Modeling stroke rehabilitation processes using the Unified Modeling Language (UML)

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Abstract

In organising and providing rehabilitation procedures for stroke patients, the usual need for many refinements makes it inappropriate to attempt rigid standardisation, but greater detail is required concerning workflow. The aim of this study was to build a model of the post-stroke rehabilitation process. The model, implemented in the Unified Modeling Language, was grounded on international guidelines and refined following the clinical pathway adopted at local level by a specialized rehabilitation centre. The model describes the organisation of the rehabilitation delivery and it facilitates the monitoring of recovery during the process. Indeed, a system software was developed and tested to support clinicians in the digital administration of clinical scales. The model flexibility assures easy updating after process evolution.

Introduction

Rehabilitation is an individually tailored programme of medical practice focused to reverse all or the most of disabling conditions produced by a disease that cannot be reversed by medical care alone [1].

Stroke rehabilitation is the process of helping a post-stroke patient regain the highest possible level of independence and quality of life. A growing body of evidence indicates that effective rehabilitation interventions delivered just after medical stability has been reached [2] can enhance the recovery of functional disabilities [3], [4].

Stroke continues to be a major public health concern, with more than 750,000 cases occurring each year in the United States; nearly one-third of these strokes are recurrent [5], [6], [7]. About 196,000 strokes occur in Italy every year, of which 80% are first strokes and 20% recurrent [8], [9]. Stroke is the leading neurological cause of acquired adult disability, and the third most frequent cause of death in industrialised countries [10]. One year after the acute event, one-third of the patients continue to be totally dependent on their caregivers [8]. Furthermore, as the population ages, the social and economic burden of stroke is expected to increase.

The heterogeneity of stroke aetiology and the initial severity of the lesion, differences in the resulting impairments, the variability of responses to rehabilitation treatments, and individual characteristics such as motivation, social support and learning ability all make the process of post-stroke recovery difficult to predict.

The stroke rehabilitation guidelines are “systematically developed statements, grounded on the current scientific knowledge, to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances” [11]. However, although they provide general recommendations, they should be interpreted by healthcare professionals in such a way as to ensure the best strategies at local level. There is therefore a considerable degree of discretion when going from reading the guidelines to treating patients in clinical practice [12], [13]. Rehabilitation depends on organisational factors such as equipment, facilities, personnel competences, and the harmonised cooperation of staff in a particular healthcare institution. However, despite clinicians’ general mistrust of clinical guidelines, it was shown that the improvement in patient outcomes is greater the more the rehabilitation process adheres to their recommendations [14]. Moreover, it is recognised that it has to be provided by a specialised and multidisciplinary team of health professionals [15], [16], [17], [18].

An efficient and effective process must be well organised, characterised by a continuous improvement in outcomes, simple to control, clear in all its details to all of the players involved, and flexible enough in order to allow its frequent and easy updating [19]. The first step towards improving the complex process of post-stroke rehabilitation is to describe it clearly and in detail. One way of doing this is to model it because modelling makes it easier to break it down into its component parts, which can be handled one at a time. These are subsequently recombined in order to create a network of interdependence. Modelling increases the readability of a process and its evolution, and thus facilitates its control.

One widely used tool in process modelling is the Unified Modeling Language (UML), a visual modelling and specification language that is capable of providing multidimensional insights into a system using behavioural, conceptual, and physical abstractions [20]. It has not only become a gold standard in modelling complex processes and software systems, but has also been applied to e-healthcare with various objectives, including optimising hospital processes, [21] planning chemotherapy and organising hospital-based cancer registration processes, [22], [23] modelling the organisation of randomised controlled trials, [24] and creating a medical image case-based retrieval system for pathologists [25]. The UML allows the whole application domain to be simply visualised and understood.

The aim of the study was to design the first UML model of the multidisciplinary stroke rehabilitation process. The model was grounded on international guidelines and refined following the clinical pathway adopted at local level by an Italian specialized rehabilitation centre. A process representation through a comprehensive conceptual model was implemented in UML and then a part of the model was translated into a relational database for the digital administration and collection of assessment tests by means of clinical scales.

Section snippets

Organisational framework in rehabilitation medicine

Rehabilitation is used in different contexts such as cardiology, oncology, neurology, orthopaedic. The rehabilitation objectives and the type of therapy are obviously different in the different contexts. An older person who has had a stroke may simply want rehabilitation to be able to dress or bath without the help of a caregiver. A younger person who has had a heart attack may go through cardiac rehabilitation to try to return to work and normal activities. Someone with a lung disease may get

The context of the stroke rehabilitation process

The rehabilitation of post-stroke patients is a proactive, person-centred and goal-oriented process aimed at improving function and/or preventing deterioration of function, and bringing about the highest possible level of patient independence [15]. The complete effective care of stroke includes the early management of acute stroke in the Emergency Department, the planning of post-acute rehabilitation in a specialised centre and finally at home, and following up the patient [12]. The proposed

Discussion

A UML model providing an essential description of the stroke rehabilitation process was implemented. The model infrastructure is based on an organisational framework which is common to the rehabilitation medicine regardless the specialty chosen. The model describes what is needed to offer effective multidisciplinary rehabilitation to post-acute stroke patients admitted to an advanced Italian rehabilitation centre and how all of the actors take part in the process.

First, the main phases of the

Conclusions

To the best of our knowledge, ours is the first UML model of the multidisciplinary stroke rehabilitation process. It assumes post-acute stroke patients admitted to a specialised rehabilitation centre, and concentrates on representing the fundamental entities involved in the rehabilitation process. The model is grounded on and coherent with the international guidelines for the stroke rehabilitation process. It is then refined according to the clinical pathway adopted by a specific rehabilitation

Summary

The heterogeneity of stroke aetiology and of the initial severity of the lesion, differences in the resulting impairments, the variability of responses to rehabilitation treatments, and individual characteristics such as motivation, social support and learning ability all make the process of post-stroke recovery difficult to predict. In organising and providing rehabilitation procedures for stroke patients, the usual need for many refinements makes it inappropriate to attempt rigid

Conflict of interest statement

None declared.

Acknowledgements

We would like to thank the doctors, therapists and nurses for their contribution and Kevin Smart for his help in preparing the English version of the manuscript.

References (42)

  • N.F. Gordon et al.

    Physical activity and exercise recommendations for stroke survivors; an American Heart Association Scientific Statement From the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council

    Circulation

    (2004)
  • American Heart Association. Heart Disease and Stroke Statistics—2003 Update. American Heart Association, Dallas, Tex:,...
  • W. Rosamond et al.

    American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee

    Circulation

    (2007)
  • G.F. Gensini et al.

    SPREAD—Stroke Prevention and Educational Awareness Diffusion Ictus cerebrale: Linee guida italiane, Milano, Pellicole e stampa

    (2010)
  • C. Francescutti et al.

    The impact of stroke in Italy: first step for a national burden of disease study

    Disabil. Rehabil.

    (2005)
  • D.A. Greenberg et al.

    Neurologia clinica

    Lange Clinical Book

    (2004)
  • I. Sim et al.

    Clinical decision support systems for the practice of evidence-based medicine

    J. Am. Med. Inform. Assoc.

    (2001)
  • P.W. Duncan et al.

    Adherence to postacute rehabilitation guidelines is associated with functional recovery in stroke

    Stroke

    (2002)
  • National Stroke Foundation, Clinical Guidelines for Stroke Management 2010, Melbourne, Australia,...
  • Stroke Unit Trialists’ Collaboration, Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst. Rev. 1...
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