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Designing a Model of a Digital Ecosystem for Healthcare and Wellness Using

the Business Model Canvas

Article in Journal of Medical Systems · April 2016

DOI: 10.1007/s10916-016-0488-3

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Journal of Medical Services manuscript No.
(will be inserted by the editor)

Designing a Model of a Digital Ecosystem for Healthcare and

Wellness Using the Business Model Canvas.
Cosio León Marı́a · Nieto-Hipolito Juan Ivan · Garibaldi-Beltrán
Julián · Amaya-Parra Guillermo · Luque-Morales Priscy.

Received: date / Accepted: date

Abstract Wellness is a term often used to talk about Keywords Digital Ecosystem · Healthcare · Wellness ·
optimal health as “dynamic balance of physical, emo- Business Canvas Model · Legal e-Health requirements
tional, social, spiritual, and intellectual health.” While
healthcare is a term about care offer to patients for im-
proving their health. We use both terms as well as the 1 Introduction
Business Model Canvas (BMC) methodology to design
The term digital ecosystem integrates and uses the con-
a digital ecosystem model for healthcare and wellness
cepts from natural domain; evolving to the sectors spe-
called DE4HW; the model considers economic, techno-
cific ecosystem integrated by digital infrastructures, ai-
logical and legal asymmetries, which are present on e-
med at creating a digital environment for network ser-
services beyond of geographical regions. BMC method-
vices and organizations with common resources or ex-
ology was embedded into the global project strategy
pectations. Digital ecosystems build communities that
called: IBOT (Initiate, Build, Operate and Transfer);
dynamically share geographical regions, business, know-
it is a methodology to establish a fully functional, inte-
ledge, infrastructures, and human resources. These units
grated national telemedicine network and virtual edu-
are named digital business ecosystem [23, 32].
cation network; of which we took phases rationale. The
The model here described is a product of an ecosys-
results in this work illustrate the design of DE4HW
tem develop project, which is led by two private com-
model, into the first phase of IBOT, using the BMC,
panies, one from Mexico (Siteldi Solutions), and the
which enables to define actors, their interactions, rules
other one from Spain (IKUSI), as well as an academic
and protocols, in order to build the target model, while
institution, from Mexico, the Autonomous University
IBOT strategy manages the entire project goal through
of Baja California (UABC); all of them interested to
the time, up to the transfer phase, where an integral ser-
build a successful product for asymmetric scenarios on
vice platform of healthcare and wellness is turned over
economic, technological and legal areas; using a model
the stakeholders.
that defines a set of services, actors and interactions to
This article is part of the bilateral research project C0011- consolidate an integral service platform of healthcare
2013-CONACYT-CDTI-209240 supported by National Coun- and wellness.
cil for Science and Technology, CONACYT (Mexico)- Cen-
ter for Industrial Technological Development, CDTI (Spain).
Through the ESTS-ECDP consortium (Autonomous Univer-
sity of Baja California - Siteldi Solutions and IKUSI España)
1.1 Methods

Autonomous University of Baja California
Transpeninsular Road, Ensenada - Tijuana #3917, Playitas.
Ensenada, Baja California, Zip Code 22860.
Tel.: +052-646-177-0707 ext 64343
E-mail: cosio.maria@uabc.edu.mx
Siteldi Solutions
Canario Street #111, Colinas de Santa Barbara, Sta Brbara,
28017 Colima, Colima.
Three methodologies are used to develop DE4HW model;
one a global project strategy called IBOT (Initiate,
Build, Operate and Transfer), it is a methodology to
establish a fully functional, integrated national tele-
medicine network and virtual education network; from
it, we took phases rationale to manage the entire project;
it was proposed by Latifi et al. Latifi et al. [14].
2 Cosio León Marı́a et al.
IBOT has proven its effectiveness on develop telemedi-
cine and telehealth projects, from developing [16], and
developed [12] countries; however, IBOT requires fur-
ther analysis to improve its effectiveness [13], one of
its challenge is described in [14], a long-term follow-
up study in order to ensure sustainability and conti-
nuity to meet the project goals. With the purpose to
ensure in DE4HW both characteristics from its early
design stages, we embedded the Business Model Canvas
(BMC) proposed by Osterwalder et al. Osterwalder et
al. [24] into the IBOT, in intention to uncover legal and
economic interactions, among health ecosystem actors
and their rationale; besides insigns for modeling and
assessment, speeding up the design of the business dig-
ital ecosystem model, DE4HW. The use of IBOT and
BMC becomes to the model into a transitional model,
which have room for change as IBOT phases and BMC
requirements exist. Finally, Service by layer Pattern [5],
a methodology for grouping services.
1.1.1 The Rationale on BMC
The Osterwalder BMC [24], is an iterative service de-
velopment process which describes the business funda-
mental to create, develop and take a value. This work
highlights three questions hidden in the business model
canvas: How, What and Who, also a block subset fo-
cused on their economic bases (see Fig. 1).
• The How group members are: key partners, key ac-
tivities and key resources.
• Value Proposition is the unique element in the What
group.
• The Who group members are: customer relation-
ship, channels and customer segment.
1.1.2 The Rationale on IBOT method
The IBOT model has been effective in creating sustain-
able telemedicine and e-health integrated programs in
asymmetric scenarios and may be a good model for es-
tablishing such programs in developing countries [15].
IBOT defines four phases to the concept and establish-
ment of the International Virtual e-Hospital (IVeH) as
follows:
• The initial phase starts with an assessment of the
utility of instituting a telemedicine program based
on a survey.
• Building phase, is based on the initial technical as-
sessment and on the goals of the project (build the
network; develop the main physical telemedicine cen-
ter with training areas, servers, administrative of-
fices, and, educational rooms with own produce train-
ing and educational material.)
• Operating phase, this part of the process focuses
on creating telemedicine experts, ambassadors, and
champions.
• Transfer phase, signifies the completion of teleme-
dicine program that is now turned over to the local
public institution, or the government.
1.1.3 The Rationale of Service by Layer Pattern
The concept Service Layer pattern introduces a logical
grouping of services, whereby the same group of services
share a common type of functionality, with the purpose
to reduce redundancy, logic levels, and helping for an
easy evolution of the services [5].
1.2 Research Question
The research question on this work is: Are technological
devices, healthcare guidelines, data mining from conti-
nuous monitoring, and social interactions the elements
in DE4HW model required to cover full support for el-
derly and healthy people trying to improve their quality
of life? To answer appropriately the research question,
we divided it into the following questions:
1. What is the importance of including wellness e-services
focused on elderly healthy people?
2. Which are key factors for achieving success on pro-
viding healthcare and wellness e-services?
3. Which are legal requirements on providing health-
care and wellness services in Mexico and Spain?
4. Which are key partners to increase probability of
economic success on providing healthcare and well-
ness e-services in Mexico and Spain?
5. Which are the value propositions for DE4HW model?
Each questions will be answered by each correspond-
ing section, and summarized in section 6, Conclusions
and future work.
1.3 The Work Contributions
Contributions of this work are threefold. First, the busi-
ness model of a digital ecosystem for healthcare (actors,
interactions, resources, and requirements); secondly, the
definition of services and their interactions through BMC
outputs; and lastly, a synthesis of challenges for digital
ecosystems on economic, technological and legal asym-
metric scenarios as a synthesis of the BMC results’ anal-
ysis, considering requirements on first phase of IBOT
methodology.
Digital Ecosystem DE4HW
Fig. 1 BMC, blocks [24]
2 Related Work
In intention to select a methodology to design health-
care ecosystem, an exploration process was executed;
resulting following works, Lee et al. [17] described a
Regional Healthcare Ecosystem Analyst, it can accept
user-inputted data to rapidly create a detailed Agent-
Based simulation Model of the healthcare ecosystem
(i.e. all healthcare facilities, their adjoining community,
and patient flow among the facilities) of any region to
better understand the spread and control of infectious
diseases. The focus of this methodology is not in the
DE4HW model research goals, because it does not in-
clude chronic diseases support services or health prod-
ucts for elderly people.
Another methodology is the IPHI (Intermediate Pro-
cessors of Health Information), proposed by Liyanage
et al. [19] to cope with routine data. The goal of IPHI
is to create a health ecosystem by processing data in a
way that promotes improved data quality and, poten-
tially, health care delivery by providers of healthcare,
as well as providing greater insight to legitimate users
of data. Pang et al. [25] proposes an ecosystem driven
strategy which is formulated by merging the traditional
healthcare and mobile internet ecosystems. The author
proves the strategy’s effectiveness using as a case of
study an open-platform design. Strategy is focused on
mobile scenarios.
Methodologies described above have a single technolog-
ical vision; on the other side of the methodologies spec-
trum, mature proposals, such as the Lean Six Sigma
Methodology, are the most used and useful tools in a
running business. The methodologies Six Sigma [11],
Lean Thinking and Lean Six Sigma [18] focus on con-
tinuously increasing quality products or services (Six
Sigma) while reducing waste (Lean Thinking) adding
value on services or products. Although, the goal in
3
this work is to design a new business model to cope
with economic and legal asymmetric scenarios, having
the patient as the primary focus for services goal, as in
Henrik Baerbak et al. described [3]; that is why was se-
lected the BMC, while IBOT becomes to DE4HW into
a transitional model aware of IBOT phases feedback.
3 BMC criteria on Initiate IBOT Phase
The BMC analysis allows to define actors, software mod-
ules and hardware relationship, in the electronic ecosys-
tem model described in section 4, Service by Layer
Model; although, it is necessary to validate them, an
initial validation work was performed considering two
different perspectives (Developer and Stakeholder per-
spectives) to build the BMC.
3.1 BMC from Developer to Stakeholder perspective
Findings by group are:
• The How group:
∗ Key partners: it is necessary to consider govern-
ment and private health institutions, they are
an important source of information about the
current state of the provision of telehealth ser-
vices, legal requirements, real scenarios to prove
models, and qualified personnel to design guide-
lines for teleattention protocols as well as future
clients. Furthermore, technological and software
vendors relationships make possible interopera-
bility among ecosystem actors; software develop-
ment; renewing products and services and cost
reduction.
∗ The Key activity block is service and intellec-
tual property protection. It allows to protect the
product rationale of other business competitors.
∗ Key resources to achieve DE4HW model goal
are: developers with hardware and e-Health ser-
vices expertise, also Information and Communi-
cation Technology (ICT) infrastructure.
• The What group: it considers the value and effi-
ciency characteristics to resolve client requirements.
To achieve the above, it is necessary to offer tai-
lored solutions through service by layer model fur-
ther crosslayer services in intention to reduce ecosys-
tem redundancy and increase cost effectiveness.
• The Who group: it describes the customer relation-
ship, channels and customer segment as well as who
are clients; concluding that hospitals, medical net-
works and other organization are the target group,
so the customer relationship is through training up-
dates, hardware and software innovation meetings.
4 Cosio León Marı́a et al.
Fig. 2 BMC, Developer to Stakeholder perspective
• The last two blocks are regarding to the capital
flow: training personnel, maintenance and innova-
tion of the DE4HW model, are positive economic
flows; while the IT (Information and Technology)
personnel and ICT are infrastructure cost.
3.2 BMC from Stakeholders - Patient perspective
The BMC analysis shown in Fig. 3, uncovers two new
actors, non-present in the last BMC analysis a) medical
personnel associated with ecosystem services, they have
training requirements and medical protocols to bring e-
Health services, and b) IT personnel (non-staff), they
are another service provider required by stakeholders
and DE4HW clients; who are patients or healthy elderly
people (health promotion services), therefore, front-end
solutions according to customer segment must be ac-
complished.
4 Services on DE4HW model
The Service by Layer Pattern concept served as the
basis for layer of the model forward described, almost
all layers has crosslayer interactions, in intention to
reduce functional redundancy; however, but ensuring
entire model functionalities, see Fig. 4. For better un-
derstanding of model rationale, we use a case of study
which considers diabetes (type I and II), and cardio-
vascular disorders, most relevant pathologies in Mexico
and Spain, geographic target of the study, with legal
and economic asymmetries.
4.1 Chronic Disease Geographical Information
System) –CDGIS
This layer will provide information about healthcare
centers and chronic diseases geographical distribution
as well as geographical reference of clients close to real
time. The later information will be accessed by au-
thorized personnel to protect clients’ location. CDGIS
layer is a dynamic environment changing and learning
from clients (Storage and Management Patient Data –
SMPD layer) and external data sources as (e.g. Mexi-
can Social Security Institute -IMSS, Mexican Social Se-
curity and Services of Government Workers –ISSSTE,
National Institute of Statistics and Geography -INEGI
in Mexico, and the Ministry of Health, Social Services
and Equality -MSSSI, National Institute of Statistic -
INE, in Spain).
Digital Ecosystem DE4HW
Fig. 3 BMC from Stakeholders - Patient perspective
4.2 Protocols for Management Specialized Systems
–PMSS
PMSS focuses on e-Health services for e-clinic, e-home,
and e-community (Health Promotion and Tracking Care
layer called (HPTC)). PMSS layer will have interactions
with healthcare centers. The PMSS modules are:
• Electronic healthcare guidelines and protocols.
• A training module for medical and paramedical per-
sonnel to support services delivered by DE4HW.
• A direct communication channel with IT personnel
support.
• Psychological support for caregivers, medical and
paramedical personnel module.
Modules should accomplish the legal requirements
in Mexico and Spain: Mexican Official Norm NOM -
206-SSA 1-2002 [31], Health services regulation, which
defines the criteria about emergency services. In Spain
modules must accomplish The Royal Decree 223/2004,
February 6.
Guidelines and protocols must accomplish the Inter-
national Classification of Primary Care (ICPC) a type
of classification of medical terminology at international
level, which encodes medical elements of health such as
5
reasons (consultation), diagnosis or problems and pro-
cesses of care [40].
4.3 mHealth
The mHealth layer includes two sublayers; the first one,
interoperability sublayer, supporting and managing non-
invasive sensors coupled to mobile technology; the se-
cond one, perception sublayer, complies with electronic
mobiles devices with non-invasive sensors. This layer
provides inputs through the mobile application and sen-
sors to SMPD layer. Developers and manufacturers of
DE4HW must be aware of the following electronic de-
vices legal requirements:
1. Electronic devices legal rule in Mexico, NOM-001-
SCFI-1993, Electronic devices - Electronic house-
hold powered by different sources of electrical power
- Safety requirements and test methods for type ap-
proval. [27].
2. Electronic devices which use different electric energy
sources - security requirements and test methods
[10].
3. Devices must also accomplish with Wireless commu-
nication rule in Mexico or Mexican Official Norm
6 Cosio León Marı́a et al.
Fig. 4 DE4HW distribution services layers
NOM-121-SCT1-2009, Telecommunication - radio-
communication systems [28].
4. Spain has the directive 93/42/CEE Sanitary pro-
ducts [36].
5. Royal decree 1591/2009, from October 16, by which
regulates medical devices [21].
6. Royal decree 437/2002, from May 10, by which es-
tablishing the criteria for granting operating licenses
to manufacturers of medical devices custom [22].
7. 2011/65/EU Electric and Electronic devices [35].
8. Directive 1999/5/EC Harmonized [37].
9. Directive 2006/95/EC low voltage [39].
10. Directive 2004/108/EC electromagnetic compatibi-
lity [38].
11. IEC 60601-1-2:2007 electromagnetic compatibility
[7].
12. IEC 61000-4-3 Wireless Communication [8].
13. IEC 62133 Rechargeable battery products [9].
14. IEC 60086-4 no-rechargeable battery products [6].
4.4 Storage and Management Patient Data –SMPD
SMPD goal is to unify data through health improve-
ments, chronicity, impairment, and functional depen-
dence profiles; this layer gathers information from PHR
and mHealth layers. SMPD provides data to PMSS,
HCQI and CDGIS layers. Semantic interoperability me-
chanisms will be built using terminology from: CIE-9
[20], SNOMED CT [4], and Health Level 7 (HL7) stan-
dards [33]. Mechanisms in this layer must be aligned to
the Mexican Official Norm NOM-024-SSA3-2010 [29],
which establishes the functional objectives and func-
tions to be observed by Electronic Health Record Sys-
tems. Mexican Official Norm NOM-040-SSA2-2004 [30],
about health information.
4.5 Healthcare Quality Indicators –HCQI
This layer includes tools for data mining, fusion and vi-
sual data analytic to gather information (business intel-
ligence) from data on SMPD layer, which allows deter-
mine different kinds of cost analysis see Table 1. HCQI
also provides information, to improve the e-healthcare
services gathering information from entire layers. The
business intelligence will be determined by pathology
thrown as a set of dashboards, which will show results
from the type of study, see Table 1 on column 1.
4.6 Personal Health Records –PHR
According to [34], a PHR is an electronic application
through which individuals can access, manage and share
their health information, and that of others for whom
Digital Ecosystem DE4HW
Table 1 Healthcare Quality Indicators
Type of Study Cost Health Units
Units
Cost-benefit Monetary Monetary
Cost-effectiveness Monetary Health effects.
Cost-Utility Monetary Quality-adjusted
life years (or
similar).
they are authorized, in a private, secure, and confi-
dential environment. The NCBI (National Center for
Biotechnology Information) [2], defines the same term
as a longitudinal patient maintained records of indi-
vidual health history and tools that allow individual
control of access (MeSH term). PHR layer gathers data
from HPTC layer and sends data to SMPD layer, also
PHR provides user entry information to HPTC layer.
4.7 Health Promotion and Tracking Care –HPTC
This layer includes three sublayers (Feedback, Educa-
tional, and Social resources); its target is to prevent
chronic diseases and improve health status from pa-
tients anytime, and anywhere. This layer displays in-
formation from CDGIS, SMPD, and HCQI layers. It is
necessary to define filters by users group, medical staff
from healthcare centers, patients, healthy elderly peo-
ple, caregivers, or relatives.
5 Discussion
Two roles are key in a business ecosystem: keystone
and niche player. Keystones are the engine of evolution
in an ecosystem; in DE4HW model the keystone role
is performed by the SMPD layer, due to data could
be constantly recombined to provide an ever renewing
product and service; while niche players are the HCQI
and HPTC layers; the rest of layers are primary con-
text sensors gathering data from clients, patients about
physiological parameters.
The PMSS layer considers communication channels
among clients, developers and physicians to reinforce
economical successful probability, in the BMC this topic
appears as a business keystone from stakeholders - pa-
tients perspective.
It is necessary a deeper analysis to define attention
protocols for medical and paramedical personnel, using
the ICPC classification [40], to achieve interoperability
HPTC layer and other healthcare ecosystems.
7
The service layer pattern design paradigm defined
by Erl, et al. [5], enhances the resources optimization;
DE4HW model was designed considering above paradigm;
resulting a logical group of services, shown in Fig. 4;
sharing common type of features between layers, with
the purpose to reduce redundancy, logic levels, and hel-
ping for an easy evolution of the services.
5.1 Economic, Technological and Legal Asymmetries,
Challenges
Relevant considerations about economic, technological
and legal asymmetries on the model design
• Differences on regulatory requirements must be taken
in consideration for business healthcare ecosystem
development, in order to offer services beyond of
geographical barriers without legal penalties.
• Data to support decisions have differences about op-
portunity, due to technological gap.
• There are issues about interoperability among data
storage systems. Mexico does not define clear rules,
while Spain has important progress in this area.
• Seamless connectivity is an issue, it is more rele-
vant in Mexico than in Spain because of connecti-
vity costs.
• An analysis focused on patients’ necessities shows
that it is necessary to define differentiated attention
protocols for medical and paramedical personnel,
due to cultural and legal requirements differences.
6 Conclusion and future work
This paper presents results of using the BMC and IBOT
to design a digital ecosystem for healthcare- wellness
model. BMC methodology helps to find interactions
among actors as well as to discover new ones, although,
findings strongly related with the teams expertise and
sample clients are not enough evidence to design this
kind of services; therefore, we gather relevant informa-
tion from the state of art [26], considered in the model
design.
The research contributions have been within the
digital ecosystem model, it considers actors, interac-
tions, resources, legal requirements, and devices. Ecosys-
tems are characterized by several interactions, in inten-
tion to optimize resources, we propose crosslayer ser-
vices to reduce redundancy and complexity, while inter-
operability problems are reduced using syntactic stan-
dards.
In Table 2 answers of research questions driving this
work are summarized, and our immediate directions are
8 Cosio León Marı́a et al.

Table 2 Research questions answers

Question Answer
Question 1 Dynamic balance of physical, emotional, social, spiritual, and intellectual health are the major aspects to
decrease functional dependence, and chronicity condition, therefore wellness services are key to tackle this
kind of conditions.
Question 2 The legal, social, ethical, organizational, economical, clinical, usability, quality, and technical aspects (BMC
analysis), are the key factors for successfully on DE4HW model to provide services into different countries.
Question 3 Legal requirements are described by layer, see section 4.
Question 4 See Figs. 2 and 3, Key partners block.
Question 5 See both perspectives on Figs. 2 and 3, on Key Values block.

the design a pilot trial of a Random Controlled Trial;
it will be executed in Mexico and Spain; secondly, ap-
ply them into two groups including patients, caregivers
and medical personnel. Once pilot trial provide data,
we will iterate using the TRIZ methodology [1], in or-
der to make design adjustments and continue with the
following steps of the IBOT strategy.
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