**Acknowledgements**

agent (champion) and secondly if the change management process also manifests in other business processes, for example, during the budget process or facilities design process.

The effectiveness of the change management process is measured in terms of performance indicators (maturity level 4). Maturity level 5 implies that processes are in place to ensure

The maturity of the micro-level telemedicine service – as far as the *money*-domain is concerned – is measured in terms of the costs to operate and maintain this service. On macro-level the financial sustainability of the *money-*domain is considered, firstly, with respect to the specific telemedicine service and, secondly, on a higher level, with respect to the macro-economic

This subdomain of the TMSMM is the concern of health economics, which is a branch of economics concerned with the functioning of macro-economic healthcare systems as well as health affecting behaviours and interventions – such as the use of technology [36]. Health economists throughout the world still graple with challenges to find financial justification for telemedicine services [37, 38]. No clear-cut financial model has yet been developed. It is also not the intension of the TMSMM to provide answers concerning *how* the financial sustainability and return on investment can be measured and managed, but merely *if* it is being managed

A maturity level of 1 is typical to projects in the research and development or pilot phases, where the focus is on technical feasibility [27]. At level 2 some form of financial management system is in place. However, the service relies on donor or R&D funding. A maturity level of 3 indicates that the telemedicine service will sustain financially, without external funding. With the context of health economics, many approaches can be found with respect to the measurement of the return on investment(ROI). The TMSMM does not dictate the method of ROI-measurement. Rather, a maturity level of 4 indicates that such measure is decided upon

Macro-level continuous improvement and optimization within context of the *money* domain requires not only financial sustainability, but also reinvestment – in which case a maturity level

In this chapter a telemedicine service maturity model (TMSMM) is presented. This TMSMM is developed in response to the need for a framework according to which the maturity of existing and proposed telemedicine projects can be measured with the purpose of supporting

The TMSMM was developed by following an iterative process involving telemedicine practitioners from five different South African provincial departments of health (DoH). With

continuous improvement in terms of these performance indicators.

**5.5. Financial sustainability (***Money***-domain)**

and these measures are indeed realized.

decision making towards sustained telemedicine services.

healthcare system.

234 Telemedicine

and measured.

of 5 is allocated.

**6. Conclusion**

The work presented in this article is based on research for purposes of the PhD thesis of Liezl van Dyk, for which financial support was provided by the National Research Foundation (NRF) of South Africa. The authors also wishes to acknowledge Jill Fortuin (Medical Research Council of South Africa) for her role in the initial workshops that lead to the development of the TMSMM as well as Kim Viljoen and André Hartmann (Stellenbosch University), who contributed to the definition of the capability statements through the execution of their respective MEng projects.
