Eco-Sustainability and Efﬁciency of Healthcare Complex Systems

Ilaria Angela Amantea

1 a

and Marinella Quaranta

1,2 b

Computer Science Department, University of Turin, Turin, Italy

Department of Law, University of Bologna, Bologna, Italy

Keywords:

Healthcare, E-Health, Digitalization, Complex System, Simulation, BPM.

Abstract:

Healthcare is one of the most difﬁcult complex systems to optimize. The challenge is in the multiple factors

to balance. Some are common to many other industries, while some are riskier, and the whole system must be

well-balanced to ﬂow and ensure the functioning of a vital service for the citizens. The close interconnection

between the various factors means that making changes on one aspect will have cascading effects on many

other aspects. Therefore, the optimization must not be done considering a single parameter, but considering

the whole chain. According to the European objectives of digitalization and eco-sustainability, in this paper

we present an overview of the impact of digitalization of certain paper documents on process activities, times,

costs, and spaces of archives.

1 INTRODUCTION

Healthcare structures are ”complex systems”.

Namely, a complex system is a system made of

(i) interacting component parts and (ii) exhibits

dynamical behavior that cannot be inferred from

the behavior of the parts themselves (Motter, 2004).

Complex systems have also been deﬁned as an

ensemble of many elements that interact in a dis-

ordered way, resulting in robust organization and

memory (Ladyman et al., 2013). Thus a complex

system is a collection of interconnected elements that

present emergent behavior, which means that a whole

system displays properties and behaviors that are not

directly predictable from each behavior of individual

parts. They also include non-linear dynamics (small

changes lead to impacting effects), and properties

that may be difﬁcult to anticipate or control. This

also makes them vulnerable to some failures (e.g.

cascading failures) and unpredictable behavior.

Generally, in healthcare, there are a relevant

amount of features to take into account. There are

medical norms, medical guidelines, and medical pro-

tocols that are strictly related to the diagnosis, cure

and prevention of conditions, diseases and patholo-

gies. These elements are not only regulated by the law

but also by practical elements, e.g. the ability to man-

https://orcid.org/0000-0003-1329-1858

https://orcid.org/0000-0003-2691-0611

age emergencies and criticalities that fall outside the

guidelines. Healthcare structures have a large number

of variables, thus, there is a multitude of tasks that

could suffer from bad management, as for less visi-

ble criticalities and bottlenecks. Once they become

visible, they can be optimized.

Time can be pivotal in healthcare structures, but

reducing time in tasks generally leads to an increase

in number of patients to be taken care of. With a

new load of patients, staff get overloaded with work

or might have to work under pressure, as usually an

increase in workload does lead to a congruent ad-

justment in staff employment. Human staff cannot

be subject to machine-like rhythms, they need and

have the right to rest. They are also entitled to bal-

anced and reasonable work shifts. Such conditions

are needed not only to be compliant with contracts

but also because a tired physician could make mis-

takes in treating patients. Less rest impacts on risk of

clinical and treatment errors. Cost is also pivotal in

healthcare structures. Normally cost optimization is

linked to cutting staff or services, but this enhances

the issue of the quantity and quality of care services

provided to the citizen, and again, it impacts the work-

load of the remaining staff. Times, costs, and quali-

ties are the three features to be balanced in healthcare

structures. Depending on the goal, it is possible to

optimize two of such features, which inevitably de-

teriorates the third feature. It is not possible to opti-

mize all three features if available resources continue

Amantea, I. and Quaranta, M.

Eco-Sustainability and Efﬁciency of Healthcare Complex Systems.

DOI: 10.5220/0012857400003758

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 14th International Conference on Simulation and Modeling Methodologies, Technologies and Applications (SIMULTECH 2024), pages 423-430

ISBN: 978-989-758-708-5; ISSN: 2184-2841

423

to stay the same. This scenario could lead to new gen-

eralized problems (long attendance lists, delays, daily

errors, etc.). Optimizing all three features only be-

come possible in case available resources increase.

The European Union has been pushing for years

towards the digitalization of public systems, public

administration, courts, healthcare etc. and member

states are following along.

The European Union prioritizes digitalization,

particularly in public administrations, and has made

signiﬁcant progress through the ”NextGenerationEU”

recovery plan, which includes numerous digitaliza-

tion projects(Amantea et al., 2023). In the e-health

sector, the European Commission has proposed the

European Health Data Space, aiming to facilitate the

free movement of citizens by ensuring health data ac-

cessibility across member states. Despite high-level

legal norms and national legislation supporting digi-

talization, effective implementation requires internal

protocols within healthcare infrastructures. Without

these protocols, traditional paper processes may per-

sist(Amantea et al., 2022a). Therefore, especially

for public facilities like hospitals, digitalization will

mean compliance with European prescriptions.

In Italy, hospitals currently print an enormous

amount of paper for prescriptions, informed consents,

medical forms, clinical documents, reports, internal

organizational documents, etc. In terms of costs,

these printing costs in the long run can weigh on the

total budget of a hospital, while in time terms, the

time used in printing these papers signiﬁcantly length-

ens waiting times for patients. These documents must

be kept in the possession of healthcare facilities for

a certain amount of time set by the law (on average

from 2 to 10 years depending on the type of docu-

ment). This also means that several rooms must be

saved as archives and cannot be used for clinical care.

There are further obligations set by the law on these

kinds of documents: paper documents (such as med-

ical reports) must be physically collected from the

patient, while the physical search and distribution of

medical reports implies additional time for the admin-

istrative staff of the hospital, the existence of an ofﬁce

with designated personnel, an archive, the presence

of patients and physical waiting queues in structure.

Also, in case long-archived documents are needed, a

manual search through a considerable amount of pa-

per is needed.

Our research is based on a collaboration with

healthcare facilities in Piedmont, our collective aim is

to ease the digitalization process. We will refer to the

digitalization of the “Azienda Sanitaria Locale Torino

3 - ASLTO3”, which is a local health care service, a

public health entity working in the Piedmont Region.

The goal of this paper is to show how digitalization

could come as a solution: by digitizing some docu-

ments that are currently on paper, it could be possible

to maintain the same quality of service while reducing

costs. This would also be possible due to the already

existing server and information system. However, this

speciﬁc function of the system is not yet in use.

The savings in costs could be used to increase hu-

man resources or equipment, which would lead to an

improvement in the workload, an increase in the well-

being of the working environment, and could lead to

a decrease in times (e.g. printing times and times for

searching in the archives). Finally, it could also in-

crease the total number of visited patients.

The paper is structured as follows: Section 2 will

outline the methodology and the background; Sec-

tion 3 shows the case study experiments that imply

processes, simulations, results, and related comments

and observations; ﬁnally, Section 4 presents some

conclusions.

2 METHODOLOGY

In medicine, the organization of health processes is a

fundamental aspect to examine and it should be exam-

ined by taking a holistic and systemic approach. Also,

computer science gained a relevant role in techni-

cal hardware and information systems improvements

(Dumas et al., 2005).

To analyze the healthcare facilities’ business pro-

cesses, we used the business process management

methodology (BPM) (Dumas et al., 2018) a discipline

combining data science and management studies to

perform business process improvement, modeling and

simulation (Sulis and Di Leva, 2017). A key objective

within BPM is change management (Amantea et al.,

2020a). By emphasizing a process-centric method-

ology, we illustrate the business process through the

standardized language of the Business Process Model

and Notations (BPMN). The methodology takes a

process-centric stance and involves a process-aware

information system alongside the iGrafx simulation

tool. These tools are used to reshape their business

processes. Through the integration of these meth-

ods, we can scrutinize activities, resource allocation,

timeframes, costs, delays, and bottlenecks (Martinho

et al., 2016). These information are based on au-

thentic data stored within the information system (IS).

For all these reasons BPM methodology is one of the

most used methodologies to optimize many aspects of

healthcare system and/or regarding the e-health sys-

tem processes (Amantea et al., 2020b; Amantea et al.,

2022b; Amantea et al., 2021; Sulis et al., 2019).

SIMULTECH 2024 - 14th International Conference on Simulation and Modeling Methodologies, Technologies and Applications

424

The reorganization of processes involves three

main stages:

• The analysis of the context: the analysis is

needed to examine the current context of a pro-

cess, in order to grasp which improvements are

needed at different levels.

• The business process analysis and simulation:

the analysis examines step by step a chosen pro-

cess with the aim of creating the As-Is model of

the process. The As-Is model is used for simu-

lation and its performance indicators are used for

validation.

• The re-engineering and scenario analysis: with

the knowledge of delays, bottlenecks, and errors

in the process, a new scenario (To-Be model) is

proposed by building a process proposing differ-

ent conﬁgurations in a what-if analysis. The ﬁnal

purpose is the optimization of the chosen process.

The speciﬁc functions and tasks of the process can

be addressed by a set of process performance mea-

sures (also called key performance indicators or KPIs)

(Van Looy and Shafagatova, 2016). These perfor-

mance measures usually include time, costs and re-

sources. The goal of business process analysis is

to create and specify a visual representation of pro-

cesses, such as a ﬂowchart or a process map. The As-

Is model depicts the state of the business process as it

now exists, the graphics help in visualizing the ﬂow

of activities and several crossroads, which are called

gateways. The gateways lead to different paths as a re-

sult of the decisions made. There is further integrated

information such as the number of human resources

carrying out the tasks, their attributes (aka schedule,

expenses, and capacity), the duration of tasks, the pol-

icy management, and the real-life workload. As a re-

sult, the stakeholders may be able to test and validate

the model by using the simulation to get an assess-

ment of the performance metrics.

3 EXPERIMENTS AND RESULTS

The context of our experiment is the “Azienda San-

itaria Locale - Torino 3 (ASLTO3), which is one lo-

cal healthcare service, a typical public health entity in

Italy. It involves a number of hospitals and territorial

hubs in speciﬁc areas of Italian regions. They provide

public health services to the population of a speciﬁc

area in Piedmont. In this paper we only take into con-

sideration a department, the radiology department, of

the ASLTO3. This means that our experiment has

been conducted on all the radiology departments of

hospitals and territorial hubs that fall under the au-

thority of the ASLTO3. The digitalization experiment

will take into consideration the paper process of ad-

ministrative documents, not diagnostic documents or

medical records. The medical staff is shared between

hospitals and territorial hubs. All the medical staff

pertain to the ASLTO3 as a whole and thus it operates

in every structure. As for this centralization, the cost

center and the archive are the same for all the radiol-

ogy departments.

3.1 The Processes

Figure 2 shows the the current (As-Is) administrative

process carried out both in the hospital and in the terri-

torial hub in the radiology department. In both cases,

they need to print the prescriptions and the informed

consent for the exams in order to archive them. In

particular, at administrative level, when the patient ar-

rives he/she is asked what exam should be done, the

identity documents, and the prescription. The patient

can have printed or online prescription. If it is printed

on paper, a code is printed for the speciﬁcations of

the exam and the procedure of acceptance records the

presence of the patient in the ward. If the prescription

is digital, the administrative workers still have to print

a paper version as the current legislation provides for

the retention in paper of the prescriptions of any the

exams carried out at the hospital. In the hospital and

in the territorial hub the administrative procedure is

almost the same, the difference is the amount of staff

dedicated to such task. In the hospital 2 or 3 adminis-

trative workers are dedicated to it, while in the territo-

rial hub there is just 1 administrative or even just the

X-ray technician. Finally, there are different typolo-

gies of exams.

Figure 1 shows the To-Be process, an optimized

version of the current process with the time, printing,

and archiving adjustments. This scenario implies that

the internal protocol is updated and harmonized with

national and EU standards on digitalization, making

full digitalization possible.

In detail, there can be two different scenarios be-

cause we are trying to digitalize two types of docu-

ments: the prescriptions and the informed constent.

The prescriptions are easier to digitalize because they

need a server for the storage (complying with the

GDPR), some protocols and legal documents just at

an internal level. The server already exists and in-

formed consents need more legal adjustments at re-

gional and national level. Therefore, being two differ-

ent procedures, if we can digitalize the prescriptions,

it does not automatically mean that informed consent

can be digitalized as well. In conclusion, if everything

Eco-Sustainability and Efﬁciency of Healthcare Complex Systems

425

Figure 1: Digital process. To-Be process.

Figure 2: Paper process. As-Is process.

SIMULTECH 2024 - 14th International Conference on Simulation and Modeling Methodologies, Technologies and Applications

426

will be digitalized the process will appear exactly as

Figure 1, else the activity “Archive paper” will still

appear.

3.2 The Simulations Setup

The ASLTO3 is made by 3 hospitals and 4 territorial

hub. For reasons of space, we decided to take into

consideration the data of the radiology department re-

lated to one of the hospitals and one of the territorial

hubs.

The generators of simulations are set up with an

average of 29,694 incoming patients for the hospi-

tal and an average of 14,080 patients for the territo-

rial hub in one year. Finally, in Table 1 there is the

percentage of each type of exam conducted in a year

in the hospital, while territorial hub percentages are

shown in Table 2.

Table 1: Percentage of each type of exam made in Hospital.

Exams type Percentage

X-Rey 45.6%

TC 28.8%

Eco 20%

RM 4%

Interventional 1.6%

Table 2: Percentage of each type of exam made in territorial

hub.

Exams type Percentage

X-Rey 92.2%

Eco 7.3%

Screening 0.5%

The considered paper cost is related to the pre-

scriptions and the informed consent.

The prescriptions are needed for most of the ex-

ams, but not all the exams. The same goes for in-

formed consent, it is not always needed as it is related

to the level of risk of the medical exam. The informed

consent does not always have the same format, it can

change in relation to the exam.

3.3 Comparisons and Results

In the healthcare sector, in our case in the radiol-

ogy department, there are many interconnected fac-

tors that impact and depend on each other, such as

activities, time, costs, number of papers, and archive

space. Below we will analyze them individually and

then follow with ﬁnal observations.

3.3.1 Activities and Time in the Processes

Activities. Comparing Figure 2 and Figure 1 is vis-

ible that if the prescriptions can be just digital, the

paper branch will disappear and, in the digital branch,

of course, will disappear also the activity “Print pre-

scription”.

Finally, at the end of the To-Be process, the ac-

tivity “Archive paper” will disappear. This, however,

will only come as a consequence of several adjust-

ments.

To make such activity disappear both the digital-

ization of the prescriptions and the digitalization of

the informed consents are needed. In case only pre-

scriptions are digitalized the archive activity would

remain. Also, this scenario is only possible if there

were legal interventions at the national level to har-

monize the digitalization of informed consents, which

would as well make them visible in the electronic

health record of each patient. Only in this scenario

it would be possible to delete the storage task.

Time. With the change of the activities, the working

time will be affected. In this case, the simulation is

related to the working time of the administrative staff

and not to the working time of exams themselves. The

working time of exams can only be affected by clini-

cal variables.

Excluding ﬁrst-aid patients, the radiology exams

considered in this paper, exclusively cover booked pa-

tients and hospital patients. Patients tend to have an

order of arrival staggered according to the established

time of the clinical exams. Therefore, those waiting

times are not so representative. They are mostly re-

lated to delays in the arrival of external patients or

delays in the transport of patients from the hospital

wards.

What is affected is the time in the sequence of the

activities of acceptance:

1. “Receiving patient” + “Acquire prescription &

patient data” + “Print prescription” + “Send pa-

tient to exam”

2. “Receiving patient” + “Patient Acceptance” +

“Print code” + “Send patient to exam”

3. “Receiving patient” + “Acquire prescription &

patient data” + “Send patient to exam”

The ﬁrst two are related to the current paper process

(As-Is) branches and the last one is related to the dig-

ital process (To-Be).

Table 3 shows a comparison between the current

process (As-Is) and the digital process (To-Be). The

simulation results of both processes is expressed in

the administratives’ working time (in minutes) per pa-

tient.

Eco-Sustainability and Efﬁciency of Healthcare Complex Systems

427

Table 3: Comparison between the current process (As-Is)

and the digital process (To-Be) simulations results of the

administrative working time (in minutes) per patient.

Average Working Time per patient

As-Is 2.37 minutes

To-Be 1.66 minutes

3.3.2 Number of Paper Prints and Costs

Number of Paper Print. To understand this point we

need to make two premises:

• Prescriptions are required for each exam except

for preventive screenings, where patients receive

invitations at home. If a patient arrives with a dig-

ital prescription, administrative staff must print it

for archiving purposes. If the patient has a pa-

per receipt, a code must be printed and stapled to

the prescription, counting as a second sheet. Le-

gal compliance for prescriptions can be managed

with internal adjustments.

• Informed Consents are not required for all ex-

ams, and for those that do, the format and number

of pages vary. Informed consent forms must be

printed in duplicate: one copy for the patient and

one for the healthcare facility. Table 4 provides a

summary of this information.

Table 4: Paper pages needed for the informed consent for

type of exam.

Exams type Printed pages for informed consent

TC 2 (X2)

Interventional 2 (X2)

Eco 2 (not for all exams) (X2)

Screening 1 (X2)

RM 5 (X2)

In this case, the simulation helps us to understand the

extent of the potential savings and present an argu-

ment in support of the legislative harmonization for

digitalization of informed consent and prescription.

If the harmonization becomes effective, the simulated

savings will become effective.

The simulation results reported in Figure 3 show

the number of papers that are printed on average in

one year for the prescription, and the same for in-

formed consent. They both are presented in relation

to the hospital and to the territorial hub.

The digitalization of the prescriptions and of the

informed consent are two different procedures. Thus,

there will likely be an intermediate situation (i.e. the

“Partially Digital” scenario) in which all the prescrip-

tions are digital but not the informed consent. The

informed consent could be sent online to the patient,

while it should be archived in a paper format. This

means that there is still a paper copy to be taken into

consideration for the informed consent. However,

there would be a relevant reduction in paper which

is evident in Figure 3.

Of course, in case of fully digitalization the

amount of paper would be zero.

Figure 3: Number of paper used in the hospital and in

the hub in the AS-IS (“Paper”) situation and in the To-Be

(“Partially Digital”) situation. Related to the prescriptions

and to the informed consents.

Table 5: Paper pages saved using the partial digitalization

and the full digitalization, expressed in number of pages and

in percentage concerning the current situation.

Saving N. in% Saving N.

of paper of paper

Partially Fully

Digital Digital

Tot Hospital 59,688 71.3% 83,682

Tot hub 14,151 99.5% 14,222

In conclusion, starting from Figure 3, Table 5

shows that just with partial digitalization, i.e. dig-

italize the prescriptions and the informed consents

for the hospital, printing just the copy for the hospi-

tal archive, “Partially Digital”) almost 60,000 paper

sheets will be saved in the hospital and almost 1,500

in the hub. With a full digital system, almost 85,000

paper sheets will be saved in the hospital and almost

14,000 in the hub.

Costs. Figure 4 reports the results of the simulation

on costs for the hospitals and the hub. These are re-

lated to the cost of the paper and the printing costs

in proportion to hard copies. The Figure also shows

a comparison between the As-Is and the To-Be “Par-

tially Digital ” scenario.

Also in this case, if all informed consents can be

ﬁlled out, signed, and kept totally in digital, the cost

of printing and paper would be zero.

In conclusion, starting from Figure 4, Table 6

shows that just with partial digitalization, i.e. digi-

talize the prescriptions and the informed consents for

SIMULTECH 2024 - 14th International Conference on Simulation and Modeling Methodologies, Technologies and Applications

428

Figure 4: Cost of paper consuming and printing costs re-

lated to the AS-IS (“Paper”) situation and in the To-Be

(“Partially Digital”) situation, divided for prescriptions and

informed consents.

Table 6: Costs saved using the partial digitalization and the

full digitalization, expressed in Euro and in percentage con-

cerning the current situation.

Saving Cost in% Saving Cost

in euro in in euro in

Partially Fully

Digital Digital

Tot Hospital 1,193.46C 71.3% 1,673.34C

Tot hub 283.02C 99.5% 284.44C

the patient, so printing just the copy for the hospital

archive (“Partially digital”) almost 1193.46 C will be

saved in the hospital and almost 283.02C in the hub.

While with a full digital system almost 1600 C will be

saved in the hospital and almost 300 C in the hub.

3.3.3 Archive

Removing physical storage in healthcare facilities

has several beneﬁts. It eliminates the need for ﬁle

placement and manual searching, which can be time-

consuming and require multiple staff members. Dig-

ital databases allow for quick retrieval of ﬁles within

seconds. Physical storage demands large spaces in

healthcare buildings and poses risks such as docu-

ment loss, damage from ﬁres or ﬂooding, and the

need for regular disposal to make room for new doc-

uments. With the increasing number of required doc-

uments due to technological advancements, the need

for larger storage spaces is growing

3.3.4 Final Remarks

All the simulations shown until now are related to one

hospital and one hub of the radiology department.

As remarked before, the ASLTO3 involves 3 hos-

pitals and 4 hubs, which implies that both the cost

center and the archive are centralized for all the radi-

ology departments. Our aim is to show the impact of

the digitalization of just these two documents of one

department on the cost center and the archive of the

ASLTO3. Table 7 and Table 8 show respectively the

possible number of saving sheets paper and the possi-

ble saving costs for the ASLTO3.

Table 7: Paper pages saved using the partial digitalization

and the full digitalization, expressed in number of pages and

in percentage concerning the current situation.

Saving N. Saving N.

of paper of paper

Partially Fully

Digital Digital

Tot ASL Hospitals 179,064 251,046

Tot ALS hubs 56,604 56,888

Tot ASL 235,668 307,934

Table 8: Costs saved using the partial digitalization and the

full digitalization, expressed in euro concerning the whole

ASLTO3.

Saving Cost Saving Cost

in euro in in euro in

Partially Fully

Digital Digital

Tot ASL Hospitals 3,580.38C 5,020.02C

Tot ALS hubs 1,132.08 C 1,137.76C

Tot ASL 4,712.46C 6,157.78 C

Although the single results shown may not be im-

pressive, the impact of all these interconnected factors

is relevant. We only took into consideration two ad-

ministrative documents among all administrative doc-

uments, we excluded medical documents, and our

scope got as far as only one hub and one hospital

among all the ASLTO3. Also, these administrative

documents only came from the radiology department

of the chosen hospital and hub. This means that what

is saved in terms of time and costs in this scenario ex-

ponentially grows if adopted in the whole ASL TO3.

This is shown in Table 7 and Table 8. Table 7 refers

to savings in number of hard copies, wheres Table 8

refers to saving in costs. Using paper not only creates

a physical and printing cost but also creates a storage

space problem.

Saving time in healthcare facilities leads to a cas-

cading effect by freeing up staff to handle other tasks,

address bottlenecks, and increase available human re-

sources. Cost savings can be redirected to invest in

medical equipment or additional staff, improving both

care quality and work conditions by reducing over-

time and balancing workloads. This results in better

patient care, fewer errors, and higher patient satisfac-

tion, which can reduce legal complaints.

With technological advancements come new legal

standards, particularly for health data, requiring more

Eco-Sustainability and Efﬁciency of Healthcare Complex Systems

429

administrative documents and storage space. Switch-

ing to digital databases eliminates the need for addi-

tional storage, repurposing current storage areas for

medical use and cutting costs. Additionally, new doc-

uments require more storage space, increasing the

costs of renting adequate places. Digital databases

cut these costs, eliminating the need for new storage

spaces and allowing current storage areas to be repur-

posed for medical rooms or storage.

In Italy, the healthcare system is public, which

means it is publicly funded. If optimizing document

management in just one department can have a sig-

niﬁcant positive impact on public services and funds,

it also has the potential to bring massive beneﬁts on

a national scale. This optimization currently involves

only 1 ASL out of 12. Considering that Italy has 20

Regions, and Piedmont is just one region, this type of

optimization could bring to the whole public service

and public funds a great impact in scale.

4 CONCLUSIONS AND

IMPLICATIONS

This work shows the interconnection, the analysis,

and the impact of multiple factors in the complex ter-

ritorial health system.

It has been demonstrated that in the medical ﬁeld,

digitalizing just two administrative documents (non-

clinical) of just one department would have a consid-

erable impact on activities, time, costs, number of pa-

per ﬁles, and storage spaces throughout the territory.

The successful optimization of administrative health-

care activities is fundamental as it can be expanded

proportionally and exponentially throughout the en-

tire national territory. The interconnection of factors

brings a cascading optimization effect, bettering the

entire health service on multiple fronts. Last but not

least, these kinds of optimizations are indispensable

to align with the digitization and eco-friendliness re-

quired by the European Union. In the next future, we

will continue this collaboration with ASLTO3 to try

to implement the digitalization of the prescriptions.

REFERENCES

Amantea, I. A., Di Leva, A., and Sulis, E. (2020a). A

simulation-driven approach to decision support in pro-

cess reorganization: A case study in healthcare. In Ex-

ploring Digital Ecosystems, pages 223–235. Springer.

Amantea, I. A., Quaranta, M., Molinari, M., Peduto, C.,

and Demarchi, F. (2023). The e-dossier as a tool to

optimize civil courts: The cuneo case. In In Proceed-

ings of the 13th International Conference on Simula-

tion and Modeling Methodologies, Technologies and

Applications, pages 425–431.

Amantea, I. A., Robaldo, L., Sulis, E., Boella, G., and

Governatori, G. (2021). Semi-automated checking for

regulatory compliance in e-health. In 2021 ieee 25th

international enterprise distributed object computing

workshop (edocw), pages 318–325. IEEE.

Amantea, I. A., Robaldo, L., Sulis, E., Governatori, G.,

and Boella, G. (2022a). Business process modelling

in healthcare and compliance management: a logi-

cal framework. Journal of Applied Logics—IfCoLog

Journal of Logics and their Applications, 9(4).

Amantea, I. A., Sulis, E., Boella, G., De Marchi, F., Mazz-

ini, L., Alloatti, F., and Bolioli, A. (2020b). Adopting

assistive technologies in healthcare processes: a chat-

bot for patients with amyotrophic lateral sclerosis. In

Italian forum of ambient assisted living, pages 163–

174. Springer.

Amantea, I. A., Sulis, E., Boella, G., Marinello, R., Grosso,

M., and Crespo, A. (2022b). A modeling frame-

work for an innovative e-health service: the hospi-

tal at home. In Simulation and Modeling Method-

ologies, Technologies and Applications: 10th Inter-

national Conference, SIMULTECH 2020 Lieusaint-

Paris, France, July 8-10, 2020 Revised Selected Pa-

pers 10, pages 111–132. Springer.

Dumas, M., La Rosa, M., Mendling, J., and Reijers, H.

(2018). Fundamentals of business process manage-

ment, volume 1. Springer, 2nd edition.

Dumas, M., van der Aalst, W. M., and ter Hofstede, A. H.

(2005). Process-aware Information Systems: Bridg-

ing People and Software Through Process Technology.

John Wiley & Sons, Inc., New York, NY, USA.

Ladyman, J., Lambert, J., and Wiesner, K. (2013). What is

a complex system? European Journal for Philosophy

of Science, 3:33–67.

Martinho, R., Domingos, D., and Resp

ıcio, A. (2016). Eval-

uating the reliability of ambient-assisted living busi-

ness processes. In ICEIS (2), pages 528–536.

Motter, A. E. (2004). Cascade control and defense

in complex networks. Physical Review Letters,

93(9):098701.

Sulis, E., Amantea, I. A., Boella, G., Marinello, R., Bianca,

D., Brunetti, E., Bo, M., Bianco, A., Cattel, F., Cena,

C., et al. (2019). Monitoring patients with fragilities in

the context of de-hospitalization services: an ambient

assisted living healthcare framework for e-health ap-

plications. In 2019 IEEE 23rd International Sympo-

sium on Consumer Technologies (ISCT), pages 216–

219. IEEE.

Sulis, E. and Di Leva, A. (2017). An agent-based model

of a business process: The use case of a hospital

emergency department. In International Conference

on Business Process Management, pages 124–132.

Springer.

Van Looy, A. and Shafagatova, A. (2016). Business process

performance measurement: a structured literature re-

view of indicators, measures and metrics. Springer-

Plus, 5(1):1797.

SIMULTECH 2024 - 14th International Conference on Simulation and Modeling Methodologies, Technologies and Applications

430