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Health Informatics

Arlen Meyers Editor

Digital Health
Entrepreneurship
Second Edition
Health Informatics
This series is directed to healthcare professionals leading the transformation of
healthcare by using information and knowledge. For over 20 years, Health
Informatics has offered a broad range of titles: some address specific professions
such as nursing, medicine, and health administration; others cover special areas of
practice such as trauma and radiology; still other books in the series focus on
interdisciplinary issues, such as the computer based patient record, electronic health
records, and networked healthcare systems. Editors and authors, eminent experts in
their fields, offer their accounts of innovations in health informatics. Increasingly,
these accounts go beyond hardware and software to address the role of information
in influencing the transformation of healthcare delivery systems around the world.
The series also increasingly focuses on the users of the information and systems: the
organizational, behavioral, and societal changes that accompany the diffusion of
information technology in health services environments.
Developments in healthcare delivery are constant; in recent years, bioinformatics
has emerged as a new field in health informatics to support emerging and ongoing
developments in molecular biology. At the same time, further evolution of the field
of health informatics is reflected in the introduction of concepts at the macro or
health systems delivery level with major national initiatives related to electronic
health records (EHR), data standards, and public health informatics.
These changes will continue to shape health services in the twenty-first century.
By making full and creative use of the technology to tame data and to transform
information, Health Informatics will foster the development and use of new
knowledge in healthcare.
Arlen Meyers
Editor

Digital Health
Entrepreneurship
Second Edition
Editor
Arlen Meyers
School of Medicine
University of Colorado Denver, Anschutz Medical Campus
Denver, CO, USA

ISSN 1431-1917     ISSN 2197-3741 (electronic)

Health Informatics
ISBN 978-3-031-33901-1    ISBN 978-3-031-33902-8 (eBook)
https://doi.org/10.1007/978-3-031-33902-8

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland
AG 2020, 2023
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and
transmission or information storage and retrieval, electronic adaptation, computer software, or by similar
or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Contents

1 
Introduction to Digital Health Entrepreneurship��������������������������������    1
Sharon Wulfovich and Arlen Meyers
2 
Driving Outcomes-Digital Health Business Model Innovation������������    7
Jeffrey M. Nathanson
3 Innovating with Health System Partners: Value Propositions
and Business Models��������������������������������������������������������������������������������   39
Susan L. Moore
4 
Overcoming the Barriers to Dissemination and Implementation ������   51
Alan S. Young
5 Financing Your Digital Health Venture��������������������������������������������������   63
Peter Adams
6 
The Role of Artificial Intelligence in Digital Health ����������������������������   75
Anthony Chang
7 
Getting Reimbursed for Digital Health��������������������������������������������������   87
David D. Davis
8 Legal Environment of Digital Health: Rules, Regulations
and Laws that Govern Digital Health Business Design
and Ownership ���������������������������������������������������������������������������������������� 101
Jonathan A. Mintz
9 Digital Health Intrapreneurship������������������������������������������������������������ 111
Uli K. Chettipally
10 Digital Health Trends������������������������������������������������������������������������������ 123
Rubin Pillay
11 Cybersecurity ������������������������������������������������������������������������������������������ 131
Richard Staynings

v
vi Contents

12 Patent Law at the Collision Point of Artificial Intelligence

and Life Science Innovations������������������������������������������������������������������ 157
Vani Verkhovsky, Logan Bielewicz, and Quan Nguyen
13 Business Exit Strategy ���������������������������������������������������������������������������� 179
John Shufeldt
14 The Why and How of Entrepreneurship Education
in Healthcare Training���������������������������������������������������������������������������� 187
Owen Berg and Arlen Meyers
15 
Pediatric Digital Health Entrepreneurship ������������������������������������������ 211
Sharief Taraman, Carmela Salomon, and Allen Yiu
16 
Artificial Intelligence and Ethics������������������������������������������������������������ 225
Arlen Meyers, Doreen Rosenstrauch, Utpal Mangla, Atul Gupta,
and Costansia Taikwa Masau
Index������������������������������������������������������������������������������������������������������������������ 241
Chapter 1
Introduction to Digital Health
Entrepreneurship

Sharon Wulfovich and Arlen Meyers

Overview and Importance of Digital Health Entrepreneurship

Digital health entrepreneurship is the pursuit of opportunity under conditions of

uncertainty with the goal of creating user defined value through the deployment of
digital health innovations. It is the pursuit of information and communication tech-
nologies (including telemedicine, wearables, mobile health and data analytics) to
transform the medical field with the goal of improving patient outcomes, increasing
quality of health care, improving the health professional experience and reducing
costs. Using this quadruple aim framework, we will discuss how digital health
entrepreneurship has the potential and opportunity to greatly improve the U.S. health
care system.
In terms of improving patient outcomes, there is always room for improvement.
Digital health technologies have the potential to not only measure patient outcomes
in in more diverse and complete ways but also simultaneously improve patient out-
comes. There are many current examples that illustrate this potential including mul-
tiple studies on the impact of telehealth on chronic conditions. For example, multiple
studies have shown that telehealth can improve outcomes in patients with conges-
tive heart failure [1–4]. A systematic review that analyzed 14 randomized controlled
trials with a total of 4264 patients found that remote monitoring systems decreased
hospital readmission rates by 21% and all-cause mortality by 20% [5]. This pro-
vides evidence for the use of telehealth on improving patient outcomes. Additional
telemonitoring technology and other telehealth technologies need to be created,
accepted and used in order to continue improving patient outcomes.

S. Wulfovich
UC San Diego, School of Medicine, La Jolla, CA, USA
A. Meyers (*)
University of Colorado School of Medicine, Society of Physician Entrepreneurs, Denver, CO, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 1

A. Meyers (ed.), Digital Health Entrepreneurship, Health Informatics,
https://doi.org/10.1007/978-3-031-33902-8_1
2 S. Wulfovich and A. Meyers

There are many factors that influence the quality of health care. The growing
physician shortage greatly impacts access and as a result the current and future qual-
ity of health care. According to the 2018 report by the Association of American
Medical Colleges (AAMC), there may be a shortage of up to 120,000 physicians in
the United States by 2030 [6]. Digital health entrepreneurship has the potential to
lower the effect of this shortage on health care. For example, the application My GI
Health (My Total Health) (https://mygi.health) is a digital health platform that sys-
tematically compiles patient reported gastrointestinal symptom data and turns it into
a report for the physician to read before seeing the patient. This allows the clinic
visit to become more focused on addressing the problem versus collecting patient
information [7]. A cross-sectional study compared the identification of risk factors
by the My GI Health algorithm to those of physicians and found that the algorithm
was able to identify a greater quantity of risk factors [8]. This shows that there can
be great value in using digital health platforms and checklists. It could reduce the
time needed for each patient and allow physicians to focus on doctor-patient com-
munication while seeing more patients in a given day. This idea could be scaled to
many specialties and used to maximize and improve doctor-patient communication
and interactions, increasing the quality of care provided.
Similarly, the growing physician shortage results in an increased burden on all
health professionals. Health professionals are overworked and have a high rate of
burn out. Digital health entrepreneurship has the potential to improve the health
professional experience. The application discussed above, My GI Health (My Total
Health), can not only increase the quality of care but also greatly improve the health
professional experience. In reducing the amount of time that health professional
collect data from patients specifically data that could be accurately and efficiently
be located by applications, health professionals can reduce the time needed for each
patient. This could allow health professionals to feel less overworked and focus on
providing quality care. This is just one example of how new digital health technol-
ogy could greatly improve the health professional experience.
Healthcare costs are continuing to rise—in 2016 U.S. healthcare expenditures
made up 18% of the total GDP or $3.4 trillion [9]. According to the National Health
Expenditure Data from the U.S. Centers for Medicare and Medicaid Services
(CMS), healthcare spending is projected to increase at an average rate of 5.5% per
year (2017–2026), reaching a projected $5.7 trillion by 2026 [10]. Digital health
could help lower these increasing costs. For example, the Veterans Health
Administration (VHA) initiated a national home telehealth program entitled “Care
Coordination/Home Telehealth” (CCHT) [11]. vThis program used health informat-
ics, telehealth, and disease management technologies to allow veterans with chronic
conditions to live at home and delay the need for long-term residential care [11].
The data collected over a 4 year period from 17,025 participants demonstrated a
25% decrease in total bed days of care and a 19% decrease in total hospital admis-
sions [11]. The continued growth of this program (over 380,000 enrolled veterans)
has resulted in significant financial savings with an average yearly saving ranging
from $1238 to $1999 per patient in 2011 [12]. This impact is continuing to grow and
illustrates the potential of digital health in lowering health care costs while continu-
ing to provide quality care.
1 Introduction to Digital Health Entrepreneurship 3

This quadruple aim does not fully illustrate the benefits and importance of digital
health entrepreneurship. Digital health entrepreneurship provides other benefits to
healthcare industry and population health including bringing new perspectives, empow-
ering individuals, increasing use of preventative medicine, and increasing access to
care. Digital health entrepreneurs are not just healthcare providers, cooperation with
non-healthcare related is highly common (and sometimes even needed). The increase
in communication and collaboration between a diversity of disciplines brings new per-
spectives and solutions. Digital health empowers individuals with the rise of the do-it-
yourself applications and devices. Individuals can now take greater control over their
health, by using applications that are convenient and accurate to control or track the
progression of an illnesses or simply monitor health. Additionally, these devices may
even have an innovative new approach to treatment. It is through these applications and
devices, that digital health plays an increasing role in preventative medicine. It can help
detect and intervene promptly as well as be used as a tool to improve health. Lastly,
digital health is also enabling an increase in access to healthcare for rural and remote
communities. Communities where hospitals or clinics are not conveniently accessible
can now use telemedicine to get access to care more conveniently.

Recent Trends

Recent trends in digital health entrepreneurship highlight the growing acceptance of

digital health as well as areas of improvement. They include:
1. Stable levels of investment and new investment vehicles—Investors are
becoming more confident in the digital health sector, Quarter 1 of 2018, marked
the largest Quarter 1 for digital health with $1.62 Billion invested in 77 digital
health deals [13].
2. Technologies are being applied to medicine—Social media, blockchain, arti-
ficial intelligence, internet of things
3. Policy and regulatory changes—Regulations and policies are being changed
to hamper or adapt to the dissemination and implementation of digital health
innovation. For example, the FDA recently issued the Digital Health Innovation
Action Plan [14] and the twenty-first Century Cures Act (Cures Act) [15]. These
improved policies allow products to get to patients in a more efficient and
timely manner.
4. Large companies are getting involved—Apple, Amazon, Google, Facebook,
Microsoft
5. More health IT education—Education programs are offering more degrees
and interdisciplinary courses in digital health entrepreneurship and data science
[16]. These programs are being offered both at undergraduate and gradu-
ate levels.
6. Academic medical centers, innovation centers, accelerators, incubators
and generators are increasingly emphasizing digital health development
and implementation
4 S. Wulfovich and A. Meyers

7. The rise of physician entrepreneurs—Physicians are becoming more involved

in early stage start-ups and many medical students are forgoing residency for
startup involvement [16].
8. Digital health clinical trials—Entrepreneurs are starting to collect evidence of
the effectiveness and necessity of their products and services [16, 17]
9. Increased medical and non-medical collaboration—Entrepreneurs in the
healthcare field are bringing non-healthcare related entrepreneurs to help.
Additionally, the complexity of the healthcare industry creates the need for
team members with healthcare experience. The vast amount of regulations
including HIPAA, FCC, FTC and FDA create many barriers to success.
Additionally, the intricate healthcare delivery system contains reimbursement
models coupled with various stakeholders. This makes it very challenging to
create a functional, compliant and profitable product and especially challenging
if there is not a team member with relevant healthcare related experience. The
fact that medical and non-medical entrepreneurs are starting to work together
has enabled an evolution of regional digital health ecosystems.
10. Increased comfort in using digital health technologies—Patients, healthcare
providers and individuals are becoming more comfortable using digital health
technologies as part of their daily practice.

Barriers and Possible Solutions

Although digital health entrepreneurship has picked up in the past couple of years
and continues to grow at a high rate. There are many barriers that digital health
entrepreneurship faces. Here are some highlights and possible solutions:
1. Physicians as Entrepreneurs—There are many persistent barriers for physi-
cians to become entrepreneurs including: lack of an entrepreneurial mindset;
lack of courage to persist with an entrepreneurial venture; lack of knowledge
(intellectual property, business development, funding, recruiting team members,
FDA clearance etc.); poor innovation culture; lack of recognition; anti-­
entrepreneurial culture of education and training; high opportunity costs and risk
management [18].
Possible Solutions: developing social support and mentorship networks,
increasing early-on education about entrepreneurship and innovation
2. Targeting multiple stakeholders—the healthcare industry is constantly depen-
dent and intertwined with multiple stakeholders (patients, providers, payers,
partners etc.). Therefore, it is very challenging to simple target one stakeholder
without making sure that the other stakeholders also see value for the given prod-
uct or service.
1 Introduction to Digital Health Entrepreneurship 5

Possible Solutions: create fully integrated solutions that fulfill the needs of
multiple stakeholders; understand every stakeholders point of view
3. Security and privacy—Privacy and security are very important concerns for the
healthcare industry. A recent national survey, the eighth Annual Industry Pulse
Survey from Change Healthcare and HealthCare Executive Group, found that
for about half of the organizations surveyed, privacy and security concerns were
the leading factor on why adoption of these technologies was not more exten-
sive [19].
Possible Solutions: make it a priority, lots of trials
4. Risk adverse nature of the health industry—In order to ensure quality patient
care, the health industry is naturally very risk adverse. This results in a lot of
oversight and the hurdles that come with it. Entrepreneurs need to worry about
satisfying the FDA, FCC, HIPPA, FTC etc.
Possible Solutions: Consider the risks early on in product development; clini-
cal trials and evidence go a long way
5. Successful Implementation into Clinical Practice—Healthcare Providers
May Not Have all the Information that they Require to Know whether to
Recommend or Use a Given Digital Health technology in a Given Scenario
Possible Solution: Communication with healthcare providers on the scenarios
when to recommend or use a given digital health technology, create better
knowledge exchange programs

The New Era of Medicine

We are entering the new digital era of medicine where telemedicine, virtual reality,
robotics, smart phones, and other technological advancements are slowly becoming
part of regular healthcare practices. Digital health technology offers a way to change
many of the current issues that the U.S. healthcare system faces. However, there is
an urgent need for entrepreneurs, both in the healthcare field and non-related fields,
to challenge the status quo, work together and forge ahead. As discussed, digital
health entrepreneurship has many benefits. It has the potential to transform the med-
ical field by improving patient outcomes, increasing quality of health care and
reducing costs (specifically long-term costs).
This book provides an overview of a large variety of topics ranging from artifi-
cial intelligence to regulatory affairs in digital health with the aim of helping digital
health technologists, entrepreneurs, health care providers, investors, service provid-
ers and other stakeholders transform the healthcare system.
6 S. Wulfovich and A. Meyers

References

1. Antonicelli R, Testarmata P, Spazzafumo L, Gagliardi C, Bilo G, Valentini M, et al. Impact of

telemonitoring at home on the management of elderly patients with congestive heart failure. J
Telemed Telecare. 2008;14:300–5.
2. Dang S, Dimmick S, Kelkar G. Evaluating the evidence base for the use of home telehealth
remote monitoring in elderly with heart failure. Telemed J E Health. 2009;15:783–96.
3. Kvedar J, Coye MJ, Everett W. Connected health: a review of technologies and strategies to
improve patient care with telemedicine and telehealth. Health Aff (Millwood). 2014;33:194–9.
4. Polisena J, Tran K, Cimon K, Hutton B, McGill S, Palmer K, Scott RE. Home telemonitor-
ing for congestive heart failure: a systematic review and meta-analysis. J Telemed Telecare.
2010;16:68–76.
5. Clark RA, Inglis SC, McAlister FA, Cleland JGF, Stewart S. Telemonitoring or structured
telephone support programmes for patients with chronic heart failure: systematic review and
meta-analysis. Br Med J. 2007;334:942–5.
6. Association of American Medical Colleges. The complexities of physician supply and
demand: projections from 2016 to 2030. 2018. https://aamc-­black.global.ssl.fastly.net/produc-
tion/media/filer_public/85/d7/85d7b689-­f417-­4ef0-­97fb-­ecc129836829/aamc_2018_work-
force_projections_update_april_11_2018.pdf.
7. Almario CV. The effect of digital health technology on patient care and research. Gastroenterol
Hepatol (N Y). 2017;13:437–9.
8. Almario CV, Chey WD, Iriana S, Dailey F, Robbins K, Patel AV, et al. Computer versus physi-
cian identification of gastrointestinal alarm features. Int J Med Inform. 2015;84:1111–7.
9. Reid TR. How we spend $3,400,000,000,000. The Atlantic. 2017; https://www.theatlantic.
com/health/archive/2017/06/how-­we-­spend-­3400000000000/530355/
10. Centers for Medicare and Medicaid Services. NHE Fact Sheet. 2018. https://www.cms.gov/
research-­statistics-­data-­and-­systems/statistics-­trends-­and-­reports/nationalhealthexpenddata/
nhe-­fact-­sheet.html. Accessed 27 July 2018.
11. Darkins A, Ryan P, Kobb R, Foster L, Edmonson E, Wakefield B, Lancaster AE. Care coordi-
nation/home telehealth: the systematic implementation of health informatics, home telehealth,
and disease management to support the care of veteran patients with chronic conditions.
Telemed J E Health. 2008;14:1118–26.
12. Darkins A. Experience of the VA and IHS. In: The role of telehealth in an evolving health care
environment: workshop summary; 2012. p. 99–113.
13. Zweig M, Tran D. Q1 2018: funding keeps climbing as digital health startups double down on
validation. 2018. https://rockhealth.com/reports/q1-­2018-­funding-­keeps-­climbing-­as-­digital-­
health-­startups-­double-­down-­on-­validation/. Accessed 6 Aug 2018.
14. U.S. Food and Drug Administration. Digital health innovation action plan. 2017. https://www.
fda.gov/downloads/MedicalDevices/DigitalHealth/UCM568735.pdf.
15. U.S. Food and Drug Administration. 21st Century Cures Act. 2016.
16. Zajicek H, Meyers A. Digital health entrepreneurship. In: Rivas H, Wac K, editors. Digital
health: scaling healthcare to the world. Berlin: Springer; 2018. p. 271–88.
17. Meyers A. Recent trends in digital health entrepreneurship. 2017a. https://www.linkedin.
com/pulse/recent-­trends-­digital-­health-­entrepreneurship-­arlen-­meyers-­md-­mba. Accessed 6
Aug 2018.
18. Meyers A. Barriers to physician entrepreneurship. 2017b. https://www.linkedin.com/pulse/
barriers-­physician-­entrepreneurship-­arlen-­meyers-­md-­mba/. Accessed 6 Aug 2018.
19. Change Healthcare. Change healthcare releases 8th annual industry pulse report. 2018. https://
www.prnewswire.com/news-­releases/change-­healthcare-­releases-­8th-­annual-­industry-­pulse-­
report-­300596765.html. Accessed 6 Aug 2018.
Chapter 2
Driving Outcomes-Digital Health Business
Model Innovation

Jeffrey M. Nathanson

Driving Outcomes-Digital Health Business Model Innovation

This is a unique time for healthcare and digital health entrepreneurs. New demands
have been layered on top of long standing system challenges to deliver cost effective
quality healthcare.
Various healthcare components are seeking internally or externally developed
innovations to achieve this valued outcome. New interventions and new business
models are required to deliver these new value propositions sustainably.
Our society has been threatened by one of the most pervasive, painful health
emergencies of our lifetimes. We are years past the initial discovery of COVID-19.
Along with the immediate catastrophic health impacts, the global pandemic wrought
dramatic and widespread tsunamis of change, testing the healthcare status quo, our
health priorities and values. Our definition of what constitutes physical and mental
health, how our system delivers care, are all being questioned and are ripe for dis-
ruption through innovation.
Simultaneously, we are attempting to withstand the pandemic’s almost knock-­
out blow to the world’s economic health. We are wrestling with numerous complex
challenges stemming from inflation and recession. We are grappling with a complex
adaptive system (CAS).
These attributes are layered on top of existing fundamental intrinsic challenges
for the current system. Throughout these experiences, we have recognized, though
we have not yet built a comprehensive and resilient health information and deliv-
ery system.
The problems digital health entrepreneurs might solve are enormous
and urgent.

J. M. Nathanson (*)
Strategic Catalysts, LLC, Denver, CO, USA

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 7

A. Meyers (ed.), Digital Health Entrepreneurship, Health Informatics,
https://doi.org/10.1007/978-3-031-33902-8_2
8 J. M. Nathanson

Pandemic Challenges

The COVID-19 pandemic battered and stress tested the delivery of positive out-
comes for physical and mental health. The care system components-networks,
workforces and other stakeholders have been challenged in ways never experienced
nor anticipated previously. The response to COVID-19 has changed the way con-
sumers and clinicians seek and provide healthcare services. We have learned the
value of real time health information systems that inform the delivery of care.
Whole person care, care access, care quality, data driven decision making and
value based outcomes are all being re-evaluated and redefined from our recent lived
experience with the pandemic. We felt the overwhelming pain and frustration of
overworked healthcare staff and burnout. We witnessed grieving family members
saying goodbye to failing loved ones through video chat apps. We witnessed end of
life rituals postponed or held virtually. We experienced the challenges of insufficient
materials and inefficient supply chains. Scheduling, testing and implementing new
health innovations like at-home testing in the middle of the siege were novel and
challenging. Access to new care protocols, accurate real time public health informa-
tion and new guidelines were difficult to find even though there has been an increase
in the use of electronic health records. The battles against misinformation about the
pandemic and therapeutic interventions were daunting. Contact tracing and tracking
were unfamiliar terms, yet they were new processes to engage the public to join the
fight. Collecting incidence data was complex, rigorous and vexing. Analyzing out of
date data to inform real time interventions was frustrating and painful.
These hurdles for delivering care stressed the system for stakeholders and patients
during the siege. Now, there is an accelerated quest to deliver new care modalities
and build new efficiencies. The pandemic’s strains and frustrating experiences have
provided insights on the processes and resources needed to reduce the pains of the
future. Necessity drives innovation. What have we learned from the experience?

Equitable Whole Person Care

Traversing these health gauntlets was difficult enough, yet, an additional cold hard
truth revealed itself. A disproportionate incidence rate of COVID-19 was discov-
ered in low income and specific racial and ethnic groups. Data showed chronic co-­
morbidities of overweight, diabetes and heart conditions also had high correlation
with the incidence of COVID-19. These chronic conditions were more prevalent
among lower income groups and people of color-African American and Latino.
These factors contributed to greater COVID-19 hospitalization rates and eventually
disproportionate death rates.
Unfortunately, these results were not surprising. Disparities and gaps in our eco-
nomic and health delivery systems have been apparent for years, though insuffi-
ciently acknowledged or resolved.
2 Driving Outcomes-Digital Health Business Model Innovation 9

The impacts of chronic disease disparities rendered or exacerbated by the social

determinants of health (SDoH) have been tested and confirmed in numerous pub-
lished research studies. These health disparity drivers include the increased burden
of disease, injury, violence or opportunities to achieve optimal health that are expe-
rienced by socially disadvantaged populations as defined by race or ethnicity, sex,
geographic location, socio-economic status [1]. The conclusions have alarmed some
for years. Wrestling these complex issues has not been sufficiently publicized,
accepted, pursued, nor resolved. The epic COVID-19 health emergency though, has
intensified and amplified the shrill alarm.
Inclusive, whole person public health interventions that improve clinical
(physical and behavioral) and social health outcomes is a new goal.

A Digital Divide

These health disparities including digital inequities added to the widely permeating
distrust from previous healthcare experiences for communities of color. The lack of
access to broadband services, limited digital device ownership, and low computer
literacy all constrain the inclusive delivery of digitally enabled whole person con-
tinuum of care. Health delivery enhanced through digital transformation (digital
health) for some, may further exacerbate existing gaps for patients left behind.
Despite these challenges, consumer’s overall acceptance and demand for digital-­
first health solutions has increased dramatically. We have seen increased adoption
rates for digital products and services. Dr. Estaban Lopez, Google HCLS Market
Lead America, shared in a personal conversation July 2022, searches on Google
reached 1 billion per day during the height of the pandemic. We saw an increase in
the utilization of digital health contact tracing aps and the apps supporting at home
testing for COVID-19.
COVID-19 created the necessity for real time digital information, mobile contact
and communications processes, community engagement, digital health passports.
non-contact, efficient ways to access care remotely enhancing the adoption of vir-
tual care like Telehealth.

Mental Health-The Next Pandemic

Strong emotions generated by the pandemic-uncertainty, fear, isolation and loneliness

have all rendered another pandemic in the offing, stressed societal and personal men-
tal health. The broader healthcare system is working toward delivering sustainable
care at scale to targeted and mass markets. To achieve goals for behavioral health
delivery system segments though, efficiencies from digital tools will be needed. Many
reports indicate aggregated behavioral health resources, referral processes, and sched-
uling assistance will be enhanced by digital resources scaling telehealth audio, video
10 J. M. Nathanson

or combined services. Even before the pandemic, mental health support smart phone
apps including wellbeing and meditation facilitation were marketed and downloaded.
We are now seeing more and more behavioral health platforms and marketplaces that
aggregate provider panels to assist patients gain access to the care they need in an
efficient and cost effective process.
Who is going to develop these solutions? Government sets policy though will
not, by itself, solve these care delivery challenges. Larger industry components may
recognize these opportunities, but will they disrupt themselves? Will they strive for
lower costs while attempting to maintain profit? Research institutions will not bring
solutions to these problems to market. A new perspective is required to resolve
many challenges. This is a unique time for entrepreneurs.

New Care Delivery Modalities

Telehealth[2, 3]

Prior to COVID-19, virtual visits had far less market penetration compared to in-­
person medical interventions. There were concerns about the quality of virtual
health visits. Was there sufficient patient doctor connection for a diagnosis? Was
there reimbursement for the encounter at sufficient parity?
Concern over viral disease transmission and contactless care options during the
apex of the pandemic in 2020 increased consumer and physician adoption of live
virtual telemedicine substantially. Of physicians surveyed in 2020, 64% viewed
telehealth more favorably than before COVID-19 [2].
Vaccines and therapeutics have reduced disease severity. The pandemic is mov-
ing to an endemic stage of disease management. In person visits are being encour-
aged. Virtual visits subsequently have decreased, though the volume remains
substantially higher than before COVID-19. In 2021, only 58% of surveyed physi-
cians viewed telehealth more favorably than before COVID-19. Two thirds of con-
sumer survey participants reported accessing live telemedicine through their
clinicians as opposed to insurance, employer or other service [2].
Several studies recognized the value of telehealth for personal care and overcom-
ing the divide in equitable delivery of care. There are now enhanced criteria includ-
ing health equity metrics for qualifying and adopting digital health tools and
interventions. Overall health outcomes coupled with social determinant outcomes
are now key considerations. Equitable design processes aiding digital health tools
development are an increased focus. More than ever design, development and inte-
gration into the healthcare work environment and standard workflows are now all
product considerations.
Health efficacy and reduced disparities are the new goals for demonstrating
health equity for socially disadvantaged patient populations.
According to the U.S Centers for Disease Control (CDC),
2 Driving Outcomes-Digital Health Business Model Innovation 11

Health equity is achieved when every person has the opportunity to “attain his or her full
health potential” and no one is “disadvantaged from achieving this potential because of
social position or other socially determined circumstances.” Health inequities are reflected
in differences in length of life; quality of life; rates of disease, disability, and death; severity
of disease; and access to treatment [4].

Two prestigious reports, “The Future of Telehealth Roundtable” from the National
Committee for Quality Assurance (NCQA) and the Harvard Business Review
(HBR)’s “The Telehealth Era Is Just Beginning” promoted equitable access to tele-
health resources in a post-pandemic world.
The Telehealth Roundtable identified three key strategies to promote equitable
access in telehealth delivery:
• Tailoring telehealth services that cater to personal patient preferences and needs,
as some individuals face struggles due to their primary language and socioeco-
nomic status
• Addressing regulatory, policy and infrastructure barriers to access and changing
regulations to allow fair telehealth access and expanded provider eligibility for
licensure
• Leveraging Telehealth and Digital Technologies to Promote Equitable Care
Delivery [5].
The HBR article explored the post COVID-19 telehealth marketplace based on
health improvements delivered previously at reduced costs within two preeminent
healthcare systems, Kaiser Permanente and Intermountain Health Systems. The
authors projected use cases for telehealth and remote patient monitoring deploying
value propositions generated recently for their two organizations. Combined with
policy suggestions, they projected the substantial value the entire Healthcare
Delivery system might capture if virtual care were adopted and deployed throughout.
The article presents five substantial market opportunities that wider telehealth
utilization could generate:
• A reduction in expensive, unnecessary ER visits through greater disease man-
agement focus.
• An improvement in timeliness and efficiency of specialty care
• Access to the best doctors
• A reversal of America’s chronic-disease crisis
• Mitigation of health care disparities [3].

Telehealth Reimbursement

The rapid adoption of these new care modalities has also included changing reim-
bursement regulations for virtual visits. The U.S. House of Representatives Bill
4040 to extend reimbursement passed in July 2022. The bill will allow beneficiaries
to receive telehealth services at any site regardless of type. If passed by the
12 J. M. Nathanson

U.S. Senate this would extend services through January 2025. Through the pan-
demic, CMS reimbursed for digital, video and audio only services [6]. Entrepreneurs,
new market entrants, retail giants, select incumbents and tech players like Amazon
and Google are offering various telehealth products in all 50 states.

 ederal Requirement Drivers-Key to Enhancing

F
Digital Health

There are several other key drivers promoted by the federal government that are
enhancing the adoption of digital health products. The Interoperability and Patient
Access final rule (CMS-9115-F) gives patients access to their health information
when they need it most and in a way, they can best use it. The MyHealthEData ini-
tiative, focused on driving interoperability and patient access to health information
by liberating patient data using CMS authority to regulate Medicare Advantage
(MA), Medicaid, CHIP, and Qualified Health Plan (QHP) issuers on the Federally-­
facilitated Exchanges (FFEs) [7].
Lack of seamless data exchange in healthcare has historically detracted from
patient care, leading to poor health outcomes, and higher costs. The CMS
Interoperability and Patient Access final rule establishes policies that break
down barriers in the nation’s health system to enable better patient access to
their health information, improve interoperability and unleash innovation, while
reducing burden on payers and providers. Patients and their healthcare providers
will have the opportunity to be more informed, which can lead to better care and
improved patient outcomes, while at the same time reducing burden. In a future
where data flows freely and securely between payers, providers, and patients,
we can achieve truly coordinated care, improved health outcomes, and reduced
costs [8].
CMS has also mandated a new Patient Access API: CMS-regulated payers, specifically MA
organizations, Medicaid Fee-for-Service (FFS) programs, Medicaid managed care plans,
CHIP FFS programs, CHIP managed care entities, and QHP issuers on the FFEs, excluding
issuers offering only Stand-alone dental plans (SADPs) and QHP issuers offering coverage
in the Federally-facilitated Small Business Health Options Program (FF-SHOP), are
required to implement and maintain a secure, standards-based (HL7 FHIR Release 4.0.1)
API that allows patients to easily access their claims and encounter information, including
cost, as well as a defined sub-set of their clinical information through third-party applica-
tions of their choice [8].

The purpose of the new CMS Rule is to support seamless and secure access,
exchange, and use of electronic health information. More specifically, hospitals,
including psychiatric hospitals and Critical Access Hospitals (CAHs), are required
to send electronic patient event notifications of a patient’s admission, discharge,
and/or transfer (ADT) to care coordination by empowering providers to proactively
reach out to their patients to ensure proper follow-up care after a medical emer-
gency [8].
2 Driving Outcomes-Digital Health Business Model Innovation 13

Venture Capital Investment in Digital Health 2020, 2021

If investment in an entrepreneurial segment is an indication of opportunity, digital

health continues to acquire funding at record pace for a new market segment. Year
over year investment funding continues to increase. This funding growth demon-
strates a maturing market and stability. Investors continue to see value created and
product adoption.
According to Rock Health’s annual year-end report, digital health funding among
US-based startups soared to a record $29.1 billion across 729 deals in 2021.With an
average deal size of $39.9 million, 2021 also saw 88 digital health deals over $100
million. Although biopharma and medtech R&D held the top funding slot, mental
health and diabetes interventions had increases in funding. Two new sectors emerged
with financing, digital health infrastructure and interoperability startups had
increases in acquired capital, securing $2.2 billion across 40 deals. Overall the
healthcare marketplace experienced a 3.2X year-over-year funding growth in 2021
according to Rock Health’s analysis [9, 10]. StartUp Health in their assessment of
investment during the first half of 2022, tracked $16 B in investment [11].
This figure is in line with previous investment trends for healthcare marketplaces
and more broadly multi-sided health platforms. The pandemic reinforced the power
of digital marketplaces, their ability to connect and match previously disparate par-
ties and facilitate timely transactions-for example matching clinical talent with
facilities in need [10].
Given this level of venture investment digital health is one of the fastest growing
segments in the VC universe. There is an acceleration in scale, income growth and
acquisitions. There is an engagement in the broader consumer and enterprise soft-
ware offerings. Nationwide scale in years not decades, is the new timeline for tech
companies.
…Companies that take in Capital without investing in infrastructure, business model inno-
vation, or talent and leadership are headed for tough future quarters to meet the expectations
that come with high valuations [9].

Growing Direct to Consumer Market

Community members and patients were anxious to have readily available at home
remote testing. The government, payers and healthcare delivery providers accepted
and promoted direct to consumer COVID-19 sampling and testing channel to over-
come congestion at public mass testing and vaccination centers. The intent was to
enhance convenience and greater vaccine adoption rates. Often these tests were
administered with a smartphone app. The public’s health literacy was tested though
enhanced. New bio-medical science concepts like antigen and anti-body testing,
therapeutics and contact tracing were introduced to a broader public
understanding.
14 J. M. Nathanson

Our experience with this pandemic, has provided greater awareness of the steps
to researching and adopting new therapeutic interventions. Through our experience,
we have learned more about vaccine research, monoclonal antibodies, RNA vac-
cines and boosters, clinical trials, disease variants and rapid digital enabled, home
based testing.
According to a recent reported study “Policy changes, aging patients and cover-
age cutbacks are the primary culprits driving a roughly 10% continual annual
growth rate in out-of-pocket healthcare payments, according to recent market pro-
jections.” The study by Kalorama Information reported nearly $500B in consumer
out-of-pocket healthcare expenditures. Consumers have become a major payor of
sorts [12, 13].
Even before COVID-19, with shrinking profit margins, employers have been
unwilling to support increasing employee health plan costs. Just less than half of our
population is covered under employer sponsored health insurance, and this percent-
age is declining. More employers are considering providing employees fixed yearly
health stipends to allow them to purchase their own benefit packages. Consumers,
whether part of an employee health plan or an individual purchased plan, are chal-
lenged with greater responsibility for their health and payment for any cost increases.
Study after study has determined, regardless of whether the costs are insurance
premiums, copayments, deductibles for employer, direct consumer purchased health
plans or self-pay, consumers are shouldering increased costs. All varieties of “health
system” components are shifting this increased healthcare cost burden and the
responsibility for health to the patient [14–17]. For the first time, consumers, the
users of health services, are responsible and increasingly engaged with how they use
health services as they become patients. It has been difficult to gain the benefit of
behavioral economics when someone else pays for the costs of healthcare, like
employers or insurance companies. A change to the payment formula is needed. Is
opportunity hiding?
Most healthcare experts acknowledge unhealthy behaviors are healthcare cost
drivers for upwards to 80% of all healthcare costs from a variety of chronic medical
conditions like diabetes, hypertension, cardiovascular disease and the impact of
overweight or smoking. Considering the variety of healthcare service components
requiring increased participation from consumers, patients are key targets for greater
engagement. A key question remains, are consumers willing to pay for the value of
maintaining their health? Are they willing to have a more proactive role in maintain-
ing healthy behaviors as the data points to potential increased reduction in costs?

Healthcare System Needs

Data analytics, and AI have taken center stage combing through troves of data and
organizing supply chains of personal protective equipment (PPE) or ventilators. AI
systems were placed in overdrive to identify, analyze, monitor and screen COVID-19
data and facilitate drug and vaccine targeting.
2 Driving Outcomes-Digital Health Business Model Innovation 15

Digital transformation has delivered cost reductions, productivity enhancements

and efficiency improvements to other industries, like online retail. We have seen
engaged consumers driving incredible profitability. Similar improvement gains
have been promised for healthcare though the comparable outcomes have not yet
been fully realized.
Despite the pandemic, the healthcare system was economically challenged as
long term healthcare costs in the United States continue to rise while national health
outcomes woefully lag most industrialized nations. The United States has a lower
average life expectancy and higher avoidable mortality than other middle and high
income countries [18].
Some healthcare delivery systems have profited during the pandemic, others
have been stressed financially. Regardless, many can agree that the entire healthcare
delivery system is searching for resiliency and sustainability. Demonstrable ROI
and efficiency gains are key building block for the adoption of digital resource
interventions.
Financial distress partly emanating out of COVID-19 has become a real and
medium term threat to many hospital systems nationwide. As of mid 2022, most
U.S. hospitals and health systems have survived financially, though under stress.
Expenses have remained high from supply chain challenges, inflation and labor
shortage pressures. Operating margins are in the red, significantly lower than pre-­
pandemic levels [19].

Overcoming Staffing Shortages

Hospital systems are feeling the pain of competing for workers in the aftermath of
the pandemic. Housekeeping and food service staff are in great demand by the
hospitality sector-hotels and restaurants. At the center of the workforce challenge
though is the shortage of clinical staff, particularly nurses. Nurses are the back-
bone of the healthcare system. Through the pandemic, they were the tip of the
spear caring for patients. Through the siege of COVID-19 they were stressed to
burnout.
Although for years, a staffing shortfall has been predicted, the pandemic exacer-
bated this stark reality. There is now a real nurse staffing crisis. Many nurses battled
through exhaustion, despair and fear out of a sense of duty and faith that medical
researchers would find ways to combat the disease. Throughout COVID-19 nurses
were fatigued, weakened and frustrated and then confronted by the disease’s latest
resurgence. More and more nurses are leaving healthcare-rapidly.
Nurses, many of the baby boomer generation, left their positions and entered
retirement. Some left nursing for a while to spend time with their families. Others
sought out less stressful jobs other than acute care. Others have been enticed to
accept contracts with temporary and traveling nursing agencies at two to four times
their rate of pay and cost to the hospitals. These and other clinical staff member
vacancies leave hospitals strained to deliver high quality care [20].
16 J. M. Nathanson

New approaches are needed to overcome these labor shortage challenges. New
technology applications and digital solutions are being sought. Can artificial intel-
ligence and machine learning aid in some of the more mundane administrative nurs-
ing tasks?
Many hospitals have developed innovation centers and business development
units to identify, develop and deploy disruptive and creative innovations that ema-
nate or are tested at their organization. They are exploring how technology can sup-
port clinicians and other clinical components to serve at the top of their licensure
and relieve more administrative duties. Are there technologies to aid in diagnoses?
Can scribes or voice based technologies relieve some of the burden of documenta-
tion for these clinicians? [20]
Children’s Hospital, Los Angeles (CHLA) has targeted a set of pediatric care
problems and challenges they wish to solve using innovative digital solutions. They
have engaged and recruited a global ecosystem of pediatric innovators, entrepre-
neurs and investors to facilitate their multifaceted strategy to develop, test and adopt
internally and externally generated innovations. A personal conversation August 30,
2022 with Omkar Kulkarni, MPH, Chief Digital Transformation Officer and Chief
Innovation Officer for CHLA revealed some key components. KidsX accelerator
works with a consortium of over 40 children’s hospitals to support, test early stage
digital health products and mentor a cohort of company leaders to achieve product
and business model validation. CTIP, the West Coast Consortium for Technology
and Innovation in Pediatrics is focused on accelerating medical device product/mar-
ket fit-assessments, development and adoption.
Geisinger Health System in Pennsylvania, although not an “early adopter” of
innovations, established a tele ICU monitoring system prior to COVID-19. Serving
patients remotely from a command center, additional health professionals provide
monitoring and alert functions, reducing the burden for on-site doctors and nurses.
The tele ICU technology analyzes patient data continuously fed from monitors, life
support systems, electronic health records and other sources of information.
In the mid 2000's, Geisinger experienced full capacity at Intensive Care Units
for several of their hospitals. It was very difficult to hire enough Intensivists and
to retain them due to the physician shortage at the time. In response, they
deployed tele ICU to remote ICUs that were both in network and outside of the
network to ensure all ICU beds were utilized. The original goal was to improve
patient safety and the efficiency of delivering care. The initial outcomes achieved
have been significant. Published data showed between 29-64% decrease in mor-
tality and a 50 percent decrease in patient length of stay” [21]. After the tele
ICU was in place, other uses for telemedicine were developed including inpa-
tient consultation and clinic office visits. The HIPAA compliant telehealth solu-
tion provides a two way, audio/video system offered in either a mobile app or
technically outfitted clinics.
During the surge of the pandemic, outpatient clinics saw a surge of effort to care
for patients remotely. This allowed patient needs and their plan of care to be fol-
lowed during a period when patients and physicians were trying to care for people
who could not or did not want to, come in for a face to face clinic visit.
2 Driving Outcomes-Digital Health Business Model Innovation 17

Susan Fetterman, R.N., MSN, MBA FACHE, former Chief Administrative

Officer and Director of Business Strategy for Geisinger Clinic was instrumental in
developing the tele ICU program and is a leader in the telehealth innovation field.
Queried on the fervent search for post COVID-19 innovations, she observed in a
personal conversation August 17, 2022, “the pandemic drove the ‘why’ and the
‘how’ to implement digital health products…The innovation space is very busy
right now.”
Finance leaders in hospitals, medical practices and health systems are now lever-
aging the best technologies they can acquire to optimize their operations, facilities
management, patient communications and revenue cycle management systems.
There is an emphasis on increasing efficiency and overcoming the waste in the sys-
tem. Are there technologies to improve coding? Are there bots and assistant systems
that can help automate phone calls prior to a nurse intervention. Are there technolo-
gies to support patient self-scheduling and service? [20]
Throughout the industry, there is a search for alternative sources of revenue
and above all a readjustment of perspective on resiliency planning. There is a
search for technologies to overcome manual functions better served digitally.
With rote functions managed through digital resources, staff team members can
focus on other attributes of instability and unpredictability going forward into
the future.

Longstanding National Market Conditions

On top of the acute economic impact the pandemic has leveled for U.S. healthcare,
costs have continued to rise despite our recognition that most activities supporting
health happen outside of the clinic and hospital walls. Numerous researchers have
estimated the relative impact on healthcare from health behaviors, social, and envi-
ronmental factors on health outcomes. The pandemic has demonstrated the weighti-
ness of these factors. While these researchers have used different methodologies to
estimate the relative weight of these factors, health (clinical care) is estimated to
account for anywhere from 10 to 27 percent of health outcomes, while health behav-
iors and socio-economic factors are estimated to account for 60 to 85 percent of
health outcomes.
Despite the pandemic, year after year, healthcare costs in the United States have
increased while our health outcomes are worse than most industrialized nations. We
spend close to $4.3 trillion annually [22], or $12,530 per person in 2020, accounting
for over 19.6% of our National Gross Domestic Product (GDP) [23]. The percent-
age of the population with health insurance peaked at 91.1% in 2022 [24].
According to the Kaiser Family Foundation roughly 49% of the U.S population
have health insurance through their employers [25]. Employers originally pro-
vided healthcare to attract and retain employees-enhancing their productivity and
health as a benefit for their families. As a result, the consumers of healthcare ser-
vices did not fully pay for it. Without cost considerations, consumers used their
18 J. M. Nathanson

health services. Concurrently, providers of health services could sell them at rea-
sonable margins. We have now reached a tipping point. Cost increases are no
longer sustainable for consumers, employers, payers, providers or healthcare
delivery systems.
With the endemic, the cost containment imperative has never been more pro-
nounced. Engaged healthcare players for the last several years including state and
federal government have all sought cost saving measures. The National Academy of
Sciences, Institute of Medicine in 2012 recommended adopting new efficiency mea-
sures and information technologies to reduce costs by upwards to one third [26]. A
few years earlier the Institute for Healthcare Improvement developed and promoted
the “triple aim”-high patient satisfaction, quality; improved health outcomes and
reduced costs as an assessment tool to measure the value of new health interven-
tions [27].
Electronic Health Records (EHRs) originally funded by the 2009 HITECH Act
were a parallel attempt to improve health delivery efficiency and lower costs. Actual
use though, added new administrative burdens for physicians and nurses dramati-
cally decreasing provider satisfaction. Along with nurses, physicians are retiring at
a rapid pace. The greying provider workforce, private practice consolidation
throughout the industry and decreased patient interaction while using these elec-
tronic tools have revealed a fourth required aim in addition to the other three-the
quadruple aim- provider satisfaction.
Now, along with customer design and development, integration into the health-
care work environment and standard workflows are all now considerations. Not
only are impacts on overall health considered but also social determinant outcomes.
A fifth goal is demonstrating health efficacy and reduced health disparities for
socially disadvantaged patient populations.
Entrenched healthcare market incumbents have little incentive to disrupt the sys-
tem. They are aware of the market requirements for cost reduction. Without incen-
tives, though, these current “system” members have no reason to help “decrease the
cost curve.” Will a passionate digital health entrepreneur find a solution that delivers
the desired quintuple aim?
This is a unique time for healthcare solutions. COVID-19 and market indicators
point to an increased need for new approaches that deliver these multifaceted aims.
Digital interventions have clearly impacted other industries, through cost reduc-
tions, productivity enhancements and efficiency improvements. Mobile phones, tex-
ting, facetiming, streaming and social media have all seen significant ubiquitous
adoption and engagement.
These same processes and systems might positively impact the delivery of
healthcare services in a sustainable fashion. Now with the experience of COVID-19,
digital entrepreneurs have significant opportunities to intervene with demonstrable
virtual care cost efficiency, high consumer satisfaction; improved equitable quality
and improved health outcomes across the entire population base with more data
analysis informing decisions.
2 Driving Outcomes-Digital Health Business Model Innovation 19

 ealthcare Is Ripe for Disruption. It Is Hard, Not Impossible.

H
Yet, Where Do We Start?

Generally, the costs for starting a business have decreased, aided by digital products
and systems. With more and more startups, there is increased competition for financ-
ing and market share. Speed to market and lower customer acquisition costs are all
key elements for startup competitive advantage. There are now tested tools and
systems to better target the “pain” of potential customers and determine if a pro-
posed solution has traction. There are new methodologies to assess customer perso-
nas and analyze the specific sub tasks and processes needing improvement within a
system like healthcare. If we use the National Academy of Sciences study as a
benchmark there is a close to a trillion dollars of wasted expenditures in healthcare
to finance these new approaches.
Although still striving for significant market penetration, we have seen all the
major tech companies, Amazon, Google, Apple, Oracle, SAP and even Uber intro-
duce products and services to disrupt the delivery of health. They are focused on
transforming healthcare taking advantage of their relentless focus on consumer
experience to create new solutions for the greater market. To be sure, whoever enters
the digital health marketplace will use many of the tools and processes high-
lighted below.

Healthcare-A Complex Adaptive System

Understanding the Healthcare (Health) marketplace landscape is difficult, though

not impossible. Healthcare is a complex adaptive system (CAS). With its unique
properties, it generates wicked problems like childhood obesity, toxic stress, the
need for integrated mental health, data liquidity, affordable housing and other social
determinants. Government has tried to understand the system and wrestle some of
these wicked problems. We have learned though, it is complicated. Government sets
policy. Incumbents and other large industry components may identify these oppor-
tunities, but will they disrupt themselves? They are geared to grow. Will they strive
for lower costs while attempting to increase margins to grow profit? Research insti-
tutions will not bring solutions for these problems to market. A new perspective is
required. This is a unique time for entrepreneurs.
For an entrepreneur seeking opportunity within the system, understanding the
complex system of health is required. What are the components of the complex
adaptive system? What are the wicked problems? How are these wicked problems
generated? How are they wrestled to efficiency?
Complex Adaptive Systems (CAS) are dynamic and non-linear. There are a wide
variety of elements in the system. There are independent agents each with their own
20 J. M. Nathanson

goals and behaviors. These behaviors are likely to change, evolve and conflict. One
agent’s action, process or function can change the context for the others. The agents
respond in unpredictable ways, either innovatively, creatively or in error. They are
part of a living system. The whole is not the sum of the parts. A key trait of a CAS is
they lack a single system point of control. There is no single actor in charge. The
individual components are not always linked in a system. Sometimes, the compo-
nents are self-organizing into a collection of individual strands of value generation
delivering health with the constraints of the components within the adjacency of the
rest of the system. The healthcare CAS as a result is unpredictable. Throughout the
CAS, various segments create value throughout the created supply chain. Yet, each of
the components are usually dependent on health and cost outcomes generated by
other individual component performances rather than operating as an integrated whole.
As a result, wicked problems arise and are entrenched in complex adaptive sys-
tems. A problem doesn’t achieve wicked status just because it’s large or difficult
though. Building a skyscraper is a huge and complicated problem. Deriving the field
equations for Einstein’s Theory of General Relativity is extraordinarily hard to do.
But neither of these problems are wicked problems. “Wickedness” is not merely a
matter of degree of difficulty. First outlined by two University of California,
Berkeley professors in 1973, wicked problems elude description and defy solution
[28]. Wicked problems stem from numerous causes, spread in every direction and
tend to become entangled with other wicked problems. What’s worse, conventional
approaches usually just make things worse. They can be a societal scourge, such as
poverty, or a seemingly more specific problem, like health data liquidity, homeless-
ness or Alzheimer’s disease.

Discovering Opportunity Within Healthcare Wicked Problems

How would an entrepreneur start? Where would you begin to address this unique
need for disruption of a strand or an entire huge health system while gaining a
defensible market opportunity? Entrepreneurs have the potential to turn their prod-
ucts into great opportunities yet, it often takes process, methodology and focus.
Gaining insight on the components by mapping the complex adaptive system and
the customer problems are key steps in the process. How would an entrepreneur
whiteboard map the system? What are the associations between actors? What are
the constellation of actors and their various interactions? What are the various
enablers or inhibitors for each of the segments? Where are the various points of
greatest pain or friction that customers wish to resolve?
While mapping the healthcare CAS, the entrepreneur must identify the key stake-
holders (see Fig. 2.1). Who are the customers experiencing the pain and how will they
pay for the solution? Are there feedback loops that influence the actors? Once the
CAS components and relationships are mapped, there are specific tools, processes,
and powerful communities needed to turn the identified healthcare problems into
large opportunities for impact and ROI. A systems approach to solutions is necessary.
2 Driving Outcomes-Digital Health Business Model Innovation 21

Fig. 2.1 Mapping health

Start with the Problem

If we compare the various highlighted processes, wicked problems will most likely
be more difficult to analyze and map than individual jobs to be done. They tend to
require a systematic approach to finding a path to solution, ROI and impact-­
delivering the quintuple aim.
Tom Higley, another successful serial entrepreneur and angel investor founded
10.10.10. The organization was built on the premise that entrepreneurs can change
the world for the better by focusing exclusively on turning wicked problems into
entrepreneurial opportunities.
To be effective, Higley argues that startup founders and teams need to gain
deeper understanding of the requirements for solutions and potential value creation
they might develop and control. With his team, Higley developed a 10-day program
for 10 recruited and vetted serial entrepreneurs, to unpack 10 wicked problems in a
vertical segment by developing market based solutions.
Higley advises startup founders to begin with a problem they care about. He sug-
gests entrepreneurs start with a customer they care about with a problem they care
about. Higley recently tweeted all customers have problems; all problems have
solutions. Yet, not all solutions have problems, and not all problems have customers
(Higley 2017) [29–31]. This may become a mantra for digital health
entrepreneurs.
Jan Ground PT, MBA and retired Director of Virtual Care at Kaiser Permanente
Colorado, shared in an August 21, 2022 phone call, “I always focus on the quantifi-
able problem the company is trying to solve internally or externally. A critical factor
for effective digital implementation is the interoperability with the EMR in a sin-
gle click.”
22 J. M. Nathanson

Innovating Business Models

Startup tools and systems are available to help determine potential customers’ pain,
test and validate the viability of a proposed solution. There are tools for customer
discovery and development, and resolving lean and business model canvases to cre-
ate new business models.
“Designing toward the North Star of improved outcomes at reduced costs will
allow entrepreneurs to embrace business model innovation-and specifically value
based care models-regardless of the specific reimbursement codes that may or may
not include specific provider-patient care interactions” [9].

Gaining Marketplace Insight

Steve Blank and Eric Ries introduced a new standard process for bringing entrepre-
neurial opportunities to market [32–35]. First, they recognized startups were not
miniature enterprises. Their shared experience and insight as serial entrepreneurs
revealed startups were not really, yet in business. They recognized from their own
experience with startup failure and success, that most-startups didn’t always have a
clear understanding of true market needs or customer wants before they spent all
their investment funds. Startups, they recognized, were in fact unique search orga-
nizations seeking a repeatable and scalable business model. They began to work
with Alexander Osterwalder to easily display a business model in a short tem-
plate [36].
Together with Blank and Ries’s insights with Lean Startup methodology,
Osterwalder recruited and led a team effort to invent, describe, design, challenge
and pivot a business model through the Business Model Canvas. The team recog-
nized a single page broken into nine key components would effectively describe a
business model. (see Fig. 2.2 below).
Blank and Ries urged entrepreneurs and eventually investors to forget business
plans. They realized that business plans made assumptions about customers that
were not correct. Instead they recognized, tested and demonstrated a methodology
that increases speed to market focusing on delivering paying customers. They
coined the term “lean startup” methodology with unique shortened, iterative prod-
uct development cycles.
Their goal was to quickly discover and determine market insights regarding the
“pain” a prospective customer experiences, first through customer discovery and
then a process called customer development. The processes enhanced an entrepre-
neur’s recognition and determination of the (customer’s) market pain, the depth of
the pain and their willingness to resolve the pain through a purchased or created
solution. The methodology includes a design process, hypothesizing a solution,
testing the hypotheses, iterating toward the development of an initial product offer-
ing and quantifiably testing the startup solution with prospective customers. The
2 Driving Outcomes-Digital Health Business Model Innovation 23

Fig. 2.2 The business model canvas was designed by Strategyzer, AG, https://www.strategyzer.
com, Creative Commons Attribution-Share Alike 4.0 Unported License

process focused on iterative product releases validated through data driven learning
continuously improving the product/solution offering.
Their process demonstrated finding market interest was best done through a mini-
mum viable product (MVP) a far more agile and effective iterative approach than
building a costly prototype to beta test a product. It is a way to fail fast and learn. They
urged entrepreneurs to “get out of the building” to speak to prospective customers.
Their efforts focused on finding “product/market fit” [32–35]. Entrepreneurs and
investors have grown to see product/market fit as the match between the customer’s
needs and the solution the entrepreneur’s company is providing.
• Product/market fit is the sought-after prize for early stage startups. When there is
alignment with customer needs and the developed solution, customers are so
eager to ease their job to be done, they jump at the chance to open their wallets
to use what is developed.
• Product/market fit is the magic for digital health startups as well, like Omada,
Cirrus MD, Rx Revue, Dispatch Health, Burst IQ and Concert Health.
Blank and Ries shared the Lean Startup Methodology through multiple distribution
channels-universities, federal agencies, venture and angel investors, and business
accelerators. Steve Blank developed iCorps in 2011 with funding from the
U.S. National Science Foundation (NSF) to train scientists and engineers in how to
commercialize their discoveries. Their process now is a dominant method for
24 J. M. Nathanson

starting and building a company and has spawned a cottage industry of lean startup
books, workshops and websites.
Testing and validating product/market fit or testing digital health products, there
is really no difference. There are other elements determining healthcare fit in addi-
tion to the standard consumer requirements. There are heightened expectation levels
for product features in healthcare including user interfaces or the quality of user
experience, the UI/UX. Healthcare purchase decisions also, have additional ele-
ments for purchase and adoption-does it work and is it HIPAA compliant? Does it
get the job done, particularly in clinical settings? Does it deliver the quintuple aim
and can the company deliver those results and document validated outcomes?

Measuring Outcomes

We are experiencing the next wave of electronic health records use. Better and more
complete data is being collected to help inform health decisions. We are even seeing
the international collection of standards for health outcome metrics. The International
Consortium for Health Outcome Measurements, (ICHOM), has created a set of care
standards for various conditions and the expected data driven outcomes that matter
to patients. All the while they promote tracking the costs per institution required to
achieve those expected outcomes. The leaders and founders are the Harvard
Business School, Boston Consulting Group and the Karolinska Institutet. They
formed after the publishing of Harvard Professor Michael Porter’s Book that out-
lined the argument for using health outcomes data to redefine the nature of competi-
tion in health care [37]. Might we see the compensation formula change to one that
compensates for value instead of volume?
Digital health provides a key enhancement to increased focus on data collection
and data analysis. Huge challenges persist with health data liquidity and the interop-
erability of health data systems. We are still challenged to secure data and ensure it
is tied to a specific identity.
As the digital health market matures there are twinkles of bright shining stars
delivering solutions. There is an increased need to go further, to understand the key
elements needed to seize more substantial entrepreneurial opportunity in healthcare.

Product Development Innovation

The insights from Blank and Ries added to a product development process that
evolved around Stanford University. In the early 1990s a new company IDEO, was
formed by a group of designers and product development professionals bringing a
key ingredient to many new products developed in Silicon Valley. Design thinking
was created, focused on the needs of the customer. A new process for rapid product
2 Driving Outcomes-Digital Health Business Model Innovation 25

development and a new cottage industry was created, filled with whiteboards, indi-
vidual brainstorming, sticky pads, dot voting and filling out templated “artifacts”.
With their early success, the IDEO founders brought the idea of a customer cen-
tered design training institute to Stanford University. The non-degree oriented
Stanford d. School was formed. Customer insight gained from customer interviews
informed the customer centered “design thinking” practiced in the new design
efforts of IDEO, the Stanford d. School and their minions.
New systems for product development propagated within the Silicon Valley area
surrounding the Stanford campus. One of the area spin-out corporate unicorns was
Google. The founders, Larry Page and Sergey Brin fostered the development of
additional internal design and product development processes, they called them
design sprints. Their goal was to build and test prototypes for a product in just five
days. They too wanted to fail quickly. They focused on small teams challenged to
rapidly progress from problem to tested solution using a proven repeatable step by
step process. They cleared participating staff schedules for an entire week to deter-
mine how customers react to a product design prior to the investment of time and
expense for a completed product.
Testing the process within various Google divisions, Jake Knapp of Google
Ventures wrote a step by step cookbook for these sprints [38]. Over the five days,
each day there is a targeted sprint process uniquely focused on one of five key steps
Map, Sketch, Decide, Prototype and Test.

Customer Development Innovation

Accurately determining customer pain proved to be challenging though. Sometimes

the customers true pain was elusive to the assessment process. How could an entre-
preneur ensure they learned candidly from prospective customers their truthful feel-
ings about a product hypothesis or MVP? This became known as the “mom
test”-recognizing a mother would often tell you what you wanted to hear rather than
a candid, truthful review of your product idea? [39]
Understanding the customer assessment process became a passion for Tony
Ulwick, the key product manager for the IBM PC Jr. a computer system-developed
and launched with great market acclaim only to be ultimately deemed a market
failure, as it missed solving the markets’ key needs. Ulwick created the “job to be
done” theory to decrease the customer’s reporting bias in describing their pain [40].
Together with Harvard University Professor Clayton Christensen, Ulwick postu-
lated innovation was borne on understanding the “job to be done” methodology to
discover ways to improve systems and processes for customers. Ulwick hypothe-
sized the assessment of the “job to be done” would uncover key insight within a
market segment. Without these prospectives, customer interviews he postulated,
were little more than hopeful wandering with unsystematic inquiry that may occa-
sionally turn up interesting tidbits of information. These intellectual wanderings
26 J. M. Nathanson

rarely uncover the best ideas or an exhaustive set of opportunities for growth. To aid
the process, he developed an outcome driven innovation process.
Ulwick developed a simple system called “job mapping” breaking down the
tasks the customer wants completed into a series of discrete process steps. The
methodology provided a complete view of the constraints or points of friction a
customer might want help in overcoming.
With this process and the insight gained, entrepreneurs can assess the features
and benefits most significant and helpful to the customer. Ulwick’s methodology
provides a comprehensive framework with identified metrics customers themselves
use to measure success in executing a task. This approach would be most appropri-
ate to map the jobs to be done in certain healthcare processes and condition man-
agement settings.

The Business Model Innovation Process Detailed

Capturing Value

Instead of describing a new product or service, business model innovation delin-

eates the innovative processes and rationale for how a business creates, delivers and
captures value.
Business model innovation is built on a key first step. How does your business
create, deliver and capture value for customers?
Through these design processes, and quantifiable testing the hypothesized solu-
tion with prospective customers, the startup entrepreneur gains a clear understand-
ing of their needs and job to be done. The startup aligns its key resources, processes
and profit formula toward crafting and delivering their new value proposition.
Customer value is the customer's perception of the worth of your product or service.
Worth can mean several things: the benefit these products or services provide to the
target market, or the value in money they offer for purchase.

The Lean Canvas

Ash Maurya, another entrepreneur and author in pursuit of even greater speed in
product development, created another enhanced, yet compatible methodology for
raising the odds for success-the Lean Startup [41].
Through insight from his predecessors in Lean Startup methodology and cus-
tomer development processes, Maurya determined that Osterwalder’s Business
Model Canvas might be more appropriate for the enterprise than the startup.
2 Driving Outcomes-Digital Health Business Model Innovation 27

Fig. 2.3 Lean canvas is adapted from the Business Model Canvas, by Ash Maurya of LeanStack,
https://blog.leanstack.com/why-­lean-­canvas-­vs-­business-­model-­canvas/ Image implementation by
Neos Chronos Limited (https://neoschronos.com). Creative Commons Attribution 4.0
International License

Following Ulwick and Christiansen, he determined that to better understand the

customer value creation process, an entrepreneur must better understand customer
problems. He developed a modified process to map those problems.
Maurya created a new template to change the emphasis of the business model canvas
to include the segments of problem, solution and unfair advantage (see Fig. 2.3).
These same processes and methodologies can significantly aid a digital health
entrepreneur in finding opportunities in helping resolve the pain in the Health mar-
ketplace highlighted throughout this chapter. We have indications opportunity
resides in a variety of use cases in terms of cost reduction strategies for example.
Recent studies have found that the costs for major procedures continue to escalate.
The key medical specialties with the highest out-of-pocket cost estimates year over
year for patients, include: Orthopedics Plastic Surgery, Urology and Neurology all
of which are significantly higher than average across all specialties. These represent
marketplace pain. Are there business opportunities present in delivering care
through digital means that will cut the cost of delivering care into these segments?
To be sure.
28 J. M. Nathanson

 etails: Identifying Market Needs and Creating Solutions

D
that Work

The methodology that these business model thought leaders have built and are con-
stantly improving on is a Customer Discovery and Development Process. This is
focused on-identifying prospective customers and their needs through an iterative
interviewing process. Once prospects are identified, they are interviewed to deter-
mine key points of “pain” in their health job to be done workflow. Once there is a
determination of the company’s solution hypothesis, product or service hypotheses
and product concepts are tested through a proffered minimum viable product (MVP)
that are hypothesized to resolve the customer pain.

The Discovery Process of Customer Development

Customer Search Stages

Development of product hypotheses based on perceived market

problem:
Customer Discovery-identify customers and needs your product may be able to
resolve. Product specifications are identified. Initial testing of product hypotheses
through prospect interviewing.
Customer validation-Product concepts are validated and tested with pro-
spective customers in follow up interviews to determine if there is product/
market fit. Solution hypotheses are tested to determine a minimum viable prod-
uct offering.
Customer creation-generating demand through product presentations
Customer Sales/Scale-Spending time and money to build and scale sales process

Customer Customer Customer Customer

Discovery Validaon Creaon Sales/Scale

Customer Development Process Participants?

Several team members should be involved in gaining, building products for and
keeping customers.
Speaking directly to customers, understanding their inputs and formulation of
marketing requirements is the domain of product management, business develop-
ment and sales. Key team members in these roles should participate in prospective
customer interviews. Understanding the comprehensive impact of the voice of the
customer is also important to senior executives and finance.
2 Driving Outcomes-Digital Health Business Model Innovation 29

Customer Search Stages Detailed

Customer Discovery

Product hypotheses are formulated based on defining the customer’s work flow prob-
lems and the potential solution to resolve the problem. The goal is to gain information
about the prospective customers- the health information “pain” they face and the over-
all market for potential products. The goal is to Identify the prospective customers
(who will buy our products) what are their “jobs to be done” and how will the product
resolve their “pain”. This stage of the process identifies the prominent points of fric-
tion, headache or “pain” as well as the amount they are willing to pay to solve the
problem. The intent is to determine whether the MVP product or service can resolve
the pain and if the customers believe our concept resolves their problem. The greater
the “pain” the larger the interest in “buying” your product offering.

Customer Validation

In this stage, a product concept or aggregation of products is developed that is

expected to satisfy the customer’s needs. This phase, testing our solution hypothe-
sis, is referred to as finding product/market fit. It is time to prepare to sell the prod-
uct. This is also when we are striving to develop a repeatable sales process that can
be replicated and scaled to sell to early stage customers.
This phase draws on the information gleaned in the customer discovery phase.
The information aids in the development of a business model canvas, sales collat-
eral, value propositions and product positioning. Customer types (existing and new)
are significant in impacting sales, marketing and business development.
According to Steve Blank, one of the principal creators of the customer develop-
ment process, this is the step when you determine if the designed product is viable.
If the feedback suggests product modification, returning to the first stage to deter-
mine a better solution.

Value Propositions

Your goal is to determine the depth of the pain prospective customers are feeling
and the price they would pay for resolving their pain. You want to develop and test
a group of value propositions. A value proposition is a short statement that com-
municates why buyers should choose your products or services. More than a prod-
uct or service description-it’s the specific solution your products provide and the
promise of value that a customer can expect you to deliver. The validated value
propositions will be tested in a variety of marketing materials and channels pre-
sented to a variety of respondents. Once tested these value propositions will be used
to continue your sales processes in the next phase.
30 J. M. Nathanson

Customer Creation

During this phase, you work toward creating demand for the validated product in the
marketplace. The focus of this phase is on getting more customers trying the ini-
tially validated product or products. During this phase, you figure out how to scale
or function well with growth.
Listening to prospective customers, understanding their needs and their reaction
to the minimum viable product is essential at this stage. The goal is to offer the best
solution to customers and retain them in the long run by delivering a sustainable
product offering.

Customer Sales/Scale

The last stage of the customer development process is building a sustainable, repeat-
able sales process at scale. Here the focus is on specific roles for marketing, product
development and finance to assure the fulfillment of customer interest.

Customer Development Interviews

Customer development interviews are designed to be simple and easy to manage.

You want to gain insight into the “pain” respondents are experiencing regarding
whole person health. We want to develop a survey instrument that can allow open
ended responses to product oriented questions. As interviews are conducted the goal
is to understand targeted customer types and identify “customer personas” to ensure
you are assessing the needs of specific types of individuals with targeted jobs to be
done. Once you target those individuals, you want to contact them for an interview.
Through your customer development you are trying to identify the customers
(who will buy your products) and what are their “jobs to be done”? How will your
product solve their “pain”? The first stage of the process identifies the prominent
points of friction, headache or “pain” [42].

Customer Development Interview Questions Defined

As we develop our iterative interviewing with prospective customers we want to

gain insights and reactions to our various hypotheses through a variety of questions.
• Problem Hypothesis: A hypothesis that addresses the problem you are looking
to solve. Is it an actual problem people have? What’s the scope of the problem?
Why does the problem exist?
2 Driving Outcomes-Digital Health Business Model Innovation 31

• Solution Hypothesis: A hypothesis that addresses the proposed solution to a

problem you have identified. Does your solution solve the problem in the cus-
tomer’s eyes?
• Price Hypothesis: A hypothesis that addresses the feasibility of our solution.
Can it generate revenue? Are customers willing to purchase at our price to allevi-
ate their pain?
• Go-to-Market Hypothesis: A hypothesis that addresses how we will get our
solution in the hands of the customer. Is our MVP (minimum viable product)
able to be distributed? How will they find our product? How will they purchase
our product?
• Tell me how you currently do __ (Job to be done) ___________________.
• How is that process working for you?
• If you could do anything to improve your experience with ___________________,
what would it be?
• What’s the hardest part about ______________?
• What do you like/dislike about ______________?
Can you tell me a story about a time you struggled with [issue related to your prod-
uct idea]?
Why is that [hard, frustrating, etc.]?
What was the hardest part about this problem you faced?
Why was this the hardest part?
How did you solve this problem at the time?
How did you find t h a t solution? What frustrates you about this solution? Are
you actively searching for/ trying out other solution? [41]

Go to Market Strategies

Go-To-Market strategies are critical for market adoption of digital health compa-
nies. Julie Yoo, of the Andreessen Horowitz investment firm writes about them in an
article, “The New Go-To-Market Playbook for Digital Startups”. She describes the
digital health market overall as slow to mature. She observes, multiple healthcare
technology products have struggled to gain traction. The slow adoption of these
products, she postulates, was their inability to find an “executable path for sustain-
able distribution and value capture.” Distribution was “historically a very steep hill
to climb.” Market maturity was stifled by integration, absorption and payment hur-
dles for new technology-based products. Budgets and care plans were fixed without
room for new approaches. As a result, there were long enterprise sales cycles for
initial paths to market. Without sufficient capitalization, few companies could with-
stand the cash flow challenge [43].
The current growth of the digital health marketplace, Ms. Yoo suggests, has been
driven by the unique revisioning of Go-To-Market (GTM) strategies. She observes
since 2010, the primary market and distribution channel for digital health products
32 J. M. Nathanson

was through incumbent providers, payers, life sciences companies and self-insured
employers.
She identifies several new key go-to-market strategies she is tracking in her
work. As a leading investor in digital health, her focus is on a sustainable distribu-
tion and value capture with key customer segments [43].
The first GTM is a business to consumer to enterprise model of product
marketing-­she calls B2C2B. The company gains traction with consumers. Once
aggregated, they are a valuable resource for enterprise customers.
The second GTM Yoo describes is a business to small business model (B2SMB).
Digital health companies for example, have become a market for infrastructure
services.
Yoo observes a third GTM opportunity for digital health companies is the
adoption of Risk Based contracting. She believes this payment strategy is a key
to digital health startups as they take responsibility for the comprehensive care for
a patient. Value based reimbursement has gained increased emphasis throughout
healthcare. Nimble digital health companies with their customer engagement
capabilities are uniquely able to successfully navigate this emerging reimburse-
ment approach [43].
The most successful digital health market leaders are built on evidence-based
product validation. One leader, Omada Health, has 10 peer-reviewed studies dem-
onstrating their product efficacy. They also demonstrated to the U.S. Centers for
Disease Control how their virtual program could deliver the Diabetes Prevention
Program cost effectively with higher outcomes. The company demonstrated how
their program was delivered digitally, privately and securely. They also showed how
the long-standing program could be scaled cost effectively. So convinced of their
outcomes and metrics, they have become a leader in Risk Based contracting manag-
ing cohorts of patients with their disease management system.

Revenue-Value Based Reimbursement

For years, the Centers for Medicare and Medicaid Services (CMS) and other policy
organizations have promoted value-based care models to reimburse for quality care.
The models include the Accountable Care Organization, Medicare Shared Savings
and the Next Generation ACO Model. Additionally, six common value-based care
models are developing as alternatives to the standard fee for service reimbursement
model. digital health companies would do well to monitor and keep abreast of these
revenue models.
• Bundled payments focused on an entire episode of care.
Patient-centered Medical Homes (PCMH), a primary care physician coordinates
a centralized care setting providing a more personalized care approach.
Accountable care organizations (ACOs) are patient centered networks designed
to improve quality and delivery of patientcare through a group of physicians and
2 Driving Outcomes-Digital Health Business Model Innovation 33

healthcare providers working together to leverage health information technology

to gather data and improve patient care at reduced costs.
Shared Savings is passed on to providers by payers through reimbursements based
on quality and spending targets.
Shared Risk also known as downside risk models hold the provider accountable to
the ACO to have their costs stay at or below the target rates set for delivery of
targeted outcomes.
Global Capitation requires the provider assume 100% of the risk in a value-based
care model. This model designates a specific amount for each patient served and
allows the provider to keep any savings [44].
Another set of GTMs Yoo observed is a trend first identified by Rock Health in an
article on multi-sided virtual care platforms or marketplaces [45].
The article identifies a variety of new platform value strands emerging in the
maturing digital health marketplace-infrastructure and service/product offerings:
• Care management platforms-condition management
• Convenience care-common condition management
• Remote pharmacy infrastructure
• Unified virtual platforms
• Retail platforms
• Integrated digital and physical care platform
• Tech infrastructure platforms
• Data integration-Links to EMRs
• Biomarker tracking
Companies building these platforms have crafted unique business models based on
determination of their customer and path to payment. They strive to build competi-
tive advantage through technical assets, hard assets, human capital and intellectual
property [45].
Significantly, Rock Health’s 2021 year-end digital health funding study identi-
fied $3.2B in funding for healthcare marketplaces in 2021 [9]. digital health plat-
forms or marketplaces include two sided or multi-sided networks and platforms.
Two-sided networks—This go-to-market approach builds a product or service that
is valuable to one market constituent, and then leverages that network of users, and/or
the data generated by those users, into a sale to a second market constituent [43].
Multi-sided platform—The multisided platform business model is, basically, a
service or product that connects two or more participant groups, playing a kind of
intermediation role. Its value proposition is to enable this connection, making it
easier for them to find and relate to each other [46].
These business models typically engender network effects and have mutually
reinforcing dynamics based from the two complementary customer sets. A two-­
sided marketplace works well when its design allows it to add increasing numbers
of users to create a network effect-when a product (like delivering a health outcome)
or a service (like a network of social service providers) becomes more valuable as
more people use it.
34 J. M. Nathanson

Building Customer Value

• Time saved to find the service brokered by the marketplace

• Hassle and friction reduced in finding services
• Increased trust in marketplace system vs. the alternative
Highlighting distribution strategies, Yoo identifies another GTM, Distribution
partnerships through aggregators. She cites the growing number of single digital
health solutions as a cause for vendor fatigue and a drive to streamline the aggrega-
tion and purchase of digital health products through aggregators or already existing
incumbent channels for enterprises [43].
The marketplace for hybrid products is evolving. Companies offering new com-
bined care delivery products with advanced analytics are finding renewed go-to
market traction with payers. McKinsey & Co identified this adoption trend to better
serve individuals with increasing complex healthcare needs [47].
They observe continuous provider interventions for chronic disease and long-­
term condition management supported by payers. Acquisitons and adoption of
“next-generation” managed care models by nine of the top ten payers are key indi-
cators of a growing trend in care delivery. From their assessment these models for-
tell a payor reoriention focused away from operational concern targeting financing
and pricing risk toward a more integrated managed care model to better align incen-
tives to provide higher-quality, beter experience, lower-cost and more accessible
care [47].
The authors also observe a shifting market with growing investments in alterna-
tive sites of care and pursuit of diversified business models for health systems
encompassing a greater range of care delivery assets (physician practices, ambula-
tory surgery centers and urgent care centers) that are generating returns above
expectations. These lowered costs are generated by enhanced coordination,
improved patient experience and enhanced quality of provided services. They sense
indications of greater emphasis toward innovative tech-enabled care that “unlocks
value by integrating digital and non-acute settings into a comprehensive, coordi-
nated and lower-cost offering” [47].
The healthcare services market is shifting, with technology enhancing all seg-
ments of the healthcare ecosystem. Payers and providers are better enabled to link
actions and outcomes. Consumers are engaged with real-time and convenient access
to health information. There is an increased integration of data analytics, utilization
management and clinical information systems. Areas such as behavioral health and
social determinants of healthare are driving innovation. Patient engagement and
population health management are enhancing innovation
Regardless of the initial strategy to market, successful health innovators
resolve identified market pains for specific customer segments. They deliver
tested value propositions through new distribution channels, funded by new
revenue models
2 Driving Outcomes-Digital Health Business Model Innovation 35

Additional Business Model Considerations

Healthcare requires innovation. Despite the pandemic, healthcare costs continue to

increase while health outcomes are worse than most industrialized nations.
Remember over $4 trillion is spent on healthcare annually, over $12,500 per person
and rising, accounting for almost 20% of our National Gross Domestic Product. \\If
one-third of the market is waste, then there is a $1.3 trillion-dollar market for effi-
cient, engaging digital health products that deliver on their value propositions.
Startup founders and teams seek to gain a deeper understanding of the require-
ments for solutions and potential value creation they might develop and control. The
quest for digital health entrepreneurs is an “executable path for sustainable distribu-
tion and value capture”. The market has improved in terms of system integration,
absorption and payment [43].
The first step is assessing how your business creates, delivers and captures value
for customers.
Then, your business is fundamentally envisioned around this clear, new customer
need. Your challenge is to align your key resources, processes and profit formula
around your new value propositions.
There are many new players in the field. We have seen the entry of Apple, Google,
Salesforce and Microsoft. Each of these have their own distribution networks and
value propositions.
Amazon is still trying to find its optimal path to impact the healthcare industry.
Recent acquisitions indicated a major new thrust. One Medical, a membership-­based,
technology enabled concierge primary care network offering digital and in-office care
and PillPack, an on-line drug by mail provider were acquired. The combination
seemed to foretell a vertical integration of healthcare services. Though, recently it was
announced that the internal virtual Amazon Care offering was going to be closed.
We expect that despite their size and product development expertise they will all
use similar variations of the design methodologies to bring their products to market.
Yet, will they truly disrupt healthcare? Or, is this a great time for passionate aligned
entrepreneurs?

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consumer-­adoption-­of-­telemedicine-­in-­2021/
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­healthcare-­value-­creation-­through-­next-­generation-­business-­models
Chapter 3
Innovating with Health System Partners:
Value Propositions and Business Models

Susan L. Moore

Health Care Innovation and Digital Health Opportunity

In 2001, as part of its historic in-depth analysis of health care in the United States,
the National Academy of Medicine (NAM) found that information technology (IT)
had the potential to promote the provision of health care that achieved the six key
aims of being safe, effective, patient-centered, timely, efficient, and equitable [1]. In
its report, the committee noted the potential for health IT to play a critical role in the
transformation of the health system. Over the decade and a half since, technological
advances in health care and otherwise have occurred at an extraordinary pace,
resulting in a “digital revolution” as new, previously unimagined systems and solu-
tions have come into being, together with the ability to capture near-unfathomable
volumes of data that promise hidden answers to all of health care’s problems [2].
A clear trend has emerged over the last few years with regard to the use of exist-
ing and emerging digital health technologies to identify and implement novel solu-
tions, augmented by a perceived need for collaboration among industry partners,
technology developers, health care leaders, clinicians, patients, community mem-
bers, and public health practitioners. The passage of the twenty-first Century Cures
Act reflected additional interest in this direction at the federal level by providing
$4.8 billion to the National Institutes of Health over 10 years, dedicated to multiple
initiatives that drive innovation in digital health [3]. Increasingly, these technologies
are miniaturized and mobilized, taking advantage of ever-increasing computing
power contained in smaller and smaller devices [4]. The pace of global market
growth in mobile digital health alone clearly demonstrates the extensive landscape

S. L. Moore (*)
Colorado School of Public Health, University of Colorado at Anschutz Medical Campus,
Aurora, CO, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 39

A. Meyers (ed.), Digital Health Entrepreneurship, Health Informatics,
https://doi.org/10.1007/978-3-031-33902-8_3
40 S. L. Moore

of opportunity in this sector, with a 47.6% compound annual growth rate and a pro-
jected market value of up to $59 billion by 2020 [5].
In 2015, the New England Journal of Medicine (NEJM) Group announced a
new resource, NEJM Catalyst, targeted toward clinical decision makers and health
care leaders who seek to drive transformative change in health care through inno-
vation [6]. In a business context, the concept of innovation represents not only the
new idea itself, but the application of the new idea as a solution to an existing
problem or unmet need [7]. Considered from this perspective, innovation encom-
passes a range of activities designed to discover, develop, and improve solutions,
processes, operations, functions, and outcomes. As a result, it seems only natural
that the health care industry, with its commitment to continually improving
aspects of health care such as quality, value, delivery, and overall population
health, would be a welcoming environment for innovation, even disruptive
innovation.
In a recent survey of health care leaders, Catalyst reported that hospitals and
health systems, health care information technology (IT), and primary care were
identified as the top three areas most in need of innovation [8]. Moreover, respon-
dents overwhelmingly felt that not only was innovation essential to improve
health care, but that the principal drivers of innovative change would come from
outside health care organizations [8]. Health care executives, administrators, and
clinicians all believed that crucial change for hospitals and delivery systems over-
all and in health IT in particular would come from focused startups rather than
internal experts or existing organizations, which is good news for digital health
entrepreneurs.
However, despite identified need and express willingness to innovate, health
care is a complex adaptive system [9–11]. Such systems are non-linear, dynamic,
and inherently chaotic, exhibiting emergent behaviors and unanticipated conse-
quences [10]. As a result, innovation in one area of health care can cause unex-
pected problems in other areas. In The Digital Doctor, Robert Wachter describes
in detail how a series of perfectly logical, automated, error-checked steps within
a state-of-the-art computerized prescription order-and-dispensing system resulted
in a 16-year-old patient being given an overdose of medication that was 39 times
higher than what he should have gotten [12]. Awareness of such risk leads to
notable reluctance among health system stakeholders when it comes to adopting
unproven solutions.
Resistance to change is also a factor that affects innovation adoption, driven in
part by the complex adaptive system, but also by innovation fatigue among end
users [13]. A 2016 study in the Annals of Internal Medicine found that for each hour
health care providers spent providing direct clinical care to patients, they spent an
additional 2–3 hours performing administrative work—the majority of it due to
required interactions with electronic health records and similar systems [14]. No
matter how impressive the technology, it’s perhaps quite understandable why pro-
viders might be reluctant to further burden themselves without good reason. In
short, without substantial evidence of impact and worth, innovative digital health
solutions may never be adopted at all.
3 Innovating with Health System Partners: Value Propositions and Business Models 41

 aking the Case for Digital Health Solutions:

M
The Value Proposition

One way for digital health entrepreneurs to distinguish themselves and their prod-
ucts from the mass of competitors, promote adoption, and increase their chances of
establishing advantageous relationships with health system partners is to develop a
strong value proposition.
A value proposition is a clear, concise statement that convincingly articulates
why a customer should purchase a particular product. A digital health company or
product can have more than one value proposition, depending on how many differ-
ent market sectors or unique customers are being targeted. At its core, the value
proposition describes what the product does to solve a problem or meet a need, for
whom, and what benefit can be expected as a result. An effective value proposition
should address the following key elements [15]:
• Relevance
• Quantified value
• Unique differentiation
Relevance refers to the product’s appropriateness and ability to meet the customer’s
needs or solve a problem that the customer has. Quantified value refers to the spe-
cific benefits that the product can provide to the customer. Finally, unique differen-
tiation refers to the set of identifiable factors that enable a product to stand out from
other similar products in the market in ways that make the product well-suited for
the customer (the product’s fit).
The Value Proposition Canvas, created by Alexander Osterwalder, is a diagram
and visual tool set that digital health entrepreneurs can use to define and refine their
products and offerings, understand and describe their customer and target market,
and identify ways to achieve fit (Fig. 3.1) [16].

Fig. 3.1 The Value Proposition Canvas (©Strategyzer AG) Source: https://strategyzer.uservoice.
com/knowledgebase/articles/506842-­can-­i-­use-­the-­business-­model-­canvas-­or-­value-­propo
42 S. L. Moore

On the left side of the Value Proposition Canvas is the Value Map (the square
box). The Value Map is where the user defines the features and characteristics of
their innovative, entrepreneurial solution. The more specific the definition, the bet-
ter; vague and nebulous descriptions won’t help promote clarity or understanding
either for the entrepreneur or the customer. At the same time, it’s best to keep things
short and sweet, because the more detailed the explanation required, the less likely
the customer is to be successfully engaged by what the entrepreneur is trying to do.
The three sections of the Value Map are:
• Products and Services: This section is where the user identifies the specific
items or things that their solution is, does, and provides to the customer. The list
created in this sector of the map comprises the central elements of a value
proposition.
• Gain Creators: This section should be used to identify the ways in which a digi-
tal health solution can provide or create value for the client.
• Pain Relievers: This section should be used to match the needs that a customer
has to the particular aspects of the digital health solution that will solve the cus-
tomer’s problems for them.
Both gain creators and pain relievers should ideally be written in such a way as to
describe not only the what, but the how. The ideal statement should be explanatory,
but succinct, with no more than one short sentence per gain creator or pain reliever.
The right side of the Value Proposition Canvas contains the Customer Segment
Profile circle. The sections of this circle can be used to quantify and describe a cus-
tomer in a detailed, structured fashion. This allows the entrepreneur to simplify the
customer down to core components which comprise the central nature of a business
relationship: namely, what does the customer do in their work (the customer’s jobs),
what needs or problems does the customer have (the customer’s pains), and what
precise advantages the entrepreneur’s solution can provide (the customer’s gains).
Rather than trying to use the circle to create a single profile that represents all
things to all customers, separate profiles should be created for each customer market
segment. This allows the capture of unique elements that might be different from one
customer to another, which in turn helps identify a specific value proposition for each.
In order to craft a good value proposition, therefore, digital health entrepreneurs
first need to understand their customers’ profile characteristics and their overall
target market. This includes the things that their customers need to do and the prob-
lems or the difficulties that their customers currently have which could be solved by
a digital health product.

Understanding the Health Care Market

The health care market represents a significant opportunity for digital health busi-
ness investment. National health expenditures in 2016 amounted to $3.3 trillion and
accounted for 17.9% of total national gross domestic product [17]. Within those
3 Innovating with Health System Partners: Value Propositions and Business Models 43

expenditures, hospital care accounted for 32%, physician and clinical services
accounted for 20%, and prescription drugs accounted for a 10% share. Health care
spending is expected to continue growth at a rapid pace, and is projected to increase
overall by almost 75% to $5.7 trillion over a mere ten years [18]. As of March 2018,
hospitals and health delivery systems in the United States accounted for $991 bil-
lion in market share, which alone represents a full 5% of national gross domestic
product ($19.4 trillion, 2017) [19, 20].
According to the American Hospital Association, there are currently 5534 hospi-
tals in the United States, including 4840 community hospitals, 209 federal govern-
ment hospitals, 397 non-federal psychiatric hospitals, and 88 other hospital types
including prison hospitals, long term care facilities, and school infirmaries [19].
Among community hospitals, the vast majority (n = 2849) are not-for-profit and
non-governmental, with an additional 956 nonprofit hospitals supported by state
and local government. The remaining 1035 community hospitals are classified as
for-profit or investor owned. Geographically, 62% of community hospitals are
located in cities and other metropolitan localities, with the remaining 38% located
in rural areas.
Hospitals don’t always operate as independent entities—in fact, just the oppo-
site. Two-thirds (68%, n = 3321) of community hospitals are classified as members
of health delivery systems, and 35% (n = 1689) are members of health care net-
works [19]. Health delivery systems are each owned or managed by a central orga-
nization. A system can be structured as multiple hospitals in association or as
diversified, integrated delivery systems that include a single hospital combined with
three or more other integrated health service organizations, such as primary care
clinics, that represent at least 25% of the overall business makeup. In contrast,
health care networks represent multiple organizations in collaboration to deliver
coordinated services to their region. Membership in one does not preclude member-
ship in the other, as an organization can be a member of both a system and a network.
When it comes to meeting health care needs and providing benefits to hospital,
health system and practice partners, it’s important to recall that the actual decision-­
making customer is not the organization itself, but one or more of the people within
it. There are over 13 million people in the United States health care workforce in
2018, of whom just under one million (n = 968,743) are physicians [21]. According
to the American Medical Association’s Physician Practice Benchmark Survey, most
physicians (68%) work in group practices, whether single-specialty (43%) or multi-­
specialty groups (25%), as opposed to other practice types, and under ten percent of
health care providers are directly employed by hospitals [22]. Only 17% of physi-
cians work in solo practices, and fewer than half of physicians (47%) own their own
businesses.
Examples of hospital, health system, and health care practice influencers, key
stakeholders and decision makers include:
• C-suite executives. Among the roles filled by these personnel are chief executive
officer, chief financial officer, chief operating officer, and chief information or
technology officer. These individuals hold high-level responsibility for organiza-
44 S. L. Moore

tional and operational performance, and often have the final say over budgets,
discretionary spending, and other financial matters.
• Health care administrators. These personnel include various management and
leadership roles, such as innovation managers, practice managers, and team leads.
• Health care providers. Providers include physicians, nurses, and advanced
practice providers such as nurse practitioners and physician assistants [23, 24].
As targeted end users who often serve in leadership roles, providers often have
particularly strong influence on digital health product decisions.
• IT professionals. Database and application administrators, security specialists,
and technical support managers all have the potential to influence purchasing
decisions for products that need to be integrated into existing information system
architectures.
• Patients and caregivers. In addition to making purchasing decisions as consumers,
patients and caregivers often serve in advisory capacities for hospitals, health sys-
tems, and practices, and provide their insight and expertise accordingly.

 ospital, Health Delivery System, and Health Care Practice

H
Pains and Gains

As part of creating an entrepreneurial profile for targeted health care customers, it is

essential to appreciate the work that potential health care clients are trying to do, the
challenges that they are experiencing, and the sectors of the market that hold the
greatest possibility of benefit. Digital health products and solutions that align with
health care market needs are significantly more likely to be adopted. In short, what
matters to the potential client must also matter to a digital health entrepreneur.
While a comprehensive review of all current health care needs is beyond the scope
of this chapter, several key concerns are presented below.
A Commonwealth Fund survey of 33 innovation centers affiliated with health care
delivery systems across the United States found that nearly 90% of respondents were
focused on care coordination, disease-specific outcomes, and access issues [25].
Additional areas of emphasis included patient engagement (84%), population health
(77%), and clinical decision support (74%). These spheres of opportunity are closely
aligned with critical needs identified by health system leaders [26, 27]. Such pains
include but are not limited to providing value-based care, particularly in a rapidly-
changing legislative environment with the potential to exert major impact on industry
payment models and reimbursement approaches; providing care that is more patient-
centered, consumer-focused, and personalized; and improving health outcomes and
care management at the population level in addition to the individual level. Each of
these broad topics can be further segmented, for instance into an interest in predictive
analytics for chronic condition management or a desire to improve care across the
continuum by addressing the social determinants of health. Being aware of these and
other health care trends in developing and promoting solutions that are responsive to
the market will contribute to entrepreneurial success.
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ryhdikäs, — vaatteissa, jotka verhosivat häntä kuin arat ajatukset.
Tuokin palmikon nauharuusu oli kuin kauniin kukan lehti! Mutta
kaikesta kauneinta oli hymy ja se viehkeän itsetiedoton ystävällisyys,
mikä loisti pitkulaisista, puhdasviivaisista kasvoista…

*****

Päivällinen tuulenkäännös sai illalla aikaan mylvivän myrskyn, joka

kiskoi Jäämereltä korkeita vesivyöryjä ja löi ne rannan
kallionyppylöitä vasten.

Suuri kainulais-tupa, jossa oli katto matalalla ja ikkunat pienet, oli

tupaten täynnä väkeä.

Kaikki olivat sijoittuneet paikoilleen ja heidän äänettömyytensä oli

synkkä. Heidät oli täyttänyt värisyttävä ahdistus, kun he odottelivat
sitä kauhunhekumaa, mikä nyt tarjottaisiin heille; suomalainen veli
Karjalainen aikoi nimittäin puhua tänä iltana.

Karjalainen nousi, laihana, tummana ja kookkaana. Hän nousi kuin

ilmestys siitä kelmeästä valonhäiveestä, mikä levisi lampusta tuvan
sakeaan ilmaan. Mustain silmien tavattoman voimakas katse siirtyi
verkkaan seurakunnan yli, ja se vaikutti kaikkiin kuin äänetön
raskaus rajuilman edellä. Hän risti kätensä ja sulki silmänsä, rinta
kohoili voimakkaasti. Sitten hän alkoi sangen hiljaa ja verkalleen:
"Isä meidän, joka olet taivaissa!"

Sanat kuuluivat kaukaiselta merenkohinalta. Tavut aaltoilivat,

huokailivat —, vyöryivät hitaina, kumeina toisiaan vastaan, kun hän
rukoili mielettömällä hartaudella, hervottomalla antaumuksella, aralla
nöyryydellä. Ja kun hän kummallisen alakuloisella, pehmeällä
äänenpainolla, jossa tuntui sydämen väristys, kerjäsi Jumalaa
viidennessä rukouksessa: "Ja anna meille meidän syntimme
anteeksi!" — silloin naiset herahtivat nyyhkytyksiin, ilman
kauhistuksen tuskaa, vain epämääräiseen liikutukseen rauenneina.
Mainingit Karjalaisen mahtavasta sielusta, sankariolennosta levisivät
ulospäin, kuulijakuntaan, hervoittivat sen, paisuivat värisyttävän
kylminä ja kuumina sen hermojen yli.

Karjalainen istuutui. Hän viritti virren, herkentyneet mielet liittyivät

siihen, ja laulu kohosi ilmoille. Sen läpi kiiti pyörteenä hekuman
tunne, ja ilma tuvassa väräjöi, niinkuin se olisi ollut elävää verta, jota
aistillinen kiihko ja levottomuus vapisuttaa.

Peloittavia olivat ne sanat, jotka sitten alkoivat purkautua

Karjalaisen rinnasta, niinkuin hän olisi ollut merihädässä.
Kurjannäköiset merilappalaiset, joilla oli likaisenkellervät
sarkavaatteet ja joiden leveillä, luisevilla kasvoilla oli naivi, pelästynyt
ilme, huojuttivat yläruumistaan ja tähyilivät avuttomina ympärilleen.
Kiihkomieliset, selkoselälleen avatut silmät, joissa oli Suomen
metsien synkkyys, sekä naisten uikutus herpaisivat tähän saakka
tyyninä pysyneet kalastaja-norjalaiset. Yli tämän kuoron, joka alkaen
kuumina huokauksina ja puuskuvana itkuna kohosi vähitellen
yksiääniseksi parkunaksi, kumisi Karjalaisen soinnukas ääni, ja silloin
tällöin kuului Jäämereltä tulevan myrskyn ankara töytäys huoneen
nurkissa, kun se vonkui läpi laakson ja riehui suurten autioiden
lakeuksien yli. Ihmiset huusivat ja takertuivat kiinni toisiinsa.
Karjalainen pysähtyi ja seisoi kuin jumala, katsellen miten
ihmismadot kierivät tomussa.

Mutta muutamat olivat riettaita julkeassa, teeskennellyssä

uskonhurmiossaan, kuten eräs nainen Jussan kotipitäjästä. Hän oli
ensimäinen hyppimässä ja rämyämässä leveä kita ammollaan.

Karjalainen alkoi taas puhua. Hänen kasvonsa alkoivat seljetä.

Huumaavalla riemulla ja äänenpainolla, joka imi voimansa kylläisestä
sydämestä, lukee hän paksusta Raamatusta: "Sillä karitsa, joka on
valtaistuimen keskellä, on kaitseva heitä ja johdattava heidät elämän
vesien lähteille ja Jumala on pyyhkivä pois kaikki kyyneleet heidän
silmistänsä". — Hän myhäili, hän hymyili, kuulijat myhäilivät,
hymyilivät, ja ratkesivat nauruun. Muutamat hypähtivät ylös,
tanssivat ja riehuivat mielettömyyden huimassa ilossa, kumosivat
tuoleja, penkkejä ja lavitsoita, heittäytyivät riemusta ulvoen toistensa
syliin, naiset ja miehet yhtenä rypäänä. Eräs nuori, lihava vaimo
riehui kuin tanssiva velho. Housut valahtivat alle polvien. Hänen
miehensä nykäisi häntä päällystakista: "Vedä housut ylös!" Mutta
vaimo ei tajunnut mitään. Riiviöt hymyilivät toisilleen helakasti.
"Daavidkin tanssi alasti Herran arkin edessä".
 Ja kun tanssijat vähitellen lopen väsyivät ja laskeusivat pitkäkseen
humalaisina, nousi kokouksen johtaja, sanoen: "Tunnustakaamme
syntimme!"

Tuo lihava vaimo virkosi äkisti, kävi ripeästi käsiksi housuihinsa,

kiskoi ne ylös ja työnsi tarjottimelle ainoan ainokaisen syntinsä: — —
— "muuan matkaileva veli — — kun nyt on pitkämatkalainen ja
lisäksi uskonveli, niin eihän ole aina niin helppoa — — —", ja hän
kiitti synninpäästöstä mehevällä hymyllä, Jussan-puolelainen
rämäkkä vaimo ei halunnut olla toista hitaampi, vaan kiiruhti
kertomaan muutaman riettaan jutun.

Ja sitämukaa kuin monet ahdistetut omattunnot kevenivät, niin

että vihdoin voitiin sanoa oltavan melkein puhtaita synnistä, alkoi
mieliala kohota. Miehet hakkasivat tupakkaa nysiinsä, pakinoivat
hevosista ja juttelivat Jumalasta. Naiset leiriytyivät Karjalaisen
ympärille, ja yksi voitti toisensa moninaisilla, suloisilla tarinoilla
Hengen melkein uskomattomista armotöistä kertojaa kohtaan.
Hurmahenkiset ahmivat silavaa ja lohta ja hörppivät suuhunsa
kahvikupin toisensa jälkeen.

*****

Jussa oli aivan hämmennyksissään, kun hän myöhään illalla kulki

asuntoonsa lahdenrantaa pitkin. Karjalainen oli suuri ja kaunis kuin
profeetta, kun hän rukoili, kun hän lauloi, kun hän puhui, ja kun hän
istui aivan vaiti… "Isä meidän joka olet taivaissa!" — Vieläkin
humisivat tavut hänen korvissaan aalloten raskaasti ja hitaasti kuin
ne laineet, jotka vaienneessa ilmassa vierivät hitaina, unisina lahden
yli… Jospa hän joskus voisi puhua niinkuin Karjalainen! Niin, jospa
hän voisi joskus tulla papiksi!… Seisoa kirkon korkean kuvun alla,
korkealla saarnastuolissa, yksin, erillään joukosta, pitkässä, mustassa
kaavussaan, valkoinen kaulus kaulassa, — kalpeana, rukoilevana,
kaikkien katseiden hivellessä häntä.

Hän pysähtyi puutarhan portin luona. Vain yksi, ylhäällä katon

rajassa oleva ikkuna loisti valoa. Hän näki jonkun varjon liikkuvan
uutimen yli pari kertaa. Siitä heräsi hänessä hivelevä tunne ja ajatus,
että Elna nyt meni maata ja sulki silmänsä, nuo ruskeat silmät,
joiden katse oli niin painava. Ajatus tuli yhä mieluisammaksi, kuta
kauemmin hän siinä seisoi. Ja kauan hän seisoi. Silmäluomet alkoivat
vaipua kiinni, lopulta hän näki vain riutuvan valoviirun siitä
hohteesta, minkä revontulet kokosivat suuresta, meressä loistavasta
pallosta. Vielä kuuli hän rauhallisten maininkien sihisten vierivän
lahdessa.

Pää vaipui karvaiselle peskin kaulukselle, ja Jussa uneksi, että

Elnan hengitys lämmitti hänen kasvojaan ja että ruskeiden silmien
verhottu katse liukui hiljaa häntä kohden… Hän heräsi juuri siinä
hetkessä, jolloin hän aikoi tarttua tuohon katseeseen kädellään.
IV.

Eräänä kuumana kesäpäivänä istui Biettar Oula erään Hukan

viisisoutuisen varjossa rannalla, ja pureskeli kuivattua poronlihaa,
vahvistaakseen itseään pitkälle tunturiretkelle. Hän oli ostanut
kokonaisen porokuorman kahvia ja sokeria sekä tarpeellista
rihkamaa, — kuten ompeluneuloja ja lankaa, pienen padan ja hiukan
saippuaa. Elle alkoi käyttää sitä viime aikoina yhä enemmän, —
hienostuakseen.

Kun hän oli valmis, hän työnsi jäännökset parkitusta poronnahasta

tehtyyn säkkiin, jonka hän sitten sitoi säkkisatulaan, ja aikoi juuri
lähteä, kun Hukka tuli kaarrellen alaspäin, kiiruhtavin ja raskain
askelin.

Äkätessään aamulla Biettar Oulan, Hukka oli laskenut oikean

pattivalan, luvaten häväistä ja korventaa tämän. Mutta hän oli sen
lykännyt ja lykännyt ja oli sillävälin touhunnut lepäämättä pihalla ja
tuvassa ja purkanut kiehuvaa sappeaan oman väkensä yli: sitä
hänen ei tarvinnut aristella. Äh, olisipa se tullut vuosi sitten! Silloin
asia oli aivan veres, ja silloin hän olisi laskettanut kaksikymmentä
ruostunutta rautakuulaa Biettar Oulan läpi, — sen kirotun
sudensyötin… Me vanhenemme, ja ikä hieroo meistä pois
intohimomme, rohkeutemme. Vielä puolikymmentä vuotta sitten
Hukka ei koskaan epäröinyt, kun oli tarvis purkaa jäytävää
närkästystään tai sanoa salattu totuus. Mutta nyt! Hän oli kuitenkin
keksinyt selityskeinon leväperäisyyteensä. Järkevä ihminen, kuten
Biettar Oula, — niin hän oli tänään tuuminut ja sanonutkin —, olisi
tietysti ajanut takaisin kotiinsa tuon huikentelevaisen tyttölapsen, jos
olisi sen sattunut näkemään, — ja olihan koko juttu jo vuoden
vanha. Eihän sille mitään mahtanut, että tytönheilakka oli ollut kyllin
huimapäinen, lähteäkseen pojan jälille tunturien taa…

Hukassa ei ollut nytkään mitään innostavaa kiihkoa, joka olisi

hänet ohjannut Biettar Oulaa kohti, ainoastaan heikko toivo, että
rohkea viha heräisi ratkaisevana hetkenä; koettaa sieti kuitenkin.
Hän seisahtui, varjostaen kädellä katsettaan… Ehkä sentään oli
parasta alkaa varovaisesti. "Biettar Oulahan siinä?"

Niin oli.

— Sinun karjasi on lännessä, tuntureilla?

— Niin, kolme penikulmaa täältä.

— Eikö ole vaikea kulkea niin tukevasti puettuna näin lämpymällä

säällä? — Biettar Oulalla oli päällään kaksi sarkatakkia, ja suuri,
sarkapäällystäinen neljän-tuulen-lakki oli täytetty haahkanuntuvilla…
Mutta hänen ahavoituneilla, täysruskeilla kasvoillaan ei näkynyt
hikipisarta; hänen kehittyneitten raajojensa lihakset olivat kiinteät ja
lujat kuin jäntereet.

— Niin niin, — no onnea kotimatkalle!

 Hukka oli tänään paljon touhunnut toteuttaakseen suuren
päätöksensä, — ja tähän se sitten kuivi koko juttu! Hän istuutui
hirrelle ja viipyi siinä kauan murheellisena ja nolona. Lopulta tuo
vanha uros, tuo kerran niin häikäilemättömän rohkea ja itsevaltias
Hukka puhkesi itkuun. Ei hän olisi uskonut näin mitättömäksi
joutuneensa. Jumala paratkoon — eihän hän enää uskalla opettaa
tunturilappalaisellekaan jänislaukkaa!… Oli niinkuin hän nyt vasta
olisi huomannut, että käsiselät olivat alkaneet tummua ja niissä oli
pyöreitä, ohutta karvaa kasvavia kuoppia, ja orvaskesi oli rypistynyt
läskikerrosten kadottua. Hän oli parina viime vuonna usein puhunut
pistäytyvänsä Arkangelissa vanhan ystävänsä konsuli Kokowstzeffin
luona. Tänä vuonna hänen oli täytynyt lykätä se retki huonon
terveydentilan takia ensi vuoteen. "Ja Herra tiennee, tuleeko siitä
silloinkaan tosi!"

Ja vanhus itki hereästi. Hänet oli niin säälimättömänä yllättänyt

ahdistava tunne siitä, että hän oli vaipumassa tyhjyyteen.

*****

Biettar Oula oli ehtinyt ulos lehtimetsästä. Hänen vanha, tuttu

polkunsa nousi jyrkästi tuntureille, harmaata, sammalpeittoista
kivirinnettä myöten, missä vanhoja, homehtuneita luita paistoi
auringonvalossa, vaalenneina ja puoleksi ohuen nurmen peitossa; —
siinä olivat jäännökset eräästä venäjänpuolelaisesta rosvojoukosta,
jommoisia muinaisina aikoina Venäjän-Karjalasta samoili lukuisasti
lappalaisalueille ryöstäen ja murhaten.

Täällä tunturilla oli eräs sellainen joukko muuanna synkkänä

syysiltana tavoittanut erään tunturilappalaisen ja pakoittanut hänet
oppaakseen. Alamäki oli vaarallinen, sanoi lappalainen, ja senvuoksi
heidän piti sitoa itsensä kiinni toisiinsa. Itse hän, soihtu kädessään,
kulki edellä, ja joutuin, puolijuoksua. Mutta jouduttuaan aivan
kallionjyrkänteelle, hän viskasi soihdun rinnettä alas, pujahtaen itse
piiloon erään kiven taakse; karjalaiset riensivät soihdun jälessä, ja
syöksyivät jyrkänteeltä kuoliaiksi.

Biettar Oula oli ehtinyt kauas tunturilakeudelle ja asteli nyt

kesäyön viileässä auringonpaisteessa. Siellä täällä oli nurmitäplä,
jolle viimevuotinen kuloheinä antoi harmaan vivahduksen. Kellervä ja
harmaanviheriä jäkälä levisi tiheänä ja paksuna kivikkorinteitä pitkin
ikuisen lumen peittämän tunturihuipun juurella. Puro luikerteli
harmahtavien pajupehkojen ja yhteentakertuneiden, pyöreälehtisten
vaivaiskoivujen välitse ja katosi muutamaan muuranrämeeseen.

Kuovi pyrähti lentoon harmaalta kivipaadelta, kalkutti pitkällä,

alaspäin kaartuvalla nokallaan riuduttavan alakuloista ääntä, jossa
kajaili lakeuden yksinäisyys, — ja laskeusi aroin, varovaisin
siivenlyönnein toiselle paadelle.

Läheisten tunturihuippujen lumi hohti kullalta ja kaukaisemmat

uivat kuin valkoiset joutsenet yön sädeloisteessa. Ja puhtaan taivaan
väri oli syvä kuin meren.

Väliin kaikui rinteiltä ja rotkoista vesiputousten kaukainen kumina

lakeuden ylhäiseen äänettömyyteen.

Biettar Oula kulki erään mutkittelevan halkeimen yli, ja kohta

avautui hänen eteensä suuri alanne, minkä pohjalla lepäsi pieni,
pitkulainen järvi. Aivan rannalla sijaitsi hänen purjekankainen
kesätelttansa. Ohut, sininen savu kohosi teltan edessä palavasta
pienestä nuotiosta. Taustalla, ikuisella lumiaavalla makoilivat porot
päivää paistattaen, suloisesti nauttien rauhaa, jota hyttyset eivät
häirinneet. Alempana, kuivalla sammalmättäällä, oli Aslak pitkänään,
kädessään sauva ja koirat ympärillään.

— Atshe! Atshe! (Isä! Isä!), huusi pikku Andi, joka parastaikaa

harjoitteli suopungin heittämistä pajupensaaseen. Elle istui nuotion
ääressä, ommellen valkeita sarkahousuja Biettar Oulalle.

— Tervetuloa kotiin, Oulatsham! — No — — miten onnistui

matkasi?

— Kiitos, hyvin vain! Biettar Oulalla oli paljon kerrottavaa

istuessaan syömässä keitettyä, tuoretta lohenmullosta, ja Elle korjasi
talteen ostokset. Biettar Oula kertoi sisämaan uutisia. Jussa oli
matkustanut Suomeen erääseen suureen kaupunkiin, lukeakseen
papiksi. "Hänestä tulee varmaan suuri herra", sanoi Elle. "Ja
uskovainen hänestä voi myös tulla, kun hän ehtii kylliksi tutkia
Jumalan sanaa. Ja olihan hän niin taitava suomessa".

Ja Nikko Nillen ämmä kuuluu olevan sairaana, tiesi Biettar Oula.

— Niinkö — vai niin! Kyllä Nikko Nille nyt kohta pakahtuu

kärsimättömyydestä kuolinuutista odottaessaan… Ellei ämmä vaan
virkoa taas, muista aiettaan mennä vielä kolmannelle.

— Minäpä haluaisin, sanoi Biettar Oula, "lähettää Nikko Nillelle

pikaviestin tästä uutisesta, jos hän olisi lähempänä. Uutinen on sen
arvoinen, että minä voisin sen takia ostaa hänen ystävyytensä
makeineen karvoineen. Hän ehkä kuitenkin voisi hyljätä kavalan
ajatuksensa, että muuttaisi etelään syksyllä ennen meitä ja
pyyhkäisisi edestämme ne porot, jotka pääsevät muuttomatkalla
pakoon meiltä. Hän on tullut pitkäkyntiseksi, Nikko Nille".
 Biettar Oula taisi närkästyä moraalin puolesta, kun kunnon mies
lankesi syntiin. Ja nythän oli sitäpaitsi valoisa kesä; hänen mielensä
oli niin kevyt ja valoisa, ja hänen pahattyönsä melkein vuoden
vanhat: Biettar Oula teurasti vain syksyllä tai talvella; silloin liha ja
nahka olivat parhaimmallaan… Niin että Biettar Oula saattoi hyvin
puhua pitkäkyntisistä ihmisistä näin kesällä, kun mieli oli valoisa ja
kevyt.

Elle laski käsivartensa hänen hartioilleen, katsoi hyvin hämillään

alaspäin ja sanoi: "Jospa voisit hyljätä rajut tapasi, Oulatsham!"

Biettar Oula hymyili; hänen oli tapana suoriutua Ellestä hymyilyllä,

kun tämä herkesi puhumaan hänen "rajuista tavoistaan". Vahvempia
sanoja hän ei oikein uskaltanut käyttää. Mutta tuo leppeä ilme sai
Ellen niin hämilleen — ja aseettomaksi. Biettar Oula hiveli hänen
soman täyteläistä selkäänsä. Ei kellään muulla tunturien naisella ollut
niin kookasta, rehevää ruumista. Povi huokui lyhyen, väljän
lapintakin alla.

— Katsohan! sanoi Biettar Oula. "Kas vain!… Millainen käsi sillä

pojalla onkaan! Hän oikaisee suopungin juuri oikealla hetkellä. Se
tarttuu pensaaseen kuin kärppä. Kas vain!… Pensas hosuu ja riitelee
vastaan kuin vasikka… Kyllä ihmiset taitavat olla oikeassa, kun
arvelevat, että Andista tulee tunturien paras mies".

— Matta mitä tulee tunturien ensimäisestä tytöstä? kysyi Elle ja

vilkaisi häneen hymyillen puoleksi leikillään, puoleksi hämillään.

— Oh, älä siitä kovin murehdi! Sinähän olet aivan nuori vielä.

— Mutta muista, että Andi on kolmivuotias viime juhannuksesta.

Ja minä olen vielä parhaissa voimissani. Olisihan kovin hyvä saada
vävypoika jostakin kyläläisestä. Voisimme silloin asua oman
vävymme luona, käydessämme talvella kylässä. Ja Biettar Oulan
tytär kyllä saisi kosijoikseen kylän parhaat… Et tietysti halua miniää
kylästä?

— Miniää kylästä! — Jo sellainen ajatuskin oli Biettar Oulalle

vastenmielinen: mikä tunturilappalainen hakisi itselleen vaimon kylän
tytöistä? — "Kyllä se sotkisi meidän telttamme navetaksi… Näyttäisi
siltä kuin meillä olisi karjapiika istumassa teltassamme lavitsalla, —
lavitsa sen tietysti pitäisi saada. Ja piru sitä vartioisi, ettei se jonakin
arvaamattomana hetkenä tupsahtaisi nuotioon ja palaisi poroksi
edessämme! — Sillä et kai suunnittelekaan, että Biettar Oulan poika
lähtisi ajelemaan lantaa ja tekemään heinää parille likaiselle
lehmälle!"

He istuivat katsellen poroja, jotka makailivat pienissä ryhmissä

lumilakeudella. Niiden korvat huiskuivat tyytyväisesti, silmät
tähystivät raukeasti varhaisen aamun viileässä päivänpaisteessa, ja
leuat liikkuivat verkalleen niiden märehtiessä.

Yksi toisensa jälkeen ne nousivat ylös, venyttelivät ja oikoivat

jäseniään ja laskeusivat alas lumitantereelta. Samassa hälyttivät
koirat; mutta Aslak vain lateli tavalliset toransa, käänti kylkeä ja
nukkui taas. Porot alkoivat muovailla uusia sarventynkiään, jotka
vielä olivat verevät ja rustomaiset ja karvaisen nahan peitossa, —
takoivat ja kolkuttivat niitä toisella takakoparalla tai kiveä vastaan ja
käänsivät silmiään ylöspäin, tarkistaakseen sarvien muotoa.

Muori Biettar, joka oli nukkunut teltassa, pisti päänsä ulos teltan
ovesta. "Hyvää huomenta, Oula! — Sinä olet palannut. Nyt saamme
lypsää vaatimet!"
 Kun aurinko oli suoraan idässä, menivät ihmiset maata, ja porot
hajautuivat laitumelle.
V.

Nikko Nille oli aivan varmaan aikonut sovittaa niin, että hänellä olisi
sopiva etumatka Biettar Oulan edellä etelään muutettaessa.

Mutta silläaikaa kun hän ja muut tunturilappalaiset hautoivat

tuumiaan ja harjoittivat vakoilua, oli Biettar Oula eräänä
arvaamattomana päivänä lyönyt kamansa kokoon ja lähtenyt
teilleen, ennenkuin kuultiin hiiren hiiskausta.

Hän oli jäänyt syystiloille ainakin viisi penikulmaa kylästä

pohjoiseen, erään laakson pohjoispuolelle, juuri sinne, missä
mäntymetsä loppui ja tunturikoivu alkoi, erään puron luo ja aivan
postimiesten polun alapuolelle.

Biettar Oula ei huolinut vältellä valtateitä eikä etsiä syrjäsoppeja —

kuten porovarkaat.

Räntäiset ilmat olivat tätä nykyä, ja telttaa ympäröiviä puita

verhosi märkä harso. — Eräänä iltapäivänä pysähtyi Nikko Nille
teltan eteen, tervehtien hyvän päivän.

— Jumala antakoon! vastasi Biettar Oula, ottaen hänet

sydämellisesti vastaan ja vieden hänet telttaan.
 — Sinultakin on hävinnyt poroja muuttomatkalla, sanoi Biettar
Oula, heidän istuutuessaan poronnahoille.

— Niin, niin on! Ja nyt minä kuljeksin etsimässä niitä naapurien

porolaumoista.

— Minä näin, että yksi sinun poroistasi on minun karjassani.

Nikko Nille hämmästyi niin äkikseltään ja osasi sen niin huonosti

salata, että Biettar Oula olisi loukkautunut, jos olisi nähnyt hänen
ällistyneet kasvonsa.

Sillä totta puhuen Nikko Nille ei järin uskaltanut toivoa, että vieras
poro, joka oli joutunut Biettar Oulan ylettyviin, näkisi vielä päivän
valon.

Mutta Biettar Oulan kasvoilla pysyi tavallinen, rehellinen ilme,

niinkuin hän olisi ollut tottunut puhumaan karjaansa joutuneista
vieraista poroista.

Sillä kun yhdellä ainoalla poro-rehjalla saattoi kohentaa

muutamilta puolilta hieman ontuvaa nimeään, niin voipa Biettar Oula
kestää sen vaivan, että antoi suopungin jäädä liikuttamatta olalleen.
Ja Elle hymyili aivan ihastuneena ja oli melkein yhtä hämmästynyt
kuin Nikko Nille. Etua puolelta jos toiseltakin! — Ja muori Biettar oli
aikeen hyväksynyt. Ensin hän kyllä oli sanonut, että se olisi
hävyttömän julkea uhri kunniallisuuden alttarille; mutta kun hän
kyllin ajatteli sitä, niin hän taipui arvelemaan, että hitunen hyvää
mainetta ei myöskään pahaa tekisi. "No niin, anna elukan sitten
olla!" oli hän sanonut.
 Puhe kadonneitten porojen etsinnästä oli Nikko Nillelle oikeastaan
syyn varjo, jotta hän voi tehdä kiitos- ja sovintovierailun Biettar
Oulan luo. Biettar Oulahan ensimäisenä oli tuonut tuntureille tuon
paljon lupaavan viestin ämmän taudista. Sitten oli mennyt päiviä ja
viikkoja, ja eräänä onnen päivänä tuo tieto palasi suurempana
takaisin, kuolinuutisena. Ja Nikko Nille punastui, kun se hänelle
kerrottiin.

Niin että hän olisi hyvinkin mielellään suonut Biettar Oulalle ilon
iskeä suonta yhdeltä hänen poroistaan. Mitä merkitsi hänelle yksi
halpanen poro nyt, kun hän oli humaltunut adventtiajan suloisen
hämäristä aavistetuista: kaikki hänen kokemattomat unelmansa ja
kaipuunsa viittoivat häntä häitä kohden.

Nikko Nille säteili onnea ja kainoutta, istuessaan nauttimassa Ellen

ja Biettar Oulan ylenpalttista vieraanvaraisuutta.

Elle vaihtoi kuivat saraheinät hänen kesäkenkiinsä [komager =

pohja hylkeennahasta, kauto sekä varsi parkitusta poronnahasta], ja
hänen kanssaan oli niin erinomaisen hauska jutella avomielisesti ja
ystävällisesti. Nikko Nille oli voittanut Biettar Oulan ystävyyden. Ja
eipä siltä — hyvä oli tietää porokin pelastuneeksi. Nyt hän jonakin
päivänä lähtisi kylään — yhdessä kullan kanssa, niin yhdessä kullan
kanssa! Sen salaisuuden hän uskoi Ellelle ja Biettar Oulalle — noin
täydessä ystävyydessä.

Herra isä — kuinka hän soikaan hyvää niille molemmalle!

Hän kainosteli ilmaista onnentunteensa koko yltäkylläisyyttä; nyt

hänellä oli varaa antaa heidän tuntea, että he elivät omasta takaa.

— Eira Marit onkin paras otettava koko pitäjässä, sanoi Elle.

 — Ja sinun rinnallesi ei yksikään nuorimies pysty edes yrittämään,
mitä omaisuuteen tai miehenmieleen tulee, sanoi Biettar Oula. "Sinä
olet laintunteva ja otat osaa pitäjän asiain hoitoon".

Niin, Nikko Nille soi heille molemmille kaikkea hyvää! Soi täydestä
sydämestään.

Mutta kun Biettar Oula sitten vei hänet porolauman luo, tuntui sen
näkeminen kuitenkin kiertävän Nikko Nillen rintaan kiusallisen
pahkuran.

Vähän ajan kuluttua he keksivät Nikko Nillen poron. Toisen korvan

kärki oli katkaistu, ja toisen korvan ulkoreunassa oli kulmikas
leikkaus.

Nikko Nille piteli viivytellen tervattua suopunkiaan, joka riippui

oikealta olkapäältä vasemman kainalon alle. Mutta kun Biettar Oula
ei näyttänyt haluavan käydä ottamaan kiinni poroa, täytyi Nikko
Nillen vetää suopunki olaltaan. Hän vyyhtesi kauas ulottuvan nuoran
sopivan pieniksi renkaiksi, hiipi lähemmä poroa ja heitti, mutta heitti
ohi, — joutui hämilleen ja hermostui ja heitti ohi toisen kerran.

Silloin Biettar Oula otti suopungin, vyyhtesi sen loppuun saakka ja

heitti, niin että viuhui vain, — ja siellä kaukana lauman keskellä
kellistyi poro, niinkuin olisi saanut väkäkeihään ruumiiseensa. Hän
veti sen luokseen siirtymättä jalkainsa sijoilta.

Nikko Nille tunsi taas jonkun pahkuran kiertyvän rintaansa. Mutta

hänet valtasi liikutus, kun Biettar Oula itse lausui toiveenaan olevan
saada kutsu häihin; sieltä kyllä lähtisi lahja, jollaista kukaan ei vielä
ollut saanut.
 Biettar Oula siis todellakin piti Nikko Nillen ystävyyttä
jonkinarvoisena!

Nikko Nille soi hänelle kuitenkin kaikitenkin kaikkea hyvää!

VI.

Nikko Nille oli mennyt äskettäin ja hämärä oli jo tullut.

Teltan edessä paloi suuri, rätisevä nuotio. Muori Biettar pehmitti

saraheiniä paksulla koivunuijalla. Alasimena oli paksu, litteä kivi.
Biettar Oula koristeli poronsarvilusikkaa kukonkuvilla ja
viivakiehkuroilla. Elle levitteli pehmitetyitä saraheiniä paljaalle
kalliolle kuivumaan.

Alituiseen antaa Biettar Oula katseensa kiertää ympäröivän

viidakon reunaa, — vanhan tavan mukaan.

Äkkiä hälyyttävät koirat. Hän komentaa niitä. Hän kuulee lahojen

oksien taittuvan, ja pudonneet lehdet kahisivat. Puunrunkojen välitse
vilahtelee kolme ihmistä, tullen postipolkua myöten. He poikkeavat
nuotiota kohti. Biettar Oula saa kohta vihin kahdesta, — postimiehiä;
mutta kolmas?

— Kas — kuolema ja kirous — eikö olekin Lasse! sanoi Aslak,

vallan unohtaen nimittää häntä trondhjemiläis-seminaristiksi. Lassella
oli musta hattu, — ja kalpea oli kuin mikäkin oppinut riiviö, —
hänellä oli vyö vyötäisillä — kuten hurskaalla saarnamiehellä, eikä
lanteilla, niinkuin epäilyttävät miehet pitävät; hänellä oli lyhyt
leikkotukka, ja hän otti hatun päästään, tervehtiessään isäntäväkeä.
Hän oli sanalla sanoen tuollainen, josta Hukka olisi sanonut:
"rakastettava, hyviin tapoihin oppinut henkilö".

Sekä Biettar Oulaan että muihin vaikutti Lassen tulo kiusallisesti;

sitäpaitsi he eivät vielä olleet häntä oikein odottaneet. Biettar Oula
oli kyllä vannottanut hänellä tuiman valan, ettei hän koskaan sanoisi
julki salaisuutta, mutta sentään…

Lassea kohdeltiin joka tapauksessa kaikella huomaavaisuudella.

Biettar Oula antoi kuitenkin — postimiesten takia — sanoilleen sen
vivahduksen, ettei hänellä ja Lassella ollut mitään keskinäistä; hän
rupesi leikkisän pilkalliseksi Lassea kohtaan; mutta sanat tuntuivat
enimmäkseen väkinäisiltä.

Lasse käytti taajaan norjalaisia sanoja ja käänteitä; kertoessaan,

mitä hän oli tehnyt, hän sanoi norjaksi "jakkaran", "verkon",
"teräsvanteen" ja "kaunokirjoituksen".

Postimiehet päättivät olla yötä täällä. Heillä oli vielä matkaa kolme
penikulmaa karjamajoille, mistä he saivat soutaa edelleen jokea
myöten kylään.

Postimiehet kertoivat syödessään uutisia suuresta maailmasta.

— Vadsön vouti on keskustellut Hammerfestin voudin kanssa.

Puheenalaisena oli eräs pykälä, josta he olivat erimielisiä, ja hyvinpä
he kuuluvatkin kuumenneen. Ne tuntevat kumpikin pykälänsä, mutta
parempi kuuluu Vadsön vouti kuitenkin olevan.

— Mutta ei hänkään ole mitään asianajaja Lundan verroilla! sanoi

Aslak. "Siinä on poika, joka osaa olla viekas ja oppinut! Eipä sitä
pykälää, ettei hän taitaisi tarttua siihen… Mutta tyyris se onkin,
jumaliste!"

Biettar Oula kertoi Nikko Nillen olleen siellä iltapäivällä. Mutta

toisista ei kukaan tajunnut, mitä iloa postimiehillä oli siitä, että Nikko
Nille aikoi ajaa heilansa kanssa kylään. Totta kyllä Nikko Nillen
olentoon oli alkanut tarttua jotakin tavattoman hullunkurista, mutta
sentään… Ei kai vaan ämmä enää noussut jalkeilleen? — Niin, eihän
ollut taattua sekään…

Ristiin rastiin haasteltiin asiat; mutta väliin he istuivat ääneti,

tuiottaen nuotioon ja mietiskellen puhelemiaan.

Punaiset liekit hulmusivat läpi turpean savupilven, mikä oli niin

musta, että pilvinen, yöntumma taivas näytti vaalealta sen pitkän,
levottomasti häilähtelevän kaaren takana. Tuulen viri puhalsi silloin
tällöin tulikielekkeet leveiksi, röyhelöisiksi lehdiksi, jotka kohta taas
oikenivat ylös ilmaan ohuina ja pitkinä, notkuivat lentoon valmiina,
erkanivat, mutta sammuivat äkkiä omaan tuhoiseen tulisuuteensa.
Tulenloimo levisi kauas ympäröivään viidakkoon, missä märät, mädät
lehdet paistoivat esiin ohuen, niljakkaan lumen alta.

Väki meni telttaan ja paneutui maata lattialle, takan ympäri

poronnahoista ja hienoista, notkeista koivunvarvuista tehdylle
vuoteelle.

Pimeys tunkeutui nuotion hiilten yli, joista vielä välkähti joku

elonleimaus. Viimeinen punainen pilkahdus hukkui riutuen yöhön.

Mutta kylmä-vetinen puro luikerteli ulisten kuin sokea koiranpentu

pimeyden halki, kuohui lepoa löytämättä uomassaan, joka luisui
mutkitellen ja valonarkana laaksonrinnettä alas.
 Porot, joilla oli jo melkoisen tukevat talviturkit, lepäilivät
pehmoisella sammalella. Erään pensaan alla loikoivat paimenet, pää
ja kädet työnnettyinä peskin suojaan ja lämpimät, pitkäkarvaiset
koirat vatsan ja jalkojen peitteenä.
VII.

Pimeä antaa verta valon kalpeihin ajatuksiin. Pimeässä välkkyvät

pöllön silmät ja himo paisuttaa petojen suonia. Joka huokonen
poreilee ydinmehua, jota tulvii kuumina helminä yli kaikkien
hermojen…

Muori Biettar oli maannut valveillaan koko yön, sappi kiehuen,

mieli myrtyneenä siitä, että Lasse nyt tulisi vaatimaan noita kuutta
vaadinta. Kuinka hänen mielensä olikaan kuohunut, kun hän oli
huomannut poikansa raukean epävarmuuden Lassea kohtaan! Hän
ärtyi ja makasi nyt kiroillen ja älmentäen turkispeitteen alla.

Mutta sitten hän purskahti nauruun ja hänen täytyi pureksia

peskinreunaa, ettei herättäisi muita… Laumassahan oli vielä kolme
vierasta, merkitsemätöntä vasaa! Jos ei Lasse tyydy kun saa ne sekä
lisäksi rehellisenä uhrina yhden vaatimen, niin matkustakoon takaisin
seminaariinsa!… Piru kärventäköön muori Biettarin sisukset, ellei sitä
vedetä nenästä, tuota mäyräköntystä, tuota vaadin-kiskuria!… Ja
sillä vedolla kiertyy solmunuora, sen kaulaan, niin että siitä tulee
iäksi muori Biettarin kuuliainen orja. Kyllä hän tuhoo sen, tuhoo!…
Koettakoonpa vaan Elle mielensä mukaan pilata Biettar Oulan
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