The Business Models for Mobile Tele-Health in the U.S.: Applying the VISOR Framework

Transcription

1 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 Tel: (213) Fax: (213) or 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. 1 The Global Mobility Roundtable Conference, Auckland 2008

2 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 1 2, 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, 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 2 The Global Mobility Roundtable Conference, Auckland 2008

3 Mobile Health Component Figure 1: Home Health Care, Applications, Technologies and Services 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. 3 The Global Mobility Roundtable Conference, Auckland 2008

4 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 VISOR 4 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. 4 The Global Mobility Roundtable Conference, Auckland 2008

5 Table 1: Comparison of Business Model Approaches 5 Source Components Number of Components Customer 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 management, and Financial Aspects Donath (1999) Customer understanding, Marketing Tactics, Corporate N Governance and Intranet/Extranet capabilities Gordijn et. al. 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 process model, Internet-enabled commerce relationship, 8 N Chesbrough and Rosenbaum (2000) Gartner (2003) Hamel Petrovic et. al Dubosson-Torbay et. al Afuah and Tucci Weill ad Vitale Organizational form and Value proposition Value proposition, target markets, Internal value chain structure, Cost structure and profit model, Value network and Competitive strategy Market offerings, Competencies, Core technology investments, and Bottom Line Core strategy, Strategic resources, Value Network and Customer interface Value model, Resource model, Production model, Customer relations model, Revenue model, Capital model, and Market model Products, customer relationship, Infrastructure and network of partners, and Financial aspects Customer value, Scope, Price, Revenue, Connected activities, Implementation, Capabilities and Sustainability Strategic objectives, Value proposition, Resource sources, Success factors, Channels, Core competencies, Customer Segments, and IT Infrastructure 6 N 7 N 8 N 8 N Applegate Concept, Capabilities and Value 3 N Amit and Zott Transaction content, Transaction structure and Transaction governance Alt and Zimmerman Mission, Structure, Process, Revenues, Legalities and 6 N Technology Rayport and Jaworski Value cluster, Market space offering, Resource system, and Financial model Bertz (2002) Resources, Sales, Profits and Capital 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, Cost, Strategy 6 N 5 Adapted from Morris et. al. op. cit. and Schafer, et. al., op. cit. 5 The Global Mobility Roundtable Conference, Auckland 2008

6 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. REAL VALUE PROPOSITION Value Proposition for Targeted Customer Segment Revenue/Cost Model Calculations for All Partners The VISOR Framework for NDI Business Models Interface Wow Experience REAL COST OF DELIVERY Organizing Model for Processes & Relationships Service Platforms to Enable Delivery 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. 6 The Global Mobility Roundtable Conference, Auckland 2008

7 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, 7 The Global Mobility Roundtable Conference, Auckland 2008

8 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 telehealth, 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 8 The Global Mobility Roundtable Conference, Auckland 2008

9 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. References Agrell, H., Dahlerg, S., and Jerant, A.F. Patients Perception Regarding Home Telecare, Telemedicine Journal and e-health, (6:4), 2000, pp American Lung Association, Bashur, R.L., Readon, T.G., G.W.Shannon. Telemedicine: A New Health-care Delivery System Annual Review of Public Health. (21:1), 2000, pp Bowles, K., Baugh, A. Applying Research Evidence to Optimize Telehomecare, Journal of Cardiovascular Nursing, ( 22:1), 2007, pp Charles, B. Telemedicine Can Lower Costs and Improve Access, Healthcare Financial Management, (54:4), 2000, pp Choi, Y.B., Krause, J., Seo, H. Capitan, K, & Chung, K. Telemedicine in the U.S.A.: Standardization through Information Management and Technical Application IEEE Communications Magazine, (44:4), Demiris, G., Rantz, M.J., Myra A., Aud, K. D., Marek, Harry W., Tyres, Skubics, M., Hussam, A. Older Adults Attitudes Towards and Perceptions of Smart Home Technologies: A Pilot Study, Medical Information, (29: 2), pp Fife, E. and Pereira, F. Adoption of Mobile Data Services: Towards a Framework for Sector Analysis, Mobile and Wireless Systems Beyond 3G. Ed. Margherita Pagani, Pennsylvania: Idea Group Gagnon, M., Lamothe, L., Fortin, JP., Cloutier, A. Telehealth Adoption in Hospitals: An Organizational Perspective Journal of Health Organization and Management; (19:1), 2005, pp Garcia, C., Urdiales, F., Garcia Sigler, Dominguesz, M, de la Torre, Duran J., Coslado Artizabal, F., Perez Parras, S,. Trapero Miralles, R. and F. Sandoval, F. On Practical Issues About Interference in Telecare Applications Based on Wireless Technologies Telemedicine and e-health, (13: 5), 2007, pp The Global Mobility Roundtable Conference, Auckland 2008

10 Gardner-Bonneau, D. Untapped Potential: Speech Technologies and the Home Health Care Market, Speech Technology, March 1, 2006, Glendinning, D. Slow Connection: Medicare and Telehealth, Admednews.com, September 3, Hammack, G. Redefining Telemedicine. September 20, Healthcare Business Market Research Handbook, Pharmalicensing Limited, 2006, Retrieved February 11, Hoppszallern, S. Bridging the Distance, HHN Most Wired Magazine, April ticlesmostwired/data/07/winter/07mw_winter_dataset&domain=hhnmostwired Kim, Donlok, Cabral, James E. Jr. and Kim, Y. Networking requirements and the role of multimedia systems in Telemedicine, Larsen, D., Hudnall Stamm, B., Davis, K. and Magaletta, P. Prison Telemedicine and TeleHealth Utilization in the United States, Telemedicine Journal and e-health, (10:2), 2004, pp. S81-S89. Lewis, C. My Computer, My Doctor: A Constitutional Call for Federal Regulation of Cybermedicine, American Journal of Law and Medicine, (32: 4), 2006, pp Lindberg, D. and Statement, A.B. Written testimony to the Telemedicine hearing before the Subcommittee on Investigations and Oversight, Committee on Science, Space and Technology, U.S. House of Representatives, 103th Congress. U.S. Government Printing Office, Lunden, I. Plenty of scope for networking in healthcare industry, Financial Times, February 11, 2008, pp. 6. Mageretta, J. Why Business Models Matter Harvard Business Review, May Mayo, M.C. and G.S. Brown, G.S. Building a Competitive Business Model Ivey Business Journal, (63) 1999, pp McGee, M. E-health on the horizon, Information Week, May 17, 2004, pp.53. Morris, M., Schindehutte, M., and Allen, J. The Entrepreneur s Business Model: Towards a Unified Perspective, Journal of Business Research, (58) 2005, pp Muirhead, G., An Update on Telemedicine, Patient Care, (34: 6), 2000, pp Nagy, B., Telemedicine s Depth Now Going Beyond Rural Areas, Managed Healthcare Executive, (16; 9), 2006, pp National Institute of Justice, Implementing Telemedicine in Correctional Facilities, Report no. NCJ Washington, DC, U.S. Department of Justice. Phillips Medical System, Ten-HMS Study Demonstrates Clinical and Financial Efficacy of Home Monitoring Phillips Medical Systems, Rahimpour, M., Lovell, N., Celler, B., McCormick, J. Patient s Perception of a Home Telecare System, International Journal of Medical Informatics, (77:7) 2007, pp The Global Mobility Roundtable Conference, Auckland 2008

11 Sanders, J.H. Telemedicine, 1994: Challenges to implementation. Written testimony to the Telemedicine hearing before the Subcommittee on Investigations and Oversight, Committee on Science, Space and Technology, U.S. House of Representatives, 103 rd Congress, U.S. Government Printing Office, Schafer, S., Smith, H. J. and Linder, J. The Power of Business Models Business Horizons, (48), 2005, pp Seibert, P.S., Whitmore, T., Patterson, C., Parker, P.D. Telemedicine Facilitates CHF Home Health Care for Those with Systolic Dysfunction International Journal of Telemedicine and Applications, Shoor, R. Long-distance Medicine: Telecommunication Promises to Deliver Better Care, Business and Health, June 1994, Slywotzky, A.J. Value Migration. Corporate Decisions Inc.:USA, Smith, D. The Influence of Financial Factors on the Deployment of Telemedicine, Journal of Health Care Finance. (32:1), 2005, pp Statura, M. Telemedicine/Tele-health: A National Development Tool and Economic Engine, International Journal of Economic Development, (18: 3), 2006, pp Stewart, D.W. and Q. Zhao Internet Marketing, Business Models and Public Policy Journal of Public Policy, pp Tangalos, E.G. Telemedicine: An Information Highway to Save Lives. Written testimony to the Telemedicine hearing before the Subcommittee on Investigations and Oversight, Committee on Science, Space and Technology, U.S. House of Representatives, 103 rd Congress, U.S. Government Printing Office. U.S. Department of Commerce. U.S. Statistical Abstract, Department of Commerce, Washington, D.C Varshney, U. Pervasive Healthcare and Wireless Health Monitoring, Mobile Network Applications, (12), 2007, pp Wang, H. Digital Home Health: A Primer Parks and Associates, Dallas Texas, Wasley, T.P. What has government done to our health care? Washington, DC: Cato Institute, Washington D.C., Western Governor s Association Telemedicine Action Report, Williams, F. and Moore, M. Telemedicine: Its Place on the Information Highway August The Global Mobility Roundtable Conference, Auckland 2008