# Toward a Comprehensive Understanding and Evaluation of the Sustainability of E-Health Solutions
## 8 Discussion
However, all the mentioned evaluation methods were either too narrow, in that they were designed to evaluate a specific type of e-health (e.g., health connected applications), or too general and did not comprehensively evaluate the sustainability of the e-health solutions. Therefore, there is a need for a sustainability assessment method that comprehensively assesses all sustainability aspects of e-health solutions. To cover a wider range of studies, we used the OpenGrey ([[http://www.opengrey.eu/accessed](http://www.opengrey.eu/accessed)]([http://www.opengrey.eu/accessed](http://www.opengrey.eu/accessed)) on 7 November 2021) database to search for relevant papers in the grey literature. However, the papers found in the results were irrelevant to the focus of this SLR. For example, some papers discussed sustainability from a manufacturing perspective rather than focusing on the sustainability of digital solutions. Furthermore, some of them focused on software sustainability from developers' perspectives, in which no relevant aspects can be extracted and used to reflect the sustainability of e-health solutions. The rest of the results discussed sustainability from an ecological perspective. In addition, we searched other types of documents (i.e., other than articles and conference papers) in the three libraries (Scopus, Web of Science, and IEEE), and no relevant documents were found. Therefore, the grey literature was not included in this review. We believe that our proposed sustainability model lays the foundation for developing a sustainability analysis and assessment method. Furthermore, there is a potential to use the sustainability model as a practical guide that supports healthcare institutions in reasoning about e-health solution sustainability. The model and the assessment method were demonstrated to assess the sustainability level of an e-health solution (i.e., HIS) successfully. The sustainability assessment in the case study received a low score of 52%, which matched the actual status of the e-health solution. Before applying the sustainability assessment method, the gathered information indicated a low level of sustainability, which means the e-health solution will not be sustained. A similar sustainability evaluation was predicted by the sustainability assessment method, which means only few aspects contributed to the sustainability; hence, the e-solution will not be sustained in the long-term unless most of the performance in most of the aspects are improved. The results revealed the unsustainability risk of this e-health solution and highlighted the aspects in which improvements could be introduced. Furthermore, it was observed that the organization dimension has the greatest influence on the other dimensions. This conclusion aligned with the results of the SLR, in which the organization dimension was frequently found in the studies to be an important dimension that influences sustainability the most. This was apparent in the case study, in which the organization dimension received a score of 42%. This score resulted from the unfulfulfillment of most of the organizational aspects, such as the top management support and stakeholders' involvement. By this, the other dimensions (i.e., resources and economic dimensions) were negatively impacted, in that the funds were not provided, which impacted the availability of the resources. Furthermore, the unfulfillment of the resources and economic dimensions negatively impacted the social dimension, as users were not satisfied with using a system that had many limitations and did not meet their needs. Moreover, the lack of sustainable funding is an issue that directly impacts the sustainability of e-health solutions, because e-health solutions are improving rapidly and the demand for new changes and updates is increasing correspondingly. In order to keep up with the demand, adequate sustainable funding is required to continue the use of the system.