UBC Faculty Research and Publications

Patient and health care professional perspectives on using telehealth to deliver pulmonary rehabilitation Garde, A; Inskip, Jessica Ann; Lauscher, Helen Novak; Li, Linda C; Dumont, Guy; Ho, Kendall; Hoens, Alison; Road, Jeremy; Ryerson, Christopher J; Camp, Patricia G. 2018

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Original paperPatient and health care professionalperspectives on using telehealth todeliver pulmonary rehabilitationJA Inskip1,2, H Novak Lauscher3, LC Li2,4, GA Dumont5, A Garde5,K Ho3, AM Hoens2, JD Road6, CJ Ryerson1,7,and PG Camp1,2,7AbstractThe objective of this study was to identify the necessary features of pulmonary telerehabilitation (P-TR)from the perspectives of individuals living with chronic lung disease and health care professionals (HCPs)who deliver pulmonary rehabilitation (PR). Focus groups were carried out with patients (n ¼ 26) and HCPs(n ¼ 26) to elicit and explore their opinions about the critical elements of in-person PR and ideas for howthese elements could be supported using technology. A questionnaire was used to assess technology use,PR experience, and general health status. Four key elements of PR were identified as critical to P-TR: thesocial aspect of PR; communicating with HCPs for education and support; using biosensors for monitoringand promoting self-knowledge; and the evolution of support with progress over time. A range oftechnology-enabled devices and programs were suggested as means to recreate aspects of these integralelements. Consultations with patients and HCPs suggest that users are interested in technology and want toensure it recreates the important aspects of PR. Patients and HCPs identified similar key elements for P-TR.The opinions and suggestions of patients and HCPs should be the driving force of innovation if P-TR is tosucceed in improving health outcomes.KeywordsChronic lung disease, telerehabilitation, technology, qualitative methods, focus groups, chronic obstructivelung disease, pulmonary rehabilitationDate received: 9 January 2017; accepted: 29 March 2017BackgroundPulmonary rehabilitation (PR) is an exercise and edu-cation program for people with chronic lung condi-tions, including chronic obstructive pulmonarydisease (COPD), pulmonary fibrosis, and asthma.1–3PR provides individualized exercise and educationsessions to increase activity tolerance, reduce symp-toms, and improve skills to manage chronic lung dis-ease.1–3 PR is typically provided in person in a groupformat, with individuals supervised by health-careprofessionals (HCPs) in a hospital or community set-ting.1–4 Unfortunately, however, there are not enough1 Centre for Heart Lung Innovation, University of BritishColumbia (UBC), Vancouver, British Columbia, Canada2 Department of Physical Therapy, UBC, Vancouver, BritishColumbia, Canada3 Digital Emergency Medicine, UBC, Vancouver, British Columbia,Canada4 Arthritis Research Canada, Richmond, Canada5 Electrical and Computer Engineering, UBC, Vancouver, Canada6 Division of Respiratory Medicine, Department of Medicine,UBC, Vancouver, British Columbia, Canada7 Providence Health Care, St. Paul’s Hospital, Vancouver, BritishColumbia, CanadaCorresponding author:PG Camp, Centre for Heart Lung Innovation, University of BritishColumbia, 166-1081 Burrard Street, Vancouver, BritishColumbia, Canada V6Z 1Y6.Email: Pat.Camp@hli.ubc.caChronic Respiratory Disease2018, Vol. 15(1) 71–80ª The Author(s) 2017Reprints and permission:sagepub.co.uk/journalsPermissions.navDOI: 10.1177/1479972317709643journals.sagepub.com/home/crdCreative Commons CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproductionand distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages(https://us.sagepub.com/en-us/nam/open-access-at-sage).PR programs to meet the needs of individuals livingwith chronic lung disease.4Telehealth, the remote delivery of health-relatedservices using information communication technol-ogy, may support alternative approaches to delivertraditional in-person PR.5 Pulmonary telerehabilita-tion (P-TR) may help overcome access barriers forindividuals living in nonurban areas and those unableto participate in person due to other commitments,such as employment. It may also be used as an adjunctto in-person PR to support self-management and pos-itive behavioral change. Monitoring bioparametersusing technology, known as telemonitoring, as partof P-TR may also enhance preventive managementby providing early warnings of deterioration, whichmay minimize hospitalizations and decrease healthcare costs.Telehealth and telemonitoring have demonstratedbenefits for self-management in patients living withother chronic conditions6–10 and provide opportuni-ties for supporting those living with chronic lung dis-ease.10–13 However, several studies in telehealth andtelemonitoring in COPD have demonstrated mixedresults. Pinnock et al.14 and Fairbrother et al.15explored telemonitoring using quantitative and quali-tative methodology and found that telemonitoring ofoxygen saturation combined with daily symptom andtreatment questionnaires increased patients’ knowl-edge of their condition and gave them direction onwhen and how to contact their HCPs. However, theuse of telemonitoring for patients with COPD did notimpact hospital admissions or improve quality of life.14Studies on telehealth and telemonitoring in thecontext of rehabilitation (tele-rehabilitation) have alsobeen conducted but without consistency in terms ofthe intervention. A range of P-TR formats have beenexamined: some trials have delivered education usingtelehealth but retained in-person exercise training,13while others are currently exploring individualizedexercise training at home while using telemonitoringand videoconferencing.16,17 The variability may bedue, in part, to the various communication technolo-gies and exercise tracking devices that offer manyways to monitor activity and communicate educationmaterials, advice, and reminders that could supportthe delivery of P-TR. However, while the technolo-gies and capacity exist, there are many questionsabout the necessary features of P-TR and how toimplement them effectively. Furthermore, acceptanceof technologies by patients and HCPs is critical to thesuccess of novel telehealth initiatives.18 To maximizethe likelihood of success, users should be involved inearly stages of development of new technologies19 orwork in codevelopment on system design and test-ing.20,21 This may be particularly pertinent in an olderpopulation, and in more rural settings, where chroniclung disease rates are high.22,23Ultimately, to define the requirements of P-TRdelivered by HCPs for individuals living with chroniclung disease, we must first determine patient andHCPs needs. In this study, we sought opinions ofindividuals living with chronic lung disease, andHCPs delivering PR, to determine the critical featuresof P-TR and how technologies could support thesefeatures.MethodsThis study was approved by Providence Health Care/University of British Columbia Research EthicsBoard (H14-01329). Participants provided writteninformed consent. The design included questionnairesand focus groups. Separate focus groups were heldwith patients and HCPs. Seven focus groups wereconducted with patients (n ¼ 26) in hospitals or com-munity health settings and two with HCPs (n ¼ 26,one in person in hospital and one online using web-based videoconferencing).Individuals with chronic lung disease wererecruited to provide perspectives from both peoplewho participated in PR programs and those who didnot participate due to difficulty traveling to programlocations. Potential patient participants were notifiedabout the study by the hospital-based PR programstaff and if interested their contact details forwardedto the study team. The study team was not involved inthe patients’ care. Individuals were eligible if theywere 35 years or older, diagnosed with a chronic lungcondition, and fluent in English.Eligible HCPs were registered as a physiotherapist,nurse, respiratory therapist, kinesiologist, or physi-cian, with regular experience in treating COPDpatients (a consistent component of their patient pop-ulation within the preceding 6 months); involved inexercise prescription, monitoring, and progression ina PR program; and fluent in English. The HCPs wererecruited locally and through a network of PR pro-grams in the province.Participants completed a questionnaire about theirdemographics and current technology use (regular usedefined as daily or weekly use). Patients identifiedtheir lung disease; years since diagnosis; assessment72 Chronic Respiratory Disease 15(1)of self-reported health status (5-point scale rangingfrom Excellent to Poor); and current activity level(recall of activities over the past 7 days). The HCPswere asked questions about their health discipline,years of PR experience, and primary PR responsibil-ities. Counts and proportions were calculated using R(Version 3.1.1, Vienna, Austria)24 and Microsoft Excel(2007, Microsoft Corporation, Washington, DC).The PR expert and lead facilitator (P.G.C.) dis-cussed the potential of using telehealth to deliverPR and demonstrated some portable devices relatedto health, physical activity, and oxygen saturation:pulse oximeters (Model 8500 Handheld Pulse Oxi-meter, Nonin™, and Kenek O2 Pulse Oximeter;LionsGate Technologies, Vancouver, Canada), ped-ometers, activity trackers (Fitbit™), and smartphoneapplications. A semi-structured, open-ended discus-sion was cofacilitated by the PR expert and an eHealthcontent expert (H.N.L. or J.A.I.). The focus groupquestion guide (Appendix 1) included participants’PR experiences, their vision of technology-deliveredPR, and what parameters were critical to P-TR. Focusgroups were 1.5 to 2 hours, audio-recorded, and tran-scribed verbatim.All identifying information was removed from thetranscripts. An inductive approach to the analysis wasused; content analysis was performed to categorizethe findings according to emergent themes guidedby the research questions. First, two research teammembers coded the transcripts independently with theassistance of NVivo (Version 10.2.1, QSR Interna-tional, Doncaster, Australia). An open-codingapproach was tempered with keeping in mind thebroader areas of inquiry as outlined in the focus groupquestions. The two researchers met to discuss thecodes they derived to ensure consistency. Overall,coding was consistent across the two researchers, andcodes with the same meaning but to which a differentdescriptor was applied were renamed for consistency.Units of analysis/excerpts of text to which the codeswere applied were scrutinized for discrepancies;where disagreement occurred, the instances were dis-cussed and where appropriate, the codes changed. Theresearchers reviewed the codes and grouped them intomeaningful categories. This process was done itera-tively, with researchers meeting to discuss categories,reconcile differences in interpretations, draw broadthemes in relation to the research questions, and deter-mine that saturation was met. Once the categorizationwas established, themes outlined, and all meaningfulunits of analysis/excerpts grouped accordingly, tworandomly selected coded transcripts were read by athird team member to confirm that no codes, cate-gories, or themes were omitted.ResultsThe study involved 52 participants, including 26patients who participated in 7 focus groups. Patientcharacteristics are shown in Table 1. Most patientswere diagnosed with COPD (73%), followed byasthma, and interstitial lung disease (ILD). Fifteen(58%) participants had participated in PR; three ofthese participants had challenges attending all PR ses-sions. Patient physical activity characteristics areshown in Table 2. Twenty-six HCPs participated intwo focus groups (one in person and one online). TheHCP characteristics are shown in Table 3. Half of theHCPs were respiratory therapists, just under half werephysical therapists, and one was a nurse.Patients’ and HCPs’ use of consumer technologies isshown in Figure 1. Most patients were regular users ofa home computer, less than half were regular users ofcellphones and less than a quarter were regular users ofsmartphones or tablets, of the patients who weren’tregular users of computers, a majority (6/8) answeredthey were “not at all comfortable” with the technology.Similarly, a majority of patients who were not regularusers indicated that they were “not at all comfortable”with tablets (15/21) or smartphones (11/22). All HCPsused computers on a regular basis, and more than 75%were regular users of tablets and smartphones.The focus groups revealed several elements thatboth patients and HCPs considered essential for P-TR. Grouped into four major themes, describedTable 1. Patient characteristics.N 26Women: Men 13: 13Age, mean (min; max) 71.5 (45; 88)Participated in hospital pulmonaryrehabilitation, n (%)15 (58%)Chronic lung disease, n (%)Chronic obstructive pulmonary disease 19 (73%)Asthma 7 (27%)Interstitial lung disease 4 (15%)Health rating, n (%)Excellent 0Very good 2 (8%)Good 6 (23%)Fair 9 (35%)Poor 10 (38%)Inskip et al. 73subsequently, these elements included the socialaspect of PR, communicating with HCPs, using bio-sensors for monitoring and self-knowledge, and theevolution of support with progress over time. TheHCPs also raised unique points on technology andscope of practice.Theme 1: Maintaining the social aspectof pulmonary rehabilitation virtuallyPatients and HCPs both identified the social aspect ofgroup exercise and education as a critical componentof PR. Patients relayed how the social aspectincreased their accountability, motivation, and feelingof belonging to a group. To recreate the social aspectand build virtual networks, patients suggested groupvideo chats with peers, group exercise sessions withindividuals in their own home, and interactive videogame consoles (Table 4). Others described exchan-ging contact information and creating a formal buddysystem with routine check-ins. In communities wheremultiple individuals live with lung disease,participants imagined a central gathering site suchas a local community center or gym, where PR couldbe delivered—enabling the social aspect with remoteHCP support.I just had visions of a room with equipment where youcould actually do the program on a big screen TV andsomeone could lecture and you could sit down after anddo the education portion and have kind of everybodythere at once cause I don’t know about you too but Ilike having people around. I work out better when I’m ina group of people. (Female, 69 years)The HCPs described blogs that facilitate patientinteraction and motivation with intermittent modera-tion by an HCP, noting this strategy has been success-ful in other diseases. A group blog or messagingservice was also suggested for “other patients to con-tact each other, ‘oh how are you getting on today?’and that could be their own support group” (HCP,ID1). The HCPs also identified value in smartphoneapplications that enable activity logging, social inter-action, and gamification of exercise to reinforce goal-setting and provide rewards.Theme 2: Communicating with HCPsfor education and supportTraditional PR includes a large amount of face-to-face time with a variety of HCPs; patients receiveindividual exercise prescription and group educationmodules with opportunities to ask questions andreceive one-on-one counseling. Patients described theencouragement from their HCP as particularly impor-tant for their progress in the exercise component, spe-cifically including the importance of havingTable 2. Patient physical activity profile.During the last 7 days, on how many days did you do:None,N (%)At least one day,n (%)Average numberof days/weekVigorous physical activities (heavy lifting, digging, aerobics, fast bicycling) 14 (56) 11 (44) 2.4Moderate physical activities (carrying light loads, bicycling at a regular pace,doubles tennis)6 (26) 17 (74) 3.4At least 10 minutes of walking 4 (15) 22 (85) 4.5Which of the following best describes your usual daily activities or work habitsoutside of leisure exercise time Number of patients, n (%)Usually sit around and don’t walk around very much 7 (27)Stand or walk quite a lot during the day but don’t have to carry or lift things very often 11 (42)Usually lift or carry light loads or have to climb stairs or hills often 8 (31)Do heavy work or carry very heavy loads 0 (0)Table 3. Health care professional characteristics.N 26Women: Men 23: 3Age, years, mean (min; max) 43 (27; 59)Experience working in pulmonaryrehabilitation, years (SD)4.7 (3.8)Type of health care professional, n (%)Respiratory therapist 13 (50%)Physical therapist 12 (46%)Registered nurse 1 (4%)SD: standard deviation.74 Chronic Respiratory Disease 15(1)instructors with a caring personality and a personaltouch (Table 4).Patients described how tele-technologies couldfacilitate their interaction with HCPs. Patients dis-cussed having encouraging messages on tape, such as“you’re doing great”, “get out of bed”, “get your acttogether,” and other reminders or feedback. For theeducation component, patients suggested video-sharing programs so that they could watch the videosmultiple times including with their families to enhanceinvolvement in their care. One participant noted shewould use it to “educate my husband because the moreI learn the more I can help him learn what’s wrong withme . . . help him understand what I’m doing and tryingto do” (63 years). The opportunity to ask questionsfollowing the videos, and between medical appoint-ments, using technology was also highlighted.Some HCPs were concerned about the frequency oftechnology-enabled communication and the bound-aries of their role. There were suggestions of havingspecific times for check-ins, when HCPs are expectedto be online and present. Overall, additional opportu-nities for new ways of communicating with patientswere viewed as positive (Table 4).Theme 3: Using biosensors for monitoringand promoting self-knowledgePatients and HCPs are accustomed to monitoring bio-parameters during PR. The utility and challenge ofbioparameters was apparent to patients and HCPs whodescribed the opportunity to learn about physiology,without forgetting to monitor other symptoms (Table4). Patients identified heart rate and oxygen saturationas key bioparameters to record when exercising athome to inform titration of exercise to an appropriateintensity. Patients described using these parameters toidentify their limits, when they should rest or workharder. Above all, patients described that it wasempowering to know their bioparameters and observeimprovements over time.Patients described learning to make associationsbetween the numbers they record and how they feel,having to rely on the numbers less as they progress.Patients who described being more confident in iden-tifying how they feel found the bioparameter infor-mation less important—they could identify whatreaction was necessary and respond accordingly.HCPs also recognized that patients were empoweredby their understanding and use of bioparameters.HPC’s identified that it is important for technologysolutions to be customizable to different patients,depending on their goals, medical needs, and exerciseactivities: “a suite of different things that could be partof the technology that’s based on what the patient’sgoals are” (HCP, ID16). Some HCPs identified chal-lenges in having patients consistently record theirnumbers in inpatient PR and were concerned aboutensuring that individuals exercising off-site wouldrecord this information: “people are supposed torecord their numbers and they consistently forget toso it ends up falling on me to do that. So even whenit’s very simple . . . you’re already supposed to collectit, they just don’t.” (HCP, ID3)Theme 4: Evolution of support as the patientprogresses over timeThe changing nature of support that patients requireover time was evident in the patient and HCPFigure 1. Patients’ and health care professionals’ regular use of consumer technologies. Regular use was defined as dailyor weekly use.Inskip et al. 75description of PR. In the early stages of rehabilitation,patients described many individual barriers to exer-cise, including fear and anxiety, which were alle-viated by working with trained HCPs in the hospitalsetting. Other patients echoed that having a safe envi-ronment at the start of their rehabilitation was critical.As patients progressed through the PR program, theydeveloped more confidence (Table 4).In imagining a remote telehealth-based program,patients and HCPs also identified how technologicalfeatures could be individualized and support the tran-sition from a formal PR program to ongoing physicalactivity maintenance. One HCP described how P-TRcould evolve and have different tiers of managementdepending on the patients’ progression (Table 4).Another HCP described how the use of technologyat home might promote “more onus on the individualto be active in their rehab . . .working in their day today life and so they take it on, integrate it into theirown lives” (HCP, ID3).Health care professional perspectives ontechnology and scope of practiceHCP’s raised concerns unique to their perspectiveand scope of practice in an increasingly technicalTable 4. Quotes supporting main themes from patient participants and health care professionals.Themes Patient participants Health care professionals (HCPs)Theme 1: Maintaining thesocial aspect ofpulmonary rehabilitationvirtually“through Google Plus . . . you can have up to10 people on at the same time. . . . So youcould have people doing things at the sametime. . . . I would probably start it withsome kind of social interaction before Ieven started the exercise component, likesome kind of education session first andgetting acquainted and getting to knoweach other and talking it out so that youfeel somewhat of a mini-bond and then gointo some form of exercise.” (Female, 63years)“I’ve seen somebody taking online diseaseself-management program who didn’t getout of the house much, they metsomebody online who commiseratedabout . . . bathroom renovations and howyou’re managing your chronic disease, youknow, during that time. And so people stillhave the ability, depending how it’sstructured, to make connections withother people with similar trials andtribulations or things dealing with theirillness.” (HCP, ID19)Theme 2: Communicatingwith HCPs for educationand support“for me it’s the personality . . . she has thepatience . . . if you do have a problem youcan talk to her . . . she’s alwaysavailable . . . I can phone her.” (Male, 78years)“I think any time we can enhancerelationships between the clinicians andthe patients or clients, whether it bethrough the type of relationship via anelectronic format, it enhances care andpatient outcomes.”(HCP, ID19)Theme 3: Using biosensorsfor monitoring andpromoting self-knowledge“those things help you learn for yourselfwhen you should quit doing what you’redoing and [conversely] you can dosomething because you feel better withouthaving a meter.” (Male, 78 years)“patients can become a bit fixated bynumbers and not by feel and then they’reout somewhere they don’t have thisfeedback and they’re not sure how theyfeel cause they’re so used to usingnumbers all the time . . . you kind of needto get a balance between how they feel andbeing able to record it themselves withoutalways seeing the numbers.” (HCP, ID1)Theme 4: Evolution ofsupport as the patientprogresses over time“as the program wears on and I noticeimprovement myself then I think you need,you don’t need it as much, you know, youcan kind of wean yourself in asense . . . you’re developingconfidence . . . I noticed that even now,right, we rely on [our HCP] much less asthe amount of time goes on.” (Female, 63years)“if I had a client starting something rightaway I think a weekly check-in where I cansay okay, this has been your week . . . havea look at the data you’ve compiled, we canchat about it briefly . . . then, as theyprogress through the program, theybecome more self-sufficient then there’sless and less follow-up . . . sort of a weaningschedule.” (HCP, ID3)76 Chronic Respiratory Disease 15(1)world. The workload implications of incorporatingP-TR in addition to their regular duties, and therequirements to be technologically adept, wereraised as a concern: “I would want it to not be offthe side of the desk of people already working to capac-ity and beyond. It would need to be some dedicatedtime, dedicated people . . .who were . . . computersavvy” (HCP, ID10). Others reiterated that techno-logy training would also be essential to the successof P-TR.The HCPs appreciated the value of using technol-ogy to increase access to rehabilitation services tounderserved communities: “you could see peopleimprove and these are people who otherwise wouldnot have had that . . . it’s satisfying cause you’vehelped somebody who would have probably just dete-riorated” (HCP, ID3). When considering their ownpractice and job satisfaction, several agreed havinga balance of in-person and remote patients wasappealing:I wouldn’t want to be just monitoring people from adistance all the time, but it would actually be quite anice mix if you’re doing in-person pulmonary rehab aswell as the distance and there’s sometimes when it’skind of nice to get a break from the direct interactionoccasionally. (HCP, ID6)To maintain this balance and minimize the burden,HCPs suggested splitting the technological workloadbetween PR professionals rather than having dedi-cated HCPs for P-TR.ConclusionSummary of main findingsThis study explored patient and HCP perspectiveson the format and parameters for delivering PRusing telehealth technologies. Patients were lessfrequent users of consumer technologies thanHCPs and appeared less comfortable with them butwere still receptive to technological adaptations ofPR. Specifically, we identified four themes basedon participants’ perceptions and experiences thatwere critical to P-TR, including social aspects,communication with HCPs, measuring biopara-meters, and evolving support. Participants sug-gested possibilities to recreate these criticalelements using technology for application to P-TR. These essential elements were reiterated andsupported by HCPs.Limitations of this studyPatients were purposefully selected to include per-spectives from individuals who attended in-personPR and those who did not attend due to distance lim-itations. We did not recruit urban patients who did notparticipate in PR, which may limit the breadth of theideas and generalizability. However, the developmentof P-TR, and its increased flexibility, will likely ben-efit urban patients as well. All participants resided inBritish Columbia, Canada, where there is reliableInternet and cellphone connectivity. In spite of this,less than a quarter of the participants with chroniclung disease were regular users of tablets or smart-phones. Currently, this may limit the choice of tech-nologies used and the reach and impact of P-TRprograms but would likely change in the future, astechnology-savvy patients with COPD are referredto PR. In addition, we did not explore how other fac-tors such as disease characteristics, gender and age, orthe presence of comorbid conditions could haveimpacted our results. Future research should focuson these factors. Finally, the current study does notaddress patients who declined to participate in PR dueto other relevant reasons such as anxiety, motivation,or confidence to exercise. These patients may not begood candidates for P-TR programs or would requirea transition to more independent exercise as their pro-gram progressed.Context in existing literatureNew technologies and increased individual Internetconnectivity provide the opportunity for a telerehabil-itation strategy tailored to individual patients andenvironments. P-TR may help overcome access bar-riers for individuals living in rural areas. Previousstudies have used novel technologies to deliver PR,demonstrating the feasibility of P-TR.13,25–27 Self-monitored home-based exercise has been shown toimprove dyspnea and health status,26 and participants’compliance with accelerometer/smartphone activitymonitoring is high and associated with improvedactivity levels.25 Longer term studies that observehealth outcomes and how people use technology inP-TR remain warranted.Technology is already a large part of HCPs’ prac-tices. Charting on electronic health records, bookingpatients online, and communicating with patientsusing different media mean that most HCPs arerequired to be familiar with technology; however,HCPs described not wanting to lose the in-person partInskip et al. 77of their job completely. There was also hesitationabout supporting patient technology use and trouble-shooting. Assistance from dedicated informationtechnology staff may be necessary to facilitate theimplementation and success of P-TR. In turn, it willbe critical to clearly outline expectations for patientsand HCPs when adopting P-TR—highlighting whencommunication will or will not be real time.Telerehabilitation has been used to manage chronicdiseases including cardiac disease,28 stroke,29,30 mul-tiple sclerosis,31 and arthritis.32–34 In adapting suc-cessful in-person rehabilitation programs, the focushas primarily been on the technological require-ments,35 human factors,36 and barriers to use.29 Thepatient experience of rehabilitation is very important,and a variety of needs assessments with patients andHCPs have been used to identify interest in rehabilita-tion programs and help with their design.37,38 Theongoing assessment of new programs using qualita-tive methods also helps to understand the patientexperience and identify important issues.39–41The next steps for P-TR include addressing imple-mentation costs, staffing, safety, patient referral, anddischarge processes. The cost-effectiveness of tele-health for consultation in COPD appears promising,with reduced hospitalizations and acute exacerbationscompared to traditional care.42 Full health economicand health impact analyses of P-TR are currentlyunderway for a web-based PR program.43 Policieson HCP training and standards will also need to bereviewed; the interdisciplinary composition of PRmeans that HCPs are under the jurisdiction ofdifferent colleges and regulations. These practicalconsiderations will be important for successfulimplementation.Implications for clinical practiceTelehealth solutions hold promise to increase accessto PR. Our consultations with patients and HCPs sug-gest that users are interested in technology and wantto ensure it recreates the important aspects of PR. Thecritical elements of PR were identified as the socialaspect, opportunity to communicate with HCPs, mon-itor bioparameters, and have individualized care thatevolves with individuals’ progress. The technicalaspects and interdisciplinary nature of P-TR raisepractical challenges that must be overcome for suc-cessful implementation.The results of this study have implications for thedesign and implementation of P-TR. Before designinga P-TR program and selecting which exercise andcommunication devices available on the market willbe used, decision makers should determine that thetechnology supports patient and HCP needs. The opi-nions and suggestions of patients and HCPs should bethe driving force of innovation if P-TR is to succeed inimproving health outcomes.AcknowledgementsWe would like to acknowledge the study participants fortheir interest in discussing their experience in PR and shar-ing their ideas for telehealth. We would also like to thankLauren Coxson who assisted with data entry and calcula-tions during her summer student placement.Declaration of conflicting interestsThe author(s) declared no potential conflicts of interestwith respect to the research, authorship, and/or publicationof this article.FundingThe author(s) disclosed receipt of the following financialsupport for the research, authorship, and/or publication ofthis article: This project was funded by the Canadian Insti-tutes of Health Research [Catalyst Grant e-Health Innova-tions #316713, 2015]. Drs. Pat G Camp and Christopher JRyerson are Michael Smith Foundation for HealthResearch Career Scholars. Dr. Jessica Inskip is supportedby a British Columbia Respiratory Rehabilitation Fellow-ship from the BC Lung Association.References1. McCarthy B, Casey D, Devane D, et al. Pulmonaryrehabilitation for chronic obstructive pulmonary dis-ease. Cochrane Database Syst Rev 2015; 2: CD003793.2. Nici L, Donner C, Wouters E, et al. 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The evaluation ofan interactive web-based pulmonary rehabilitation pro-gramme: protocol for the WEB SPACE for COPDfeasibility study. BMJ Open 2015; 5: e008055.Appendix 1Focus group question guide1. What’s your experience with pulmonaryrehab? For those who haven’t gone throughthe program yet, what are your thoughts aboutit?Probe: What motivated you to join the program orkeep at it?2. If you haven’t gone through the program, whatdo you want to get out of pulmonary rehab? Ifyou have, what about pulmonary rehab made itvaluable?3. Imagine that we were going to create a tech-nology version of pulmonary rehab. Whatwould that look like?Possible probes: based on the answers related to theexperience of PR. Also: What features would it have? How would itwork? What would it do? How would it fit into your life? What are the advantages of using technology? Do any of the examples that we mentioned(app, wearable, internet-based) work? Would it need to measure heart rate, oxygensaturation, and shortness of breath? Would it need to store the information? Does it need to be able to provide reports thatyou can print out or send to your health-careprofessional? Does it need to have reminders and tips? Would you prefer technology that you wouldwear every time you exercise or would youprefer to keep track of your exercise and enterthe information on the internet?4. What would motivate you to use thetechnology-based pulmonary rehab program?Probe: Are there other pieces of technology you use?5. Who would a technology-based pulmonaryrehab program best be suited for? Who wouldbenefit most from it?6. Are there any other ideas you would like to addabout anything we have discussed or aspects ofthe topic?80 Chronic Respiratory Disease 15(1)


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