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 Multimedia Appendix 1. There was no time limit for searching the articles, but the language was limited to English and only full-text papers were included in the study.

The screening process was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) checklist [25,26]. After retrieving relevant articles, reference management was performed using EndNote software (Version X7, Clarivate) and duplicates were removed. The titles, abstracts, and full texts of the retrieved studies were screened. The initial search and screening processes were conducted by one of the authors (FV). In the next step, the other authors independently screened and appraised the remaining articles and resolved discrepancies by discussion and reached a consensus.

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 [27]. As qualitative methods were used in the selected studies, the CASP checklist for qualitative research was used. It consists of 10 questions, with “yes,” “no,” or “can’t tell” as the answer options. The calculated scores showed if the quality of each study as high (7-10), medium (4-6), or low (1-3). The assessment was conducted by 2 researchers (FV and HA) independently (see Multimedia Appendix 2).

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. Figure 1 shows the article selection process.

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 [1,14,19,23,28-36], and the second group comprised 10 studies that evaluated existing business models or frameworks used in the telehealth industry [37-46]. These studies were published between 2005 and 2020. The first group comprised studies conducted in the United States (n=5), the Netherlands (n=1), Germany (n=2), Taiwan (n=3), Italy (n=1), and England (n=1); the second group included studies conducted in the Netherlands (n=6), China (n=1), Australia (n=2), and Sweden (n=1).

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 [4]. Business models serve as an analytical framework for identifying and overcoming barriers to the implementation and extensive use of telehealth technologies and help apply beneficial emerging technologies. These models also help identify the value proposition of telehealth services and its challenges, as well as the appropriate revenue model, organizational structure, and stakeholder engagement model [1]. However, business models must be adapted to the social, geographical, and economic contexts of the technology. Understanding each component of a business model is essential to evaluate the success of telehealth services [13,47]. Moreover, providing a business plan based on the well-known business models or frameworks, especially in the early stages of product development, will reduce potential risks and significantly save the costs related to the establishment of services and technologies [14,29,31].

A business model should be able to create and transfer value to the customers in a profitable and sustainable manner [23,30]. Therefore, some studies have emphasized the differences among the business models used for various types of telehealth technologies in each country [13,48]. For example, the results of the study conducted by Fredriksson et al showed that it is more appropriate to use different business frameworks for specific purposes. These frameworks should be in line with the context and purpose of using the technology [20]. However, the application of business models in the field of telehealth does not guarantee the success of new technologies, and before taking any action, legal issues and challenges related to licensing, compensation methods, liability, data sharing, and data protection must be resolved [28].

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 [33]. Cost structure plays an important role in customer acceptance, and different financial strategies need to be considered for various circumstances, revenue makings, and geographical areas [33]. Thus, a successful business model must be able to provide the highest value and increase the customers’ willingness to pay [1,36].

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 [34].

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 [35].

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 [37-46]. This model was helpful to meet the requirements of the health system and provided added value by increasing patient satisfaction and reducing the cost of care [37,43]. It also provided a better understanding of the business characteristics and covered various economic aspects of technology implementation [40].

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 [42]. However, when insurance companies supported the B2B model, it was more sustainable than the B2C model. Other studies used the FBBM, Johnson framework, and STOF model. The use of these models was influenced by cash flow to generate revenue and predict outcomes [44-46]. Similarly, Antoniotti et al showed that government and private payers are very influential in making telehealth payments and revenue policies should be considered in business models [49].

Although business sustainability is one of the major challenges lying ahead for the expanding telehealth industry, few studies have concentrated on this aspect [32,34,35]. The key aspects of the long-term sustainability of telehealth business include developing a skilled workforce, empowering consumers, reforming funding, improving digital ecosystems, and integrating telehealth into routine care. These requirements should be considered in implementation planning to ensure that effective integration of telehealth within complex health systems is in place and staff are willing to use telehealth technologies [50,51]. In another study, Cui et al highlighted that the sustainability of telemedicine must be improved by appropriate legislation, uniform standards, and powerful management [52].

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 [38]. In situations where the stakeholders, their roles, and the impact of their roles are different, the existing business models do not have the necessary flexibility for adaptation. Moreover, the customers (organization purchasing technology) and users (technology user) are different sometimes and considering the requirements of both groups may influence the design of the business model [53].

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 [38,42]. Although several business models have been proposed for use in the telehealth industry, using a combination of models and their components can help commercialize the technology more successfully. Telehealth business models can also be used in combination with traditional patient care models to double their value proposition [40,43].

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.