Technovation 124 (2023) 102748 Contents lists available at ScienceDirect Technovation journal homepage: www.elsevier.com/locate/technovation Value capture and embeddedness in social-purpose-driven ecosystems. A multiple-case study of European digital healthcare platforms Asta Pundziene a, Neringa Gerulaitiene a, *, Sea Matilda Bez b, Irène Georgescu b, Christopher Mathieu c, Jordi Carrabina-Bordoll d, Josep Rialp-Criado e, Hannu Nieminen f, Alpo Varri f, Susanne Boethius c, Mark van Gils f, Víctor Giménez-Garcia e, Isabel Narbón-Perpiñá e, Diego Prior-Jiménez e, Laura Vilutiene a a Kaunas University of Technology, School of Economics and Business, Gedimino str. 50, LT-44239, Kaunas, Lithuania b University of Montpellier, Montpellier Management, 163 rue Auguste Broussonnet, 34090, Montpellier, France c Lund University, Faculty of Social Sciences, Paradisgatan 5c, 22100, Lund, Sweden d Universitat Autonoma de Barcelona, Department of Microelectronics and Electronic Systems, Calle Campus Universitario SN Cerdanyola V, 08290, Cerdanyola del Valles, Spain e Universitat Autonoma de Barcelona, Department of Business, Calle Campus Universitario SN Cerdanyola V, 08290, Cerdanyola del Valles, Spain f Tampere University, Faculty of Medicine and Health Technology, Personal Health Informatics, Korkeakoulunkatu 3, 33720, Tampere, Finland A R T I C L E I N F O A B S T R A C T Keywords: We aim to answer the question of the effect of a social-purpose-driven ecosystem on value capture from digital Embeddedness health platforms. We call the social-purpose-driven ecosystem a phenomenon which seeks social impact before Digital healthcare platform profits and aims to empower citizens for individual and collective well-being. Thus, capturing value from digital Social-purpose-driven ecosystem platforms embedded in a social-purpose-driven ecosystem fundamentally differs from profiting from purely Value capture Multiple-case study commercial digital platforms and poses significant challenges to platform owners and public policy. Previous Profiting from innovations research has focused mainly on profiting from technological innovations but has yet to consider the contextual role of the social-purpose-driven ecosystem. We applied the Profiting from Innovation (PFI) framework to fill this gap. Furthermore, based on the results of the multiple-case study of five European digital healthcare platforms, we extend the PFI framework. As a result, we define four unique contingencies which enable value capture from digital healthcare platforms embedded in a social-purpose-driven ecosystem: 1) multilayer value creation, (2) multipurpose complementary assets, (3) emerging dominant design, and (4) distributed socio-economic returns mechanisms. The study offers two managerial and policy contributions. First, it calls on platform owners and policymakers to acknowledge the contextual effect of a social-purpose-driven ecosystem. Second, multilayer value creation, multiple complementary assets, dominant design and distributed socio-economic returns mechanisms can positively affect capturing value from digital healthcare platforms. 1. Introduction example, by bundling several digital technologies into a defined struc­ ture, a platform becomes an ecosystem for technological and business Digital technologies, such as artificial intelligence (AI), cloud innovations (Hermes et al., 2020). computing, the internet of things (IoT), virtual and augmented reality, The body of knowledge on digital platforms is robust. Recent blockchains, and connectivity technologies like 5G, create many op­ research has emphasised: (1) the role of the platforms as intermediaries portunities for the healthcare industry (e.g., Rippa and Secundo, 2019; for transactions among different parties who benefit from the growth of Cohen et al., 2017; Horoshko et al., 2021; Secinaro et al., 2021; Presch both sides (e.g., Hagiu and Wright, 2015); (2) direct and indirect et al., 2020; Shaygan and Daim, 2021). Organisations can deploy new network effects and the specific characteristics of the different sides (e. functionalities and thereby create new products and services. For g., Rietveld and Eggers, 2017; McIntyre and Srinivasan, 2017; Parker * Corresponding author. E-mail address: neringa.gerulaitiene@ktu.lt (N. Gerulaitiene). https://doi.org/10.1016/j.technovation.2023.102748 Received 31 August 2021; Received in revised form 26 February 2023; Accepted 9 March 2023 Available online 23 March 2023 0166-4972/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/). A. Pundziene et al. Technovation 124 (2023) 102748 and Van Alstyne, 2005; Gawer, 2014); (3) the role of loyalty and strong digital platforms. ties among platform users and different sides more generally (e.g., Some theoretical and empirical research on platforms’ value capture Afuah, 2013; Fuentelsaz et al., 2015); (4) compatibility across the has been conducted on private for-profit business sectors and reflects the evolving technologies, different generations of platforms and multiple behaviour of post-industrial organisations (e.g., Hein et al., 2019; Van platforms and leveraging users across all these changes (e.g., Kretschmer Alstyne and Parker, 2017; Gambardella et al., 2021), which has left a and Claussen, 2016; Eisenmann et al., 2011; Cennamo et al., 2018; significant knowledge gap about digital platforms value capture within a Özalp et al., 2018); (5) the architecture of a platform, its modularity and social-purpose-driven ecosystem, such as healthcare, education and its governance (e.g., Gawer, 2014; Anderson et al., 2014; Tiwana, 2015; government services. Cennamo et al., 2018); and (6) the application of emerging technologies To fill the gap, we seek to answer the research question - what is the like AI for network analytics and for mapping the interdependence of effect of a social-purpose-driven ecosystem on value capture from digital components and the dynamic nature of platform technology (Shipilov health platforms? Thus, the aim of the paper is to explore the effect of a and Gawer, 2020; McIntyre et al., 2020; Drago et al., 2021). McIntyre social-purpose-driven ecosystem on capturing value from digital et al. (2020) note that although recent research has significantly healthcare platforms. enhanced our understanding of different types of platforms and their To meet the aim, we have adapted and deployed the profiting from evolution, still, due to the variety, complexity and dynamic nature of the innovation (PFI) framework (e.g., Teece, 1986; 2006; 2018), which we platforms, issues relating to their business models – organisational believe is relevant for analysing the value created and captured in boundaries, governance mechanisms, scope, the antecedents and char­ social-purpose-driven ecosystems. Furthermore, we have adopted the acteristics of the mutual interdependence of different sides in creating qualitative method and multiple-case study research design (Eisenhardt, and capturing value, and the dynamics of the interplay between core 1989; Gioia et al., 2013; Yin, 2003). We have gathered data from mul­ platform technologies and complementors – remain unresolved. tiple sources (interviews, publicly available documents and archival Kapoor and Teece (2021) identified three essential features of tech­ data) on five digital healthcare platforms that provide remote healthcare nology concerning value creation and capture: emerging, enabling and services in five European countries (Finland, France, Lithuania, Spain embedded. A platform, being a bundle or set of ever-advancing tech­ and Sweden). nologies (some of which might have an emerging nature), meets, in Our study makes a threefold contribution to the prior PFI and plat­ essence, two of these three features: enabling and embedded. Through forms literature. First, we bring forward the concept of a social-purpose- continuous development, the enabling nature of a platform can spawn a driven ecosystem, which well explains the behaviour of the business wide range of applications and complementary innovations. Besides, the sectors that put social impact before profit, e.g. healthcare, education, embedded nature of a platform prescribes its success based on the and government. The study results assist healthcare policymakers, adopted business model and the ecosystem it operates. Kapoor and providers and healthcare-related private companies (e.g. MedTech) to Teece (2021, p.2) state that “the enabling feature captures the impact of fundamentally understand the origins and necessity of value-based any technology as it relates to the multiplicity of applications that the healthcare, which is now empowered by digital technologies. In order technology can spur over time while” recognising the need for extensive to maximize the value of healthcare, all social-purpose-driven ecosystem coordination and specialised investments across the different applica­ stakeholders need to jointly orchestrate the quality, accessibility and tions for that potential to be realised. The embedding feature captures costs of care in an optimal way to avoid an unbearable burden for the surrounding business model and the ecosystem encompassing a society. technology’s commercialisation while recognising the need for align­ Second, we propose four unique PFI components that are significant ment within the complementary activities and technologies for in­ while capturing value from digital healthcare platforms embedded in a novators to derive value from the focal technology." social-purpose-driven ecosystem: 1) multilayer value creation; 2) Thus, we argue that capturing value from digital platforms multipurpose complementary assets; 3) emerging dominant design, and embedded in a social-purpose-driven ecosystem fundamentally differs 4) distributed socio-economic returns mechanisms. Digital platforms from profiting from purely commercial digital platforms and poses sig­ operating in the healthcare sector are expected to aid in orchestrating nificant challenges to platform owners and public policy. We define a value-based healthcare for the benefit of society. Thus, the four identi­ “social-purpose-driven ecosystem” as a set of interconnected and inter­ fied components urge platform owners to pay attention to multiple acting for-profit and non-profit organisations – enterprises, social en­ stakeholders and the multilayer value they can harvest from the plat­ terprises, public, nongovernment and sometimes government form. Furthermore, complimentary intangible assets (e.g. networks) organisations whose business models address social needs, concerns and play an important role in value creation and capture from digital missions (e.g., Crutchfield and Peterson, 2016; Tsai et al., 2020; Kim and healthcare platforms. Moreover, platforms supporting technological Lee, 2019). In a social-purpose-driven ecosystem, actors vary in the interoperability and modular architecture can efficiently create multi­ degree of: 1) autonomy from national governmental affairs, 2) profit layer value and intangible assets by “vertical integration”. Finally, reinvestment into social needs and missions, and 3) customer expecta­ diverse platform modules account for various social and economic tions for public services. However, the “social” in a benefits and, thus, can be funded by private and public sources, which social-purpose-driven ecosystem reflects that the object of the ecosystem ensures the sustainability of the digital healthcare platform. is a phenomenon which has social impact as an ultimate goal, aims to Third, we empirically explore the significance of the embeddedness empower citizens for individual and collective well-being and focuses on feature of digital healthcare platforms. Our findings advance digital supporting and working with grassroots or “bottom-up” communities of platforms literature and the PFI framework by spotlighting how citi­ users (e.g. Stokes et al., 2017; Avelino et al., 2019). “The “social” re­ zens/patients and social structures such as social-purpose-driven eco­ lations or practices do not indicate any teleology or beneficial nature of systems shape the use of digital technologies. The study advises innovation.” (Avelino et al., 2019, p.197). healthcare policymakers, providers and other stakeholders that tech­ The central object of healthcare is the patient and their relationship nological embeddedness is an essential factor in explaining why digital with the doctor and medical staff that is directly entailed. It corresponds healthcare platforms’ performance has been unsatisfactory low. Digital directly with the “social relationships” concept – when “users and platforms are the product of a socio-political process resulting in rules communities collaborate using digital technologies to co-create knowl­ and resources immersed in the technology. Furthermore, human in­ edge and solutions for a wide range of social needs and at a scale and teractions create digital platforms, which, in turn, influence each citi­ speed” (Stokes et al., 2017, p.10). Thus, the centrality of the patient and zen/patient and other stakeholders’ behaviour. Thus, healthcare as a doctor in a social-purpose-driven ecosystem makes value capture from social-purpose-driven ecosystem is a complex and heavily regulated digital healthcare platforms in essence different from purely commercial social structure that imposes rules and resources that currently do not 2 A. Pundziene et al. Technovation 124 (2023) 102748 favour the sustainable scaling of digital healthcare platforms. and office, rendering healthcare proximity to the patient. “Proximity” is The paper is organised as follows. First, the theoretical background an important feature that creates value for the patient during pre- provides insights into the specifics of the digital transformation of a hospital, outpatient and post-hospital periods. healthcare system as a social-purpose-driven ecosystem. Next, we define Fig. 1 summarises how digital technologies and health data add a digital healthcare platform in relation to the advanced functionality value by broadening the scope of the “functionality” of the healthcare and accountability of healthcare empowered by digital technology. The provided by enabling P4 medicine, enhancing the “accountability” for following section reviews the PFI framework to adapt it to social- healthcare outcomes, and increasing the “proximity” of healthcare ser­ purpose-driven industries. Next, we discuss the socio-economic value vices to patients and their homes. Digital technology enables the captured from digital healthcare platforms. Then, we illustrate the collection and analysis of the big data needed for early diagnostics, conceptual model developed with multiple digital healthcare platforms efficient treatment plans, and measuring clinical outputs and the patient case studies. Finally, based on abductive reasoning, we provide propo­ experience. Measuring healthcare outputs paves the way for value-based sitions and suggest additional research questions that investigate the healthcare, where results, rather than the process, are paid for. Finally, effect of the embeddedness of a platform in a social-purpose-driven increasing the proximity of healthcare services to patients and their ecosystem. homes enables patients to save time and money in travelling to a healthcare provider. It also ensures timely healthcare interventions 2. Theoretical background when necessary. Thus, Fig. 1 shows how digital technology, including digital platforms and health data, creates value in the healthcare system. 2.1. Digital transformation in the healthcare industry as an example of a social-purpose-driven ecosystem 2.2. Defining digital healthcare platforms Globally, healthcare systems are in the middle of a significant change Gawer (2014, p. 1230) defines digital platforms as “evolving … driven by ongoing digital transformation (Massaro, 2021; Biancone meta-organisations that: (1) federate and coordinate constitutive agents et al., 2021). Advances in the collection and intelligent analysis of who can innovate and compete; (2) create value by generating and massive amounts of data have opened up new possibilities in disease harnessing economies of scope in supply or/and in demand; and (3) prevention and care. Digital technologies are moving some care from entail a modular technological architecture composed of a core and a hospitals to homes (Olivero et al., 2019; Gualano et al., 2017; Fournier periphery”. et al., 2020). Moreover, the wide-scale availability of medical data and Platform scholars argue that a digital platform is an open architec­ decision-support solutions is changing the role of citizens/patients and ture with a governance model designed to facilitate interactions or medical professionals (Sousa et al., 2019; Madhavan et al., 2021). mediate transactions (Gawer, 2014; 2022; Parker et al., 2016; Teece, One term used to describe the ongoing transition is P4 medicine, 2018). The main goal of these platforms, also called transaction plat­ initially coined by Hood (2013). The four P’s are: predict, prevent, forms,1 is to generate interactions between groups of actors comprising personalise, and participate. In P4 medicine, care is tailored to each consumers, producers, and third-party actors (Parker et al., 2016; individual based on massive amounts of medical data, which are now Jacobides et al., 2018; Teece, 2018).2 In this context, the physical assets more readily available. P4 medicine is being driven by improvements in or service provided is secondary. Rather, digital platforms set architec­ data analysis, machine learning, genome sequencing and sensing tech­ tural and governance rules to balance platform control, engage partici­ nologies. P4 medicine strongly focuses on prevention and individual and pants and co-create value for one another (De Reuver et al., 2018 ; population wellness. Ideally, in P4 medicine, the disease is predicted Parker et al., 2016; Ghazawneh and Henfridsson, 2013; Tiwana, 2015). before symptoms develop so that effective prevention, medication or Fig. 2 illustrates the typical architecture and components of the another intervention is initiated before symptoms even occur. When the digital healthcare platform. Digital healthcare platform is the integra­ disease becomes prevalent, personal data can be compared to data from tion of technologies, including electronic health records (EHR), assets people with similar conditions and, thus, utilised to personalise treat­ and data processing capabilities, User Interfaces (UI) and Application ment and medication (Hood, 2013; Sagner et al., 2016). Besides, P4 medicine relies on large-scale social participation to enable consumers via multi-sided digital platforms to collect data from multiple sources, especially genetic data, which are affordable due to the significant ad­ vances in efficiency and the reduced costs of genome mapping (Sagner et al., 2016). Another important trend in modern healthcare is value-based per­ formance, which emphasises the achievements and measurements of the actual value of the care provided to patients. In Porter and Teisberg’s (2006) value-based model, the central goal is to maximize health and efficiency in terms of “health outcomes achieved per euro spent.” In value-based healthcare, value is measured over the entire cycle of care during a patient’s illness and includes recovery, rehabilitation and Fig. 1. Digital technology and health data as enablers of advanced health­ long-term health management. Universal and equitable coverage is also care services. essential to ensure that healthcare is value-based and accessible to all citizens (Azzopardi-Muscat and Sorensen, 2019; Campra et al., 2021a,b; Wren and Connolly, 2019). Maximising value, in practice, is a difficult joint optimisation problem. The key factors are costs, quality of care and 1 unlike an innovative platform, for which the main goal is to orchestrate accessibility of care. Blindly maximising quality or accessibility can industry innovation by offering technological building blocks that are used easily lead to unbearable costs for society. Thus, digital technologies and by complementors to develop new products and services (Parker et al., 2016; health data enable “accountability” as a precondition of value-based Cennamo et al., 2018; Gawer, 2014). healthcare. To operationalise value-based healthcare, again digital 2 In this article, we will not pursue an engineering design perspective, healthcare platforms come to aid. focusing on a product’s architecture and components (Gawer, 2014). Instead, Finally, digital technology and remotely accessible health data we focus on the value created by and captured from the interactions that a enable healthcare providers to bring healthcare services closer to home platform unlocks. 3 A. Pundziene et al. Technovation 124 (2023) 102748 et al., 2020). Fourth, platforms also offer super-modular/super-additive value creation. From studying several digital healthcare platforms, Hermes et al. (2020) identified six new forms of value creation: (1) information services (e.g., access to communities, online learning platforms, doctor recommendations and online schedulers); (2) remote and on-demand healthcare (e.g., telemedicine providers, biomarker collectors and sim­ ple intelligent apps for self-care); (3) data collection (by home lab kits and mobile devices to create a blockchain-based personal health record); (4) market intermediaries (health e-commerce, e-prescriptions and healthcare planners); (5) data management and analysis for healthcare providers (e.g., intelligent population health management, intelligent diagnostics, cloud service providers, and augmented and virtual reality providers); and (6) investors and consultants (e.g., incubators and ac­ celerators). All these new forms of value creation rely on the platforms’ new types of digital interaction and allow new actors to emerge in the healthcare industry. Thus, the emergence of digital platforms in healthcare has influenced how value is co-created among multiple stakeholders and allows novel value to emerge (Sarker et al., 2012). Reflecting on value creation raises the question of the business model of healthcare platforms (Teece, 2018), especially since business models for digital platforms rarely emerge fully formed. Platform leaders must design, manage and alter the platform’s architecture to discover the Fig. 2. Visualisation of the digital healthcare platform architecture and com­ right way of capturing value from digital healthcare platforms (Helfat ponents from the technological perspective. and Raubitschek, 2018). The growth of a platform often relies on the network effect, which is Programming Interfaces (API) to provide a customised, end-to-end a part of relational intellectual capital (Alfiero et al., 2021; Evans et al., healthcare solution and applications. Digital healthcare platform con­ 2015), and in which a product or service becomes more valuable as more stitutes an infrastructure that facilitates two-way communication and people use it. Network effects have the unusual property that demand information exchange between different consumers/partners such as can become self-sustaining (Shapiro and Varian, 1999). As the user base medical professionals, patients, platform and third parties – e.g., appli­ increases, the more compelling the proposition becomes for attracting cation developers, relatives and caregivers. Consumers/partners can new users (Economides, 1996; Katz and Shapiro, 1985). Network effects access the platform directly or through third-party platforms via user explain, in part, the rapid growth of platform value (Cusumano et al., interfaces. Third parties access the platform through the standardised 2019). Thus, exploring what a patient-centric digital healthcare plat­ application programming interfaces. Arrows indicate two-way interac­ form means, unpacking not only the actors and their interactions but tion between consumers/partners, third parties and platforms. (See also network effects. Fig. 2.). Research has looked at the drivers that facilitate the network effect Value creation has a unique meaning for the healthcare industry. and, thus, the existence and growth of a platform (Cusumano et al., First, most studies on platforms have adopted the perspective of profit- 2019). Adding information and fostering a community is critical (Van driven firms (Teece, 2018). However, there are many calls for healthcare Alstyne et al., 2016). Whether the underlying information is to consider value from a patient’s perspective. The emergence of digital user-generated or algorithmic content generated from user data, inter­ platforms has altered the way care is delivered. Such platforms have acting with the platform creates value that attracts further interaction. transformed the way people interact (e.g., Facebook), search for infor­ In accounting, these network effects are intangible rather than tangible. mation (e.g., Google), buy products (e.g., Amazon) and utilise services Applying the sociology of work and organisations reveals digital (e.g., Airbnb) (Hermes et al., 2020). Complex, interacting, multi-sided platforms’ “boundary-spanning function” (Kislov et al., 2017; Lander, markets are replacing traditional simple linear value chains of care 2016). Platforms become integrated into the coordination and organis­ with super-modular/super-additive value creation (Jacobides et al., ing mesh in the formal organisational and household ecosystems they 2018; Clemons, 2018; Hermes et al., 2020). enter. Work occurs in both settings but under different conditions and Second, this shift has required the use of digital technologies (such as authority relations. From this perspective, a platform can also add or the IoT, big data analytics, AI, robotics, blockchains, additive simplify work in the contexts it enters. However, it is necessary to learn manufacturing and cybersecurity) and raises a question about the how to use it before it can be routinely used. An assessment of whether a confidentiality of the data and the confidence placed in health systems platform is a welcomed asset or an alien nuisance and a stressor to be and professionals. avoided is made in most contexts, which can be essential for its Third, by creating complex interacting multi-sided markets, the way continued use after its initial adoption (Kim and Malhotra, 2005). traditional sets of individuals and organisations interact has changed Summing up, digital platforms are deeply embedded in the ecosystem (Blumenthal, 2011; Davidson et al., 2018; Hansen and Baroody, 2020). through connected technologies (e.g. super-modular and Traditional actors deal with existing physical care processes and ser­ super-additive), multi-sided markets, network effect and vices, which are becoming digital or are being replaced by new digital boundary-spanning function. In addition, healthcare adds a medical procedures. The actors involved in interacting to co-create social-purpose-driven context and makes the ecosystem more particular, value are patients (e.g., physical traits and medical history), profes­ especially for capturing value. sional groups (e.g., physicians, nurses, administrators and insurers), clinical organisations (e.g., hospitals, testing laboratories and care fa­ 2.3. Rethinking the PFI framework in the context of healthcare as a cilities), treatment options, healthcare delivery processes, regulators (e. social-purpose-driven ecosystem g., state agencies, policymakers and credentialing entities), non-governmental organisations, new digital intermediary firms and PFI (Teece, 1986) addresses a fundamental question – how to profit finally, families (Fichman et al., 2011; Agarwal et al., 2020; Hermes from technological innovation. The question is still valid concerning 4 A. Pundziene et al. Technovation 124 (2023) 102748 digital platforms operating in social-purpose-driven ecosystems. Digital quality development. technology has inflicted radical changes on the object and process of The maturity of a digital entrepreneurship ecosystem is related to the innovation. Innovating software and the process of integrating different availability of and access to the variety of relevant complements, the technologies is often much more important than hardware, device or entrepreneurial efforts that create new practices within the ecosystem equipment innovation. Although the logic behind innovations for a (e.g., a change to the EPO’s attitudes towards patenting ICT inventions), stand-alone product and digital services is significantly different, “the access to data, and relevant rules and regulations that guide innovators core independent variables in the PFI model – the strength of the through collaborative relationships in a complex and dynamic appropriability regime, complementary assets, complementary tech­ ecosystem (e.g., Nambisan, 2017; Elia et al., 2020). Digitalisation nologies, standards (and associated installed base effects), and timing – questions the critical elements for profiting from a platform, such as a are more relevant than ever for a world” (Teece, 2018, p.1369). Besides, network effect. Indeed, purely digital platforms are not tied to a the significant effects of an ecosystem and business models have been particular type of hardware since the user can easily switch platforms. acknowledged as an integral part of PFI in explicating the success of Thus, the network effect alone is not necessarily a long-term competitive digital innovation (e.g., Teece, 2018; Gambardella et al., 2021). advantage (Tucker, 2018). At present, a social-purpose-driven health­ How to profit from digital innovation relates to standard PFI con­ care ecosystem is emerging, and most of the complements, architecture structs. For example, protecting and managing intellectual property is of the ecosystem, processes and regulations are pushed by entrepre­ necessary for preventing easy imitation. However, digital innovation, neurial efforts and heavy investments. However, private and public especially process innovation, has traditionally rarely been patentable, actors in the healthcare ecosystem have different paces of change and especially by the European Patent Office (EPO). On the other hand, the the capacity to absorb innovations. Public actors’ primary mission is to EPO (2019) reports that “ICT industries will continue to be among the ensure healthcare quality in the most effective way (Secundo et al., most R&D-intensive sectors. The role of patents in promoting these 2019). The Social-purpose-driven performance mode leaves few re­ technologies [e.g., AI and blockchain] is evident as they secure the in­ sources to invest in developing and adopting digital innovations. vestment needed for advances in this field. Using the stakeholder feed­ back obtained in 2018, we will continue to further adapt our practice to the 3. Methodology needs of the users to effectively support the development of ICT industries.”3 Thus, the EPO is responsive to the need for a robust appropriability Although there is some understanding of how the ecosystem affects regime that prevents easy imitation and helps digital technology in­ the adoption of digital technologies, we still need to gain knowledge on novators to capture value. the social-purpose-driven ecosystem as a phenomenon and its effect on In many industries digital multi-sided platforms prevail, and plat­ value capture from digital healthcare platforms, which are also rela­ form owners compete not just with a single service but with a portfolio tively new phenomena. Thus, we carry out an explorative multiple-case of interconnected services and related ecosystems; thus, complementary study approach to investigate a contemporary phenomenon of digital and intangible assets help them to obtain vital resources and to manage healthcare platforms within its real-life context, such as the social- the risk, costs and competition. Furthermore, complementors not only purpose-driven ecosystem (Denzin et al., 2017; Eisenhardt, 1989; add value to a platform but also benefit through access to the customer Miles and Huberman, 1984; Yin, 2003). pool, data or other assets that help to improve their complements. The research question and objectives determine the choice of method However, in a social-purpose-driven ecosystem like healthcare (Gaudet and Robert, 2018). The qualitative research approach aims to platform owners, complementors, users and payers might follow answer the “why” and “how” of the phenomenon under investigation (e. different and sometimes conflicting missions (social good vs profits of g., Yin, 2003). We aim to answer the research question, “what is the the private owner) and have an indirect relationship: e.g., user and payer effect of a social-purpose-driven ecosystem on value capture from digital are two different entities. While complementarity and intangible assets health platforms?”. In answering the research question, we have two retain the significance of their role, the public-private partnership brings objectives to explore – what is the contextual role of embeddedness in a new challenges. social-purpose-driven ecosystem, and how can digital platforms capture The networked nature of digital innovation has enabled relatively value embedded in a social-purpose-driven ecosystem? The questions effortless data collection, big data processing, and real-time connectivity “what” and “how” are exploratory, supporting the case study approach. and mobility. However, there are challenges with the timely stand­ Furthermore, the case study research aims to understand and explain, ardisation of technology, APIs, data access and usage, and digital service rather than measure the complex and dynamic phenomenon in its real delivery, especially in a highly regulated sector such as healthcare. In context (Yin, 2003), what is in line with our research question and healthcare as a social-purpose-driven ecosystem regulatory burden and objectives. liability is very high. Thus, standardisation and certification of digital Although it is possible to analyse a single case study, the aim of our healthcare platforms run most of the time by publicly authorised in­ study requires adopting a multiple-case design. The multiple-case study stitutions and do not keep pace with MedTech business expectations. allows the observation of the presence or absence of similarities, espe­ This aspect also applies to access to and management of healthcare data. cially in real-world cases and when results have contextual conditions In this context, value capture mechanisms and business models have (Eisenhardt, 1989; Yin, 2003), which obtained in our case as we explore to change. Hermes et al. (2020) provided more specifics to platform value capture from digital health platforms embedded in a specific business models by posing the question: Which side should be charged? context of the social-purpose-driven ecosystem. In accordance, more What is the best pricing strategy? How should switching and recently, Eisenhardt (2021) stated that such a multi-case study approach multi-homing costs be handled? How should a price for digital services is relevant when the research question is a black box, and there is little be set if there are many diverse stakeholders? In social-purpose-driven empirical evidence. In our case, we seek to fill in the gap on the effect of ecosystems like healthcare, pricing and whom to charge are mostly a social-purpose-driven ecosystem on value capture from digital health regulated by the government or other authorised institutions. Besides, platforms. citizens always expect no or low co-pay for healthcare services. Thus, Our literature review led to some propositions that indicated where technological R&D-based digital healthcare services are expected to to look for relevant evidence besides reflecting an essential theoretical have low margins and, in the best case, profits reinvested into healthcare issue (i.e., that specificities value capture from a platform in a social- purpose-driven ecosystem). For example, the profiting from in­ novations (PFI) framework explains that capturing value from techno­ 3 https://www.epo.org/about-us/annual-reports-statistics/annual-report/2 logical innovations depends on the strength of the appropriability 018/insights/patents-in-digital-technologies.html, accessed 6 April 2021. regime, ownership of complementary assets and technology, standards, 5 A. Pundziene et al. Technovation 124 (2023) 102748 business model, and getting the timing right (Teece, 2006, p.1138; about digital healthcare platforms. Selecting countries belonging to this Teece, 2018; Gambardella et al., 2021). As explained in our literature project ensures a spread of Northern and Southern, Eastern and Western review, we expected to find an adaptation of these tenets in real-world European healthcare systems in which digital platforms are playing cases when the digital platform operates in a social-purpose-driven increasing roles. Table 1 is a detailed overview of the healthcare systems ecosystem. The question was thus (1) whether we would find an adap­ in the five countries. Analysis of the respective healthcare systems al­ tation of these tenets in each of our cases and (2) whether we would find lows us to control the context of the study. Furthermore, the healthcare a similar replication of the adaptation across several cases. Finding systems of the five countries are similar. Thus, similarity allows us to similar replications would generate empirical evidence of core compo­ make a comparison of the digital healthcare platforms in the five nents of value capture from the digital healthcare platforms embedded countries later in the analysis (cf. criteria 1 and 2). in a social-purpose-driven ecosystem and thus allow us to produce Second, independent research teams scanned the existing digital theoretical propositions (Yin, 2003). Massaro et al. (2019) also argued platforms in each country and selected one for deeper study respecting that the advantage of multi-cases is that they afford cross-comparative our criteria 3, 4 and 5 (see Annex 1). Finally, digital health platforms had opportunities allowing researchers to discover new variables and com­ to agree to provide access to data on the how they create and capture plex processes within a social context. Besides, a multiple-case study value, which can be sensitive information. Thus, the platform selection increases the external validity of the conclusions (i.e., their generaliz­ was an opportunity- and theory-driven (Ghauri et al., 2020; Patton, ability) and extends the result’s generalizability to a broader context 1990). (Yin, 2003). Our research question and objectives comply with the characteristics provided above and thus makes multi-cases an appro­ 3.2. Data collection priate method for this study. Data collection was carried out, considering Yin’s (2003) chain of 3.1. Research setting and case selection evidence logic: 1) we established the research question and objectives (cf. methodology); 2) we have developed a Case study protocol clearly Our multiple-case study design is based on a holistic unit of analysis, describing the purpose of the protocol, data collection procedures, the a digital healthcare platform. We also bound the case with several outline of the case study report, protocol questions (operationalization criteria to carry out analysis across the multiple digital healthcare of the phenomenon and interview questions); 3) we have developed the platform cases. The platforms had to (1) be in the healthcare sector (a Case study database (shared among an international team of researchers sector that by nature is a social-purpose-driven ecosystem; cf. literature in an online repository and complying with the confidentiality re­ review); (2) be in contexts considered similar but not in the same quirements), setting the links between the 1) Case study protocol and 2) country (to reflect cross-country specificity); (3) to be a digital platform citations and the source of information (publicly available and archival (to meet digital platform definition and aim to capture value for it), (4) data, interviews), and conditions under with data was collected (cf. developed by a start-up or small group of researchers (and not involve a section 3.3). We followed a two-step data collection process in line with big company as the goal is replication and not contrasting); (5) being the Case study protocol (Yin, 2003; Gnyawali and Park, 2011 ; Stigliani considered a promising digital healthcare platform for that we looked and Ravasi, 2012). for a platform with external recognition, such as winning innovation First, we collected secondary data with the aim to explore the context prizes or obtaining external funding. of the digital healthcare platforms (see Tables 1 and 2 and Annex 1). The We followed a two-step process to select our cases that would respect secondary data (publicly available and archival data) included infor­ these bounding criteria. First, we selected the five countries (Finland, mation on digital healthcare platforms and their ecosystems (e.g., a France, Lithuania, Spain, and Sweden) of the DiHECO project, European country’s health system, national digital regulations, funding and health project funded by the Horizon 2020 programme to advance knowledge ICT in the country, platforms, respondents, etc.) and was accessed via Table 1 Overview of the healthcare systems in the countries analysed. Case Country Populationa Type of the Funding Healthcare Health expenditure Life expectancy Access to care (population no. (2019, healthcare system providers as a share of GDP, (years of life at eligible for core services thousands) in the country 2018 (%)b birth, 2018)c (% population, 2019))d 1 Finland 5517.9 Mixed Public Public and 9.04 81.8 100 insurance, private private healthcare providers 2 France 67012.9 Mixed Public Public and 11.26 82.8 99.9 insurance, private private healthcare providers 3 Lithuania 2794.2 Mixed Public Public and 6.57 75.8 98.1 insurance, private private healthcare providers 4 Spain 46937.1 Mixed Public Public and 8.98 83.5 99.9 insurance, private private healthcare providers 5 Sweden 10230.2 Mixed Public Public and 10.90 82.6 100 insurance, private private healthcare providers a Eurostat Statistics. Available at: https://ec.europa.eu/eurostat/statistics-explained/index.php?title=File:Demographic_balance,_2019_(thousands).png. b The World Bank Data. Available at: https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS. c OECD Data. Available at: https://data.oecd.org/healthstat/life-expectancy-at-birth.htm. d OECD Data. Available at: https://www.oecd-ilibrary.org/sites/524da6c0-en/index.html?itemId=/content/component/524da6c0-en. 6 A. Pundziene et al. Technovation 124 (2023) 102748 Table 2 The World Bank, OECD and the platform owners’ websites, press re­ Data sources and usage. leases and platform guidebooks when available; details about the re­ Data source Type of data Use in the analysis spondents (e.g., their role) were accessed via Linkedin profiles and websites (see Table 2). Relevant information was collected before the Publicly available data The World Bank website Familiarise with the (in total 27 press and reposts; national healthcare interviews with the respondents of the selected digital healthcare articles; 9 websites, systems, platforms’ platforms. and 7 LinkedIn organisational contexts Second, the semi-structured interviews were carried out to provide a profiles) and interviewees; deeper understanding and explanation of the effect of a social-purpose- OECD website and reports; OmaOlo: websites of Triangulate evidence from driven ecosystem on the value capture from digital healthcare platforms. DigiFinland, Hämeenlinna the interviews and The protocol questions as part of the Case protocol were developed by an hospital and OmaOlo; 3 archival data; international team of researchers in English and later translated into the press articles; national language and back. Thus, the interview questions and the Hospitalide: website of procedure were planned in advance. In addition, five pilot interviews Hospitalide; 11 press articles; LinkedIn of the (one per country) were performed to test and edit the interview ques­ CEO; tions to assure clarity and the proper scope of the study. This assured the Emergency telehealth Clarify and support content validity, and readability of the interviews carried out across five program: websites of the emerging interpretations different countries. There were five groups of questions: (1) questions partnering hospitals; 6 about the effect of a press articles; LinkedIn of social-purpose-driven about the country’s health ecosystem, the platform and respondent; (2) the respondents; ecosystem on value questions about multilayer and embedded value created; (3) questions capture from digital about complementary assets of the platform; (4) questions about health platforms. standardisation and collaborative processes; and (5) questions about La Meva Salut: website; socio-economic value capture mechanisms. After each interview, addi­ practical experience in using the APP and web in tional questions were asked about the current funding of the digital the last 2 years, 5 press platform. Interviewees were selected to be able to reflect our interview articles. questions best. Thus, we have interviewed managers and owners of the The post-op tablet: platforms to reflect on strategic decisions and challenges; medical staff to academic articles; 2 press reflect on expected clinical outcomes and patient perspective; and ICT articles. Archival data (in total 1 OmaOlo: user guide; 1 Familiarise with the specialists who knew the technological side of the platform. In addition, user guide, 1 project webinar of the platform; platforms’ functionality platform leaders and medical doctors had double affiliations, reflecting description, 1 and organisational the perspective of researchers, innovators and product owners (see Annex 2). workshop contexts; Thus, the selected interviewees assured: 1) access to multilayer and presentation and 3 Hospitalide: 1 webinar of webinars) the platform; multidisciplinary knowledge on the platforms; and 2) motivated an­ Emergency telehealth Triangulate evidence from swers to all our questions. Interviews were carried out in the national program: the project the interviews and language by the authors from the same country as the platform’s origin description; publicly available data. and then translated into English. Primary data was collected between La Meva Salut: 1 workshop December 2020 and August 2021. Table 2 summarises the sources of the presentation; The post-op tablet: webinar data and the data usage. presentation of the The fact that the data collection was carried out in each case by platform. different researchers reduced the risk of bias in the data collection (e.g. Interviews (in total Pilot interviews (5) with the Testing the feasibility of Goffin et al., 2019). Each interview was recorded, transcribed and 18,25 h of Interviews) product owner, medical the protocol to the professional, nurse, senior interviewees and content translated into English what enabled international team of researchers manager and CEO to test validity; cross analyse the cases. the protocol and feasibility of the questions. We have 3.3. Data analysis performed pilot interviews, one per each case. The analysis of the cases comprised examination, categorization, Gain information about tabulating, and general recombining of data to arrive at empirically the effect of a social- grounded results (Yin, 2003). We followed several analytical strategies purpose-driven ecosystem to define what should be analysed and why. Put differently, linking the on value capture from digital health platforms; data to the theoretical propositions and establishing criteria for inter­ clarify and analyse the preting the findings. First, we had theoretical propositions deriving from content to address the aim the Profiting from the innovation (PFI) theory (cf. methodology), which of the study; served as lenses giving criteria to select relevant information during data Semi-structured interviews (23) with product owners, collection, but also for purposeful data analysis. Second, we have medical professionals, developed case descriptions, which provided a background for CEOs, partners of the cross-case analysis. (see Annex 1). Also, we have applied several domi­ platforms, senior nant analytical techniques, such as patent matching, explanation managers, representatives building, and cross-case analysis. Below, we describe the application of of the Ministry, ICT experts, innovation analytical techniques in more detail. managers, project leaders, We have applied (Gioia et al., 2013) methodology to set a data nurses, and psychologist; structure (see Fig. 3) and apply patent matching, explanation building, 4,6 interviews on average and cross-case analysis analytical techniques. During the analysis of the per each case. Triangulate the evidence cases, the coding themes emerge from a cycled process between data and with publicly available concepts (Gioia et al., 2013; Eisenhardt, 1989; Corbin and Strauss, 1990; and archival data. Miles and Huberman, 1994). The researchers first skim-read the tran­ scribed interview texts to decide how to analyse the corpus. Next, we 7 A. Pundziene et al. Technovation 124 (2023) 102748 Fig. 3. Data structure of the study. conducted the coding process of first-order concepts until we reached handling data processing and interpretation through a series of research saturation. Several themes emerged concerning the initial propositions workshops enabled us to focus on the depth and meaning of data anal­ offered by PFI about value capture (Lincoln and Guba, 1990). We then ysis, especially while comparing results across counties. used the pattern-matching constant comparative analysis method: each unit was compared to the previously categorized units so that all could 4. Results be categorized. In this paper, we created categories of findings using coding, which helped establish a common meaning across the five cases Our study explores the effect of a social-purpose-driven ecosystem on (Gioia et al., 2013). The identified first-order concepts, grouped into value capture from digital health platforms. We studied five cases of second-order themes, are multiple beneficiaries, the value created, digital healthcare platforms in different European countries: Finland, co-specialised assets, intangible assets, standardization, vertical inte­ France, Lithuania, Spain and Sweden. Fig. 3 reflects the data structure gration, complying with a social purpose, and capturing value (see and logic of aggregating first-order concepts into second-order themes Fig. 3). Finally, 8 s-order themes were aggregated into the four theo­ and theoretical dimensions. Based on the analysis of the results, we came retical dimensions based on a PFI framework (e.g., Teece, 1986; 2006; to four aggregated theoretical dimensions that support and extend the 2018). PFI framework. We structured the presentation of the study’s results in Thus Fig. 3 displays the data from each case according to each line with the four identified PFI dimensions and supported findings with category. Thus, we can compare the manifestation of PFI tenets in each quotes from the interviewees. case and identify similarities and differences. In addition, Fig. 3 shows the logical link between the data to the propositions deriving from the 4.1. Multilayer value creation by digital healthcare platforms empirical data. Further, the result section explains four emerged prop­ ositions with interview quotes as evidence (cf. Section 5). The discourse on digital healthcare platform value creation We have not used software to process data; instead, we had several commenced with questioning for whom the value is created. Although joint research workshops (one hybrid in Spain and three online) devoted the number and nature of the beneficiaries vary depending on the type to coding the first-order concepts and aggregating second-order themes and scope of the digital health care platform, patients and doctors are and dimensions. Although the software is an effective tool for processing prime stakeholders of the platforms. It is well illustrated by the Director data, thorough discussions carried out by the researchers’ teams on the of Medicine and Nursing, Emergency telemedicine programme, LSMU context and semantics of the codes ensured the quality of data coding, Kaunas Clinic: “I think that the beneficiaries of the platform are obviously aggregation, and interpretation (John and Johnson, 2000). Thus, doctors and patients, first and foremost. Then I think that the beneficiary is 8 A. Pundziene et al. Technovation 124 (2023) 102748 Fig. 3. (continued). also the health insurance funds because they are the customer of the service in the children operated upon and the treating doctors and nurses, a further principle. In fact, science could also use that data, and technology developers indirect but great beneficiary was discovered – the siblings of the chil­ could also use it because they could analyse that data and think about some dren operated upon. As the project leader of the post-op tablet stated, start-ups or how to improve the system.” Director, DigiHealth Finland adds: “As the children put it, when they know that the sibling is going to the hospital, “Main beneficiaries of the collected data include patients, primary and sec­ they never know if the siblings or the parents will come home, because the ondary health care, social care, health care of schools and municipal-level sibling may become ill and they may stay in the hospital, and so they stayed decision-makers.” Some new beneficiaries are mentioned by the Direc­ for 14 days. With the help of the new tablet, they [the parents and the child tor of the Master of Internet of Things for e-Health, La Meva Salut: operated] do not have to go in, and then the children said that it was such “Beneficiaries are the medical staff, patients, relatives, IT experts (medical security when the siblings received treatment at home because then they knew staff with high-level profile even statistics). However, perhaps the “main” they were home when the sibling came home from school.” The post-op stakeholders are the medical staff, the patients and their relatives, but there tablet also allows less specialised doctors at smaller hospitals to con­ are different roles for them.” The study shows a particular hierarchy nect with doctors from university hospitals, providing learning oppor­ among the beneficiaries of digital healthcare platforms. Provided quotes tunities. The family sometimes brings the post-op tablet to doctors’ support that patients and doctors are the prime focus of digital health­ appointments at home hospitals. “They (the patient’s parents) bring their care platforms. However, payers are health insurance funds, which are post-op tablet (to the appointment at the local hospital), and they then con­ public in most cases and indirect beneficiaries such as families, other nect with us through the tablet, and we can look at the patient together”. As medical staff, ICT providers, researchers and others. part of the impact of a social-purpose-driven ecosystem, digital health­ Each type of beneficiary is looking for a unique value proposition care platforms support knowledge-sharing and learning opportunities that would motivate them to adopt digital technologies. Moreover, there across distant geographies. A Senior Specialist for eHealth systems and is no one solution for all. For example, “My wife and I were confronted with information resources at the Ministry of Health of The Republic of the Google search. We found that there were lots of forums about maternity Lithuania echoes the post-op tablet project leader: “It is expected that this hospitals but no decision support. The platform’s purpose is to collect patient platform will help to reduce unnecessary referrals of the patients to major and family feedback about patient experiences posted on the internet. The centres, and then the time saved could be devoted to the care of other patients website allows patients to rate hospitals and clinics following the TripAdvisor and also improve the quality of services provided to patients themselves, since model.” States the CEO of the Hospitalide. The Former CEO of the Public consulting specialists in distant centres could provide services to the popula­ Health Department, La Meva Salut, explained: “Everybody needs to un­ tion without transporting them, and it is likely that the patient’s health option derstand and see the added value: the administration itself, the professionals could improve since the care itself would be of higher quality and efficiency." (physicians and nurses), patients, and the industry”. Furthermore, aside In addition, Hospitalide creates value for the patient who has more from the direct developers and users of the post-op tablet, the parents of information about hospitals and care services and can choose according 9 A. Pundziene et al. Technovation 124 (2023) 102748 to this additional information. Additionally, value creation is oriented to assets, e.g., digital technologies, know-how, networks, and access via hospitals to, for instance, control the e-reputation: “The hospital will gain partners or platform stakeholders. For example, Hospitalidee has (1) a an improved reputation, it will take control of the opinions [we have private unique database of patient profiles that it can model if needed, (2) sections of the platform for a hospital to track, analyse, and answer timely to specific AI algorithms such as one to allow to control the patient feed­ patient feedback]" explains the CEO of Hospitalidee. A family doctor, the back (spot fake comments) and (3) a value of protecting doctors against intensive user of LMS at La Meva Salut, notes that the platform helps to defamation and thus processes to moderate and certified patient feed­ manage a doctor’s workload, which is an essential issue in many cases: back “We moderate everything that is individual concerning judgments of “It [the platform] allows health workers the possibility of organising their people or judgments of competence. For example, the nurse did not talk to me agenda and having more time for face-to-face medical consultations." well, that is fine. On the other hand, a nurse who did not talk to me well is Finally, probably the most critical value created by the Post-op tablet moderate” (CEO, Hospitalidee). The former CEO of the Public Health is security, shared by healthcare staff and the parents of the children Department, La Meva Salut explains: “Intangible things are more impor­ who have been operated on. One of the nurses using the tablet for tant: for example, there is the capacity to use the platform for health pre­ treatment underscores this: “It gives security, and the parents can feel vention”. Director of the Master of Internet of Things for e-Health- secure at home. They can contact us whenever and know exactly who they are Universitat Auònoma de Barcelona, La Meva Salut explain: “The plat­ writing to.” Both are reading the queries and looking at photos, form itself is an intangible asset, where the whole data storage is held.” In the increasing the security of the nurses when making decisions and offering case of the post-op tablet, the primary value is the intangible asset of advice. security – security for the parents in being able to immediately and Due to the photo function combined with the easy access and directly contact the healthcare staff they know, security for the health­ ongoing communication, the nurse states that they also “catch infections care staff in being able to obtain photos and two-way contact (secure at a very early stage, even before the parents have noticed anything … and we video-conferencing) with the parents, and security for the siblings of not can start treatment earlier.” This has positive medical benefits for the seeing their parents and ill brother or sister leave for the hospital for a child, the parents do not need to come to the hospital, and all save potentially unknown period of time. As the project leader of the post-op money. tablet says: “The tablet offers a safer means of meeting and treating patients.” 4.2. Multipurpose complementary assets of the digital healthcare platforms 4.3. Emerging dominant design of the digital healthcare platforms The phenomenon of complementary assets was first acknowledged Our study indicates that digital healthcare platforms run on several by Teece (2014) as assets that co-create superior value in combination. It standards that relate to different competence areas of the platform. First, is perceived that complementary assets can serve as “the second form of we have to take into account the standards that are associated with isolating mechanism that affects the risk of being imitated” (Rumelt, digital technologies, e.g., as OmaOlo explains: “The company is respon­ 1984 p.557). In order to capture value, digital healthcare platforms also sible for ensuring service and applications integrations to Kanta. The HL7 require complementary assets, especially as health data is regarded as a FHIR standard plays a key role in integrating services. For user authentica­ co-specialised asset by its nature (e.g., Teece, 2018; Pundziene et al., tion, OAuth 2.0 is a key standard.” The former CEO of the Public Health 2022). Co-specialised assets are factors which cannot create value in the Department at La Meva Salut continues: “La Meva Salut follows the Eu­ absence of any other (e.g., Teece, 1986). For example, complementary ropean OpenEHR standard, HL7 FHIR and SCORM terms.” The second assets can include networks, capabilities and know-how, health data, type of standard relates to digital healthcare service and delivery stan­ technology and equipment, sale and service infrastructure, etc. (Hall­ dards. In the case of its Emergency telemedicine programme, LSMU berg and Brattström, 2019). As Hallberg and Brattström (2019, p.170) Kaunas Clinic, Lithuania, says: “Healthcare services are regulated by posit, “These complementary assets can be accessed by the innovating several leading national healthcare and digital healthcare regulations. It is firm through market contracting, collaborations/joint ventures, and foreseen to combine the services and capabilities of the national eHealth acquisitions/integration.” system, main emergency telemedicine centres of Kaunas Clinics, Santara Senior Specialist for eHealth systems and information resources at Clinics or Vilnius University Hospital and other hospitals.” CEO TIC Salut in the Ministry of Health of The Republic of Lithuania explains that: “The Social Foundation, La Meva Salut explain: “The information in the medical healthcare system in Lithuania is organised in a way that healthcare providers history is standardised, however from other public or private providers, it is use their information systems and then provide data to national eHealth not standardised.” Furthermore, it is important to standardise health system – national electronic health records (EHR)". All patients, doctors and records across European countries “in order to have a European portal, the relevant healthcare providers can access their own health data.” Grupo different countries must decide to homogenise the data models where the Pulso, e-health solutions at La Meva Salut continues: “To connect data clinical information is located. If the purpose is a single medical record, as from third parties is an important feature and growing benefit to be developed. long as countries do not share data models, reaching this objective will be very When the new M-connecta platform under development will be finished, it complex. In order to have good integration between systems, semantic will be possible to push information from outside the platform (i.e. app, interoperability is needed” - (Platform IT Manager of the Health Depart­ wearables, etc.). Currently, it just shows the information available in public ment at the Generalitat de Catalunya -Catalan Government, La Meva health institutions’ records”. Our study shows that health data is a major Salut). In the case of the post-op tablet, the Swedish National Board of co-specialised asset of digital healthcare platforms as to possess complete Health and Welfare provides licences to National Specialised Medical health data requires access and integration of health data from multiple Care services. The development of the tablet is funded entirely by na­ stakeholders of the platform. Besides, the secondary use of health data is tional public/state research funds. Currently, it is used by only one an opportunity for researchers and new businesses. As a family doctor hospital in one county healthcare district. Tablet services are not yet and intensive user of LMS at La Meva Salut says: “I never asked for access standardised. The broader use of the tablet is undergoing development to the data for research topics, but it would be one of the possible and evaluation. applications.” Finally, Hospitalidee offers a standardised interface for collecting Furthermore, most digital intellectual property is not patented, patient experience (same way of registering and rating hospitals and especially in Europe and thus has a weak appropriability regime. As a filling in comments) and a standardised format for presenting and result, complementary assets are essential for digital health platforms to analysing the patient experience posted on each hospital. The CEO of compete successfully and reap significant benefits (Hallberg and Hospitalidee says about the possibilities of standardisation of analysing Brattström, 2019). Most of our analysed platforms pose complementary the hospitals feedback: “If we have all the traffic, we can propose analyses.” 10 A. Pundziene et al. Technovation 124 (2023) 102748 Initially, the public health authority did not collaborate with Hos­ how that will go.” So, while the demand side is secure and can expand, it pitalidee as they were concerned about potentially competing with is unclear who will assume the supply side. Hospitalidee in data collection. Now, however, they co-develop webi­ Thus, the social benefits of digital healthcare platforms go first. nars promoting digital patient feedback and are creating a process for Although the ultimate goal of the platforms is patient clinical outcome Hospitalidee to help fill in a national digital survey on patient experi­ and safety, the effectiveness of the healthcare system: “The use of the ence: “They send me the patients [and in addition] I will recover PREMs and platform is a more efficient way of assigning the public budget. Future de­ PROMs [for them] thanks to the patients that I have been able to acquire and velopments will allow increased efficiency” (Director of the Master of that the hospitals had miss out.” Internet of Things for e-Health- Universitat Autònoma de Barcelona, La The emergency telemedicine program services are described as: Meva Salut), however, there is a need for value capture model to cover “Doctor working at the telemedicine centre at the university will then operational costs of digital technology adoption and platform mainte­ communicate with both the patient and the doctor at the district, district nance. This is a challenging issue without a clear solution so far. Hos­ hospital and will be able to interview the patient, will be able to examine the pitalidee, at its creation phase, was capturing value by participating in patient through a high-quality image, will be able to review the tests he has innovation contests and won several ones that unlocked or got money already carried out, medical devices may be connected there, and he can awards; but in the scaling phase, it had to be founded on private funding: carry out and evaluate additional tests himself at a distance, and then the “I won many prizes and therefore scholarships and credits, I have money communications consultant will advise either to continue the treatment of that easily at the very start […] then it is to say that there were many crossings of patient in the district or to transport them to a university hospital, or he will the desert, there was a lot of very tough time. I sold everything at home, house, decide that it is possible to spend the house.” This is similar to La Meva Salut car, everything, to pursue my project and ensure [hospitalidee] survival” platform services: “Users access via web or via app, the medical staff ac­ During a non-recorded meeting, Hospitalidee explained refusing cesses via a local application. Research community accesses directly to external funding because the business angel was not considering the datasets through pre-established forms.” specificity of health and wanted only to make a profit even if it was Security and privacy regulations [in Sweden] precluded the option of going to hurt doctors. It is why finding a business model generating developing a functionality whereby photographs could be sent by pri­ revenue such as creating a premium offer that the hospital pays for, was vate to the treating healthcare staff out of fear that photos taken on vital for Hospitalidee. This freemium model appears on hospitalidee phones would be stored on phones or cloud services. This required PowerPoint distributed to hospitals. developing the system on a closed, direct-channel tablet. As the pediatric Public digital healthcare platforms like the Emergency telemedicine doctor using the tablet says: “After all these meetings, [with regulatory program, the post-op tablet or La Meva Salut started as nationally or officials], we reached the conclusion that we cannot do pictures and film via international funded projects and are looking for support from the na­ an app, we can do all other things [written communication] … but we want a tional health insurance fund: “I imagine that this should be covered by the photo, and we cannot get a photo … because we could not do anything with compulsory healthcare insurance budget anyway” (Director for Public enough security. A secure solution that lived up to [the regulator’s] re­ Health, Research and Education at Emergency telemedicine program). quirements for security.” Cost savings for the national healthcare system comes as an argument in favour of many platforms. The post-op tablet allows the healthcare 4.4. Distributed socio-economic returns mechanisms of digital healthcare system to save money on in-patient care, as parents of medically stable platforms patients who otherwise would stay longer in the hospital due to inse­ curity of the parents about assessing the condition of their child from In contrast to PFI’s prior research, digital healthcare platforms home. In these cases, as the PI of the project states, “these children can in embedded within the social-purpose-driven ecosystem, be they the some cases go home earlier (with the post-op-tablet) because they have this public or private sector, prioritise the platform’s social impact and bridge, this direct line to us, with them. We can offer much stronger support benefits for patients. A medical doctor, in the city of Hämeenlinna, on with the post-op- tablet”. The Director DigiHealth Finland, OmaOlo con­ OmaOlo states: “Lifestyle-related chronic diseases are a major public health tinues: “When patients do not always need to visit a doctor but can-do risk. OmaOlo enables patients to do lifestyle assessments at their own pace symptom assessment with OmaOlo from their home sofa and get guidance, and get personalised guidance. OmoOla is a vital tool for preventative health municipalities and state save money and resources”. A medical doctor, in care.” The Director of Medicine and Nursing at the Emergency tele­ the city of Hämeenlinna, OmaOlo echoes: “When COVID-19 symptom medicine program continues: “Social returns and economic returns. Now I assessment and time reservation was done automatically using OmaOlo, an have to open up my description of this project. We know how we have average of 10 min of nurse’s time was saved. With the massive number of calculated, we have calculated that about 13 percent of unnecessary trans­ assessments, time savings were really significant." portation is from the districts to our medical institution and from our insti­ Based on the provided analysis of the results, we have distilled four tution to the district, and we have calculated the costs and time costs of those PFI dimensions that are specific to digital healthcare platforms oper­ transportations. And in Lithuania, it is challenging to calculate the benefits ating in a social-purpose-driven ecosystem: (1) multilayer value crea­ patients are experiencing. Because time spent unnecessarily contains a certain tion, (2) multipurpose complementary assets, (3) emerging dominant cost of health deterioration, it is complicated to calculate how much it will design and (4) distributed socio-economic returns mechanisms. Fig. 3 improve or worsen. However, purely from economic things, I have to open up provides a full set of first-order concepts, second-order themes and now because I have been looking at that project as it was written for a long aggregated dimensions that constitute our data structure. time, so now I am not going to say it any time soon.” The post-op tablet has been developed in a social-purpose, non-commercial context. Its devel­ 5. Discussion and implications opment was funded by a public/state research and innovation fund to improve healthcare system efficiencies. Despite the multiple benefits Our study aimed to answer the following research question: “What is generated by the post-op tablet, its non-commercial origins mean that the effect of a social-purpose-driven ecosystem on value capture from when the project period is over it is unclear who will take over its digital health platforms”. By analysing five European digital healthcare operation, further development and maintenance. The project leader of platforms, we have explored value capture from digital healthcare the post-op tablet states: “At the moment, I own responsibility for all this [as platforms that are embedded into the social-purpose-driven ecosystem project leader] everything that is on the tablets, all the service, all the in­ and, thus, prioritise social impact ahead of profit. Previous research has surance, and it all has been developed on a project grant. But the day it is to focused mainly on digital platforms in diverse business sectors that are be turned over to the clinics, and we say now you the users have to take all the not social-purpose sensitive, such as manufacturing, automotive and responsibility, to implement and maintain them [the tablets], we do not know social media (Hagiu and Wright, 2015; Anderson et al., 2014; Gawer, 11 A. Pundziene et al. Technovation 124 (2023) 102748 2014; Cennamo et al., 2018; Cusumano et al., 2019). Several studies that can be regarded as an isolation mechanism to protect intellectual explored the digital transformation of the healthcare sector in more property under the weak appropriation regime when innovations are not general terms (Fournier et al., 2020; Bates, 2010; Drago et al., 2021; patentable (e.g. Gambardella et al., 2021). Second, to provide access to Azzopardi-Muscat and Sørensen, 2019) and different types of digital idiosyncratic resources, such as complementary technologies, healthcare platforms and their ecosystems (Ruokolainen et al., 2022; know-how and health data (e.g. Ruokolainen et al., 2022). Third, when Biancone et al., 2021; Pundziene et al., 2022; Sermontyte-Baniule et al., digital healthcare services are modularised, platform owners can 2022). However, reviewed studies did not cover the effect of a develop niche complements and offer them to other platforms as an social-purpose-driven ecosystem on value capture from digital health additional income source. Furthermore, complementary assets can help platforms. platform providers to obtain vital resources and to manage risks, costs Thus, our theoretical and empirical research findings spotlight four and competition. Finally, they can be helpful when negotiating mergers dimensions vital to capture value from digital healthcare platforms: 1) and acquisitions, complying with federal and State regulations (i.e., for multilayer value creation, which is related to individual well-being or legal or tax purposes), and for financial reporting and strategic planning healthcare system-wide benefits; 2) multipurpose complementary as­ (leasing, financing and joint ventures). Newsad et al. (2014) listed sets, which assure completeness of health data, but also co-sharing of common intangible assets in digital healthcare as electronic health re­ needed resources to assure the competitiveness of the platform under the cords (EHRs), certificates of need, state licensure, Medicare certification, weak appropriation regime; 3) emerging dominant design or rather lack patents, and workforce. Our case study supports that complements serve of it so far. Emerging digital healthcare platforms are scattered across multiple purposes to digital healthcare platforms. In contrast to prior the value chain focusing on upstream or downstream services and are studies, our study shows that complementary assets, such as ability to embedded in local healthcare systems, making it difficult to unify access public funding and network with policy makers and knowledge technological but also digital healthcare service and its delivery-related institutions (e.g. Universities) (e.g. OmaOlo, Emergency telemedicine standards; 4) distributed socio-economic returns mechanisms that program, La Meva Salut, the post-op tablet) helps to capture value from should help to capture value from digital healthcare platforms are still digital healthcare platforms at early stages of their development. Thus, emerging. There are clearly defined social benefits; however, economic our second proposition is as follows. returns mechanisms still stumble to secure the sustainable development Proposition 2. Multipurpose complementary assets are vital to enable of digital healthcare platforms, especially scaling. socio-economic return from digital healthcare platforms. Teece (2014) identified dominant design as an important factor for 5.1. Propositions and future research directions profiting from innovation. As a result of market competition, the dominant player can impose standards on the rest of the competitors and Summing up our conceptual and empirical research, we provide the new entrants (Teece, 2018). On the other hand, some more complex following propositions to highlight our findings and future research standards, e.g. wireless telecom and the internet of things, are developed avenues. collectively together with some standards-setting bodies, such as IEEE. Porter (2010, p.2477) indicates that “achieving high value for pa­ "De facto standards will continue to play a vital role in the digital tients must become the overarching goal of healthcare delivery, with economy” (Teece, 2018, p.1380). Our study supports that digital value defined as the health outcomes achieved per dollar spent”. healthcare platforms do comply with digital technology standards, such Furthermore, White (2018, p.2) notes that “the value proposition as it as the HL7 FHIR standard for integration of services; OAuth 2.0 is a key may exist in healthcare is likely very complex and may be subject to standard for user authentication and openEHR (e.g., OmaOlo and La significant potential covariates as well as errors in its most fundamental Meva Salut), however, the findings of the study also indicate that there is assumptions.” Our study confirms that: 1) patients’ well-being is a lack of system-wide integration and deployment of standards, e.g. at regarded as the first priority for all groups of stakeholders of the digital present platforms operate on a local level and are not fully integrated, healthcare platforms; this virtue creates a social-purpose-driven context especially there is lack of interoperability between the private and for digital healthcare platforms’ performance; 2) the value proposition public owned digital healthcare platforms and their integration with of the digital healthcare platforms is complex and multilayer. In contrast national EHR. Bates’s (2010) echoes that a significant factor contrib­ to the prior research, our findings posit a complex hierarchy of benefi­ uting to the less-than-optimal EHRs performance is a lack of support for ciaries of digital healthcare platforms, which serves different purposes in integrated healthcare services. Most cases report that platforms’ stake­ value creation and capture. Patients are the highest priority and end holders are developing networks that allow or will allow closer coop­ users of the digital healthcare platforms. However, to capture value from eration and better interoperability among different parts of the digital healthcare platforms, healthcare insurance funds (typically platforms and, furthermore, national EHR. Coordination of the upstream public in Europe) and employers are significant stakeholders of the and downstream players, along with the multiple digital healthcare platforms, capable of securing the platforms’ sustainable development, markets, is essential for dominant design to emerge (e.g. Bresnahan and maintenance and scaling. Thus, digital healthcare platforms need to Trajtenberg, 1995; Gambardella et al., 2021). However, Hospitalidee offer tailored value propositions to key groups of platform beneficiaries and Emergency telemedicine program cases show that establishing and stakeholders at the same time. Our study shows that besides patient collaborative networks between private and public, but also between well-being, cost reduction and enhanced efficiency of the healthcare public and public healthcare providers and platform owners, is not easy system is a major expected value to healthcare insurance funds (the at all. The absence of "vertical integration" is a significant obstacle to the major payers of digital healthcare services in Europe); workload digital healthcare platforms to capture value at the right time to ensure reduction and productive time optimisation is a significant value to the sustainable scaling of the platforms, especially in medical doctors and public healthcare providers. Thus, our first prop­ social-purpose-driven ecosystem. osition is as follows. Without standards and a dominant design, it is difficult to: 1) achieve needed interoperability at the level of technology, but also digital Proposition 1. Multilayer value creation in line with the hierarchy of healthcare services development and their delivery; 2) assure modu­ the beneficiaries and shareholders enables socio-economic returns from larisation of digital healthcare services, which allows platform owners to digital healthcare platforms. specialise within the ecosystem and develop complements; 3) to assure Teece (2018) acknowledged that complementary assets are signifi­ competitive advantage of the platform and multiple funding sources in a cant in evaluating the success of digital transformation and the complex and maturing digital healthcare platform market. competitiveness of digital platforms and ecosystems. Complementary Our study shows, that standards and dominant design of digital assets serve multiple purposes in digital healthcare platforms. First, it 12 A. Pundziene et al. Technovation 124 (2023) 102748 healthcare platforms is emerging at present, but not fully there. Thus, 1) platforms need to create multilayer value for multiple groups of platform owners stumble with fragmented returns on socio-economic beneficiaries that have their own hierarchy – patients as a priority, value created. doctors, payers, complementors; 2) digital healthcare platforms can Thus, our third proposition is as follows. utilise multipurpose complementary assets to sustain competitive advantage; however, more importantly, to build idiosyncratic networks, Proposition 3. Emerging dominant design through vertical integra­ build complete sets of health data, share costs of the resource ownership tion of digital healthcare platform beneficiaries and stakeholders can and isolate value from the competitors; 3) support of the emergence of enable socio-economic returns from platforms. the dominant design of the digital platform services through the Analysed case studies provided evidence of social value generated by standardisation of the digital technologies and services; vertical inte­ the platforms, such as increased patient satisfaction and saved time due gration of the health ecosystem stakeholders that possess different ele­ to online consultations, but also identified better quality of care and ments of complementary assets extending beyond the public sector. improved health outcomes. For example, the analysis of the emergency Finally, 4) assure distributed socio-economic returns mechanisms to telemedicine programme found that patients were often assessed by two leverage public and private funding. Fig. 4 illustrates the role of four doctors, one in the emergency department of the district or regional unique components: multilayer value creation, multipurpose comple­ hospital and the other remotely in an emergency telemedicine centre. mentary assets, emerging dominant design and distributed We also confirmed that digital healthcare platforms saved resources and socio-economic returns mechanisms in enacting value capture from other related costs of healthcare services (cost-effectiveness). This is in digital healthcare platforms embedded within the social-purpose-driven line with Visconti and Morea (2020) research reporting that the ecosystem. socio-economic impact of digital platforms can foster the overall sus­ tainability of the healthcare ecosystem. Their results showed that essential savings could be achieved through digitalisation, supporting 5.2. Theoretical implications the research question of estimating the impact of digital solutions that lessen supply chain bottlenecks. Also, digitalisation can generate extra While the number of publications on digital healthcare platforms is benefits that produce incremental economic and financial margins. growing, little has been said about how the embeddedness of a digital Jennett et al. (2003) further identified the main social benefits: healthcare platform in a social-purpose-driven ecosystem affects its increased access to health services, cost-effectiveness, enhanced value capture. The contextual effect of the ecosystem and the business educational opportunities, improved health outcomes, a better quality model concept was acknowledged as an integral part of the Profiting of care, better quality of life and enhanced social support. from Innovations (PFI) framework, which can explicate the success of We went further than confirming prior research outcomes by iden­ digital platforms (e.g. Teece 2018; Helfat and Raubitschek, 2018). Thus, tifying the key role of distributed socio-economic returns mechanisms. in this paper, we applied the PFI framework and extended it by Indeed, healthcare organisations hold back in the diffusion of privately- explaining the value captured from digital healthcare platforms owned platforms. For example, the CEO of Hospitalidee, an outsider to embedded in a social-purpose-driven ecosystem. Our study makes a the healthcare industry, had to fund the platform on its own resources threefold contribution to the prior PFI and platforms literature. First, we until he successfully engaged healthcare providers to pay for patient propose four unique PFI components that are significant while capturing feedback. This empirical fact questions the role of the origins of inno­ value from digital healthcare platforms: 1) multilayer value creation, 2) vation that maximises healthcare service quality. On the one hand, the multipurpose complementary assets, 3) emerging dominant design, and healthcare system (when the public healthcare system is dominating, e. 4) distributed socio-economic returns mechanisms. Second, we empiri­ g. European countries), in the first instance, rejects privately founded cally explore the significance of the embeddedness feature of digital digital healthcare platforms, on the other hand, it lacks resources and healthcare platforms and the contextual effect of the ecosystem. Third, capabilities to successfully create and maintain platforms owned by the healthcare providers or the State. More importantly, our study confirms and spotlights the need for these platforms to have a business model assuring sustainable income survival. Gawer (2022) states that platform owners can capture a significant part of the created value through the distributed network, monitored and controlled resources without own­ ing them. Big Tech companies can serve as an example when they suc­ ceed in concentrating value capture based on distributed value creation, pervasive networks and connectivity and business model innovation (Gawer, 2022). Our study reports that four of five platforms were funded either by national or international competitive funding with no continued funding or by the State. To ensure sustainable, continuous funding of the digital healthcare platforms owned by healthcare pro­ viders or the State, distributed funding mechanisms are needed. We call distributed funding when several diverse sources of funding are used at the same time. One of the possible solutions is multiple or distributed funding streams, without which these platforms would not survive. Thus, our fourth proposition is as follows. Proposition 4. Distributed funding streams, including public and private sources, are significant in enabling socio-economic returns from digital healthcare platforms. Complying with a social-purpose-driven value proposition can better assure multiple funding streams, espe­ cially public ones. Digital platforms have unique features and capabilities to create and capture value in the digital economy (Gawer, 2022). However, our research illustrated that to make full use of the new opportunities Fig. 4. Enacting capturing value from digital healthcare platforms embedded in a created by digital healthcare platforms, some conditions should be met: social-purpose-driven ecosystem. 13 A. Pundziene et al. Technovation 124 (2023) 102748 we propose a concept of a social-purpose-driven ecosystem, which well purpose-driven ecosystem on value capture from digital health plat­ explains the behaviour of the business sectors that put social impact forms. We have deployed multiple case study research design to inves­ before the profits, such as healthcare, education, and government. tigate digital healthcare platforms in five countries (Finland, France, Lithuania, Spain and Sweden). The multiple case study approach 5.3. Policy and managerial implications allowed us to compare different digital healthcare platforms and high­ light their similarities and differences. As a result, we have identified The results of this study may have several consequences for platform four unique components of the PFI framework that enact capturing owners and policymakers. The multiple case study demonstrates that value from digital healthcare platforms which are embedded in a social- although each country has established public and private funding purpose-driven ecosystem: 1) multilayer value creation; 2) multipurpose schemes, still continuity and scaling of a digital healthcare platform can complementary assets, 3) emerging dominant design; and 4) distributed depend on distributed funding sources. Distributed funding means using socio-economic returns mechanism. The paper offers a threefold several funding sources together to fund digital healthcare platform contribution to the scholarly discussion by proposing four unique con­ services instead of just one primary source. For example, EU or tingencies, empirically testing the contextual role of embeddedness into nationally-funded research and innovation projects face the challenge of the ecosystem, and proposing a concept of a social-purpose-driven maintaining a newly created digital healthcare platform when the ecosystem to spotlight the different nature of healthcare which puts project funding ends. At this stage, private funding, e.g. business angels social impact before profits. Practical implications of the study call for or venture capital, is still a too-early option. Thus, public or public- platform owners and policymakers to consider the four identified con­ private funding needs to be raised. Thus, we call on platform owners tingencies in order to enact value capture from digital healthcare and policymakers to acknowledge the contextual effect of a social- platforms. purpose-driven ecosystem when “social-purpose” makes the platform’s This paper has some limitations that do not diminish the study’s scaling process longer than regular start-up; less attractive to private strengths. We identify three limitations which also can be seen as future investors due to the time factor but also due to the lower margins and research opportunities: 1) the study examined platforms that are new heavily regulated environment; it entails high risks related with the safe entrants owned by the public entities in the majority, thus the question management of health data and high complexity and diversity of the of how Big Tech or MedTech – incumbent born – platforms capture value healthcare ecosystem. Furthermore, we offer four unique contingencies from digital healthcare platforms embedded in social-purpose-driven which are essential conditions for value capture from digital healthcare ecosystem still remains open; 2) to allow the comparison, we examine platforms: 1) multilayer value creation; 2) multipurpose complementary platforms operating in five European countries with the similar health­ assets; 3) emerging dominant design, and 4) distributed socio-economic care system. However, we do not analyse the US or other private returns mechanisms. To capture value from digital healthcare platforms, healthcare ecosystems, which might bring new insights; 3) we have not platform owners need to tailor value propositions to patients and doc­ focused on any specific clinical area of the digital healthcare platforms. tors, but also to public payers, such as public health insurance funds. Thus, future research can elaborate on value capture from digital Furthermore, complementary assets are vital to isolate digital platforms’ healthcare platforms in a specific clinical area. intellectual property from easy imitation. On the other hand, leverage These three research opportunities start an emerging sub-stream of idiosyncratic resources, e.g. health data, needed to continue to develop research on profit from innovation in the social-purpose ecosystem. and scale. It is important to support emerging standards, and consoli­ dation of the stakeholders (vertical integration via networks’ develop­ Data availability ment) assures completeness of the digital healthcare platform’s services value chain and, thus, enhance the effectiveness of the platform per­ The authors are unable or have chosen not to specify which data has formance. This is possible due to eliminating duplications of efforts been used. while building new alternative platforms. Dominant design can be seen as a threat as well. The existence of the dominant design can be in favour Acknowledgements of mature and big platforms and burden new entrants. Finally, platform owners and policymakers need to master distributed socio-economic We appreciate the respondents’ time and motivation to provide data returns mechanisms – to ensure several diverse funding sources at the for the study and Guest Editors’ and Reviewers’ efforts to improve our time to cover social returns and periods between the projects. paper. The study is part of the DiHeco project, which has received funding from the European Union’s Horizon 2020 and innovation pro­ 6. Conclusions and limitations gramme under grant agreement No 952012. With this paper, we aimed to explore what is the effect of a social- Annexes. Annex 1 Descriptions of the cases analysed. Case Case name Short description of the platform Country of Date of Platform owner External recognition of the no. application creation platform 1 OmaOlo Omaolo.fi service provides a home-centred solution for Finland 2014 Public institution Not found symptom assessment and for accessing support. Health and wellness checks can be done as a self-service, and the solution advises patients when they should search for professional help and guides the citizens to reserve appointment times from physical or virtual clinics. Service can also be used for creating, storing and following up self- care programs and plans for citizens. Linkage to health and wellness coaching is also under development. (continued on next page) 14 A. Pundziene et al. Technovation 124 (2023) 102748 Annex 1 (continued ) Case Case name Short description of the platform Country of Date of Platform owner External recognition of the no. application creation platform 2 Hospitalide This platform allows patients to grade and share their France 2015 Start-up Wan several innovation experience about any care service. Some media call it ‘the prizes such as « Hôpital de TripAdvisor’ of health organization. It has two ambitions: demain” and « prix “e-santé" » first to contribute to information transparency between patients and health organisations; and second, to push health providers to consider not only the quality of care and outcomes, but also the quality of the patient care journey. 3 Emergency An upcoming project for telemedicine in an emergency Lithuania 2020 Project-based Funded by European Union telehealth setting in Lithuania is a pilot project for the provision of initiative of the R&I project program emergency telemedicine services, funded by the European Hospital Union. It was launched in 12 medical institutions in order to increase the availability of emergency medical services. The main aim of this project is to develop and test a model for the provision of emergency telemedicine services, which, if successful, will be developed in other hospitals in Lithuania. This project combines the services and capabilities of the national e-health portal, main emergency telemedicine centres of Kaunas Clinics, Santara Clinics or Vilnius University Hospital and other hospitals. 4 La Meva Salut La Meva Salut platform allows consulting and Spain 2015 The Health Not found downloading clinical reports, diagnoses, certificates and Department of the the results of clinical analyses and tests. It also allows Catalan Government accessing the current medication plan to go directly to the pharmacy, request for a primary care visit and access to various digital health services. The platform incorporates an online consultation service, so-called e-Consultation, for making health inquiries to professionals, carrying out procedures and sending documents. Therefore, it is a space where patients not only passively receive their medical documents but can also interact with the health system to make an appointment. However, most of the functionalities are still aimed at consulting information. 5 The post-op The tablet directly connects the parents of paediatric Sweden 2018 Project-based Externally funded R&I tablet surgery patients who have been operated on for a select organization project number of uncommon diagnoses. These patients may reside at a great distance from the treating hospital. Through the tablet the patient’s parents can send emails, photos, video conference and chat with the treatment healthcare professionals in a secure manner without having to leave their home and avoid travelling. The level of communication security and direct channel is significant as the correspondence and especially photos are usually of a highly intimate and sensitive nature. Annex 2 Information on the interviews and interviewees Case Case name Country of the Interview Duration of the Information about the interviewees no. case no. interview 1 OmaOlo Finland 1 30 min Product owner from the publicly owned company developing service 2 45 min Product owner from the company, focus on User Experience 3 30 min Medical professional from city health organization involved in the development and usage of the service 2 Hospitalide France 4 60 min CEO 5 40 min Employee 6 72 min Partner - Doctor 7 45 min Current Partner – Association for medical professional 8 41 min Potential Partner – Association for non-drug interventions 3 Emergency telehealth Lithuania 9 46 min Director of Medicine and Nursing program 10 42 min Director for Public Health, Research and Education 11 38 min Representative of Ministry of Health of The Republic of Lithuania - Responsible for emergency health 12 42 min Emergency medicine physician 13 45 min Senior specialist for eHealth systems and information resources at Ministry of Health of The Republic of Lithuania 4 La Meva Salut Spain 14 60 min Director of the Master of Internet of Things for e-Health. UAB Professor. University 15 45 min CEO TIC Salut Social Foundation. IT provider. Public Company (Catalonia) 16 45 min Family doctor. Clinician user of the platform. Public Healh Service (Catalonia) (continued on next page) 15 A. Pundziene et al. Technovation 124 (2023) 102748 Annex 2 (continued ) Case Case name Country of the Interview Duration of the Information about the interviewees no. case no. interview 17 45 min Innovation Manager. Content & App provider. Pulso (Evidence group) Private company 18 40 min Former CEO of the Public Health Department. EIT Health Expert. Catalan Government 19 47 min Platform IT Manager of the Health Department at the Generalitat de Catalunya. 5 The post-op tablet Sweden 20 68 min Project leader 21 56 min Paediatric nurse 22 43 min Psychologist, project evaluator 23 70 min Medical doctor – paediatric surgeon References Qualitative Research 10 (4), 482–498. Available at: https://doi.org/10.1525 /irqr.2017.10.4.482. 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