This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.
Telehealth technology is an excellent solution to resolve the problems of health care delivery. However, this technology may fail during large-scale implementation. As a result, business models can be used to facilitate commercialization of telehealth products and services.
The purpose of this study was to review different types of business models or frameworks and their components used in the telehealth industry.
This was a systematic review conducted in 2020. The databases used for searching related articles included Ovid, PubMed, Scopus, Web of Science, Emerald, and ProQuest. Google Scholar was also searched. These databases and Google Scholar were searched until the end of January 2020 and duplicate references were removed. Finally, articles meeting the inclusion criteria were selected and the Critical Appraisal Skills Programme (CASP) checklist was used for appraising the strengths and limitations of each study. Data were extracted using a data extraction form, and the results were synthesized narratively.
Initially, 4998 articles were found and after screening, 23 were selected to be included in the study. The results showed that new telehealth business models were presented in 13 studies, and the applications of the existing business models were reported in 10 studies. These studies were related to different types of services, namely, telemonitoring (4 studies), telemedicine (3 studies), mobile health (3 studies), telerehabilitation (3 studies), telehealth (2 studies), assisted living technologies (2 studies), sensor-based systems (2 studies), and mobile teledermoscopy, teleradiology, telecardiology, and teletreatment (1 study related to each area). In most of the business models, value proposition, financial variables, and revenue streams were the main components.
Applying business models in the commercialization of telehealth services will be useful to gain a better understanding of the required components, market challenges, and possible future changes. The results showed that different business models can be used for different telehealth technologies in various health systems and cultures. However, it is necessary to evaluate the effectiveness of these models in practice. Moreover, comparing the usefulness of these models in different domains of telehealth services will help identify the strengths and weaknesses of these models for future optimization.
Currently, health care systems are experiencing significant increases in costs mainly due to the shortage of health care professionals, increasing life expectancy, growing elderly population, and identification of new diseases and treatment methods [
Currently, commercialization in the telehealth industry has received significant attention and innovative technology–based start-ups are expanding. In fact, the real value of these innovations lies in their commercialization [
Recently, different business models have been proposed for the telehealth industry [
This study was a systematic review conducted in 2020. A systematic review is a type of review in which a systematic method is used to summarize evidence on questions with a detailed and comprehensive method [
To select the most relevant studies, inclusion and exclusion criteria were set. According to the inclusion criteria, all research papers, reviews, conference papers, theses, and dissertations in which business models or business frameworks and their components were discussed in relation to telehealth, telemedicine, and mHealth were included in the study. No time frame was considered for searching the articles and the search was conducted until the end of January 2020. Papers published in English and full-text availability were the other inclusion criteria.
According to the exclusion criteria, books, book chapters, letters to the editor, and studies in which a business model or framework was used in fields other than telehealth, telemedicine, and mHealth were excluded. Publication languages other than English and unavailability of full texts were the other exclusion criteria.
The databases used for searching articles included Ovid, PubMed, Scopus, Web of Science, Emerald, and ProQuest. Google Scholar was also searched. The searches were conducted until the end of January 2020 and duplicate references were removed. Additionally, the OpenGrey database was searched to find grey literature. The search process was carried out by reference and citation tracking, and the scientific profiles of the authors of the articles were examined to find further related articles.
To develop a search strategy, MeSH (Medical Subjects Headings) terms such as commerce, mHealth, and telemedicine and key terms such as business, business model, value chain, eHealth service, and commercial phenomena were used. The search strategies, number of records, and search dates are presented in
The screening process was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) checklist [
Data were extracted using a data extraction form comprising the name(s) of the author(s), year of publication, country, research objective, research method, business model, the model’s components, and a summary of the results. The first author (FV) initially collected the data, and the reports were reviewed independently by other researchers too. In case of disagreement, the researchers discussed the issue and resolved it by reaching a consensus.
In this study, the business models or frameworks and their components used for the commercialization of telehealth services were the main data items that were reviewed and compared in different studies.
The quality of the studies was assessed using the Critical Appraisal Skills Programme (CASP) checklist [
In most of the selected studies, qualitative methods were used. Therefore, meta-analysis was not possible. The papers were divided into 2 groups. The first group included those studies in which a new business model or framework was presented, and the second group included papers analyzing existing business models used in the telehealth industry. To summarize data, tables were developed based on the data extraction form. The main components of the business models are also presented in figures for better understanding.
The preliminary search results in the selected databases included 4998 articles. After excluding duplicates, 2403 articles remained. Then, the titles of these articles were reviewed, and 2282 articles were excluded due to poor alignment of their aims with those of this study. In the next step, the abstracts of the 121 remaining articles were reviewed and 85 papers were excluded because their content was mostly irrelevant to the aims of this study. The full texts of the remaining articles (n=36) were reviewed, and 13 articles were excluded as they were mainly related to health care businesses (n=2), health organizations (n=4), Internet of Things (n=3), business strategy (n=1), sustainable business models in various industries (n=1), and organizational reports (n=2). Finally, 23 papers were selected to be included in this review.
Article selection process based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) [25،26].
The papers selected for inclusion in this review were divided into 2 main groups. The first group included 13 studies that presented a new business model or framework [
Summary of the studies presenting a new business model or framework for use in the telehealth industry.
Author(s) (year) and country | Objective | Methods | Business model | Model components | Results |
Barker et al (2005) [ |
To describe a business model that was developed specifically to distribute telemedicine services throughout the state of Arizona at the lowest possible cost | Qualitative study (case study) | Arizona Telemedicine Program (ATP) business model | Five components: vendor services layer, infrastructure services layer, operational services layer, professional services layer, and client layer | The ATP business model was a layered model where each layer supported the upper layer, and the membership model has allowed the ATP to develop a modern telecommunication network that delivers services to clients at a lower cost because of its distributed network and services. |
Mun et al (2005) [ |
To provide a business model of teleradiology | Qualitative study (literature review) | Teleradiology business model | Five teleradiology business models: stand-alone teleradiology practice, the “nighthawk”/on-call coverage, solo radiologist practice, expert/second-opinion teleradiology, and a global virtual radiology service based on workload sharing and reallocation | This successful business model will depend on the ability to produce the highest-quality product at the lowest cost. |
Fife and Pereira (2008) [ |
To provide a VISORa business model framework for mobile telehealth | Qualitative study (case study) | VISOR business model framework | Five components: value proposition, interface, service platforms, organizing model, and revenue model | The VISOR framework suggests that widespread adoption of mobile health care can only be achieved when the interface, service platform, organizational model, and revenue model are addressed simultaneously. |
Kijl et al (2010) [ |
To design a business model for a myofeedback-based teletreatment service (MyoTel) in patients with chronic neck and shoulder pain or whiplash injury | Mixed methods study (quantitative and qualitative case study) | Abstract cost benefit model (ACBM) | Two components: demand and supply | The business model engineering strategy provided important insights that led to an improved, a more viable, and a feasible business model; the related value network design and the process of early-stage business model engineering reduce risk and produce substantial savings in costs and resources related to service deployment. |
Lin et al (2010) [ |
To analyze the business model of a service innovation case by evaluating a telecardiology service | Qualitative study (case study) | Telecardiology business model | Nine components: value proposition, target customer, distribution channel, (customer) relationship, value configuration, capability, partnership, cost structure, and revenue model | The telecardiology service continued to succeed because of the mutual benefits it offered to the providers and users. A telecare service is meaningful to the general public only when the business model is sustainable. |
Lin et al (2011) [ |
To generate a framework to analyze 6 major telemedicine projects in Taiwan | Qualitative study (interviews with hospitals, security firms, and not-for-profit organizations) | Telemedicine framework | Six components: value proposition, target customers, service process, resources and capabilities, partnership and cost structure, and revenue model | Value proposition, partnership, resource, and capability affect service processes and cost structures. This in turn impacts customers’ acceptance of telemedicine. |
Fachinger and Schöpke (2014) [ |
To identify, describe, and develop business models of sensor-based fall detection systems | Qualitative study (literature review) | Consistent business model | Nine partial models: customer, market, financing, proceeds, production, resources, procurement, network, and strategy | A sustainable business model was built by interconnecting 9 partial business models. |
Peters et al (2015) [ |
To describe, analyze, and classify a business model | Qualitative study (literature review) | CompBizMod framework | Four components: value proposition, value co-creation, value communication and transfer, and value capture | This business framework was useful for coordinating the perspectives of different telemedicine institutions, evaluating competitors, and designing competitive advantages. |
Fusco and Turchetti (2015) [ |
To identify the best business model to optimize value creation for most project stakeholders | Qualitative study (interviews with decision makers, physiotherapists, patients, and caregivers) | Telerehabilitation business/governance models | Three components: key activities, customer/patient segments, and key resources | Telerehabilitation business models reduced costs and the number of people on the waiting list. Actually, due to changes in the health sector and innovative governance, patients can be involved in the recovery process. |
Lee and Chang (2016) [ |
To find a business model to improve the health management of patients with chronic kidney disease | Qualitative study (literature review) | Mobile health management business model | Four components: data, data analysis/service, user, and partner | Requirement analysis and design of the mobile health management business model led to the provision of a cheap and professional support and management services platform for the disease. |
Oderanti and Li (2016) [ |
To investigate the commercialization of assisted living technologies and provide a sustainable business model | Qualitative study (literature review) | Sustainable business model | Seven components: value proposition, product innovation and commercialization, infrastructure management, customer relations management, financial viability and sustainability, stakeholder credibility, and revenue streams | The comparative advantage of a sustainable business framework was the most important factor that encouraged older people to pay for eHealth despite their free health services. Further, this sustainable model reduced the pressure on the British health system. |
Pereira (2017) [ |
To identify the value proposition of telehealth | Qualitative study (literature review) | VISOR business model | Five components: value proposition, interface, service platforms, organizing model, and revenue model | The VISOR framework illustrates that although technology issues, such as security and privacy considerations, remain key factors that will determine the rate of adoption of telehealth, nontechnological challenges are equally, if not more, important. |
Arkwright et al (2019) [ |
To provide a business model for the success of telehealth programs | Qualitative study (literature review) | Telehealth business model | Eight models: direct-to-consumer (patient), organization-to-organization, clinician-to-clinician, oversight and processes, online patient access/portals/technology, mHealth/medical applications, hardware/software, and international telehealth program | A successful telemedicine business model must be safe, appropriate for the patient’s needs, patient-centered, user-friendly, compliant, mission driven/strategically aligned, and have demonstrable value for the patient. |
aVISOR: value proposition, interface, service platform, organizing model, and revenue.
The study by Barker et al [
In 2 studies, business models were presented for mHealth services [
In the field of telerehabilitation, 2 different business models were presented in 2 of the included studies [
Fusco and Turchetti also presented 4 models of business governance for telerehabilitation after total knee replacement. These models included 1 conservative model, 2 partnership models between primary care units and supporting companies that supplied equipment for primary care units, and 1 model based on cooperation between stakeholders. The results showed that the innovation structure was enhanced from the first to the fourth business model. The main components of these models were key activities, customer and patient segments, and key resources. These models reduced costs and the number of people on the waiting list [
In telecardiology, the results of the study by Lin et al showed that using a sustainable business model with the 9 components including value proposition, target customer, distribution channel, (customer) relationship, value configuration, capability, partnership, cost structure, and revenue influenced the acceptance of technology by the general public and provided mutual benefits for service providers and patients [
In 2 studies, a business framework for telemedicine was presented [
The results of the study conducted by Fachinger and Schöpke showed that a sustainable business model in sensor-based fall recognition systems consists of 9 interconnected components, building blocks, or partial models including customer, market, financing, proceeds, production, resources, procurement, network, and strategy; the combined application of these components led to the creation of a sustainable business model [
In 2 other studies, the new business models were slightly modified [
Arkwright et al presented 8 common and successful telehealth business models in their study. These models included the direct-to-consumer (patient) business model, organization-to-organization business model, clinician-to-clinician business model, oversight and processes business model, online patient access/portals/technology, a business model based on mHealth/medical applications, a hardware/software model, and an international business model. The researchers believed that a successful telehealth business model should be safe, patient-centered, user-friendly, consistent, mission-oriented, strategy-oriented, and of proven value to the patient [
Key aspects of the new business models or frameworks for the telehealth industry.
The findings of this study showed that 10 studies examined existing business models or frameworks used in the telehealth industry (
The results of Marjomaa's study [
Summary of the studies that evaluated existing business models or frameworks used in the telehealth industry.
Author(s) (year) and country | Objective | Methods | Business model | Model components | Results |
Dijkstra et al (2006) [ |
To provide a business model for telemonitoring | Qualitative study (literature review) | Freeband business blueprint method | Four components: service domain, technological domain, organizational domain, and financial domain | Using 1 flexible infrastructure for multiple telemonitoring services, infrastructure costs can be shared among multiple services. A partnership between home care organizations, central contact centers, suppliers of monitoring devices, and wireless sensor network providers is required for telemonitoring. |
Leunissen (2008) [ |
To validate the process of the business model design of Myotel (see |
Qualitative study (case study) | STOFa model | Four components: service domain, technological domain, organizational domain, and financial domain | The business model is sustainable (viable, suitable for growth, and sustainable), if it has added value for all stakeholders involved. |
Simonse et al (2011) [ |
To review business models in home health services | Qualitative study (literature review) | Johnson framework |
Four components: customer value proposition, profit formula, key resources, and key processes | There is an imbalance as to where money can be earned, where money can be saved, and where other value is created. Home health care providers are delivering extended, preventive, or outsourced health care from hospitals. |
Marjomaa (2015) [ |
To develop a generalizable business model for mHealthb services in chronic disease management | Mixed methods study (quantitative and qualitative) |
Alexander Osterwalder’s |
Nine components: customer segments, value propositions, channels, customer relationships, revenue streams, key resources, key activities, key partnerships, and cost structure |
Focusing on business model design early in the mHealth technology development phase can help researchers and designers overcome common challenges and create commercially viable mHealth services. |
Hidefjäll and Titkova (2015) [ |
To design a business model for a wearable biofeedback system | Qualitative study (literature review and interviews with relevant representatives) | Alexander Osterwalder’s |
Nine components: customer segments, value propositions, channels, customer relationships, revenue streams, key resources, key activities, key partnerships, and cost structure | Instead of solely focusing on the material development of the technology, development needs to be seen as part of a larger commercialization process consisting of conceptual, material, and institutional development with the business model design in focus to meet health care system requirements. |
Grustam et al (2017) [ |
To assess the B2Cc model for telemonitoring |
Qualitative study (literature review) | B2C | Three components: design, structure, and governance | The B2C model in telemonitoring chronic heart failure potentially creates value for patients, who are shareholders of the service. Moreover, implementation of telemonitoring for chronic diseases via the B2C model can potentially free up financial resources, which can either be used to support a greater number of people with the same technology or can be invested in new treatments and therapies. |
Grustam et al |
To create the B2Bd and B2C care models and explore the differences in care coordination and transaction costs between these models for telemonitoring | Qualitative study (literature review) | B2B and B2C | Six components: structure, financing, public policies, technology alignment, consumers (customers), and accountability |
In principle, care coordination in the B2B and B2C models for telemonitoring chronic diseases differs in terms of design elements and design themes. The transaction costs could potentially be lower in the B2C model than in the B2B model, which could be a promoting economic principle. |
Grustam et al |
To describe a B2C model for the implementation |
Qualitative study (literature review) | Alexander Osterwalder’s |
Nine components: customer segments, value propositions, channels, customer relationships, revenue streams, key resources, key activities, key partnerships, and cost structures |
A B2B model was developed toward a B2C model offered in telemonitoring with the goal of synergizing equipment manufacturers, health care providers, payers, and legislators to enable telemonitoring for the entire population and increase the speed and scalability of the technology. |
Leeuwerden (2018) [ |
To increase the commercial viability of business model innovations with SHAALe technology in dementia care | Mixed methods study (quantitative and qualitative) |
Alexander Osterwalder’s |
Nine components: customer segments, value propositions, channels, customer relationships, revenue streams, key resources, key activities, key partnerships, and cost structures |
Cost-benefit studies were essential to the success of ambient assisted living technology, and the insurance company played an important role in continuing to use and commercialize these technologies. |
Kho et al |
To identify, describe, compare, and contrast |
Qualitative study (literature review) | Alexander Osterwalder’s |
Nine components of Alexander Osterwalder’s business model canvas: customer segments, value propositions, channels, customer relationships, revenue streams, key resources, key activities, key partnerships, and cost structures |
The 3 business elements that supported the viability, sustainability, and growth of web-based dermatology were developing key partnerships, clinician involvement in the design and implementation process, and managing the medicolegal risks and liabilities that are relevant for each country. |
aSTOF: service, technological, organizational, and financial.
bmHealth: mobile health.
cB2C: Business-to-Consumer.
dB2B: Business-to-Business.
eSHAAL: Smart Home and Ambient Assisted Living.
Business-to-Business (B2B) and Business-to-Consumer (B2C) models were used in 2 studies. The aim of 1 study was to explore the systemic and economic differences in care coordination via B2B and B2C models for telemonitoring patients with chronic diseases [
Furthermore, 3 studies used other existing business models [
In a study conducted by Leunissen, the STOF (service, technological, organizational, and financial) model was used. The results showed that the added value in the telerehabilitation business model might be changed due to the impact of cash flows [
Key aspects of the existing business models or frameworks used in the telehealth industry.
The results showed that different types of business models and frameworks have been used in the telehealth industry and they have various components. However, value proposition, meeting the stakeholders’ and customers’ requirements, and financial issues were the most common components in these models and frameworks. These components might be described using different terms along with many other components, which were found important in relation to a specific type of technology and its context of use. Although new business models and frameworks focus on specific aspects of telehealth services, namely, service delivery, innovation, technology, and interface design along with other business components, the existing business models, such as Osterwalder’s business model canvas, have been used by some researchers to gain more comprehensive insight into the telehealth industry. It seems that using these business models and frameworks depends on the context of using the technology and many other components can be added to make them more appropriate for different purposes.
The aim of this study was to review different types of business models and their components used in the telehealth industry. The search process yielded 4998 articles, from which 23 studies were included in the study. These studies were divided into 2 main categories. The first category included new business models or frameworks, and the second category included the existing business models and frameworks used in telehealth industry. These models and frameworks consisted of different components in various areas of telehealth.
As mentioned earlier, business models can help implement telehealth technology with the participation of all stakeholders and in a value-based manner [
A business model should be able to create and transfer value to the customers in a profitable and sustainable manner [
According to research findings, the main components in most telehealth business models were financial issues and cost structures that could be influenced by service processes, resources, and partners [
The results showed that it is possible to design different types of business models with various components to be used in telehealth industry. However, the components should be able to support the value of the technology in line with other components, such as the cost structure and revenue model. The components of a business model must be able to support each other, especially in unstable conditions of the health system. In addition, the components of a business model must be constantly monitored and updated [
A business model should ultimately lead to the acceptance of the technology by the general public. It should help in providing equitable distribution of services, effective diagnosis of diseases, and high quality of services, as well as in reducing pressure on health systems [
The results also revealed that some studies used existing business models or frameworks in telehealth services. Among these models, the Osterwalder business model was used more frequently than other models [
A number of other studies used B2C and B2B models. The use of the B2C model allowed all stakeholders to enjoy the benefits of innovation, reduced the burden of service delivery, and improved efficiency [
Although business sustainability is one of the major challenges lying ahead for the expanding telehealth industry, few studies have concentrated on this aspect [
The existing business models, especially the Osterwalder business model, are general tools and roadmaps that can provide a good understanding of business model components. However, one of its major drawbacks is the lack of sufficient emphasis on the importance of the digital economy and the functionalities of core enabling technologies. In fact, this business model cannot manage multiservice platforms and the use of other business models seems necessary to support it. Moreover, it is more product-oriented and the nature of key partner networks is less discussed in this business model [
Overall, applying business models in the commercialization of telehealth services will be useful to gain a better understanding of the required components, stakeholders’ interactions, market challenges, and possible future changes. In fact, understanding the innovation, market size, competitive strategy, and investment in the telehealth industry is not sufficient and the impact of such an investment on the whole society should be investigated [
In this study, different types of business models and their components used in the telehealth industry were reviewed and the main components necessary for a successful telehealth business were identified. However, this study has some limitations. In most of the selected studies, qualitative approaches were used. Therefore, conducting meta-analysis was not possible. Moreover, although the main databases were searched, there might be other databases that were not searched and non-English papers that were excluded from the study. These limitations can be addressed in future studies by searching more databases and changing the exclusion criteria.
The results showed that new business models used in the telehealth industry focused on legal, organizational, insurance, and customer-related issues. Added value, financial variables, financial sustainability in the market, competition, service platform, annual membership and subscription, national incentives, cost structure, and revenue streams were the other important components of these models. The studies that used existing business models mostly focused on aspects such as design, structure, governance, organizational issues, country-specific obligations, public policy, financing, profit formula, physician participation, risk management, and key processes.
In general, the diversity of business models and their components in the telehealth industry indicates that different models can be used for different telehealth technologies in various health systems and cultures. However, it is necessary to evaluate the effectiveness of these models in practice. Moreover, comparing the usefulness of these models in different domains of telehealth services will help identify the strengths and weaknesses of these models for future optimization.
Search strategies.
CASP (Critical Appraisal Skills Programme) checklist.
Business-to-Business
Business-to-Consumer
Critical Appraisal Skills Programme
mobile health
freeband business blueprint method
service, technology, organization, finance
value proposition, interface, service platform, organizing model, and revenue
This work was funded and supported by Iran University of Medical Sciences, Tehran, Iran (grant IUMS/SHMIS_98-1-37-14528).
None declared.