**3. The Telemedicine Service Maturity Model (TMSMM)**

maturity model development process, as well as the need to combine theoretical and empirical research as recommended by other respected scholars of maturity models [6, 9, 18, 19].

The conceptual telemedicine service maturity model (TMSMM) was developed by following an iterative process involving telemedicine practitioners from five different South African provincial departments of health (DoH). The involvement of these stakeholders in the process, ensured the contribution of their domain knowledge for solution creation and in turn, contributed to the validity of the model. As a consequence, greater user acceptance was

Between June 2011 and December 2011, a series of workshops was held throughout South Africa. Representatives included healthcare workers (e.g. specialists, radiologists, radiogra‐ phers and nurses), as well as persons responsible for the development, implementation and

The first day of these workshops was aimed at educating representatives about current stateof-the-art telemedicine. The second day of each workshop was an interactive session in which groups of delegates engaged with the maturity model. At the end of each session, workshop delegates were asked to reflect upon and provide feedback on the effectiveness of the maturity model in terms of its characteristics. This feedback, together with the thoughts of other

maintenance of hospital information and communication technology (ICT).

**Figure 1.** Scientific approach to the development of the TMSMM

achieved [20].

220 Telemedicine

The conceptual TMSMM is shown in Figure 2, which also provides a framework for the remainder of this chapter.

**Figure 2.** Conceptual model of the TMSMM

### **3.1. Design of the TMSMM**

The TMSMM is designed along three dimensions. The intercept of each pair of these dimen‐ sions form a matrix, each with a specific significance and function.

dicine service. Hence, the maturity of these systems must be evaluated in conjunction with the

The Telemedicine Service Maturity Model: A Framework for the…

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

223

References are often made to the so-called "alphabet soup" of the business world, for example the 4Ps of marketing, the 5Ps of strategy, the 4Ps of healthcare, the 5Ss of lean manufacturing, the 4Ms, 5Ms, 6Ms and 7Ms of manufacturing, and the list continues. The value of these models (representations of the real world) lies in its simplicity and re-usablity. Furthermore, the fact that these concept groupings are applied repetitively and to a variety of contexts is indicative

The TMSMM must be simple in structure and language, so that it can be understood and used by a range of stakeholders. Therefore, the domains were named and organized in a way similar to other "alphabet-soup" frameworks. After each iteration of the development of the TMSMM the domains were adjusted, based on new insights gained. The final set of domains resembles the 5Ms for manufacturing, namely "man", "machine", "material", "method" and "money".

At first glance it may seem inappropriote to apply the 5Ms of manufacturing to the domains of the TMSMM. However, the generic description for a manufacturing process is well aligned with the telemedicine service: The telemedicine service entails the sourcing and acquisition of raw material (raw patient data and information) at the right place, the right time, and according to the right specification. This information is then reworked into a useful product (a diagnosis, treatment prescription etc.) which only has value if it reaches the customer (patient) at the right

Figure 3 (orange matrix) provides a framework for the description of the telemedicine service, since it provides *domain* (red) -indicators for each of the micro-, meso- and macro-*level*

> Data Transmission processes

patient/ doctor/

internet service, mobile phone network etc.

EHR-type data/ images/ video

cost of transmission

**Micro-Level Telemedicine Processes Higher Level Telemedicine Processes** 

Meso-level

EHR mgmt within

change management within service context

service business model health economics

nurse etc. user community the society benefiting

processes Macro-level processes

service system national ICT

context of the sevice national EHR mgmt

from this service

infrastructure

national policies, strategies and ethics guidelines

maturity of the micro-level telemedicine process.

place, the right time, and according to the right specification.

Capture, Diagnose/ Analyse, React processes

**Method** work procedure service levels

**Man** patient/ doctor/ nurse etc.

**Machine** telemedicine device/ mobile phone ect.

**Material** EHR data/ images/ video ect.

**Money** operational and maintenance costs

**Figure 3.** Micro-, meso-, and macro-level telemedicine processes

**3.4. Framework for the description of the telemedicine service**

**3.3. The domain dimension (red)**

of its validity and generalizability.

*telemedicine service* processes (yellow).

#### *3.1.1. Three dimensions*

Firstly, five domains are defined (*domain* dimension), which provides a holistic view on all factors that impact on the implementation of telemedicine services. Secondly, the *telemedicine service* dimension represents five micro-level processes, one meso-level, and one macro-level process per domain. The third dimension is the *maturity scale*, which provides yardsticks for maturity measurement. The three primary colours are deliberately selected to represent each of these three dimensions. Each of the three dimensions are briefly described in section 3.2 (*telemedicine service*, yellow), section 3.3 (*domain*, red) and 3.5 (*maturity scale*, blue).

#### *3.1.2. Three matrices*

The orange matrix (refer to section 3.4) is the intercept of the *telemedicine service* dimension (yellow) and the *domain* dimension (red) and provides a framework, according to which, all aspects of the telemedicine under consideration are described. The domain-specific maturity indicators are outlined on the purple matrix (refer to section 3.6). This is the intercept of *domain* dimension (red) and the *maturiy scale* dimension (blue). The maturiy capability statements (green) in section 4 shows the maturity scale (blue) descriptors per telemedicine service process (yellow) for each respective domain.

#### **3.2. The telemedicine service dimension**

Telemedicine is per definition the delivery of healthcare service (*medicine*) over a distance (*tele*). This dimension includes all micro-level, meso-level and macro-level processes required to make this happen.

#### *3.2.1. Micro-level telemedicine service*

The micro-level telemedicine service is broken up into five generic processes, which are applicable to any telemedicine service. All five of these processes need to be effective for the telemedicine service to be successful. (1) Patient data is captured, (2) transmitted to where the (3) data is analysed and converted into useful information (diagnosis). This useful information is then (4) transmitted back so that it can be (5) acted upon.

#### *3.2.2. Meso-level and macro-level telemedicine services*

The systems engineering mindset dictates that complex systems (such as a health system), should be viewed as systems of systems. The meso- and macro-level telemedicine systems are systems which are situated higher up the health systems hierarchy. It does not exclusively relate to the telemedicine service, but it has a significant impact on the success of the teleme‐ dicine service. Hence, the maturity of these systems must be evaluated in conjunction with the maturity of the micro-level telemedicine process.

#### **3.3. The domain dimension (red)**

**3.1. Design of the TMSMM**

*3.1.1. Three dimensions*

222 Telemedicine

*3.1.2. Three matrices*

make this happen.

(yellow) for each respective domain.

*3.2.1. Micro-level telemedicine service*

is then (4) transmitted back so that it can be (5) acted upon.

*3.2.2. Meso-level and macro-level telemedicine services*

**3.2. The telemedicine service dimension**

The TMSMM is designed along three dimensions. The intercept of each pair of these dimen‐

Firstly, five domains are defined (*domain* dimension), which provides a holistic view on all factors that impact on the implementation of telemedicine services. Secondly, the *telemedicine service* dimension represents five micro-level processes, one meso-level, and one macro-level process per domain. The third dimension is the *maturity scale*, which provides yardsticks for maturity measurement. The three primary colours are deliberately selected to represent each of these three dimensions. Each of the three dimensions are briefly described in section 3.2

The orange matrix (refer to section 3.4) is the intercept of the *telemedicine service* dimension (yellow) and the *domain* dimension (red) and provides a framework, according to which, all aspects of the telemedicine under consideration are described. The domain-specific maturity indicators are outlined on the purple matrix (refer to section 3.6). This is the intercept of *domain* dimension (red) and the *maturiy scale* dimension (blue). The maturiy capability statements (green) in section 4 shows the maturity scale (blue) descriptors per telemedicine service process

Telemedicine is per definition the delivery of healthcare service (*medicine*) over a distance (*tele*). This dimension includes all micro-level, meso-level and macro-level processes required to

The micro-level telemedicine service is broken up into five generic processes, which are applicable to any telemedicine service. All five of these processes need to be effective for the telemedicine service to be successful. (1) Patient data is captured, (2) transmitted to where the (3) data is analysed and converted into useful information (diagnosis). This useful information

The systems engineering mindset dictates that complex systems (such as a health system), should be viewed as systems of systems. The meso- and macro-level telemedicine systems are systems which are situated higher up the health systems hierarchy. It does not exclusively relate to the telemedicine service, but it has a significant impact on the success of the teleme‐

(*telemedicine service*, yellow), section 3.3 (*domain*, red) and 3.5 (*maturity scale*, blue).

sions form a matrix, each with a specific significance and function.

References are often made to the so-called "alphabet soup" of the business world, for example the 4Ps of marketing, the 5Ps of strategy, the 4Ps of healthcare, the 5Ss of lean manufacturing, the 4Ms, 5Ms, 6Ms and 7Ms of manufacturing, and the list continues. The value of these models (representations of the real world) lies in its simplicity and re-usablity. Furthermore, the fact that these concept groupings are applied repetitively and to a variety of contexts is indicative of its validity and generalizability.

The TMSMM must be simple in structure and language, so that it can be understood and used by a range of stakeholders. Therefore, the domains were named and organized in a way similar to other "alphabet-soup" frameworks. After each iteration of the development of the TMSMM the domains were adjusted, based on new insights gained. The final set of domains resembles the 5Ms for manufacturing, namely "man", "machine", "material", "method" and "money".

At first glance it may seem inappropriote to apply the 5Ms of manufacturing to the domains of the TMSMM. However, the generic description for a manufacturing process is well aligned with the telemedicine service: The telemedicine service entails the sourcing and acquisition of raw material (raw patient data and information) at the right place, the right time, and according to the right specification. This information is then reworked into a useful product (a diagnosis, treatment prescription etc.) which only has value if it reaches the customer (patient) at the right place, the right time, and according to the right specification.

#### **3.4. Framework for the description of the telemedicine service**

Figure 3 (orange matrix) provides a framework for the description of the telemedicine service, since it provides *domain* (red) -indicators for each of the micro-, meso- and macro-*level telemedicine service* processes (yellow).


**Figure 3.** Micro-, meso-, and macro-level telemedicine processes

### **3.5. The maturity scale**

The maturity scale of the TMSMM is based on the generic level indicators of the capability maturity model (CMM). This is done for two reasons: Firstly, most of the existing maturity models use a maturity scale, which is either identical to, or strongly resembles the CMM-scale. This is indicative of the usefulness and validity of this scale. Secondly, it opens up the possibility that the TMSMM, which is categorized as a descriptive maturity grid, is used in conjunction with comparative CMM-like maturity models, for example those developed for project management and innovation management.

The generic levels are described below:


#### **3.6. Domain-specific maturity indicators**

Domain specific maturity indicators for the micro-level as well as meso- and macro-level telemedicine service processes are shown in Figure 4 and Figure 5 respectively. Each of these rows serves as heading for each of the respective maturity grids, which are presented in the next section.
