# Toward a Comprehensive Understanding and Evaluation of the Sustainability of E-Health Solutions
## 8 Discussion  
Although sustainability is a critical issue in all sectors, it is more important in healthcare due to the complexity and sensitivity of this sector [8, 24, 31, 33, 68]. As e-health solutions are involved in many processes of healthcare provision, the sustainability of these solutions should be particularly considered by healthcare decision-makers and management. However, the results of this SLR indicated a significant scarcity of studies investigating the sustainability of e-health solutions and providing methods to assess and evaluate their sustainability. The issue of not having a unified sustainability definition in healthcare was mentioned in most of the primary studies, yet their scope did not focus on resolving this issue or referring to other studies that tackled it. There exist some studies that focused on defining sustainability in healthcare [6, 69]. However, the scope of these studies was defining the sustainability of healthcare innovation generally, and not focusing on e-health solutions. Therefore, a unified definition of the sustainability of e-health solutions remains a need, and further studies are required to investigate how e-health sustainability is perceived and defined in practice and in the literature. Based on the focus of the definitions elicited from the literature, our proposed definition of the sustainability of e-health solutions is _the ability of e-health to continue meeting the expanding demand for facilitating healthcare provision through the cost-efficient use of digital technologies_. Moreover, the studies emphasized the importance of having multidimensions to assess e-health sustainability, as it is not enough to focus on only one dimension such as financial, environmental, or technology [7, 32, 38]. Correspondingly, the organization dimension was found to dominate more than the technology dimension and aspects related to e-health solutions [33]. This is because the same e-health solution can exhibit different levels of success when implemented in different healthcare organizations [33]. As the budget for e-health is a global issue in all healthcare systems, top management and decision-maker support is one of the organizational factors that help overcome this issue [25]. This is because when the top management supports the adoption of the e-health solution, then the funding will be readily facilitated [25], which contributes to its sustainability. These findings demonstrate the alignment of the dimensions in the developed model with the sustainability of e-health solutions. Furthermore, it is important to consider the variation of the influences on sustainability among the dimensions, in which sustainability should not be an all-or-nothing concept [25]. Instead, each dimension impacts the sustainability of e-health to a different degree according to the context of the e-health solution [25]. Although all dimensions are intrinsically interconnected and must be considered as they influence each other [32], most studies that stated the dimensions of e-health sustainability did not explore the influence degree of dimensions on the sustainability and on each other, except for study [37], in which it argued that the clinical acceptance has the greatest influence on sustaining telehealth, which was the focus of the study. Determining the degree of influence of the dimension reflects the importance of each dimension and therefore helps to assess the sustainability of the e-health solution, which was not discussed in depth in the primary studies [38]. In addition, two experts mentioned that when evaluating sustainability using our proposed model, healthcare IT experts should decide on the weights of the dimensions and select the applicable aspects based on their judgment. The aspects and elements with high importance should be mandatory in assessment, while other aspects with less importance can be eliminated based on the context. Some of the selected studies in this review have proposed a model or framework containing dimensions of e-health sustainability.