**5. Maturity capability statements for the meso and macro level processes of each domain**

The scope of this chapter does not allow for detail maturity capability statements for mesoand macro-level processes. In this section follows a brief discussion on each of these processes.

#### **5.1. User communities (***Man***-domain)**

Telemedicine services inevitably cut across epistemic communities, for example medical practitioners, engineers, patients or public health actors [29]. The users of each step of the telemedicine process are members of one of these communities. The health worker / patient community and the society as a whole are added as respectively as meso-level and macro-level telemedicine systems, within the context of the user domain, since the maturity of the teleme‐ dicine service is dependent on the extent to which this service is accepted within these communities [27].

Maturity level 3 indicates that this activity is accepted as standard practice by the entire community. For example, if healthcare professionals are exposed to this telemedicine service as part of their training and if these practices are accepted by their professional societies or a it socially acceptable to use technology to communicate healthcare information.

*Evidence-based practice* is an interdisciplinary approach, which started in medicine as *evidencebased medicine* and spread across other fields over the past two decades [30]. Evidence based medicine aims for the ideal that healthcare professionals should make "conscientious, explicit, and judicious use of current best evidence in everyday practice." As such, healthcare workers and other professionals are familiar with this concept.

Evidence-based practice dictates that all practical decisions made should (1) be based on research studies and (2) that these research studies are selected and interpreted to some specific and quantitative norm. A maturity level of 4 applies if such research studies are successfully being executed with context of the respective user community.

According to the World Health Organization task shifting entails the reallocation of certain tasks from more-specialised to less-specialised health care workers across the board. For example, tasks are shifted from the physician to the non-professional health care worker [31, 32]. A maturity level of 5 indicates that the telemedicine service deliberately causes task shifts for an entire professional community.

#### **5.2. Information and Communication Technology (ICT) infrastructure (***Machine***-domain)**

ICT infrastructure refers to all of the hardware, software, networks, facilities etc. that are required to develop, test, deliver, monitor, control or support applications and IT services. [33]. The maturity of the ICT infrastructure depends on its availability, reliability and maintaina‐ bility (maturity level 3) as well as the measurement thereof (maturity level 4). Continuous improvement (maturity level 5) within this context relates to technology upgrades and scalability.

## **5.3. EHR systems (***Material***-domain)**

must be possible to measure and report on the costs related to this process. On maturity level

**5. Maturity capability statements for the meso and macro level processes**

The scope of this chapter does not allow for detail maturity capability statements for mesoand macro-level processes. In this section follows a brief discussion on each of these processes.

Telemedicine services inevitably cut across epistemic communities, for example medical practitioners, engineers, patients or public health actors [29]. The users of each step of the telemedicine process are members of one of these communities. The health worker / patient community and the society as a whole are added as respectively as meso-level and macro-level telemedicine systems, within the context of the user domain, since the maturity of the teleme‐ dicine service is dependent on the extent to which this service is accepted within these

Maturity level 3 indicates that this activity is accepted as standard practice by the entire community. For example, if healthcare professionals are exposed to this telemedicine service as part of their training and if these practices are accepted by their professional societies or a

*Evidence-based practice* is an interdisciplinary approach, which started in medicine as *evidencebased medicine* and spread across other fields over the past two decades [30]. Evidence based medicine aims for the ideal that healthcare professionals should make "conscientious, explicit, and judicious use of current best evidence in everyday practice." As such, healthcare workers

Evidence-based practice dictates that all practical decisions made should (1) be based on research studies and (2) that these research studies are selected and interpreted to some specific and quantitative norm. A maturity level of 4 applies if such research studies are successfully

According to the World Health Organization task shifting entails the reallocation of certain tasks from more-specialised to less-specialised health care workers across the board. For example, tasks are shifted from the physician to the non-professional health care worker [31, 32]. A maturity level of 5 indicates that the telemedicine service deliberately causes task shifts

**5.2. Information and Communication Technology (ICT) infrastructure (***Machine***-domain)**

ICT infrastructure refers to all of the hardware, software, networks, facilities etc. that are required to develop, test, deliver, monitor, control or support applications and IT services. [33].

it socially acceptable to use technology to communicate healthcare information.

and other professionals are familiar with this concept.

for an entire professional community.

being executed with context of the respective user community.

5 the cost effectiveness of the process are continuously improved.

**of each domain**

232 Telemedicine

communities [27].

**5.1. User communities (***Man***-domain)**

The maturity scale described below applies equally to meso-level, local EHR systems and the macro-level, national EHR systems.

Syntactic interoperability involves a common data format and common protocol to struc‐ ture any data so that the manner of processing the information will be interpretable. When the different systems involved in a telemedicine service are capable of communicating and exchaning data, they are syntactically interoperable [35] and a maturity level of 2 is indicated.

"Beyond the ability of two or more computer systems to exchange information, semantic interoperability is the ability to automatically interpret the exchanged information meaning‐ fully and accurately in order to produce useful results as defined by the end users of both systems" [35]. A maturity level of 3 is awarded if semantic interoperability is achieved. If no intentional record keeping protocol is in place, the maturity of these three processes is gauged at 1.

Business intelligence (BI) is a broad category of applications and technologies for gather‐ ing, storing, analyzing, and providing access to data to help enterprise users make better business decisions. A maturity level of 4 indicates that such applications and technologies existsBusiness analytics (BA) is often used as synonymn for BI. However, for purposes of the chapter, it is recognized that for BA statistical methods are used to develop an understand‐ ing of business performance and to provide a feedback loop towards continuous business improvement.

#### **5.4. Change management (***Methods-***domain)**

The need for deliberate and effective change management is echoed throughout studies on the implementation of telemedicine services [1-4, 23, 26, 37]. Change management is the process of changing processes. Within context of the TMSMM, change management is posi‐ tioned as meso-level process of the Methods-domain (Figure 9).

The majority of telemedicine services do not sustain after pilot phase [22, 27, 26] even though the concept was technologically proved during prototype and pilot phase. In those cases, the change management process was ineffective (maturity level 1).

A champion is a user from the community who takes the role of innovator and advocate. Many authors [1, 25, 26] mention the involvement of a so-called champion as a critical suc‐ cess factor to the successful implementation of telemedicine services. Maturity level 2 ap‐ plies when such a champion is either self-appointed or appointed by the institution.

A maturity level of 3 indicates sustainable institutional commitment to accomplish change. This commitment is firstly demonstrated by the formal and permanent appoint of a change 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.

each iteration a cross-functional group was involved in workshop format. Self-assessment maturity models, like the TMSMM proved to be particularly effective with cross-functional

The Telemedicine Service Maturity Model: A Framework for the…

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

235

This descriptive maturity model can be used as basis for the development of a prescriptive and eventually comparative maturity model for which the following design principles applies [39]: Firstly, decision calculus is included the assist in the evaluation of different alternatives. Secondly, an adoption methodology is included which features a procedure model, advice on

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

[1] Yellowlees, P. Successfully developing a telemedicine system. Journal of Telemedi‐

[2] Edwards, J. Hype Cycle for Telemedicine (G00214814). Gartner Industry Research, 28 July 2011. [Online]. Available: http://my.gartner.com/resources/214800/214814/

[3] Khoja, S., Scott, R., Casebeer, A., Mohsin, M., Ishaq, A. and Gilani, S. E-health readi‐ ness assessment tools for healthcare institutions in developing countries. Telemedi‐

[4] Van Gemert-Pijnen, J.E., Nijl, N., Van Limburg, M., Ossebaard, H.C., Kelders, S.M., Eysenbach, G., and Seydel, E.R. A Holistic Framework to Improve the Uptake Impact

hype\_cycle\_for\_telemedicine\_\_214814.pdf?li=1. [Retrieved on 8 March 2012].

Department of Industrial Engineering, Stellenbosch University, South Africa

cine Telecare, Bd. 11, Nr. 7, pp. 331-336, 2005.

cine e-Health, Bd. 13, Nr. 4, pp. 425-432, 2007.

and interdisciplinary groups.

**Acknowledgements**

respective MEng projects.

Liezl van Dyk and Cornelius S.L. Schutte

**Author details**

**References**

how to concretize and adapt improvement measures.

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 continuous improvement in terms of these performance indicators.

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

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 healthcare system.

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 and measured.

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 and these measures are indeed realized.

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 of 5 is allocated.
