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Business Models for Mobile Tele-Health

The Business Models for Mobile Tele-Health in the


U.S.: Applying the VISOR Framework

Elizabeth Fife, Ph.D. and Francis Pereira, Ph.D.


Institute for Communication Technology Management (CTM)
Marshall School of Business
University of Southern California
444 S. Flower Street, Suite 1000
Los Angeles, California 90089-8204
Tel: (213) 740-0980
Fax: (213) 740-1602

e-mail: pereira@marshall.usc.edu or fife@marshall.usc.edu

Dr. Francis Pereira is Director of Industry Research at the Center for Telecom Management (CTM), and Lecturer in
the Information & Operations Department, Marshall School of Business, University of Southern California. He
received his Ph.D. in Political Economy and Public Policy from the University of Southern California, and teaches
courses in economics, statistics and electronic commerce. His areas of research include trade and financial flows in
the Association of South-East Asian Nations. For the past thirteen years, his research has focused on key business
issues in telecommunications field, particularly adoption rates of E-commerce applications especially in the small
and medium size enterprises, and business models in the new multimedia environment and the effects of emerging
technologies on these models.

Dr. Elizabeth Fife has over ten years of research experience in the field of telecommunications. Current work
includes cross-cultural analysis of mobile users’ behavior. As the Associate Director of Industry Studies, at the
Center for Telecom Management at the University of Southern California, Dr. Fife’s research includes topics such
as ICT use in the developing world, IT adoption by small and medium-sized businesses as well as models for
technology adoption and diffusion. Dr. Fife has a dual appointment in USC’s Marshall School of Business and the
Viterbi School of Engineering. She received her Ph.D. from the School of International Relations, University of
Southern California, with an emphasis in political economy.

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THE BUSINESS MODELS FOR MOBILE TELE-HEALTH IN


THE U.S.: APPLYING THE VISOR FRAMEWORK
Abstract
The growth in Internet browsing for health-related information together with demographic changes in the
industrialized countries strongly suggest a latent demand for mobile telemedicine as well as personal monitoring
and applications that can lower costs and improve the quality of healthcare delivery. The mobile device provides a
convenient and usable option for delivering information between the consumer and healthcare professional.
Wireless applications for transferring, accessing and updating patient records could provide a potential solution to
the escalading cost of health care, particularly as the population ages. Despite its potential, mobile-telehealth has
not progressed as rapidly as anticipated, and there are very few deployments to date.

Much discussion has focused on the technology challenges associated with mobile healthcare, whereas we focus
on the social, regulatory, and market forces that will affect adoption of mobile-telehealth. Using the VISOR 1
business model framework, we analyze the value proposition of mobile-telehealth and adoption factors. We find
that while the value proposition for mobile healthcare is substantial, significant obstacles in the organizational
structures and service platforms exist which must be addressed to accelerate adoption in the U.S.

Keywords: Business models, tele-health, mobile applications

Introduction

Although aggregate and per capita costs of health care in the United States are the highest in the world, many
Americans still remain uninsured, under-insured or live in communities that are medically under-served. More
importantly, the heath care industry in the United States has been experiencing substantial and ever-increasing cost
pressures. It is estimated that annual health care expenditures in the United States, exceed some $2 trillion dollars,
and this expenditure is expected to double by 2010 (U.S. Department of Commerce, 2007). Many have argued that
early detection and preventive care is a solution to the escalating costs of medical care.

In this respect, mobile tele-health specifically, and in its larger context, tele-medicine, may provide a means of
assisting in health maintenance and detection. Tele-medicine is generally defined as “the use of telecommunications
and computer technologies, including patient remote sensing and monitoring, and the use of telemetry devices, with
medical expertise to facilitate health care delivery” (Kim et. al. 1995). It has long been thought that telemedicine
has significant potential for developing into an integral component of the global health care system. Through remote
sensing, collaborative patient care and access to electronic libraries and medical databases (Lindberg 1994),
telemedicine has held the potential to engender better and more extensive access to health care, lower medical costs,
reduce the isolation of medical care professionals and increase medical productivity (Gagnon et. al. 2005; Bashur et.
al. 2000). Thus, as depicted in Figure 12, mobile telehealth is a sub-set of tele-medicine, and can be defined as the
use of patient monitoring and telemetry devices to convey, using wireless transmission technologies, patient health
data and information over geographical areas.

While mobile-tele-health is relatively new, Telemedicine has existed since the 1920s 3 (Willams and Moore 1995),
but thus far, has been used only sparingly for real-world patient-physician consultations. And while Telemedicine
offers significant advantages, its limited use suggests a lack of compatibility with existing experiences and values.

1
VISOR represents Value Proposition, Interface, Service Platform Organizing Model and Revenue Source and are the inter-related components
necessary for a successful business model.
2
Adapted from Wang, 2006
3
A form of telemedicine was used in the 1920s, when radio was used to link public health physicians standing at watch at shore stations in order
to assist ships at sea that had medical emergencies. In the late 1950s, attention was drawn to closed circuit [television] systems using microwaves

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M o b ile H e a lth
C om ponent

F i g u r e 1 : H o m e H e a l t h C a re , A p p l i c a t io n s, T e c h n o l o g i es a n d S e r v i c e s

Although mobile tele-health can be seen as a discrete portion of Tele-medicine or Tele-health, its adoption and value
proposition is inextricably intertwined with the overall Tele-medicine structure in the U.S. And while the value
proposition of Tele-health is high, as this paper will illustrate, the low adoption rate argues for the existence of
significant obstacles, across multiple “categories,” that is retarding its adoption. Thus, this paper will use the
VISOR Business Model, as an organizing framework, to elucidate the value proposition that mobile tele-health (as a
component of a broader tele-medicine approach) offers to U.S. society, as well the stakeholders in the medical
industry. Concomitantly, this paper will identify the barriers, as viewed through the “VISOR lens,” that need to be
simultaneously addressed to facilitate mobile-telehealth’s adoption and widespread use.

Review of Business Models


In general, there is no accepted definition of the term “business model” (Shafer 2005). The plethora of
definitions poses significant challenges for understanding the essential components of a business model. This has
led to confusion in terminology as “business model, strategy, business concept, revenue model and economic model
are often used interchangeably… (and moreover) the business model has been referred to as architecture, design,
pattern, plan, method, assumption and statement (Morris et. al. 2005). Consequently, thus far, it has been difficult to
argue the superiority of one approach over others.

Three general categories of definitions based on their emphasis, namely economic, operational and strategic,
each with their unique set of decision variables have been identified (Morris et. al. 2005). The economic approach
focuses on how a firm can make a profit and key variables from this approach include revenue sources, pricing
methodologies, cost structures, margins and expected volumes. Fundamentally stated, this approach deals with how
a firm can make money and sustain its revenue stream into the future (Stewart and Zhao 2000). Alternatively, the
operational approach focuses on the firm’s internal processes and design of infrastructure that enables firms to create
value, with key components such as production or service delivery methods, administrative processes, resource flow
and knowledge management, with the objective of design of interdependent systems that create and sustain a
competitive business (Mayo and Brown 1999) . In the strategic approach, emphasis in on the overall direction of the
firm’s marketing position, interactions across organizational boundaries, and growth opportunities. This approach

(Kim, Cabral, Parsons et al., 1995), and in the 1970s satellites were used in large demonstration projects linking Alaskan and Canadian villages
under the auspices of the NASA.

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espouses the totality of how a firm selects its customers, defines and differentiates its offerings, creates utility for its
customers, defines the tasks it will perform or outsource, configures its resources and ultimately, captures profits
(Slywotzky 1996). Decision variables focus on stakeholder identification, value creation, visions, values and
networks and alliances.

The VISOR Approach: identifying key requirements for success


In addition, although properly formed business models are very useful and can be a strategic tool for a firm, many
business models however suffer from 4 common problems (Shafer et. al. 2005), namely:

i) Flawed or untested assumptions underlying the key premises of a firm’s business plan; these revolve around
untested assumptions about future conditions, or implicit or explicit cause-and effect-relationships that are not
well founded or logical.

ii) Limitations in the strategic choices considered; addressing and developing the business logic in only one
component of the business model, and making untested assumptions about the others.

iii) Misunderstanding about value creation and value capture; the inability of organizations to financially capitalize
on the “value” they create, which may thus negatively affect the “revenue generation” aspects of business
models.

iv) Flawed assumptions about the value network; assumptions that the current value created through the network
will continue unchanged into the future.

The VISOR4 model attempts to integrate the different approaches in business model development, as well as to
address unaddressed key elements such as the user experience and interface factors. While these factors are not
explicitly recognized in most of the approaches, as summarized in Table 1, they figure prominently in many theories
of diffusion of innovations (Fife and Pereira 2005). Furthermore, the interface and service platform factors,
incorporated in the VISOR model, are extremely important in the delivery of digital or electronic applications and
services such as Tele-health. At its core, a good business model must answer the standard questions, “Who is the
customer? What does the customer value? How do we make money in this business? What is the underlying
economic logic that explains how we can deliver value to the customers at an appropriate cost?” (Mageretta 2002).

In this respect, then the VISOR Model, as illustrated in Figure 2, defines how a firm responds to a customer need,
latent or established, thus creating and delivering the greatest value to the customer, in a profitable and sustainable
manner, and, as such, optimizes costs to value creation. Thus, from the VISOR perspective, a successful business
model is one that is able to align the respective components of the VISOR model so as to deliver the greatest value
proposition that maximize the willingness to pay on the part of its target consumers, on the one hand, with the ability
to minimize the real cost (tangible and intangible) of the provision of these services, the latter being achieved
through the optimal mix of interface experience, service platforms and the organizing model.

Value Proposition

Value proposition addresses why particular customer segments would value an enterprise’s products and services
and be willing to pay a premium price for them. The willingness to pay is a direct function of whether these
applications provide “value creation” in that they satisfy an unmet latent end-user demand, or “value substitution” in
that they provide only an alternative means for end-users to access an existing application or service.

Interface

The success of delivery of a product or service is heavily predicated on the user interface experience in terms of ease
of use, simplicity, convenience, and positive energy, and should generate an extraordinary or “wow” experience.

4
The VISOR Model was formulated by Omar El-Sawy, Director of Research at CTM and Professor of Information and Operations Management,
Marshall School of Business, University of Southern California.

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Table 1: Comparison of Business Model Approaches5

Source Components Number of Customer


Components Interface
Horowitz (1996) Price, Product, Distribution, Organizational Characteristics and 5 N
Technology
Viscio and Pasternak Global core, Governance, Business Units, Services and 5 N
(1996) Linkages
Timmers (1998) Product/service/information flow architecture, Business Actors 5 N
and Roles, Actor Benefits, Revenue sources, and Marketing
Strategy
Markides (1999) Product innovation, Customer relationship, Infrastructure 4 N
management, and Financial Aspects
Donath (1999) Customer understanding, Marketing Tactics, Corporate N
Governance and Intranet/Extranet capabilities
Gordijn et. al. (2001) Actors, Market segments, Value Offering, Value Activity, 8 N
Stakeholder network, Value interfaces, Value ports and Value
Exchanges
Linder and Cantrell Pricing model, Revenue model, Channel model, Commerce 8 N
(2001) process model, Internet-enabled commerce relationship,
Organizational form and Value proposition
Chesbrough and Value proposition, target markets, Internal value chain 6 N
Rosenbaum structure, Cost structure and profit model, Value network and
(2000) Competitive strategy
Gartner Market offerings, Competencies, Core technology investments, 4 N
(2003) and Bottom Line
Hamel Core strategy, Strategic resources, Value Network and 4 N
(2001) Customer interface
Petrovic et. al Value model, Resource model, Production model, Customer 7 N
(2001) relations model, Revenue model, Capital model, and Market
model
Dubosson-Torbay et. Products, customer relationship, Infrastructure and network of 4 N
al partners, and Financial aspects
Afuah and Tucci Customer value, Scope, Price, Revenue, Connected activities, 8 N
(2001) Implementation, Capabilities and Sustainability
Weill ad Vitale Strategic objectives, Value proposition, Resource sources, 8 N
(2001) Success factors, Channels, Core competencies, Customer
Segments, and IT Infrastructure
Applegate (2001) Concept, Capabilities and Value 3 N
Amit and Zott (2001) Transaction content, Transaction structure and Transaction 4 N
governance
Alt and Zimmerman Mission, Structure, Process, Revenues, Legalities and 6 N
(2001) Technology
Rayport and Jaworski Value cluster, Market space offering, Resource system, and 4 N
(2001) Financial model
Bertz (2002) Resources, Sales, Profits and Capital 4 N
Hedman and Kalling Value network, Resources, Capabilities, Revenue and pricing, 7 N
(2003) Competitors, Output, Management
Chesbrough (2003) Customer, Value network, Capabilities, Revenue and pricing, 6 N
Cost, Strategy

5
Adapted from Morris et. al. op. cit. and Schafer, et. al., op. cit.

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Service Platforms

IT platforms that enable, shape, and support the business processes and relationships that are needed to deliver the
products and services, as well as improve the value proposition.

Organizing Model

Describes how an enterprise or a set of partners will organize business processes, value chains, and partner
relationships to effectively and efficiently deliver products and services.

Revenue Model

In a good business model, the combination of the value proposition, the way that offerings are delivered, and the
investments in IT platforms are such that revenues exceed costs and attractive for all partners.

Value Proposition
REAL “VALUE” for Targeted
Customer Segment
PROPOSITION

Revenue/Cost Interface
Model Calculations The VISOR Framework “Wow”
for All Partners Experience
for NDI Business Models

REAL “COST”
OF DELIVERY

Organizing Model Service Platforms


for Processes & to Enable Delivery
Relationships

Figure 2
The VISOR MODEL

As shown in Figure 2, then, from the VISOR approach, a high value proposition to the target consumer segment
together with a concomitant Revenue/Cost model, could “offset” proportionally any deficiencies with the Interface,
Service Delivery or Organizing Model aspects of the model.

The VISOR Approach to Mobile Tele-Health in the United States

Value Proposition

In general, the experience over the past 40 years suggest that telemedicine is most useful when physical barriers,
such as geography, distance terrain, climate, etc, make transportation and/or direct contact between patient and
clinician difficult (Larsen 2004). However, the advancement in telecommunication technologies, both wireline and
wireless, the widespread adoption of computers, and the developments in medical and sensor, tele-medicine and/
mobile tele-health have the potential to alleviate some of the challenges in health care cost management.

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Thus, in the United States, the value-proposition for tele-health is attractive. Health care in the United States
has been experiencing substantial and increasing cost pressures which could be addressed in part by tele-health care.
These savings could be generated from reduced costs for serving patients, through management of chronic diseases,
savings in time and travel for doctors and patients, fewer unnecessary referrals, and the replacement of doctors with
less medically trained personnel supported by Telemedicine. There would also be savings from the provision of
better health care, generating cost reductions from early diagnosis and treatment.
Mobile tele-health and tele-homecare, have the ability to provide management for chronic diseases, such as
Diabetes Mellitus, Hypertension, Chronic Obstructive Pulmonary Disease (COPD) and heart disease. For example,
COPD is an important cause of hospitalization in for the aged population in the U.S. Approximately 65% of the
638,000 hospital discharges in 2004 were in the 65 years and older population. (American Lung Association 2007).
Additionally, it is estimated that one in five Americans will develop Congestive Heart Failure (CHF), and
outcomes related to heart failure still remain relatively poor, despite advances in pharmacological therapy and
medical care (Seibert et. al. 2008). For CHF patients, appropriate disease management is critical. CHF is the leading
cause of hospital admission for people over 65 years in the U.S, with a re-admission rate of 44% within a six-month
period. Treating high risk heart failure patients is estimated to account for some 1% to 2% of the total heart care
budget in the U.S. and Europe. Studies show that tele-monitoring has led to a 26% reduction in number of days
patients stayed in hospitals and experienced improved survival rates (Phillips 2003).
From a patient’s perspective, several studies also suggest general satisfaction with tele-health and tele-home
health services, even among older adults, particularly for CHF, COPD and chronic wound care, with satisfaction
levels increasing with increased levels of tele-health care intervention (Agrell et. al. 2000; Rahimpour et. al. 2007;
Demiris et. al. 2004).
And while the cost-savings generated by Telemedicine for U.S. correctional institutions has been variously
documented, including an $1 billion dollars to the State of Texas since the inception of its Electronics Health
Networks in 1994 (Choi et. al. 2006; McGee 2004), the potential for mobile tele-health may provide even greater
benefits in this area.
Interface

Patient usage of a service is heavily predicated on the user interface experience in terms of ease of use,
simplicity, and convenience. In mobile health applications it is anticipated by many that the device of choice on the
care-giver side will be the personal digital assistant (PDA) which is popular among physicians for communication
and reference to medical databases for prescription information. It appears that training issues should not be as
complex given that healthcare professionals routinely use handheld and wireless devices. On the patient side, the
ubiquity of cell phone ownership has made it an obvious choice for application developers who have added insulin
and heart rate monitoring functions to this device. Another area of concentration is the home where telemonitoring
and remote patient education are seen as areas of burgeoning need. The small-scale clinical trials that have been
carried out have found that “extreme” simplicity is needed in the home environment as patients using such devices
may have recently been released from the hospital, may be older, and may have limited experience with computers.
Also, health problems such as rheumatoid arthritis, vision problems, and other conditions need to be taken into
account in designing the user interface (Gardner-Bonneau 2006).

Overall, the usability of wireless applications is a critical issue, as devices must be designed to accommodate
patient’s capabilities, whether they are lacking in stamina, they are facing dementia, or disabilities that require
adaptation of an interface. Intuitive interfaces that learn with the individuals have been put forth as the solution to
limiting and changeable usage abilities. It appears that even non-technical individuals are interested in learning
how to use mobile and wireless services if they allow them more independence (Varshney 2007).

Service Platform
Despite the potential economic benefits and the fact that telemedicine technology has existed since the 1920s,
usage has not been widespread, due to structural, technical and social constraints. These barriers remain today and
include low compatibility with existing medical practices, complexity of telemedicine equipment and interfaces,
multiple technical standards (Lewis 2006; Charles 2000; Western Governors Association 1995) physicians’
unfamiliarity with the technology, and ineffective change management and training (Wasley 1992). Additionally,

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with mobile tele-health and the existence of different wireless technologies, such as GSM, GPRS, 3G, WiFi,
Bluetooth and Zigbee, there is the possibility of interference (Garcia et. al. 2007). Network security is a primary
concern, thus a general requirement for wireless tele-health is a high level of security to protect health care data.
Encryption, authentication and controlled access are critical features (Varshney 2007). As a result, most of the
wireless applications in use today are considered “low risk” and involved simple patient data, checking
prescriptions, and text messaging (Lunden 2008).
One solution to current wireless network challenges is a multi-network approach; Varshney argues that a
reliable and usable wireless infrastructure that is easily accessed and supports prioritized communications could be
achieved by such an approach, using cellular networks, wireless LANs, and satellites to help provide coverage,
redundancy, and reliability (Varshney 2007). Switching among multiple networks could potentially provide a
higher degree of scalability and service quality that would overcome limitations in current wireless networks.
Organizing Model

Overall, the medical health social system is very structured and complex. For example some 12 State and Federal
Agencies regulate the industry, which would include the Food and Drug Administration, the Drug Enforcement
Agency, and the Department of Health and Human Services (Lewis). In the case of mobile Tele-health, such
regulations would also include the Federal Communications Commission. With regards to Tele-medicine and tele-
health, the lack of clear support from key institutions, such as the American Medical Association and most medical
colleges and medical schools, save the American College of Radiology, presents another impediment. This
ambivalence is linked to several major social impediments to the use of telemedicine, including the incompatibility
of state laws regarding telemedicine and licensure issues (National Institute of Justice 2002).

Under the present individual state licensure system, the potential of tele-medicine is limited to the somewhat
arbitrary borders of a state. Physicians are required to have medical licenses in each state in which they practice.
This clearly limits the potential geographic benefits telemedicine could provide (Hammack 2006). Additionally,
some twelve state and federal agencies regulate telemedicine.

Also, there is significant uncertainty regarding whether malpractice insurance policies cover services provided by
telemedicine (Smith 2005). The legal problems associated with telemedicine malpractice liability are especially
intricate when services crosses state borders (Gagnon et. al. 2005). In a highly litigious society like the United
States, physicians are reluctant to increase their exposure to potential malpractice lawsuits.

Finally, like other communications technologies, there is a concern regarding the security of personal medical
information stored in telemedicine systems (Smith 2005). Sanders notes the possible use of encrypting algorithms
and legal precedent (yet to be defined) determining “reasonable and customary” efforts in protecting individual’s
information (Sanders 1994).

Revenue Model

The cost of implementing a telemedicine infrastructure, and the reimbursement of tele-medicine services, remain
two of the major obstacles to tele-medicine, both in the U.S. and in Europe (Statura 2006; Hoppszallern 2007). At
present, neither the technology costs, nor the consultations over the technology are reimbursed (Nagy 2006).
Currently, a large majority of telemedicine initiatives are sponsored by organizations where reimbursement is not
crucial, like research centers, the Armed Forces or state-owned hospitals, and these initiatives are frequently
financed by demonstration grants. Only a small number of for-profit medical centers are involved in telemedicine
and many of these, like the Mayo Clinic, are employing closed telemedicine systems (Tangalos 1994). Furthermore,
medical organizations are reluctant to purchase equipment because of the risk that it will be quickly outdated
(Charles 2000; Muirhead 2000). For example, of the more $400 billion expended by Medicare in 2006, only $2
million was spent on medical services conducted electronically (Glendinning 2007).

Although many studies show the potential cost savings of tele-heath and remote monitoring, most of these
studies involve small sample sizes with diverse types and doses for tele-homecare intervention and for few select
chronic illnesses, principally heart failure (Bowles and Baugh 2007). One comprehensive study that tried to estimate

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the potential savings from telemedicine was prepared in 1992 study by the Arthur D. Little consulting company
which estimated that then that telemedicine would result in savings of $36 billion annually (Shoor 1994). The fact
that the savings estimates today remain strikingly similar to those made in 1992 reflects how little progress has been
made over the past two decades to capture the economic benefits of telemedicine in the United States (Healthcare
Business Market Research 2006). Thus, in the United States, where health care is most often a privatized, for-profit
concern, many companies are loath to take the first step, share information with competitors, or put themselves at
financial risk regarding investment in an “unproven” technological direction.

Conclusion
Applying the VISOR framework it is clear that besides the presence of technology issues, such as security, it is
the non-technological challenges that are particularly significant to the widespread adoption of mobile healthcare in
the United States. These include regulatory, organizational and revenue-based issues. Thus, the VISOR framework
suggests that widespread adoption of mobile healthcare can only be achieved when the interface, service platform,
organizational model, and revenue model are addressed simultaneously. Resolving regulatory issues related to the
transfer of patient records may help catalyze the more integrated adoption of mobile healthcare, instead of individual
applications by the patient and care-givers which is evident today. As yet, there has been little in the way of federal
government support for in the United States to facilitate the adoption of mobile health (or telemedicine). As such,
the potential for efficiencies and benefits from mobile-health are still yet to be realized.

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11 The Global Mobility Roundtable Conference, Auckland 2008