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With a growing population of health care clients in the future, the organization of high-quality and cost-effective service providing becomes an increasing challenge. New online eHealth services are proposed as innovative options for the future. Yet, a major barrier to these services appears to be the lack of new business model designs. Although design efforts generally result in visual models, no such artifacts have been found in the literature on business model design. This paper investigates business model design in eHealth service practices from a design perspective. It adopts a research by design approach and seeks to unravel what characteristics of business models determine an online service and what are important value exchanges between health professionals and clients.
The objective of the study was to analyze the construction of care models in-depth, framing the essential elements of a business model, and design a new care model that structures these elements for the particular context of an online pre-care service in practice.
This research employs a qualitative method of an in-depth case study in which different perspectives on constructing a care model are investigated. Data are collected by using the visual business modeling toolkit, designed to cocreate and visualize the business model. The cocreated models are transcribed and analyzed per actor perspective, transactions, and value attributes.
We revealed eight new actors in the business model for providing the service. Essential actors are: the intermediary network coordinator connecting companies, the service dedicated information technology specialists, and the service dedicated health specialist. In the transactions for every service providing we found a certain type of contract, such as a license contract and service contracts for precare services and software products. In addition to the efficiency, quality, and convenience, important value attributes appeared to be: timelines, privacy and credibility, availability, pleasantness, and social interaction. Based on the in-depth insights from the actor perspectives, the business model for online precare services is modeled with a visual design. A new care model of the online precare service is designed and compiled of building blocks for the business model.
For the construction of a care model, actors, transactions, and value attributes are essential elements. The design of a care model structures these elements in a visual way. Guided by the business modeling toolkit, the care model design artifact is visualized in the context of an online precare service. Important building blocks include: provision of an online flow of information with regular interactions to the client stimulates self-management of personal health and service-dedicated health expert ensure an increase of the perceived quality of the eHealth service.
Innovative eHealth technologies have the potential to provide solutions for several challenges within health care, including the growing number of chronic diseases, rising shortage of health staff, and the pressure to increase cost savings within healthcare [
A growing number of scholars at the intersection of medical informatics, public health, and business are investigating eHealth and related technologies [
Business model design was conceived when online services such as those provided by Amazon were established, and new constructs were needed for the purpose of explaining and improving the understanding of this phenomenon of eBusiness [
Internet technologies create new opportunities for eHealth service provision and change the way in which actors interact within new models of value exchange. Although the clinical results of eHealth innovations have proved to be very promising, their implementation is not so straightforward. In fact, problems have been encountered in the adoption of most eHealth innovations [
For designing a business model, it is essential to understand its characteristics. First, the business model should be an integrative network model, integrating a network organization with network technology [
The conceptual framework visualizes the essential elements for analyzing and designing a care model (
Conceptual framework for analyzing and designing a care model.
We follow Herzlinger, who suggests putting the client in charge of health care in order to generate more freedom of choice, openness, and transparency in the design of business models [
We follow Amit and Zott, who relate transactions to both the economic theory of transactions and the network theory in organizational behavior [
Value attributes can be attached to transactions. These attributes—the potential properties of transactions—can add value to both the perceived quality and convenience of the eHealth service for the client. For instance, “quality value” is focused on improving the product or service performance, and “convenience value” is defined as “making products or services more convenient and easier to use” [
Care model constructs.
Element | Construct | Definition |
Actor |
|
In the value network of service providing, the firm, the organization [ |
|
Health professional | A professional working at a health care providing service organization, such as the medical specialist, the general practitioner, specialized nurse, etc. |
|
Client | A person using the services of a professional organization [ |
Transaction |
|
Reciprocal exchange of value. Core transaction, value proposition in return for monetization. |
|
eHealth |
Providing a solution for a fundamental problem in a given situation [ |
|
Monetization | When and how is money raised? Monetization involves pricing including the systems determining timings of payments and methods of collecting revenues [ |
Value attributes |
|
Properties of transactions, that add value to the use, effort experience, and risk reduction [ |
|
Quality | Value of improving the product or eHealth service performance [ |
|
Convenience | Value of making products or services more convenient and easier to use [ |
In this study, we further investigate the construction of business models in depth by framing the essential elements of actors, transactions, and value attributes. In order to design a business model that structures these elements specifically for the Internet technology-enabled precare service context, we address the following research question, “What characteristics of business model design in precare contribute to the convenience and quality of eHealth services provided by a health professional to a client?”.
To deconstruct the service relationship between the client and the health professional, a designerly modeling approach is valuable in locating the different actors, transactions, and value attributes that fit the preferred value proposition focusing on the convenience and quality of eHealth services. These elements of a business model are a steppingstone in the creation of building blocks; compositions of actors, transactions, and attributes that are valuable in the design of business models of eHealth services within the precare phase.
The next section addresses the Methods in which we report on the research method and the toolkit developed for the visual design of business models. Then the Results section provides an empirical analysis of the actors’ perspectives on the business model for a precare service and presents the newly designed business model artifact for this precare service. In the final section, we draw conclusions and discuss the research limitations and suggestions for future research.
To arrive at a better in-depth understanding of the business-modeling phenomenon within its real-life context, we adopted a case study method [
PRE is a start-up organization launched by a professional cardiologist. The purpose of PRE is to make clients aware of their lifestyle and heart risk by supporting them with an online service for living a healthier life. On the PRE Web application, a client creates a personal online account and gets feedback information, including a grade for his or her personal lifestyle and a percentage chance of heart failure. These results are based on an online questionnaire (up to 300 questions), and a small physical examination (taking blood for glucose levels). PRE regularly gives advice on how the client can improve his or her lifestyle, and provides the client with a lifestyle score, updated bimonthly (
PRE (anonymized case name for the start-up organization with an online precare service for living a healthier life ) Web application service.
Purposeful sampling was used to take a closer look at a relevant eHealth situation, the PRE case. An in-depth investigation of different perspectives was conducted in order to study a variety of views, rather than the mean or average. The sample of data collection (
The PRE service has been implemented as a full operational service after a pilot implementation to ensure the quality of the online service. There were two clients that experienced the system for a minimum of two months that were invited to join an interactive session. Furthermore, a cardiologist (owner of PRE), a manager, and a precare specialist participated in an interactive session. The data were collected over a time span of three weeks. With interactive sessions, participants were guided to deconstruct business models associated with the PRE service.
Sample of participants in interactive sessions.
Network actor | Respondent | Interview | Visual model |
PRE care service provider | CEOa/cardiologist | 1 | 1 |
Intermediair | Manager | 1 | 1 |
Occupational health | Precare specialist | 1 | 2 |
Client | Client X | 1 | 1 |
|
Client Y | 1 | 1 |
Total | 5 | 5 | 6 |
aCEO = Chief Executive Officer
In the data collection, a visual modeling method was used to support the participant in deconstructing the business model into separate actors, transactions, and valuable attributes. The researchers developed this toolset by combining the toolsets of the visual brainstorm method of the Board of Innovation [
Each participant was asked to visualize the business models concerning the PRE service by using blank sheets of paper, markers, and the mapping toolset (
Impression of the use of the visual business modeling method during the interactive sessions.
There were three types of data that were analyzed: (1) visual modeling data, (2) interview data, and (3) documented data. All the types of qualitative data were combined to frame, analyze, and synthesize the business model view of each respondent. The visual business models created by the participants were analyzed by means of a comparative analysis. The in-depth analysis of different perspectives meant that a variety of views, rather than the mean or average, were investigated. By analyzing the different visual models created from the different perspectives, the created models were transcribed into digitalized models. When comparing these models and extracting valuable actors, transactions, and attributes, conclusions were drawn regarding the elements contributing to the convenience and quality of the service. Based on these insights, building blocks were created that can be used in the design of an eHealth service. For the building block design, the actor-transaction toolset was used as a basis for designing the new business model for the precare phase of care.
The framing of all business model views resulted in the identification of important actors, transactions, and value attributes. In addition to the two client and health professional actors in the conceptual framework, eight new actors were identified, framed with eight different types of transactions and six additional value attributes.
There were three actor perspectives that were synthesized from the six individual business model views.
Business model view A from client perspective.
Business model view B from PRE (anonymized case name for the start-up organization with an online precare service for living a healthier life) health professional perspective. PME:preventive medical examinations.
The first perspective analyzed in the deconstruction of the PRE care model is the perspective of the online service provider. The health care professional is the developer and owner of the service.
Online service provider overview of actors, transactions, and value attributes.
Actors | Transactions | Value attributes |
ICT specialist | Online precare service, PRE health protection |
|
Health specialist | Recommendations | Timeliness |
Intermediate organization, 365/ArboNeda | License for precare software products | Efficient |
From the health professional perspective, three new actors were identified as an essential part in the care model. These essential actors are key developers and a partner to deliver the service to the client. First, the
In framing the relation between the client and the health professional, PRE is an online precare service providing professional lifestyle advice. The PRE service consists of a “flow” of digital triggers and recommendations, including weekly tips and tricks, video messages from the health professional, and extensive bimonthly advice. This transaction in which the service provides health protection recommendations only takes place if the client’s heart risk and lifestyle score are below seven on a scale of ten. These scores are based on the client’s responses to several questions regarding his or her lifestyle, which are included in the yearly Preventive Medical Examinations (PME) of the occupational health service. Employers in the Netherlands are legally obligated to offer PME to their employees.
The software products in the transaction between the health professional and the intermediate organization provide the basis for the pricing and licensing of the business model. The precare software modules are paid for by the intermediate organization with a license fee. The license covers the use of the online heart risk and lifestyle assessment services (including the estimation of scores and recommendation messages) from PRE software modules in its online PME questionnaire. The precare intervention service is an additional option in the contract provided by the intermediate organization to the companies.
The aim of the health professional in the design of the PRE service is to disseminate lifestyle advice to as many clients as possible. Therefore,
The second perspective, from which insights are derived, is the perspective of the coordinator of the PRE service within the 365/ArboNed network of business-to-business customers. In protecting health within the firm environment, the network coordinator pointed out the existence of two different situations: (1) the normal situation when the client is at low risk and thus no intervention is needed, and (2) the service situation where intervention from PRE is needed (
From the network coordinator perspective
Network coordinator’s overview of actors, transactions, and value attributes.
Actors | Transactions | Value attributes |
Marketing department | Service contract | Reliability |
Companies within network | Software products transaction, PME digital feedback report | Privacy |
Office practitioner | Check-up measurement | Availability |
Vitality health specialist | Personal coaching | Privacy |
|
Product support feedback | Personal interaction |
The relation between the health professional and the intermediate organization involves a value transaction, as the software modules are paid with a license fee. The precare software products are embedded in the PME. 365/ArboNed has incorporated the heart risk and lifestyle scores in the PME assessment as a unique selling point in its service package proposition to companies. In addition to providing feedback to the client regarding the outcome of the test, 365/ArboNed gives feedback concerning the preventive medical results to his or her employer. The employer can optionally request a report on the lifestyle scores of different departments in the company.
Within the company contract packages, the PRE intervention service based on employees’ heart risk and lifestyle scores is optional. When a company chooses to include the PRE intervention service in its contract with 365/ArboNed, and one of the clients in its employ needs intervention coaching—when the PME results show high risk—direct contact is made between the client and PRE. This transaction is described in the health professional’s perspective.
The PME is a questionnaire that consists of three hundred questions assessing a client’s everyday lifestyle and behavior. The client receives a summary of the outcome of the questionnaire in the form of a digital feedback report. If the client’s lifestyle score is below seven, and his or her employer has included the PRE service in its precare service package, a PRE intervention is initiated. Besides the intervention transaction between PRE and the client, this also entails a personal start-up meeting between the precare specialist and the client, and an appointment with the office practitioner.
If the client’s lifestyle score is below seven on a scale of ten, a PRE intervention transaction will be started. To establish this intervention transaction, two new transactions are initiated. First, direct and personal contact between the precare specialist and the client is established, and second, between the precare specialist and the office practitioner. In a face-to-face start-up meeting, the vitality and health expert (VHE) can support the advice the client receives from PRE, and motivate the client to improve his or her lifestyle. The office practitioner has to measure the client’s heart rate and take a blood sample to determine cholesterol levels.
The VHE provides the developers of the precare service (the PRE team) with feedback in order to improve the overall quality of the service. The feedback is related to the process coordination of the PRE service, and how the ICT architecture behind the service can be improved. Although this transaction can be valuable in the design of any eHealth service, in this case the experience of the VHE with PRE is of importance because the incorporation of PRE in the PME’s of 365/ArboNed only started toward the end of the year in 2012.
In addition to the attributes of efficiency and timeliness, the managers of the intermediate organization came up with four new value attributes in the care model of precare services. First, the client’s
To explore the transactions from the clients’ point of view, two clients, client X and client Y, were interviewed. The created care models showed many similarities, and only differed on a few attributes of the transactions between PRE and the client (
From the client perspective, one new group of actors was identified. This group of actors comprises the other clients making use of the professional intervention service. These “coclients” can vary from familiar colleagues to anonymous users. Close contact between coclients can help motivate clients to improve their lifestyle and their heart risk and lifestyle scores. According to client Y, the business-related context of the interaction among clients provides a supportive boost in sharing and comparing heart risk percentages and lifestyle scores, information that is generally perceived as highly personal.
Client’s overview of actors, transactions, and value attributes.
Actors | Transactions | Value attributes |
Coclients | Self-management | Pleasantness, reliability, |
|
Flow to next care stage | Timeliness, effectiveness |
In the deconstruction of the care model by the clients, self-management was identified as a new transaction. Self-management refers to the interventions, training, and skills by which patients can effectively take care of themselves, and learn how to do so. In contrast to the other transactions, which involve an exchange of activities between two actors, this transaction is the client’s relation with himself or herself in the self-management of his or her state of health. The earlier identified transactions of a personal tailored feedback report, a professional intervention service, personal coaching and check-up measurement, and online social sharing serve to support the self-management of the client.
In the interaction with other clients, comparison and motivation were mentioned when the interviewed clients deliberated about their health-protection activities. Clients compare their scores and thereby motivate each other.
Within the transactions between the PRE online service and the client, client X identified
When comparing the different business models created from the different actor perspectives, conclusions can be drawn regarding the elements of a business model that contribute to the convenience and quality of the eHealth service in precare. These elements can be divided into actors, transactions, and attributes. Only when both actors confirmed the transactions or relating attributes took place between them, the transactions or relating attributes were validated.
Concerning the positioning of actors, three major insights emerged from the analysis results. First, a professional such as a health care provider should be involved in the development of an eHealth service in order to ensure that the client feels secure when entering personal information into an online system. Moreover, the professional qualifications of the involved health care provider ensure the reliability of the advice provided to the client. Second, an intermediate organization with a large network can be valuable in connecting the provided service with potential clients. Third, face-to-face contact, such as with the precare specialist or office practitioner, has an influence on how the client perceives the quality and convenience of the service. This direct contact serves to support the client’s self-management. The actual presence of the precare specialist is important, since the transaction between this actor and the client, the actual support, has a lesser influence in the minds of the client’s on the perception of the service.
From the deconstructed care models, we derived three insights with regard to the transactions contributing to a valuable eHealth service. The first transaction is the aim of any eHealth service in precare, and entails self-management of the client. This transaction is supported by the second interaction between the client and the eHealth service. This connection needs to consist of a flow of information from the client to the service, and, based on this information, a flow of advice from the service to the client. A distinctive characteristic of the interaction between the client and an eHealth service is the digital nature of both flows. Another transaction positively influencing the self-management of the client is the motivational boost provided by interaction with other clients when they compare scores and share tips.
Finally, insights can be derived from the attributes the participants attached to the transactions. Based on the results, we can conclude that four attributes contribute to the convenience and quality of online services, and thereby influence the design of eHealth services. These attributes are the client’s privacy when providing the service with personal information, the reliability of the advice received by the client, the timeliness of the advice received by the client, and the preferred type of contact with a precare specialist. Both privacy and reliability are perceived values of the client when a professional health care provider is involved in the development of an eHealth service. Direct contact with a precare specialist or office practitioner positively influences the perceived quality and convenience of an eHealth service. Timeliness involves the time management of the advice transaction between service and client; a continuous flow contributes to the convenience and quality of the service.
Based on these insights, we constructed five building blocks. These building blocks—elements of a business model consisting of actors, transactions, and value attributes—contribute to the convenience and quality of an eHealth service. Together these building blocks form a business model that can be used in the design of any eHealth service in the precare phase.
The involvement of a health professional, involving a professional health care provider in the development of an eHealth service will ensure privacy and reliability in the transactions between client and service.
Interaction with the health professional, information flow from the client to the service, and a continuous flow of advice back to the client are needed in accomplishing self-management of the client.
Coordinating network organization, involving an intermediate organization with a large network can assist in extending the service’s reach, connecting the service with potential clients. However, on the basis of the results, no conclusions can be drawn concerning the nature of the transaction between the organization and the client.
Direct contact, face-to-face contact between the client and a precare specialist supports self-management of the client and his or her perception of the eHealth service. The type of transaction has less influence, and is therefore labeled with a question mark.
Interaction with other clients, the presence of other clients making use of the same eHealth service has the potential to motivate the client and support his or her self-management.
In order to design an effective business model for eHealth service solutions, all building blocks need to be integrated. All building blocks are of equal importance; the combinations of actors, transactions, and attributes all contribute to the convenience and quality of an eHealth service.
The five building blocks integrated in the business model design for eHealth services in precare. ICT: information and communication technology.
Taking up the design challenge of creating an innovative business model for an eHealth service, we framed the characteristics of a business model and constructed a care model that structures the actors, transactions, and value attributes for the particular context of an online precare service. Based on in-depth insights on which value exchanges between a health professional and a client are important, we constructed the building blocks of a care model for precare eHealth services. From five actor perspectives, we identified and defined the care model actors, transactions, and attributes that contribute to the perceived convenience and quality of this particular eHealth service. The generated insights and design contribute to this situation, but also have broader relevance for comparable online eHealth services. As more generic implications for the design and implementation of eHealth innovations, we propose to: (1) involve a health professional, since this will ensure privacy and reliability in the transactions between the client and the service; (2) provide an online flow of information with regular interactions to the client in order to stimulate self-management of personal health; (3) involve an intermediate organization with a large customer base to extend the service’s reach; (4) involve a service-dedicated health expert for personal face-to-face contact with clients in order to ensure and increase the perceived quality of the eHealth service; and (5) include social interaction with other clients of the online service with a view to motivating and supporting the self-management of personal health.
As more generic implications for the design and implementation of
Although the study was executed in depth and from multiple role perspectives, the choice of a single case study method comes with limitations. These include the two clients who used the precare service for different lengths of time; one client tested the service for two months, and the other for one year. Also both clients had a low heart failure risk and high lifestyle score. These differences influenced their perception of the service, but overall the ways in which they visualized the care models had more commonalities then differences. A first suggestion for further research is to conduct a multiple case study with more interviewees per role perspective. A second research suggestion is related to the visual business modeling method, in which the participants could freely modify and add actor, transaction, and attribute cards. Permitting this degree of flexibility and creativity in codesigning could have positively affected the participants’ openness to the implementation of the care model innovation. This research by design method required reflection on action, demonstrated with the deconstruction part of this study. Further research experiments on the visual elements in the business modelling kit and on the codesigning situation can bring the modelling method to a next level of intervention. Another relevant direction for further research would be to quantitatively validate the influence of the separate building blocks on the convenience and quality of the service, in contribution to the knowledge field of care models in eHealth. Also further quantitative research on monetization (eg, cost structures and revenue streams) is worthwhile to investigate. Furthermore, an interesting related avenue for further research in complex value network structures is the in-depth analysis to overcome the key barriers for the integration and adoption of eHealth services. Concerning the monetization barriers, such as willingness to pay, issue of having no financial reimbursement structure for eHealth services, requires further research. A final consideration in this case study relates to the venture context. The eHealth service was studied in a business start-up context. The importance of building blocks might change or new blocks could appear in different phases of the service’s life cycle. Understanding the developments a business model in eHealth goes through enables forward-looking design of business models for eHealth services. In addition, our final research suggestion is to study the influence of the different stages of a service’s life cycle on the design of its business model.
This study provides an overall business model that is informative and serves as a source of inspiration for the creation of eHealth services in the precare phase of care that provide convenience and quality to the end user. By using a visual modeling method in codesign with the actors involved, the essential actors, transactions, and value attributes of a business model were discovered in the context of the PRE case study. We revealed eight actors in the business model of the precare service. Essential for providing the service are: the intermediary network coordinator connecting companies, the service dedicated ICT-specialists, and the service dedicated health specialist. In the transactions we found a certain type of contract, such as a license contract and service contracts for precare services and software products. In addition to the efficiency, quality, and convenience value attributes, important value attributes appeared to be: (1) timeliness, (2) privacy and credibility, (3) availability, (4) pleasantness, and (5) social interaction. As such, the final business model emphasizes the importance of real-time contact between the client and a health care provider in online interactive intervention programs. Moreover, larger groups of clients could be treated in the precare stage at the same time, thereby educating and helping clients to self-manage healthier behavior, while also stimulating dialogue and support between clients.
information and communication technology
preventive medical examinations
anonymized case name for the start-up organization with an online precare service for living a healthier life
vitality and health expert
None declared.