Towards business ecosystems for connected health

Digitalisation is seen as a vehicle for restructuring practices of social and health care in Finland. A conceptual model of connected health has evolved over time focusing on bringing together individuals and health professionals by means of ‘eHealth’, ‘telecare’, ‘telemedicine’ or ‘telehealth’ services and data connected via the Internet of Things. Digital transformation has triggered the emergence of innovative connected health services, as well as novel business models in the health and healthcare sector. Additionally, current literature emphasises growing importance of ecosystems in advancing the connected health business. The main reason for this, the increased understanding of business ecosystems would allow companies to create coherent services that would be easier for patients and health professionals (e.g. doctors and nurses) to use. This paper aims to develop and present a conceptual model for business ecosystem for connected health by mapping service needs for healthcare in the future. For this research, we conducted 16 meetings/workshops related to business models and business ecosystems. We also involved different end-user groups in our research (seven doctor interviews, four workshops with nurses and digital discussions and workshops with 12 parents with sick chil-


Introduction
The preparation for the restructuring of social and health care is advancing quite rapidly in Finland.Häyrinen [1] marks the overall transformation to be a change of practices by means of digitalisation, which is supported by the general population's technological literacy, intent to adapt easier and better alternatives compared to conventional solutions, and by the growing health tech industry's positive promotion.Services such as Kanta and Kelain are technologically ready [2] and many more disruptive healthcare services are on the way.
Since the birth of the Internet, a lot of "e"-terms have started to appear in the media and in literature [3].Such terms include email, ecommerce and also eHealth."eHealth" as a term was first coined in 2000 and has lived up to most of its promises [4].A certain pattern can be observed in the healthcare sector parallel with the development of information and communication technologies.Considering this pattern and the recent advancements in the development of communication networks (such as 5G) [5], it is important to analyse how the healthcare sector and the business ecosystems within could evolve in the future.
Additionally, the recent growth of sensor-based technologies has made the availability and transmission of mass scale data more accessible.The Internet of Things (IoT) is one of the biggest enablers for such advancement for a connected society.Martikainen et al. [6] marked increasing interest of different stakeholders in healthcare IT systems development in a recent period.For a connected society where health information will be more easily accessible and usable in healthcare, "connected health" is a term that is being jargoned recently [7].Connected health as a terminology can be easily confused with "connected healthcare" due to diction similarity.However, while connected healthcare is a model for healthcare delivery that uses technology, connected health allows availing proper information at proper hands at the proper time according to the UCD Connected Health Research Unit [8].Connected health is often referred to as a model for health/ lifestyle management, with the surge of healthcare services like MyData, Kanta and Kelain data from connected health sources all being useful in healthcare.We consider that these two terms are converging and becoming interchangeable in the future [9].
Galbraith et al. [10] state that 'connected health' is a more recent term which replaces or is used interchangeably with 'eHealth', 'telecare', 'telemedicine' or 'telehealth'.Complementing this notion, we refer to John Iglehart [7], where he marks connected health to be an umbrella term combining multiple tech-aided health service concepts.The point is, connected health is not only about eHealth, mHealth, telecare, telemedicine or telehealth as an isolated service type.Combining all of this and harnessing the potential of sensorbased data collection using IoT devices and AI-aided data analytics, connected health offers a new dimension of healthcare service delivery.
Caulfield & Donnelly [11] provides one of the most comprehensive definitions of connected health, where it is marked to encompass such terms as wireless, digital, electronic, mobile and telehealth.They also mention that connected health refers to a conceptual health management model where devices, services or interventions are designed around patients' needs, and health related data is disseminated in a way that patients can receive care in the most proactive and efficient manner.
A conceptual model of connected health has evolved over time with particular focus on connecting patients and the health professionals by means of 'eHealth', 'telecare', 'telemedicine' or 'telehealth services and data connected via the Internet of Things (IoT).The IoT can be characterised in connected health as dealing with billions of connected 'things' such as sensors or devices to enhance healthcare decision making.Building the connected health model focused on patients' needs and efficient use of patient data through digital analytics promises results that is more efficient.
Pitkänen & Pitkäranta [12] identify digitalised workflows of healthcare professionals as enablers of improvement in the healthcare services of the future.Pang et al. [13] and Gomes & Moqaddamerad [14] point out the necessity and potential of ecosystemic business development in the futures healthcare sector, which will be highly aided by tech.
In the Finnish healthcare sector, we observe a significant number of health/ wellness/healthcare service startups and SMEs, alongside numbers of bigger corporations.Gomes & Moqaddemerad [14] stated that there is an increasing number of private players in the healthcare-related business sector who are interested in the revenue streams as well as the service provisioning objectives of the sector.In our attempt to delve into this sector, we use the concept of business models as a boundary-spanning unit of analysis [15] to make sense of the developments in the sector.While taking an ecosystemic perspective, we use business models as the

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FinJeHeW 2017;9(2-3) 97 theoretical lens to identify and build a conceptual model business ecosystem for connected health by focusing on the value creation and value capture logic of different stakeholders.
In this paper, our focus is to understand the concept of business ecosystem for 'connected health'.We attempt to find answers to the following research questions in this paper: RQ 1: What could be a potential business ecosystem construct for future connected health?RQ 2: How could a business ecosystem construct be mapped for the connected health using a business model framework?
Most of the research efforts regarding connected health is concerned with chronic diseases and the global ageing problem [10,11,16,17].However, some studies discuss the impact of connected health on cost efficiency [18,19], especially with regard to preventive medicine [19], the role of pharmacists [16], and patientprofessional electronic communication [20], among others.However, it is not evident how the concept of connected health, often referred to as a health/ lifestyle management model, fits with the healthcare system.Though this paper does not attempt to offer fully generalisable results concerning connected health's overall applicability, we attempt to test its fitness to a different specific use case that will broaden the applicability of connected health: the pediatrics day surgery case.The research case will be further discussed in a forthcoming chapter.

Definitions and prior research
This chapter outlines the definitions and prior research related to the topic of this paper.We start by discussing the business and innovation ecosystem, continue with a discussion of the Internet of Things (IoT) and serviceoriented architecture (SOA), and end with a discussion on business models in ecosystemic contexts.

Business and innovation ecosystems
Digital technologies are becoming increasingly intertwined with traditional non-digital products and services [21,22].The concept of 'ecosystems' in businessrelated contexts comes from biological sciences, which, similarly to biological ecosystems, depicts multiple interdependent networks of organisation in a specific context [23].
As digital technology companies began to realise the need to co-evolve for business sustainability, business ecosystems also attracted much attention.The collection of firms that cooperate to produce a holistic and integrated technological system that eventually serves the overall customer set of the intended sector are considered Business Ecosystems [23][24][25][26][27].One of the earliest authors on business ecosystems, J. F. Moore [28] noted that in the business ecosystem, organisations neither compete, nor cooperate, but rather with the presence of both, co-develop their capabilities around innovations.
Mäkinen & Dedehayir [23] marks business ecosystems are considered to comprise suppliers, complementors, system integrators, distributors, advertisers, finance providers (VCs, corporate investors, governmental funding agencies, investment banks, and etc.), universities, other research bodies, regulatory authorities, standardisation authorities and customers [29][30][31][32][33].We acknowledge that participating stakeholders in both business and innovation ecosystems are similar.However, the aim of an innovation ecosystem is usually to innovate for the purpose of improving the sector through innovation and testing.
Innovation is such a business activity that is not on the list of core necessities of every business entity; rather, innovation brings new opportunities and additional competitive advantages.On the contrary, business ecosystems are defined as a collection of firms to produce holistic value for customers through co-evolution [24][25][26]28].Innovation can be one of multiple objectives in the case of a business ecosystem.We observe 'innovation ecosystem' to be a slightly separate construct for which the main purpose is to support and foster inno-

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FinJeHeW 2017;9(2-3) 98 vation.Mäkinen & Dedehayir [23] adds that business ecosystem and innovation ecosystem as concepts are used interchangeably in management literature.Endogenous and/or exogenous forces usually trigger the emergence of an ecosystem.While business ecosystems in most cases form through endogenous forces, innovation ecosystems often take the other route.
In ecosystems, there are many roles to be played by the participating stakeholders.Some key roles that are discussed in the literature are often titled as: keystone/platform leader/ecosystem leader, niche player/ complementor, wannabe and dominator [23,28,34,35].
The Keystone plays the role of orchestrating the overall ecosystem activities and as a consequence, their decision affects the performance of other stakeholders to some extent, as well as their own.Tiwana et al. [36] highlights designing the overall platform/architecture of the ecosystem as one of the key activities of the keystone by defining the purpose and scope of the ecosystem.
Though Keystone is supposed to be a leader of the network of companies, often it is the case that another participating firm challenges the keystone by supplanting other members of the network through vertical and horizontal integration and thereby becomes more powerful.This type of rivaling firms are dubbed as wannabes.In case a wannabe succeeds in its challenging role, they are also often dubbed dominators [35].Finally, despite being mostly unnoticed for their direct contribution to the building of the ecosystem and evolution, niche players/complementors represent the biggest population of the ecosystem.Niche players support the keystone in order to create and capture customer value [23].Moore [28] states that a keystone firm plays an important role for ecosystem's value creation, value capture and even value sharing within the ecosystem, thus they can attract more complementors to the ecosystem for further participation.

The IoT & service oriented architecture
The core role of the Internet has changed over the last three decades from the 'Internet of Computers' to the 'Internet of People' and later to the 'Internet of Things' [14,37].Among other potential applications of the IoT, healthcare is one of the primary ones [37].Healthcare has substantially affected the era of Internet with relatively cost-efficient and smart solutions, which are predominantly within eHealth and mHealth domains.With sensor-based innovations and IoT inclusions in the healthcare sector, more incentives are assumed to appear [38,39].
IoT solutions can significantly impact the quality of healthcare services through the availability, accessibility, collection, processing and presentation of meaningful data.Such improvements are possible through monitoring, sensing, communicating, logistics management, diagnosis, recovery, therapy and also administrative tasks [38,39].Though this paper does not deeply discuss technical details of the technology, the serviceoriented architecture of the IoT seems to be a valid conceptual lens.Xu et al. [38] presented a simplified service-oriented architecture (SoA) of the IoT. Figure 1 presents the four-layered SoA.

Sensing Layer Networking Layer
Service Layer Interface Layer

Basic networking support & data transfer
Creation and management of services.

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FinJeHeW 2017;9(2-3) 99 In the first layer of sensing, there is usually physical hardware for data collection.Since the IoT is considered to network numerous connected devices, in this layer, those devices sense and collect relevant data.In the second layer, the network layer, the role of connecting all of the 'things' in the network is done.The network layer is also capable of aggregating information from existing IT infrastructures.This is a vital part of the IoT architecture due to the fact that a network is assumed to be enormous and the reliability of the solution needs to be sustainable.
The service layer mostly relies on middleware technologies, which actually provides solutions that an application promises to deliver.Middleware technologies provide the IoT infrastructure with a cost-effective platform by reusing hardware and software platforms together.The final layer is called the 'interface layer'.It deals with the user interface of the application.This four-layered, service-oriented architecture will be later used to draw the theoretical framework used for this study.

Business models and ecosystemic contexts
Business models as a concept came to light during the post-dot-com boom as hype and continued to be a popular term within the ICT industry to explain many different phenomena [21,40,41] including those related to business applications [14].Most of the business model-related discussions initially evolved around ebusinesses, such firms' value creation logic, and competitive advantage issues [42].
Teece [43] & Veit et al. [44] highlight substantial impact of the Internet and Internet-related developments on the business model literature due to the emergence of new business opportunities.They also marked the more generalised phenomenon of faster technological advancements being a key for practicing different business models.To that end, during the last decade we have observed academic contributions focusing on different industries.Some examples include: smart power [45], healthcare [14,46], SMEs [47], ecosystemic contexts [21,46], and the Internet of Things [13,14,48].
In the literature, business models as a conceptual tool are viewed as an architectural [40] system of interdependent activities [49] and an interrelated set of core logic and strategic decision variables [50,51] that explain transaction content, transaction governance and transaction relationship structures for value creation and value capture [52,53].Reflecting on the above definition of business model, we agree with Xu et al. [45] and Iivari [54] that most business model-oriented effort is focused on the firm level and neglect the potential of analysing the interdependence of the growth and success of firms that are evolving in the same business ecosystems.Amit and Zott [52] approach business models as a boundary-spanning new unit of analysis that allows utilisation of the business model concept in the ecosystemic context.
Existing literature identifies value creation and value capture as fundamental to business modeling.It explains how a specific firm or an ecosystem creates value for their customers and in return how the firm/ecosystem captures value for themselves.Business modeling on a firm level seems to be more straightforward compared to an ecosystemic context due to value logic itself.Combining the 4C conceptualisation with the previously discussed Service-oriented Architecture (SoA) of the IoT, we conceptualise the value creation and capture logic in an ecosystemic context.On the one hand, this model explains how value is created for end-users from the 4C perspective.On the other hand, the SoA can explain why end-users will return value to the ecosystem.We illustrate this theoretical conceptualization in figure 2.

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FinJeHeW 2017;9(2-3) 100 For the 4C typology, we take a stance similar to Yrjölä et al. [56] and consider these types as being layers which are stacked on top of each other and the lower layers can be considered prerequisite enablers.In ICT-enabled industries, customers first and foremost need connectivity solutions related to the ecosystem.In the next layer, customers should be delivered content services.
In the next layer, context, customers should be able to understand the structure of the complex set of solutions and navigate around different solutions with ease and transparency.Finally, in the commerce layer, there can be third-party commercial solutions built on other solutions to offer added-value.
Similarly, we look at the SoA logic from a layered perspective, where the interface layer is the imminent source of value capturing.Next to that is the service layer where different sort of context-and contentoriented middleware services will be created and thus value can be captured.In the sensing layer, there would be different sensor-based devices which collect necessary data for customers, which in turn will generate part of the captured value.Finally, in the network layer, indirect value can be captured for the ecosystem for supplying network and connectivity services.
In explaining the business model value creation and capture logic for the ecosystem, we see an arguable fit between these two perspectives for their matching purposes and also their overlapping characteristics.However, the relationship between these models is likely to be complex.We conceive this initial perspective to be useful in mapping the value creation and value capturing logic in the ecosystemic context and the overall construct of the ecosystem.

Methods
This study is a part of a research project comprising a wide consortium of business researchers, user experience researchers, health professionals and a large number of companies working together towards an innovation ecosystem for the future-connected health context.This project aims to make a first version of the "Nordic central hospital testlab" that will support companies in the co-creation of services for future hospitals.The first pilot in our research project is service cocreation in the context of pediatric day surgeries.
For this study, the research case is twofold.First, the wider sphere involves understanding the construct of an innovation ecosystem.Second, we approach understanding the innovation ecosystem construct by looking at a pediatric day surgery pilot, specifically how connected health services can affect the processes within in the future.Figure 3 illustrates this twofold case of the study.Despite having the goal of understanding the construct of an innovation ecosystem for the connected health context, in practice it is complex to define the structure of the ecosystem and the processes of pediatric day surgery.Mason [57] states that to understand a complex setting and retain flexibility and sensitivity to a context that has been less explored before, a qualitative research method would be more suitable.

Commerce
We apply the concept of business models as a boundary-spanning unit of analysis [15,52] with the 4C-SoA perspective.This research relies on a philosophical standpoint that overlaps between constructivism and critical realism [58,59].Furthermore, in practice, we apply a qualitative case study for this research where we can collect a rich set of data.
Table 1 summarises the overall data collection for this research between January 2016 and June 2016 in different forms, which is relevant to business models and ecosystem building.Data collection for the study involved focused/themed meetings with companies, consortium meeting, meeting with project researchers, training and workshop.Altogether, for this research, 27 hours and 50 minutes of activities were recorded which covered business, business model and ecosystemrelated discussion.Since the amount of total discussion hours is quite large for transcription, we summarised the discussions and analysed them.During the course of this study, we met with eight (8) companies individually to discuss their business models and how they can be embedded into a connected health context to offer services that will add value to healthcare.
For the business model-related discussions, the Business Model Wheel [60] was applied to analyse organisational business models.In meetings with project researchers, we initially tested the applicability of the 4C model and the SoA model as a tool to map different services to understand the ecosystem construct.While service mapping as a term often describes the detailed processes involved in offering specific service [61], in the scope of this research, we opt to use this term to indicate a broader perspective.The map of different services we tend to draw from in this study reflects different needs for services (e.g.needed interface and integration between different services) in future healthcare.Additionally, this map helps to understand the construct of business ecosystem for connected health.Based on the feedback from project researchers, further analysis is conducted.
In parallel with business model and ecosystem-related data collection, we involved different end-user groups in our research (7 doctor interviews, 4 workshops with 4-8 nurses and digital discussions and workshops with 12 parents with ill children.The needs and technology opportunities were clarified with different stakeholder groups focusing on surgery preparations (in the home and at the hospital), surgery itself and the steps that are conducted after the surgery (in the home and at the hospital).During these events with doctors, nurses and patients of ill children, we attempted to uncover healthcare needs for the future where connected health solutions can intervene.
During one-hand discussions with doctors, nurses and parents also helped us initially understand user readiness and technology literacy besides opening up the service needs.On the other hand, through the meetings and workshops with the consortium companies, we could identify potential connected health solutions for a forthcoming pediatric day surgery case.Finally, the internal discussions with project researchers helped us define the boundaries and draw the broad map of services which are feasible for both service providers and end-users.

Results
In this chapter, first, we present some of the vital findings from the discussion with end-user groups (doctors, nurses and parents of ill children) regarding needs of services in future healthcare and about user readiness.Then, we discuss the broad service map for a connected health ecosystem based on our discussion with companies in the project consortium and internal project researchers.
Opinions from the end-user group suggested that given the abundance of health-related data with existing wellness wearables, there should also be some use of these data in healthcare as well.One of the admitted drawbacks of many wellness wearable or apps is that the data is not always clinically valid.However, technological advancements in the health tech sector promise to bring different wearables that will also yield clinical data.For pediatric day surgery, connected health services aiding the process needs integration into hospital information systems in order to automate the preparation processes in the pre-surgery process.Wireless sensor solutions, structured data formats, scoring of patients in the early phases, and automated integration into EPRs would make a big impact on the efficiency of surgical processes.Such low-cognition and automated processes could be useful in pediatrics, geriatrics and other similar cases in which the patient does not have access to online systems and mobile devices, or could not take care of her-/himself.
In pediatrics day surgery, the patient journey comprises four major stages.They are pre-surgery, surgery, postsurgery and rehabilitation.During this patient journey, there are numerous instances where connected health services can intervene to improve the efficiency of services.Such instances start from as early as scheduling an initial appointment for remote observation of patients undergoing rehabilitation.More needs, such as connected health intervention in pediatrics day surgery include direct & secure communication between doctor/nurse and parents/patients, patient data acquisition, navigation in the hospital, recovery room, patient discharge, patient feedback, etc.
Utilising flexible and wearable devices for vital sign monitoring promote telemonitoring services in rural areas, in addition to promoting patient involvement in self-care, and preventing and tracking illness.The virtual connections and so called virtual hospital services will be more used in the future also, e.g., in pre-and postsurgery phases.It can be used to suggest parents if, for instance, a child develops a risk of an infected wound during rehabilitation.
Although healthcare as a sector is moving towards adapting digital services, the brick-and-mortar healthcare delivery cannot be replaced altogether.One important obstacle that might arise during the implementation of such connected health-enabled healthcare in the future might be resistance to change from a group of end-users.This resistance of change includes adapting to newer technologies while also adapting new processes against established healthcare processes.
Taking our findings from the end-users group (doctors, nurses and parents of ill children) discussions in consideration, we tend to focus on the technology industry to understand the feasibility of identified needs.In order to further understand the construct of a connected health business/innovation ecosystem, findings from end-user discussions were presented to participating companies in the project consortium, who were asked about their initial offering for the case.Depending on their offering for the ecosystem and their business propositions, we coded them using the 4C and SoA perspectives.In this phase, we observed a fifth layer of firms that are necessary for the case of innovation ecosystems besides the 4 parallel layers discussed in the 4C-SoA framework, the ecosystem layer.In the ecosystem layer, we identify firms which patronise the idea of ecosystem building and also could be or are business ecosystem leaders in their own industry.
Figure 4 portrays the mapping of services needed in the pediatrics day surgery.Building on the 4C-SoA business model perspective for ecosystems, it is observed that value creation and capture logic in the connected health innovation ecosystem context are intertwined with each other.Contemplating deeply, we deduce that for connected health innovations, interventions are needed in data collection, data processing, data analysis and healthcare data contextualisation.Thus, we draw two horizontal layers, each containing two separate service types as building blocks.The content service layer comprises virtual context services and contentprocessing services.Similarly, the physical context layer comprises interface services and sensing services.Additionally, we identify two vertical layers, which are the ecosystem layer and the connectivity/networking layer.
Connectivity/networking layer companies provide connectivity for the medical devices and sensors.While the ecosystem layer companies promote, facilitate and patronise the idea of ecosystem building and maintenance.The network/connectivity layer aggregates existing IT infrastructures, and it is the base for the IoT architecture.The difference between these vertical layers and horizontal layer is that the business models in these vertical layers are not necessarily directly related to the connected health business context, but they facilitate connected health businesses.Also, these vertical layers ideally serve ecosystemic value to both the horizontal layers by providing connectivity and ecosystem facilitation.
The two horizontal layers constitute actual connected health services that can improve healthcare efficiency in the future.The idea of connected health is built on individual's health related data, and efficient utilization of that data through reliable services; these two layers deal specifically with that.The physical context layer comprises business models that sense data directly from physical premises where healthcare is provided, such as: hospital premises, the individual's home and an ambulance.Similarly, there are services where the system needs end-users' (patient/doctor/nurse) direct participation for data collection through service interfaces.Interface services also allow human participants to communicate in an organised manner.The content service layer is considered a high-level system layer composed of IoT applications and middleware systems besides healthcare data contextualisation services.In this layer service providers utilise the data combining hardware and software solutions for archiving, processing, and analysing the data.The service layer relies on cost-effective service platforms, using mostly middleware technologies.If we look at the physical context layer in the case of pediatric day surgeries, sensors are used to collect and monitor vital signs, that is, patient data.The new concept of wearable, non-invasive vital sign sensors is introduced in medical monitoring and well-being applications.The ideal design for wearable monitoring devices is to use flexible substrates, i.e., printed electronics and advanced materials combined with low-power electronics, IC circuits and IoT.Flexible monitoring devices can be embedded into clothing to monitor human vital signs such as body temperature, heart rate, blood pressure, pulse oxygenation, and blood glucose.Interface services offer solutions for end-users.End-user applications retrieve analysed data from databases to view health/healthcare information.
It is important to point out that in the content service layer, there is a need to offer combined service applications for end-users.Such combined service applications would manage healthcare data contextualisation via efficient data processing services.We cannot expect that the parents and children are downloading new applications during each phase of the pediatric surgery case.In connected health, contents can vary from vital healthcare data, such as an individual's health history, to communication between individual and health professionals (text, audio and video).
Furthermore, we observe the possibility of building commerce-oriented business models for connected health, harnessing the potential of the Physical Context Layer and the Content Service Layer.We also attempt to define the value flow from these different layers to conceptualise how and why this can work in practice.We attempt to show the relatedness of each layer in the ecosystem by connecting them with arrows.Furthermore, Table 2 summarises our understanding with regard to the value flows within the ecosystem.In Figure 4, we display a service map for the connected health business/innovation ecosystem -a Nordic central hospital test lab.While identifying different techaided services that will be needed in future healthcare, there is a need for technological readiness from service providers.In the current market situation, such connected health solutions are emerging to positively impact and improve efficiency in healthcare.However, there is room for significant improvement and value addition through other services.With an ecosystemic approach, connected health startups and SMEs offer services faster and with reliable service quality, hence faster growth for the overall sector.
The Nordic central hospital test lab offers product testing, feasibility testing and coaching.However, we consider it an innovation ecosystem due to its relationships with additional stakeholders ranging from global corporations, national healthcare organisations, SMEs, University hospitals, other hospitals to extend and cocreate offers from the startups and SMEs.It is arguable that the biggest value of such an innovation ecosystem is to offer a bigger picture to incoming startups and service innovators.Additionally, such innovation ecosystems can foster the advancement of the healthcare sector via co-creation activities in an ecosystemic setting.Connected health is an emerging context and we believe that a holistic support programme for newborn startups is going to foster further business ecosystem building.

Discussion & conclusions
Connected health as a concept is perceived to be a model of health/ lifestyle management in earlier research, while we see that connected health services are moving forward to serve as an important element in the healthcare sector through data and information aggregation, processing and proper dissemination.Connected health as a research focus had so far been targeted for issues like global ageing population and chronic diseases [10,11,16,17].In this study, we approached the issue of connected health from a different angle of pediatrics day surgery, which broadens the scope of this emerging concept.Additionally, there is a need to uti-lise the ecosystemic perspective in understanding the health/healthcare-related businesses [13,14], how an ecosystem grows and what their benefits are.Building upon an innovation ecosystem perspective, our study introduces a new research avenue.
This paper outlines the need for innovation ecosystems in order to have high-functioning business ecosystems in the future for health and healthcare-related businesses.Healthcare being a very sensitive service sector, it is of the utmost importance that the users are given the highest priority while designing new services.Also, unlike many other profit-oriented industries, the overall value created by service providers in the healthcare sector needs to constantly assure uncompromised service quality with clinical accuracy while capturing substantial economic value for the business entities.
The Nordic central hospital test lab as a case is striving to build an innovation ecosystem.On the one hand, ecosystem-layer companies can benefit from coopetition model in such innovation ecosystems while also encouraging new companies to participate in their own business ecosystems, which in turn results in business sustainability.On the other hand, for incoming startups, this type of innovation ecosystem offers facilitation services ranging from business guidance, product testing, access to a broad network of companies as well as access to new markets for business.In our observation, an exogenous construction of an innovation ecosystem is a proactive step towards a successful business ecosystem building for the connected health context.
In responding to the research questions, we mapped the services needed through connected health solutions to understand the business/innovation ecosystem of the Nordic central hospital test lab utilising a broad literature base and thorough empirical analysis.Though the broad service map that we present in this paper was intended for building an innovation ecosystem, we perceive it to be generalisable for constructing business ecosystems in connected health contexts as well.The new business ecosystems will eventually be headed by business entities such as 'keystones', whereas in this case the Nordic central hospital test lab will play the role for the orchestration of ecosystems.The rise of FinJeHeW 2017;9(2-3) 107 dominators or wannabes in these kinds of innovation ecosystems are less likely because of a common interest in innovation and nurturing startups and SMEs mostly for the new healthcare-related service creation.However, one key difference that can be observed for this case is that niche players or contributors are bigger companies who aim to build their own business ecosystems.It is imperative that a lot of startups who are coming for testing and building will move out of the innovation ecosystem to other business ecosystems.
Since this is one of the key aims of innovation ecosystems like the Nordic central hospital test lab, orchestrators need to continuously look for new startups/SMEs in the pipeline to keep up the ecosystem.
The literature covered in the study involves understanding the phenomenon of connected health, understanding the meaning of business and innovation ecosystems, the service-oriented architecture of the IoT as well as the business model perspective.Additionally, the empirical dataset gathered during this research allowed us to apply our theoretical learning.Figure 4 and Table 2 summarise our answers to Research Question 1 by explaining the service map and value flow from a constructionist viewpoint.
With regard to the second research question, business and innovation ecosystems are very complex and mapping them is challenging because of the number of stakeholders involved in an ecosystem.However, acknowledging the fact that broad mapping of services to understand the ecosystem construct has the inherent risk of missing some detail of the overall ecosystem, we propose the two-way mapping of an ecosystem.First, the ecosystem construct should be understood.That is, we need to logically organise the key services needed in the ecosystem to be able to create significant value.Second, in order to test the feasibility of the ecosystem construct, it is required to check the value flow between different services, hence service providers.
This paper contributes to the literature in multiple ways.First, we discuss a new problem, pediatric day surgery, from the perspective of connected health.Second, this paper provides a new angle for ecosystem building in connected health context by broadly map-ping the services needed.Third, we combine business model literature with IoT literature to provide a conceptual framework to understand ecosystems by service mapping in ICT contexts.In sum, our theoretical contribution touches the boundaries of business model literature, IoT literature, business/innovation ecosystem literature as well as connected health literature.
This paper offers interesting insights for managerial entities as well, let it be business management or hospital management.Our mapping can help to approach connected health ecosystem building.Also, beyond the context of connected health, such broad service mapping concepts can be applied to ecosystem building in other industrial contexts.
We anchored our study in a broad range of literature to manage the issue of connected health that has not been approached from an ecosystemic perspective.Thus, we had to manage a broad range of literature from multiple disciplines, but we lacked academic literature upon which we could build.Additionally, the strategy of non-transcription might have implications for the validity of the research.To address this problem, summaries were shared with participants or reflection meetings were organised to remove misinterpretations.
In this article the view of connected health business ecosystem was analysed from the perspective of industrial offerings and their interfaces based on the service needs identified from end user groups (doctors, nurses and parents of ill children).This will help companies to build services that easier to use health professionals and patients.In the future research, the natural next step for this research is to study how an end user (health professional, patient, caregiver) get added value of developed services.From the pediatrics day surgery perspective, we would like to present the patient journey path in more detail as a continuation of this research.Additionally, we would like to combine our understanding of the business/innovation ecosystem construct and end-user group feedback towards a business model for the ecosystem.

Figure 2 .
Figure 2. Value creation & value capture logic: 4C-SoA business model perspective for an ecosystemic context.

Figure 3 .
Figure 3.The two-fold case of the study.

Figure 4 .
Figure 4. Service map for the connected health business ecosystem-Nordic central hospital test lab.

Table 1 .
Business model-related data collection method for the research.

Table 2 .
Value flow map between different layers of the ecosystem.