Ecosystem disruption and regulatory positioning: Entry strategies of digital health startup orchestrators and complementors

Through a multiple case study of six digital startups in the healthcare ecosystem, we develop a framework of entry through innovation in a regulated ecosystem. The framework reveals the interplay of two dimensions that have not been examined in conjunction so far: 1) the degree of ecosystem disruption brought by the entrant's innovation; 2) the impact of regulation/policy on the entrant's innovation. Based on these two dimensions, our data reveal four scenarios for entrants: dual constraint; regulatory-enabled orchestration; regulatory-constrained complementation; and dual enablement. The paper provides several contributions to ecosystem research, including a new definition of ecosystem disruption, the joint consideration of two key dimensions of ecosystem entry, and an emergent framework illustrating specific strategies, governance mechanisms, and the likelihood of success for each entry scenario. We show that start-up entrants can be successful orchestrators if they are enabled by regulation, that they can shift their positioning to seize enabling regulations, and that being an orchestrator or a complementor is a strategic choice related to an entrant's ecosystem disruption strategy.