Key components and critical factors for developing a telehealth business framework: a qualitative study

It is more than a decade that the advancement of Information and Communication Technologies (ICT) has been used to promote the quality and speed of health care services in the form of telehealth and other health care technologies. These technologies can help to solve the problems associated with health care services, equal distribution of resources, and health care costs [1, 2]. Telehealth technology supports the provision of a variety of health care services, such as patient care, tele-education, and tele-consultation, and includes a set of complex technologies, organizational models, clinical services, and evaluation tools. Despite the potentials of this technology to increase the quality of, and access to health care services, its successful implementation and commercialization have always faced several challenges [3, 4]. Although many new health technologies have been accepted clinically and technically, a small number of telehealth innovations has been widely implemented, probably due to not using profitable and sustainable business models (BM) or business plans (BP) [5, 6].

It should be noted that having advanced technology does not guarantee success in the market, and new technologies need to be supported by appropriate business models to survive in the market and make successful commercial deals [7, 8]. Business models play important roles in the implementation of technologies and related products and are used as a basis for interaction with stakeholders [9]. These models provide a path through which innovation, technology, and knowledge are joined together to make the most of the tangible and intangible assets [10]. Although, a variety of business models and plans are used in telehealth industry [11], it seems that providing a telehealth business framework with well-defined components can help the business managers to focus on the most important issues and increase the chance of success. Such a framework is based on understanding the context of telehealth in a broader picture and together with existing challenges and opportunities help to focus on the major aspects of successful telehealth business. It is notable that while a model usually shows a simplification of a phenomenon or a specific aspect of it, a framework usually represents a structure or overview of various descriptive categories, e.g. concepts, constructs or variables, and the relations between them. [12] According to the literature, so far, few studies have been conducted to introduce a telehealth business framework. For example, the CompBizMod framework included four dimensions which were value proposition, value co-creation, value transfer, and value capture [5]. Using this framework, service providers can evaluate their business models and consider components that lead to competitive advantages [5]. However, this framework focused on the value and had few components.

Dargahi et al. introduced a reference business model with three layers; namely, the infrastructure layer, the interface layer, and the business layer, so that it could be used in the development of evaluation criteria for e-health and mobile health technologies at the national and regional levels [13]. However, using such broad components might be difficult for people working in the field of business. In another study, Hasani et al. proposed 24 different factors in six components, including infrastructure management, strategies, financial issues, bidding, environmental management, and technology as a framework for designing and developing an e-health business model [14]. In this framework, general components of e-health business were considered, and the current telehealth business models were not taken into account. It seems that in the previous studies, a review of the general business models was the main part of the research to create the framework and a limited number of components were extracted based on these models. However, in the current study, the aim was to identify the key components and critical factors for developing a telehealth business framework from the experts’ perspectives. This approach helped to gain a deeper understanding of the concepts that should be considered for developing a telehealth business framework.

The present qualitative study was conducted in 2020. Before conducting the research, it was reviewed and approved by the review board and ethics committee of Iran University of Medical Sciences (IR.IUMS.REC.1397.1328). In this research, all methods were carried out in accordance with relevant guidelines and regulations of the ethics committee.

In the present study, 45 eligible people were invited to participate in the interviews, and 22 of them agreed to take part. Table 1 presents the participants' characteristics.

It is notable that to respect the confidentiality issues, we de-identified the interviewees’ personal information and used the letter "P" which indicates a participating interviewee and the number following that indicates the specific interviewee providing the quote out of the 22 interviewed.

The research results included four themes, 16 subthemes, and 48 categories as presented in Table 2.

Although the use of telehealth technology has largely increased around the world, there are still a number of certain issues, such as proposed values, budget allocation, legal supervision, licenses, resources, technical and business issues which need to be taken into account [22]. Van Limburg et al. explained that the sustainability of telehealth technology is low mainly due to some challenges such as the lack of technical infrastructure, limited financial resources, inappropriate scalability, and uncertainty about the effectiveness of the technology. However, these issues can be taken into account before running a telehealth business by creating an appropriate business plan [9]. To develop an effective business plan, a telehealth business framework can work as a reference model to address key components and critical factors for a successful telehealth business. Therefore, the present study aimed to identify the key components and critical factors for developing a telehealth business framework from the experts’ perspectives.

The results indicated that the key components of the telehealth business framework were as follows: created value, key resources, key activities, key partners, licenses and permissions, product pricing, product revenue, product marketing, supporting services, and getting feedback from customers. In fact, paying attention to these components is important to facilitate product commercialization before running a telehealth business. It should be noted that these components are related to each other, and any changes in one component may influence other components. As Chen et al. highlighted, a deeper understanding of the nature of each component is necessary to gain success in a telehealth business [23]. For example, created value can be different in each telehealth technology and can directly or indirectly affect users’ attitudes towards using the technology. Similarly, Acheampong and Vimarlund indicated that the created value in telemedicine was diverse and often referred to improving the quality of care, accessibility of health care services, and efficiency of care [24]. Other studies also emphasized the value proposition and diversity of this component in the fields of mobile health and telehealth in different country [23, 25].

Similar to the created value, key activities can be different in various telehealth businesses and include a range of activities that a business needs to undertake to deliver the value to the customers. The study conducted by Chen et al. showed that key activities might be related to the product design or a set of research activities before production [23].

Among key resources, financial resources are of high importance in commercialization, the success of a telehealth business, and the long-term sustainability of a telehealth product in the health market. In a similar study conducted by Arkwright et al., the results showed that different financial resources, such as fee-for-service (FFS) payments, value-based payments, periodic payments of clients, and external funding had a positive impact on the success of a telehealth business [26]. However, Effertz et al. found that there are five general approaches to sustaining a telehealth center. These are grants, telehealth network membership fees, income from providing clinical services, per encounter charges, and operating as a cost center and most centers use more than one approach [27].

According to the results, key partners in a telehealth business should be identified, too. The success of a telehealth business depends more on the collaboration between partners and stakeholders rather than the technology. The success of such collaborations and partnerships also depends on the ability of the public sector and the willingness of the private sector to participate in a business [28].

Regarding licenses and permissions, while some of them might be general and optional, the security-based ones are of high importance in a telehealth business, and the telehealth products should be eligible to obtain them. Similarly, the results of the research conducted by Wijesooriya showed that telehealth technology licenses might be different across a country or around the world and obtaining them is a main challenge of telehealth businesses [29].

Product pricing and revenue were other key components in a telehealth business framework. It seems that the price of telehealth products is one of the main challenges ahead of the widespread deployment of telehealth services. According to Pereira, the pricing mechanism should be transparent and follow an appropriate pricing method, such as pay-as-you-go, subscription, the buffet model, or micropayments. In addition, pricing can be considered as a component of the revenue model in which other aspects, such as partner revenue sharing, product cost structure, and potential volume of the product should be taken into account [6].

In terms of product marketing, the findings indicated that the telehealth product marketing methods might be different from other types of marketing mainly due to the wide range of technologies, customers, stakeholders, and services in a telehealth business. Providing adequate supporting services for manufacturers and customers can facilitate marketing and increase revenue. It is also essential to identify the end-users and customers before running a telehealth business and determine their requirements [24].

As customers’ opinions are important for sustainability of a business, their feedback should be investigated regularly, as they may influence the success or failure of a telehealth business. In fact, due to the wide range of customers, many contextual and cultural factors must be considered in a telehealth business [23]. Moreover, to evaluate the quality and impact of telehealth products and services, some of the highest-priority dimentions, such as access to care, financial impact, patient’s and provider’s experience and effectiveness need to be measured to inform future telehealth quality improvement efforts [30].

Apart from the key components, a number of critical factors should be taken into account in developing of a telehealth business framework. The results showed that success factors, challenges and barriers a head of a telehealth business may influence making decision about running a telehealth business. Regarding success factors, the results showed that technical and non-technical support for a product and economic benefits are of great importance for a telehealth business. Similarly, some researchers found that paying attention to the technological, organizational, and managerial issues can help to reach success in a large scale implementation [31, 32]. It seems that making an agreement between health care organizations and a telehealth business and involving health care professionals in the process of marketing can also affect the success of a telehealth product [32].

As the results showed, there is no guarantee of success in starting a telehealth business due to some challenges and barriers. The results of other studies have also indicated that telehealth technologies face different challenges and need a legal framework for licenses, compensation, responsibility, data sharing, and data protection [30, 33, 34]. Moreover, the nature of technology commercialization is complex and challenging, because customers’ requirements change quickly, and the technology life cycle is short in the modern technology environment [35].

The results of the present study also indicated that legal and financial barriers to the telehealth business may prevent running or continuation of a successful business or hinder the commercialization of telehealth products. Therefore, legal actions need to be taken in some important areas like reimbursement, privacy/security, liability, and issuing licenses [36]. In terms of financial barriers, allocating more resources are necessary, as most of the telehealth products need long-term financial support [25].

Overall, the current study contributed to introduce key components and critical factors in developing a telehealth business framework. Such a framework can play an important role in reducing risks and costs and can increase the likelihood of success in a telehealth business [22]. Moreover, it can facilitate developing a business plan, which, in turn, is a strategic tool for business success [37, 38].

The present study aimed to identify the key components and critical factors for developing a telehealth business framework from the experts’ perspectives. The key components were created value, key activities, key resources, key partners, licenses and permissions, product pricing, revenue, marketing, supporting services, and getting feedback. The success factors, challenges and barriers of a telehealth business were the critical factors which could influence the success or failure of a telehealth business and should be taken into account along with the key components when developing a business plan. A telehealth business framework can be used as a reference model to develop telehealth business models and plans. It also shows necessary aspects of a successful telehealth business and is a step towards increasing revenue and profit. However, further research is recommended to validate the key components by other experts in the related fields and to examine the application of the framework in practice.