**1. Introduction**

General consensus exists that information and communication technology has the potential to enhance health systems applications and many good examples of such applications exist all over the world. Unfortunately, with respect to eHealth and telemedicine, there are also examples of disillusionment and scepticism. Many studies acknowledge the importance and challenge of finding models suitable for use in the facilitation, evaluation, and measurement of the success rate of eHealth and telemedicine projects. These measures are vital for facilitating the success, sustainability and optimisation of telemedicine services [1 -4].

#### **1.1. Purpose**

The purpose of this chapter is to present the *TeleMedicine Service Maturity Model* (TMSMM), a maturity model, including a capability statements that can be used to measure and manage the maturity of any telemedicine process.

#### **1.2. Why a maturity model?**

In many respects, telemedicine projects have experienced similar problems to those of the US military projects, implemented during the 1980's. These projects, involving software contrac‐ tors, ran over-budget and were completed far later than planned, if at all. In order to address this, the US Defense Software Engineering Institute (SEI) developed a process maturity framework to aid in the capability evaluation of the software contractors, to be used as part of the contract awarding process [9]. This model, which was orginally based on Crosby's Quality Management Maturity Grid [5], became the Capability Maturity Model (CMM) and later the

Capability Maturity Model Integration (CMMI). The CMM and CMMI also serve as compli‐ ance standards [6, 7].

developed and in use within the context of telemedicine and ehealth. Jennett *et al.* [12] specifically refers to eHealth readiness when arguing that time, money and energy can be saved if the *status quo* of an eHealth/telemedicine system context is determined before implementa‐

The Telemedicine Service Maturity Model: A Framework for the…

http://dx.doi.org/10.5772/56116

219

Legare *et al.* [13] identified six different assessment tools which use likert scale questionnaires to measure e-readiness within a certain health context: The first of these tools were developed in 1996. The *Organizational Information Technology/ Systems Innovation Readiness Scale* supports, within the context of telehealth, the evaluation, diagnosis and treatment selection for different steps in patient care. The second, third and fourth tools mentioned by [13] followed on each other and are focussed on home-based telehealth applications. Specifically the most recent two tools, namely the *eHealth Readiness Assessment Toolset for Healthcare Institutions in Developing Countries* [3] and a generic telehealth readiness assessment tool [12], was considered during

Maturity grids are typically descriptive frameworks, used for self-assessment purposes. With a maturity grid a number of levels of maturity are described in a simple, textual manner,

In contrast to CMM-like models, the purpose of maturity grids is not to provide a means of certification. Companies often follow a number of approaches in parallel and maturity grid assessment may be used as a stand-alone assessment, or as a subset of a broader improvement initiative [10, 11]. Furthermore, a typical maturity grid allows for the visualization of maturity

According to the classification presented in this section, the Telemedicine Service Maturity

Most of the maturity models developed within the context of health systems fit this description. Examples of these include, the Quintegra Maturity Model for Electronic Healthcare [14], the Healthcare Information Management Systems Society (HIMSS) Maturity Model for Electronic Medical Records, the Health Industry Insights Maturity Model for Information Systems and Technology (IST) development in hospitals [15], as well as the Picture Archiving Communi‐

None of the frameworks mentioned in this section are an "off-the-shelf" answer to the need for a framework to guide in the implementation and management of telemedicine services. However, all of the models mentioned in this section provided input to the development of a

The scientific approach in the development of the TMSMM (refer to Figure 1), resembles the procedure suggested in [17]. This procedure takes into account the iterative nature of the

Model (TMSMM) presented in this chapter is considered to be a maturity grid.

tion.

the development of the TMSMM.

normally not exceeding a few pages of text [9, 10].

cation Systems (PACS) maturity model [16].

new maturity model, which is presented in this chapter.

levels, which is not necessarily the case for CMM-like models.

*1.3.3. Maturity grid*

**2. Methodology**

The CMM was the inspiration for the development of dozens of other maturity models which were developed and applied in various domains and contexts. With a maturity model the maturity (i.e. competency, capability, level of sophistication) of a selected domain is assessed based on a more or less comprehensive set of criteria. [6]. Maturity models, firstly, provide a way of measuring the status quo by means of maturity level indicators. Secondly, they facilitate an improvement process that best suits the enterprise, while remaining within the prescribed best practice parameters of the particular domain [8].

Most definitions of maturity combine an evolutionary or experiential element with the adoption of 'good' (or appropriate) practice [9]. It is proposed that a telemedicine service maturity model will address the need for a framework that can be used to measure and grow the maturity of existing and prospective telemedicine services. This model should be useful for self-assessment and well as benchmarking to guide a telemedicine service or project towards the identification and adoption of best practices.

#### **1.3. Maturity models within the context of health systems**

As result of a meta-analysis of maturity models Fraser et. al. [9] divided maturity models into three groups.


This categorization appealed to a number of authors to follow [10, 11] and is also of significance to this study:

#### *1.3.1. CMM-like models*

CMM-like models [9] are based upon a more formal architecture, specifying a number of goals and key practices to reach a predefined level of sophistication [11]. Many CMM-like models follow a standard format, are internationally recognized and are also use for certification purposes. Within the context of health systems, the British National Health System Infrastruc‐ ture Maturity Model (NIMM) is possibly the only maturity model that fits this description.

#### *1.3.2. Hybrids and likert-like scales*

Hybrids and Likert-like questionnaires are comparable with maturity grids, but the focus is more inclined on scoring specific statements of "good practice" and not on describing the overall levels of maturity [11].

Technology readiness, system readiness and organizational readiness instruments are typical examples of this type of maturity assessment [10]. A few readiness instruments are already developed and in use within the context of telemedicine and ehealth. Jennett *et al.* [12] specifically refers to eHealth readiness when arguing that time, money and energy can be saved if the *status quo* of an eHealth/telemedicine system context is determined before implementa‐ tion.

Legare *et al.* [13] identified six different assessment tools which use likert scale questionnaires to measure e-readiness within a certain health context: The first of these tools were developed in 1996. The *Organizational Information Technology/ Systems Innovation Readiness Scale* supports, within the context of telehealth, the evaluation, diagnosis and treatment selection for different steps in patient care. The second, third and fourth tools mentioned by [13] followed on each other and are focussed on home-based telehealth applications. Specifically the most recent two tools, namely the *eHealth Readiness Assessment Toolset for Healthcare Institutions in Developing Countries* [3] and a generic telehealth readiness assessment tool [12], was considered during the development of the TMSMM.

#### *1.3.3. Maturity grid*

Capability Maturity Model Integration (CMMI). The CMM and CMMI also serve as compli‐

The CMM was the inspiration for the development of dozens of other maturity models which were developed and applied in various domains and contexts. With a maturity model the maturity (i.e. competency, capability, level of sophistication) of a selected domain is assessed based on a more or less comprehensive set of criteria. [6]. Maturity models, firstly, provide a way of measuring the status quo by means of maturity level indicators. Secondly, they facilitate an improvement process that best suits the enterprise, while remaining within the prescribed

Most definitions of maturity combine an evolutionary or experiential element with the adoption of 'good' (or appropriate) practice [9]. It is proposed that a telemedicine service maturity model will address the need for a framework that can be used to measure and grow the maturity of existing and prospective telemedicine services. This model should be useful for self-assessment and well as benchmarking to guide a telemedicine service or project

As result of a meta-analysis of maturity models Fraser et. al. [9] divided maturity models into

This categorization appealed to a number of authors to follow [10, 11] and is also of significance

CMM-like models [9] are based upon a more formal architecture, specifying a number of goals and key practices to reach a predefined level of sophistication [11]. Many CMM-like models follow a standard format, are internationally recognized and are also use for certification purposes. Within the context of health systems, the British National Health System Infrastruc‐ ture Maturity Model (NIMM) is possibly the only maturity model that fits this description.

Hybrids and Likert-like questionnaires are comparable with maturity grids, but the focus is more inclined on scoring specific statements of "good practice" and not on describing the

Technology readiness, system readiness and organizational readiness instruments are typical examples of this type of maturity assessment [10]. A few readiness instruments are already

ance standards [6, 7].

218 Telemedicine

three groups.

**•** CMM-like models

**•** Maturity grids

*1.3.1. CMM-like models*

*1.3.2. Hybrids and likert-like scales*

overall levels of maturity [11].

to this study:

**•** Hybrids and Likert-like questionnaires

best practice parameters of the particular domain [8].

towards the identification and adoption of best practices.

**1.3. Maturity models within the context of health systems**

Maturity grids are typically descriptive frameworks, used for self-assessment purposes. With a maturity grid a number of levels of maturity are described in a simple, textual manner, normally not exceeding a few pages of text [9, 10].

In contrast to CMM-like models, the purpose of maturity grids is not to provide a means of certification. Companies often follow a number of approaches in parallel and maturity grid assessment may be used as a stand-alone assessment, or as a subset of a broader improvement initiative [10, 11]. Furthermore, a typical maturity grid allows for the visualization of maturity levels, which is not necessarily the case for CMM-like models.

According to the classification presented in this section, the Telemedicine Service Maturity Model (TMSMM) presented in this chapter is considered to be a maturity grid.

Most of the maturity models developed within the context of health systems fit this description. Examples of these include, the Quintegra Maturity Model for Electronic Healthcare [14], the Healthcare Information Management Systems Society (HIMSS) Maturity Model for Electronic Medical Records, the Health Industry Insights Maturity Model for Information Systems and Technology (IST) development in hospitals [15], as well as the Picture Archiving Communi‐ cation Systems (PACS) maturity model [16].

None of the frameworks mentioned in this section are an "off-the-shelf" answer to the need for a framework to guide in the implementation and management of telemedicine services. However, all of the models mentioned in this section provided input to the development of a new maturity model, which is presented in this chapter.
