# Toward a Comprehensive Understanding and Evaluation of the Sustainability of E-Health Solutions
## 2 Related Work  
Most of the existing studies discuss sustainability in healthcare from a managerial level only. [PERSON] et al. [11] proposed a sustainability model for changes in healthcare. The model was in the form of a self-assessment tool, which consisted of 10 factors that were prioritized over 100 identified factors. These factors were categorized into three main domains and given weights as follows: process (31%), staff (52%), and organization (17%). Each of the ten factors has four levels, by which the user chooses one level for each factor that describes the current situation. However, some important aspects were missing in these factors, such as the economic and funding estimation, the probability of laying off staff and its impact on the organization, and the social-cultural aspects of the organization and the staff. [PERSON] et al. [12] constructed a model to predict the sustainability of changes in healthcare. The study proposed nine factors associated with multiple levels for each factor. However, this model lacks factors concerning patients, such as their satisfaction with the change. One of the important aspects of sustaining changes in healthcare, which is rarely addressed in the existing literature, is the willingness of healthcare stakeholders (e.g., patients, healthcare providers, families, and managers) to adjust themselves to the change [13].  
[PERSON] and [PERSON] [14] proposed a sustainability model consisting of three levels for software products. In their work, they defined the sustainability dimensions to be individual, social, economic, environmental, and technical. The dimensions were at the top level of the model. At the same time, the middle level included the values, indicators, and regulations. The activities of the model, such as reducing waste, are placed in the lower level. This model focused on environmental sustainability and lacked a steady assessment method that can measure the impact of each factor in anticipating the sustainability of the solution. A systematic integrative review [3] on healthcare sustainability revealed that out of 92 studies, only 6 studies used purpose-designed tools to evaluate sustainability. [PERSON] et al. [3] emphasized the lack of a unified and rigorous sustainability definition and inconsistency in the way it is conceptualized [3]. Another study [6] concluded the lack of a comprehensive definition of sustainability was the essential challenge that hindered the field from moving forward. Other studies discuss sustainability in healthcare with a focus on developing tools [1] and frameworks [2; 15] for sustaining the healthcare organizations rather than focusing on the changes within these organizations. Furthermore, another study discussed the role of digital solutions in sustaining healthcare in general by presenting different types of interactions that can happen via digital platforms [16].  
A study conducted by [PERSON] et al. [17] found the importance of IT competence among nurses for the quality of using new technologies in work. This indicates that there are different aspects that should be considered when evaluating the quality of an e-health solution.