# Toward a Comprehensive Understanding and Evaluation of the Sustainability of E-Health Solutions
## 4 Results
### The Sustainability of E-Health Solutions
#### 4.2.3 Evaluation/Assessment Methods
[8] designed the SCH-CAT catalog for software quality requirements that are critical to the sustainability of connected health (CH) applications. Although the SCH-CAT catalog targets the design phase of CH applications, a checklist can be generated from it, which includes a set of requirements to be used to evaluate the sustainability of CH applications in the implementation phase. The catalog was applied to assess the sustainability of a running CH application called Blood Donor+. A questionnaire containing requirements as checklist questions was used to evaluate the CH app, in which the answer is one of the three options: yes (+1), no (+0), and partially (+0.5). The overall score was calculated and the threshold score that determines the app's sustainability was set to be 50%. Based on a literature survey, [PERSON] et al. [35] constructed a conceptual framework that can support the efforts of developers, researchers, managers, and policy makers to ensure the implementation of sustainable e-health systems in resource-constrained settings. In the study, the framework was used to assesses the contribution of four e-health frameworks. The framework consists of four sustainability aspects, namely, social, environmental, economic, and technological, all of which contain indicators that can be used to evaluate the sustainability of e-health systems. [PERSON] et al. [36] discussed two models, the TeleMedicine Maturity Model (TMMM) and the CeHRes roadmap, that were demonstrated to be effective in facilitating, implementing, and sustaining telemedicine projects. The CeHRes roadmap serves as a guide to the establishment of a telemedicine service, whilst the TMMM is concerned with maturation of the existing telemedicine service. In the study, the authors proposed a new model by combining these two models. In the proposed model, it was suggested that each maturity level of TMMM serves as a stage gate for each of the phases of the CeHRes roadmap. Maturity levels are initial, managed, defined, quantitatively managed, and optimized. The maturity levels are used to evaluate the maturity categories, which are technology, users, work processes, finances, and policies. By applying the proposed model to an e-health solution, the resulting maturity level of each category determines its sustainability. [PERSON] et al. [38] argued that the focus of healthcare technology assessment should be shifted from efficiency and effectiveness to sustainability. They proposed a reference framework containing efficiency and effectiveness dimensions to achieve the sustainabilitydimension of healthcare technology. They defined efficiency as the plans (i.e., things are done in the right way), effectiveness to be the goals (i.e., the right things get done. ), and sustainability as when the right relationships exist with other service systems. As they indicated, efficiency can be measured with reference to the structure, whilst the effectiveness of a system is measured with reference to its specific context and in relation to the general environment; sustainability therefore can be achieved.