,
national, longitudinal patient EHRs. Regional integration efforts
have helped in the effort to share data. Interoperability beyond
regions will be a continued, costly future direction for the U.S.
No doubt informatics research and operational efforts on
ontologies will continue to facilitate this work, although efforts
have been ongoing for decades. What is needed is consensus
about ontologies, especially for nursing.
As EHR implementations increase, it is possible that the
traditional view of EHRs may fade. EHRs may be less
organization- and site-specific, becoming dispersed with data
owners related to roles (patient, healthcare provider, insurer,
lab, pharmacy, etc.) and data pulled and integrated from
geographic or other defined areas. A particular need for the
future is more interdisciplinary views and collaborations for
EHRs. Given the importance of teams in healthcare, the next
generation of EHRs, no matter how they are instantiated, should
offer collaborative workflow tools and methods for synthesizing
data and information for “at-a-glance” views across disciplines,
sites, types of agencies, and traditional EHR modules.
Potential areas for future research include the following:

•Evaluative research on the impacts of EHRs from various
viewpoints of patients, healthcare providers, teams, care
outcomes, and quality of care
•Impacts of integrative views of patient-centered data across
traditional EHR modules and disciplines
•Cost-effectiveness research and comparative effectiveness
for EHR designs
Usability and Improving the User Experience for Health IT
In the U.S., recent efforts will likely ensure that improving the
user experience is a future trend in health IT. As noted in
Chapter 21, two federal agencies are currently involved in EHR
usability initiatives: the National Institute of Standards and
Technology and the Office of the National Coordinator for
Health Information Technology, whose Meaningful Use Stage 2
language includes a section on EHR usability. In June 2012 the
Food and Drug Administration released draft language called
“Applying Human Factors and Usability Engineering to
Optimize Medical Device Design,” available at
www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/G
uidanceDocuments/ucm259748.htm. These kinds of regulations
are likely to proliferate in the future and become more stringent
because of patient safety issues.
Given healthcare provider and consumer voices, health IT
usability is a much needed future trend. Federal requirements
will continue to expand and vendors will have to respond to the
need for improved products. Organizations will need to increase
their knowledge about and skills for improving the user
experience. An excellent resource for meeting this challenge is
the Healthcare Information and Management Systems Society
(HIMSS) Usability Maturity Model.31 Additional information
on this model can be found at HIMSS.org by searching the
terms usability and maturity.
Research directions for improving the user experience are many.
Examples include the following:

•Comparative effectiveness research on EHR and device
designs, especially for complex patient views, such as clinical
summaries, care transitions, and Electronic Medication
Administration Records (eMARs).
•Developing and implementing best design practices agnostic
of vendors. Perhaps decoupling user views from underlying
code could occur so that optimal designs could be downloaded
by healthcare providers and layered onto their local data.
•Determining outcomes for varying application designs. For
instance, improved displays can positively affect clinicians'
situation awareness and performance in intensive care units
(ICUs).32–34 Similar studies for other applications could be
completed.
Big Data and Data Visualization
The term big data was initially defined in 2000 by Francis
Diebold, an economist at the University of Pennsylvania (see
his paper at
http://utpl.academia.edu/nopiedra/Papers/1316242/Big_DataDyn
amic_Factor_Models_for_Macroeconomic_Measurement_and_F
orecasting). Big data resulted from vast quantities of available
data due to advances in storage technology. Initially
downplayed as ambiguous, the term became popular after an
October 2010 information management conference featuring
IBM and Oracle.35 For health practitioners the important
concept is that huge amounts of data are being generated and
relatively inexpensive storage technology will make them even
more available in the future.
No matter what term is used, the world is generating mass
amounts of data. IBM estimates that 2.5 quintillion bytes of
information are generated each day. That is three times the
equivalent of the Library of Congress each second.36 In the life
sciences, genomic data have created large datasets for analyses.
Biomedical informatics efforts are underway to integrate data
across disparate fields. For example, the National Center for

Integrative Biomedical Informatics from the National Institutes
of Health is developing interactive, integrated, analytic, and
modeling technologies from molecular biology, experimental
data, and published literature.37
Within healthcare, local data warehouses combine longitudinal
EHR, administration, and financial data into a searchable
database. Sensor data and input from mobile and remote
technologies could be integrated with EHR data in the near
future. Personalized medicine efforts and nanotechnology
promise the expansion of these kinds of databases. Regional
efforts and interoperability will also add to the amount of
available data. Healthcare providers and informaticists will
become familiar with the term big data and using big data will
become a reality.
With large datasets an unparalleled opportunity exists to
examine data and issues across thousands of data points and
patients for data integrated across fields (population data,
genomics, etc). However, current efforts are hampered by issues
in data quality, missing clinical concepts, lack of standard
terminology, and the need for specialized tools.
Analytics
One of the pressing issues with big data is making sense of vast
amounts of stored data. Chapter 4 discussed one method for
achieving this goal—knowledge discovery and data mining—but
others are available, including analytics. The goal of data
analytics is to understand big data, develop predictive models,
and discover new insights. Analytics help in sense making by
revealing patterns in the dataset. Figure 31-2 provides an
example from biology and computer science. At the intersection
of science, design, and data, data visualization involves
understanding principles of human perception, design, and
computing capabilities.38
In the life sciences, interdisciplinary teams of biologists and
computer scientists developed interactive visualization tools
like MulteeSum to compare genes in fruit flies.39 In healthcare,
analytic tools for searching data warehouses are emerging and

are called business intelligence tools. Because analyzing data
and making conclusions from stored data can affect
organizational and patient care decisions, the data visualization
effort will be an important future trend.
Many analytic tools are available in the marketplace to assist
healthcare practitioners. See, for example, a white paper by
Gartner Consulting that compares currently available tools at
http://www.qlikview.com/us/explore/resources/analyst-
reports/gartner-magic-quadrant-business-intelligence-bi-
platform.
Research directions for big data and analytic tools include the
following:
•Developing interactive visualization tools for health
practitioners, especially for nursing, pharmacy, and those less
often emphasized
•Developing big data sets combining published literature,
population data, and regional data warehouses
•Detecting patterns for interventions and outcomes in
regional data warehouses
Nanotechnology
The statement “Big things come in small packages” is
appropriate to the field of nanotechnology. Nanotechnology is
the study of controlling and altering matter at the atomic or
molecular level.40 The focus of the field is the creation of
materials, devices, and other structures at the nanoscale (1 to
1000 nm). The produced items are referred to as nanomaterials,
which are composed of smaller subunits called nanoparticles.
Nanotechnology is a diverse field that requires a collaborative
environment across multiple domains (e.g., surface engineering,
physics, organic chemistry, molecular biology, and materials
science).
History of Nanotechnology
Even though the majority of research in the field of
nanotechnology has been conducted in the past few decades, the

field began in 1959 when Richard P. Feynman presented a
lecture titled “There's Plenty of Room at the Bottom.”41 In this
talk he discussed being able to manipulate individual atoms,
which would allow for more flexibility and use in synthetic
chemistry.
The field expanded in the 1980s with the invention of the
scanning tunneling microscope and the discovery of fullerenes.
With the scanning tunneling microscope, scientists could
visualize particles at the nanoscale. In 1985 Harry Kroto and his
collaborators discovered a molecule composed solely of carbon,
which they named Buckminsterfullerene.42
Buckminsterfullerene is a spherical molecule composed of 60
carbon atoms. This gives the molecule a high structural
integrity and makes it very stable. This discovery laid the
foundation for the development of one of the most well-
recognized nanoparticles, the carbon nanotube. A carbon
nanotube is a nanoparticle composed of carbon atoms bound to
one another to form a tubelike structure (Fig. 31-3). Carbon
nanotubes are a member of the fullerene family of molecules.
They have a unique combination of thermal conductivity,
mechanical properties, and electrical properties
FIG 31-2 Example of visualization tools used to compare fruit
fly attributes.
(From Fowlkes CC, Eckenrode KB, Bragdon MD, et al. A
conserved developmental patterning network produces
quantitatively different output in multiple species of
Drosophila. PLoS Genet. 2011;7[10]:e1002346.)
that makes them useful in the development of structural
materials.
Nanofabrication and Nanomedicine
Nanomaterials and nanoparticles are used in electronics,
biomaterials, and healthcare. Some claim that this area of
science and technology has the opportunity to revolutionize our
world. Manipulation of particles at the nanoscale allows the
creation of unique materials with special properties (e.g.,

unique chemical, physical, or biologic properties, such as
increased electrical conductivity or strength). The special
properties are due to the particles' incredibly small size, which
allows absorption or unique movement, and also due to
increased surface areas that interact with their environments,
creating increased interactions of materials.
Nanofabrication.
Nanofabrication is the development of materials used in
structures, electronics, and commercial products. Fabricated
nanoparticles are typically added to larger physical structures to
enhance them, resulting in increased strength, elasticity,
conductivity, or antimicrobial properties. Much work has been
done with carbon nanotubes because the tubelike structure
provides increased material strength. Carbon nanotubes are now
commonly used in electronics as wiring for electrical
components. For example, a research group at Rice University
bound carbon nanotubes to Kevlar fibers to make durable,
conductive wires that can be used in wearable electronics and
battery-heated body armor.43 Quantum dots, whose elements
move in all three dimensions, are another nanoparticle often
used in electronics as semiconductors.
The number of commercially available items containing
nanoparticles has increased at an aggressive pace over the past
two decades. When the Project on Emerging Nanotechnologies
(PEN) began its inventory in 2006, 212 products were listed.
Now PEN estimates that more than 1300 manufactured,
nanotechnology-enabled products have entered the commercial
marketplace around the world.44 Items containing nanoparticles
are very diverse, ranging from everyday items such as nonstick
cookware and lotions to unique items such as self-cleaning
window treatments. Probably the most commonly used and
commercially available product is silver nanoparticles, due to
its antimicrobial properties.
Nanomedicine.
Nanomedicine centers on the application of nanoparticles and
nanoscience techniques to healthcare and clinical research.45

Its primary goal is the use of nanotechnology for the diagnosis,
treatment, and prevention of diseases. Applications include
nanoparticles as delivery devices for pharmaceutics, diagnostic
devices, and tissue replacement.46 Due to their size and design,
nanoparticles behave differently than traditional particles since
they avoid the body's immune defense mechanisms, avoid
filtration by the body, and interact more with tissues.
Antibodies and a variety of other surface-engineered materials
can be conjugated to
FIG 31-3 A carbon nanotube.
(Copyright Owen Thomas/123RF Stock Photo.)
the surface of nanoparticles, increasing their specificity for
individual cell types (e.g., tumors). Importantly, the use of
nanomaterials reduces medication dosages and effects on
nontargeted tissues. Current research focuses on exploiting the
highly soluble, targeting properties of nanoparticles to improve
the delivery of cancer drugs to tumor-containing tissues47 and
on using nanoparticles to deliver nonviral genes and small
interfering ribonucleic acid (RNA) to combat viruses and
cancer.48
Another very intriguing area of nanomedicine research is
advanced imaging and thermotherapy. Quantum dot
nanoparticles are used in conjunction with magnetic resonance
imaging (MRI) techniques to produce exceptional images of
tumorous tissues. Chemical or physical groups can be attached
to these nanoparticles via surface engineering, so that they seek
out tumor cells and increase the resolution of images.49 These
same nanoparticles can then be used in the treatment of tumor
cells using techniques such as thermotherapy. The process
aggregates nanoparticles in tumorous tissues and then excites
the nanoparticles using targeted radio waves, lasers, or focused
magnetic waves. The excitation causes the metals in these
nanoparticles to heat up, raising the temperature of nearby
tissues (localized hyperthermia) and causing targeted cell
death.50

Work is being done to develop in vitro early detection methods
using nanoparticles. Thus nanoparticles are being used as
diagnostic tools. One example is the use of a dime-sized
microfluidic device containing a network of carbon nanotubes
coated with tumor-specific antibodies.51 A patient's blood
sample passes through the device and any tumor cells are bound
to the nanotubes. Another sensor includes chips containing
thousands of nanowires able to detect proteins and other
biomarkers produced by cancerous cells. These types of
advances could, in the future, enable the widespread detection
and diagnosis of cancer in very early stages.
Cautions about Nanotechnology
Even though nanoparticles are incredibly effective and useful,
caution is warranted. Unintended consequences of
nanomaterials are due to secondary effects, such as cytotoxicity.
For the same reasons that nanoparticles are effective (i.e., their
size and increased surface interactions), they also can cause
toxicity to the environment and humans. This is a key area of
concern and current research in the nanoscience and
nanomedicine community.52,53 Many authors discuss inherent
toxicity due to nanomaterials' cationic surface charge.52–55
This surface charge is necessary for cellular uptake. If the
charge is too high, it can create holes within the cell
membranes, resulting in membrane degradation, erosion, and
ultimately cell lysis. Clearance of nanoparticles from the human
body is another key area of concern because nanoparticles may
be rapidly eliminated by the kidneys or, alternatively, remain in
circulation for long periods of time, increasing exposure and
potential toxicity.
Synthetic methods such as the use of surface engineering and
biodegradable components to construct nanoparticles are being
employed to counteract the inherent toxicity of nanoparticles.
These processes are used to alter the cationic surface charge of
most nanoparticles by reducing the cationic charge, making it
neutral or completely changing it to an anionic charge.
However, if the surface charge of nanoparticles is reduced too

much, the bioavailability of the nanoparticles is also decreased.
Because of potential toxicity, nanoparticles must be evaluated
carefully before they are approved for routine use in the clinical
arena.55–56
Nanoinformatics
Nanoinformatics was created in an effort to help manage the
large volumes of data being produced by the field of
nanotechnology. The foundations for nanoinformatics began in
2007 by the U.S. National Science Foundation.57 The focus of
nanoinformatics is the use of biomedical informatics techniques
and tools for nanoparticle data and information. In October
2011 the U.S. National Nanotechnology Initiative (NNI)
document was developed, which outlined the following three
major goals for nanoinformatics:
1.Enhance the quality and availability of data about
nanoparticles
2.Expand nanotechnology theory, modeling, and simulation
3.Develop an informatics infrastructure58
The first goal has received the most attention to date. A number
of groups are standardizing nanotechnology terms and
developing ontologies to represent the relationships between the
terms. The two most recognized standards organizations in
nanotechnology are the Nanotechnology Standards Panel of the
American National Standards Institute and the Nanotechnology
Technical Committee of the International Organization for
Standardization. The National Cancer Institute leads one of the
most well-recognized ontology programs in nanotechnology, the
NanoParticle Ontology.
Some progress has been made on the second and third NNI
goals. The U.S. National Science Foundation hosts a site named
nanoHUB that offers a wide variety of nanotechnology
simulation tools for use by the general public and researchers.
Overall, good progress has been made in the young field of
nanoinformatics. However, the future will include much more

work in this area.
In the future, one of the most pressing goals is to create an
available public database of easily computable, nanoparticle
data. To accomplish this, the extensive available literature on
nanoparticles needs to be mined for relevant properties matched
to existing standards systems or ontologies. This kind of
database could then be used for future data mining and model
development. Beyond that, a next goal could be to develop
predictive modeling software for developing quantitative
structure activity relationships for nanoparticles. This would
allow researchers to develop computer-generated structural
images of nanoparticles and test them in a simulated
environment, allowing toxicity predictions and estimates of
bioavailability.
Issues in Regulation and Ethics
Authors are debating the regulatory and ethical implications of
nanomaterials because of the unique properties and potential
toxicity inherent in these materials. While some indicate that
current frameworks are adequate to allow regulatory and ethical
assessments,59,60 pressing considerations are evident. For
example, current cosmetic products such as sunscreens are
seldom labeled as containing nanomaterials,61,62 leaving
consumers uninformed. No regulations require such labeling as
yet.
Scientists can manufacture completely new materials with
nanoscience yet reliable information about the safety of
nanomaterials lags behind their fabrication.62 Exact risks for
patients, employees, and scientists are not yet known. The
potential applications for nanomaterials are enormous; likewise,
their risks and regulatory and ethical implications are equally
grand. Future applications could enhance oxygen storage in
blood. This would, of course, be a boon to patients with
emphysema but it has implications for ethics and regulation of
sports competitions, as well as general use in humans.63 More
alarming findings are emerging. For instance, researchers found
that nanoparticle uptake by salmon negatively altered feeding

behavior and lipid metabolism.64 This finding is of particular
concern because this kind of nanoparticle ingestion mimics
typical feeding activity in the food chain. Whether regulatory
controls will keep pace with discoveries such as these is an
issue.
Once nanomaterials are more commonplace in healthcare,
ethical issues arise for the workplace related to hazards, risks,
and projected controls.65 Ethically, workers will need to be
informed about potential exposure to nanomaterials and risks
related to inhalation, skin absorption, or unintended ingestion.
This implies a responsibility for accurate assessment by
employers, communication about risks, and perhaps even a form
of informed consent by workers. For patients, expanded
informed consent may be needed for nano-based medications
because all interactions are unlikely to be identified during
testing.46,66 Clearly, safety, regulatory, and ethical concerns
are paramount for nanomaterials.
The field of nanotechnology is exciting but caution is
warranted. By virtue of the rapid advancements, nanotechnology
is a major future direction for informatics, informatics research,
commercial product development, health products, and impact
assessment.
Conclusion and Future Directions
Health informatics specialists and leaders cannot afford to leave
the future to chance. They must proactively and systematically
identify future trends and directions in society, healthcare,
technology, and informatics. This information and knowledge
can provide the foundation for designing and building the health
information systems of the future. The methods and trends
discussed in this chapter provide tools and thoughts for health
informaticists to use to identify important trends locally and
regionally.
Acknowledgement: David E. Jones's contribution was
supported by Grant Number T15LM007124 from the National
Library of Medicine.

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Discussion Questions
1. In your setting, which future trends are likely to have the
largest effect on patient care and related information systems?
2. The 10 trends identified by Naisbitt are listed in Box 31-3.
Add two columns to this box. In the first new column project
where these trends will be in the next 10 years. In the second
new column describe how your projected impact might
influence future directions in informatics.
3. Select one of the chapter topics in this book. For example,
you might select PHRs in Chapter 15. Use the three levels of
change to describe how your selected area of informatics might
evolve over the next several years.
4. Use Box 31-4 to access and explore a futures research
methodology that was not discussed in this chapter. Describe
the methodology and how it could be used in health informatics.
5. Compare and contrast the trends of EHR directions and
consumer-centered health informatics. Where do they overlap
and where do they differ?
6. Describe how nanomaterials might affect your own life in
the near future. Consider the consumer products you use and
your role in healthcare.
7. Using futures research methods, identify how you think
nanotechnology might impact both health IT and health
informatics.
Case Study
You have just been hired as the chief informatics officer (CIO)
for a new health system. The health system has 23 acute care
facilities and 36 outpatient clinics. It serves as a regional
referral center for three states in the Midwest. Your installed
base includes a vendor-supplied EHR from a national firm.
Work on the data warehouse is just beginning. You have more

than 300 varying applications across sites, including everything
from a stand-alone pharmacy application for drug interactions
to a cancer registry. Your goal is to provide IT support for the
organizational vision of being the premier health organization
in patient safety for the region. One of the first things you want
to do is to plan for the future of IT.
Discussion Questions
1. Given the future directions discussed in this chapter, select
the two directions you want to emphasize. Provide rationale for
your choices.
2. Discuss how you can use methodologies from futures
research to plan for your preferred future with the future
directions you selected in Question 1.
3. Outline steps to introduce the chief executive officer to
nanotechnology and its potential impact on the organization.
4. You want to increase collaborative work with a local
university. What future directions for education do you think
are most important as CIO?
Pageburst Integrated Resources
Informatics
Nancy Staggers
Ramona Nelson
David E. Jones
discipline that is grounded in the present
while planning for the future.

Objectives
At the compl
etion of this chapter the reader will be prepared to:
developments in healthcare, health
informatics, and informatics research
2.Analyze techniques and challenges of planning for future dire
ctions and trends
the role of informatics in
nanotechnology, and implications for he
althcare
5.Analyze the advantages and disadvantages of nanotechnology
in health and health informatics
Key Terms
Backcasting, 499

Cytotoxicity, 505
Extrapolation, 497
Nanomedicine, 504
Nanotechnology, 502
Trend analysis, 497
Abstract
Informatics
Nancy Staggers
Ramona Nelson
David E. Jones
discipline that is grounded in the present
while planning for the future.
Objectives
At the completion of this chapter the reader will be prepared to:
developments in healthcare, health
informatics, and informatics research
2.Analyze techniques and challenges of planning for future

directions and trends
the role of informatics in
nanotechnology, and implications for healthcare
5.Analyze the advantages and disadvantages of
nanotechnology in health and health informatics
Key Terms
Backcasting, 499
Cytotoxicity, 505
Extrapolation, 497
Nanomedicine, 504
Nanotechnology, 502
Trend analysis, 497
Abstract

Chapter 31 Future Directions and Future Research in Health Informa.docx

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