TeleNeonatology is an emerging digital health innovation that connects hospitals with limited neonatal expertise to specialized Neonatal Intensive Care Units (NICU) via real-time video communication. It holds significant potential to improve neonatal outcomes, reduce unnecessary patient transfers, and alleviate pressure on NICU resources. Despite these advantages, the implementation of TeleNeonatology in the Netherlands remains limited. This thesis investigates the economic considerations that shape such implementation efforts, with a specific focus on how they influence adoption decisions across the different involved stakeholders.
As an empirical entry point, this thesis draws on the 2024 TeleNeonatology pilot between Erasmus MC and Amphia Hospital. The pilot provided operational and economic data. However, the pilot
did not demonstrate measurable clinical improvements, underscoring the need to assess implementation primarily through an economic lens.

The research is structured using the NASSS framework (Non-adoption, Abandonment, Scale-up, Spread, and Sustainability). The NASSS framework provides a structured lens to analyze why health technologies are adopted, abandoned, or fail to scale sustainably. In this thesis, the framework is not only applied to assess TeleNeonatology but is extended with explicit economic dimensions across all seven domains. This adaptation allows economic considerations, such as investment costs, reimbursement models, distribution of benefits, and long-term sustainability, to
be systematically examined. By operationalizing economic questions within each domain, the framework becomes a tool to reveal where misalignments occur between cost savings at the
system level and financial incentives at the institutional level. This integrative approach enables the study to move beyond traditional cost-effectiveness analysis and to uncover how economic logics interact with institutional structures in shaping adoption decisions.

This thesis employs a mixed-methods explanatory design to investigate the economic dimensions of TeleNeonatology. Three complementary methods were combined: a systematic literature review to synthesize existing knowledge, a cost minimization model to analyze economic dynamics in a structured way from different perspectives, and semi-structured stakeholder
interviews to explore institutional perspectives and decision-making rationales. The unifying element is the NASSS framework. This ensured that each phase of the research addressed not
only its own objectives, but also contributed to a coherent overall analysis of how economic factors interact with the organizational, and systemic conditions of implementation. By structuring the
study in this way, the thesis provides both breadth and depth: breadth through systematic coverage of economic considerations across the seven NASSS domains, and depth by combining quantitative modeling with qualitative insights.

The systematic literature review reveals that while high initial investment costs, reimbursement uncertainty, and unclear long-term funding models are frequently cited as barriers, they are rarely
analyzed in direct relation to actual implementation outcomes. Economic considerations are often treated as abstract constraints rather than operationalized decision criteria, creating a disconnect
between economic evaluations and real-world adoption processes. Furthermore, most studies address only isolated aspects within a single NASSS domain rather than examining the interdependencies across domains. Notably, the Organization and Adopter System dimensions receive the least systematic attention, indicating that research to date has insufficiently explored how institutional arrangements and stakeholder dynamics shape the economic feasibility of telemedicine implementation.
The cost minimization model indicates that TeleNeonatology reduces average costs per patient across all perspectives considered, with substantial savings for both the healthcare (€3,940) and societal (€4,081) perspective. These gains derive primarily from avoided NICU admissions, fewer inter-hospital transfers, and mitigation of indirect family burdens. While such results highlight the efficiency of TeleNeonatology in reducing resource utilization, their interpretation differs when viewed from a hospital perspective. In the Dutch system of specialist medical care, hospital services are reimbursed through a case-based payment model, where each treatment trajectory is declared as a billable product at regulated or negotiated tariffs. For insurers, these payments constitute expenditures, whereas for hospitals they represent revenues. Accordingly, modeled cost differences that appear as savings at the payer or system level should be reinterpreted as revenue changes resulting from shifts in the volume of billable products at the hospital level. In other words, the same model outcome that evidences cost savings simultaneously signals income reductions for individual providers, underscoring how interpretation shapes the economic meaning of results across perspectives. This reflects the so-called wrong pocket problem, whereby the actor that bears the costs of implementation is not the one that accrues the financial benefits. Therefore, interpretation strongly shapes the economic meaning of results across perspectives.
The stakeholder interviews corroborate this misalignment. Most institutions operate with only partial visibility over the broader cost-benefit dynamics, and no single actor possesses a full, system-wide economic overview. Decision-making remains fragmented, with hospitals, insurers, and policymakers each prioritizing their own budgetary constraints. This siloed perspective leads to structural misalignments between where costs are incurred and where benefits accrue. Overall, this thesis concludes that economic considerations are necessary aspects for sustainable telemedicine implementation, but are often misunderstood or overlooked in practice. The intervention demonstrates efficiency at the system level, yet its benefits are unevenly distributed and often translate into financial drawbacks for the very providers expected to adopt it. By applying an economics-extended NASSS framework, the study shows that the critical barriers lie in organizational and system-level arrangements, where existing funding structures fail to align incentives across actors. The resulting paradox is that a demonstrably cost-reducing innovation risks stagnation unless governance and financing models evolve to match system-wide value with institutional sustainability.

Based on the generated insights the following recommendations from an economic standpoint should be taken into consideration when implementing TeleNeonatology:
1. Establish structured stakeholder alignment from the start
Misaligned incentives and fragmented perspectives are key barriers. Implementation should begin with a formal steering group including hospitals, insurers, parent organizations, and policymakers. This group should define shared objectives (e.g., reducing transfers, improving parental experience, cost containment), meet regularly, and maintain transparent communication (e.g. with dashboards) economic and financial outcomes.
2. Embed economic evaluation directly into pilot design
Pilots should systematically track economic outcomes across key stakeholder perspectives (hospital, insurer, parental, system). When implementing models, not every perspective must be explicitly included, rather, it is the interpretation of results that determines their relevance. A model showing societal savings, for instance, may simultaneously imply revenue losses at the hospital level. To avoid siloed evaluations particularly those limited to the societal perspective, pilots should explicitly incorporate mechanisms for cross-perspective interpretation, ensuring that economic evidence is actionable and supports informed implementation and scaling decisions.
3. Develop sustainable financial mechanisms to resolve the “wrong pocket problem”
Under current reimbursement structures, avoided transfers reduce hospital revenues even when the system saves costs. To prevent this misalignment, mechanisms should be tested that redistribute savings fairly, such as shared-savings contracts or per-consultation reimbursements. One concrete option is an insurer-funded pool: hospitals would annually report avoided transfers and, if TeleNeonatology led to a net revenue loss, receive compensation up to the breakeven point. This ensures hospitals are not penalized for enabling system-wide efficiency and creates a sustainable basis for broader adoption.

Future research based on this thesis could focus on scaling TeleNeonatology beyond pilot settings including the defined recommendations, and enabling longitudinal evaluation of financial outcomes across diverse hospital networks. In addition, applying the adapted NASSS-economic framework to other telemedicine domains can validate its broader relevance and support comparative insights across digital health innovations. While grounded in the Dutch healthcare system, these insights are relevant for other telemedicine applications and countries, provided that local financial and institutional conditions are carefully taken into account.