Table 3.

Description of the case study process in the light of the complexity areas characterizing clinical processes.

Clinical process complexity area	Sub-area	Case study instantiation	Effect on the model
Medical knowledge	Evidence based medicine, guidelines, recommendations	National Guidelines Clearinghouse [68], where clinical guidelines from Australia [69], United States of America[70], Scotland [71], and Canada [72] were the main evidence-based recommendations used.	The selected guidelines were the base of the pre-modeling meta-model and were included as general constraints to be followed in the protocol definition
		Earlier versions of the guidelines were also considered in the model, since patients may have started the rehabilitation process before the last version of the guidelines/recommendation was issued.	Each guideline was labeled with the validity date, and the specific task in the evaluation process was connected to the date.
	Local practices	Textual and graphical clinical pathways were developed locally and used as main reference.	The local pathways were remapped on the guidelines.
	Clinician personal experience, habits and skills	The personal habits, expertise, and information needs of the different actors (clinician, nurse, and therapist) were considered in the model.	All the process participants were interviewed during context analysis to define all the information processed so that it could be included in the model.
	Learning by practice	There are established and sometimes sub-optimal behaviors (e.g., clinical scales recorded in paper-based patient’s diaries) that the modeling methodology can highlight and that can be improved by implementing a new software module.	The model should represent the actual practices without introducing changes that imply specific training. It should be validated with the process participants before the release.
	Building evidence from practice	To evaluate the compliance to guidelines, the model included structured and organized information, that can be collected for secondary use.	The model included the collection of logs.
Response to treatment	Time frame – short-term or long-term response	Rehabilitation is usually characterized by long-term response with an alternate outcome.	The model allowed a variable waiting time between two actions (e.g., introducing a control on outcomes and not on time) and the possibility to map different responses (e.g., using forks) to map different behaviors.
	Compliance – depending on patient’s engagement	All the rehabilitation exercises conducted not in constant presence of the therapist can be ineffective due to patient’s misunderstanding of the indications or exercise descriptions. This problem becomes crucial when the therapist has to teach hoe therapy to the patient.	The model considered that some activities need to be repeated and included the management of educational information for the patient at home (i.e., booklets).
	Expected outcomes	Outcomes are essentially clinical scales evaluating functions during activities of daily life, independence quality of life and mental state. Both the outcomes measures reported in the recommendations and the ones used locally were considered in the model.	The model included the organization and the electronic collection of the outcome variables. A data structure for the outcome measures used locally was defined.
	Patient feedback to reshape therapy – depending on patient’s empowerment and education	Psychometric questionnaires to report directly the patients’ feedback about how they feel or about a specific function they need to rehabilitate were considered in the model.	Patient-reported outcome measures were integrated in the software to collect clinical scales.
		Likert scales scoring directly how the patients perceive their status before and after therapy (i.e., the general perceived effect, GPE) were included in the model.	GPE was integrated in the software to collect clinical scales.
Personalization of care	Patient-centric approach – treatment definition considering patients preferences and history	There are some patient-dependent cautions to be considered during the rehabilitation of specific functions, e.g., required aids or level of assistance… that should be considered in the model.	The possibility to carry out the same treatment using different aids or different level of assistance was modeled in the treatment class.
		There are some patient dependent cautions to be considered in the definition of treatment duration and schedule e.g., patient ability to be focused to the training, patient resistance and strength.	A dynamic setting of treatment duration and schedule was included.
	Treatment adaptation considering occurring changes	Consider possible interactions between the patient comorbidities and the chosen treatment, that may become evident after clinical pathway definition.	The possibility to manage discovered interactions as alternative pathways in current treatment was included.